Friday, July 29, 2011

And Now Something Completely Different

Depending on the time of day it is that I happen to have written what it is you're reading, it may seem more or less coherent than other times of the day. I think I'm fairly lucid at the moment, but that's the tricky part about very powerful opiates - of all the people in a given conversation, I'm the person least likely to able to recognize if I'm making sense.  I feel pretty good that what I'm thinking is sensible. That doesn't seem to resolve the issue of whether I am in fact making good sense, or not.  So, I wanted to write while I'm feeling fairly lucid and my ability to recognize my keyboard by touch seems to be fairly unmolested. (I'm not getting a bunch of green and red squiggly lines underneath what I'm typing right now).

For the sake of completeness,  I have in my system right now some paracetamol, hydrocodone and oxycontin.  I take the oxycontin twice a day because it's time-released. At lunch (well, lunchtime since food isn't on my menu for obvious reasons) today, I took 60 miligrams, which I will repeat at about midnight, unless I seem to feel less ouchy, in which case I'll take 40. If that holds, I'll stay on that dose for a couple of days, or titrate up and or down as feels better for me. My doctor has allowed for me to take up to 80 at a time. If that fails to trivialize the pain along with the hydrocodone, I have morphine available to take if I want (and have used it some, particularly the first day, less so the following days. I've resisted taking any of it since I've been up today - a good sign which I hope persists).  I took 15 milligrams of hydrocodone about an hour and a half ago.

Plus, there are after effects of some of the shit they gave me while banging around inside my body. I understand that memory loss is not an uncommon consequence of this type of sedation.  I also understand that memory and cognitive problems are commonly attendant to taking the types of pain medication that I'm on now. I don't know if this is true since I can't remember things I've forgotten, and my current ability to properly order events in my mind is, well, less than ideal.

Valium. I don't like it one bit. Not at all. It makes me dizzy and ditzy and amused of things in a way I find otherwise personally uncomfortable.  Yet even while I'm finding something completely amusing and realizing that it's absolutely stupid, I can't stop myself being amused by it. This is disagreeable to me on so many levels, but I think could be a very useful strategy in marketing.  Fuck piping in the smell of popcorn into a theater section. Or oversalting bar nuts to increase one's thirst.  Just have a valium salt-lick in any theater, and even the most horribly written, boring movie will become a blockbuster if my experience with valium at all generalizes.

Hydrocodone.  I've taken a lot of this in my life, and it's not really a big deal. It makes me sleep somewhat more soundly (which I don't know if that's because of taking the edge off of the pain for which I'm taking it, or if it's just a property that mid-grade opiates have on my system. Perhaps I should squirrel a few away and test this when I have no pain going on to see if it just puts me on my ass without being related to the stress that being in pain brings.)  Otherwise, I don't mind it much after a day or two when the itching on my face stops. This is clunky since you wait until pain is starting to come up to scratch, and then react. Its benefit is that it's a low dose that lasts only a few hours so if the pain I'm in, say, now just naturally settles down in a few hours time, then my time being medicated beyond what is necessary is slighter than with longer lasting agents.  But since it's a surgical thing I had done, this just seems ungainly, and I wind up taking these more often than I probably absolutely need to because I know once it wears off, the pain is going to spike again.

Some better system than this is easily devised, but many doctors seem to have a hesitance to appropriately dose patients to control the actual pain their patients are in instead of the amount of pain a doctor decides for their patients they should be asked to bear for no good reason.  As a result, I am fairly confident that many people prolong putting off preventive and elective procedures at an early stage for far less financial cost until they're at a level some asshole doctor decides is bad enough to adequately manage.  Then the person can get the thing taken care of and have their pain adequately managed. (When I say pain, I should really say something like symptoms - pain is one instantiation of discomfort; there are others. But I had surgery, so my big issue at the moment is actual pain the kind of which but for the drugs I'm on would be absolutely crippling to me.)

Morphine:  this makes me feel like I just can never take an adequate breath. And this causes me some panic from time to time because even though I know I'm in no danger of suffocating or stopping breathing at the low dosage I'm on, it feels like that and that sometimes scares me. I think it's also strong enough that I don't feel itchy when I take it.  No clue why that is though - that's just my guess.

Oxycontin: I can understand why people would turn to this as a recreational drug addiction worth the cultivating. It's insidiously pleasant to take. I know it's just a time released version of oxycodone, equivalent, in my current dosing scheme, to taking a standard percocet tablet once an hour, but without limiting factor of Tylenol toxicity in my liver. It does a good job at normalizing the level of pain I feel without the clunky mechanics of having to take individual tablets on a busier harmonic scale to achieve the same result. The overlap period in its dosing is twice a day instead of once every couple of hours results in less stress for me by equalizing the level of pain in a way that's not ad hoc like taking the vicodin is.  The pitfall here is that it's a long-acting agent and isn't amenable to addressing the so-called "break-through" pain (see my write up on vicodin for that).

The euphoric effect these give me doesn't last long. After about two days of being on opiates, I don't really feel that anymore.  However, the downside is that also after a couple of days, they no longer work as well at alleviating the pain I'm in. I develop a tolerance to drugs fairly quickly, and it originally takes a fair bit beyond a standard dose to actually achieve the desired, therapeutic result.

But doctors and surgeons tend to think they know better than patients know how a given patient will react (or fail to react) to a given treatment protocol. 3 milligrams of vicodin might work well for one patient while 7 milligrams may not work much at all for another. Splitting the difference and giving them all 5 is no way to address individual patient issues while working within the confines of drug protocols writ large for economic reasons. That is to say, it's much easier for each tablet to be made assembly-line style, than to create a whole slew of formulations to be handed out on an individualized basis. So, if you need 7 milligrams of something to treat something I only need 3 milligrams to treat, doctors should do the math on that and write a prescription sufficient to account for the total needed, and then instruct patients how to cut pills to take a full tablet plus a partial other tablet for the necessary dosing to take place. Or, if you only need a third or of the pill, how to cut that and then take what's necessary.

Saying, well, your pain just has to deal with the limits I'm willing to treat by under-medicating you the whole time for the fact that others are responding great to this scheme is the sign of a doctor who cares not about patient care and actually reducing a patient's difficulty. That's a doctor who's more concerned about his ability to cash a check. Find a new doctor who will listen to you and work with you to adequately treat the symptoms you actually are experiencing.

Further, it is no argument of any kind that people who are legitimately suffering pain should have to suffer because some people abuse prescription medication.  That some people will go out commit credit card fraud is not an argument that people who will not should be nevertheless not be able to use a debit card. We recognize this; why is it different when we're dealing with actual human suffering?

Fortunately, I have it within my means to pick what doctors I want. Other than skill and personality (this is a big factor for me in picking a doctor. After all, I do pay considerable sums of money to my doctors for their expertise, and if I'm spending that kind of money, at the very least I'd like not to be treated as an inconvenience, or as something the doctor must just endure as necessary to cash the very large checks their time forces me to write), and the quality of their work as well as how willing they are to manage my concerns both in the office and after I leave.

These are not only factors on a personal level, these are also legal requirements imposed on doctors. It is against the law for a physician to fail to adequately manage his/her patient's signs and symptoms on any basis other than medically indicated propriety.

As an example of how little many doctors care of the actual discomfort/pain/fear/nervousness their patients experience, I had to have an emergency root canal some years ago. Just one of those freaky things where I got hit in the just right way that one of my teeth split right down the middle. It hurt, quite a bit. So, instead of going all the way up from south Tacoma to Seattle where my then dentist's office was, I convenience shopped for a dentist.

That is to say that there was a dental office on the same block, so my bloody mouth and I walked over and had a root canal done right then and there. During the procedure, the dentist in question anesthetized one half of my gum (the outer, not the inner side where the roof of the mouth is), which he begrudgingly, finally did after I stopped the procedure to let him know I could feel the whole fucking thing. He said that I shouldn't be able to (which I agreed - I shouldn't have to sit through a root canal with insufficient analgesia, and that is indeed a professional ethics violation for a physician to do, as well as a cause to lose one's license for malpractice, and can potentially result in criminal prosecution as a bonus). Finally, he anesthetized the whole area (which I could still feel, but within a manageable range of discomfort).

Afterwards, he wrote me a prescription for Tylenol and Motrin.  Neither of these requires a prescription to get, and I was certainly unimpressed with being "prescribed" something I had lying around the house.

So, I paid him the over $4,000.00 bill he was due for services (poorly)rendered. On the spot. In full. And then I went straight to my regular dentist's office for a.) pain killers and b.) to take the imprint for the crown and to have the crown work done.

This other hack dentist is no longer practicing in my state having lost his license for malpractice.  I am simply not a patient who tolerates ineptitude or the shirking of one's legal, ethical responsibilities. If you have some trepidation about fully treating a patient's condition to include not only managing the physical signs but as well as their symptoms (how they are experiencing it all in the first person context - if a patient tells you they're hurting while you're cutting into them, take their word for it. Don't decide on their behalf you know better than they know what they're feeling, which is, incidentally, in my state a professional obligation of all physicians, as well as being a criminal statute for inadequately managing the condition), then do not go into that field.  Study something else where your work doesn't harm people.

Plus, I have the resources, patience and determination to see things through until their resolution. A lot of the cases about this do not get successfully resolved because the people filing the complaint fail to see the complaints through. You just don't file a complaint and consider the work done. Complaints generate investigations. Investigations open up lines of questions. If you don't continually force those questions to be asked and then answered (including the questions that will be asked of you), then you've done no work at all.  Like when I was a police officer, I showed up to every hearing at whatever relevant state agency that took place and might have even required my presence (sometimes my state allows this "showing up" to be handled over the phone, like with adminstrative hearings through the Department of Licensing for DUI hearings) to make sure that the facts are represented all the way through, in service of fleshing out a.) the objectively true issue, and b.) how to address those with compassion towards particular people who happen to have made a significant error. The process has several ends, one of which is justice. A part of that is mercy while still punishing someone for their misdeeds.

You better believe that the same is going to be equally true if I'm actually personally injured or made to suffer by the actions (or lack of actions required of someone by virtue of professional ethics and/or legal duty imposed on their profession) taken by another.

And no. I don't take settlements from insurance companies. I didn't initiate action against the good doctor to get a settlement. I took action because if he's going to do that to me even when I can out of pocket cover the full expense of the medical procedure and treatment, then people who are ill-able to handle that kind of expenditure are most probably being treated at least that poorly. People who are by definition without redress attendant to financial security and ability to hire a lawyer to represent them through the whole of the process.

Not having to shop around for an attorney on a contingency basis which determines what, if anything, they'll be paid out of the likely best possible court award a case like mine would get (and let's be frank, failing to manage one person's pain after a root canal is fairly low level malpractice compared against wrongful death cases where the verdict is less than the cost of litigation or surgical procedure bill) isn't an incentive to attorneys to take up those cases. So, it's kind of in the hands of people who can afford to piss away that kind of money on the exclusive grounds to grind an axe. People who can't afford that, aren't going to be a serious concern for a doctor who knows that through sheer disparity in financial privilege, he's going to remain largely immune from having to consider the poor person on public assistance much more than just a passing nuisance.

Well, this one certainly ended in a direction I didn't aim to make it.  I guess I'm not in fact as lucid as I feel that I am.  Fortunately, I recognize the difference between feeling something is true and knowing if something is true; they aren't the same thing.


bladerunner said...

You sound perfectly lucid to me. Hell, I wish more patients were like you. (I work in EMS).

Maybe that's because it's a pet peeve of mine; analgesics in EMS are WOEFULLY undergiven by certain agencies. I WISH more people complained about their care, and did so eloquently; nobody who should cares, because often the consequences are subtle, and the providers don't have the empathy they should. "Well, they aren't dead" is considered a valid argument. I know if anyone I love gets sick inside my city limits, there's a solid 50% chance of me ending up in jail for assault.

So good on ya for getting a bum thrown out!

And I hope your mouth recovers well! Tooth pain is the only pain in my adult life that ever made my eyes leak pain-water.

Justicar said...

It's so frustrating to me personally, and socially.

So some people have troubles with drugs. Why does this dictate the treatment available to anyone else?

Oh it doesn't. In fact, it's an ethics violation not to prescribe opiate pain medications to an opiate addict if the use of them is medically indicated.

All that a doctor has to do there is monitor the patient for signs of seeking behavior.

Most drug dependence that comes as a result of medical interventions is physical, not psychological. How do we treat that? By a very easy process of giving the patient a longer period of opiates to take in regularly scheduled reduction in the potency until the difference the body notices between having it and not having is indistinguishable. Works 100% of the time.

Why I should have to contend with people who have troubles with drugs for receiving well-established, medically indicated and entirely appropriate relief from pain following a surgery is not entirely obvious to me.

I can understand why sometimes pain meds are withheld with respect to bad drug interactions for an imminent surgery. This needs to be studied and a solution be devised. We can and should do better on that front.

Saying "well, you just have to suffer for 45 minutes after half your leg was ripped off because, you know, chemistry is hard" is not sufficient.

When I had my ankle reconstructed in 2000, my doctor would write prescriptions for 10 percocet tabs at a time with instructions to make an appointment for more. So, I made an appointment the following day and said, look, I'll be out of these by tonight. You took out some bone, restructured some ligaments and implanted some plastic. Yesterday. Do you think I'm making it up for the lulz?

He laughed and wrote me for like 100 tablets. About a quarter of those wound up in the toilet.

Were I a doctor, I'd hand out vicodin to everyone. Physical? Let's see here, that's four of these beauties. Know where you'd find most of those tablets in a year's time? In some bathroom medicine cabinet where most prescription drugs go to die.

Even if everyone took them all, the fears of rampant drug-induced robberies wouldn't come to fruition.


Southern Geologist said...

I can certainly identify with some of the problems here. After having my wisdom teeth (seven!) pulled several years ago I was given codeine/tylenol with instructions to take one every six hours. I had to take one every four because A. it didn't last six hours and B. The dose wasn't strong enough to do much more than dull the pain in a VERY minor sense so I was trying to achieve a temporary cross-over effect (a couple of hours where the pain was half-ass eased instead of quarter-ass eased). As a result of this I ran out of the pills a day early and had to call the office to put in for a refill. I repeat: A day early. They informed me that an early request for medication constituted signs of dependence and therefore they couldn't give me any more. I'm quite certain that it was obvious by the tone of my voice that I was in great pain, but apparently this didn't matter. ONE DAY EARLY.

Apparently the extent of my pain became fully understood around the time I started yelling because after a few minutes of heated discussion involving topics such as not giving me a high enough dose to actually do some real good for the pain, no record of substance abuse (I was seventeen and living with my parents for fuck's sake, this was all on their records), incompetence and other related subjects it suddenly became legal to refill the prescription for me.

More recently, I've been given Hydrocodone (500 mg) as a result of injections I've been receiving in the wrist to cure carpal tunnel like symptoms. Unfortunately, the hydrocodone does not work on me. I had a mild euphoric effect on the first couple of days but no pain loss. Now it does nothing. I've even altered the dose once or twice (being very careful to avoid hitting the paracetamol limit - the only good junkie is a dead junkie, after all!) just to see if, say, 1500 milligrams would do anything. Nope.

I pointed out to the doctors that it hasn't been working on me and was informed that it was the best they could do because there is a law here in the state of good ol' Texas which requires that you get a separate prescription pad for any pain medication stronger than hydrocodone. Getting access to said pad requires getting through a shitload of red tape so they had been unable to do it. One of them also made a point of noting that when she was working in Utah -- FUCKING UTAH, Mormon wonderland with all sorts of ridiculous liquor laws and illicit drug laws -- that this was never a problem.

Sometimes I hate my state.

So, as a result of a dumbass state law I have pain that which is manageable on its own (not agonizingly severe), but I am for all intents not being treated for it. If this was an isolated issue I would consider it a minor annoyance, but given that this is a statewide problem (and to a lesser extent a problem throughout the US) I have to think of the poor bastards who do really need pain medication and aren't getting it due to an institutionalized, childish hatred of drug addicts. Fuck.

Justicar said...

I hate Texas anyway; this is just one more reason to despise that place.

I'm by no means rich, but I'm very clear with my doctors about what I expect as a standard of care. I'm not one to remind people of the obvious, but my physicians work for me, and I'm not particularly sentimental. I appreciate their years of medical school, and their expertise. It's why I'm willing to pay them for the completion of a mutually beneficial transaction.

I'm a firm believer in paying good money for good work. These people spend a long, long time learning how to do a narrow range of things really, really good. I have no problems at all paying handsomely for their services and skills. But their judgment doesn't replace mine. I make my own decisions and cede to no one the right to determine for me in advance what is ok for me. The first time I have discuss with my doctor whether the pain is really that bad is the time I fire his ass.

I had veneers put on late last year. Love them. I also knew, as did he, that I'd have to have a few surgeries. I should have two, maybe three, more to deal with. So, going in we did the math on the expected price for all of what I wanted done to be done. Low range was between $65,000 - $70,000. That's a whole lot of money, and I've yet to meet a physician whose practice is so good as to let that much guaranteed money walk out the door - I pay cash. Well, cashier's check for a sum that large. There's no way in hell I'm going to argue with a doctor who's just cut me open whether I'm really hurting.

If that's how dude's going to practice medicine, that same check buys an awful lot of lawyer time with the state's medical licensing board. It is explicitly illegal in my state to not follow the standard of care with respect to pain management.

My dental office is no exception; they're all fine people. The office is closed down for me, I go in and get whatever done, and then I'm taken home. Sorry, I just can't deal with other people some days. And I don't like dentists in the first place. I get a sedative to go in for teeth cleanings. People milling around in my mouth freaks me out.

Anyway, at our consultation when I was mulling over which office I liked better, I chose this one, and told him that I expect to be kept comfortable, and I won't be asking twice. Here's your check, and I look forward to excellent results and being kept quite well managed.