tag:blogger.com,1999:blog-49475381733412452892024-03-24T16:31:52.913-07:00Complex Regional Pain Syndrome:This is MY life, doc!My thoughts, feelings, and opinions, as yes, though in continuous agonizing pain, underweight for six foot, I can think. And feel. And wonder why they treat this the way they do. I don't run and if I walk, not on a wheel.Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.comBlogger231125tag:blogger.com,1999:blog-4947538173341245289.post-23924100940380728052012-10-15T11:41:00.000-07:002012-10-15T11:41:03.979-07:00Pregabalin and Gabapentin for Neuropathic Pain and CRPS<b>Pregabalin and Gabapentin for Neuropathic Pain and CRPS</b><br />
<br />
<span style="font-size: x-small;"> </span><br />
<span style="font-size: x-small;">By Brett R. Stacey, MD, and Pamela Campbell, MD</span><br />
Comprehensive Pain Center, Oregon Health & Science University,
Portland, Oregon
<br />
<div class="style2">
<br /></div>
<div class="style2">
Recently, pregabalin (Lyrica®) was approved by the Food
and Drug Administration (FDA) for the treatment of post herpetic
neuralgia (PHN) and painful diabetic peripheral neuropathy
(DPN). Pregabalin has a chemical structure similar to gabapentin
(Neurontin®), a medication originally developed to treat
seizures that is now widely used to treat many varieties of
neuropathic pain including CRPS. Both medications reduce
pain by normalizing overactive pain pathways. Pregabalin is
the first drug ever approved in the United States for two
different neuropathic pain conditions. We believe it will
be an important treatment option for many patients with CRPS. </div>
<div class="style2">
<br /></div>
<div class="style2">
Gabapentin has been a great advance in treating CRPS and
neuropathic pain. In addition to its effectiveness, it is
very safe, with no reports of fatal overdose or organ failure.
However, it does not work for everyone and sometimes the side
effects are very bothersome. Does pregabalin offer an improvement?
</div>
<div class="style2">
There are currently at least six large studies with pregabalin
for the treatment of PHN and DPN. In these studies pregabalin
shows up to a 50 percent decrease in pain scores. This is
better than the roughly 30 to 40 percent reduction in pain
scores observed in the trials of gabapentin for the same indications.
In addition to pain relief, patients treated with pregabalin
report improvements in sleep, mood, and day-to-day function.
Because of its longer half-life, pregabalin can be dosed on
a twice a day schedule. (Gabapentin is dosed three times a
day.) At high doses, much of the gabapentin is never absorbed
from the bowel, whereas pregabalin is easily absorbed at all
doses, making for more predictable dosing. Data suggest that
pregabalin can begin reducing pain as quickly as one day after
it has been started. This is quicker than ever reported with
gabapentin. Finally, preliminary results from a study of patients
with neuropathic pain who had not responded to gabapentin
and two other medicines shows that even in those patients,
pregabalin can provide significant relief. The majority of
patients in this study (who had PHN and DPN) strongly preferred
pregabalin to gabapentin.<br />
<br />
In addition to neuropathic pain, pregabalin has been shown
to be effective in fibromyalgia pain, the pain after spinal
cord injury, and anxiety. </div>
<div class="style2">
<br /></div>
<div class="style2">
Pregabalin comes in 8 dosage strengths from 25mg up to 300mg.
All capsule sizes are the same price Roughly 1,800 mg of pregabalin
is approximately $90, while pregabalin twice a day for all
doses is around $118.<br />
<br />
Gabapentin and pregabalin have similar side effects. The most
common are dizziness and sedation. Patients placed on gabapentin
usually experience side effects as they titrate slowly up
to an effective dose, which is roughly 1,200 to 3,600 mg per
day. Conversely, for patients taking pregabalin the typical
starting dose of 150 mg per day can be helpful.. The range
of effective doses is 150 to 600mg per day. For both medications,
side effects tend to decrease over time. Less common side
effects include peripheral edema and weight gain especially
when taken in combination with oral hypoglycemics.<br />
<br />
Pregabalin is categorized by the FDA as a schedule V drug,
the lowest level of surveillance from the FDA. This means
it is a controlled substance.<br />
<br />
The earliest reports of gabapentin's use in treating pain
were case reports of a few patients with CRPS who improved
with gabapentin. Unfortunately, there have never been larger,
controlled studies that definitively prove the benefits of
gabapentin. As of yet, there are no studies in CRPS for
pregabalin. CRPS and all other nerve pathology other than
PHN and DPN are considered off label since studies in nerve
pain have only been done in these specific conditions. </div>
<div class="style2">
<br /></div>
<div class="style2">
<span style="font-size: large;"><b>Our clinical experience</b></span>
</div>
<div class="style2">
Here at Oregon Health & Science University, we have 8
years of research experience with pregabalin and since September
of 2005 many of our patients have received it. Almost every
patient converted to pregabalin from gabapentin prefers pregabalin
either because of improved pain control or fewer side effects.
Some patients have pain relief immediately. As everyone reading
this knows, treating neuropathic pain is challenging, so pregabalin
certainly doesn't work for everyone. Our experience coupled
with the extensive research supporting its use in other painful
conditions makes us optimistic that pregabalin will prove
to be a valuable tool in treating CRPS.<br />
</div>
<div align="right" class="style2">
<em>Updated August 14, 2006</em></div>
<div align="right" class="style2">
</div>
<div align="right" class="style2">
<a href="http://rsdsa.org/Research_Articles/stacy_campbell_pregabalin_gabapentin.htm" rel="nofollow" target="_blank">12http://rsdsa.org/Research_Articles/stacy_campbell_pregabalin_gabapentin.htm</a><em> </em></div>
Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com8tag:blogger.com,1999:blog-4947538173341245289.post-35501323559441581102012-10-15T11:30:00.000-07:002012-10-15T11:30:01.347-07:00Q & A About Methadone (RSDSA-Reviewed 10/09/2006)00<div class="style2">
<span style="font-size: large;"><b> Q & A About Methadone</b></span></div>
<div class="style2">
</div>
<div class="style2">
<br />
By Lynn R. Webster, MD, FACPM, FASAM <br />
<span style="font-size: x-small;">Medical Director, Lifetree
Pain Clinic<br />
Medical Director and CEO, Lifetree Clinical Research,
Salt Lake City, Utah </span></div>
<div class="style2">
<br /></div>
<div class="style2">
<br /></div>
<div class="style2">
<b><span style="font-size: large;">Q. What are methadone's benefits and potential dangers?</span><br />
</b>Research demonstrates that methadone can be effective in
treating some forms of neuropathic pain but also requires
specific knowledge to use safely. Several states have recorded
increases in accidental overdose deaths, many of them involving
methadone. More research is needed into the exact reasons
for the deaths, but at last some contribution appears to be
tied to methadone prescribed for pain. There is difficulty
in analyzing methadone's distinct contribution because lethal
blood levels may vary depending on the decedent's degree of
opioid tolerance, the severity of chronic pain and the action
of polydrug combinations. Levels of methadone typically reported
as a cause of death may actually be therapeutic in some chronic
pain patients on long-term methadone therapy. Regardless,
methadone does present some unique pharmacologic properties
that need to be understood to utilize it safely. </div>
<div class="style2">
<br /></div>
<div class="style2">
<b><span style="font-size: large;">Q. What should a clinician know about methadone before
prescribing it for pain? (YES, pain, not "just" addiction, as if that is to be taken any more lightly!!!)</span></b></div>
<div class="style2">
<b><span style="font-size: large;"> </span><br />
</b><i>Pain experts typically administer opioids in the belief that
patients quickly develop near complete tolerance to respiratory
depression</i>. Research is beginning to indicate that clinicians
may underestimate the risk of respiratory depression, particularly
in the initial conversion to methadone. <i><b>Methadone is eliminated
from the body at a slower rate than many other opioids. Its
long, variable half-life averages around 48 hours but can
be up to 100 hours. Methadone's properties increase its potential
for polydrug interactions</b></i>. </div>
<div class="style2">
<br /></div>
<div class="style2">
<span style="background-color: magenta;">Also, if patients defy medical
direction and escalate methadone doses in an attempt to control
their pain, the results can be lethal.</span></div>
<div class="style2">
<br /></div>
<div class="style2">
<br /></div>
<div class="style2">
<b><span style="font-size: large;">Q. What is methadone's relationship to sleep?</span></b></div>
<div class="style2">
<b><span style="font-size: large;"> </span><br />
</b>Methadone-related deaths may be influenced by a patient's
dosing schedule, including time of the last dose of the day
in relation to the onset of sleep. In particular, the presence
of sleep apnea appears to pose a risk: New research suggests
a relationship between doses of methadone and increased incidence
of sleep apnea, particularly in combination with benzodiazepines.
If patients are at risk for sleep apnea, clinicians are advised
to obtain a sleep study to determine whether patients require
supplemental oxygen, continuous positive airway pressure (CPAP)
or some other support to safely consume methadone for pain.</div>
<div class="style2">
<br /></div>
<div class="style2">
<br />
<b><span style="font-size: large;">Q. What is the safe approach to an initial dose of methadone?</span><br />
</b>Clinicians are advised to start methadone therapy with a
low dose and titrate slowly to an analgesic effect. Published
conversion tables are inadequate in giving equianalgesic doses
of methadone compared to other opioids. Cross tolerance from
other opioids to methadone is incomplete, and the tables are
designed for a single dose, not for chronic administration.
The result may be a recommended starting dose that is too
high.</div>
<div class="style2">
For now, safe practice supports starting methadone with a
ceiling dose of no more than 20 mg/day (10 mg/day for elderly
or infirm patients). Dose changes should not occur more often
than weekly to allow a steady state of methadone to develop
and for the peak side effects to become clear. For patients
who are being converted from another opioid to methadone,
clinicians should slowly titrate downward the other opioid
as they slowly titrate methadone upward. This practice will
minimize the risk of withdrawal and the risk of overdose involving
either methadone or a combination of the two opioids.</div>
<div class="style2">
<br /></div>
<div class="style2">
These guidelines represent a more conservative recommendation
than seen elsewhere. Certainly, some patients are able to
tolerate a much more rapid conversion or titration. Nevertheless,
given the reports of deaths associated with methadone, these
starting guidelines should help clinicians ensure patient
safety and give methadone pain therapy a greater chance of
success.</div>
<div class="style2">
<br /></div>
<div class="style2">
<br /></div>
<div class="style2">
<b><span style="font-size: large;">Q. How should patients be counseled?</span></b></div>
<div class="style2">
<b><span style="font-size: large;"> </span><br />
</b>Patient counseling must include an emphasis on following
all medical instructions to the letter: no escalation of doses
and no mixing of methadone with other prescriptions, alcohol
or illicit substances. Patients should be warned that any
deviation in this regard can be dangerous, even fatal.</div>
<div class="style2">
<br /></div>
<div class="style2">
Patients should be apprised of the danger of taking anyone
else's prescriptions and of the need to lock up all prescription
opioids to prevent them being stolen or consumed by others.</div>
<div class="style2">
<br />
</div>
<div class="style2">
<br />
</div>
<div class="style2">
<br />
</div>
<div class="style2">
<b>References</b></div>
<div class="style2">
Center for Substance Abuse Treatment, Methadone-Associated
Mortality: Report of a National Assessment, May 8-9, 2003.
CSAT Publication No. 28-03. Rockville, MD: Center for Substance
Abuse Treatment, Substance Abuse and Mental Health Services
Administration, 2004. Available <a href="http://dpt.samhsa.gov/reports/index.htm" target="_blank">here</a>.</div>
<div class="style2">
<br /></div>
<div class="style2">
Webster LR. Methadone-related deaths. <i>J Opioid
Manage.</i> 2005;1(4):211-217.</div>
<div class="style2">
<br /></div>
<div class="style2">
Webster, LR, Fakata, K. Sleep Apnea Associated with Methadone
and Benzodiazepine Therapy Presented at the American Academy
of Pain Medicine 22nd Annual Meeting, February 22-25, 2006,
San Diego, CA. Poster 165.</div>
<div align="right" class="style32">
RSDSA Review.</div>
<div align="right" class="style2">
<em>Updated October 9, 2006</em></div>
<div align="right" class="style2">
<br /></div>
<div align="right" class="style2">
<em><a href="http://rsdsa.org/Treatment/webster_methadone.html" rel="nofollow" target="_blank">http://rsdsa.org/Treatment/webster_methadone.html</a></em></div>
Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com2tag:blogger.com,1999:blog-4947538173341245289.post-48148670006979166512012-10-15T09:52:00.001-07:002012-10-15T10:02:03.729-07:00Weighing the Results: Patients and specialists share stories about Hyperbaric Oxygenation Therapy<table bgcolor="#FFFFFF" border="0" style="height: 615px; width: 550px;"><tbody>
<tr><td bgcolor="#FFFFFF" colspan="2" height="44" valign="top"><span class="style19">Stories of Hope</span></td>
</tr>
<tr>
<td bgcolor="#FFFFFF" colspan="2" height="16" valign="top"> </td>
</tr>
<tr bgcolor="#FFFFCC">
<td bgcolor="#FFFFFF" colspan="2" valign="top">
<span class="style3"><b>Weighing the Results: Patients and specialists share stories
about Hyperbaric Oxygenation Therapy</b></span><br />
<span class="style3"><b><br />
</b>By Patricia McAdams</span><br />
<span class="style3"> </span>
<br />
While Hyperbaric Oxygenation Therapy (HBOT) promises relief
to many individuals with Reflex Sympathetic Dystrophy (RSD)
and Complex Regional Pain Syndrome (CRPS), everyone's experience
with this therapy is different.<br />
<br />
Glenn J. Shamdas, 48, who has had CRPS for seven years, tried
HBOT because of a recommendation from a friend after she received
a complete remission. He was not helped.<br />
<br />
"I had a total of 20 sessions in four weeks - which is
a commonly prescribed schedule. Unfortunately, in my case,
no significant improvement was experienced."<br />
<br />
Dana Marsolino, 52, who was in two bad car accidents and is
still in a lot of daily pain, found no relief either. "I
tried the hyperbaric chamber four times and had to quit due
to my bad shoulders and neck," she says.<br />
<br />
"I could not tolerate lying inside [the chamber] for
that length of time, no matter how they adjusted the pillows."<br />
<br />
Laura Rentsch, 45, has a somewhat complicated story. She
had 20 sessions over four weeks, but endured considerable
side effects.<br />
<br />
"During the dives I would experience deep pain in my
RSD leg that would subside when we got to the final depth.
I would also experience vertigo frequently after the treatment."<br />
Rentsch said that her swelling calmed down and she had better
range of motion in her foot for some time, but she had also
been given two Pamidronate treatments prior to the HBOT. Pamidronate
helps with constant deep bone pain and she believes this drug
did help her.<br />
<br />
"Ultimately I cannot say the HBOT helped me, but I can't
say that I would not recommend it to others. It may very well
have helped me, but other contributing factors that lead to
less swelling and better range of motion need to be considered.
My treatments occurred during the summer and I generally have
lower pain levels and better range of motion during warmer
weather. And the Pamidronate did reduce the bone pain."<br />
<br />
Susan Rodriguez, who has been a certified hyperbaric specialist
from San Bernardino, Calif., for many years, says that she
has not heard of this problem before. Vertigo is an extremely
unusual side effect. She suspects it may have been triggered
if a patient had an underlying vestibular problem to begin
with. It may have been a result of Rentsch's reaction to the
Pamidronate. It could also be the result of compression or
decompression or other underlying factors.<br />
<br />
Indeed, Rentsch had a severe reaction to the Pamidronate.
It caused sudden hearing loss and extreme tinnitus - a loud
roaring motor sound in her ears. Certain powerful medications,
particularly those given by IV, as Pamidronate was given to
Rentsch, can literally poison the ears of genetically susceptible
individuals. Ear poisoning can affect one's hearing or balance,
or both. In this case, it is possible that an underlying vestibular
problem may have been present.<br />
<br />
<span style="color: red;"><span style="background-color: white;"><u><i><b>A more common side effect of HBOT is claustrophobia. For
some, like Deb Brown, 60, of north central Florida, claustrophobia
was too big a hurdle to overcome. One session was quite enough,
she says. There were only two very small sections of clear
plastic in the particular chamber she was in that she could
look out of during the session.</b></i></u></span></span><br />
<br />
"I dare say it felt like it had done some good,"
says Brown. "Perhaps had I been sedated with an extremely
light sedation, I would have handled it better."<br />
<br />
According to Allan Spiegel, M.D., Palm Harbor, Fl., the claustrophobia
problem is minimal for most of his patients, because his chambers
are like clear glass. Still, about 10 percent of his patients
struggle with this problem, as Brown did. He gives them sedation,
however, if they need it. "Mild sedation works wonders,"
he says.<br />
<br />
"But one of my patients overcomes the problem by closing
her eyes after she lies down on the cot, before being wheeled
into the chamber. For some reason that makes a difference,"
he says. "And then we put some calming music on."<br />
<br />
There are several kinds of chambers used for HBOT. Spiegel
uses Sechrist chambers in his medical center. Rodriguez, however,
prefers Gulf Coast chambers, which she says are somewhat larger.
Patients can sit in these chambers and they will be very comfortable.
These chambers are 13 feet long and five feet around.<br />
<br />
"No one has ever become claustrophobic in our chambers because of the large size," she adds.<br />
<br />
While the effectiveness of this therapy may vary from individual
to individual, for some, it has been a Godsend.<br />
<br />
Tanya Kee, now 33, had a knee injury in 1999, followed by
surgery, which made the knee worse. She developed RSD in her
leg, which put her into a wheelchair.<br />
<br />
About three years after her original injury, Kee learned
about HBOT and went through 56 sessions with success for her
right lower leg and foot.<br />
<br />
"Probably within a half dozen dives, I noticed a difference,"
she says. "Even my friends said that I looked amazing,"
she added, noting that oxygen affects so much of the body.<br />
Kee's leg improved slowly, but steadily. "After about
two months I went from being in a wheelchair for the most
part, to walking and being able to lead a much better life."<br />
<br />
Unfortunately, she had to stop therapy because she sustained
a new injury to her arm at this time that caused her RSD to
spread to her arm, neck, back, neck and right side. She said
that HBOT increases blood flow in muscles and makes her muscles
too painful.<br />
"Prior to that, though, it was a great experience,"
she says. "My leg has not worsened since then. It's still
painful, but I don't use my wheelchair unless we go to Disney
or places where we do a lot of walking."<br />
<br />
Elsie Eten, age 57, had suffered with RSD for nine years
before she learned about HBOT. Eten, who Spiegel calls his
"Poster Child," (See: Hyperbaric Oxygenation Therapy:
Can it relieve your pain?) had endured years of medical procedures
before she met Spiegel and began treatment.<br />
<br />
"I was at a point in my life with the RSD and pain that
I was ready to try anything, or I was ready to die, because
I could not take the pain anymore.<br />
<br />
"After the first few days I could feel the difference,"
she says. "I was feeling better, the pain was less, and
I was taking less pain medication.<br />
<br />
"After four weeks, I was pain free for the first time
in eight or nine years. I slowly quit taking Oxycontin, Loratab,
and Zanax. About two weeks later - six weeks after I began
therapy - I was pain free and drug free. I could not believe
it!<br />
<br />
"I wanted to go back to nursing so badly that I think
I went back too soon. As soon as I was off my medications
I went back to work without getting my body back into shape
and strong. After a month at work, my pain started to come
back. After three months, I had to quit my job because of
my pain. I had to start taking Laratab again too."<br />
<br />
Eten says she goes for HBOT treatments every five or six
months and it still helps. She is unable to work, but she
is able to go out with her husband sometimes and see friends. <br />
"Even though I am not cured of RSD, I feel like I got
some of my old life back. I recommend HBOT for RSD. My doctor
told me when you have chronic pain, it takes a lot of different
modalities to keep the pain at a manageable level and I believe
that."<br />
Connie Waltz, director of nursing at the Robert M. Lombard
Medical Center in Columbia, Pa., where Eduardo Pace is being
treated (See: Beyond Pain: Some hope for healing), has treated
a number of individuals with RSD.<br />
<br />
"Absolutely, I would recommend Hyperbaric Oxygenation
Therapy for RSD," she says, adding that the sooner a
person starts HBOT after they have been diagnosed, the better.
Patients who have had RSD for a long time are tough to treat.
The two patients they had, who were newly diagnosed, had especially
good results.<br />
<br />
"One person stopped after 10 treatments, because of
financial reasons," says Waltz. "She saw amazing
results. She could open her hand and use it. The swelling
went down. The natural pink color returned, instead of a dusky
blue.<br />
<br />
"The other person had it in his shoulder," she
says. "Within 20 treatments, he had range of motion."<br />
<br />
Hyperbaric Oxygenation Therapy appears to be one more tool
in the toolbox of managing chronic pain for many individuals.<br />
<br />
Like Spiegel and Waltz, Rodriguez is passionate about the
ability of Hyperbaric Oxygenation Therapy to make a difference
for patients with RSD.<br />
<br />
"RSD can shatter your life," she says. "Mothers
can't be mothers. Husbands can't support their families. Kids
can't lead normal lives<span style="color: #660000;">.<u><i><b> And no one believes you about the
pain.</b></i></u></span><br />
<br />
"People's lives depend on this therapy," she says.
"Integrated with other ongoing therapies, it holds real
promise."<br />
<br />
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Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com1tag:blogger.com,1999:blog-4947538173341245289.post-6763775447114522772012-10-08T09:03:00.001-07:002012-10-08T09:03:15.398-07:00Pain Management from your STATE (well, the docs? From my perspective, I have had like one good one...lol, so there you have it! You aren't the only ones getting wet guys.<h1 class="c_title">
<span class="TitleHead" id="dnn_ctr5251_dnnTITLE_titleLabel">Pain Management</span>
</h1>
<div class="DNNModuleContent ModDNNHTMLC" id="dnn_ctr5251_ModuleContent">
<div class="Normal" id="dnn_ctr5251_HtmlModule_lblContent">
The legislature passed <a href="http://apps.leg.wa.gov/documents/billdocs/2009-10/Pdf/Bills/Session%20Law%202010/2876-S.SL.pdf">Engrossed Substitute House Bill 2876</a>
during the 2010 legislative session. This bill directs five boards and
commissions to adopt rules concerning management of chronic noncancer
pain. These boards and commissions include the <a href="http://www.doh.wa.gov/LicensesPermitsandCertificates/MedicalCommission/MedicalResources/PainManagement.aspx">Medical Quality Assurance Commission</a>, <a href="http://www.doh.wa.gov/LicensesPermitsandCertificates/NursingCommission.aspx">Nursing Care Quality Assurance Commission</a>, <a href="http://www.doh.wa.gov/LicensesPermitsandCertificates/ProfessionsNewReneworUpdate/Dentist.aspx">Dental Quality Assurance Commission</a>, <a href="http://www.doh.wa.gov/LicensesPermitsandCertificates/ProfessionsNewReneworUpdate/OsteopathicPhysician.aspx">Board of Osteopathic Medicine and Surgery</a>, and <a href="http://www.doh.wa.gov/LicensesPermitsandCertificates/ProfessionsNewReneworUpdate/PodiatricPhysicianandSurgeon.aspx">Podiatric Medical Board</a>.<br />
The professions include: <br />
<ul>
<li>Physicians </li>
<li>Physician Assistants </li>
<li>Osteopathic Physicians </li>
<li>Osteopathic Physician Assistants </li>
<li>Advanced Registered Nurse Practitioners </li>
<li>Dentists </li>
<li>Podiatric Physicians </li>
</ul>
The boards and commissions are committed to protecting and improving
the health of people in Washington State. Overdose deaths and
hospitalizations involving prescription opioid analgesics are
increasing. Washington State has a higher death rate associated with
opioids than the national average. <br />
Each board and commission has adopted their final rules and the department has officially filed the adopted rules. <br />
The goal of the new pain management rules is to keep patients safe
and give practitioners who prescribe opioids the best practices in pain
management. A key component of the rules is to encourage practitioners
to become better educated in the safe and effective uses of these
powerful drugs. The rules contain specific mandatory elements required
by the law, as well as guidance for practitioners who care for patients
with chronic noncancer pain.<br />
Some of the key points for the new rules include: <br />
<ul>
<li>A dosing threshold trigger for consultation with a pain specialist </li>
<li>Criteria to be considered a pain specialist </li>
<li>Elements for a patient evaluation </li>
<li>Periodic review of a patient’s course of treatment </li>
<li>Guidance for episodic care practitioners </li>
<li>Consultation exemptions for special circumstances and for the practitioner </li>
<li>Continuing education</li>
</ul>
Please join our <a href="http://listserv.wa.gov/cgi-bin/wa?SUBED1=WA-PAIN-MGT-PRESCRIBING-RULES&A=1">interested parties list</a>
to receive email notifications about the pain management prescribing
rules. If you already belong to a listserv for one of the professions
listed above, you do not need to join the pain management listserv. We
will send the information to those interested parties lists as well. </div>
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Medical Quality Assurance Commission</h3>
<a href="http://www.doh.wa.gov/portals/1/Documents/3000/MDPAPainMgmt.pdf" tabindex="0">Adopted rules</a> - Effective 1/2/2012<br />
<h3>
Nursing Care Quality Assurance Commission</h3>
<a href="http://www.doh.wa.gov/portals/1/Documents/6000/NursingPainMgmt.pdf" tabindex="0">Adopted Rules</a> - Effective 7/1/2011<br />
<h3>
Dental Quality Assurance Commission</h3>
<a href="http://www.doh.wa.gov/portals/1/Documents/2300/DentalPainMgmt.pdf" tabindex="0">Adopted Rules</a> - Effective 7/1/2011<br />
<h3>
Board of Osteopathic Medicine and Surgery</h3>
<a href="http://www.doh.wa.gov/portals/1/Documents/2300/OsteoPainMgmt.pdf" tabindex="0">Adopted Rules</a> - Effective 7/1/2011<br />
<h3>
Podiatric Medical Board</h3>
<a href="http://www.doh.wa.gov/portals/1/Documents/2300/PodiatryPainMgt.pdf">Adopted Rules</a> - Effective 7/1/2011<br />
<br />
<a href="http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement/AdoptedRules.aspx" rel="nofollow" target="_blank">http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement/AdoptedRules.aspx </a><br />
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<br />
<h3>
Will these rules impact all types of pain management? </h3>
No. The rules do not apply to the treatment of chronic cancer pain or
acute pain caused by an injury or a surgical procedure. The rules also
do not apply to palliative, hospice, and other end of life care.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="2"></a><br />
<h3>
Why is the state doing rules?</h3>
The 2010 legislation requires five boards and commissions that
regulate seven professions to adopt new rules related to chronic pain
management. Three boards and commissions must also repeal current pain
management rules. These boards and commissions have separate
disciplining and rulemaking authority. The legislation requires rules
for each profession. Rules are enforceable, unlike guidelines that are
suggestions.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="3"></a><br />
<h3>
Why is this important?</h3>
Pain management is a dynamic and challenging area of medical care.
This care often includes the use of opioids. Overdose deaths and
hospitalizations involving prescription pain medicine have increased in
Washington State over the past 16 years. In 2009 there were 17 times
more deaths and seven times more hospitalizations than in 1995. The
legislature is concerned about the health risks of managing chronic,
long-term pain, and in 2010 passed Engrossed Substitute House Bill 2876
in response to these concerns.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="4"></a><br />
<h3>
What professions must comply with the rules?</h3>
The legislation specifically names the Medical Quality Assurance
Commission (MQAC), Nursing Care Quality Assurance Commission (NCQAC),
Board of Osteopathic Medicine and Surgery (BOMS), Dental Quality
Assurance Commission (DQAC), and Podiatric Medical Board (PMB).<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="5"></a><br />
<div style="text-align: right;">
<a href="http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement/FrequentlyAskedQuestionsforPractitioners/Background.aspx#Top">Back to Top</a></div>
<h3>
When are the rules effective?</h3>
The rules for osteopathic physicians, osteopathic physician
assistants, dentists, advanced registered nurse practitioners, and
podiatrists are effective July 1, 2011. The BOMS, DQAC, NCQAC, and PMB
are the boards and commissions that adopted these rules. The rules for
physicians and physician assistants are effective January 2, 2012. The
MQAC is the commission that adopted these rules.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="6"></a><br />
<h3>
What about existing rules?</h3>
Three boards and commissions (MQAC, BOMS, and PMB) must repeal
existing pain management rules. The repeal effective dates for each of
the boards and commission are the same as the effective dates for the
new rules.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="7"></a><br />
<h3>
What about other professions who also prescribe?</h3>
There are other professions with prescribing or dispensing authority,
such as optometrists, veterinarians, and pharmacists. The 2010
legislation did not require those professions to adopt rules on this
subject.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="8"></a><br />
<h3>
What was the process to create these rules?</h3>
The five named boards and commissions each appointed two
representatives to form a workgroup. The workgroup developed pattern
rules for consideration by each of the boards and commissions. The
workgroup conducted five open public meetings and provided opportunities
for the public to provide comments. Each of the five boards and
commissions considered the draft pattern rules and filed proposed rules
in January and February 2011. Five public rule hearings were held in
March and April 2011. Each board and commission adopted final rules
after their hearing.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="9"></a><br />
<h3>
Why did the workgroup contain just these professions?</h3>
The workgroup was comprised of representatives from the five boards
and commissions required to adopt rules. The 2010 Legislature did not
require other professions to adopt rules on chronic pain management. The
workgroup and the department did recognize the very important role that
pharmacists and other professions have in this subject matter and input
was sought from other professions and stakeholders.<br />
<br />
<a href="http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement/FrequentlyAskedQuestionsforPractitioners/Background.aspx#1" rel="nofollow" target="_blank">http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement/FrequentlyAskedQuestionsforPractitioners/Background.aspx#1</a></div>
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<h3>
Why is there a requirement to consult a pain specialist?</h3>
The law has several requirements for the rules that are built around
consultation with a pain specialist. These include a dosage amount that
must not be exceeded without consulting a practitioner specializing in
pain management, circumstances when this dosage amount may be exceeded
without the consultation, and rules regarding consultation with a
practitioner specializing in pain management.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="2"></a><br />
<h3>
Are there practitioner exemptions for the consultation requirement?</h3>
Yes. The rules describe the specific criteria to be an exempt
practitioner or to be considered a pain specialist. You are encouraged
to consult your legal counsel for practice-specific questions.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="3"></a><br />
<h3>
For my patient who has been on a dosage regimen higher than 120 mg MED, do I have to consult with a pain specialist?</h3>
Not necessarily. The rules provide exemptions for exigent and special
circumstances. You must document adherence to all standards of practice
defined in the rules for your profession and the patient is following a
tapering schedule, or requires treatment for acute pain, or you
document your reasonable attempts to obtain a consultation, or you
document that your patient’s pain and function is stable and the patient
is on a nonescalating dosage opioids.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="4"></a><br />
<h3>
Will I receive a certificate to show that I am an exempt practitioner or a pain specialist?</h3>
No. The rules do not require that you submit proof to anyone that you
are exempt or a pain specialist. The rules only require that you meet
the required criteria. Practitioners should always retain documentation
that shows they meet education, training, or CE requirements.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="5"></a><br />
<div style="text-align: right;">
<a href="http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement/FrequentlyAskedQuestionsforPractitioners/Consultation.aspx#top">Back to Top</a></div>
<h3>
Who is going to pay for a required consultation with a pain specialist?</h3>
The boards and commissions do not have jurisdiction or authority over
insurance coverage or who will pay for care. The rules do not address
this topic.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="6"></a><br />
<h3>
Is there a list available of the pain specialists in the state?</h3>
No. Licenses are issued by profession and not by specialty. The department does not have a list of pain specialists.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="7"></a><br />
<h3>
There are not enough pain specialists in the state. How is this going to work?</h3>
This is a concern for the boards and commissions. For this reason,
the rules contain options and exemptions related to the consultation
requirement.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="8"></a><br />
<h3>
Why aren’t face-to-face consultations required?</h3>
The boards and commissions understand the challenges that patients
and practitioners in rural areas face when attempting to obtain care.
The rules intend to provide for flexibility for patients and
practitioners in rural or remote locations. The law requires that the
rules minimize the burden on practitioners and patients. Requiring only
face-to-face consultations would have placed a greater burden on
practitioners and patients.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="9"></a><br />
<h3>
Why is an advanced registered nurse practitioner (ARNP) listed as a
pain specialist; but a physician assistant is not included in the list?</h3>
ARNPs are independent practitioners. PAs are not independent
practitioners and work under a supervising physician or osteopathic
physician. The rules do not restrict PAs from providing pain management
care under the supervision of a pain specialist.<br />
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<span class="TitleHead" id="dnn_ctr10006_dnnTITLE_titleLabel">Continuing Education</span>
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Is there a grace period to obtain the continuing education required to be exempt or a specialist?</h3>
No. The boards and commissions determined that the required
continuing education (CE) is attainable within a short period of time.<br />
<h3>
Will the continuing education be monitored?</h3>
No. But, the disciplinary authorities do conduct random audits on
practitioners to ensure the CE requirements are met. You may be asked to
provide copies of completed CE and should always retain these records.<br />
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<h3>
If I took continuing education on pain management three years ago, do I have to take it again in the next three to four years?</h3>
Yes. The continuing education must be completed within the last two
years for physicians, dentists, ARNPs and podiatrists. Osteopathic
physicians must complete the CE every three years which is the CE cycle
for this profession.<br />
<h3>
How much continuing education is required and how often?</h3>
It depends upon your profession.<br />
<ul>
<li>All of the professions included in the rules require 12 hours
within the last two years in order to be exempt from the consultation
requirement. At least two of these hours dedicated to long acting
opioids.</li>
<li>Osteopathic physicians have a three-year CE cycle. They may complete 18 hours within the last three years.</li>
<li>The rules suggest a one-time (lifetime) completion of at least
four hours of CE related to long-acting opioids or methadone. This is
included in the rules because the boards and commissions believe it is
important that practitioners who prescribe opioids should be familiar
with its risks and use. </li>
</ul>
<a href="http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement/FrequentlyAskedQuestionsforPractitioners/ContinuingEducation.aspx" rel="nofollow" target="_blank">http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement/FrequentlyAskedQuestionsforPractitioners/ContinuingEducation.aspx</a><br />
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<h3>
Why do the rules set a morphine equivalent dosage (MED) amount?</h3>
The law requires that the rules must contain dosing criteria to
include a dosage amount that must not be exceeded unless the
practitioner either consults with a practitioner specializing in pain
management or the prescriber or patient are exempt. An MED is used
because one drug is not necessarily the same as another. One drug may
need a higher dosage amount than another to achieve the same result.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="2"></a><br />
<h3>
What table should I use to determine the daily morphine equivalency dose (MED)?</h3>
The rules include a generally accepted definition for MED. The boards
and commissions determined to not include a conversion table in the
rules. Technology, knowledge, and medication changes occur frequently.
Conversion tables could quickly become outdated. The boards and
commissions believe practitioners should be able to decide which
conversion table to use. The Washington State Agency Medical Director’s
Group (AMDG) provides information on dosing guidelines. Please see the
pain management webpage for resources like the AMDG.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="3"></a><br />
<h3>
Is there a separate MED for children?</h3>
No. The legislation does not specify any specific patient population.
The rules were clarified to indicate that the 120 mg MED is for adults
and based on an oral dose. The rules further indicate that great care
should be used with prescribing opioids to children and that appropriate
referral to a specialist is encouraged.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="4"></a><br />
<h3>
If I prescribe below 120mg MED for a patient, do I need to consult a pain specialist?</h3>
No. The mandatory consultation threshold for adults is 120mg MED. A
consultation with a pain specialist is required if the prescribed dosage
amount exceeds 120mg MED orally per day, unless the consultation is
exempted. The exemptions are listed in the rules.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="5"></a><br />
<h3>
If a patient has been at 140 mg MED for several years, do I need to consult a pain specialist?</h3>
No. For a patient with stable pain and function, on a non-escalating
dosage of opioids, the consultation requirement would not be required as
long as the practitioner documents these items.<a href="http://www.blogger.com/blogger.g?blogID=4947538173341245289" name="6"></a><br />
<h3>
Are there exemptions to the consultation requirement?</h3>
Yes. The exemptions are listed in the rules under two sections:
Consultation – Exemptions for exigent and special circumstances; and
Consultation – Exemptions for the (specific practitioner profession
named), for example “dentist”, “physician”, etc.<br />
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Do the rules include a prescription monitoring program (PMP)?</h3>
No. The pain management legislation requires the boards and
commissions to include guidance on tracking the use of opioids. In 2007
the legislature authorized the Department of Health to develop and
implement a PMP when funding is available. The department recently
received a grant and is developing a PMP. The rules include references
to the use of any available PMP or emergency department-based
information exchange.<br />
<h3>
I would like to have a conversation with someone about these rules. Who can I contact?</h3>
We encourage you to review the rules and the FAQs. If you have general questions, please email them to <a class="ApplyClass" href="mailto:mailto:painmanagement@doh.wa.gov">painmanagement@doh.wa.gov</a>.
You can also call 360-236-4997. You may also send technical profession
questions to us and we will direct them to the appropriate board or
commission. For situation specific questions related to your practice,
we encourage you to speak with your legal counsel. <br />
<h3>
Will the state monitor or audit individual practices?</h3>
No. <br />
<h3>
How can I stay informed about implementation of these rules?</h3>
We have created a <a href="http://listserv.wa.gov/cgi-bin/wa?SUBED1=WA-PAIN-MGT-PRESCRIBING-RULES&A=1">pain management listserv</a> and <a href="http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement.aspx">website</a>
to keep people informed. You can join this listserv, or the listserv
for one of the named professions, to receive regular emails about the
pain management. You may also send questions to <a href="mailto:mailto:painmanagement@doh.wa.gov">painmanagement@doh.wa.gov</a>.<br />
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Why is “should” used sometimes and “shall” used at other times?</h3>
The law requires that the rules contain certain mandatory elements
and provide guidance for other elements. For this reason the rules have
requirements for some areas and guidance or recommendations for others.
“Shall” is used to mean “has a duty to,” that is, to require the
performance of the act. “Should” is used to mean a recommendation or
guidance for the act.<br />
<h3>
Is there a grace period before practitioners must comply with the rules?</h3>
No. The requirements begin when the rules are effective.<br />
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<br />
<i>So folks, we are all under heat: the docs are looking at this invasion of their previously respected autonomy. Respect, and then you get caught in the middle. And as for me, " my dope, " what makes me well, seems to lie elsewhere.</i><br />
<br />
<i>But to those who are coming into frustrating arenas when pain docs are <u><b>forced to</b></u> put previously reliable and nonproblematic patients on "contract" it isn't "always" of their own doing.</i><br />
<br />
<i>I got my medical card because I don't want the State OR Federal Government involved in something they don't give a shit enough about except to throw stuff at that probably long term, likely will cause some serious problems.</i><br />
<br />
<i>To follow, Washington's new FAQ on pain management for patients, a few odds and ends: who said it was a free country: </i> </div>
</div>
Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com2tag:blogger.com,1999:blog-4947538173341245289.post-92149634751120814152012-10-08T09:01:00.002-07:002012-10-08T09:01:41.311-07:00Oh, God: sorry folks, a violation-cuz even TRAMADOL (R) falls into this, ketamine, all of it-ONE LIST I INTEND TO STAY THE HECK AWAY FROM ASAP!!! SOON!!!!<h1 class="c_title">
<span class="TitleHead" id="dnn_ctr2895_dnnTITLE_titleLabel">Prescription Monitoring Program (PMP)</span>
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Legislation in 2007 gave the Department of Health authority to
create a Prescription Monitoring Program. The program’s purpose is to
improve patient care and stop prescription drug misuse by collecting all
the records for Schedule II, III, IV, and V drugs. This information is
then made available to medical providers and pharmacists as a tool in
patient care. The state law creating the program is <a href="http://apps.leg.wa.gov/RCW/default.aspx?cite=70.225">RCW 70.225</a>.<br />
<br />
The program is a patient safety tool. Practitioners will have access
to the information before they prescribe or dispense drugs. This will
help to prevent overdoses, prevent misuse, and promote referrals for
pain management and for treatment of addiction.<br />
<br />
The program <a href="http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PrescriptionMonitoringProgramPMP/Rules.aspx">rules</a> (WAC 246-470) became effective on August 27, 2011.<br />
<br />
The program started data collection from all <a href="http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PrescriptionMonitoringProgramPMP/Dispensers.aspx">dispensers</a> on October 7, 2011.<br />
<br />
Providers can now register at <a href="http://www.wapmp.org/practitioner/pharmacist/">http://www.wapmp.org/practitioner/pharmacist/</a>.<br />
<h2>
PMP Legislative Changes</h2>
Substitute Senate Bill 6105 (2012) was signed into law on March 29,
2012. The bill requires the department in collaboration with the
veterinary board of governors to establish alternative data reporting
requirements for the Prescription Monitoring Program by either
electronic or non-electronic methods.<br />
<br />
Information about the rulemaking and how to participate is available on the <a href="http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PrescriptionMonitoringProgramPMP/Rules.aspx">rules</a> page.<br />
<br />
Veterinarians are required to report to the Prescription Monitoring
Program until June 7, 2012. We encourage continued reporting until the
permanent rule is adopted.<br />
<br />
Effective June 7, 2012, the bill also clarifies that controlled
substances dispensed for one day use do not have to be reported to the
PMP.<br />
<br />
For more information, please contact Chris Baumgartner, Program Director, at 360-236-4806 or <a href="mailto:prescriptionmonitoring@doh.wa.gov">prescriptionmonitoring@doh.wa.gov</a>.<br />
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Practitioner Query Site <a href="http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PrescriptionMonitoringProgramPMP.aspx" rel="nofollow" target="_blank">http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PrescriptionMonitoringProgramPMP.aspx</a></li>
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<br />
<i>Well, I am sorry guys, but if this crap doesn't seal your desire to get off this garbage, then uh, well, I am sticking with smoking legal dope with my friends (not on my property thanks, long story, very and equally stupid.</i><br />
<br />
<i>Do you need some hack watching every trip you make to the drug store....what if you buy Sudafed? Well, enough of that: you end up watched in my area by police. Yeah, it's a dangerous world. I am sticking with what works. So hang tight. Lock it all up. I mean it. Don't mess around. If you have to take this, and can't get on and into something like using medical marijuana? Do yourself a favor...and just well, make sure it has a combo, and a key. People get very desperate, and having been the type that would help someone out when I began this journey, it was educational.</i><br />
<br />
<i>I knocked off all but the PRN for the winter. And it sits in it's hiding place, untouched for almost a month...the rest, I dumped. I don't need the headache and hassle, or what it does to the body and mind over time, necessary or not. Consume THC? Every chance I get.</i><br />
<br />
<i>Just not at home, hmmm. Stupid, eh? </i>Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com2tag:blogger.com,1999:blog-4947538173341245289.post-59390129595529863402012-10-08T08:49:00.000-07:002012-10-08T08:49:10.593-07:00While maybe it doesn't work for FB, maybe, doubtfully, it will hereOf course, I probably wasted my time with that.<br />
<br />
Not that they ever pay attention to it.<br />
<br />
<br />
Well, as long as free speech is still legal....and I remember to cite my sources...<br />
<br />
I might settle for being LEFT ALONE except by RSD/CRPS patients who want to learn~or a friend here for a visit....Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com0tag:blogger.com,1999:blog-4947538173341245289.post-88717564602559087422012-10-07T06:47:00.001-07:002012-10-07T06:47:31.572-07:00A Surviveable III? Hmm this RSDer got CASED again...glad I switched to something elseShockingly, this seems to have had moved into adults now: one anyhow. Who wanted dope real bad. Sent a list via email of what I took at the time just to see what she would say. The response all the more inspired me to turn to the magic plant, as my friend {Name withheld, per request} calls it (formerly agoraphobic, poor guy has to go unmedicated for bloody nine months: el zippo, unless he wants prozac shoved down his throat. I don't think anyone here wants to see what psych meds did to this body. After the RSD developed...<br />
<br />
Well, I at I ate as many calories/protein, smothie/shakes until I couldn't anymore: it is what likely saved me from looking worse than now. But nevertheless, turns out that doctors don't just pray on the sick. So do people.<br />
<br />
omeone, unnamed, I got the email (to follow in Word format with Id info removed-even though my feelings, privacy, person, etc was completely violated, and lied to for drugs basically, as you will see, since it reads in part (see, she is in bad pain now-cuz I won't "help" and my new phone isn't listed, etc, and well, see for your self. I formed this because this is one way that I have gotten screwed: people find out you have a shitty disorder like this: like any of us have: Deb, Kat's and it is so retarded. <br />
<br />
I would rather throw some hash in a bowl, and smoke it amongst friends. And really, I am finding out who they really are. They are the ones who, for example: compare who is the first and the last to wish you a Happy Birthday? <br />
<br />
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<object width="320" height="266" class="BLOGGER-youtube-video" classid="clsid:D27CDB6E-AE6D-11cf-96B8-444553540000" codebase="http://download.macromedia.com/pub/shockwave/cabs/flash/swflash.cab#version=6,0,40,0" data-thumbnail-src="http://i.ytimg.com/vi/U_RUZ3863mU/0.jpg"><param name="movie" value="http://www.youtube.com/v/U_RUZ3863mU?version=3&f=user_uploads&c=google-webdrive-0&app=youtube_gdata" /><param name="bgcolor" value="#FFFFFF" /><param name="allowFullScreen" value="true" /><embed width="320" height="266" src="http://www.youtube.com/v/U_RUZ3863mU?version=3&f=user_uploads&c=google-webdrive-0&app=youtube_gdata" type="application/x-shockwave-flash" allowfullscreen="true"></embed></object></div>
That was my decision just a few months ago, beginning treatment with medical marijuana. I made the following video, later on, about fourreen days ago; i was locked out for a while folks, so we have some catching up to do!!!!<br />
<br />
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<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.youtube.com/embed/CsX5H2Kwlng?feature=player_embedded' frameborder='0'></iframe></div>
<br />
<br />
What order does it come in?<br />
More importantly, what unique waus do they do to say it??? To some in my life, well, they screwed the pooch. I am so sorry to say this (not) but I have about had it with doctors! Well, screw it. This winter ends, I am done. I hope to have secured (this isn't a joke, and no it's not to "get high." Call it self preservation and the need to STAY healthy by not going to a doctor. I went to the damn doctor when RSD full body wrecked my vagus? LOL, funny, you guys watched while I got worse. HELLO. I signed out of the damned hospital. Done. I wrote that last day in my former apartment that I couldnot wait to get off this crap so people won't case me. Guess what. One down. Weed. I only want the fine work of Mr Rick Simpson. Right on! This is not a joke. <br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjBQ0Tj1_NsHdVBRUXW9VXYiOsxh3fVDNOUlRNim5I1py1u_owQwLVvsBcJqEeAe6sOV6iTjtPeJ7kJsCKP5yP_6dqzqfbh51bCIlNE9_FL-bq0ntSt3RjaOFkQyo1Z0ijiQIU4XBPZ9YE/s1600/MORE+and+ALL+RICK.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjBQ0Tj1_NsHdVBRUXW9VXYiOsxh3fVDNOUlRNim5I1py1u_owQwLVvsBcJqEeAe6sOV6iTjtPeJ7kJsCKP5yP_6dqzqfbh51bCIlNE9_FL-bq0ntSt3RjaOFkQyo1Z0ijiQIU4XBPZ9YE/s1600/MORE+and+ALL+RICK.JPG" /></a></div>
This is what the Rick Simpson Oil product looks like. I use a 67% strength. The following link discusses CRPS in greater context. I am healthier and happier. I don't want to discuss it anymore. Anything further for me? Is unnecessary. Your dope, whatever that is: ketamine, or combinations to minimalize discomfort...<br />
<br />
The way I see if is we have a disease that violates enough of God's laws, and with every treatment being considered experimental? I am on disability and would rather cut out things like cable tv so this can be possible for me. Someone I still think is an ass was correct about ONE thing: You can choose your health. It's not unreachable to get legal (if you reside in one of the growing number, 17 so far!!!) and in my own opinion, if you are going to be a lab rat, shouldn't you at least have a choice.<br />
<br />
Make it all available to every RSD patient in every state-whether MMJ is legal or not, make a damned exception. The suffering I see amongst friends makes me sick. But when their 'dope' has to be something that keeps them miserable, depressed, I admire those still hopeful. But too sad for them to want to hang out on FB long.<br />
<br />
I do things like hang out at a friend's.<br />
<br />
Starting PT.<br />
<br />
So for me? Who knows, is it "the dope?" Seens to be, so I hope folks fine something for themselves. fast and soon.<br />
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<br />Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com0tag:blogger.com,1999:blog-4947538173341245289.post-9970750789472250252012-09-30T18:04:00.000-07:002012-09-30T18:04:08.122-07:00NEAT 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"<br />
<br />
<img height="2" src="http://www.healthwaveproducts.com/images/bgleft2.gif" width="10" />
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<h1>
H-Wave Therapy Machine</h1>
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<a class="cart" href="http://www.healthwaveproducts.com/Personal-Care/H-Wave-Therapy-Machine.htm#">
<img align="top" alt="H-Wave Therapy Machine" border="0" class="thumbnail" height="289" src="http://www.healthwaveproducts.com/images/H-wave2-L.jpg" width="225" /></a>
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<span>Item #: HWave</span> <br />
What is the H-Wave machine?<br /><br />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.<br />
<ul class="bullet">
<li>Unique, effective technology </li>
<li>Developed & manufactured in the U.S.A.
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<li>Ultra-low frequency stimulation -
improves circulation & increases fluid
shifts </li>
<li>High frequency stimulation - to break
pain cycle </li>
<li>Battery powered & portable </li>
<li>3-channel clinical model </li>
<li>2-channel home model </li>
</ul>
<b>Price:</b> <strike>
$3,100.00</strike> , <span style="color: red;">now
$2,400.00</span>
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<b>Price: $2,400.00</b><br />
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<b> </b><b><img align="top" alt="TBSoya - Tribest Soyabella Soy Milk Maker" border="0" class="X-thumbnail" height="100" src="http://www.healthwaveproducts.com/images/soyabella-S.jpg" valign="top" width="86" /> <span class="blacksmall">Automatic <nobr><a class="FAtxtL" href="http://www.healthwaveproducts.com/Soy-Milk-Makers.htm#" id="FALINK_3_0_2">Soymilk Maker</a></nobr>
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<br /><span class="price">$119.00 Retail</span><br />
<span class="price">$94.95 Your Cost</span></b></b></div>
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<b><b><span class="price">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:</span></b></b></div>
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<b><b><span class="price">It approaches, at least, affordability with NATURAL good health...YUM. I like that!!!</span></b></b></div>
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<b><b><span class="price"><a href="http://www.healthwaveproducts.com/default.htm">http://www.healthwaveproducts.com/default.htm</a> </span> </b></b></div>
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Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com1tag:blogger.com,1999:blog-4947538173341245289.post-91982828048732619672012-09-30T17:56:00.000-07:002012-09-30T17:56:55.806-07:002006 RULING LIFTS MEDICARE CAP ON THERAPIES FOR RSD/CRPS: LINK TO CMS (RE-POST RSD HOPE)<div class="separator" style="clear: both; text-align: center;">
<a href="http://www.rsdhope.org/cap-for-yearly-physical-therapy.html">http://www.rsdhope.org/cap-for-yearly-physical-therapy.html</a> </div>
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Details for: OUTPATIENT THERAPY CAPS: EXCEPTIONS PROCESS REQUIRED BY THE DRA</h3>
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<td align="left" width="30%"><strong>For Immediate Release:</strong></td>
<td align="left" width="70%">Wednesday, February 15, 2006</td>
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<td align="left" width="30%"><strong>Contact:</strong></td>
<td align="left" width="70%"><acronym title="Centers for Medicare & Medicaid Services">CMS</acronym> Office of Public Affairs<br />202-690-6145</td>
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<br /><br />
<strong>OUTPATIENT THERAPY CAPS: EXCEPTIONS PROCESS REQUIRED BY THE DRA</strong>
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<div style="margin: .5em;">
<b><u>Background:</u></b> 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.<br />
<br />
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.<br />
<br />
<b><u>Exceptions Process:</u> </b> 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.<br />
<br />
The exceptions process allows for two types of exceptions to caps for medically necessary services:<br />
<br />
<ul>
<li><u>Automatic Exceptions.</u> 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.</li>
<li><u>Manual Exceptions.</u> 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.</li>
</ul>
<br />
<b><u>Automatic Exceptions to the Therapy Caps:</u></b> 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.<br />
<br />
In addition to conditions, there are clinically complex situations
that can justify an automatic exception to the therapy caps for <u>any</u>
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.<b> </b> Those complex situations include:<br />
<br />
<ul>
<li>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.</li>
<li>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.</li>
<li>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. </li>
</ul>
<br />
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. <br />
<br />
<ul type="disc">
<li>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</li>
<li> services, the services are excepted from the PT/SLP cap. There is no effect on the occupational therapy cap. </li>
<li>The beneficiary had a prior episode of outpatient therapy during this calendar year for a <u>different</u> 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.</li>
<li>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.” </li>
<li>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. </li>
<li>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. </li>
</ul>
<br />
<b><u>Use of Modifier</u></b><u>:</u> 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.<br />
<br />
<b><u>Further Information:</u></b> Further information regarding
automatic exceptions and the process for requesting and documenting
manual exceptions is published on the CMS website at: <i><u>www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage</u></i>.<br />
<br />
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 <a href="http://www.cms.hhs.gov/Transmittals/2006Trans/list.asp#TopOfPage">www.cms.hhs.gov/Transmittals/2006Trans/list.asp#TopOfPage</a>.<br />
<br clear="all" />
<b>ATTACHMENT</b><br />
<br />
<b><u>Diagnosis Codes That Qualify for an Automatic Exception to the Caps</u></b><br />
<div align="left">
<br /></div>
Note: On this table, conditions are represented in normal type and complexities are bold with asterisks.<br />
<br />
<table border="1" cellpadding="0" cellspacing="0" style="width: 541px;">
<tbody>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>ICD-9</b></div>
</td>
<td valign="bottom" width="431">
<b>Description</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
V43.64</div>
</td>
<td valign="bottom" width="431">
Joint replacement, hip<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
V43.65</div>
</td>
<td valign="bottom" width="431">
Joint replacement, knee<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
V43.61</div>
</td>
<td valign="bottom" width="431">
Joint replacement, shoulder<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
V49.63-49.67</div>
</td>
<td valign="bottom" width="431">
Upper limb amputation status<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
V49.73-49.77</div>
</td>
<td valign="bottom" width="431">
Lower limb amputation status<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>250 – 250.93</b></div>
</td>
<td valign="bottom" width="431">
<b>Diabetes mellitus*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>278.01-278.02</b></div>
</td>
<td valign="bottom" width="431">
<b>Overweight, Obesity, and other hyperalimentation *</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>290.0-290.4</b></div>
</td>
<td valign="bottom" width="431">
<b>Dementias*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>294.0-294.9</b></div>
</td>
<td valign="bottom" width="431">
<b>Persistent mental disorders due to contions classified elsewhere*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>311</b></div>
</td>
<td valign="bottom" width="431">
<b>Depressive disorder NEC*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>323.0-323.0</b></div>
</td>
<td valign="bottom" width="431">
<b>Encephalitis, myelitis, and encephalomyelitis*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
331.0-331.9</div>
</td>
<td valign="bottom" width="431">
Other cerebral degenerations<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
332.0-332.1</div>
</td>
<td valign="bottom" width="431">
Parkinson's disease<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
333.0-333.99</div>
</td>
<td valign="bottom" width="431">
Other extrapyramidal diseases and abnormal movement disorders<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
334.0-334.9</div>
</td>
<td valign="bottom" width="431">
Spinocerebellar disease<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
335.0-335.9</div>
</td>
<td valign="bottom" width="431">
Anterior horn cell disease<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
336.0-336.9</div>
</td>
<td valign="bottom" width="431">
Other diseases of spinal cord<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
337.20-337.29</div>
</td>
<td valign="bottom" width="431">
Reflex Sympathetic Dystrophy<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
340</div>
</td>
<td valign="bottom" width="431">
Multiple sclerosis<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
342.00-342.9</div>
</td>
<td valign="bottom" width="431">
Hemiplegia and Hemiparesis<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
343.0-343.9</div>
</td>
<td valign="bottom" width="431">
Infantile cerebral palsy<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
344.00-344.9</div>
</td>
<td valign="bottom" width="431">
Other paralytic syndromes<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
348.9-348.9</div>
</td>
<td valign="bottom" width="431">
Other conditions of brain<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
349.0-349.9</div>
</td>
<td valign="bottom" width="431">
Other and unspecified disorders of the nervous system<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
353-357</div>
</td>
<td valign="bottom" width="431">
Neuropathies<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
359.0-359.9</div>
</td>
<td valign="bottom" width="431">
Muscular dystrophies and other myopathies<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>386.0-386.9</b></div>
</td>
<td valign="bottom" width="431">
<b>Vertiginous syndromes and other disorders of vestibular system*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>401.0-401.9</b></div>
</td>
<td valign="bottom" width="431">
<b>Essential Hypertension*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>402.00-402.91</b></div>
</td>
<td valign="bottom" width="431">
<b>Hypertensive heart disease*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>414.00-414.9</b></div>
</td>
<td valign="bottom" width="431">
<b>Other forms of Chronic Ischemic Heart Disease*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>415.0-415.19</b></div>
</td>
<td valign="bottom" width="431">
<b>Acute pulmonary heart disease*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>416.0-416.9</b></div>
</td>
<td valign="bottom" width="431">
<b>Chronic pulmonary heart disease*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>427.0-427.9</b></div>
</td>
<td valign="bottom" width="431">
<b>Cardiac dysrhythmias*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>428.0-428.9</b></div>
</td>
<td valign="bottom" width="431">
<b>Congestive Heart failure*</b><br />
</td>
</tr>
</tbody>
</table>
<br />
<br />
<table border="1" cellpadding="0" cellspacing="0" style="width: 541px;">
<tbody>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
430-432.9</div>
</td>
<td valign="bottom" width="431">
Intracranial hemorrhages<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
433.0-434.9</div>
</td>
<td valign="bottom" width="431">
Occlusion and stenosis of precerebral and cerebral arteries (<b>for occlusion only</b>)<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
436</div>
</td>
<td valign="bottom" width="431">
Acute, but ill-defined, cerebrovascular disease<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
437.0-437.9</div>
</td>
<td valign="bottom" width="431">
Other and ill-defined cerebrovascular disease<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
438.0-438.9</div>
</td>
<td valign="bottom" width="431">
Late effects of cerebrovascular disease<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>443.0-443.9</b></div>
</td>
<td valign="bottom" width="431">
<b>Other peripheral vascular disease*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>453.0-453.9</b></div>
</td>
<td valign="bottom" width="431">
<b>Other venous embolism and thrombosis*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
457.0-457.1</div>
</td>
<td valign="bottom" width="431">
Postmastectomy lymphedema syndrome and other lymphedema<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
478.30-478.5</div>
</td>
<td valign="bottom" width="431">
Disesases of vocal cords or larynx<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>486</b></div>
</td>
<td valign="bottom" width="431">
<b>Pneumonia, organism unspecified* </b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>490-496</b></div>
</td>
<td valign="bottom" width="431">
<b>Chronic Obstructive Pulmonary Diseases*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
710.0-710.9</div>
</td>
<td valign="bottom" width="431">
Diffuse diseases of connective tissue<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>707.99-707.9</b></div>
</td>
<td valign="bottom" width="431">
<b>Chronic ulcer of skin*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>711.00-711.99</b></div>
</td>
<td valign="bottom" width="431">
<b>Arthropathy associated with infections*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>713.0-713.8</b></div>
</td>
<td valign="bottom" width="431">
<b>Arthropathy associated withother discorders classified elsewhere*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>714.0-714.9</b></div>
</td>
<td valign="bottom" width="431">
<b>Rheumatoid arthritis and other inflammatory polyarthropathies*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
715.09</div>
</td>
<td valign="bottom" width="431">
Osteoarthritis and allied disorders<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
715.11</div>
</td>
<td valign="bottom" width="431">
Osteoarthritis, localized, primary, shoulder region<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
715.15</div>
</td>
<td valign="bottom" width="431">
Osteoarthritis, localized, primary, pelvic region and thigh<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
715.16</div>
</td>
<td valign="bottom" width="431">
Osteoarthritis, localized, primary, lower leg<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
715.91</div>
</td>
<td valign="bottom" width="431">
Osteoarthritis, unspecified id gen. or local, shoulder<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
715.96</div>
</td>
<td valign="bottom" width="431">
Osteoarthritis, unspecified if gen. or local, lower leg<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
718.44</div>
</td>
<td valign="bottom" width="431">
Contracture of hand<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
718.49</div>
</td>
<td valign="bottom" width="431">
Contracture of joint, multiple sites<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" width="110">
<div align="center">
<b>719.7</b></div>
</td>
<td width="431">
<b>Difficulty walking*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" width="110">
<div align="center">
721.91</div>
</td>
<td width="431">
Spondylosis with myelopathy<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" width="110">
<div align="center">
723.4</div>
</td>
<td width="431">
Other disorders of the cervical region, brachia neuritis or radiculitis NOS<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" width="110">
<div align="center">
724.02</div>
</td>
<td width="431">
Spinal stenosis, lumbar region<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" width="110">
<div align="center">
<b>724.3</b></div>
</td>
<td width="431">
<div align="center">
<b>Other and unspecified disorders of the back, sciatica*</b></div>
</td>
</tr>
<tr>
<td nowrap="nowrap" width="110">
<div align="center">
<b>724.4</b></div>
</td>
<td width="431">
<div align="center">
<b>Other and unspecified disorders of the back, thoracic or lumbosacral neuritis or radiculitis, unspecified*</b></div>
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
726.10-726.19</div>
</td>
<td valign="bottom" width="431">
Rotator cuff disorder and allied syndromes<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
727.61-727.62</div>
</td>
<td valign="bottom" width="431">
rupture of tendon, nontraumatic<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" width="110">
<div align="center">
733.00</div>
</td>
<td valign="bottom" width="431">
Osteoporosis with wedging of vertebra<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" width="110">
<div align="center">
780.93</div>
</td>
<td valign="bottom" width="431">
Memory Loss<br />
</td>
</tr>
</tbody>
</table>
<br />
<br />
<table border="1" cellpadding="0" cellspacing="0" style="width: 541px;">
<tbody>
<tr>
<td nowrap="nowrap" width="110">
<div align="center">
781.2</div>
</td>
<td valign="bottom" width="431">
Abnormality of gait<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" width="110">
<div align="center">
781.3</div>
</td>
<td valign="bottom" width="431">
Lack of coordination<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" width="110">
<div align="center">
781.8</div>
</td>
<td valign="bottom" width="431">
Neurologic neglect syndrome<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
<b>781.92</b></div>
</td>
<td valign="bottom" width="431">
<b>Symptoms involving nervous and musculoskeletal symptoms, abnormal posture*</b><br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
784.3-784.69</div>
</td>
<td valign="bottom" width="431">
Aphasia and other speech disturbances<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
787.2</div>
</td>
<td valign="bottom" width="431">
Dysphasia<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
806.00-806.99</div>
</td>
<td valign="bottom" width="431">
Fracture of vertebral Column with Spinal Cord Injury<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
810.00-810.13</div>
</td>
<td valign="bottom" width="431">
Fracture of clavicle<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
811.00-811.19</div>
</td>
<td valign="bottom" width="431">
Fracture of scapula<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
812.00.812.59</div>
</td>
<td valign="bottom" width="431">
Fracture of humerus<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
813.00-813.93</div>
</td>
<td valign="bottom" width="431">
Fracture or radius and ulna<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
820.00-820.9</div>
</td>
<td valign="bottom" width="431">
Fracture of neck of femur<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
821.0-821.39</div>
</td>
<td valign="bottom" width="431">
Fracture of other and unspecified parts of femur<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
828.0-828.1</div>
</td>
<td valign="bottom" width="431">
Multiple fractures involving both lower limbs, lower with upper limb, and lower limb(s) with rib(s) and sternum<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
852.00-852.59</div>
</td>
<td valign="bottom" width="431">
Subarachnoid, subdural, and extradural hemorrhage, following injury<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
853.00-853.19</div>
</td>
<td valign="bottom" width="431">
Other and unspecified intracranial hemorrhage following injury<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
854.00-854.19</div>
</td>
<td valign="bottom" width="431">
Intracranial injury of other and unspecified nature<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
881.0-881.2</div>
</td>
<td valign="bottom" width="431">
Open wound of elbow, forearm, and wrist<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
882.0-882.2</div>
</td>
<td valign="bottom" width="431">
Open wound of hand with tendon involvement<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
884.0-884.2</div>
</td>
<td valign="bottom" width="431">
Multiple and unspecified open wound of upper limb with tendon involvement<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
887.0 – 887.7</div>
</td>
<td valign="bottom" width="431">
Traumatic amputation of arm and hand (complete) (partial)<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
897.0-897.7</div>
</td>
<td valign="bottom" width="431">
Traumatic amputation of leg(s) (complete) (partial)<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
952.00-952.9</div>
</td>
<td valign="bottom" width="431">
Spinal cord injury without evidence of spinal bone injury<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
941.00-952.9</div>
</td>
<td valign="bottom" width="431">
Burns<br />
</td>
</tr>
<tr>
<td nowrap="nowrap" valign="bottom" width="110">
<div align="center">
959.01</div>
</td>
<td valign="bottom" width="431">
Head Injury<br />
</td>
</tr>
</tbody>
</table>
<br />
</div>
<br />
<table border="0" style="width: 100%px;">
<tbody>
<tr>
<td>
Page Last Modified: 12/02/2011 12:00 PM
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<br />Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com1tag:blogger.com,1999:blog-4947538173341245289.post-16000255190740502292012-09-30T12:29:00.000-07:002012-09-30T12:29:19.498-07:00Rick Simpson Oil: WARNING: DISPENSARY ONLY: DO NOT DO THIS ON YOUR OWN~BUT WHY NOT WITH RSD? IT IS WORKING FOR ME~YUP, ME.<br />
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<a href="http://cannabisni.com/">Home</a><a href="http://cannabisni.com/medicinal-cannabis-news">Medicinal</a><strong>How to make hemp oil by Rick Simpson</strong></div>
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How to make hemp oil by Rick Simpson</h1>
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on <time datetime="2009-12-02" pubdate="">02 December 2009</time>. Posted in <a href="http://cannabisni.com/medicinal-cannabis-news">Medicinal Cannabis News & Information</a>
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For those of you who have watched the documentary "<a href="http://cannabisni.com/cannabis-documentaries/364-run-from-the-cure-the-rick-simpson-story">Run from the Cure</a>", this should answer any questions about producing your own hemp oil.<br />
<img alt="hemp oil cures cancer" height="275" src="http://cannabisni.com/images/stories/cannabisoil.jpg" style="display: block; margin-left: auto; margin-right: auto;" title="rick simpson hemp oil" width="400" /><br />
<span style="color: red;"></span><br />
<span style="color: red;"><b>Caution:</b></span>
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.<br /><br /><span style="color: red;">How much to make and take?</span><br />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 <nobr><a class="FAtxtL" href="http://cannabisni.com/medicinal-cannabis-news/1194-how-to-make-hemp-oil-by-rick-simpson#" id="FALINK_3_0_2">pain relief</a></nobr> in minutes.<br /><br /><span style="color: red;">Will I get high?</span><br />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.<br /><br /><span style="color: red;">Will I become addicted?</span><br />Hemp
oil does not cause your body to crave more. It is non-addictive,
harmless and effective for practically any medical condition.<br /><br /><span style="color: red;">Is this the same as <nobr><a class="FAtxtL" href="http://cannabisni.com/medicinal-cannabis-news/1194-how-to-make-hemp-oil-by-rick-simpson#" id="FALINK_1_0_0">hemp seed</a></nobr> oil?</span><br />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.<br /><br /><span style="color: red;">Are hemp and marijuana the same?</span><br />The word marijuana is one of over four hundred slang terms used worldwide to describe the cannabis and/or hemp plant.<br /><br /><span style="color: red;">Are all hemp plants the same?</span><br />When buying or growing hemp, procure a strain that has the highest possible THC content. To energize someone <nobr><a class="FAtxtL" href="http://cannabisni.com/medicinal-cannabis-news/1194-how-to-make-hemp-oil-by-rick-simpson#" id="FALINK_2_0_1">suffering from depression</a></nobr>,
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.<br /><br /><span style="color: red;">How do I use it?</span><br />High quality hemp oil can be vapourized, ingested or used topically. Add the oil to creams and salves for external use.<br /><span style="color: red;"><br />Where can I get information about making the oil?</span><br />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.<br /><br /><b><span style="font-size: small;"><span style="color: red;">Rick Simpsons process of making hemp oil</span></span></b><br /><br /><span style="color: red;">Starting material:</span><br />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.<br /><br /><strong>1 -</strong> Place the completely dry starting material in a plastic bucket.<br />
<strong>2 -</strong> 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.<br />
<strong>3 -</strong> 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.<br />
<strong>4 -</strong> Add solvent until the starting material is completely covered.<br />Use the stick to work the plant material. As you are doing this, the THC dissolves off the plant material into the solvent.<br />
<strong>5 -</strong> Continue this process for about 3 minutes.<br />
<strong>6 -</strong> 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.<br />
<strong>7 -</strong> Second wash - again add solvent to the plant material and work it for another 3 minutes to get the other 20%.<br />
<strong>8 -</strong> Pour this solvent-oil mix into the bucket containing the first mix that was poured off previously.<br />
<strong>9 -</strong> Discard the twice-washed plant material.<br />
<strong>10 -</strong> Pour the solvent-oil mix through a coffee filter into a clean container.<br />
<strong>11-</strong> 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.<br />
<strong>12-</strong> Add solvent-oil mix to the rice cooker until it is about ¾ full.<br /><b><br /><span style="color: red;">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.</span></b><br /><br /><strong>13 -</strong> Plug the rice cooker in and set it on high heat.<br />
<strong>14 -</strong> Continue adding solvent-oil mix as the level in the rice cooker decreases until it is all in the cooker.<br />
<strong>15 -</strong> 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.<br />
<strong>16 -</strong> 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.<br />
<strong>17 -</strong> 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).<br />
<strong>18 -</strong> Put on your oven mitts and remove the pot containing the oil from the rice cooker.<br />
<strong>19 -</strong> Gently pour the oil into a small stainless steel container.<br />
<strong>20 -</strong> 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.<br />
<strong>21 -</strong> 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.<br />
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.<br /><span style="color: red;"><br />To anyone starting to use hemp oil as a medication, here are some simple facts.</span><br />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.<br /><br />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?<br /><br />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.<br /><br />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.<br /><br />I wish you the best luck and health.<br />Warmest regards,<br />Rick Simpson.<br />
Source <a href="http://www.phoenixtears.ca/" target="_blank">www.phoenixtears.ca</a><br />
<a href="http://www.cannabisni.com/medicinal-cannabis-news/944-interview-with-rick-simpson-run-from-the-cure">Rick Simpson Interviewed by Jindrich Bayer</a><br />
<a href="http://cannabisni.com/medicinal-cannabis-news/2132-medical-freedom-fighter-rick-simpson-interviewed-by-james-martinez-on-achieve-radio-">Rick Simpson Interviewed by James Martinez on Achieve Radio</a><br /><strong><span style="color: red;"></span></strong><br />
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People are really afraid of the truth.Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com0tag:blogger.com,1999:blog-4947538173341245289.post-51784922437549156302012-09-18T19:22:00.001-07:002012-09-19T09:07:53.245-07:00<div class="separator" style="clear: both; text-align: center;">
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"MELTDOWN RSD" AN EVENING RSD STYLE<br />
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Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com0tag:blogger.com,1999:blog-4947538173341245289.post-12314871867046532362012-09-17T11:34:00.000-07:002012-09-17T11:34:00.548-07:00A little Shrek<div class="separator" style="clear: both; text-align: center;">
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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-<strong><em>even with hearing protection and earplugs, sometimes at the same time!!!</em></strong> I know of folks through the Hyperacuasis Network who have <strong><em>gotten RSD/CRPS </em></strong>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, <strong><em>I have a fucking problem!</em></strong> 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?<br />
<br />
Not this:<br />
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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 <strong>plethora</strong> of medication:<br />
<br />
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.<br />
<br />
Zonegran 400mg at bedtime<br />
Tegretol 400mg BID<br />
Duragesic 75 (was far higher before weed and was also on other meds-MTD)<br />
Keppra 500mg (need liquid and need it higher, maybe 750mg?) at bedtime<br />
Clonazepam (dose with held) and I take it for seizures since childhood,<br />
<br />
I have CRPS, aka "CRAPS"<br />
<br />
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.<br />
<br />
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.<br />
<br />
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.<br />
<br />
And yeah-but hey, I made the best of it.<br />
<br />
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.<br />
<br />
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 <strong><em><u>accurate</u></em></strong> understanding of the pain you really are in, since kids are perceptive, they can tell, just like a pet.<br />
<br />
What qualifies me to say all this? I also have diagnosable fibromyalgia.<br />
<br />
This is me now!<br />
<br />
<br />
<br />
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 <strong>3 years</strong> 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.<br />
<br />
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.<br />
<br />
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 <strong><em>my opinion-as an RSD sufferer </em>and as an RN-</strong> 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 <strong><u>day EXERCISE program.</u></strong><br />
<br />
My body has been ruined by pain specialists and docs who couldn't tell their asses from a hole in the wall.Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com0tag:blogger.com,1999:blog-4947538173341245289.post-13081940208959494122012-09-17T09:15:00.000-07:002012-09-17T09:15:26.779-07:00When is Rx-Opioid “Addiction” Something Else?<div id="uds-searchControl">
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<span>Thursday, August 23, 2012</span></h2>
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<a href="http://updates.pain-topics.org/2012/08/when-is-rx-opioid-addiction-something.html"><span style="color: black;">When is Rx-Opioid “Addiction” Something Else?</span></a> </h3>
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<img align="right" alt="Addiction2" height="175" src="http://lh6.ggpht.com/-5aUG_ycM-u4/UDZgBfSyiYI/AAAAAAAAAhg/1ByEzIPu5yM/Addiction24.jpg?imgmax=800" style="display: inline; float: right; margin: 0px 0px 5px 10px;" title="" width="150" />The 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 <i>complex persistent opioid dependence</i>; however, this may be an oversimplification.<br />
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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 (<i>de novo</i>) addiction arising as a direct result of the therapy (iatrogenic).<br />
<a href="http://www.blogger.com/null" name="more"></a><br />
Writing in an early online edition of the <i>Archives of Internal Medicine</i>, 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.<br />
<ul>
<li>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. <br /></li>
<li>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. </li>
</ul>
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.”<br />
<br />
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 <i>Diagnostic and Statistical Manual of Mental Disorders</i><i> (DSM-5)</i> [discussed in prior UPDATE <a href="http://updates.pain-topics.org/2010/03/apa-finally-gets-opioid-addiction.html" target="_blank"><span style="color: #a9501b;">here</span></a>], 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.<br />
<br />
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 <i>DSM-5,</i> and the present <i>DSM-IV</i>, such as “failure to fulfill major role obligations at work, school or home,” can readily be attributed to pain rather than to addiction.<br />
<br />
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.<br />
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.<br />
<br />
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.<br />
<br />
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.<br />
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 <b><i>complex persistent dependence</i></b> for months after a taper” [emphasis added].<br />
<br />
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.<br />
<br />
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.”<br />
<br />
<b><span style="color: #d20000;">COMMENTARY: Unclear Distinctions</span></b><br />
<br />
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.<br />
<br />
They acknowledge that the usual criteria for diagnosing opioid addiction are not appropriate in patients treated for pain and conclude, “<em>Whether or not it is called addiction</em>, 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.<br />
<br />
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 [<a href="http://updates.pain-topics.org/2012/08/opioids-on-trial-but-wheres-evidence.html" target="_blank"><span style="color: #a9501b;">discussed in UPDATE here</span></a>]; 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.<br />
<br />
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?<br />
<br />
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.<br />
<br />
A question not asked by Ballantyne and colleagues is: <i>Would a fully informed patient with chronic pain, knowing the risks of dependence, still consent to long-term opioid therapy?</i> Without the prospect of better, more effective alternative therapies, it might be surmised that a great many patients would likely answer “yes.”<br />
<br />
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.<br />
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.<br />
<br />
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.<br />
<br />
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.<br />
<br />
<b><span style="color: #d20000;">Backstory Sheds More Light</span></b><br />
<br />
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].<br />
<br />
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.<br />
<br />
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 <em>dependence may arise independently of addiction</em> in persons with pain, and problematic opioid use and other aberrant behaviors once thought to be cardinal symptoms of addiction or substance abuse are <i>inapplicable in the pain management setting</i>.<br />
<br />
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.<br />
<br />
Very importantly, Ballantyne and LaForge also state the following…<br />
<blockquote>
<i><span style="color: #8c0000;">“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.” <br /><br />“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.”</span></i></blockquote>
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 <em>de novo</em> 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, <a href="http://pain-topics.org/pdf/e-Briefing-Vol3-No1-2008.pdf" target="_blank"><span style="color: #a9501b;">PDF here</span></a>].<br />
<br />
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.<br />
<br />
Two fairly recent and frequently-cited studies by Boscarino and colleagues [2010, 2011; also discussed by Twillman in an <i>UPDATE</i> <a href="http://updates.pain-topics.org/2012/08/group-petitions-fda-to-change-opioid.html" target="_blank"><span style="color: #a9501b;">here</span></a>] used validated <i>DSM-IV</i> and <i>DSM-5</i> 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 <em>de novo</em> iatrogenic addiction. Furthermore, as conceded above by Ballantyne et al. [2012] and Ballantyne and LaForge [2007], without significant adjustments, <i>DSM</i> criteria are inapplicable or misleading in persons with chronic pain; so, the findings of Boscarino et al. are most likely distorted and invalid.<br />
<br />
The most convincing evidence of this misrepresentation had been presented in a study by Elander et al. [2003]. Using standard <i>DSM-IV</i> 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. <i>(This study also was acknowledged by Ballantyne and LaForge [2007] in their paper, but was not referenced by Boscarino et al.)</i><br />
<br />
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.”<br />
<br />
However, it should be recognized that, even though <i>de novo</i> 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 <em>coming into pain treatment</em> may have current or past substance-use disorders, whether abuse or addiction and related to opioids or to other drugs including alcohol.<br />
<br />
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.”<br />
<br />
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.<br />
<br />
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.”<br />
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 <br />
<br />
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.”<br />
<br />
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.<br />
<br />
<b><span style="color: #d20000;">Concluding Notes on Addiction — Distinctions Do Make a Difference</span></b><br />
<br />
<img align="right" alt="Green-Eyed Monster" border="0" src="http://lh6.ggpht.com/-E-enTxdSWek/UDZgBoftJpI/AAAAAAAAAhk/yttCc6zl9n0/Addiction34.jpg?imgmax=800" style="background-image: none; border-bottom-width: 0px; border-left-width: 0px; border-right-width: 0px; border-top-width: 0px; display: inline; float: right; margin: 0px 10px 5px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" title="" />A 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.<br />
<br />
In an interesting essay on “The Role of Addictions in Human Culture” [<a href="http://thoughteconomics.blogspot.com/2012/01/role-of-addictions-in-human-culture.html" target="_blank"><span style="color: #a9501b;">here</span></a>], 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. <br />
<br />
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.<br />
<br />
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....”<br />
<br />
At greater length, about a year ago in August 2011, the American Society of Addiction Medicine (ASAM) came out with a new Policy Statement [<a href="http://www.asam.org/for-the-public/definition-of-addiction"><span style="color: #a9501b;">here</span></a>] presenting their definition of the disease of addiction. The short version states:<br />
<blockquote>
<i><span style="color: #8c0000;">“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.”</span></i><br />
<i><span style="color: #8c0000;"></span></i><br />
<i><span style="color: #8c0000;">“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.”</span></i></blockquote>
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 <i>UPDATE</i> <a href="http://updates.pain-topics.org/2011/08/asam-redefines-addiction-as-brain.html" target="_blank"><span style="color: #a9501b;">here</span></a>]. 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.<br />
<br />
In <i>The War of the Gods in Addiction</i> [2009, <a href="http://www.amazon.com/War-Gods-Addiction-David-Schoen/dp/1882670574" target="_blank"><span style="color: #a9501b;">here</span></a>, pp 4-5], psychoanalyst David E. Schoen, LCSW, MSSW, describes rather dramatically what he believes are two essential components of addiction…<br />
<blockquote>
<i><span style="color: #8c0000;">“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.” </span></i><i><span style="color: #8c0000;"> <br />“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.”</span></i></blockquote>
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.<br />
<br />
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 [<i>UPDATE</i> <a href="http://updates.pain-topics.org/2010/04/severe-chronic-pain-is-killer-study.html" target="_blank"><span style="color: #a9501b;">here</span></a>], as well as increased suicide risk [see <i>UPDATE</i> <a href="http://updates.pain-topics.org/2011/07/more-about-chronic-pain-opioids-suicide.html" target="_blank"><span style="color: #a9501b;">here</span></a> and <a href="http://updates.pain-topics.org/2012/03/ugly-truth-headache-and-suicide.html" target="_blank"><span style="color: #a9501b;">here</span></a>] in these patients.<br />
<br />
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.<br />
<br />
<br />
<br />
<b><span style="color: #6e6e6e;">REFERENCES:</span></b><br />
<ul>
<li><span style="color: #6e6e6e;">Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006;144:127-134. </span></li>
<li><span style="color: #6e6e6e;">Ballantyne JC, LaForge KS. Opioid dependence and addiction during opioid treatment of chronic pain. <i>Pain</i>. 2007;129(3):235-255 [</span><a href="http://www.ncbi.nlm.nih.gov/pubmed/17482363" target="_blank"><span style="color: #a9501b;">abstract</span></a><span style="color: #6e6e6e;">]. </span></li>
<li><span style="color: #6e6e6e;">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 [</span><a href="http://archinte.jamanetwork.com/article.aspx?articleid=1309576" target="_blank"><span style="color: #a9501b;">abstract</span></a><span style="color: #6e6e6e;">]. </span></li>
<li><span style="color: #6e6e6e;">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. </span></li>
<li><span style="color: #6e6e6e;">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. </span></li>
<li><span style="color: #6e6e6e;">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. </span></li>
<li><span style="color: #6e6e6e;">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. </span></li>
<li><span style="color: #6e6e6e;">Jones JD, Mogali S, Comer SD. Polydrug abuse: A review of opioid and benzodiazepine combination use. Drug Alcohol Depend. 2012;125:8-18. </span></li>
</ul>
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Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com0tag:blogger.com,1999:blog-4947538173341245289.post-42212321481702627982012-09-15T05:39:00.000-07:002012-09-15T05:39:34.540-07:00OPIATE/OPOID TOLERANT PATIENTS REDUCE OR ELIMINATE NEED FOR HIGH-DOSE DUE TO MARIJUANA TX<div class="webs-bin" id="webs-bin-505446ff0cf2a9dfdda0afcb">
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OPIATE/OPOID TOLERANT PATIENTS REDUCE OR ELIMINATE NEED FOR HIGH-DOSE DUE TO MARIJUANA TX</div>
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by David Wild, Pharmacy Practice News</div>
<div>
<br />
<br />
<span style="font-size: small;">Montreal—An
oral cannabinoid was associated with up to 60% reductions in pain in
10 patients with refractory complex regional pain syndrome (CRPS),
according to research presented at the 2010 annual World Congress on
Pain in Montreal. The study investigators also reported that most of
the patients were able to discontinue long-term opioid therapy and
reported significant improvements in quality of life.</span><br />
<span style="font-size: small;">The
findings support the need for more studies that will examine
cannabinoid treatment in the CRPS population, said Mark Ware, MBBS,
assistant professor in the Departments of </span><br />
<br />
<span style="font-size: small;">Anesthesia and Family Medicine
at McGill University in Montreal, Quebec, Canada.</span><br />
<span style="font-size: small;">“Given
that few drugs have proven efficacy against CRPS, this study strongly
suggests we should take a closer look at cannabinoids for treating this
condition,” noted Dr. Ware, who was not involved in the study. “What’s
notable here is that even with high doses of nabilone of up to 10
mg/d, patients experienced few adverse events. Although these first
reports show doses of this magnitude are safe, clinicians should always
start low and go slow when initiating cannabinoid treatment.”</span><br />
<br />
<span style="font-size: small;">Researchers
have become increasingly interested in examining the use of
endocannabinoids for various pain conditions, but the efficacy of this
class of medications for treating CRPS has not been examined to date.
To help fill this gap, investigator May Ong-Lam, MD, clinical assistant
professor in the Department of Medicine at St. Paul’s Hospital in
Vancouver, Canada, examined data from 10 patients with CRPS who were
treated with nabilone (Cesamet, Valeant Pharmaceuticals North America),
an oral cannabinoid.</span><br />
<br />
<span style="font-size: small;">The 10 patients were a
mean age of 40 years and had developed CRPS following fractures, soft
tissue injuries, invasive procedures or surgeries.<i><b> Prior to nabilone
treatment outset, patients reported moderate to severe allodynia,
autonomic changes, burning pain and varying levels of physical
disability, despite receiving a range of therapies. These therapies
included tricyclic antidepressants, anticonvulsants, selective
serotonin or norepenephrine reuptake inhibitors, nonsteroidal
anti-inflammatory drugs, g-aminobutyric acid analogues, neuroleptics,
ketamine and nerve-blocking procedures.</b></i></span><br />
<br />
<span style="background-color: yellow;"><b><span style="font-size: small;">Nine
of the 10 patients also were receiving high-dose opiates, including
hydromorphone (10-16 mg/d), transdermal fentanyl (125 mg every three
days), oxycodone (30-80 mg/d), morphine (90-240 mg/d), codeine (240
mg/d) and oxycontin (200 mg/d). Without exception, patients rated their
pain as 10 on a 10-point visual analog scale (VAS) prior to receiving
nabilone</span></b></span><br />
<br />
<br />
<span style="font-size: small;">Dr. Ong-Lam initiated treatment
with nabilone, a drug approved for the treatment of
chemotherapy-related emesis, at a dose of 0.5 to 1.0 mg at bedtime and
titrated up until patients reported at least a 50% decrease in VAS
scores without experiencing adverse events. Following treatment for
three months to two years, patients’ pain scores dropped to between 3
and 6 on the VAS. Moreover, seven of the 10 patients were able to
discontinue opioid therapy as well as other pain medications. Among the
three patients who continued to receive opioids, cannabinoid treatment
corresponded with decreases in pain. This reduced pain was associated
with improved sleep, and ability to resume work, bear weight, and
conduct daily household chores.</span><br />
<br />
<span style="font-size: small;">Dr. Ong-Lam
emphasized the striking results in this small, retrospective analysis,
suggesting that larger studies examining the opiate-sparing effects of
cannabinoids in CRPS patients are necessary.</span><br />
<span style="font-size: small;">“These
patients improved significantly in quality of life and most were able
to reduce or discontinue opioids,” Dr. Ong-Lam reiterated.
“Furthermore, patients did not develop major adverse reactions or become
tolerant of the drug.”</span><br />
</div>
<span style="font-size: small;">Resource: <a href="http://www.pharmacypracticenews.com/ViewArticle.aspx?d=Web+Exclusives&d_id=239&i=January+2011&i_id=694&a_id=16601">Pharmacy Practice News</a></span><br />
<h4>
<span style="font-size: small;">Incoming search terms:</span></h4>
<ul>
<li><span style="font-size: small;">crps</span></li>
<li><span style="font-size: small;">refractory crps</span></li>
<li><span style="font-size: small;">marijuana effect on crps</span></li>
<li><span style="font-size: small;">Marijuana for crps</span></li>
<li><span style="font-size: small;">crps marijuana</span></li>
<li><span style="font-size: small;">cannabinoids opiates</span></li>
<li><span style="font-size: small;">marijuana complex pain regional</span></li>
<li><span style="font-size: small;">Marijuana therapy for Opiates</span></li>
<li><span style="font-size: small;">marijuana to relieve crps pain</span></li>
<li><span style="font-size: small;">marijuana used in treating crps</span></li>
</ul>
<a href="http://braatah.com/refractory-crps-patients-discontinue-opiates-with-cannabinoid-treatment/" target="_blank"> http://braatah.com/refractory-crps-patients-discontinue-opiates-with-cannabinoid-treatment/</a>Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com0tag:blogger.com,1999:blog-4947538173341245289.post-42067776737710255072012-09-12T03:39:00.002-07:002012-09-12T03:39:39.700-07:00Jennifer Schwartz RSD Foundation<a href="http://www.causes.com/causes/121511-the-jennifer-schwartz-reflex-sympathetic-dystrophy-foundation/actions/1680832" target="_blank">http://www.causes.com/causes/121511-the-jennifer-schwartz-reflex-sympathetic-dystrophy-foundation/actions/1680832</a><br />
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PLEDGE: September is National Pain Awareness Month!
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Thank you, Jennifer.
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<a class="green button show_inviter large" href="http://www.causes.com/causes/121511-the-jennifer-schwartz-reflex-sympathetic-dystrophy-foundation/actions/1680832#">Invite Friends</a>
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<span class="single-item"><img alt="Dfb" class="clearfix" src="http://causes-prod.caudn.com/photos/photos/lK/Gm/AM/IR/y6/Pp/nM/DFB.jpg" /></span>
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<div class="description clearfix">
The month of September is National <nobr><a class="FAtxtL" href="http://www.causes.com/causes/121511-the-jennifer-schwartz-reflex-sympathetic-dystrophy-foundation/actions/1680832#" id="FALINK_2_0_1">Pain</a></nobr> Awareness month! This entire month is dedicated to bring awareness to all ailments as it relates to pain diseases.
<br />
<br />More specifically, National Invisible <nobr><a class="FAtxtL" href="http://www.causes.com/causes/121511-the-jennifer-schwartz-reflex-sympathetic-dystrophy-foundation/actions/1680832#" id="FALINK_1_0_0">Chronic Pain</a></nobr>
Awareness Week is September 10-16, 2012. This involves a multitude of
pain diseases, but it specifically touches us because it applies to our
daughter, Jennifer, who as you know, suffers from RSD/CRPS, as do many,
many others. This is a great time of the year to go above and beyond to
bring attention and awareness to these diseases and to help others.
<br />
<br />From all of us that fight on behalf of those who suffer, we thank
you! We don't only fight for Jennifer, we fight and work to promote
awareness for all those suffering. Because every patient, every
sufferer, deserves a voice!
<br />
<br />And for each one of you helping us give those brave survivors a
voice, know that you may never meet them, but your thanks go beyond
words.
<br />
<br />Sincerely,
<br />Alan & Joyce </div>
</div>
Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com0tag:blogger.com,1999:blog-4947538173341245289.post-11130587805387179672012-09-12T03:36:00.001-07:002012-09-12T03:36:54.771-07:00A change in direction...I am going to have, now that I have settled on using medically (highly) recommended and by more than one physician, to smoke (in my state), legally grown mariuana..... Sort of funny after a lifetime of being accused of being a drug-seeker.<br />
<br />
I am also, going to be writing my book on explaing how I got RSD, my understanding of it, on making sense of why a doctor would tell me that I Will ALWAYS be a "druggie" and the lack of my family's understanding, what I have: <b>RSD/CRPS.</b><br />
<br />
<b>Fellow pain sufferers know: </b>FEW OTHERS DO.<br />
<b> </b><br />
Oh, I will be "growing-and learning "all about it."<br />
<br />
<br />
Doctors orders. I need to be making sure I follow HIS orders. HIM I trust. Dr. J? I trust<br />
<br />
But oddly enough when I called the pain doctor: they don't give a shit. I didn't "respond" to treatment:<br />
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<b>MY 38TH BIRTHDAY: I DON'T CARE AND WHICH YEARS HAVE I HAD RSD.</b></div>
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<i>VERSUS WHICH ONES.....</i></div>
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<i>I have been <b>properly diagnosed...</b></i>so what is the fucking point now?</div>
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<i>There is ONE thing that works. No one wants to hear it-but when I have a review next year?</i></div>
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<b>I GET TO SUBMIT MY MMJ EXPENSES: </b>they easily can end up PAYING ME to live here, some have such huge expenses or are on MMJ ahh, just keep a way to keep lights (God) on, the internet going, and spend whatever I can (and save <b>all receipts on all things related to MMJ: </b>and NEXT YEAR? HAHAHA, I will have my ounce a week, or damned close, and to HELL with it all!</div>
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<b>Oh, this is me now, sorry:</b></div>
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Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com0tag:blogger.com,1999:blog-4947538173341245289.post-40432173623889034072012-09-11T13:08:00.000-07:002012-09-11T13:43:12.783-07:00A SERIES OF NOT SO GREAT DAYS<div class="separator" style="clear: both; text-align: center;">
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<br />Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com0tag:blogger.com,1999:blog-4947538173341245289.post-63590388548220529322012-09-10T20:31:00.002-07:002012-09-10T20:31:47.776-07:00SOME VENTING-GUESS ONE NURSE MIGHT SAY I HAVBE ISSUES, EH KAT? HER PRESENCE!I am sad to say, that my doctor, as my weight has plunged over the last year, and these photos tell the story how in 18 or so months, the pain of CRPS has driven my caloric needs therough the roof in the last year: my doctor called last night to say he was making the referral, when he saw in my log, my BMI has hit a low of 17.5.<br />
<br />
Guess I never met any fibro "only" if it can be put that way, and though I know it's painful, I am on board with ya know, has one side of your face turned beat red, your feet swell uncontrollably-and the only.<br />
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Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com0tag:blogger.com,1999:blog-4947538173341245289.post-70553175828693384152012-09-10T14:02:00.002-07:002012-09-10T14:02:34.170-07:00HAVE YOU SEEN MY SUBCUTANEOUS FAT YET-ME TODAY<div class="separator" style="clear: both; text-align: center;">
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<tr><td class="tr-caption" style="text-align: center;">THIS (IS PART) OF WHY I HURT</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">LAST NIGHT: IN BAD PAIN & FEELING LIKE I AM LOSING THIS ONE.</td></tr>
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<b>MY PROBLEM? i WOKE UP</b><br />
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<b> </b>Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com0tag:blogger.com,1999:blog-4947538173341245289.post-11010650540762996652012-09-10T13:29:00.000-07:002012-09-10T13:29:00.217-07:00JANUARY 2012 TO AUGUST (C) 2012<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjgbPLHDHKWjQgDqVBrZ20FX4vH8GUoPCXBv7Fu-mEoupmx4t0wkZ3HCu5vhKwdyx9xLgpjrU660C8wEYJMjPQpLT7ZDNGoXxewrqGJbkyDWpp5tQ4u0gE27hYYvhpasJ6Q0fbGQaHRnAA/s1600/no+ur+fat.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjgbPLHDHKWjQgDqVBrZ20FX4vH8GUoPCXBv7Fu-mEoupmx4t0wkZ3HCu5vhKwdyx9xLgpjrU660C8wEYJMjPQpLT7ZDNGoXxewrqGJbkyDWpp5tQ4u0gE27hYYvhpasJ6Q0fbGQaHRnAA/s320/no+ur+fat.jpg" width="277" /></a></div>
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<tr><td class="tr-caption" style="text-align: center;">END OF THE DAY-BEGINNING OF MONTH JULY 2012</td></tr>
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<b>LIKE THE MISTRESS OF DISGUISE?</b><br />
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<b> <span style="font-size: large;"><b>JANUARY 2012 </b></span></b></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikg7aJlT_LDvTLBuzKSEGSyQi7i2n1MMKkO_SJC15GI4gPzF0R7_8l54sQs1YSZI0Mg-IT8XzySWTe5qyCNStB6MJkdOuSF3WCzgeVyCFXQkwv1PZevN5-yc1L4UdIyE7zPCLhM25mFxA/s1600/1-10-2012A.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikg7aJlT_LDvTLBuzKSEGSyQi7i2n1MMKkO_SJC15GI4gPzF0R7_8l54sQs1YSZI0Mg-IT8XzySWTe5qyCNStB6MJkdOuSF3WCzgeVyCFXQkwv1PZevN5-yc1L4UdIyE7zPCLhM25mFxA/s320/1-10-2012A.jpg" width="320" /></a></div>
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<b>FEBRUARY 2012 </b></div>
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<span style="font-size: large;"><b>MARCH 2012</b></span></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgHC_iz5uY2x0Z_TtOxUb5mVDszjX4s-fz6qnwoVWkkUFjsw6wnpxtOMAbvfUPUhyFgJkx4-IGUZ-oAzyjcSJPY-l_eamFicPrqcrdfCXQit72y5eBGuGSYro9RAM9AAEgiWgaQ8WfFZiE/s1600/03-15-12_my_actual_port.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgHC_iz5uY2x0Z_TtOxUb5mVDszjX4s-fz6qnwoVWkkUFjsw6wnpxtOMAbvfUPUhyFgJkx4-IGUZ-oAzyjcSJPY-l_eamFicPrqcrdfCXQit72y5eBGuGSYro9RAM9AAEgiWgaQ8WfFZiE/s320/03-15-12_my_actual_port.jpg" width="239" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">a PORT?</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh1pJUvh658x7bWeZcTC0YI0wYWmOmm7gnvAAkWDBkSE-GhIocOZAtRvIW0a0fXZ-zUiwjCinJslKkArvEoE2aETKgSmxr9WHPo2YrNzf4Bk7M0sYT-Xbl-NhnW8iLVGm_py5NfDF5iYog/s1600/03-15-2012-after+port+procedure+(3).jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh1pJUvh658x7bWeZcTC0YI0wYWmOmm7gnvAAkWDBkSE-GhIocOZAtRvIW0a0fXZ-zUiwjCinJslKkArvEoE2aETKgSmxr9WHPo2YrNzf4Bk7M0sYT-Xbl-NhnW8iLVGm_py5NfDF5iYog/s320/03-15-2012-after+port+procedure+(3).jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">NIGHT OF SURGERY-I WAS SPREADING ALREADY</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZ9vwq4htR1RNdO_KlvH6I-PYOFalO5L-QbpUiXfM4JpxM4X-3VqQk4VVNL3dNfudOaz5VPl9NDhtmEKFa1cLNZo3HEb0wy8_gBnTzj-UZtIiguejqyhDDQoJvNjTnj5ZjXR8v91mAMGY/s1600/03-26-2012.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZ9vwq4htR1RNdO_KlvH6I-PYOFalO5L-QbpUiXfM4JpxM4X-3VqQk4VVNL3dNfudOaz5VPl9NDhtmEKFa1cLNZo3HEb0wy8_gBnTzj-UZtIiguejqyhDDQoJvNjTnj5ZjXR8v91mAMGY/s320/03-26-2012.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">END-OF MARCH 2012</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLD1P_uflWc6qU9N4h4D2bawtuMhamtc8LvvwEXB7f5SW39AS2gRtRW78CC8y6yS5Gws2lUpTPW4tdxbdiydI1If96Ot7XXO55rVd2IgfNFZCWzulFn44gH4XQZyM7VAkvWrMRhW4VU-U/s1600/03-28-2012_A.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLD1P_uflWc6qU9N4h4D2bawtuMhamtc8LvvwEXB7f5SW39AS2gRtRW78CC8y6yS5Gws2lUpTPW4tdxbdiydI1If96Ot7XXO55rVd2IgfNFZCWzulFn44gH4XQZyM7VAkvWrMRhW4VU-U/s320/03-28-2012_A.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">APRIL 2012</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg86zMPjqHcdnGDxW-tZYX3hawnc4OnSa4IPCV1xqbo1uA7ifQyOXzkDvzYztxSp1iijfYUWj_hCOnVm7Ox-MRsGvA9Zr3gZt2HWYuVlO1STyH6shkqC8C1FlM4NXZEdkVAG-_9GOKojoM/s1600/2012-05-24+11-50-31.432.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="180" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg86zMPjqHcdnGDxW-tZYX3hawnc4OnSa4IPCV1xqbo1uA7ifQyOXzkDvzYztxSp1iijfYUWj_hCOnVm7Ox-MRsGvA9Zr3gZt2HWYuVlO1STyH6shkqC8C1FlM4NXZEdkVAG-_9GOKojoM/s320/2012-05-24+11-50-31.432.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">JUNE 2012</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjeo5XwqCMn47LZWp-VkzHWlbcfZ_90AZM5vopu6tN9s0366tOEzUlJ5rqapQPs9JEvDJJb7l-PncZ7-EHVgDWy-vM7BKt81DxIl-Xjgce74NaxMNJndeDL0xxWa_Z_134f9oiEe5Vy-x8/s1600/2012-06-30+07-47-14.668.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="180" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjeo5XwqCMn47LZWp-VkzHWlbcfZ_90AZM5vopu6tN9s0366tOEzUlJ5rqapQPs9JEvDJJb7l-PncZ7-EHVgDWy-vM7BKt81DxIl-Xjgce74NaxMNJndeDL0xxWa_Z_134f9oiEe5Vy-x8/s320/2012-06-30+07-47-14.668.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">JULY 2012</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZN9pUmyyMqCfop9V7NwpKAlupjJ23qQeiSOR04OUZMfIomUiYnPE5EcrB-MOAaMxvhWUM_HR4SkZF55wi6_RyVBSZD5IcNZTkY-S29PyXtYl2CDk3nT0xEupxeVyNcQwV3m0DYDwyUp0/s1600/2012-07-09+00-40-39.015.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="180" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZN9pUmyyMqCfop9V7NwpKAlupjJ23qQeiSOR04OUZMfIomUiYnPE5EcrB-MOAaMxvhWUM_HR4SkZF55wi6_RyVBSZD5IcNZTkY-S29PyXtYl2CDk3nT0xEupxeVyNcQwV3m0DYDwyUp0/s320/2012-07-09+00-40-39.015.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">JULY 2012</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiuFqX3_70dqO8HFXjp94nwrSAV4lim-WDdYSHVrWKJS4_JDrT5_DIztkx_AlI0DbxAly6vMu2dRlJS5YT3_GhyphenhyphensVLGAMNk4a-CAhaJKOmniWs0oM7unDj1m2QeySh53LrF-OQsaSMu3MI/s1600/2012-07-14+07-41-35.477.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="180" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiuFqX3_70dqO8HFXjp94nwrSAV4lim-WDdYSHVrWKJS4_JDrT5_DIztkx_AlI0DbxAly6vMu2dRlJS5YT3_GhyphenhyphensVLGAMNk4a-CAhaJKOmniWs0oM7unDj1m2QeySh53LrF-OQsaSMu3MI/s320/2012-07-14+07-41-35.477.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">AUGUST 2012</td></tr>
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<tr><td class="tr-caption" style="text-align: center;"> AUGUST 2012</td></tr>
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<div style="text-align: center;">
CAN'T REMEMBER IF IF MID-END OF AUGUST:</div>
<div style="text-align: center;">
VM SAYS THAT I NEED SURGERY ON MY STOMACH.</div>
<div style="text-align: center;">
I HAVE A HIATAL HERNIA-A NISSEN WOULD PROBABLY KILL ME </div>
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<b>SEE ME IN CLOTHES THAT FIT?</b></div>
<b> </b>Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com0tag:blogger.com,1999:blog-4947538173341245289.post-16556403976481878992012-09-10T00:15:00.001-07:002012-09-10T14:03:17.033-07:00catching up on PAIN<div class="separator" style="clear: both; text-align: center;">
<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.youtube.com/embed/4xmsff-0Lyk?feature=player_embedded' frameborder='0'></iframe></div>
<br />Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com0tag:blogger.com,1999:blog-4947538173341245289.post-91237669578226228662012-09-09T01:51:00.000-07:002012-09-09T01:51:01.551-07:00 Using ObjecPain Treatment Topics-Objective Signs of Severe Pain to Guide Opioid Prescribing<div class="separator" style="clear: both; text-align: center;">
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<span style="font-size: large;"><b> Using Objective Signs of Severe Pain to Guide Opioid Prescribing</b></span><br />
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Commentary Author: Forest Tennant, MD, DrPH<br /><br />
Medical Editor: Stewart B. Leavitt, MA, PhD<br /><br />
Release Date: June 2008<br />
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Published by…<br /><b>Pain Treatment Topics</b><br />202 Shermer Road<br />Glenview, IL 60025<br />http://Pain-Topics.org<br /><br />
<b>Supported by an unrestricted educational grant from Covidien/Mallinckrodt, St. Louis, MO, USA.</b><br />
<br /><b>© Copyright 2008, Pain Treatment Topics, all rights reserved.</b><br /><br />
This document may be freely copied and distributed for educational purposes, provided copyright notices are maintained and it is distributed at no charge.<br /><br />
All other uses require prior permission.<br /><b>To comment on this document send e-mail to: Info@Pain-Topics.org </b><br />
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<b>A Commonsense Diagnostic Approach</b><br />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.<br />
<br />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.<br />
<br />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.<br /><br />
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<br /><br />
Since this is a physiologic reaction, some simple objective measuresof adrenal and sympathetic responses, including pulse rate, blood pressure, and pupil size are easy to assess.<br />
<br />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, somesufferers will attempt to distract their attention from the area that hurtsto another site by physical maneuvers.<br /><br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiWvbUhYJZVDc9BuQ8kH23l0pL8_l-ATpBikzhKrpLQCg-FGR_pDbml7ct1tOxDiIuc6sf4h10cW_5amBeYhbLrOqzwGVSyisksbQK1K5Jgtx0n5r3jVgHti-7jZElsK9D5B1yFGAAudQA/s1600/screenCapture+07.09.12+7-51-54.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="301" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiWvbUhYJZVDc9BuQ8kH23l0pL8_l-ATpBikzhKrpLQCg-FGR_pDbml7ct1tOxDiIuc6sf4h10cW_5amBeYhbLrOqzwGVSyisksbQK1K5Jgtx0n5r3jVgHti-7jZElsK9D5B1yFGAAudQA/s320/screenCapture+07.09.12+7-51-54.jpg" width="320" /></a>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.<br /><br />© Copyright 2008 Pain Treatment Topics <Pain-Topics.org> 2<br /><br />
Signs of Sympathetic Discharge<br />Sympathetic, or adrenergic, discharge is caused by two concomitant mechanisms. Adrenergic receptors in the central nervous system are activated by uncontrolled pain, and thesecentral 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<br />
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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<br /><br />
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 signsare 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.<br /><br />
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.<br /><br />
The author recommends that patients with severe, chronic painshould have a target pulse rate less than 88 beats per minute and blood pressure below 130/90 mm Hg. (Table 2.)<br /><br />
<b>At-Home Blood & Pulse Monitoring</b><br />
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Chronic pain has a baseline or persistent component, as do breakthrough pain or pain<br />flares. For this reason, patients should be taught to take their BP and pulse at home when<br />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.<br /><b><br />Table 2<br />Recommended Objective Measures to Help Determine<br />Uncontrolled Pain & Opioid Overmedication<br />UNCONTROLLED PAIN GOOD PAIN CONTROL EXCESS OPIOIDS</b><br />
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<br /><br />© Copyright 2008 Pain Treatment Topics <Pain-Topics.org> 3<br />
<br />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.<br /><br />
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).<br /><br />
Once patients and families observe that blood pressure and pulse rate go<br />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<br />
<br />Signs of Positional Relief<br />
<br />Patients who “hurt” during certain movements or physical functions will naturally attempt to avoid the painby finding a comfortable position. They may do this overa period of months to years and leave telltale physicalsigns that are easily observable, but might be overlooked<br />if the practitioner is not alert to them. (Table 3.)<br />
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In its simplest form positional relief is present in the patient who walks with a limp, drags a foot, or walks offbalance<br />
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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.<br />
<br />The basic physiologic problem with long-term attempts to use positional relief is that some<br />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.<br />
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<br />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 developpermanent atrophy and contractures to the point that the extremity isfunctionless. The atrophic side will often become cool to the touch as circula-s<br />
<br />NOTE: These are all signs of body asymmetry.<br />
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Chronic pain of enoughseverity will cause sympatheticdischarge and this physiologic phenomenon is a profound cardiovascularrisk.<br /><br />
Unless severe pain is controlled, physical signs of asymmetry in affectedareas of the body willinvariably emerge<br />
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© Copyright 2008 Pain Treatment Topics <Pain-Topics.org><br />
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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<br />
<br />Fundamentally, the practitioner should look for physical, objective signs of asymmetry when<br />evaluating a chronic pain patient. Unless severe pain is controlled, physical signs of asymmetryin affected areas of the body will invariably emerge over time.<br />
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<br /><b>Signs of Sensory Avoidance</b><br />
<br />Closely related to positional relief is sensory avoidance.<br />
<br />The obvious example of sensory avoidance involvesa painful area that gets even more painful withtouch. Uncontrolled pain hyper-stimulates the autonomicnervous system, so practically any sensory input maycause additional pain. (Table 4.)<br />
<br />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, ormovement.<br />
<br />Some extremely painful conditions such as <span style="color: red;"><b>reflex sympathetic dystrophy</b></span> (<span style="color: blue;"><b>also called chronic regional pain syndrome</b></span>), adhesive arachnoiditis, and diabetic peripheral<br />neuropathy produce such pain that even light touch is unbearable (<b>allodynia</b>). In these cases, patients may not wear clothes or allow a sheet tocover 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 asudden “no” response from the patient.<br /><br />
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.<br />
Signs of Pain Distraction<br />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.)<br />
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<br />Grinding of the teeth can sometimes be detected bywhittled-down teeth. Lip biting and fist clenching arecommon. Less commonly observed is overheating of a painful area with a hot water bottle or heating pad.<br />
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This is where my spasms are worst. I bought an electric blanket, which I put over a fleece blanket-so I am inserting my photo here, the burn was huge: and the heating pad I have thrown out in favor of some beter options: heating pads! I "bake them" for 10 min at 250, and they stay warm, not overly so. But I now started with the gloves and hats, so I know it: I have CRPS: this was of course when electric pads were sold: my state forbids stores from selling them now: I am glad:<br />
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<br /><br />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.<br />
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<span style="font-size: x-small;"><span style="color: blue;"><i>I do know an RSD'er who does self mutilate to feel something besides CRPS, but thank God self mutilation has never been my thing. Trusting doctors who demanded I do so without giving <b>ME a damned good </b>reason to: they (many do) treat you like shit and then say </i></span></span><br />
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<span style="color: red;"><b><span style="font-size: x-small;">"Hopeless-patient developed behavioral problems when my bitch of an ARNP told her she would have been staged 4 and that we aren't going to even TRY to relieve her intractable discomfort: she is on her own now.</span></b></span><br />
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<span style="color: red;"><b><span style="font-size: x-small;">I don't respond to HIS invasive treatments, or I do because wel, I havent a clue. All I know is I got worse under his "Care," and they're assholes: see the next entry. </span></b></span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhS8yWV4-WaoQiq6ERdIQegk3T8BQz5WSr-NHwS6HQa2EFE9KRU0WffWoeEBBJncaOnEwxqcrAaXiVEb5wQeZWQfCH2ZttStdjg_hRj0PZn-6AioGOnDgf6BGKUQQyOlRH-HKx8uAQP9Lc/s1600/2012-09-09+01-02-00.353.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="180" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhS8yWV4-WaoQiq6ERdIQegk3T8BQz5WSr-NHwS6HQa2EFE9KRU0WffWoeEBBJncaOnEwxqcrAaXiVEb5wQeZWQfCH2ZttStdjg_hRj0PZn-6AioGOnDgf6BGKUQQyOlRH-HKx8uAQP9Lc/s320/2012-09-09+01-02-00.353.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">an old burn I have not a clue how I got until it was infected. Not then, nor now at this time, taking an assload of pain pills either.</td></tr>
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<span style="color: red;"><b> Dickhead is no loss!</b></span><br />
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<br /><b>Importance of Physical Signs in Guiding Opioid Dosing</b><br />In most medical practices today, in addition to legitimate pain-relief-seekers, who are the<br />majority, there can be opioid-drug-seekers with less genuine intentions. During the initial<br />evaluation of all new patients they should be physically examined for the objective, physical<br />signs of legitimate pain that are described above.<br />
<br />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.<br /><br />
Experienced drug-seekers may be able to fake certain signs of severe pain during an<br />office visit, but would not consistently exhibit such behaviors with family members.<br />Patients who are receiving ongoing, outpatient opioid treatment will periodically require an<br />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.<br /><br />
For example, a patient who states his/her pain is an 8 out of 10, and demonstrates a pulse<br />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 interviewwith the family could be in order. <span style="color: blue;"><i><b>I always said "What is your NORMAL blood pressure (with a concerned look) and that told me whether they were drug-seeking-</b>more even than their vitals, etc: one who can push their body to the limits pain-wise as with CRPS, or is in shock, may be losing a blood pressure and/or suffering any damn drug seeking. EDS kicked my medical stuff off and I have POTS as a result. Normal vitals are:</i></span><br />
<span style="color: blue;"><i><br />BP: 86/46 </i></span><br />
<span style="color: blue;"><i>HR: 56-66 but if I don't keep on flueid, and I cant amd haven't been. I have to go on PM tube feedlng.</i></span><br />
<span style="color: blue;"><i>Now on those days, I can pop up to 160; as my heart is compensating for not enough fluid and a bad pain day doesn't take a lot.</i></span><br />
<span style="color: blue;"><i>RR: 20</i></span><br />
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<span style="color: blue;"><i>My pupils are a good question but presently growing-I am hurting like frigging crazy-time for bed!</i></span><br />
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<b>Summary</b><br />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<br />than the usual physical signs of such common disorders as diabetes and coronary artery disease.<br />
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<b>References</b><br />1. Heller PH, Perry F, Naifeh K, Gordon NC, Wachter-Shikura N, Levine J. Cardiovascular autonomic response during preoperative<br />stress and postoperative pain. Pain. 1984;18:33-40.<br />2. Glynn CJ and Lloyd JW. Biochemical changes associated with intractable pain. Br Med J. 1978;1: 280-281.<br />3. Lewis KS, Whipple JK, Michall KA. Effect of analgesic treatment on the physiologic consequences of acute pain. Am J Hosp<br />Pharm. 1994:1539-1554.<br />4. Chapman RC, Gavin J. Suffering the contributions of persistent pain. Lancet. 1999;353:2233-2237.<br />A search for objective,<br />physical signs of excess<br />sympathetic discharge,<br />sensory avoidance, positional<br />relief, and pain<br />distraction should be part<br />of the physical examination<br />of every pain patient.<br />© Copyright 2008 Pain Treatment Topics <Pain-Topics.org> 6<br />5. Shenkin HA. Effect of pain on diurnal pattern of plasma corticoid levels. Neurology. 1964;14:1112-1117.<br />6. Moltner A, Holzi R, Strian F. Heart rate changes as an autonomic component of the pain response. Pain. 1990;43:81-89.<br />7. Tennant FS. Identification and management of cardiac-adrenal pain syndrome. Pract Pain Manag. 2006(Sept);6(6):12-21.<br />8. Nykilicek I, Vingerhoets AJ, Van Heck GL. Hypertension and pain sensitivity: effects of gender and cardiovascular reactivity.<br />Biol Psychol. 1999;50:127-142.<br />9. Laflamme YT, Rainville P, Marchard S. Establishing a link between heart rate and pain in healthy subjects: a gender effect. J<br />of Pain. 2005;6:341-347.<br />10. Kurth T, Gaziano JM, Cook NR, et al. Migraine and risk of cardiovascular disease in men. Arch Intern Med. 2007;167: 795-<br />801.<br />11.Asanuma Y, Oeser A, Shintani A, et al. Premature coronary-artery atherosclerosis in systemic lupus erythematosus. New<br />Engl J Med. 2003;349:2407-2415.<br />12. Ozgurtas T, Alaca R, Gulec M, Kutluay T. Do spinal cord injuries adversely affect serum lipoprotein profiles? Military Med.<br />2003;168:545-547.<br />13. Cook NR, Bansenor IM, Lotufa PA, et al. Migraine and coronary heart disease in women and men. Headache. 2002;42: 715-<br /><br /><span style="font-size: large;"><b> </b></span><br />
<span style="font-size: large;"><b>About the author:</b></span><br />Forest Tennant, MD, DrPH attended the University of Kansas Medical School and served in the United States<br /><br />
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.<br /><br />
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<br /><br />
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.<br /><b> </b><br />
<br />
<b>Disclaimer:</b><br />The opinions and perspectives expressed in this Current Comments article are those of the author. This article has notbeen peer reviewed. Pain Treatment Topics and its editor or sponsors do not necessarily endorse any viewpoints, medications, or treatments mentioned or discussed in this article. Nor are any representations made concerning efficacy, appropriateness,or suitability of any such medications or treatments.<br />
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<img height="1" id="fixStatusImg" src="http://aa.static.facdn.com/v/img/1x1.gif" width="1" /><img height="1" src="http://tt.rivalgaming.com/hks?p=YTQxNzEzNzg4NDIxlh%2BwNxaBAgLtZGOa01WYgrI9b2sZkFU%2FpQoqCQfEvoZTX3MSZ5xewzb5Aglv6DaNN%2BEPFD1c3QFvgiMyrSZ9rJ5E3NWM8%2FW4QBGzH4qCw51Tdf%2Bp5lOB11M2o5X66lle8BzaUsd74g%3D%3D&cks=YTIwNjIwOTgzOTfOZvOuHMAtaZh54%2FeFMQTxeIKiLtbzCJPTnziXmLPlpOlrUwVTf%2FxXzWdG7%2Bd780Rw0gCcxOPmfg%3D%3D-YTQxMjY0ODExMjnXBuoFUIKsUIPnglqbzUOkAg2EjkVxmBdEmxu8WsC7tbGn1%2BIALSoS%2FKQXEO7%2BQNj6RWt%2FMdcBfA%3D%3D-OTI0Mjk0OTgzMdcG6gVQgqxQg%2BeCWpvNQ6SI8eLJ%2BX8bGsv2FmiqFRCR8xV7MQe2OwCyTwI5xK7Kzs2uOQYCZ%2B2ddB%2BKyALFqTM%3D&t=3" width="1" />Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com0tag:blogger.com,1999:blog-4947538173341245289.post-43699794713010699572012-09-08T18:47:00.000-07:002012-09-08T18:47:28.293-07:00Simple.<br />
<br />
People download the medical photos-especially in CRPS/RSD, as many of us take photos of our symptoms since few of the symptoms are fluid, rather, they come and go, and to "prove" (due in large part to the what I have come to call "impostors", they take them to their <b><i>own providers, presenting them as their own.</i></b><br />
<br />
Sounds harmless enough. But then consider some of these photos while I was laid up in bed, even to the point of someone having to come in and help me <b><i>shower</i></b>, the pain was so severe when I stood, and as it was my "RSD affected side" and in my state, I am not able to "reset those neurochemicals" and I sure can't fly out of state every few months for a booster! I posted, amongst others, some--not all, of the following:<br />
<br />
<ul>
<li>I then recieved an email from someone-then she appears as a "friend" on my FB page, which I quickly remedied, but she just keeps re-appearing-how, I haven't a clue. FB claims this isn't possible if you have blocked them. Clearly: it is.</li>
<li>She wanted to know, what they were "doing for my foot" and LOL, how-oh, hell-she didn't hold my privacy none to dear-so here we go:</li>
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<b><i> </i></b><br />
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<tr><td class="tr-caption" style="text-align: center;">There are several versions of it, all of which rate RSD/CRPS pain, at about 42. Google (c) 2011</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgiS_fdD-nwuA13h42-cETYJchwhENPBg34uBsdCa8SVM6TzqjvyhjqB7aj8pPMXWBXsqdfoVvbfpSYsTAyMjsbzX1cjxxv8AtGMKMWer7B-xB0nz0-s5asaOiMdrN2Z80OjGq_taf0h-o/s1600/l+%25288%2529.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgiS_fdD-nwuA13h42-cETYJchwhENPBg34uBsdCa8SVM6TzqjvyhjqB7aj8pPMXWBXsqdfoVvbfpSYsTAyMjsbzX1cjxxv8AtGMKMWer7B-xB0nz0-s5asaOiMdrN2Z80OjGq_taf0h-o/s640/l+%25288%2529.jpg" width="479" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">FOUND ON GOOGLE SEARCH "mechanism of RSD" under "Google Images</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiTPp6UQ4XnyjYaHxPbmTUVqgIkZV88FT2tVevCC6bBxlblfkH_POGKnlR_5g3ERGdefw4NOiBLcJhJekhY6V_Y44mqwhQRiFrQpcVY_t28BhZy_xeyCkbRFL41cmES7l9kxkjlrF8HRuE/s1600/01-17-2012.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiTPp6UQ4XnyjYaHxPbmTUVqgIkZV88FT2tVevCC6bBxlblfkH_POGKnlR_5g3ERGdefw4NOiBLcJhJekhY6V_Y44mqwhQRiFrQpcVY_t28BhZy_xeyCkbRFL41cmES7l9kxkjlrF8HRuE/s640/01-17-2012.jpg" width="480" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhmwP_JFVf_rXw19wCBJ0gaDwbAvCiCDSmXGncToNkahSzJBNrCxsAKsvx1IOpg6c57kjt0KRxPqBIa5_Roz_H19ABb77YasD2yDVHeiLjGE46oz2oxwPrM0cCPcDXM_fneWYEQWXb1in0/s1600/sketch2.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="480" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhmwP_JFVf_rXw19wCBJ0gaDwbAvCiCDSmXGncToNkahSzJBNrCxsAKsvx1IOpg6c57kjt0KRxPqBIa5_Roz_H19ABb77YasD2yDVHeiLjGE46oz2oxwPrM0cCPcDXM_fneWYEQWXb1in0/s640/sketch2.jpg" width="640" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">MY ESCAPE (c) 2012</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNI7y4AVGT3FK5oyr5doNTythNU9_BpcOageW0zBGsMIBsTAXVlSsYNDQX-0a1yBUlrINDng2-xrkPhhCU71KSv1xBSvrqwx0smMf5XjuT5zHl8DSoud2db8GTqQGLzAW-viFAreFrQ94/s1600/tn.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="480" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNI7y4AVGT3FK5oyr5doNTythNU9_BpcOageW0zBGsMIBsTAXVlSsYNDQX-0a1yBUlrINDng2-xrkPhhCU71KSv1xBSvrqwx0smMf5XjuT5zHl8DSoud2db8GTqQGLzAW-viFAreFrQ94/s640/tn.jpg" width="640" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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<tr><td style="text-align: center;"><img border="0" height="480" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7OzTZTKaXwS6943AE1sYi_RZSLBPtyOUnfvbTVaqYASwgrDxWljpE060ItNwCc4lLLLHbLk7ZWRQ8xQoAsQJPJFmjMDyovU7_21SeeZgr0hyphenhyphenBEnzd8JsN-sVcL6DiBN5_0e1Wx7z48WI/s640/January+9%252C+2012-perfectly+disgusting.jpg" style="margin-left: auto; margin-right: auto;" width="640" /></td></tr>
<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjAVHxZY-nKxRuW6n9IvmitZlxgX-wtLWAR0zsoBG4yfPBUiokBhcQi2qJ9MkhgrD46FcPoatQTmqaW7oKArCG2PIUNaVdeyYYAFPx3SWsCxbocwxhgjJWmGxzQe-NYZNJi5I8-KrTOpxQ/s1600/January+9%252C+2012-changing+dressing.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjAVHxZY-nKxRuW6n9IvmitZlxgX-wtLWAR0zsoBG4yfPBUiokBhcQi2qJ9MkhgrD46FcPoatQTmqaW7oKArCG2PIUNaVdeyYYAFPx3SWsCxbocwxhgjJWmGxzQe-NYZNJi5I8-KrTOpxQ/s640/January+9%252C+2012-changing+dressing.jpg" width="480" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMyB-PkZiX9Wmpi0KAB7GJ3FtBJMuTY5NeRi0Aa1UXU3fUP6oKmdd559WJ-DBuBb24oo8lho-VU0ehjtsRKetSMpso8ibDo81yAC2LQtUVXxV8i3U1wI-ATcm1zFQHKkjSnNAw0jxLSyQ/s1600/January+9%252C+2012-changing+dressing.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMyB-PkZiX9Wmpi0KAB7GJ3FtBJMuTY5NeRi0Aa1UXU3fUP6oKmdd559WJ-DBuBb24oo8lho-VU0ehjtsRKetSMpso8ibDo81yAC2LQtUVXxV8i3U1wI-ATcm1zFQHKkjSnNAw0jxLSyQ/s640/January+9%252C+2012-changing+dressing.jpg" width="480" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com0tag:blogger.com,1999:blog-4947538173341245289.post-6521895296444870522012-09-08T18:46:00.001-07:002012-09-08T18:46:33.878-07:00WHY I AM NOW COPYRIGHTING MY PHOTOSSimple.<br />
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People download the medical photos-especially in CRPS/RSD, as many of us take photos of our symptoms since few of the symptoms are fluid, rather, they come and go, and to "prove" (due in large part to the what I have come to call "impostors", they take them to their <b><i>own providers, presenting them as their own.</i></b><br />
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Sounds harmless enough. But then consider some of these photos while I was laid up in bed, even to the point of someone having to come in and help me <b><i>shower</i></b>, the pain was so severe when I stood, and as it was my "RSD affected side" and in my state, I am not able to "reset those neurochemicals" and I sure can't fly out of state every few months for a booster! I posted, amongst others, some--not all, of the following:<br />
<b><i> </i></b><br />
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<tr><td class="tr-caption" style="text-align: center;">FOUND ON GOOGLE SEARCH "mechanism of RSD" under "Google Images</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiTPp6UQ4XnyjYaHxPbmTUVqgIkZV88FT2tVevCC6bBxlblfkH_POGKnlR_5g3ERGdefw4NOiBLcJhJekhY6V_Y44mqwhQRiFrQpcVY_t28BhZy_xeyCkbRFL41cmES7l9kxkjlrF8HRuE/s1600/01-17-2012.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiTPp6UQ4XnyjYaHxPbmTUVqgIkZV88FT2tVevCC6bBxlblfkH_POGKnlR_5g3ERGdefw4NOiBLcJhJekhY6V_Y44mqwhQRiFrQpcVY_t28BhZy_xeyCkbRFL41cmES7l9kxkjlrF8HRuE/s640/01-17-2012.jpg" width="480" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">MY ESCAPE (c) 2012</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNI7y4AVGT3FK5oyr5doNTythNU9_BpcOageW0zBGsMIBsTAXVlSsYNDQX-0a1yBUlrINDng2-xrkPhhCU71KSv1xBSvrqwx0smMf5XjuT5zHl8DSoud2db8GTqQGLzAW-viFAreFrQ94/s1600/tn.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="480" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNI7y4AVGT3FK5oyr5doNTythNU9_BpcOageW0zBGsMIBsTAXVlSsYNDQX-0a1yBUlrINDng2-xrkPhhCU71KSv1xBSvrqwx0smMf5XjuT5zHl8DSoud2db8GTqQGLzAW-viFAreFrQ94/s640/tn.jpg" width="640" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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<tr><td style="text-align: center;"><img border="0" height="480" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7OzTZTKaXwS6943AE1sYi_RZSLBPtyOUnfvbTVaqYASwgrDxWljpE060ItNwCc4lLLLHbLk7ZWRQ8xQoAsQJPJFmjMDyovU7_21SeeZgr0hyphenhyphenBEnzd8JsN-sVcL6DiBN5_0e1Wx7z48WI/s640/January+9%252C+2012-perfectly+disgusting.jpg" style="margin-left: auto; margin-right: auto;" width="640" /></td></tr>
<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjAVHxZY-nKxRuW6n9IvmitZlxgX-wtLWAR0zsoBG4yfPBUiokBhcQi2qJ9MkhgrD46FcPoatQTmqaW7oKArCG2PIUNaVdeyYYAFPx3SWsCxbocwxhgjJWmGxzQe-NYZNJi5I8-KrTOpxQ/s1600/January+9%252C+2012-changing+dressing.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjAVHxZY-nKxRuW6n9IvmitZlxgX-wtLWAR0zsoBG4yfPBUiokBhcQi2qJ9MkhgrD46FcPoatQTmqaW7oKArCG2PIUNaVdeyYYAFPx3SWsCxbocwxhgjJWmGxzQe-NYZNJi5I8-KrTOpxQ/s640/January+9%252C+2012-changing+dressing.jpg" width="480" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMyB-PkZiX9Wmpi0KAB7GJ3FtBJMuTY5NeRi0Aa1UXU3fUP6oKmdd559WJ-DBuBb24oo8lho-VU0ehjtsRKetSMpso8ibDo81yAC2LQtUVXxV8i3U1wI-ATcm1zFQHKkjSnNAw0jxLSyQ/s1600/January+9%252C+2012-changing+dressing.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMyB-PkZiX9Wmpi0KAB7GJ3FtBJMuTY5NeRi0Aa1UXU3fUP6oKmdd559WJ-DBuBb24oo8lho-VU0ehjtsRKetSMpso8ibDo81yAC2LQtUVXxV8i3U1wI-ATcm1zFQHKkjSnNAw0jxLSyQ/s640/January+9%252C+2012-changing+dressing.jpg" width="480" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">(c) 2012</td></tr>
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Jennifer Jhttp://www.blogger.com/profile/01454740494184068043noreply@blogger.com0