I welcome readers: those here to download and cheat, my apologies:

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Sunday, September 30, 2012

NEAT STUFF FOR US ON A SITE I FOUND...ESP FOR DIETARY NEEDS!!!

On a friend's advice, I was "trolling for this and found way more"


H-Wave Therapy Machine
H-Wave Therapy Machine
Item #: HWave
What is the H-Wave machine?

The H-Wave device is a unique electro-therapeutic treatment to aid in functional restoration and pain control. The H-Wave was developed and is manufactured here in the U.S. by Electronic Waveform Lab. The H-Wave and its treatment system is not available by any other company or brand name.
  • Unique, effective technology
  • Developed & manufactured in the U.S.A.
  • Ultra-low frequency stimulation - improves circulation & increases fluid shifts
  • High frequency stimulation - to break pain cycle
  • Battery powered & portable
  • 3-channel clinical model
  • 2-channel home model
Price: $3,100.00 , now $2,400.00
Qty: Price: $2,400.00




 TBSoya - Tribest Soyabella Soy Milk Maker  Automatic Soymilk Maker & Coffee Grinder
$119.00 Retail
$94.95 Your Cost

for more blendarizers, juicers, and this is ROCKING stuff for skinny people, we "eat it up" cuz our food goes in (comes out different too I hate to say) see this site:

It approaches, at least, affordability with NATURAL good health...YUM.  I like that!!!



Posted by at 1 comment:

2006 RULING LIFTS MEDICARE CAP ON THERAPIES FOR RSD/CRPS: LINK TO CMS (RE-POST RSD HOPE)

http://www.rsdhope.org/cap-for-yearly-physical-therapy.html 

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CMS Home > Site Tools & Resources > Media Release Database > Press Releases

Press Releases


Details for: OUTPATIENT THERAPY CAPS: EXCEPTIONS PROCESS REQUIRED BY THE DRA


For Immediate Release: Wednesday, February 15, 2006
Contact: CMS Office of Public Affairs
202-690-6145


OUTPATIENT THERAPY CAPS: EXCEPTIONS PROCESS REQUIRED BY THE DRA
Background:   Section 4541 of the Balanced Budget Act of 1997 (BBA) required the Centers for Medicare & Medicaid Services (CMS) to impose financial limitations or caps on outpatient physical, speech-language and occupational therapy services by all providers, other than hospital outpatient departments.   The law required a combined cap for physical therapy and speech-language pathology, and a separate cap for occupational therapy.   Due to a series of moratoria enacted subsequently to the BBA, the caps were only in effect in 1999 and for a few months in 2003.  With the expiration of the most recent moratorium, the caps were reinstated on January 1, 2006 at $1,740 for each cap.

The President signed the Deficit Reduction Act of 2005 (DRA) into law on February 8, 2006.   The DRA directs CMS to create a process to allow exceptions to therapy caps for certain medically necessary services provided on or after January 1, 2006.  The law mandates that if CMS does not make a decision within 10 days, the services will be deemed to be medically necessary.  This fact sheet describes the exceptions process which will be implemented by our claims processing contractors.  Until contractors are able to implement the exceptions process, they are required to accept requests for adjustment of claims for services in 2006 that were denied for exceeding the caps.

Exceptions Process:   CMS has established an exceptions process that is effective retroactively to January 1, 2006.  Providers, whose claims have already been denied because of the caps, should contact their carrier to request that the claim be reopened and reviewed to determine if the beneficiary would have qualified for the exception.  In addition, providers who have not yet submitted claims for services on or after January 1, 2006 that qualify for the exception, should submit these claims for payment, and refund to the beneficiary any private payments collected because of the cap.

The exceptions process allows for two types of exceptions to caps for medically necessary services:

  • Automatic Exceptions.   Automatic exceptions for certain conditions or complexities are allowed without a written request.  A request to the contractor for an exception is not required when services related to these conditions and complexities, which are described below, are appropriately provided and documented.  We anticipate that the majority of beneficiaries who require services in excess of the caps will qualify for automatic exceptions.
  • Manual Exceptions.   Manual exceptions require submission of a written request by the beneficiary or provider and medical review by the contractor responsible for processing the claims.  If the patient does not have a condition or complexity that allows automatic exception, but is believed to require medically necessary services exceeding the caps--the provider/supplier or beneficiary may fax a letter requesting up to 15 treatment days of service beyond the cap.  A treatment day is a day on which one or more services are provided.  The request must include certain documentation, including a justification for the request.  Contractors will make a decision on the number of treatment days they determine are medically necessary within 10 business days.  These requests for cap exceptions should be submitted prior to the date the cap is expected to be surpassed to avoid placing the beneficiary at risk of incurring the costs of treatment if the request is denied.

Automatic Exceptions to the Therapy Caps:   Certain diagnoses qualify for an automatic exception to the therapy caps, if the condition or complexity has a direct and significant impact on the need for course of therapy being provided and the additional treatment is medically necessary.  A list of these diagnoses is attached.  For a condition or complexity to qualify the beneficiary for an exception to the caps, the therapy must be related to one of the listed conditions.

In addition to conditions, there are clinically complex situations that can justify an automatic exception to the therapy caps for any condition that necessitates skilled therapy services.  As in all exceptions, the services rendered above the caps must be documented, covered by Medicare, and medically necessary services.  Those complex situations include:

  • The beneficiary was discharged from a hospital or skilled nursing facility (SNF) within 30 treatment days of starting this episode of outpatient therapy.   The claim should indicate the date of discharge and name of hospital or SNF.
  • The beneficiary has, in addition to another disease or condition being treated, generalized musculoskeletal conditions or a condition affecting multiple sites that is not listed as qualifying for an automatic exception that will have a direct and significant impact on the rate of recovery.
  • The beneficiary has a mental or cognitive disorder in addition to the condition being treated that will have a direct and significant impact the rate of recovery.  

For the above complexities, the provider should include in the documentation all relevant disorders or conditions and describe the impact. For example:   A sprained ankle does not qualify for exception by condition, but if the patient also has a dysfunctional wrist on the opposite side that precludes the use of a cane, it could cause a direct and significant impact on the patient’s need for skilled physical therapy, and might cause services in that calendar year to exceed caps. 

  • The beneficiary requires physical therapy (PT) and speech-language pathology (SLP) services concurrently.   If the combination of the two services causes the cap to be exceeded for necessary
  •    services, the services are excepted from the PT/SLP cap.  There is no effect on the occupational therapy cap. 
  • The beneficiary had a prior episode of outpatient therapy during this calendar year for a different condition.  If services are medically necessary and would be payable under the cap, an exception is allowed if prior use of services for a different condition caused the cap to be exceeded and the medically necessary services to be denied.  In cases where the beneficiary was treated in the same year for the same condition, a written request and contractor approval is required for use of the KX modifier if the condition does not qualify for an automatic exception.
  • The beneficiary requires this treatment in order to return to a previous place of residence.   Document that environment and what is needed to return. For example:  “Patient is progressing (see initial and current objective measurement scores) and has a good potential for completing goals for independent use of the toilet which is required for discharge from the nursing home setting and return to the assisted living facility where she resided prior to the stroke.” 
  • The beneficiary requires this treatment plan in order to reduce Activities of Daily Living assistance or Instrumental Activities of Daily Living assistance to previous levels.    Document prior level of independence and current assistance needs. 
  • The beneficiary indicates he/she does not have access to outpatient hospital therapy services.   List reasons that justify why the patient cannot obtain necessary services from a hospital outpatient department.  Reasonable justifications include residents of skilled nursing facilities prevented by consolidated billing from accessing hospital services, debilitated patients for whom transportation to the hospital is a physical hardship, or lack of therapy services at hospital in the beneficiary’s county. 

Use of Modifier:   When services qualify for either an automatic or manual exception, provider/suppliers should add a KX modifier to each line of the claim that contains a service that exceeds caps.  This modifier represents the provider/supplier’s attestation of medical necessity.  Medical records continue to be subject to review for possible misrepresentation, fraud or patterns of abuse.  If the contractor determines that the provider/supplier has inappropriately used the modifier, the provider/supplier may be subject to sanctions resulting from providing inaccurate information on a claim.

Further Information:   Further information regarding automatic exceptions and the process for requesting and documenting manual exceptions is published on the CMS website at: www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage.

The therapy caps are discussed in Pub 100-04, chapter 5, section 10.2, Pub.100-8, chapter 3.4.1.2, and Pub 100-02, chapter 15, section 220.3.   Other information concerning the process can be found in CR4364, at www.cms.hhs.gov/Transmittals/2006Trans/list.asp#TopOfPage.

 ATTACHMENT

Diagnosis Codes That Qualify for an Automatic Exception to the Caps

Note: On this table, conditions are represented in normal type and complexities are bold with asterisks.

ICD-9
 Description
V43.64
 Joint replacement, hip
V43.65
 Joint replacement, knee
V43.61
 Joint replacement, shoulder
V49.63-49.67
 Upper limb amputation status
V49.73-49.77
 Lower limb amputation status
250 – 250.93
 Diabetes mellitus*
278.01-278.02
 Overweight, Obesity, and other hyperalimentation *
290.0-290.4
 Dementias*
294.0-294.9
 Persistent mental disorders due to contions classified elsewhere*
311
 Depressive disorder NEC*
323.0-323.0
 Encephalitis, myelitis, and encephalomyelitis*
331.0-331.9
 Other cerebral degenerations
332.0-332.1
 Parkinson's disease
333.0-333.99
 Other extrapyramidal diseases and abnormal movement disorders
334.0-334.9
 Spinocerebellar disease
335.0-335.9
 Anterior horn cell disease
336.0-336.9
 Other diseases of spinal cord
337.20-337.29
 Reflex Sympathetic Dystrophy
340
 Multiple sclerosis
342.00-342.9
 Hemiplegia and Hemiparesis
343.0-343.9
 Infantile cerebral palsy
344.00-344.9
 Other paralytic syndromes
348.9-348.9
 Other conditions of brain
349.0-349.9
 Other and unspecified disorders of the nervous system
353-357
 Neuropathies
359.0-359.9
 Muscular dystrophies and other myopathies
386.0-386.9
 Vertiginous syndromes and other disorders of vestibular system*
401.0-401.9
 Essential Hypertension*
402.00-402.91
 Hypertensive heart disease*
414.00-414.9
 Other forms of Chronic Ischemic Heart Disease*
415.0-415.19
 Acute pulmonary heart disease*
416.0-416.9
 Chronic pulmonary heart disease*
427.0-427.9
 Cardiac dysrhythmias*
428.0-428.9
 Congestive Heart failure*


430-432.9
 Intracranial   hemorrhages
433.0-434.9
 Occlusion and stenosis of precerebral and cerebral arteries (for occlusion only)
436
 Acute, but ill-defined, cerebrovascular disease
437.0-437.9
 Other and ill-defined cerebrovascular disease
438.0-438.9
 Late effects of cerebrovascular disease
443.0-443.9
 Other peripheral vascular disease*
453.0-453.9
 Other venous embolism and thrombosis*
457.0-457.1
 Postmastectomy lymphedema syndrome and other lymphedema
478.30-478.5
 Disesases of vocal cords or larynx
486
 Pneumonia, organism unspecified* 
490-496
 Chronic Obstructive Pulmonary Diseases*
710.0-710.9
 Diffuse diseases of connective tissue
707.99-707.9
 Chronic ulcer of skin*
711.00-711.99
 Arthropathy associated with infections*
713.0-713.8
 Arthropathy associated withother discorders classified elsewhere*
714.0-714.9
 Rheumatoid arthritis and other inflammatory polyarthropathies*
715.09
 Osteoarthritis and allied disorders
715.11
 Osteoarthritis, localized, primary, shoulder region
715.15
 Osteoarthritis, localized, primary, pelvic region and thigh
715.16
 Osteoarthritis, localized, primary, lower leg
715.91
 Osteoarthritis, unspecified id   gen. or local, shoulder
715.96
 Osteoarthritis, unspecified if gen. or local, lower leg
718.44
 Contracture of hand
718.49
 Contracture of joint, multiple sites
719.7
 Difficulty walking*
721.91
 Spondylosis   with myelopathy
723.4
 Other disorders of the cervical region, brachia neuritis or radiculitis NOS
724.02
 Spinal stenosis, lumbar region
724.3
Other and unspecified disorders of the back, sciatica*
724.4
Other and unspecified disorders of the back, thoracic or lumbosacral neuritis or radiculitis, unspecified*
726.10-726.19
 Rotator cuff disorder and allied syndromes
727.61-727.62
 rupture of tendon, nontraumatic
733.00
 Osteoporosis with wedging of vertebra
780.93
 Memory Loss


781.2
 Abnormality of gait
781.3
 Lack of coordination
781.8
 Neurologic neglect syndrome
781.92
 Symptoms involving nervous and musculoskeletal symptoms, abnormal posture*
784.3-784.69
 Aphasia and other speech disturbances
787.2
 Dysphasia
806.00-806.99
 Fracture of vertebral Column with Spinal Cord Injury
810.00-810.13
 Fracture of clavicle
811.00-811.19
 Fracture of scapula
812.00.812.59
 Fracture of humerus
813.00-813.93
 Fracture or radius and ulna
820.00-820.9
 Fracture of neck of femur
821.0-821.39
 Fracture of other and   unspecified parts of femur
828.0-828.1
 Multiple fractures involving both lower limbs, lower with upper limb, and lower limb(s) with rib(s) and sternum
852.00-852.59
 Subarachnoid, subdural, and extradural hemorrhage, following injury
853.00-853.19
 Other and unspecified intracranial hemorrhage following injury
854.00-854.19
 Intracranial injury of other and unspecified nature
881.0-881.2
 Open wound of elbow, forearm, and wrist
882.0-882.2
 Open wound of hand with tendon involvement
884.0-884.2
 Multiple and unspecified open wound of upper limb with tendon involvement
887.0 – 887.7
 Traumatic amputation of arm and hand (complete) (partial)
897.0-897.7
 Traumatic amputation of leg(s) (complete) (partial)
952.00-952.9
 Spinal cord injury without evidence of spinal bone injury
941.00-952.9
 Burns
959.01
 Head Injury


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Rick Simpson Oil: WARNING: DISPENSARY ONLY: DO NOT DO THIS ON YOUR OWN~BUT WHY NOT WITH RSD? IT IS WORKING FOR ME~YUP, ME.




How to make hemp oil by Rick Simpson

on . Posted in Medicinal Cannabis News & Information
48
For those of you who have watched the documentary "Run from the Cure", this should answer any questions about producing your own hemp oil.
hemp oil cures cancer

Caution: Oils that drug dealers sell can have many contaminants and often little or no THC. From my experience, most hemp oil available on the street should be avoided for medicinal use. Make your own oil or have someone you trust produce the oil to assure a very pure, high quality oil is produced.

How much to make and take?
One pound (500g) of bone-dry hemp buds will usually produce about 2 ounces (55 - 60 mL) of high-grade oil. This amount of oil will cure most serious cancers; the average person can ingest this amount in about three months. This oil is very potent so one must begin treatment with small doses. A drop of oil about half the size of a grain of rice, two to four times a day is a good beginning. After four or five days, start increasing your daily dosage very gradually. As time goes on the body builds a tolerance to the oil and more and more can be taken. In cases where people are in a great deal of pain, I recommend that their dosage be quickly increased until it kills the pain. High quality hemp oil will stop pain even when morphine is not effective. The oil can be applied to external injuries for pain relief in minutes.

Will I get high?
Following the dosage previously described, many people can take the full treatment and never get high. In regards to hemp, getting "high" is a joke, even if a person does take too much oil the effect wears off quickly and no harm is done. No one has ever died from the use of hemp medicine.

Will I become addicted?
Hemp oil does not cause your body to crave more. It is non-addictive, harmless and effective for practically any medical condition.

Is this the same as hemp seed oil?
No! This is hemp oil, made from the bud and small leaves of the hemp plant. It is the essential oil of the hemp plant. Health food store sells oil made from hemp seed that is often mislabeled as hemp oil. Although seed oil is very beneficial, it does not contain enough THC to have any effect on cancer and other serious illnesses.

Are hemp and marijuana the same?
The word marijuana is one of over four hundred slang terms used worldwide to describe the cannabis and/or hemp plant.

Are all hemp plants the same?
When buying or growing hemp, procure a strain that has the highest possible THC content. To energize someone suffering from depression, I recommend a good Sativa strain. For most other medical conditions, I strongly suggest that Indica strains be used. Indicas relax a person and provide them with more rest and sleep.

How do I use it?
High quality hemp oil can be vapourized, ingested or used topically. Add the oil to creams and salves for external use.

Where can I get information about making the oil?
The process in the video could only be described as crude at best, but the oil that is produced will cure cancer. In reality, this medicine should be produced in a controlled environment, using distilling equipment, etc. to reclaim the solvent and to purify the oil. Most people do not understand distilling and do not have access to the required equipment. This is the reason such a simple method is descried in the documentary, so if need be just about anyone can produce the oil. As in the video, again we stress that this process, if not done properly can be dangerous and we bear no responsibility if this educational information is misused.

Rick Simpsons process of making hemp oil

Starting material:
I generally work with a pound or more of good grade hemp starting material. You can use just one ounce. An ounce will usually produce 3 or 4 grams of oil. The amount of oil produced per ounce of hemp will vary from strain to strain, but it all has that wonderful healing power.

1 - Place the completely dry starting material in a plastic bucket.
2 - Dampen the material with the solvent you are using. Many solvents can be used. I like to use pure naphtha but it costs $500 for a 45-gallon drum. You can use 99% isopropyl alcohol, which you can find in your local drug stores. Alcohol absorbs more chlorophyll from the plant material than naphtha does. This gives oils made with alcohol a darker colour but does not diminish the potency of the oil to any noticeable degree. Ether, naphtha or butane and many other solvents can produce oils that are amber and transparent. Granted these clear oils do look better but dark oil can be just as potent. If the process is done properly, little or no solvent residue is left in the oil. I have been consuming oils produced using different solvents for eight years with no harmful effects. You will require about two gallons of solvent to strip the THC off one pound of dry starting material. 500 milliliters of solvent should be more than enough to strip the THC from one ounce of hemp starting material.
3 - Crush the plant material using a stick of clean untreated (chemical free) wood or some such device. Even though the starting material has been dampened with the solvent, you will find that the material can be readily crushed.
4 - Add solvent until the starting material is completely covered.
Use the stick to work the plant material. As you are doing this, the THC dissolves off the plant material into the solvent.
5 - Continue this process for about 3 minutes.
6 - Pour the solvent-oil mix off the plant material into another bucket. You have just stripped the plant material of about 80% of its THC.
7 - Second wash - again add solvent to the plant material and work it for another 3 minutes to get the other 20%.
8 - Pour this solvent-oil mix into the bucket containing the first mix that was poured off previously.
9 - Discard the twice-washed plant material.
10 - Pour the solvent-oil mix through a coffee filter into a clean container.
11- Boil the solvent off. I have found that a rice cooker will do this boil off very nicely. The one I have has two heat settings - high and low - and will hold over a half gallon (2.5 liters) of solvent-oil mix.
12- Add solvent-oil mix to the rice cooker until it is about ¾ full.

Make sure you are in a very well ventilated area and set up a fan to carry the solvent fumes away. The fumes are very flammable. Be sure to stay away from red-hot elements, sparks, cigarettes etc. that could ignite the fumes.

13 - Plug the rice cooker in and set it on high heat.
14 - Continue adding solvent-oil mix as the level in the rice cooker decreases until it is all in the cooker.
15 - Add a few drops of water to the solvent-oil mix as the level comes down for the last time. The amount of water added depends on how much starting material you had in the beginning. If I am producing oil from a pound of good bud, I usually add about ten drops of water.
16 - When there is about one inch of solvent-oil-water mix left in the cooker, put on your oven mitts, pick the unit up and gently swirl the contents.
17 - Continue swirling until the solvent has been evaporated off. The few drops of water help release the solvent residue and protect the oil somewhat from too much heat. When the solvent has been boiled off, the cooker that I use automatically goes to low heat. This avoids any danger of overheating the oil. At no time should the temperature of the oil go over 290F degrees (140 C).
18 - Put on your oven mitts and remove the pot containing the oil from the rice cooker.
19 - Gently pour the oil into a small stainless steel container.
20 - Place this container in a dehydrator or put in on a gentle heating device such as a coffee warmer. It may take a few hours but the water and volatile turpines will be evaporated from the oil. When there is no longer any activity on the surface of the oil the medicine is ready for use.
21 - Pour the hot oil into a bottle; or as in the video suck it up into a plastic syringe. Putting the oil in a plastic syringe makes it very easy to dispense the medicine.
When the oil cools off it has the consistency of thick grease. Some strains will produce very thick oil and you may have trouble squeezing it out of the syringe. If this happens, place the syringe in warm water a few minutes prior to use.

To anyone starting to use hemp oil as a medication, here are some simple facts.
Hemp oil will lower blood pressure and if you are on blood pressure medication, you may find that this medication is no longer needed. The same is true for diabetics. I have seen hemp oil control blood sugar to the extent that insulin was no longer needed.

I am not a doctor and I do not have the right to tell people what they should do. Personally, I would not consider taking any cancer treatments currently in use by our medical system, I do not recommend that hemp oil be taken along with chemotherapy. What would be the sense of making your own cure and then allowing the medical system to give you massive doses of poison?

From my experience with hemp medicine, I have found that most pharmaceutical medications are no longer needed once a person starts using hemp oil. Hemp oil seems to mix well with most natural medications but I have had a few reports from people trying to take hemp oil and pharmaceuticals who experienced stomach pain etc. All problems ceased when they stopped taking the prescription drugs.

To anyone who is going to act on this information to help a loved one, I welcome you to the world of real medicine. Again, I caution you to be very careful when boiling the solvent off. The fumes are very flammable. Be sure to stay away from red-hot elements, sparks, cigarettes etc. that could ignite the fumes.

I wish you the best luck and health.
Warmest regards,
Rick Simpson.
Source www.phoenixtears.ca
Rick Simpson Interviewed by Jindrich Bayer
Rick Simpson Interviewed by James Martinez on Achieve Radio

Must See Documentaries

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Posted by at 111 comments:

What is wrong with HONESTY? Run TO it not from it~so there you have it.

People are really afraid of the truth.
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Tuesday, September 18, 2012

 Shrek Oil

 



"MELTDOWN  RSD"       AN EVENING RSD STYLE

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Monday, September 17, 2012

A little Shrek




Fibro comes with hyperacuasis?  Oh, try it!!!!  It is like being tortured by sound.  I beg my cat to stop meowing, I cry for no reason because it all is suddenly so overwhelmingly loud and painful-even with hearing protection and earplugs, sometimes at the same time!!!  I know of folks through the Hyperacuasis Network who have gotten RSD/CRPS from the hyperacuasis and not the way I did, which is vice versa-now perhaps this is letting those idiots take up space in my head, but when they have a friend of mine who suffers horribly from pain from her cervical spine to her coccyx basically, I have a fucking problem!  She says "I see how much pain you're in, hear fibromyalgia patients whining when then have a whole ounce, plus the narcotics, and you are just dealing, sometimes pasting a smile, how do you get through it?  I don't even know what to say-I can't feel like I can even begin to say I hurt just watching you suffer."  What does she do?

Not this:

Oh, sorry about your troubles darling, but let me count my blessings or curses.  My body this morning as I PRAY that my father gives me enough money to buy a decent sum of weed to put out the flames that feel like they LEAP off my body to go with the plethora of medication:

She helps me out-not just by helping get my hospital bed out of my living room and getting my house in order, and laundry-all the things I can't do anymore, and I am legal as is she so as long as we are both in agreement-she brings "shake" and I "bake" and then-we both do.  But unfortunately, I am messy when I cook, but she wants to come in and DO it for me.

Zonegran 400mg at bedtime
Tegretol 400mg BID
Duragesic 75 (was far higher before weed and was also on other meds-MTD)
Keppra 500mg (need liquid and need it higher, maybe 750mg?) at bedtime
Clonazepam (dose with held) and I take it for seizures since childhood,

I have CRPS, aka "CRAPS"

I can't do a lot of things.  Mostly right when I want to do them.  I have to have help cleaning my house.  I also have to sleep in a hospital bed.  I have to take all that antiseizure medication, in additional to female hormones, migraine medications as needed, and medically (as more of that than anything else!!!!) and since I became I patient, and discovered a friend with "access" to shake, I can make my own stuff like cooking oils that can go for up to $75 a bottle, and as I make the hash going in-I get what I ahhhhh, put in?  And what I put into it, I get out, and that is PAIN RELIEF.

Each day I open my eyes I don't want to move, I want to lay in the hospital bed, under my plethora of hand-sewn blankets of fleece since I can't tolerate other materials than fleece in the blankets and a bottom sheet that is very soft flannel.  I wear cotton, fleece, or soft flannel only.  Some days I can't wear clothing- and others, I have to.  I function usually between 9pm and 10am, and hide in a shaded, well darkened apartment because light is so intolerably painful, I want to scream at the level of pain it costs me-marijuana, narcotic medication or not.  Oh, then there is this: we have also got the fun part!  Gee bout maybe going to looking like a fat pig from laying around and letting RSD pain be my slave and master: or allowing  my pain be my GUIDE, and lady: I am NOT comparing our disorders.

I have nerve pain-but I do also have diagnosable fibro.  But people like this piss me off because my friends look at me and say that they hear fibro patients whining about pain, and see what I suffer through, and they feel like they have nothing to complain about.  NOOOO~ you fuck with my friends, you fuck with me.  Ok, cuz they are my fucking lifeline.  I see shit about my fucking family, and almost got killed by  my sister when I was seven, and the 2 years after my daughter was born, I frigging was put in foster care and came out on my own: pregnant.

And yeah-but hey, I made the best of it.

You can make lemons or lemonaide-it is up to you.  You can be angry and pissed off, but you can whine about what you can not do, or what you can do is set small steps to get to the point where you can pick your baby up.

Or maybe he is a big kid, and you can't do it.  And try sitting down and put a blanket on your lap and let him crawl onto your lap, and curl up for a cuddle: kids can be much more a comfort than a pet even-if you have a good, healthy relationship and you give them an accurate understanding of the pain you really are in, since kids are perceptive, they can tell, just like a pet.

What qualifies me to say all this?  I also have diagnosable fibromyalgia.

This is me now!



They don't because I would be required by my insurance to take antidepressants, and having been recovered from: Bipolar I, Severe, with psychotic features for 3 years only to basically get PTSD from the shitty healthcare, but when I hear of these folks wasting the time of the rheumy's at Mayo to get fibro diagnosed on some "support page" I am sickened.

But these, and as much as I hate to say it, as Elizabeth Weiss is a fellow sufferer of RSD, she too, allows her pain to be her slave and master.  She lays in bed day after day and is clearly taking the narcotics-the oxy and the duragesic, and though many people do need to change every 48, particularly those who are of tolerance, she has many very full bottles of neurontin that she doesn't touch.

That is most likely to help her.  But with Independently mediated pain, the first thing she needs is to get where people are going to if need be, and this is my opinion-as an RSD sufferer and as an RN- make damned sure she gets daily therapies as she desperately needs it.  For example, with Dr. Schwartzmann, he generally doesn't prescribe ANY narcotics, and with kids, a 2 hour a day EXERCISE program.

My body has been ruined by pain specialists and docs who couldn't tell their asses from a hole in the wall.
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When is Rx-Opioid “Addiction” Something Else?

Thursday, August 23, 2012

When is Rx-Opioid “Addiction” Something Else?

Addiction2The onerous specter of addiction resulting from the long-term administration of opioid analgesics in patients with chronic pain has often been raised in reports from various sources and in sensational news stories. In actuality, “addiction” is probably one of the most overused and misunderstood terms in medicine, and the absolute risks of addiction newly emerging during analgesic therapy are still uncertain. Now, a recent article suggests that addiction might be better understood in patients receiving opioid therapy as a complex persistent opioid dependence; however, this may be an oversimplification.

Illicit opioids, like heroin, are well-known to produce an addiction disorder in persons who repeatedly abuse the substances for their mood-altering effects. At the same time, medicinal opioids are powerful analgesics that, when properly prescribed and used, can provide vital relief of physical pain and emotional suffering. Within the medical community there is ongoing concern about how opioid analgesics can be safely prescribed long-term for treating chronic pain without the unintended consequence of new (de novo) addiction arising as a direct result of the therapy (iatrogenic).

Writing in an early online edition of the Archives of Internal Medicine, Jane Ballantyne, MD, Mark Sullivan, MD, PhD, and Andrew Kolodny, MD, present their opinions regarding addiction in persons who are administered opioid analgesics continuously and long-term [Ballantyne et al. 2012]. In these patients, they contend that, “biologically, opioid addiction can be understood in terms of neuroadaptations,” with two of those being tolerance and dependence.
  • Tolerance, they note, is the need for increasing opioid dose to maintain the same effects. It may develop for both the euphoric and analgesic effects of opioids, and it can be influenced by psychological as well as pharmacological factors.
  • Dependence is the physiologic response either to an uncompensated increase in tolerance or to the withdrawal of a drug. The latter is revealed as unpleasant symptoms — eg, sweating, anxiety, insomnia — as well as hyperalgesia (increased pain sensation) and anhedonia (inability to feel pleasure). Withdrawal hyperalgesia and anhedonia may explain the worsening of pain and mood that is seen during an opioid taper or after detoxification; although, pain may be augmented by psychosocial stressors that influence a perceived need for more opioid medication.
The authors assert that withdrawal symptoms are powerful drivers of opioid seeking. In this regard, addiction is further defined by aberrant behaviors that, when persistent, “result in irreversible changes in the brain.”

The authors concede that “standard drug addiction criteria have long been unsatisfactory when attempting to assess iatrogenic addiction in persons with pain.” For the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [discussed in prior UPDATE here], tolerance and withdrawal — classified as “physical dependence” — will be specifically excluded from the diagnostic criteria for iatrogenic substance-use disorder (eg, addiction), so that the diagnosis will be based solely on behavioral factors denoting aberrant drug seeking and use.

However, the authors further acknowledge that drug-seeking behaviors in patients with pain are different from those listed in standard substance-use disorder criteria, and are focused on obtaining opioids from prescribers. Therefore, they claim such “aberrancy” might include “doctor shopping, frequent lost prescriptions, and repeated requests for early prescriptions.” Meanwhile, behaviors listed in DSM-5, and the present DSM-IV, such as “failure to fulfill major role obligations at work, school or home,” can readily be attributed to pain rather than to addiction.

In fact, they state, “pain patients who are treated continuously with opioids may not manifest any aberrant behaviors because they are effectively receiving maintenance therapy, which suppresses craving.” However, the authors believe that opioid craving and addiction behaviors may emerge if opioids are suddenly not available, tolerance occurs, or attempts are made to taper the medication.
In the past, such behaviors have been attributed to “pseudoaddiction,” which Ballantyne and colleagues assert is “a misleading term that suggests that aberrant opioid seeking is predominantly a consequence of inadequate pain relief and should be addressed by increasing opioid dose.” As a concept, pseudoaddiction implies that opioid seeking will cease if an “adequate dose is reached,” but the authors assert that this is not apparent in the long-term treatment of chronic pain with opioids.

To exemplify their position, the authors point to fairly recently implemented opioid prescribing regulations in Washington State, where two of the authors are located (Ballantyne and Sullivan). New rules set a ceiling threshold on daily morphine-equivalent opioid dosing for chronic pain that would require consultation with a pain specialist, unless the patient is already functioning well at a stable or tapering dose.

As the rules came into effect, the authors recall that clinicians started to taper high-dose opioid therapy in their patients. “In some cases, this tapering has occurred because the rule has been misunderstood, leading prescribers to taper doses in patients who have been stable for years, resulting in the reemergence of severe pain and extreme anhedonia, both of which are likely to be withdrawal effects,” the authors state.
The lesson learned from this is that withdrawing patients from well-established, long-term opioid therapy can destabilize them, incurring craving and “aberrant behavior.” The authors claim that, “The opioid dependence that we once believed to be short-lived or easily reversed is sometimes seen to persist as complex persistent dependence for months after a taper” [emphasis added].

Ballantyne et al. observe that the persistent opioid dependence is both physical and psychological, and is not easily reversible. They say that many patients treated long-term with high-dose opioids are unwilling to taper the medication despite “continuing pain and known risks.” For such “recalcitrant cases,” understanding dependence and accepting that it may require therapy similar to addiction maintenance treatment — including a structured environment, ongoing counseling, and monitoring — “will go a long way toward being able to treat the patients without removing a class of medications on which they have become dependent,” they state.

However, at the same time they assert, “In light of new evidence that is revealing the limitations and dangers of high-dose long-term opioid therapy, we can and must question the wisdom of providing such therapy in the first place.” They do accept that patients who are already dependent on opioid therapy should not be abandoned; but, “The question is whether to maintain these patients on a regimen of opioids with the usual precautions or to try to taper their doses at least to a safer level.”

COMMENTARY: Unclear Distinctions

The title of this paper by Ballantyne and colleagues — “Opioid Dependence vs Addiction: A Distinction Without a Difference?” — is beguiling, but confusing. They actually do not clearly define distinctions between dependence and fully manifested opioid addiction; instead, the authors seem to conflate addiction in patients treated for pain with their concept of a persistent dependence syndrome and suspected aberrant behaviors.

They acknowledge that the usual criteria for diagnosing opioid addiction are not appropriate in patients treated for pain and conclude, “Whether or not it is called addiction, complex persistent opioid dependence is a serious consequence of long-term pain treatment that requires consideration when deciding whether to embark on long-term opioid pain therapy as well as during the course of such therapy” [emphasis added]. Certainly, this interpretation of addiction is intended to question the prudence of starting or continuing opioid therapy for chronic pain.

It should be noted that all 3 authors were cosigners of a recent petition to the FDA requesting opioid analgesic labeling changes that would restrict prescribing dose and time limits, and confine use to only severe pain in the case of noncancer conditions [discussed in UPDATE here]; so, there may be some biases reflected in this journal article. It is disappointing that they do not provide any research-based data on the incidence and severity of “complex persistent opioid dependence,” so the reader is left to wonder if this occurs in all patients and to the same degree.

Based on the receptor-based pharmacology of opioids, it has long been understood that during continuous administration, there is a potential for physiologic dependence to develop over time, namely tolerance and adverse withdrawal effects. However, in principle, is this sort of dependence so vastly different than occurs with other medications for chronic conditions, such as certain antidepressants or cardiac agents and many other long-term pharmacotherapies?

With any of these, patients need to be informed at the outset that taking the medication may incur certain adverse effects and become a lifelong therapy, and that discontinuing the regimen may be difficult, uncomfortable, and/or result in exacerbation of their medical condition. In balance, however, the medication may allow patients to live more functionally normal and productive lives.

A question not asked by Ballantyne and colleagues is: Would a fully informed patient with chronic pain, knowing the risks of dependence, still consent to long-term opioid therapy? Without the prospect of better, more effective alternative therapies, it might be surmised that a great many patients would likely answer “yes.”

Of course, a key difference is that persons with depression or heart conditions typically do not have to worry about receiving ongoing and adequate prescriptions for their medications; whereas, the continuation of adequate opioid therapy for chronic pain is much less certain in today’s climate of opioid regulation, plus concerns about nonmedical use or diversion with attendant overdose and death.
While Ballantyne et al. dismiss pseudoaddiction as a valid concept, it still seems understandable that, faced with uncertainties about a continuing and adequate supply of medication, bona fide patients who are physiologically dependent on opioid analgesics might exhibit what some consider “aberrant drug-seeking behaviors.” For example, although it is not to be condoned, some patients might “doctor shop” to assure alternate sources of vital analgesics.

Furthermore, in an interesting article on the subject, Alford et al. [2006] describe a condition of “therapeutic dependence” whereby patients exhibit what is considered drug-seeking because they fear the reemergence of pain and/or withdrawal symptoms from lack of adequate medication; their ongoing quest for more analgesics is in hopes of insuring an acceptable level of comfort. These authors also propose “pseudo-opioid resistance” as describing patients with adequate pain control who continue to report pain or exaggerate its presence, as if their opioid analgesics are not working, to prevent reductions in their currently effective doses of medication.

Clearly, these situations pose dilemmas for both patients and prescribers. Ballantyne et al. [2012] caution that embarking on long-term opioid therapy must be cautiously considered at the outset, with well-informed patient consent. And, once this therapy is started, they allow, these patients should not be abandoned and opioid analgesia should be viewed as other ongoing therapy for a chronic condition that may last a lifetime, including a supportive and structured clinical environment with patient monitoring and counseling as appropriate. That sounds like good old-fashioned sound medical practice.

Backstory Sheds More Light

A great deal more can be written on this subject of opioid addiction versus dependence in patients with pain, and the true distinctions. But, to limit the discussion, we should note that some aspects of the present article by Ballantyne et al. [2012] may be unclear because, in many respects, it appears to be a shorthand version of an earlier, longer, and much more enlightening review article by the lead author, Jane Ballantyne (along with Steven LaForge) [Ballantyne and LaForge 2007].

In this earlier article, Ballantyne and LaForge point out that drug-seeking behaviors associated with opioid analgesic withdrawal “must be distinguished from long-term drug craving and the compulsive drug-seeking of addiction.” They explain at great length how true addiction is a quite complex multistage syndrome with neurobiological, psychosocial, and genetic components that manifest as an enduring pattern of deviant behaviors.

They also stress that inconsistencies in addiction terminology have greatly confused attempts to define and measure iatrogenic opioid addiction resulting from its use during pain treatment. Psychological and physical dependence may arise independently of addiction in persons with pain, and problematic opioid use and other aberrant behaviors once thought to be cardinal symptoms of addiction or substance abuse are inapplicable in the pain management setting.

Ballantyne and LaForge further assert that physiological dependence is a common and natural consequence of long-term opioid administration, and it might start to develop after as few as 3 days of continuous opioid use. However, in some cases, tolerance may relate more to disease progression or a change in pain status requiring added medication and can be mistaken for analgesic tolerance. The picture is further complicated by psychiatric comorbidities in persons with chronic pain, which can distort the presentation of physical and psychological symptoms of dependence as well as problematic opioid use.

Very importantly, Ballantyne and LaForge also state the following…
“When patients are maintained on opioids for the treatment of pain, there is currently no satisfactory means of distinguishing true addiction from problematic behaviors caused by a variety of factors other than addiction. Unfortunately, advances in understanding the neurobiological foundation of addiction have not been matched by any improvement in physicians’ ability to recognize and diagnose the condition. There is no single diagnostic marker of addiction, no definitive change on brain imaging and as yet no genetic markers to provide a reliable prognosis of risk. When it comes to iatrogenic opioid addiction, the clinician is faced with even greater difficulty: the behaviors encountered do not resemble those outlined in the criteria for addiction to illicit drugs.”

“One of the great difficulties of quantifying, recognizing, and treating iatrogenic opioid addiction is the subjective nature of the judgment on whether behaviors have crossed an ill-defined boundary between problematic opioid use and addiction. This judgment then becomes dependent on the reporting person’s experience, prejudices, and knowledge.”
Given the difficulties of definition, observation, and measurement — and potential influences of bias and prejudice — it is not surprising that estimated risks, prevalence (which includes pre-existing substance-use disorders), and incidence rates of de novo iatrogenic opioid addiction in persons treated for chronic pain have varied widely. Ballantyne and LaForge describe in some detail (with references) how reported addiction rates during opioid analgesic treatment have ranged from 0.03% to 50%, with discrepancies being clearly dependent on criteria used by investigators to define alleged addiction. Much of the data also have been discussed in a Pain-Topics e-Briefing report [2008, PDF here].

An often-cited systematic review of 67 studies by Fishbain et al. [2008] found opioid abuse/addiction incidents rates of 0% to 50% among patients in pain treatment. Of 2,507 patients studied, there were only 82 with alleged addiction for an overall incidence of 3.27%. However, none of the investigators used validated criteria of addiction and most cases represented signs of physiological dependence, problematic opioid use, and/or drug-seeking behaviors rather than observations of what might be construed as true addiction in patients with pain.

Two fairly recent and frequently-cited studies by Boscarino and colleagues [2010, 2011; also discussed by Twillman in an UPDATE here] used validated DSM-IV and DSM-5 criteria of addiction to assess patients receiving long-term opioid therapy for chronic noncancer pain. They reported that 26% of subjects met criteria for current opioid addiction and 35% to 36% for lifetime addiction; although, it is not known what percentage was de novo iatrogenic addiction. Furthermore, as conceded above by Ballantyne et al. [2012] and Ballantyne and LaForge [2007], without significant adjustments, DSM criteria are inapplicable or misleading in persons with chronic pain; so, the findings of Boscarino et al. are most likely distorted and invalid.

The most convincing evidence of this misrepresentation had been presented in a study by Elander et al. [2003]. Using standard DSM-IV criteria they found that 31% of a sample of patients with sickle cell disease taking opioids for pain met criteria for substance dependence (ie, addiction) — remarkably similar to the results of Boscarino et al. However, when the assessment was limited to only non-pain-related symptoms, the addiction incidence rate fell to merely 2%. In other words, if symptoms that could be related to seeking pain relief are discounted, radically fewer patients meet criteria for addiction. (This study also was acknowledged by Ballantyne and LaForge [2007] in their paper, but was not referenced by Boscarino et al.)

If nothing else, the extreme range of alleged “addiction” reported in the various studies to date suggests that little is known about the true risks and occurrence rates of this disorder in persons with chronic pain maintained on long-term opioid therapy. As Ballantyne and LaForge state, “Overall, there remains considerable uncertainty about rates of iatrogenic opioid addiction, and this uncertainty is largely related to lack of consensus on definition and on the distinction between problematic opioid use and true addiction.”

However, it should be recognized that, even though de novo iatrogenic opioid addiction rates among pain-treated patients are largely unknown, it still might be expected that substance abuse or addiction could be present in the population of persons with chronic pain to an extent worthy of concern. This is accepting that the prevalence of abuse/addiction in persons with pain might match that of the general population, which some authorities estimate to be 13% [in Jones et al. 2012]. This takes into account that a certain percentage of persons coming into pain treatment may have current or past substance-use disorders, whether abuse or addiction and related to opioids or to other drugs including alcohol.

Opioid-treated patients with pain who develop addiction during treatment undergo the same initial physiological adaptations as illicit opioid users, Ballantyne and LaForge [2007] observe. “Yet in pain patients,” they state, “the clinical picture of progression from use to problematic use to addiction differs markedly from that in illicit users. Continued use in an illicit setting often progresses rapidly to addiction, to the extent that dependence and addiction are indistinguishable, and this rapid progression is likely accounted for by the circumstances and motivations associated with illicit use.”

However, in patients with pain the picture is different. If the progression from simple dependence through problematic use to addiction occurs, it is more subtle and insidious. While, addiction may emerge as a separate syndrome, it is less obvious and much more difficult to identify in pain treatment settings, but it is distinct from physiologic dependence.

Ballantyne and LaForge acknowledge that the most difficult question is whether certain patients should be excluded from opioid pain treatment altogether, which raises thorny ethical dilemmas. While it might be assumed that patients with known substance-use disorders carry inordinate risks of problematic use or addiction during opioid therapy for pain, the authors claim that “evidence to date suggests that even these high-risk patients do not necessarily present an increased risk during pain treatment.”
In part, this may relate to the fact that the opioid itself is only one component of much more complex circumstances involving psychosocial, genetic, and other factors that foster addiction. Thus, Ballantyne and

LaForge propose, “provided the treatment is ‘medicalized,’ and the circumstances associated with abuse are avoided, it is possible that the drug itself will not reinstate addiction.”

These authors emphasize that more research is needed to find ways of better identifying risk and deterioration factors leading to iatrogenic substance abuse or addiction. Also, it would seem that better protocols are needed for comfortably tapering patients off of opioids if that becomes necessary, along with safe and effective options for replacing analgesia in these patients so they are not left to suffer without hope of pain relief.

Concluding Notes on Addiction — Distinctions Do Make a Difference

Green-Eyed MonsterA great deal has been written about addiction — what it is, who develops it, how it destroys lives. Yet, relatively few healthcare professionals really understand the true and vicious nature of the disease. Even persons who once became lost in the dark labyrinth of addiction, and later found their way out through an ongoing program of recovery, can at best describe the “green-eyed monster” that prowled the passageways as cunning, baffling, and powerful.

In an interesting essay on “The Role of Addictions in Human Culture” [here], Vikas Shah observes that various psychoactive drugs have been used and abused by humans for thousands of years, but only toward the end of the 19th century did “addiction” begin to be used in describing a preoccupation with drugs.

Opium and its opiate derivatives were openly and legally used in the U.S. and many other countries until the beginning of the 20th century, and alcohol was thought to cause far more health damage — in fact, opium or morphine was used as an alcohol substitute to treat alcoholics.

During the 20th century addiction took on new meaning; that of an uncontrollable “disease.” This disease — referred to as “dependence” by the American Psychiatric Association and World Health Organization — was characterized by the state of needing or depending on a substance “for support or to function or survive...,” which presents as “...a cluster of cognitive, behavioral and physiologic symptoms that indicate a person has impaired control of psychoactive substance use and continues use of the substance despite adverse consequences....”

At greater length, about a year ago in August 2011, the American Society of Addiction Medicine (ASAM) came out with a new Policy Statement [here] presenting their definition of the disease of addiction. The short version states:
“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”

“Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”
ASAM stresses that those descriptive features are not intended to be used as “diagnostic criteria” for determining if addiction is present or not, and each feature may not be equally prominent in every case [also discussed in an UPDATE here]. Application of their definition to persons with chronic pain is not discussed by ASAM, but they emphasize that diagnosis of addiction requires a comprehensive biological, psychological, social, and spiritual assessment by a trained and certified professional. It is significant that the organization recognizes spiritual manifestations as worthy of notice, and that addiction is a progressive and potentially deadly condition.

In The War of the Gods in Addiction [2009, here, pp 4-5], psychoanalyst David E. Schoen, LCSW, MSSW, describes rather dramatically what he believes are two essential components of addiction…
“First, the addictive substance… must ultimately take over complete and total control of the individual, psychologically. That is, it must take over control of normal ego functioning — thoughts, emotions, perceptions, motivations, judgments, decisions, actions, and behaviors.”  
“And the second part of this definition is crucial: the addiction takes over control in an inherently destructive and ultimately life threatening way. It is not an addiction unless it is a death sentence… of the mind, of the emotions, of the body, and of the spirit. It is a death sentence to the addict’s career, community, marriage, family and friends. It is not an addiction unless it has the lethal capacity and potential, the power to kill the individual. It is not an addiction unless it is the most powerful, controlling, possessing, dictating, and determining agenda in the psyche. It must take precedence over everything else.”
If one accepts this definition, then addiction is a quite significantly different and distinct “beast” from the complex persistent dependence described by Ballantyne et al. [2012]. Addiction is not a term or a diagnosis to be applied casually or dispassionately; for those truly afflicted, it is of life-consuming and mortal consequence.

Of further concern, Schoen’s characterization is how many persons with unrelieved pain might describe their condition as a “death sentence” — substituting the words “chronic pain” for “addictive substance” or “addiction” in the above description. And, regarding mortality, some research has indeed demonstrated significant links between unrelieved chronic pain and premature death [UPDATE here], as well as increased suicide risk [see UPDATE here and here] in these patients.

The prospect of dire outcomes for patients without relief of chronic pain is something to consider when debating whether long-term opioid therapy, even with its attendant physiological dependence, might be suitable. Or, in deciding whether opioid analgesics should be tapered or discontinued in a patient stabilized on adequate dosing, no matter what the dose or the duration of therapy.



REFERENCES:
  • Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006;144:127-134.
  • Ballantyne JC, LaForge KS. Opioid dependence and addiction during opioid treatment of chronic pain. Pain. 2007;129(3):235-255 [abstract].
  • Ballantyne JC, Sullivan MD, Kolodny A. Opioid Dependence vs Addiction: A Distinction Without a Difference? Arch Intern Med. 2012(Aug 13); online ahead of print [abstract].
  • Boscarino JA, Rukstalis MR, Hoffman SN, et al. Prevalence of prescription opioid-use disorder among chronic pain patients: comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011;30:185-194.
  • Boscarino JA, Rutstalis M, Hoffman SN, Han JJ, Erlich PM, Gerhard GS, Stewart WF. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system Addiction 2010; 105:1776-1782.
  • Elander J, Lusher J, Bevan D, Telfer P. Pain management and symptoms of substance dependence among patients with sickle cell disease. Soc Sci & Med 2003;57:1683-1696.
  • Fishbain DA, Cole B, Lewis J, Rosomoff HL, Rosomoff RS. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Med. 2008;9(4):444-459.
  • Jones JD, Mogali S, Comer SD. Polydrug abuse: A review of opioid and benzodiazepine combination use. Drug Alcohol Depend. 2012;125:8-18.
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