By Dr. Forest Tennant
Using Objective Signs of Severe Pain to Guide Opioid Prescribing
A Commonsense Diagnostic Approach
It is often said that pain treatment must be guided only by subjective perceptions of the patient
and that pain itself cannot be objectively assessed. This belief is only partially correct.
It is clearly humane to ask patients about their pain perceptions and to grade their pain on the
standard 1-to-10 scale. However, the practitioner who must separate relief-seekers from drug-seekers
when prescribing potent opioid analgesics needs to use objective measures to accomplish this critical task.
The diagnostic approach proposed here entails commonsense medical practice. The fact is that severe,
uncontrolled pain usually produces more objective physical evidence of its presence than does
the average case of diabetes or coronary artery disease.
Pain is a potent stressor that activates the entire sympathetic nervous system and the
hypothalamus-pituitary-adrenal axis to produce high serum levels of catecholamines and glucocorticoids.1-6
Since this is a physiologic reaction, some simple objective measures of adrenal and sympathetic responses,
including pulse rate, blood pressure, and pupil size are easy to assess.
The practitioner also should perform an examination to evaluate if the pain is uncontrolled, as well as to
determine if severe pain has been present for an extended period of time. For example, severe,
chronic pain may cause an afflicted person to find physical positioning relief and avoid sensory
inputs that may worsen the pain. And, some sufferers will attempt to distract their attention from the area
that hurts to another site by physical maneuvers.
The physical signs described here are categorized as relating to sympathetic discharge, positional relief,
sensory avoidance, and pain distraction. For convenience, each of these categories is in table form
on the following pages to readily assist healthcare providers.
Uncontrolled, severe pain can almost always be
identified by objective physical signs that help
practitioners differentiate between drug-seekers and
relief-seekers, as well as to determine if opioid
dose is adequate.

Signs of Sympathetic Discharge
Sympathetic, or adrenergic, discharge is caused by two concomitant mechanisms. Adrenergic
receptors in the central nervous system are activated by uncontrolled pain, and these
central receptors in turn activate the autonomic nervous system by sending electrical impulses
downward into the periphery via the vagus nerve and the autonomic nerve network.7-9 The
second mechanism is activation of the hypothalamic-pituitary-adrenal axis and the out-pouring
of catecholamines (adrenaline, dopamine, and noradrenaline) and glucocorticoids (pregnenolone,
cortisol) into the blood stream.5-7 Findings of excess sympathetic discharge can be detected in
both acute and chronic uncontrolled pain. (Tables 1 & 2.)
The author has frequently heard the comment that sympathetic discharge signs are only present
with acute pain, but these signs occur with any uncontrolled pain. Signs of sympathetic discharge
even can be detected in non-verbal or comatose patients, such as infants or bedbound
elderly. While not all of the sympathetic discharge signs are present in every patient,
elevated pulse rate, hypertension, dilated pupils, vasoconstriction, and diaphoresis are almost
always seen in patients whose pain has elevated above a critical threshold that is
biologically specific to that person. Sympathetic discharge signs can be quickly and easily assessed
in clinical practice. Medical or nursing assistants, and even the patient, can take a blood pressure
and pulse rate that can be verified by the practitioner. A simple stroking of hands or feet can detect
vasoconstriction (cold to the touch), and a light touch of skin under the eyes is a good place to feel the
moisture of excess sweating. Examining pupils will require that fluorescent lights are turned off – normal
pupil diameter is approximately 3.0 mm to 5.0 mm.
The author recommends that patients with severe, chronic pain should have a target pulse rate less
than 88 beats per minute and blood pressure below 130/90 mm Hg. (Table 2.)

At-Home Blood & Pulse Monitoring
Chronic pain has a baseline or persistent component, as do breakthrough pain or pain
flares. For this reason, patients should be taught to take their BP and pulse at home when
breakthrough pain or flares occur. This can be done using modern BP/pulse monitoring devices
that can be obtained inexpensively at most pharmacies or large retail outlets.

TABLE 1
Sympathetic Discharge Signs
􀂄 Tachycardia
􀂄 High Blood Pressure
􀂄 Dilated Pupils
􀂄 Vasoconstriction (Cold Hands or Feet)
􀂄 Diaphoresis
􀂄 Hyperreflexia
􀂄 Insomnia
􀂄 Nausea
􀂄 Diarrhea
􀂄 Anorexia

Table 2
Recommended Objective Measures to Help Determine
Uncontrolled Pain & Opioid Overmedication
UNCONTROLLED PAIN GOOD PAIN CONTROL EXCESS OPIOIDS
Pulse rate Pulse between Pulse Rate
> 88 beats per minute 64 to 88 beats per minute 130/90 mm Hg 110/70 and 130/90 mm Hg 5.0 mm 3.0 and 5.0 mm < 3.0 mm
Cold hands or feet Normal temperature Very warm hands or feet

Patients should keep an ongoing record and bring this to their practitioner for review.
This way, healthcare providers can determine if their medical regimen is effectively
controlling pain when the patient is outside the clinical setting. Additionally, patients
and their families need to know that severe, chronic pain raises blood pressure and/or pulse rate,
and that these elevations may lead to cardiovascular complications such as coronary artery disease
and cerebral vascular accidents (strokes).
Once patients and families observe that blood pressure and pulse rate go up with pain intensity,
it is easy for the practitioner to instruct them that a rise in adrenaline and cortisol is occurring, and that
these effects may produce elevated blood lipids and glucose that may hasten the development of
arteriosclerosis and/or diabetes. Essentially, chronic pain of enough severity will cause sympathetic
discharge and this physiologic phenomenon is a profound cardiovascular risk.10-13

Signs of Positional Relief
Patients who “hurt” during certain movements or physical functions will naturally attempt to avoid the pain
by finding a comfortable position. They may do this over a period of months to years and leave telltale physical
signs that are easily observable, but might be overlooked if the practitioner is not alert to them. (Table 3.)
In its simplest form positional relief is present in the patient who walks with a limp, drags a foot, or walks offbalance.
Other signs can be observed in the patient who leans in one direction to relieve back pain, or in the
headache patient who frowns on one side. In these cases a permanent crease on one side of the back or
forehead can be detected. If the patient seeks positional relief long enough, some muscle groups hypertrophy to
compensate for the extra load while others may atrophy due to minimal use. Patients who walk
abnormally to seek pain relief may have one shoe sole that wears down in one spot compared
with the opposite shoe.

The basic physiologic problem with long-term attempts to use positional relief is that some
body parts become asymmetrical. Rather than a balance of two equal sides, one side becomes
overused with subsequent muscle hypertrophy and possibly degeneration of joints. For example,
a patient with a painful right knee may typically over-weight and over-use the left hip and
knee, which may lead to degenerative arthritis and pain in the left hip and
knee that is secondary to the original pain.
The side of the body that was originally in pain – and thus favored and
underused – will undergo muscle atrophy and possibly contractures. For example,
a patient with a severe, painful neuropathy in one extremity may develop
permanent atrophy and contractures to the point that the extremity is
functionless. The atrophic side will often become cool to the touch as circulation also apparently decreases in the area.
Fundamentally, the practitioner should look for physical, objective signs of asymmetry when
evaluating a chronic pain patient. Unless severe pain is controlled, physical signs of asymmetry
in affected areas of the body will invariably emerge over time.

TABLE 3
Common Positional Relief Signs
􀂄 Walks imbalanced, wide gait, foot drag or limp
(shoes don’t wear evenly)
􀂄 Leans while sitting or standing
􀂄 Lies on floor
􀂄 Sits on edge of chair
􀂄 Looks straight ahead (won’t turn head)
􀂄 One shoulder raised or lowered
􀂄 Forehead crease on one side
􀂄 Muscle hypertrophy or atrophy of back muscles
􀂄 Difference in temperature between sides
NOTE: These are all signs of body asymmetry.

Chronic pain of enough severity will cause sympathetic
discharge and this physiologic phenomenonis a profound cardiovascular risk.
Unless severe pain is controlled, physical signs of
asymmetry in affected areas of the body will invariably emerge.

Signs of Sensory Avoidance
Closely related to positional relief is sensory avoidance.
The obvious example of sensory avoidance involves a painful area that gets even more painful with
touch. Uncontrolled pain hyper-stimulates the autonomic nervous system, so practically any sensory
input may cause additional pain. (Table 4.)
The classic case is the migraine patient who turns out the lights, lays alone in a room, and covers their
head and eyes. This patient may hurt worse with any sensory input, including light, noise, smell, eating, or
movement.

Some extremely painful conditions such as reflex sympathetic dystrophy (also called chronic regional pain
syndrome), adhesive arachnoiditis, and diabetic peripheral neuropathy produce such pain that even light touch
is unbearable (allodynia). In these cases, patients may not wear clothes or allow a sheet to cover themselves.
They may not wear shoes or socks. Patients with neuropathies of the face, head, and neck may not brush their
teeth, shave, or comb their hair. Any attempt by the examiner to touch the affected area will be met with
immediate withdrawal of the body part and a sudden “no” response from the patient.
Patients with painful conditions of the upper torso, including fibromyalgia, abdominal adhesions,
or cervical spine conditions may speak slowly, softly, and with hesitancy – for fear that a
forceful voice and the effort of speaking might produce more pain. Often patients in severe pain
will sit on the edge of their chair and stare straight ahead, because leaning back or turning their
head is painful. Patients with spinal or abdominal diseases may breath so slow and shallow
that their carbon dioxide (CO2) levels increase.2

Signs of Pain Distraction
Patients in severe pain may not only attempt to avoid sensory input and find positional relief, they also may
attempt maneuvers or techniques to distract their attention away from their pain. These can sometimes be
physically observed by the practitioner. (Table 5.)
Grinding of the teeth can sometimes be detected by whittled-down teeth. Lip biting and fist clenching are
common. Less commonly observed is overheating of a painful area with a hot water bottle or heating pad.
Sometimes permanently mottled skin or actual burns can be observed. Rarely, some patients
become so tortured with pain that they will bang their head, fist, or foot against a wall, and the
trauma of this activity may be evident. Cigarette burns or cuts may be intentionally self-inflicted.

TABLE 4
Common Sensory Avoidance Signs
􀂄 Speaks slowly, softly, hesitantly
􀂄 Wears sunglasses / stays in dark
􀂄 Delays answering questions
􀂄 Wears hat (to shield scalp, hair)
􀂄 Walks slowly, deliberately and with wide gait,
limp, or foot drag
􀂄 Stares or looks straight ahead
􀂄 Avoids noise
􀂄 Shallow breathing
􀂄 Doesn’t eat or drink
􀂄 Wears loose or no clothes over painful areas
􀂄 Won’t brush teeth, shave, or comb hair

TABLE 5
Common Pain Distraction Signs
􀂄 Grinds/grits teeth
􀂄 Clenches knuckles/toes
􀂄 Overheats skin (may show permanent burn marks)
􀂄 Hits head, fist, or foot against wall
􀂄 Cigarette burns or cuts
􀂄 Bites lips
􀂄 Gouges or squeezes skin

Importance of Physical Signs in Guiding Opioid Dosing
In most medical practices today, in addition to legitimate pain-relief-seekers, who are the
majority, there can be opioid-drug-seekers with less genuine intentions. During the initial
evaluation of all new patients they should be physically examined for the objective, physical
signs of legitimate pain that are described above.
If none are found, nonopioid treatments should be satisfactory for pain treatment. If a practitioner
encounters a questionable patient, the patient’s close family members can usually verify
behavioral signs compatible with positional relief, sensory avoidance, or pain distraction attempts.
Experienced drug-seekers may be able to fake certain signs of severe pain during an
office visit, but would not consistently exhibit such behaviors with family members.
Patients who are receiving ongoing, outpatient opioid treatment will periodically require an
adjustment in opioid dosage. Increases in dosages usually should be prescribed if the patient’s
complaints of uncontrolled pain are confirmed by evidence of excess sympathetic discharge
such as tachycardia, hypertension, cold hands/feet, or dilated pupils.
For example, a patient who states his/her pain is an 8 out of 10, and demonstrates a pulse
rate of 100 and pupil dilation greater than 5.0 mm, warrants a higher opioid dosage or an additional
opioid. Conversely, if the same patient demonstrates a normal blood pressure, pulse
rate, and pupil size, an adjustment in opioid dosage might be postponed for later evaluation. In
this case, daily at-home tracking of pulse and blood pressure by the patient and an interview
with the family could be in order.
Summary
The objective, physical signs of excess sympathetic discharge, sensory
avoidance, positional relief, and pain distraction should be sought by physical
examination in every pain patient. In this way, complaints of severe pain by a
patient can be confirmed by objective physical signs. While it is imperative
that patients (and possibly family members) should be interviewed as to their
perception of pain’s severity, pain that is above a critical threshold for each
individual produces objective, physical signs that can be even more evident
than the usual physical signs of such common disorders as diabetes and
coronary artery disease.
.
A search for objective, physical signs of excess sympathetic discharge, sensory avoidance,
Positional relief, and pain distraction should be part of the physical examination
of every pain patient.

References
1. Heller PH, Perry F, Naifeh K, Gordon NC, Wachter-Shikura N, Levine J. Cardiovascular autonomic response during preoperative
stress and postoperative pain. Pain. 1984;18:33-40.
2. Glynn CJ and Lloyd JW. Biochemical changes associated with intractable pain. Br Med J. 1978;1: 280-281.
3. Lewis KS, Whipple JK, Michall KA. Effect of analgesic treatment on the physiologic consequences of acute pain. Am J Hosp
Pharm. 1994:1539-1554.
4. Chapman RC, Gavin J. Suffering the contributions of persistent pain. Lancet. 1999;353:2233-2237
5. Shenkin HA. Effect of pain on diurnal pattern of plasma corticoid levels. Neurology. 1964;14:1112-1117.
6. Moltner A, Holzi R, Strian F. Heart rate changes as an autonomic component of the pain response. Pain. 1990;43:81-89.
7. Tennant FS. Identification and management of cardiac-adrenal pain syndrome. Pract Pain Manag. 2006(Sept);6(6):12-21.
8. Nykilicek I, Vingerhoets AJ, Van Heck GL. Hypertension and pain sensitivity: effects of gender and cardiovascular reactivity.
Biol Psychol. 1999;50:127-142.
9. Laflamme YT, Rainville P, Marchard S. Establishing a link between heart rate and pain in healthy subjects: a gender effect. J
of Pain. 2005;6:341-347.
10. Kurth T, Gaziano JM, Cook NR, et al. Migraine and risk of cardiovascular disease in men. Arch Intern Med. 2007;167: 795-
801.
11.Asanuma Y, Oeser A, Shintani A, et al. Premature coronary-artery atherosclerosis in systemic lupus erythematosus. New
Engl J Med. 2003;349:2407-2415.
12. Ozgurtas T, Alaca R, Gulec M, Kutluay T. Do spinal cord injuries adversely affect serum lipoprotein profiles? Military Med.
2003;168:545-547.
13. Cook NR, Bansenor IM, Lotufa PA, et al. Migraine and coronary heart disease in women and men. Headache. 2002;42: 715-
727.
About the author:
Forest Tennant, MD, DrPH attended the University of Kansas Medical School and served in the United States
Public Health Service, assigned to the UCLA School of Public Health as an academic research fellow. In 1975
he started the Veract Intractable Pain Clinic in West Covina, CA, initially focusing on cancer and postpolio patients.
Dr. Tennant has published more than 200 scientific articles and pioneered research on the complications
and treatment of intractable pain. He helped sponsor the California Intractable Pain Act and the Pain Patients
Bill of Rights. He is Editor in Chief Emeritus of the journal Practical Pain Management. Dr. Tennant has
no conflicting interests to declare relating to the subject of this paper

From the California Medical Board Publication, Guidelines for Prescribing Controlled Substances for Pain

Aniwaya  Advocacy was recently made aware of  the state of pain management freedom in California. Though the laws and codes in California are very ammenable to responsible and effective prescribing, we have found out that some of the California “enforcement  officers” are not aware of their States’ own laws that PROTECT the right of the chronic pain /intractable pain patients to be medically TREATED however they and their doctors see fit. The state’s own laws also protect doctors from undue harassment and “discipline.”

In case you ever find yourself being questioned about the legality of your medical treatment, I want you to be informed. Though these statutes come from CALIFORNIA law, you probably have very similar codes in your State’s Business regulations. I’ll list the quotes  below: 

Defense for pain care quotes:

 This wording added in law AB 2198 which was chartered into law on September 20^th, 2006.

 

 

SEC. 5. Section 2241.5 is added to the Business and Professions Code,

to read:

2241.5. (a) A physician and surgeon may prescribe for, or dispense or

administer to, a person under his or her treatment for a medical condition

dangerous drugs or prescription controlled substances for the treatment of

pain or a condition causing pain, including, but not limited to, intractable

pain. (emphasis added)

 

(b) No physician and surgeon shall be subject to disciplinary action for

prescribing, dispensing, or administering dangerous drugs or prescription

controlled substances in accordance with this section.

 

·         Compliance with Controlled Substances Laws and Regulations

To prescribe controlled substances, the physician and surgeon must be appropriately licensed in California, have a valid controlled substances registration and comply with federal and state regulations for issuing controlled substances prescriptions. Physicians and surgeons are referred to the Physicians Manual of the U.S. Drug Enforcement Administration and the Medical Board’s Guidebook to Laws Governing the Practice of Medicine by Physicians and Surgeons for specific rules governing issuance of controlled substances prescriptions.

·         Annotation One: There is not a minimum or maximum number of medications which can be prescribed to the patient under either federal or California law.

Adopted Unanimously by the Board in 1994 and Recently Revised

“No physician and surgeon shall be subject to disciplinary action by the Board for prescribing or administering controlled substances in the course of treatment of a person for intractable pain.”

Business and Professions Code section 2241.5(c

n  Web site is www.medbd.ca.gov  

 

 

 

**no other disease has to continually fight for their right to be medically TREATED** 

**why are we suffering for drug abusers bad choices?**

California Pain Patients Bill of Rights

California Senate Bill 402

This bill establishes the Pain Patient’s Bill of Rights and states the legislative findings and declarations regarding the value of opiate drugs to persons suffering from severe chronic intractable pain.  It, among other things, authorizes a physician to refuse to prescribe opiate medication for a patient who requests the treatment for severe chronic intractable pain, the physician to inform the patient that there are physicians who specialize in the treatment of severe chronic intractable pain with methods that include the use of opiates, and authorizes a physician who prescribes opiates to prescribe a dosage deemed medically necessary. The people of the State of California do enact as follows: SECTION 1. Part 4.5 (commencing with Section 124960) is added to Division 106 of the Health and Safety Code, to read: PART 4.5. PAIN PATIENT’S BILL OF RIGHTS 124960. The Legislature finds and declares all of the following: (a) The state has a right and duty to control the illegal use of opiate drugs (b) Inadequate treatment of acute and chronic pain originating from cancer or non-cancerous conditions is a significant health problem. (c) For some patients, pain management is the single most important treatment a physician can provide. (d) A patient suffering from severe  chronic intractable pain should have access to proper treatment of his or her pain. (e) Due to the complexity of their problems, many patients suffering from severe chronic intractable pain may require referral to a physician with expertise in the treatment of severe chronic intractable pain. In some cases, severe chronic intractable pain is best treated by a team of clinicians in order to address the associated physical, psychological, social, and vocational issues. (f) In the hands of knowledgeable, ethical, and experienced pain management practitioners, opiates administered for severe acute and severe chronic intractable pain can be safe. (g) Opiates can be an accepted treatment for patients in severe chronic intractable pain who have not obtained relief from any other means of treatment. (h) A patient suffering from severe  chronic intractable pain has the option to request or reject the use of any or all modalities to relieve his or her severe chronic intractable pain. (i) A physician treating a patient who suffers from severe chronic intractable pain may prescribe a dosage deemed medically necessary to relieve severe chronic intractable pain as long as the prescribing is in conformance with the provisions of the California Intractable Pain Treatment Act, Section 2241.5 of the Business and Professions Code. (j.)   A patient who suffers from severe chronic intractable pain has the option to choose opiate medication for the treatment of the severe chronic intractable pain as long as the prescribing is in conformance with the provisions of the California Intractable Pain Treatment Act, Section 2241.5 of the Business and Professions Code. (k) The patient’s physician may refuse to prescribe opiate medication for a patient who requests the treatment for severe chronic intractable pain. However, that physician shall inform the patient that there are physicians who specialize in the treatment of severe chronic intractable pain with methods that include the use of opiates. 124961. Nothing in this section shall be construed to alter any of the provisions set forth in the California Intractable Pain Treatment Act, Section 2241.5 of the Business and Professions Code. This section shall be known as the Pain Patient’s Bill of Rights. (a) A patient suffering from severe chronic intractable pain has the option to request or reject the use of any or all modalities in order to relieve his or her severe chronic intractable pain. (b) A patient who suffers from severe chronic intractable pain has the option to choose opiate medications to relieve severe chronic intractable pain without first having to submit to an invasive medical procedure, which is defined as surgery, destruction of a nerve or other body tissue by manipulation, or the implantation of a drug delivery system or device, as long as the prescribing physician acts in conformance with the provisions of the California Intractable Pain Treatment Act, Section 2241.5 of the Business and Professions Code. (c) The patient’s physician may refuse to prescribe opiate medication for the patient who requests a treatment for severe chronic intractable pain. However, that physician shall inform the patient that there are physicians who specialize in the treatment of severe chronic intractable pain with methods that include the use of opiates. (d) A physician who uses opiate therapy to relieve severe chronic intractable pain may prescribe a dosage deemed medically necessary to relieve severe chronic intractable pain, as long as that prescribing is in conformance with the California Intractable Pain Treatment Act, Section 2241.5 of the Business and Professions Code. (e) A patient may voluntarily request that his or her physician provide an identifying notice of the prescription for purposes of emergency treatment or law enforcement identification. (f) Nothing in this section shall do either of the following: (1) Limit any reporting or disciplinary provisions applicable to licensed physicians and surgeons who violate prescribing practices or other provisions set forth in the Medical Practice Act, Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code, or the regulations adopted thereunder. (2) Limit the applicability of any federal statute or federal regulation or any of the other statutes or regulations of this state that regulate dangerous drugs or controlled substances.

California Pharmacy Board
Source: Health Notes. Vol. 1, No. 1; pp. 4-5 1996.

DISPENSING CONTROLLED SUBSTANCES FOR PAIN

A Statement of the California State Board of Pharmacy

The Board understands that the ongoing use of opioids for cancer, post-surgical, and chronic pain is not what causes addiction or a patient’s desire for higher doses of pain medication. Patients suffering from extreme pain or progression of disease may require increased doses of medication; the appropriate dose is that which is required to adequately treat the pain, even if the dose is higher than usually expected. In addition, with long-term treatment of pain with opioids, patients may develop a tolerance to the drug or a dependence on the drug. These occurrences are considered “normal” and “to be expected” – they should not be confused by the licensed healthcare professional with drug addiction or be mislabeled as “drug seeking.”

The Board understands that an important part of effective pain management is ensuring that patients do not have difficulty obtaining adequate medication for pain relief. The Board recognizes that is it the professional responsibility of the pharmacist to recommend that patients in pain received appropriate, timely, and adequate drug therapy to reduce their pain.

BUSINESS AND PROFESSIONS CODE
SECTION 2220-2319

 

 

 

2220.  Except as otherwise provided by law, the Division of Medical

Quality may take action against all persons guilty of violating this

chapter.  The division shall enforce and administer this article as

to physician and surgeon certificate holders, and the division shall

have all the powers granted in this chapter for these purposes

including, but not limited to:

   (a) Investigating complaints from the public, from other

licensees, from health care facilities, or from a division of the

board that a physician and surgeon may be guilty of unprofessional

conduct.  The board shall investigate the circumstances underlying

any report received pursuant to Section 805 within 30 days to

determine if an interim suspension order or temporary restraining

order should be issued.  The board shall otherwise provide timely

disposition of the reports received pursuant to Section 805.

   (b) Investigating the circumstances of practice of any physician

and surgeon where there have been any judgments, settlements, or

arbitration awards requiring the physician and surgeon or his or her

professional liability insurer to pay an amount in damages in excess

of a cumulative total of thirty thousand dollars ($30,000) with

respect to any claim that injury or damage was proximately caused by

the physician’s and surgeon’s error, negligence, or omission.

   (c) Investigating the nature and causes of injuries from cases

which shall be reported of a high number of judgments, settlements,

or arbitration awards against a physician and surgeon.

 

 

 

2220.05.  (a) In order to ensure that its resources are maximized

for the protection of the public, the Medical Board of California

shall prioritize its investigative and prosecutorial resources to

ensure that physicians and surgeons representing the greatest threat

of harm are identified and disciplined expeditiously.  Cases

involving any of the following allegations shall be handled on a

priority basis, as follows, with the highest priority being given to

cases in the first paragraph:

   (1) Gross negligence, incompetence, or repeated negligent acts

that involve death or serious bodily injury to one or more patients,

such that the physician and surgeon represents a danger to the

public.

   (2) Drug or alcohol abuse by a physician and surgeon involving

death or serious bodily injury to a patient.

   (3) Repeated acts of clearly excessive prescribing, furnishing, or

administering of controlled substances, or repeated acts of

prescribing, dispensing, or furnishing of controlled substances

without a good faith prior examination of the patient and medical

reason  therefore.  However, in no event shall a physician and surgeon

prescribing, furnishing, or administering controlled substances for

intractable pain consistent with lawful prescribing, including, but

not limited to, Sections 725, 2241.5, and 2241.6 of this code and

Sections 11159.2 and 124961 of the Health and Safety Code, be

prosecuted for excessive prescribing and prompt review of the

applicability of these provisions shall be made in any complaint that

may implicate these provisions.

 

                                                                                                                                                                                                                                                                                                                  

---

The Problem

ACTIQ® and Fentora® are commercially formulated fentanyl products that dissolve under the tongue or in the inner side of the jaw (“buccal administration”). These products are simply the very best pain relief for many pain patients.

Fentanyl is often more effective than morphine or other related opioids. Unfortunately, fentanyl must be administered by injection, under the tongue, in the mouth, or by skin patch (Duragesic®). It is essentially ineffective if swallowed.

The problem has become one of cost. Many patients started on ACTIQ® several years ago when it cost was no more than $3 to $5 a dosage. This cost has progressively escalated in the past several years to the point that a single dosage may cost over $50. Many patients who started on ACTIQ® when it was relatively inexpensive can no longer obtain it because their insurance plan will simply say “No”. I have observed numerous patients who took several dosages a day and led normal, productive lives who now have returned to an impaired, painful state. Be clearly advised, that for many patients there is no opioid pain reliever that will substitute and give the same relief as fentanyl.

Here are my recommended solutions for pain patients who can’t get ACTIQ® or Fentora®, but still need fentanyl.

Solution No. 1

If you are a patient who can no longer obtain ACTIQ® or Fentora®, your doctor can submit a special request or “prior authorization” to your insurance company. Insurance companies routinely turn patients down using the excuse that ACTIQ® and Fentora® are only indicated for cancer pain, but it’s really a cost issue. When ACTIQ® was inexpensive this wasn’t a problem because a physician can prescribe any prescription drug for any clinical purpose that he deems to be indicated.

Solution No. 2

A “compounding” pharmacy can make an under-the-tongue fentanyl product often called “troche”. Likely, your physician will know of a compounding pharmacy near you. Lately, I’ve observed that many compounding pharmacies only reduce their prices or costs slightly less than ACTIQ® or Fentora®, because they know that fentanyl is the very best pain reliever for many patients, and so they want to gouge the patient.

Solution No. 3

Some patients who can no longer get ACTIQ® or Fentora® are able to do the following with good results.

1. Use a fentanyl patch (Duragesic®)
2. Supplement the patch with Ethoxydose® which is a liquid that is placed under the tongue with a dropper.

Solution No. 4

Your doctor can prescribe liquid fentanyl concentrate, and you can simply make your own “under-the-tongue” fentanyl preparation. With an allergy syringe place 2 to 7 drops on a candy or on a piece of cotton. The favorite candy is “Smartie”. The candy or cotton is placed under the tongue or in the side of the mouth just like ACTIQ® or Fentora®. Some patients believe this method is equal or even more effective than ACTIQ® or Fentora®. Others think it is not quite as effective.

Although there are many sources to purchase fentanyl concentrate, I order from: Anazao Health in Tampa, Florida.
Anazao Health
5710 Hoover Blvd.
Tampa, Florida
800-995-4363
Fax: 800-985-4363

At this time, insurance companies are not accustomed to paying for fentanyl concentrate, and few physicians are aware of this off-label opportunity and availability. The cost of making an oral dose of fentanyl concentrate is less than $5.

At this time I know of no other solutions.

What to do while looking for a GOOD Pain Doctor!

The Pain Pal Series

by  Forest Tennant M.D., Dr. P.H. Veract Intractable Pain Clinic 336 S. Glendora Ave. West Covina, CA 91790 (626) 919-0064 Fax: (626) 919-0065 veractinc@msn.com

 TABLE OF CONTENTS

 WHY DID I WRITE THIS LITTLE HANDBOOK?

 WHAT TO DO?

 WHY YOU CAN’T ENDURE PAIN.

 ENLIST A SPECIAL SOMEONE TO HELP.

 APPROACH NO. 1:  SELF-HELP WITH NON-PRESCRIPTION MEDICINES

             1.  THE RIGHT VITAMINS AND AMINO ACIDS

            2.  NON-PRESCRIPTION PAIN RELIEVERS

            3.  BENEFITS OF HEAT AND COLD

            4.  FIND A TOPICAL THAT WORKS

            5.  REDUCE YOUR RETAINED ELECTRICITY

            6.  GET SOME SLEEP

            7.  EXPERIMENT WITH SOME NATURAL HEALERS

            8.  EAT EXTRA PROTEIN

            9.  KEEP MOVING AND STRETCHING

 APPROACH NO. 2:  PRESCRIPTION MEDICINE YOUR LOCAL DOCTOR WILL PRESCRIBE

            1.  ASK FOR THESE PRESCRIPTION DRUGS BY NAME

            2.  TENS: A GREAT ADD-ON TREATMENT

            3.  TIPS ON HOW TO APPROACH A DOCTOR FOR PAIN MEDICATION

FINAL ADVICE

1.  WHAT IF THE APPROACHES IN THIS HANDBOOK DON’T SUFFICE?

            2.  HOW TO FIND A GOOD PAIN DOCTOR

            3.  WHAT IF YOUR PROBLEM IS SIMPLY NOT ENOUGH OPIODS?

            4.  TWO SIMPLE RULES FOR CHRONIC PAIN PATIENTS

WHY DID I WRITE THIS LITTLE HANDBOOK?

 There isn’t a day that goes by that I don’t get at least one phone call, fax, or e-mail from a desperate person with chronic, severe pain who can’t find a good pain doctor.  Patients tell me that most doctors they encounter don’t treat pain, won’t prescribe opioids, or have the time to work a new patient into a busy medical practice.  Many doctors restrict their pain relief medicine dosages and tell patients to “live with it” leaving the patient still suffering.  Worse, a lot of doctors who hold out as “pain specialists” tell patients they only perform nerve blocks or related “interventions” and don’t do medical management which requires that a doctor prescribe opioids and accept the patient for long term care.* The very worst are “pseudo” pain doctors who tell patients they will have less pain if they withdraw from all drugs and admit they are really an addict whose pain is simply “in their head”.  Don’t buy it.  Read on.  There’s plenty of help and some great – not just good – pain doctors.

WHAT TO DO?

This handbook outlines two approaches to keep you healthy and comfortable until you find a good pain doctor:

Approach #1.  A self-help, do-it-yourself program using inexpensive non-prescription drugs and dietary supplements that are widely available in your local pharmacies and health food stores.

Approach #2.  Enlist a local doctor of your choosing to prescribe some prescription drugs which almost any doctor will prescribe.

 If you carefully and diligently follow these 2 approaches, you will stay alive and mentally function well-enough to buy you enough time to find a good pain doctor.  If you diligently follow these approaches, you may even find them effective enough that you won’t require a pain doctor.  There are more and more pain doctors coming on line who competently provide medical pain management.  In the meantime, take good enough care of yourself to prevent your severe pain from destroying your mind, hormone system, tissues, or driving you to suicide.

WHY YOU CAN’T ENDURE PAIN?

Don’t just endure pain and lay crying in bed, ponder in despair, or think about suicide.  Help is available and good pain doctors who care and know what to do are slowly emerging all over the country.  Travel out-of-state to see one if you must.  But until you find one, protect yourself from the ravages of pain.

Yes, I said ravages.  Pain doesn’t just make you miserable and ruin your quality of life.  Daily it eats away at your brain, tissues, blood vessels, and hormones.  Fundamentally, chronic pain accelerates aging and sends you to a grave long before your time.  Most severe, untreated pain patients die of a heart attack, stroke, or infection.  If you don’t die early in life from your pain, you will likely end up with dementia and loose your precious mental capacities.  Indeed, some of my recommendations are to protect your brain and heart until you get the help you need.

*Footnote: Interventional pain specialists are usually anesthesiologists or rehab doctors who take special training to do injections around the spinal cord.  These injections can be very helpful, particularly if given within one year after the pain begins.

ENLIST A SPECIAL SOMEONE TO HELP? 

Hopefully, you have a spouse, significant other, family member or friend who can help.  You’ll need a “special someone” to help you shop at the pharmacy and health food store to follow these approaches.  You may also want to shop on the internet, order from a catalogue, or buy from a direct marketing company.

 your “special someone” this little handbook so they may better understand your needs.

APPROACH NO. 1:  SELF-HELP WITH NON-PRESCRIPTION MEDICINES

STEP ONE: THE RIGHT VITAMINS AND AMINO ACIDS

Go to your local pharmacy or health food store and get the following to take on a daily basis.

1.  A vitamin-mineral-herbal formula which contains magnesium, folic acid, and B12.  This can be a tablet, capsule, powder, or drink.  Take 2 times a day.  Extra or supplemental B12, folic acid, and magnesium may help you.

 2.  Vitamin D₃ – Often called Calcitrol.  Take 2000 units a day which is usually 1 capsule.

 3.  Taurine or gamma amino butyric acid, 500 or 750mg – Take 2 at a time 4 times a day. (Total of ^*  Take on an empty stomach with cold fluids. 

STEP ONE   Multi-vitamin/mineral/herb preparation with folic acid, B12, and magnesium Vitamin D3 (Calcitrol) Taurine or gamma amino butyric acid

*Footnote: Taurine  and Gamma-amino-butyric Acid are the amino acids that the body naturally uses to block the electrical impulses of pain.  Chronic, severe pain depletes these biochemicals.  They do not have drug interactions since they are natural compounds.  You can take them with any prescription medication.  Gamma-amino-butyric Acid can cause temporary flushing similar to niacin.  You can try either one or both to see which best controls your pain. 

STEP TWO:  NON-PRESCRIPTION PAIN RELIEVERS 

Go to a pharmacy that stocks a lot of non-prescription supplies.  Purchase a bottle of these 2 pain relievers:

1.  Ibuprofen (Advil® and Motrin® are common trade names) The dose of one non-prescription tablet is 200mg.  The prescription dosages are 400 or 800mg in each tablet.^*

 2.  Naproxen (Aleve® is the trade name product).  Dosage is 220mg a tablet.  The prescription dosage is 275 or 550mg in each tablet.² 

For 2 days each, try one and then the other.  Take 1 to 2 every four hours.  A two day trial is enough time to determine which works best on you.

 *Footnote: The over-the-counter, non-prescription forms of ibuprofen and naproxen are about 1/2 to 1/4 the dosage of what a physician will prescribe.  Consequently, you may have to exceed the dosage on the label to get pain relief.  These agents are classified as anti-inflammatory pain relievers.  Their common side-effects are nausea, vomiting, and internal bleeding caused by stomach irritation.

CRITICAL INSTRUCTIONS ON HOW TO TAKE THESE PAIN RELIEVERS   1.  Take Ibuprofen and Naproxen with another drug which I call a “potentiator”, since it makes these pain relievers more “potent”.   2.  Listed here are the potentiators you should try with ibuprofen or naproxen.   Initially try one of each with ibuprofen or naproxen to find out which is the most effective.    a.  Acetaminophen – 1 tablet b.  Excedrin® – 1 tablet c.  Aspirin – 1 tablet d.  Immodium® – 1 tablet ** e.  Benadryl® – 1 capsule of 25mg   Caution: If any of these cause you nausea, vomiting, bleeding, or black stools, you must stop them.  Take an antacid, milk, or Pepto-bismol if you have nausea. Black stools are caused by internal bleeding, and you will need to consult a doctor if this occurs.   ** Immodium® is the trade name for loperamide which is the only opioid drug that is non-prescription.  It is sold over-the-counter for treatment of diarrhea although it has pain relieving effects when taken with ibuprofen or naproxen.  Too much could possibly cause constipation.

 STEP THREE – BENEFITS OF COLD AND HEAT

Obtain some hot and cold packs from a pharmacy. There are many brands to choose from.  Most of the cold packs can be kept in your refrigerator for repeat use.  Heat is most effective after a pain-relieving cream has been applied and massaged into the skin over your painful area.  Heat drives the medication through the skin to give better relief.  Heat relaxes painful tissue and increases blood supply.  Apply some heat daily for at least 5 minutes to promote the healing effects that heat can bring.  Cold works differently.  A cold pack or ice may only need to be applied for a few seconds to be helpful.  You can simply touch your pain sites until you feel some relief.  Cold alters and diminishes trapped electricity, heat, and inflammation caused by damaged nerves and pain.  You can alternate heat and cold.  Always keep hot and cold packs ready to use on pain flare days.

NOTE:  Some persons can only tolerate heat or cold but not both.

STEP FOUR – FIND A TOPICAL THAT WORKS

Purchase a variety of pain-relieving creams, lotions, ointments or sprays from a pharmacy, health food store, internet, catalogue, or direct marketing company.  Topicals are so-named, because you apply them to the “top” of the skin.  You will find one or more that work on your pain if you test a few. Listed here are some of my favorites.  You may find another one you like better, if you experiment with several. 

Massage a topical into your pain sites and put heat or cold over them for best effects.  Topicals are funny.  One may not work for everybody, and it may not even work on all parts of your body.                    

 Alcis®                                   

Freeze It®                            

Magnesium in Oil

Aloe Vera                             

Copper cream

Cats Claw®                         

Boswella

 

Topical agents work best with massage, vibrator, infrared, or ultrasound.  Often two or more at the same time work better than one alone.

 

STEP FIVE – REDUCE YOUR RETAINED ELECTRICITY*

 

You must remove the trapped electricity (i.e. energy, heat) around your painful body sites.  A damaged or dysfunctional nerve traps the electricity that your nerves constantly generate.  Retained electricity may cause pain flares, burning, itching, redness, jerking and twitching, insomnia, headache, and loss of appetite.  You must remove your excess electricity every day since nerves constantly make it.

Do at least 2 of the following each and every day to reduce the electricity that is trapped by your damaged nerves.

*Chronic pain is partly due to damaged nerves that constantly produce and retain or “trap” electricity.  A build up of too much electricity causes a pain flare, inflammation, and additional damage to the body.  The prevention and reduction of retained electricity must be a daily practice to adequately control pain.  I call this concept the “Theory of Retained Electricity”.  Copper, brass, magnesium, and magnets act as a “lightning rod” and attract trapped electricity.  The tissues of the body are negatively charged while metals like copper and magnesium are positive and attract or “pull out” retained or trapped electricity.  The word “grounding” is related to the fact that electricity is neutralized or dissipated when it reaches the ground.  This is why walking barefoot on grass or sand is helpful.

1.  Walk barefoot on sand or grass for at least 5 minutes;

2.  Take a hot bath with Epson Salts which are magnesium sulfate.  Alternatively, sit in a Jacuzzi or walk in a swimming pool for a minimum of 5 minutes;

3.  Wear a copper or magnetic bracelet, anklet, or necklace.  Maximal time is about 2 hours; (They can make pain worse if worn too long.)

 4.  Rub your painful sites with a copper object – time is 1 to 3 minutes.  Use brass if you don’t have anything made of copper, since brass is mostly copper;

 5.  Magnets:  Apply to your painful site, stand on a magnetic floor mat, lay on a magnetic mattress, or wear magnetic soles in your shoes.  Minimal time is 30 minutes;

 6.  Massage one of the creams listed in Step Four above into your painful sites;

7.  Apply a cold pack or ice to your painful site.  Minimal time is 30 seconds;

 8.  Massage the acupressure sites nearest to your pain site.  Time is 1 to 2 minutes.  You can go to www.acupressure.com for help.

9.  Get a acupuncture or massage treatment from one of the clinics that are now in every community.  You or your special someone can actually learn massage techniques and save money.

 STEP SIX – GET SOME SLEEP 

Most severe pain patients can only sleep 2 to 4 hours before their pain will awaken them.  You can promote sleep by using one of these three medications.  You can obtain these 3 without a prescription at pharmacies or health food stores. 

You may combine these sleep medications.

Tryptophan 1000mg         

Melatonin 3 to 6mg           

Diphenhydramine (Benadryl®) 25mg

STEP SEVEN – EXPERIMENT WITH SOME NATURAL HEALERS                    Try some of the natural healers that patients and doctors have praised over a long period of time.  No guarantees but here are my favorites.  These come in tablets or capsules.  Follow the instructions on the bottle.

Boswella

Aloe Vera

Alpha Lipoic Acid

Glucosamine – particularly mixed with Boswella

When you try one of these, you will need to take it for at least 2 weeks to feel any results.

Also, go to a health food store and purchase pregnenolone, 50mg.  Take 3 a day.  Try this for 10 days.  Pregnenolone is the natural body chemical that makes many of your hormones including testosterone, estrogen, and cortisone.  It also acts as a natural pain reliever in the brain and spinal cord.  It’s very safe which is why it’s sold without a prescription in health food stores.

STEP EIGHT – EAT EXTRA PROTEIN AND AMINO ACIDS 

Protein contains the amino acids that make the body’s natural pain relievers: endorphin, gamma amino butyric acid, serotonin, and dopamine.  Each day eat a food that contains a lot of protein.  The following are about the only foods that are, by weight, over 50% protein: eggs, cheese, fish, poultry, pork, or beef.  Many pain patients report that fish oil capsules help them.  Also, I have patients who feel they benefit from the amino acids carnitine, arginine, phenylalanine, and glycine.  There are no controlled studies to definitely confirm a benefit to fish oil and some of the amino acids, but they can be cheaply obtained without a prescription from health food stores, catalogues, direct marketing companies and the internet.  They are worth trying, and adding to your self-help program.

STEP NINE – KEEP MOVING AND STRETCHING

Immobility is your enemy.  You must get enough pain relief to get out of bed, stretch, and walk early each morning.  If you spend too much time in bed or on the couch, tissue around your pain sites will atrophy and contract.  This will likely cause you, in the end, to have more pain and immobility.  To protect your pain site, you must stretch the area several times a day. 

Try to maintain, proper posture.  The natural alignment of the body is to stand up straight and walk without a limp or foot drag.  Do this daily.  Also, sit up straight and try not to lean too much to protect your painful areas.

Do these 3 things:  move, stretch, and do it again.

 

 

 

 

 

APPROACH NO. 2 – PRESCRIPTION DRUGS YOUR LOCAL DOCTOR WILL PRESCRIBE

 

STEP ONE

ASK FOR THESE PRESCRIPTION DRUGS BY NAME

 

Ask a local physician, nurse practitioner, and/or physician assistant (PA) to prescribe some of the following prescription medications listed here.  What the vast majority of MD’s won’t do is give you a potent opioid drug.  However, today they will prescribe a wide variety of effective prescription drugs.  Doctors want to help.  Few, however, have had any pain training, so they will not prescribe the most potent pain relievers. 

               

Ask specifically for one or more of the following by name:

1. Topical – applied to skin

 

                a. Lidoderm® Patch

                b. Flector® Patch

                c. Voltaren® Gel

 

2. Nerve Block Agents

 

                a.Cymbalta®

                b.Lyrica®

 

3. Mild Pain Relievers ⁵

 

                        a. Fioricet® with or without codeine

                        b.Butalbital with or without codeine

                        c. Tramadol (Ultram® or Ultracet®)

                        d. Ibuprofen (Motrin®) or other anti-inflammatory drug

 

4. Stronger (Not Strongest)

a.Propoxyphene (Darvon®)

b. Hydrocodone (Vicodin®, Norco®, Lortab®)

 

STEP TWO

TENS: A GREAT ADD-ON TREATMENT

 

TENS stands for Transcutaneous Electrical Nerve Stimulation.  It is a small electric box which is not implanted but is worn on your belt.  It sends a low level electric current into your painful area, and it enhances the spinal cord to block pain signals.  TENS also activates endorphins.  I personally believe the electric current additionally drives out or “unplugs” some retained electricity.  A TENS unit requires a doctor’s prescription.

 

In the past many people, including you, may have tried TENS and found it to be worthless for pain relief.  Here are the facts as I’ve learned them.  TENS really helps once your self-help and medication program gives you about 60 to 70% pain relief.  If you add TENS treatment, you’ll get another 10 to 20% relief.  By itself, TENS isn’t usually much help.

 

Don’t let anyone, including doctors, tell you that TENS, nerve blocks, psychotherapy, or physical therapy is a substitute for medication.  They are not.  Obtain the medications you need – FIRST.  Once you attain 60 to 75% pain relief, try non-medical measures including TENS.  You can always stop pain medicine if you find a substitute.

 

TIPS ON HOW TO APPROACH A DOCTOR FOR PAIN MEDICATION

 

It is critical that you approach a doctor correctly.  If you just ask for pain medication, he/she may show you the door, and rightly so.  Why?  Every doctor in America has been propositioned by so many drug abusers and sellers of drugs that he/she will likely be suspicious of anyone who claims pain and asks for drugs.  Do the following:

 

1.  Get an at-home blood pressure-pulse rate device and make a record of your blood pressure and pulse rate.  If the non-prescription measures described in self-help Approach No. 1 don’t control your pain, you will likely have elevated blood pressure and/or pulse rates during pain flares.  Keep a record and show it to your doctor.  He’ll be impressed and more willing to help if you’ve done some preliminary details, and documented that you have severe pain.

 

1. Take that special someone with you to vouch that you have legitimate pain.

 

2. Make a written list of all the measures you have tried.  Note on your list if the measure was helpful, hurtful, or wasteful.

3. Cooperate and don’t argue with your doctor.  Let the doctor know you will continue all the measures you’ve learned that help you as well as what the doctor prescribes.

 

WHAT IF THE APPROACHES IN THIS HANDBOOK DON’T SUFFICE?

 

Simple.  You need a good pain doctor.  One who specializes in medical management of severe, chronic pain.  If you get only partial relief, review the approaches in this little handbook.  Make sure you are diligently following them.  Then keep looking for a good pain doctor.

You must definitely find a good pain doctor if your pain drives up your pulse and blood pressure and you’ve followed the measures in this handbook without much relief.

 

 

 

 

 

HOW TO FIND A GOOD PAIN DOCTOR?

 

Start asking around for a pain doctor that does “medical management” of severe pain.  If you just ask for a “pain specialist” you may get sent to a doctor who only per forms nerve blocks, epidural injections, or detoxes you (at great expense, of course!) rather than prescribe opioid drugs which you will require if the approaches in this little handbook don’t keep you comfortable.  Who do you ask?  Start with your County or State Medical Associations.  Some websites have a referral service.  Your best bet is to ask other pain patients.  Ask them which doctors arbitrarily restrict medication or dosages, so you can avoid them.

 

Do one other thing.  Enlist a family member, significant other, clergyman, friend, or lawyer to help you find a “medical management” pain doctor.  Some very good medical management pain doctors are now cropping up in most every state.  You may have to travel out-of-state for awhile until one emerges near you, but your very life and quality of life may depend on your willingness to travel.

 

WHAT IF YOUR  PROBLEM IS SIMPLY NOT ENOUGH OPIOIDS?

 

So often I receive calls from patients who know they can control their pain if their doctors would simply raise their dosage of opioids such as hydrocodone, morphine, methadone, fentanyl, or oxycodone.  If this description fits you, you belong to a large group of suffering people.  Thousands of patients are in agony and dying before their time due to bias against adequate opioid dosages.  Obviously, this means its time to find a good pain doctor.  But in the meantime start at Step One in Approach No. 1 in this little handbook.  “Self Help” is the best medicine.  Be aggressive in reducing your retained or trapped electricity.  Keep a daily record of your blood pressure and pulse rate to help document that your pain is poorly controlled.  Always remember that opioid drugs produce some complications, so avoid opioids or minimize your opioid dosage by following this little handbook.

 

 

TWO SIMPLE RULES FOR CHRONIC PAIN PATIENTS

 

The mere fact that you’ve read this little handbook tells me you are a chronic pain patient which means you’ve had daily pain for over 3 months.  Rule No. 1 is to try and treat yourself with the approaches in this little handbook.  “Self Help” is the best medicine.  Rule 2 is to find medication that gives you 60 to 75 % pain relief BEFORE some practitioner talks you into some procedure, surgery, intervention or non-medical treatment.  Written here are the “Self Help” fundamentals to chronic pain control.  Master them.

 

 

 

 

 

 

ABOUT THE AUTHOR

 

Dr. Tennant started his pain clinic in 1975.  Originally it focused on treating the pain of cancer and post-polio.  He has authored over 300 scientific articles and books, and currently serves as Editor Emeritus of Practical Pain Management, the nation’s most widely circulated pain journal for physicians.

 

He has formerly served as a Medical Officer in the US Army and US Public Health Service.  In the past he has been a consultant to the US Food and Drug Administration, National Institute on Drug Abuse, Drug Enforcement Administration, LA Dodgers, National Football League, and NASCAR.  He has authored another handbook for pain patients called “The Intractable Pain Patient’s Handbook for Survival”.

 

WHY DID I WRITE THIS LITTLE HANDBOOK?

Thank you for coming to the Pain Research Advocate’s Blog.  This blog is maintained and updated by Aniwaya Advocates, a branch of Aniwaya Artistry.  We are all Intractable Pain patients who simply want honest research about pain as a disease made available to those who seek it out. Most of the articles here are by one doctor in particular, Dr. Forest Tennant. The reason for that is because this one doctor has done more research throughout the years with real pain patients than any other doctor we know. Plus the articles here are some of the only ones that deal with pain as a DISEASE first and foremost, not simply a SYMPTOM of a greater pathology.   We hope you find something you are looking for while you are here. Feel free to print this material out and share it with others you know in pain and/or with your treating doctor. 

 

The more we as pain patients’ stand up for ourselves and demand that we be heard, the more we will be seen as real people. We are people with a medical disease just like those with Diabetes or Thyroid problems who need help. Pain patients have true medical needs that must be addressed. We are tired of just passed off as “drug seekers” as many in the medical field have done in the past and are still doing to millions even today.

For more information about pain research, advocacy issues and how you too can get involved, there are several organizations that can help.  One is the American Pain Foundation www.painfoundation.com  ;  the American Chronic Pain Association at www.acpa.org is another.

Thank you for stopping here. Thank you for reading. Thank you mostly for choosing to be informed. 

 

Radene Marie Cook

Owner

Aniwaya Advocates,

Aniwaya Artistry

www.cook.myexpose.com