Dr. Harvey Rose, a physician in California is heavily involved with the treatment of pain. Here, in an interview with CMTI, Dr. Rose helps clarify his work on the treatment of chronic pain and the enlightenment of physicians towards the use of narcotics or whatever it takes to alleviate pain for people like us who experience chronic pain. I've taken the liberty of printing just about everything Dr. Rose dictated in reply to my questions.
In 1981 Dr. Rose was prosecuted by the Medical Board of California, then known as the Board of Medical Quality Assurance (BMQA), for over-prescribing narcotics. He took this accusation by the board as a positive sign that this was the time to make sure that physicians in California knew that pain control was possible but was not being practised for fear of being accused as he was.
Dr. Rose: Since 1981 events that I have been actively participating in have vindicated my management of those patients back in the '70s and '80s with narcotics. I have not been exonerated. Exoneration means that the Board admitted that they were wrong, and no bureaucratic agency is ever going to admit that they made a mistake, but in getting the laws changed and getting a new attitude regarding the prescribing of narcotics for chronic pain in this state, and fortunately in other states, I have been vindicated.
Q: Can you tell us briefly how the case went and what was the outcome. Are things better for the physician who is asked to prescribe pain medications and for the person with chronic pain?
Dr. Rose: After several years of hearings and appeals, my state senator, Leroy Greene, finally forced a settlement upon the Board which had found me guilty of over-prescribing. I was supposed to be reviewed for two years by a panel of doctors, but they closed the review after one year. It is interesting to note that while under review of this physician panel, I continued to prescribe for some of the patients that I had been found guilty of over-prescribing, and nothing was said to limit my prescribing for these patients.
I then went on to educate myself and found that the problem with doctors giving patients adequate amounts of opioids (narcotics) for pain relief was a spinoff of the war on drugs. I then worked within the system with my county medical society, the California Medical Association, and with the legislature with the help of Senator Greene. In the article I gave you, Anatomy of a Pain Summit, (available from CMT International) everything came to a head in 1990 with the passage of the California Intractable Pain Treatment Act, the release by our county medical society of The Painful Dilemma, a position paper on The Use of Narcotics for the Treatment of Chronic Pain, and also the American Medical Association put out a report on prescribing which I mentioned in that article.
Since then, the medical board, under a new director, had a task force on chronic pain and in 1994 put out a statement on the use of narcotics for chronic pain and the guidelines on chronic pain management…keeping good records, getting at least one consultation to establish the diagnosis of intractable pain and then a doctor could use controlled substances without fear of being disciplined by any regulatory agency. So the political climate and the regulatory climate has improved in the state of California. However, even though the fear factor has been removed, there is still a lot of education needed for physicians, nurses and pharmacists when it comes to the use of opioids in chronic pain. People in the profession still do not trust the regulatory agencies despite the change in law and their pronouncements by the medical board. Also, it's very difficult to unteach people when they've been taught through their medical training that narcotics are evil, should be used as little as possible, and that the risk of addiction is very high when, in fact, as you mentioned in your articles in your magazine, the risk of addiction is very low or nil when opioids are used properly for management of chronic pain.
A true addict uses narcotics to escape from life, to "blow their mind," whereas a chronic pain patient uses the opioid medications so that they can have an improved level of comfort and quality of life.
Texas was the first state to pass the Intractable Pain Treatment Act. The Texas law does not require consultation however. Then I was able to work with patients in other states and this summer of '95 Oregon and Nevada have passed Intractable Pain Treatment Acts. The state of Missouri also passed an Intractable Pain Treatment Act, but I was not personally involved in the activity in that state. Florida and Washington have mild Intractable Pain Treatment Act laws but they do not sufficiently protect the physician where he feels "comfortable" in relieving his patient's discomfort.
Q: I realize that doctors have to report the fact that they are prescribing narcotics. Does this then make the person receiving them an addict in the eyes of the governing body?
Dr. Rose: In California we no longer have to report patients as addicts. The state of New York does require anybody who is on narcotics, I believe for over 120 days, or some number like that, to be registered as addicts, and there was a famous case of a cancer doctor in New York City who refused to register his cancer patients as addicts and he was prosecuted for it. Not surprising, that doctor became the first chairman of a new committee in the American Pain Society, a committee involved with regulatory issues.
Q: How do you feel about drugs and addiction?
Dr. Rose: Regarding drugs and addiction, it's very important to understand the concept and definition of addiction. Let me start out by saying that tobacco companies will tell us that cigarettes are merely habit forming, not an addiction. How does one distinguish between habit forming or dependency and addiction? Let me ask you, is fingernail biting an addiction? Most people would say well, no, it's just a habit. However, if I told you that if you continue to bite your nails in a compulsive manner that you could get cancer of a cuticle, yet you couldn't stop biting them, putting yourself at risk for getting cancer of the cuticle, then that would make fingernail biting an addiction.
So, addiction is not what you do or how much you do of it or how much you feel compelled to do it, but rather, does it harm you? People say, well, if addiction means you crave something, you have a psychological craving or you have to have something and you can't give it up, that you are addicted to it…No. However, you have to eat every day, and is eating an addiction? Not necessarily. But, if you were a 300 lb. diabetic who kept eating candy and sugary soda pop and made your diabetes worse and you could not stop doing it, then you'd be a food addict.
Michael Jordan, the basketball player, understood addiction. When he was accused by reporters of being addicted to gambling, he told them very succinctly, "I'm not addicted, I can afford it." So, if you do lose the rent money and the car money and continue to gamble in a compulsive manner, then you are an addict. If you can afford it - no loss of money would be harmful to you, but you enjoy gambling and bluffing and the thrill of it and can afford it - then you are not addicted to it. If you continue to do it on a regular basis, you might be dependent but not addicted.
So, what is the harm factor in taking narcotics on a chronic basis? Interestingly enough, the only bad side effect from narcotics is constipation. Narcotics are not toxic to the stomach or to the liver or to the kidneys, and probably it's because our bodies have our own endorphin system that these medicines are not necessarily recognized as foreign substances and do not seem to harm our central nervous system. We've learned from methadone maintenance patients and from patients with cancer who live loner now but who have pain that these people can take these medications over a long period of time without evidence of abuse or addiction; that is, they take it responsibly, they take it as needed for their pain, they do not sell it, they do not take it for any sort of a psychological high, all they do is take it for relief, and the pain eats up the medicine so that they don't get a buzz or any kind of euphoria, they just feel normal.
Q: Most of our readers who have pain have severe continuing nerve or muscle pain. Many of them find that the pain medication is just as bad as the pain, either putting them to sleep while they are on it, only to wake up with the pain coming back. When they ask for stronger pain control, they are given tranquilizers to calm them so the Tylenol or whatever else they are on acts even more as a sedative.
How can we get our doctors to understand that we are active and want a quality of life that is as pain free as possible while we go about our daily lives working, playing, loving, etc., not to be drugged and a sleep most of the time. Can you comment on this please?
Dr. Rose: When medicines are taken for pain relief and you arrive at the proper dose that achieves at least 75 per cent pain relief, that is on a visual analog scale of from 0 to 10, that if you start out with the pain around nine and you drop down to about a pain level of three, you should not expect to feel dopey from the pain medicine; that does not seem to happen. If you do feel dopey from taking the pain medicine, then you are probably getting too much. There are instances, though, when you need a sufficient amount of medicine for pain relief which may make you feel a little groggy and impair your ability to function and then the stimulant type medications like Ritalin and Dexedrine are used, particularly in cancer patients, to make them more alert, and also it seems that these amphetamine type compounds also have some analgesic effect when they complement the pain relieving qualities of the opioids.
Narcotics can be taken on a continual basis for long periods of time. Tolerance usually develops to the sedative effect, to the nausea effect and sometimes even to the constipating effect, but fortunately there is very little tolerance developing to the pain relief effect unless the condition gets worse. So, if suddenly there is an increased need for the medicine, then you have to look and search for the following: has the disease gotten worse or has a new condition developed in the patient that causes pain? This should be checked out.
There are many different kinds of pain control medications and patients have to try on a basis of trial and error which works best for them. We usually start out with simple things like Tylenol or Aspirin and then we go to the non-steroidal, anti-inflammatory medicines, and, of course, CMT is not an inflammatory disease so usually the anti-inflammatories do not do much good. When they do relieve pain, they are doing it because of their analgesic effect, and, of course, the anti-inflammatory medications, which you call NSAIDs, do have side effects of stomach damage, kidney damage, etc. Large amounts of Tylenol, however, over the long period of time, have the potential for harming the liver but this can be monitored with liver function tests, particularly an enzyme called GGT. Also, for people taking large amounts of Vicodin or Tylenol with codeine, the doctor can do measurements of the Tylenol or the acetaminophen and the codeine or the hydrocodone which is in Vicodin. These can be measured in the blood to see if the patient is absorbing enough to give them some pain relief. We have some patients who take large amounts of Vicodin, not because they are abusers, but they are malabsorbers and therefore require larger amounts of this medication in order to achieve an analgesic effect.
So, one has to move up the line from Darvon to codeine, then to Vicodin which is an acetaminophen and hydrocodone and then to oxycodone which is the Percodans and the Percocets. Of course, when you get into the oxycodones and the Schedule II medicines which we call them here in the United States, or the so-called triplicate prescriptions in some states, then doctors are more reluctant to prescribe these things because there is a greater regulatory scrutiny involved with Schedule II medications. But they are very safe and very useful and should be used, and of course there's Dilaudid and morphine and methadone and the duralgesic patch for really severe pain.
In the past, it was felt that opioids were not useful in neuropathic or nerve type pain, the hot burning, stinging pains that can occur when there is nerve damage, and we have medications like the tricyclic antidepressants, such as Elavil which has a lot of side effects but can help relieve neuropathic pain. The anti-convulsant medications sometimes are also helpful in relieving neuropathic pain but they, of course, have a lot of side effects and some can also affect the bone marrow and have to be watched with blood tests and liver tests.
When these adjunctive medicines don't work, you have to give larger amounts of opioids and, in the past, when they said neuropathic pain did not respond to opioids, it was because most people were reluctant to use very large amounts. But in using large amounts - I'm talking maybe 15 to 20 pain pills a day - you can get some modicum of relief against the neuropathic pain. Now, when you start using large doses of medicines like Vicodin and Percocet which contain Tylenol, you might get in trouble with the liver, particularly if the person has a past history of liver damage from hepatitis and alcoholism. However, there is a medicine called Roxicodone which basically is a Percocet without the Tylenol. Therefore you are getting a pure opioid like oxycodone and then you don't have to worry about the Tylenol or the liver.
Then, of course, there is the Dilaudid and the morphine medicines. There is a long-acting morphine and there's methadone which is very cheap and long-acting. Some patients will take a long-acting medicine for chronic stable relief, and then, when they have an exacerbation of their muscle or nerve pain, they will take a short-acting medication like Dilaudid or the oxycodone because that only lasts three to four hours to help relieve the pain.
Q: Are some pain control drugs better than others? Are there certain drugs that are better than others for the excruciating zings and whacks that nerve pain throws at us? Some of us get nerve pain so violent we feel as though we have been stabbed or bitten. Others live with dull gnawing pain such as the constant sciatic pain I have under my right buttock and down the underside of my right leg. Some of us have nerves that twitch constantly. They can be felt twitching, and they not only hurt but the constant twitching means you can't really concentrate 100 per cent.
Some of us have some pretty bad side effects from the drugs we are given. Numbness and motor nerve paralysis can happen. As we are already predisposed to this we don't need more. Prednisone can flatten us. Can you comment on Toradol? What do some of these drugs do to the stomach and intestines? What about constipation?
Dr. Rose: As discussed, constipation is not a big problem. We tell our patients to play it by rear and have them use laxatives with stool softeners. The bulk additives like Metamucil are not too good because you need something to push the bowel out since the narcotics seem to paralyze and slow down the bowel action, so a softener or a bulk agent is not enough unless you have a pusher like Milk of Magnesia, Senokot, Doxidan and Ex-lax, those kinds of medications, to help push things along.
Toradol is an anti-inflammatory medication and its use has been restricted now in the United States because of problems with damage to kidneys and also with bleeding ulcers, but I do think one shot of Toradol occasionally, if people get relief from it, is probably worthwhile.
There is a group of medications which we call the narcotic agonist-antagonists which are not controlled substances, like Stadol, Dalgan and Nubain, which are helpful to some patients. Unfortunately, they come only as injectables - except for Stadol which comes in a nasal spray - and that makes it a problem. If you have to inject yourself too much, you could damage the tissue.
There is a new product on the market called Ultram, generic name Tramadol, which actually works on the same receptors where codeine and Vicodin work and also works in the area of the nerves where the tricyclic antidepressants like Elavil work, so this medicine has a dual action However, Ultram is not a controlled substance, therefore doctors should be less fearful in prescribing it. It's meant more for chronic stable pain. Since it has a relatively long onset of action, it is not very good for acute pain. I have some patients now that I've put on the Ultram, two tablets three or four times a day on a regular steady basis, and they've had much better control of their pain and they can still used the other medications like the Vicodin or the Percocet for an acute exacerbation and obtain relief that way.
Q: About addiction - How can we help our primary caregivers and especially our physicians understand that if we are given the correct type of pain control we will not become addicted? Where do we start?
Dr. Rose: As previously mentioned, you do not get addicted when you take narcotics or any controlled substance for pain relief because these medicines do not harm you, they give you relief. So addiction is not an issue. However, you may become dependent upon that drug and we have to warn our patients that when the pain gets better they should taper off the medicine gradually over a week or two and not stop it suddenly or they will go through withdrawal. Then they will say, "Ah, ha, I went through withdrawal, I must have been addicted." Withdrawal has nothing to do with addiction, that is physical dependency. You can get withdrawal from caffeine, you can get withdrawal from some blood pressure medicines, you can get withdrawal from the Valium-type medications.
So withdrawal, in and of itself, does not constitute addiction. This is a predictable physiological response of the body to suddenly stopping medication which has some effect on the nervous system, so tolerance, physical dependency and withdrawal do not constitute addiction. Of course, tolerance is when you require more medicine to achieve the same effect. In most chronic pain patients, after they reach a certain level, whether it's two pills a day or 20 pills a day, and they are functioning well, suddenly they start requiring larger amounts of medicine, this usually is not tolerance, it's usually because the disease has gotten worse or they have a new source of pain that has to be checked out.
Q: How do you feel about pain clinics?
Dr. Rose: My opinion on pain clinics, unfortunately, is very pessimistic. The pain clinics are geared to getting people off drugs and drug free. The program that was on 48 Hours featured a patient from Idaho with back pain, who went to the pain clinic and was told they were going to exercise his pain a way. In the program, they state that this clinic accepts only half of the patients who apply, and one wonders if those half are the ones that have the $20,000 for the three-week program. Then, they admit on that program to helping only half of those, so now we're down to 25 per cent who get relief. However, nobody ever asks the pain clinics, and very few of them do long-term follow-up studies to find out what happens to the 75 per cent that don't get into the pain clinic and don't get relief. People are very reluctant to study their failures; they only tend to trumpet their successes.
I think more attention should be paid to those people who fail the pain clinics, go back to their primary care doctors, ask for pain medicine, and the doctor says, no, I can't give it to you. What do these people do? In my experience with this, some of these people turn to alcohol, some turn to street drugs and some commit suicide, and I don't think suicide is a rational alternative to pain management. As a matter of fact, I have an old saying that, with a worst case scenario, if you truly get addicted, which rarely happens, you can get unaddicted, but you cannot get undead.
So the pain clinics can offer some help, but before I would send somebody to a $20,000 multi-disciplinary inpatient pain clinic for three weeks, I would see to it that they have a good trial of opioid maintenance using adjunctive medications like muscle relaxants, sedatives, decent diet, physical therapy and physical methods. This would be more cost effective. There are some pain clinics that are not as opiaphobic, but, unfortunately, the majority of them are. In America we now have a managed care environment taking over, and the pain clinics are very concerned about that. Because of the high costs, most managed care companies do not want to pay for people going to a pain clinic, particularly when the success rate of these pain clinics is less than 50 per cent.
Q: Address the works of Dr. Kevorkian, please. Do you agree that most people who use his services wouldn't if they were pain free? What about the quality of life, such as those of us who can eventually lose the ability to breathe on our own because our phrenic nerves become paralyzed? This can happen in CMT. Life on a ventilator doesn't appeal to some people. Life in bed, so weak we cannot feed ourselves or get to the bathroom without help, doesn't appeal to some of us either. Please talk a little about physician assisted euthanasia. Do you agree that it isn't always about pain?
Dr. Rose: Regarding Dr. Kevorkian: yes, I agree with you that many of the people who used his services would not turn to suicide as an alternative if they could have gotten adequate pain management. However, some of these patients were really not terminal and not that much in pain, but they were miserable, such as patients with Lou Gehrig's disease who waste away: they can't eat, they can't move, they can't talk, they can't swallow. With some of these patients, it's a quality of life issue, not really an issue of pain management, and when the quality of life becomes so low and there's no question about death coming soon, the only question is about when and how. I personally feel that physician assisted suicide is a more rational alternative than people suffering to their last gasp and their last gurgle. It's very interesting to know about Dr. Kevorkian, that with all the people he has helped to move on to the next plane of existence, not once has it ever been reported that a family member or friend had second thoughts or ever said a bad word about him. I think that shows that he selects his patients very carefully and not willy-nilly, the way he has been accused of doing. But, again, for many patients, if they could have gotten adequate pain management without having to go around begging and grovelling and being made to feel like some street person, they would not have requested the services of Dr. Kevorkian.
So, as you mentioned at the end of this question, it isn't always about pain, it's about compassion, about quality of life, about not wanting to be totally dependent upon others, and there comes a time when our dignity and our self-worth is so eroded by pain and suffering and disability and inability to care for ourselves and feed ourselves, that we should have the choice of asking for help to leave such existence. I don't think people fear death but I do think they fear dying and suffering, and one of the tenets of the principles of the AMA is that a patient shall be treated with compassion and respect for human dignity, and I think under that basis, should they request to be put out of their misery, physicians should have the ability within controlled circumstances to answer that call and relieve their misery.
On a personal note, I would like to be awake at my wake. I'd like to be present at my memorial service so that when people say things about me and make comments about my life and what I've done, I'd like to be around to correct any misunderstandings or half truths that might be said about me. Once that memorial is over, I can hug and kiss my loved ones and friends and say goodbye, and then my doctor can give me that blessed relief that we now only reserve for animals who are dying and suffering, and let me go on to my next plane of existence. I might say that I believe in reincarnation, so I believe I'll be back anyhow, and I don't want to have to drag out my death. Many things that doctors do now don't really prolong living but just delay death, and I think it's really a crime the way we handle death and dying in this country.
There was a survey made of doctors and nurses. The statement was made that the most common abuse of narcotics is their under-use in the treatment of pain in the terminally ill. Certainly, in the terminally ill, addiction is not an issue, so why is it that these medicines are underutilized. Basically it is not the scarlet letter of addiction, it is the scarlet letter of arrest that makes doctors reluctant to use large amounts of opioids, whether it's for the terminally ill or from chronic pain either of malignant or non-malignant origin.
Q: Can pain relief suppress the ability to breathe, and would some pain medications make it more difficult for us to keep breathing? Are there some that won't?
Dr. Rose: It is always the bugaboo that if you take too much narcotic it will suppress your respiration. However, pain itself is a stimulant to respiration, and so unless you are way, way overdosed, narcotics will not cause a problem with suppression of respiration. As a matter of fact, we have another saying, that respiratory arrest can be reversed, but arrest by regulatory agencies is very difficult and costly to reverse. So, it's not the fear of respiratory arrest th impedes the delivering of adequate narcotic medications to people in pain, it is the fear of regulatory arrest.
Q: What can people who have CMT do to help the cause for everyone with chronic pain?
Dr. Rose: Again, patients with CMT, or any painful condition, unfortunately have to go to their legislators. If you're lucky enough to find a representative in your state or province who has had a painful experience, personally, or one of his loved ones has suffered and had difficulty in obtaining sufficient pain relief, then they can be an advocate for you and put through an Intractable Pain Treatment Act like we have in California. Then have the medical board back up that law 100 per cent and make it clear to doctors that they will not count numbers and pills when they go after somebody, as long as they did a decent examination, got at least one consultation with a specialist, in the field in which the patient has their pain, to confirm the diagnosis that the pain is intractable and nothing has been missed. Then it's up to the primary care doctor to use whatever medications or method to keep that patient comfortable and give them a quality of life and some comfort.
In the court case that I quoted in my Anatomy of a Pain Summit article, the judge in his dissenting opinion recognized there was a difference of opinion in the medical community with regards to how much is too much, and then he very nicely said that each case will depend upon the individual physician's assessment of that patient's level of comfort and ability to function. The latest buzz word in the medical literature is "outcomes," not how much the patient takes, not what is their quantity of medication, but rather what is their quality of life achieved with the medication.
A state senator in Oregon who sponsored the Intractable Pain Treatment Act, told about his wife who, five years ago, was diagnosed as having terminal cancer. He could not get adequate pain medicine for her because the doctor said we don't want to give her too much, she might get addicted. Standing before the senate, he just shook his head and said, "I don't understand what addiction has to do with somebody who has terminal cancer pain." Fortunately, his wife is in remission now but he did help put through the Intractable Pain Treatment Act in the state of Oregon.
Q: What do you see in the future regarding the use of narcotics for pain control?
Dr. Rose: Regarding the future use of narcotics for pain control, we're trying to get a national Intractable Pain Treatment Act here in the United States. We have the support of the California Medical Association and the Academy of Family Physicians. It will go before the American Medical Association in December of this year. If we cannot get a National Intractable Pain Treatment Act, we're going to ask the American Medical Association to encourage its component state organizations to enact state intractable pain treatment acts like we have in California, Oregon and Nevada to help protect doctors from the overzealous regulatory agencies. Once we achieve that, as we did in California almost four years ago, then there is still the job of re-educating what I say are all the Ps involved…all the politicians, the physicians, the patients, the pharmacists…that narcotics, when used for chronic pain, are safe and effective, that addiction rarely happens unless there has been a history of substance abuse in the past - and even those patients are entitled to a trial of opioids to see if you can improve their quality of life and their ability to function - but if they show signs of abusive behavior…selling the medicine and unsanctioned overdosing, etc., and using it not for pain relief but for blowing their minds…then greater controls will have to be placed upon them or they may not be candidates for this treatment.
Then the next step is education, and it's very hard to unteach people, so Senator Greene in California and Senator Duke in Oregon are trying to put through bills to improve the levels of education in the medical, nursing and pharmacy schools so that people can learn how to use narcotics appropriately; teach them that they are not addictive and that they are some of the safest medications we can use. It is going to take years to train a whole new generation of doctors, nurses and pharmacists, but we have to start some time. Then we have to educate current practising doctors, nurses and pharmacists with regard to this and to the safety and efficacy of pain management to remove their fears and also re-educate them so they are not opiaphobic.
There is a new term in the literature called pseudoaddiction: patients who crave the medications but don't seem to get enough; usually this is a matter of under-treatment. There are some people who may resort to going to three or four different doctors. These patients may require 12 pills a day, but each doctor only gives them three or four pills a day, therefore they have to go to multiple doctors to get enough medication to relieve their pain. These patients are sometimes called doctor shoppers or doctor hoppers but they wouldn't have to shop or hop if one doctor gave them enough pain medicine to relieve their pain.
Q: What do you know and feel about the use of marijuana for pain control and quality of life? Personally, I'm pro and would like to see it legalized as a controlled substance no more or less harmful than alcohol.
Dr. Rose: I totally agree with you. Marijuana can be used successfully. We have a law in California now but are afraid the governor might veto it. It states that marijuana can be used for glaucoma, nausea of cancer and pain control. I think marijuana used in a controlled manner can be a very helpful medicine. We have a drug called Marinol right now which is tetra-hydrocannabinol, the active ingredient in marijuana, which you can buy by prescription but costs something like $750 a bottle of 100, so it is much cheaper to buy a marijuana joint on the street although it may not be as safe. So I think the whole issue on the war on drugs is that I don't think we should legalize drugs. I think we should medicalize substances like heroin, cocaine and marijuana, although marijuana probably could be treated like alcohol and tobacco. Doctors could prescribe cocaine and heroin through prescription, the way they do now in England, giving it in controlled doses, and when the person gets a nice, steady controlled dose of heroin or cocaine for their pain, they can live perfectly normal lives without getting into trouble with their bodies or the law.
There have been instances of people taking large amounts of cocaine for long periods of time who have not shown any adverse effects. Of course, when you buy drugs on the street, you don't know what dose you are getting, you don't know what the impurities are, and so addicts get diseases like hepatitis, phlebitis, etc. So what I advocate is marijuana being handled like alcohol or tobacco, with legal restrictions on it. But when it comes to heroin or cocaine, I think these patients should first try to get off these drugs in treatment-on-demand programs. When treatment fails them, I think they should be treated like the people we have on methadone programs. These people are on clean, safe, pure, cheap proper dosages of the substance so they can live normal lives and not spend all their time and energy trying to get this stuff on the street.
If you follow the money, you'll find the only people making money on the drug wars are the drug agents, the enforcing agencies and the drug lords. Everybody in the middle is losing. The public is spending more money on prisons and crime and chasing these people around when it would be much easier to furnish it to them cheaply, safely and cleanly, and take out the economic incentive for these drugs that would put the drug dealers out of business.
Q: Anything else you'd like to say about pain control and CMT?
Dr. Rose: Intractable pain is defined as an untreatable condition for which there is no known cause, although with CMT there is a cause because it is a hereditary disease. It is a chronic, painful condition, that is true, because it hurts the nerves, the nerves are involved, and for which there is no cure, or none has been found after reasonable efforts and certainly there is no cure for CMT, so CMT fits the federal definition and those of some states for intractable pain. Therefore, with our Intractable Pain Treatment Act laws, doctors can use controlled substances to alleviate the pain and suffering of these patients (with CMT) without fear of getting into trouble with regulatory and licensing agencies.
Q: Would you serve as an advocate on pain control for all of us with CMT?
Dr. Rose: Yes, I'd be happy to help you out. The 1994 Governor's Pain Summit in California said we must create by statute a positive legal duty for physicians to relieve pain and suffering. In other words, we should change the burden on physicians where in the past over-prescribing has been the fear that made doctors uncomfortable; therefore the doctor's discomfort received more attention than the patient's discomfort. We should make it clear that under-prescribing should be just as much of a regulatory onus than over-prescribing has been in the past. In this day and age no patient should ever be told again to just learn to live with the pain.