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Trusted patients in a system built for liars · Cultural Wars | America Out Loud News

• 0:08
  If we've learned anything from these past couple of years, my call Americans is that personal medical freedom and liberty are in crisis.
• 0:19
  Almar Ground Law Pulse brings together the top experts in health care related fields to keep you up being ahead.
• 0:30
  Welcome everybody.
• 0:31
  You're listening to America Outlound Pulse on the iHeart Radio Network and on the America Outloud apps for Apple, Android, and Alexa.
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  Don't miss a moment.
• 0:39
  Join us every Friday at 5 p.m.
• 0:40
  Eastern.
• 0:41
  I'm Dr.
• 0:41
  Randall Bach.
• 0:42
  And I'm honored today to have with us quasi anonymous Brian.
• 0:47
  He is going to be our man on the street.
• 0:52
  He's not on any street.
• 0:54
  We are all very particular in our ways.
• 0:57
  But I encountered Brian in my orbit through social media and vice versa.
• 1:02
  And we have certain uh similar interests and whatnot, but I have him on the show because I'll make a I'll start with this analogy.
• 1:11
  Uh gun control.
• 1:13
  Um vis-a-vis, narcotic control.
• 1:17
  Now, what are those two things have to do with each other?
• 1:19
  Well, you know, if you're a reasonable homeowner, you want to protect your home, uh, you will get a gun permit.
• 1:24
  You have to go through all the constraints and strictures and whatnot in order to get that.
• 1:28
  You have to be a law-abiding citizen, uh, not a felon, you know, and so forth, so on.
• 1:32
  Um, but then there are a lot of guns around, people shoot each other, and then there come more and more restrictions on your honest legal ability to protect yourself.
• 1:42
  Now, what does that have to do with narcotics?
• 1:44
  Well, uh, I think it's pretty obvious, but I'll elucidate, and we can have Brian talk about this topic as well.
• 1:50
  But uh, there are reasonable uses for narcotic medications, and uh some other people's kind of spoil the party, uh, people who are using it illicitly and for you know, kind of addictions out of control and whatnot, uh, bring basically a narcotic control aspect to the medical practice and also kind of uh, you know, in drive by shooting to you know, mix the analogies.
• 2:11
  Uh, there's some you know ancillary cross damage to people who have honest, reasonable pain complaints.
• 2:17
  So that's my long preface.
• 2:19
  I apologize for that.
• 2:20
  Uh, but we'll kind of get to it.
• 2:21
  Uh, tell me first of all, how off the mark am I, Brian?
• 2:24
  Maybe you can tell our our listeners and viewers uh what your particular issue was and how you got in kind of the pain management world.
• 2:32
  Thanks, Randy.
• 2:32
  I really appreciate that uh intro.
• 2:34
  And I think gun control is a uh very reasonable um comparison there.
• 2:39
  Uh I've been a pain patient, unfortunately, since uh 2009.
• 2:45
  So I was diagnosed with dysplasia, meaning that the ball and the socket did not form properly in either one of my shoulders and in both of my hips.
• 2:56
  And so starting in 2010, I got my first laparoscopic surgery, uh, whereby they went into repair the labrum, and the surgeon said you're gonna have about 10 years with this, and the remainder of your joints are likely going to fail over time.
• 3:11
  So I've had I've been under some sort of pain management um for probably 15 to 20 years, but much more intense as the joints started to fail around 2019.
• 3:25
  And I've observed substantial changes in pain management uh over these years.
• 3:31
  Um, I've worked with a specialized pain management practice, and I've gotten quite close with the physician.
• 3:37
  Um, the restrictions on them have become more severe.
• 3:41
  And bottom line is is everybody is treated like an addict until you're not, until they finally trust you and you've been uh sort of man on the street.
• 3:51
  Um my background uh to sort of be a uh a trusted uh pain management patient is uh twofold.
• 3:59
  Uh, number one, I've been in the pharmaceutical industry myself um for going on 30 years.
• 4:05
  I've primarily uh worked with hospital antibiotics and hospital medicines, but I've worked my way through primary care as well, uh, through different layers of management um and uh first line work.
• 4:19
  But um, as far as uh pain management goes, you know, I was given my first narcotic prescription back when I was probably 19 years old, and uh I had crashed a motorcycle.
• 4:33
  And I thought, hey, you know, this medicine really works, worked, put it on the shelf.
• 4:38
  And uh I didn't learn until later that NORCO was actually something that people crave.
• 4:45
  And uh I didn't know this at the time because there is a subset of patients, about eight to ten percent who don't receive mood and motivation from narcotics, meaning it would be very, very difficult for that patient to become psychologically addicted to the drug because there's no reward loop.
• 5:04
  However, all patients will become at some point physically addicted to narcotics, regardless if they're taken um within uh within uh the scope of appropriate appropriateness.
• 5:18
  Yeah, there's a lot of good stuff there.
• 5:20
  Um, before we go further down that journey, I had one other analogy.
• 5:24
  I guess um, you know, the airport uh security line.
• 5:27
  And I'm wondering whether there might be some solution for us.
• 5:30
  You know, there's TSA, whatever it is, uh pre-check, there's uh real clear IDs, uh, there's all kinds of global entry.
• 5:39
  There's a way of stratifying uh your um risky behavior in order to minimize the risk to others around you and to the system itself.
• 5:49
  The airlines ostensibly um, I mean, not saying that they're there to you know, transport people from A to B and from B to C and so forth and back.
• 5:57
  Um, and every now and then somebody wants to bollocks up the works and there's hijackings and mayhem and whatnot.
• 6:04
  And so everybody has to go through all these um pervasive checks.
• 6:10
  Um those are not necessarily you know, best use of time to do grannies, um, you know, the same way you do uh you know, say young, vigorous uh uh bearded men.
• 6:21
  Um and no offense to to your own beard and whatnot.
• 6:26
  But you know, the thing the thing is, you know, so you have to um you know they've they've tried to push back on that.
• 6:32
  So there are private jets and whatnot.
• 6:34
  A lot of you are important person, you kind of get to obviate that system because everyone's trusted within that.
• 6:40
  Uh so there might be an analogy there for you know private clinics or certain ways of of having a trust network.
• 6:46
  Um, and then there's also a way of kind of identifying people better if they have this proclivity or not.
• 6:52
  Now, you know, you don't with personal medical history, it's a little bit different, but I'm not sure how different it is.
• 6:57
  Uh, if we have to go through certain security clearances in order to get on the airplane, and we have to do them, you know, to varying extents when you rent a car and all kinds of other ways.
• 7:06
  Um, there could, I think, you know, again, this would get into HIPAA privacy issues and whatnot, but you could be a trusted traveler, you know, that you're, you know, you don't uh bang at the walls, you don't have polypharmacy.
• 7:18
  I'll I'll I while I'm doing this diatribe, um, you know, I'll tell you, you know, my own experience is from the other end.
• 7:26
  And uh, you know, I I joke, but it's actually true.
• 7:29
  I was called Dr.
• 7:30
  No, um, with an you know, without the K and the W.
• 7:34
  So you know, sort of a know it all type, and that can annoy people, whatnot.
• 7:38
  But this annoyance was Dr.
• 7:39
  No, the James Bond villain, uh, who just you know, that happened to me as uh Chinese name, but you know, uh they they called me that the drug addicts who were looking for narcotics, called me Dr.
• 7:50
  No because I said no all the time.
• 7:51
  But my no wasn't like completely unfounded.
• 7:54
  I did sort of my TSA pre-check kind of clearance uh data analysis on people when they came in.
• 8:00
  It wasn't that hard.
• 8:01
  This is before I I started doing uh any kind of the detox stuff.
• 8:05
  This is like in the 1980s and 1990s, and their computers were there, they existed, but they weren't really well connected and whatnot.
• 8:12
  So while the patient was there, if they came in brand new from some other place, they'd never been, you know, usually it was pretty parochial.
• 8:19
  I I was in a blue-collar town north of Boston.
• 8:23
  But if people came from three towns over, two towns over, and they had a story, they were allergic to the low-level narcotics, they had particular back pain, and so forth.
• 8:31
  You know, there was a type basically.
• 8:33
  It wasn't that hard.
• 8:34
  If I were working for LL Airlines, you know, they have a type they look for.
• 8:38
  They they have the fewest hijacks, uh, they have humans running the place, just like other every other airline, they just have a better or more strict algorithm for kind of sifting out people.
• 8:48
  What where are you going?
• 8:49
  They ask you like five, six questions, and they they can kind of have their personality type.
• 8:54
  Anyway, uh, you know, without thinking of it that way, I that's how I categorize people.
• 8:59
  And you know, while they were giving a urine test or whatever, or you know, doing filling out a questionnaire, I have my staff call, you know, certain of the pharmacies, and they at the time, the big one, CBS and Walgreens when I would coordinate, and they'd say, Oh, you know, Joe, um, you know, date of birth, et cetera.
• 9:14
  You know, he has he just saw this doctor and that doctor, he's got a percocette prescription five days ago for 90 of them, da-da-da.
• 9:20
  And so I would just bring that back to people.
• 9:22
  I say, you know, I would give them a little bit of rope.
• 9:24
  Have you seen anybody recently?
• 9:26
  Have you got any prescription treatment?
• 9:27
  No, no, no, no, no.
• 9:28
  And anyway, you get the idea.
• 9:29
  And so I was the one who would say no to them.
• 9:32
  And you know, people uh, you know, I tried to do it as a uh, you know, like a mama, uh, his famous teaching moments, but in a genuine way, um, I try to put it out there.
• 9:41
  It's like, well, this is an issue, I think, and maybe we could talk about detox or you know what the problems are, you know, you know, why you're in the situation, so forth, and and get something productive out of it.
• 9:50
  Usually that was not uh, you know, it's kind of like water in the desert, you know, or water on ducks back, it just kind of floated off and they raced out uh angry and whatnot.
• 9:59
  Usually they
• 10:00
  weren't paying.
• 10:00
  It was the state of Massachusetts or some form of uh government uh through Medicare disability or whatever that was paying for the visit anyway.
• 10:07
  So it's no skin off their back, they just wouldn't come back.
• 10:09
  And then the word on the street, I started to see fewer of them because I was Dr.
• 10:13
  No.
• 10:13
  Anyway.
• 10:14
  Um but uh, you know, uh it's just uh I'll just leave that out there.
• 10:20
  I don't know if you have any thoughts on that.
• 10:21
  Um, or we can talk about how you know this uh you know kind of pathway has been for you in order to manage your own pain through uh narcotics on occasion.
• 10:30
  Sure.
• 10:31
  Yes, and uh I could probably give you even a little bit more background, which is kind of interesting.
• 10:36
  Uh, working with hospital medicine, the company that I was working for, they put us up uh with preceptor ships so that we could do uh some time with the emergency room physicians.
• 10:46
  And in Mission Viejo, California, I decided to do the night shift with an emergency room physician friend of mine who was uh chief of staff and he was head of the department.
• 10:56
  And he said, Why don't you come on in and do the seven to seven shift?
• 11:00
  Seven p.m.
• 11:01
  to seven a.m.
• 11:01
  shift.
• 11:02
  And I said, All right, I'll do it and I'll bring in pizzas at midnight for everybody.
• 11:05
  So here I was in a white coat um with my uh stethoscope on.
• 11:10
  I was a trained emergency medical technician at the time, so I did have the right to be there.
• 11:15
  Um, yet I wasn't working for the hospital, and I wasn't uh a physician.
• 11:19
  So the physician had a good deal of fun with me.
• 11:23
  And he said, What I'd like you to do, Brian, is I'd like you to triage all of the pain patients.
• 11:29
  And I said, Well, you know, it's kind of a big job.
• 11:31
  And he said, Well, I tell you what, if they're not bleeding, if they're not bleeding and there's no visible signs um of uh of trauma, I want you to triage them.
• 11:40
  You go up to them first.
• 11:42
  And what I noticed is starting about 10 o'clock at night, there were a lot of patients coming in with back problems.
• 11:49
  And uh they were just nervous and angry and and just really upset.
• 11:54
  And uh I it didn't take me very long to realize who the malingerers were for narcotics.
• 12:01
  But then I thought to myself, you know, if these patients are going to all the trouble to come to this emergency room, which is in a nice area of Southern California.
• 12:10
  I mean, this is not the ghetto by any means.
• 12:13
  You know, they they must really be in in in pretty bad distress.
• 12:17
  And uh at the time, you know, this was before my own journey with narcotics and dysplasia.
• 12:23
  You know, I was upset at these people, and I'd throw them in the hallway and I'd put them, I'd put them over there, and I'd say, you know, you just wait and we'll we'll get to you.
• 12:30
  And I had a hallway full of these people.
• 12:32
  And um, then the doctor would come out and he'd say, All right, Brian, let's go interview them, bring them in one by one.
• 12:39
  And so patient would come in, and you know, the doctor would give them just kind of a once over and say, you know, yeah, back problems, that's it's real serious, you know.
• 12:48
  Let's see here.
• 12:49
  Um, you know, you you think we should get you something to kind of hold you over before we get get you into X-ray and stuff like that.
• 12:56
  And the patient would be like, oh, yeah, yeah, absolutely.
• 12:58
  So he'd give them a dose of something.
• 13:01
  And then uh once uh 15, 20 minutes went by, I'll say, all right, you want to come over to X-ray now?
• 13:06
  You'd be like, you know what?
• 13:07
  I'm actually feeling a lot better.
• 13:08
  I'll I'll probably just get out of here now.
• 13:11
  And uh the doctor looked at me and he said, that's how to deal with them.
• 13:15
  But I was upset.
• 13:16
  I'm like, why are you giving a medicine?
• 13:18
  And he says, look, Brian, he says, if you've got somebody coming in here at 10, 11 o'clock at night in full withdrawal, level nine, level eight pain is pretty much the equivalent of level nine, level eight withdrawal.
• 13:34
  These people are absolutely miserable.
• 13:36
  And he says, I can't help these people, but what I can do is I can keep them from breaking into a car tonight.
• 13:43
  I can keep them from killing themselves, at least for the next 12 hours.
• 13:47
  So what I found out is he gave them an extended release oxycodone to hold them, but he told them at the end, he says, All right, we're not doing x-rays or anything like that, but you can't come back here.
• 13:57
  This is a one-time deal.
• 13:59
  And so, you know, I learned something, and what I learned was grace.
• 14:04
  Uh, because you know, when I was on narcotics myself, you know, I didn't really realize the extent that physical dependence can have on you.
• 14:15
  You're stuck.
• 14:16
  If you've been on oxycodone, say for three months to stay ahead of the pain, which is once every six hours, which is what I've had to do, you don't get a chance to stop immediately.
• 14:28
  It is an absolute hell.
• 14:31
  So I learned to respect a little bit more uh the feelings of withdrawal.
• 14:37
  And uh I didn't quite think so poorly of the people, and I actually kind of regret some of me, maybe some of my behavior back uh around uh 2000 or so back in that emergency room.
• 14:50
  It's interesting.
• 14:50
  So a few questions.
• 14:51
  When you say you were on narcotics, I mean for pain management, or was there any kind of recreational aspect to it?
• 14:59
  No, never.
• 15:00
  Like I mentioned, um, my first go-to is RNSADS.
• 15:04
  Um, you know, Tylenol, Advil, those those types of things.
• 15:08
  But when it comes to dysplasia, what happens is again that uh that ball and socket don't match.
• 15:16
  And so the sleeve of that joint, the labrum, it doesn't just tear slowly.
• 15:22
  When it goes, it goes and it's bad.
• 15:26
  And so the surgeons, they tell you you need to put off surgery as long as you can.
• 15:32
  You want to get at least over 50.
• 15:34
  And so me and my pain management doc, you know, we had to utilize cortisone shots and from time to time to carry over into the next cortisone shot.
• 15:44
  We would utilize um oxycodone, um, hydrocodone, uh, what what have you uh from time to time, and I would take it as needed or PRN um from time to time.
• 15:55
  And there I stayed below sort of the physical addiction threshold.
• 16:00
  And I've never had that psychological addiction threshold, but I wanted to speak back to what you were mentioning about TSA and sort of the trusted traveler.
• 16:09
  Uh what has changed, especially over the five, six years uh recently, are that when you do step in to speak with a doctor um about pain, you actually get a psychological profile put on you.
• 16:23
  And so they're asking you questions.
• 16:25
  Um, do you have depression?
• 16:27
  Have you ever had depression, anxiety, um, things like that?
• 16:30
  How is your home life and things like that?
• 16:33
  Because the fact is for the majority of patients, um, a narcotic therapy will not only block that pain for four to six hours, but it also kind of solves some psychological problems if you've got them.
• 16:48
  So that is something that has been new is that uh definitely you're getting a psychological profile uh prior to a narcotic prescription.
• 16:59
  But you know, the advantage that I've had is I've had the same doctors, and that's just been very, very beneficial as a pain patient.
• 17:08
  But, you know, I was on a couple of Facebook forums for dysplasia, and the lack of actual good pain management is very, very real.
• 17:18
  Um, it's depressing to the point because the baddies have made it so difficult for good genuine people who have very, very serious pain to get control.
• 17:30
  And I think part of it is concern for not only physical addiction, but early on, I think it's a big current concern for psychological addition addiction, because if you have depression, a lot of times even a single dose of a narcotic will suddenly brighten your day and suddenly you don't have depression.
• 17:50
  So psychologically, um narcotics will have an effect as well, and that's something that is being examined more and more these days uh before a physician will engage with a prescription will engage with a prescription for a patient.
• 18:06
  So I think this might be a good moment to just take a quick break.
• 18:10
  Uh so I'd like all of you to stick around.
• 18:12
  This is fascinating.
• 18:12
  We're with uh Brian, our man on the street with pain management, uh having experienced it.
• 18:18
  Uh so we'll be right back.
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• 20:42
  So welcome back.
• 20:43
  I'm Dr.
• 20:44
  Randall Bach here to unpack myths, explore innovations and give you actionable insights into the world of medicine and health.
• 20:49
  And we are continuing on our foray into the uh mixed world of pain management and the overlap with uh pain mismanagement or uh non-pain overmanagement or however you want to call it.
• 21:05
  The world where there's malfeasance, polypharmacy, um, a lot of other things going on wherein people are misusing the um valid system of doctors and pharmacies and hospitals and whatnot um as proxy drug dealers.
• 21:21
  So there's always a black market for almost anything.
• 21:24
  You know, you can buy a watch from uh Tiffany or you can buy it from some guy on the street.
• 21:29
  Uh they might both look like Rolexes and whatnot.
• 21:32
  There's there's always, you know, kind of a mirror shadow um marketplace for a lot of our uh interests, and the more lucrative they get, the bigger the market.
• 21:42
  Anyway, uh so uh we have Brian with us uh uh still and um I just like to ask you, Brian, um, you know, how how long is it take to kind of get to know you uh from a physician standpoint?
• 21:57
  Um, and have you had the situation where you've had to switch doctors and have the doctors ever had to um be queried about what and why they're doing for you uh, you know, chronic medication.
• 22:10
  That's a great question, uh Randy, and that's something that has changed in medicine.
• 22:15
  And um, I was with my primary care provider who um I was a trusted patient with for many, many years, up until probably around 2000 2008 or so.
• 22:31
  And he was a primary care physician, and um he was caring for me with both cortisone injections for my shoulder, as well as a narcotic uh um uh prescription for as needed intractable pain.
• 22:45
  And so I had a good trusting relationship with him until one day he told me, Brian, he said, Hey, there's some new rules coming down.
• 22:52
  Our practice was just bought by a larger conglomerate called optimum.
• 22:57
  And they don't want any of our primary care providers uh doing pain management any longer.
• 23:04
  And even just simple from time to time prescriptions for narcotics.
• 23:09
  If it's a chronic pain condition, they want us to transfer our patients out.
• 23:14
  And so at that point, I received a referral to a private pain management clinic um who specializes in chronic pain.
• 23:23
  But I still went back to my primary care physician um for all other matters, and uh he only lasted another six months because you know, he'd been in practice for many, many years.
• 23:34
  And I noticed that every time I saw him, he now had an iPad in front of him and he was punching buttons and things like that.
• 23:42
  And uh I asked him, I said, You don't look happy, doctor.
• 23:46
  And he says, I'm not.
• 23:47
  I'm thinking about retiring and uh the last straw just kind of came uh this morning.
• 23:51
  I said, What happened?
• 23:52
  And he said, Well, any scheduled product, you know, such as even things like ambient for sleep um or narcotics or uh benzodiazepines, even in anything like that, all scheduled products need to come from a single physician according to this new practice.
• 24:09
  And I have one patient who filled their ambient from their psychiatrist because I was on vacation, and now I've got to do a 15-minute report back to the medical clinic because of this new thing called cures.
• 24:23
  And I said, Tell me about that.
• 24:24
  And he says, Well, it's a nationwide database now that we are supposed to go on log on and check before we write any scheduled product, even something as simple as say ambient for sleep.
• 24:39
  And if this patient is receiving scheduled products from somebody else, I'm gonna end up getting dinged and I've got to spend 15 minutes writing a report on that.
• 24:49
  So he says, to hell with this iPad to the hell with the medical group.
• 24:53
  I'm retiring.
• 24:54
  This is the last time you're gonna see me.
• 24:56
  And I was I was uh I was I was shocked and saddened.
• 25:01
  But uh as I, you know, have navigated around uh a lot of these single shingle type of medical practices um or independent groups, um, are being bought up by larger hospital concerns or larger health care concerns simply because of economies and scope and scale and uh liability.
• 25:22
  But that's one of the things that I observed as I made the transition from primary care to a pain management clinic.
• 25:30
  Yeah, it's tricky thing because I mean that is part and parcel of the kind of trusted traveler program.
• 25:37
  Um it maybe could be a quicker thing, you know, they the the TSA global entry, uh pre-check, whatever, all that stuff, you know, that you go through a process and then things move along more quickly as a result.
• 25:50
  Um it wouldn't take 15 minutes, you know, to do anything like that in the in the airport.
• 25:56
  Um once you kind of become the trusted traveler part, uh, you know, I just finished doing my taxes literally today.
• 26:03
  It's April 15th, uh, when we're recording this.
• 26:07
  Um, they it's turbo tax and filters a lot of stuff, but still is just an endless parade of meaningless questions.
• 26:16
  You know, are you you know, are you a left-handed uh, you know, you know, Native American oil um, you know, dividend receiving uh I don't know, uh you know, adoptee of of five um uh I don't know, have parents from Belgium.
• 26:35
  I mean, is you know, they just ask you a whole series of questions that are in not pertinent and whatnot.
• 26:41
  Um, you know, if you had to like drive on the highway and sit at a toll booth, I mean I I don't mind, you know, I mean I mind, but I don't mind paying because I understand we all have to pay for stuff, um, and it's not the best bargain on earth, government and whatnot, but there you have it.
• 26:54
  Um, but you know, there are other government functions, like you go on uh the highway, whatever, and there's a toll booth, or they've got those monitors now that kind of you know, catch you and have you pay, whatever.
• 27:04
  That's fine.
• 27:05
  You're paying you know, pay per drive, you pay at the you know, gas pump and pay taxes almost everywhere you go, but it's pretty quick and simple.
• 27:11
  It's like the you know, sales tax kind of thing or a certain fee.
• 27:15
  Uh, but with with the IRS, you know, you go through this, you know, kind of mental uh audit colonoscopy, whatever.
• 27:21
  Um that's you know, takes you days or weeks potentially and complicated, depending on how anyway.
• 27:27
  You know, the system in where you're going through 15 minutes is uh that's a microcosm of doing your taxes, but it's certainly you know, orders of magnitude more than going through a toll booth.
• 27:35
  So if it, you know, uh ostensibly you get the thing, you know, a little bit faster up to speed, and you know, people who have not been doing what we call polypharmacy, which is you know, doctor shopping um and carrying, you know, juggling a bunch of uh prescriptions simultaneously, those people should you know reasonably easily be weeded out of the system.
• 27:54
  That's not to say they can't figure out their secondary battle plans because people use proxies, you know.
• 28:00
  We, you know, in the Iraq war, you know, the the young men, you know, would be targeted, whatever.
• 28:04
  They they put the bombs and stuff like that in, you know, on whether they put a burke on, they look like a woman or they get an actual woman, whatever.
• 28:10
  So, you know, the target keeps moving and so forth.
• 28:13
  So people, you know, if you put a certain rule down, people will find another way to get around that rule.
• 28:17
  The shoe bomber was response to the people who had the box cutters, the box cutters, they figured out well, we're not gonna let box cutters in.
• 28:23
  Then somebody hit something in the shoe.
• 28:24
  Now we all take our shoes off, somebody had some liquid explosive, now we have to, you know, all empty our shampoo bottles, you know.
• 28:30
  So there's always like a uh back and forth.
• 28:32
  But you know, the the the sounds like the bones of the system are there to figure out um, and I mean it's an unfortunate thing for this type of medication.
• 28:40
  You know, I take some medication for you know, gouty arthritis, but I don't have to go through any rigmarole because nobody wants this medication, you know.
• 28:47
  Nobody's running around to get allopurinol or colchicine or something like that.
• 28:51
  They're not selling it on the black market, you know, the stuff's generic, it costs like 10 cents or whatever per pill.
• 28:56
  I'm happy to have it, it keeps me happy and so forth, but nobody's running around.
• 28:59
  There's no black market on this stuff, and nobody's gonna alley's you know, trying to get you hooked on it and as a business model, you know.
• 29:05
  So the drug addict, you know, markets always going to be there.
• 29:08
  And that's kind of a big thrust of my you know, intellectual slash medical career, the last number of uh probably 15 20 years or something like that, is to you know, figure out a better way around us.
• 29:21
  Um, but you know, I on your side of it, you know maybe we can kind of segue to experiences with buprenorphine.
• 29:28
  Um, and you know, a lot of these for my taste, again, uh, you know, I I I think these things are fungible, which uh means exchangeable in a way.
• 29:38
  Um, you know, if if I zip over from Mexico and I've got a you know pocket full of pesos, um, I probably can't run right to the CBS and buy something in Laredo, Texas.
• 29:49
  Uh I might have to go to the bank and trade them in, but pesos have a given worth.
• 29:53
  And then the dollar has a worth, I go to I don't know, Belgium.
• 29:55
  You know, if I'm using cash, I might have to buy some euros first, whatever.
• 29:58
  So there's all kinds of
• 30:00
  Markets and there's a there's an exchange rate between those things.
• 30:03
  And so for my taste, you know, people come in some of them in my day when I was you know writing prescriptions, whatever people come in for narcotics, you know, they this oxycontin, and then you know, when I started doing the the detox, you know, I'd have to kind of assimilate and figure out an estimate the the narcotic dose based on 150 dollars of heroin, or you know, I'm doing you know, 120 milligrams of oxycontin, whatever, and there's an exchange rate for how much suboxone that would be and whatnot.
• 30:30
  And I would try to put people on a certain amount that would cover them, but not too too too much.
• 30:35
  Um, but you know, at the end of the day, if there was a way of kind of figuring out dose loading and how many you know milligrams per person people are getting, and then figure out, you know, that it shouldn't be that hard.
• 30:46
  We live in a world world of you know, massive computer brains and AI and whatnot.
• 30:51
  There should be a way of kind of fixing the trusted traveler part of it and also eliminating the 15 minutes that wants you know 50 minute lag time that's going to kick your guy out of practice.
• 31:02
  Yeah, so I can give you a concrete example of what I'm currently doing right now, and that is um I'm recovering from a bilateral hip replacement.
• 31:12
  So uh my left hip, which had been previously operated on in 2009, uh had given up and uh it was shooting off regularly, level seven, level eight pain.
• 31:22
  It was ready for surgery.
• 31:24
  So I had a surgeon lined up down in La Jolla, top surgeon, and uh right then and there, my right hip went.
• 31:33
  And so again, with dysplasia, um, when the labrum goes, it's been worn so thin, it doesn't just tear and start to pain, it goes, and when it goes, it's shooting off seven to eight level pain as well.
• 31:48
  So I've got two hips now, shooting off pain.
• 31:51
  So this is the type of pain that's so severe that it needs to be treated with narcotics.
• 31:57
  And so I was starting to take oxycodone, 10 milligrams, and then with narcotics, when you're in that level of pain, the strategy is to stay ahead of it.
• 32:06
  And if you've got a six hour window with a single tablet, say 10 milligrams of oxycodone, you take it right before every six hours, and that's basically four doses per day.
• 32:17
  And my body will do something what's called tachyphylax or taper, and at exactly three months, the activity of the drug goes away by 100%.
• 32:30
  And I remember this happened to me for the very first time uh back for for my left uh surgery for my left uh shoulder uh replacement, and I was mortified because imagine being a patient knowing uh in the medical industry out there the amount of drug seekers there are, having your trusted patient's status at risk and having to confess to your doctor that the pain medicine that you're receiving now works at zero percent.
• 33:01
  And I was shaking having to having to have it in having to confess this to the physician assistant, and thank goodness that she has been in the industry for a long time and has been uh around the block when it comes to pain medicine.
• 33:14
  And she says, Yep, that's what happens right about this time, and it's a doubling.
• 33:20
  So 10 milligrams is now 20 milligrams, and we continue on.
• 33:25
  Luckily, for the shoulder, my pain abated, and so I began my taper down from there, and there was no consequence.
• 33:34
  I was able to taper the medicine, go down slowly, about 15% a week while still having a rescue for physical therapy.
• 33:42
  But with the hips, um, when they both went, I was on 10 milligrams again every six hours to try to stay ahead of the pain.
• 33:51
  And I go to the surgeon and he says, We're gonna get you on the schedule, it's gonna be about three months out.
• 33:56
  So I knew that that's about right about that time when I'm at risk for the tachyphylaxis or the time when the pain medicine is not going to work.
• 34:06
  And two weeks before the surgery, it stopped working.
• 34:10
  No problem, been there before.
• 34:12
  Doctor, here we go.
• 34:13
  It's now 20 milligrams.
• 34:15
  But you go into surgery, and the surgeon's very upset at you.
• 34:19
  And uh they forget that they've told you you gotta wait as long as you possibly can before surgery, and don't come in on narcotics, by the way, because it's going to be harder to get uh get a hold of you after after the surgery.
• 34:32
  But when you've got a uh condition as bad as mine was, you don't really have a choice.
• 34:38
  And so post surgery, I unfortunately lost um all narcotic coverage three months again, hence after the surgery.
• 34:47
  Um, and as a result, there was no reasonable dose to treat me with narcotics.
• 34:55
  So I utilized uh injectable tortol and other other means, ice and things like that to sort of make it three more weeks until the pain finally abated, and then you know, I had been on at that time 20 milligrams every four hours, which is a fairly high dose of the medicine.
• 35:12
  So I began my taper and I started tapering down.
• 35:16
  And uh, you know, tapering at a strict schedule is reasonable, but I had learned about um uh buponorphone, which is a substitute that you can utilize to taper down, and it has sort of a 24-hour effect.
• 35:32
  So I requested of my pain management doctor, may I move over to that for my taper?
• 35:37
  And the drug apparently has a bit of stigma, it's not typically used in good trusted patients.
• 35:43
  They just do their own taper with the medicine they have.
• 35:46
  And um he sleep he pushed me back to my primary care physician who ended up uh taking over and said, sure, yes, I know you're a trusted patient, let's give this a try.
• 35:56
  And so he was willing to allow me to do that.
• 35:59
  And like Dr.
• 36:00
  Bach was just mentioning, there's an exchange rate.
• 36:03
  So I was at about 15 milligrams three times a day.
• 36:07
  I substituted two milligrams three times a day for a total of six milligrams a day, and have been moving down a milligram every two weeks since then.
• 36:16
  Perfectly smooth, perfectly reasonable, and it's been easy.
• 36:20
  Um, the only thing I didn't realize at the time was bupenorphone, which is a um a useful, it's a narcotic.
• 36:28
  Uh, it binds to the opiate receptors so strongly that you cannot utilize any longer um oxycodone, hydrocodone, or any of the other short-acting narcotics for rescue.
• 36:41
  So uh that's one thing that was surprised to me.
• 36:43
  I didn't know my primary care physician didn't know either.
• 36:46
  He'd never prescribed the drug.
• 36:48
  Um, it's much more commonly used in uh patients who need a taper because they've been utilizing the drugs um in either an illegal way um or or otherwise.
• 37:01
  But uh I am nearly the end nearly at the end of my bupinorphone taper, still going to physical therapy, and um don't anticipate the need for uh narcotics much any longer once I once I recover.
• 37:15
  Um, but it's been an interesting ride.
• 37:18
  So we're gonna take another break, our second break and come back with Brian, uh, our man on the street pain management guy.
• 37:26
  And I'm Dr.
• 37:28
  Randy Bach.
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  And this is America Out Loud Pulse, always a beat ahead.
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• 38:49
  So welcome back.
• 38:50
  We are here for our third and final segment.
• 38:53
  This is America out of Pulse Radio.
• 38:55
  I'm Dr.
• 38:56
  Randall Block here to unpack myths, explore innovations and give you actionable insights into the world of medicine and health.
• 39:02
  And to it, I'm uh aided by um Brian who uh has been disclosing and discussing his uh pain management issues.
• 39:13
  Uh I have to say, you know, I'm I I don't know, for whatever reason, uh you you have maybe have some genetic uh tinge towards dysplasia.
• 39:21
  Uh I I have one towards analogies.
• 39:23
  Uh that's my own uh weakness and protect perhaps illness.
• 39:27
  But what one of the analogies I was thinking of as you were talking was was marriage.
• 39:31
  Um I I've been uh uh fortunate in marriage and married a good length of time, it's been reasonably stable.
• 39:39
  Uh but now and then there are upheavals, there's divorce.
• 39:42
  Um and uh obviously there can be widowhood and whatnot.
• 39:46
  Uh those are big uh changes.
• 39:48
  Those can be you know big blows to the system, and people go through uh various levels of grief.
• 39:53
  Uh, you know, they're distraught and whatnot.
• 39:56
  Um marriage tends to work well if you uh.
• 40:00
  I don't know, it seems historically whatever seems to work on a one-to-one basis.
• 40:04
  Um, there are you know polygamy uh you know aspects historically the Mormons and currently a fair you know, certain Muslim countries and whatnot.
• 40:13
  Um, and then there's another thing, you know, on the on the overlay of monogamy, which is one-on-one partnership, there's bigamy and uh variance and so forth, philandering and whatnot.
• 40:24
  And it seems like you know, the the polypharmacy part is in the sense kind of cheating uh like marriage, uh you're cheating on your spouse, and this has to be kind of a trusted relationship.
• 40:34
  We're talking about that kind of trusted traveler analogy.
• 40:37
  But the other one that kind of came to mind as you were talking was you know, this aspect of having trust with your practitioner, and if it can kind of stay on that one-to-one base, I think people can be reasonably managed through this uh minefield.
• 40:48
  You know, I like to point out, you know, that buprenorphine and the other treatments that we have for narcotics are themselves narcotics.
• 40:56
  Uh, we don't really do this, uh kind of the hair of the dog, as they say when you have a hangover, you know, some a lot of people can treat their hangover by taking the hair of the dog, which is i.e.
• 41:04
  the same stuff that they were drinking last night.
• 41:07
  Um, but ordinarily for a whiskey problem, if you're drinking a uh quart of whiskey every day, you know, we don't say, oh my God, we're we're gonna fix you up perfect, we're gonna bring you to our clinic, and we've got this clear uh liquid, uh you just drink it's like water, you drink it all, you know, whatever, five times a day.
• 41:22
  What's it called?
• 41:22
  Vodka, you know, or schnapps or something like that.
• 41:25
  We don't treat that, but uh the world of narcotics, um, uh for better for worse, my view worse, um, has always had this kind of hair of the dog treatment.
• 41:34
  Uh more than 100 years ago, um the opium addicts were treated uh with um uh morphine, and and uh they were treated with codeine.
• 41:45
  Uh heroin came along, and uh that was seen uh seen as a treatment uh for morphine addiction, and then latterly uh methadone came along to treat the heroin addicts, and now if you have people in methadone, we're like, oh, that's not great stuff.
• 41:59
  We're gonna put them on puprenorphine again.
• 42:01
  I you know, remind people puprenorphine rhymes with morphine and it's a morphine derivative.
• 42:06
  These are all the same family, they're all part of the currency world of narcotics.
• 42:10
  And the reason they're so um lovely pills, I mean, universally this these this medication works.
• 42:16
  You can't guarantee you know, somebody with a I don't know, an infection or whatever will get better with penicillin or or keflex or or some you know erythromycin, whatever.
• 42:25
  But but every human, frankly, I think every vertebrate and probably invertebrate animal, any animal with a brain out there with neurons and a central nervous system.
• 42:34
  Uh we'll say leave it with brain, we'll get you know some relief with uh uh narcotic.
• 42:39
  So you could give your cat narcotics, you can give the raccoon down the street, narcotics, they're all gonna have a great time with it.
• 42:44
  There's nobody on which it doesn't work if you're virgin uh to that medication because it it mimics our endorphin system, which frankly is named after you know, the endorphin system existed before we found morphine, whatnot, but it's named backwards, it's named after the morphines and whatnot because those things work so well.
• 43:00
  People like, well, why do they work that well?
• 43:01
  Because that's basically the axis of pleasure.
• 43:04
  Um, you know, the what is the um axis of evil uh you know is out there uh we're dealing with maybe one by one, but uh the axis of pleasure or something within our brain, and that's there to guide and mold us towards better behavior.
• 43:17
  So we have orgasm, uh, we have the runners high, we have you know, the this the high satisfaction of task completion.
• 43:24
  We produce our own little bits of uh of morphine, if you will, or heroin or whatever, uh, when we get those tests, but we can we can misuse that system by you know, kind of uh getting stimulation the wrong way, like it's kind of icky to talk about, but you know, self-pleasure um is is a way of getting an orgasm.
• 43:43
  Um, but it takes you away from the social benefit of of mating and dating and meeting and greeting and all that kind of stuff.
• 43:49
  Uh, and so people will get that kind of rats in a maze uh kind of aspect where they you know will go for the narcotic because that is a guaranteed pleasure, you know, and and then their system kind of gets perverted in a way or distorted.
• 44:04
  Um, and then we see this in a number of different you know aspects, gambling, you know, you can have a great time, you know, out of a resort or whatever, and you might you know bet on a basketball game here and there, but when it takes over your life, you know, we a lot of people will fall prey to that thing and succumb to it.
• 44:18
  Anyway, so that's a long intro to our third uh section here.
• 44:22
  Um I I you know, I tend to take up all the oxygen in the room, so I apologize about that.
• 44:28
  But um, Brian, you know, were there ever any temptations, and given you know that your history of tackable access, which is not you know unique to you, frankly, the reason narcotic addicts keep going for more and more is because they have kind of saturated the endorphin um receptors in order to get any greater stimulation, they need more.
• 44:48
  And I'll give you one sad extra example is like pornography.
• 44:52
  We have you know have a whole generation of young men um who have kind of desensitized themselves from sex because they need greater and greater kind of you know, sexually stimulating imagery or whatever to you know get excited, you know, they have in a sense the same kind of tactical access, the getting used to certain levels of stimulation.
• 45:10
  And I think you know, we see this through gambling and a lot of other aspects.
• 45:14
  So I don't know if you have any insight to the kind of hazards, the moral hazards in a sense of of narcotic usage, and and whether that's you know, been a titillation or stimulation or possibility for you, and how do you keep on the straight and narrow?
• 45:27
  And the I guess the last question would be now that you've had these surgeries, uh, do you see an exit?
• 45:33
  That's an interesting question.
• 45:34
  Um, because you know, the after both of my shoulder recoveries, uh, one was in 2020 and one was in 2023.
• 45:42
  There's really that year period before a new titanium joint is satisfactory.
• 45:49
  And so, as sort of a trusted patient, you know, I had a good relationship with my with my doctor, and I said, you know, I still like to ride motorcycles, I still like to go out to the desert.
• 45:59
  I still like to you do a number of different activities that have a cost, and the cost is it's really gonna hurt the next day.
• 46:09
  And there is there's with with orthopedic injuries, there's not a really good if you're doing this right now, there's not a good pain response.
• 46:17
  You're gonna pay for it three to four hours later.
• 46:20
  And it is nice, it is convenient to take a narcotic, take it and have six hours of quiet from the noise of that pain.
• 46:31
  And if done responsibly and from time to time, that's how I've kind of gotten through the dysplasia.
• 46:38
  But you know, as Dr.
• 46:39
  Bach mentioned, there are many people who really like that mood and motivation response from the narcotic, and who will take it for reasons other than physical pain.
• 46:50
  For me, the way that it works is it's a binary switch.
• 46:53
  For instance, five milligrams of oxycodone does nothing, 10 milligrams flips the switch, and 15 milligrams gives me no better activity than 10.
• 47:04
  So I have no desire or need to take more than the minimum.
• 47:08
  It requires to flip that switch for six hours.
• 47:11
  So, as a generally trusted patient, I'm likely going to have these drugs available to me for the next year after my my surgical recovery when I'd like to go back out and go motorcycle running, when I'd like to go back out in the desert, when I'd like to go work in the garden, if I really knock it out of the park with pain, I'll probably have them.
• 47:31
  Some people can't do that, they don't have the self-control, they don't have the discipline.
• 47:37
  And what's interesting though is the type of pain management practices that are out there, because I'm working with a practice that I've been where I've been trusted uh for quite some time, but I've watched his practice change over the years.
• 47:53
  Um, the state of California comes in and he told me specifically the things that the state is looking for are they don't want you using long-acting narcotics, so meaning oxy code oxycontin, uh the drugs that were implicated in that in the epidemic, you know, those are still bad drugs, even though they're perfectly reasonable from a clinical standpoint, if necessary, he can't write them.
• 48:18
  They're a ding.
• 48:20
  The other thing they look for is anything that's sort of a cocktail.
• 48:23
  Um, you can't be given two different types of drugs um in the same class.
• 48:28
  That's that's a no-no.
• 48:30
  And then finally, at the pharmacy level, I spoke with the pharmacist, and the pharmacy says, yes, they're you know, they're they're under scrutiny as well from the state of California.
• 48:40
  And he recommended to me, he says, if you're getting a prescription for say 30 doses, 30, 10 milligram tablets.
• 48:48
  He says it's actually better for everybody if you get 15 of the 20 milligram tablets and just pill split.
• 48:55
  And I said, Why is that?
• 48:57
  And he says, because they're looking at the quantity of the pills that are being dispensed, and they're bouncing it against you know, the overall uh, you know, prescriptions of that that are going out the door.
• 49:07
  And I thought this is it's absolutely absurd.
• 49:10
  So it is getting much much harder for an honest pain patient um to have access to these really life-enhancing medications, but they can be life destroying too, depending upon upon the patients.
• 49:24
  And I understand the need for it, but I'm seeing the pendulum swing way too far the other direction.
• 49:29
  And frankly, I had to drop off of some of the Facebook forums for dysplasia where I would give advice, uh, just simply because it's depressing.
• 49:37
  People cannot get adequate pain management for a very, very painful condition.
• 49:45
  Yeah, there's a few different jokes that um came to mind.
• 49:49
  You know, one of them is like, uh, well, it's you know, it's only 99% of lawyers that give the others a bad name.
• 49:55
  Um, you know, a certain amount of that uh in the drug world, it's not you know the
• 50:00
  There's so much like misuse that it's kind of given the others a bad name.
• 50:04
  I wouldn't say 99%.
• 50:06
  That's a joke.
• 50:06
  And the other thing is about as far as the quantity, uh, the old pizza joke, you know, guy goes in the pizza place and uh gets a certain size pizza guy's about to slice it and says we wanted to cut this slice in six slices or eight slices.
• 50:18
  Oh, you better do six because I don't think I can eat eight.
• 50:21
  Um, I'm not hungry enough to eat eight.
• 50:23
  Anyway, just like you know, it's the same thing cut a different way.
• 50:26
  It's um uh pretty amusing.
• 50:29
  Um, but yeah, we we uh you know we don't have a good system for that.
• 50:33
  Um you know, I I think you know, I I will kind of segue slightly um to the opioid epidemic, which I guess is in part and parcel giving uh you the grief that you get and others who are wanting to genuine valid uh pain management.
• 50:51
  Um that uh, you know, Trump 1.0 or Trump 45 um brought about the only um stoppage and increase in the opioid uh related deaths, the heroin deaths and uh whatnot during the 2016 to 2019 uh well took off 2017, 2017, 2018, 2019, and into 2020, uh there was a slight decline in the number of opioid deaths nationwide.
• 51:21
  And he didn't really um have any signal um significant um, you know say no to drugs, uh, you know, zero tolerance policy, like under the Reagan era.
• 51:33
  Um, but basically he had gotten people back to work in in the blue-collar um midlands, and frankly, the people who voted for him, you know, they they were in distress, you know, Michigan and and um the Midwest, Upper Midwest flipped to um you know, I guess Hillary thought it was all in the bag because they're blue states often, uh, but they were in pain in in I guess emotional pain, also a lot of oxycontin uh related overdose death pain.
• 52:01
  Um, and it was in a sense answered because the economy got better, and there, you know, he's bringing jobs home, he's making America great again and part and parcel of that was you know, the tariff scheme and whatever, you know, kind of replanting um, you know, more blue-collar work in the US.
• 52:19
  Um, and so I only brought that out because again, it's not your issue per se, but it's a national issue.
• 52:24
  We're all citizens here.
• 52:25
  Um and you know, I think we will probably see the same thing through Trump 2.0, which is um, you know, we saw an increase in in deaths of despair, the opioid epidemic deaths.
• 52:39
  I think they went up uh about 30 by about 35,000 absolute numbers of excess opioid deaths in the COVID year and beyond the lockdown year, you know, if you took 12 months from the beginning of lockdown.
• 52:53
  Um, so in that 12 month period, it was excess of 35 to 40,000 opioid deaths.
• 52:59
  Now, if you took the median age of death, which is probably you know mid-30s, 37 or so, um, and factor that in the number of you know years lost in that group, it it probably exceeds the number of of quality adjusted life years, they call them QAOI from the COVID individuals themselves, because there are more people die from COVID, say, but they were very much skewed elderly, you know, your your oxygenarians, you know, who might, you know, nursing home, half of them were nursing home quality, as it were, or lack of quality of life, where you might only have six to eight, twelve, thirteen months to live, and you lose those, yes, but it's not the same as you know, people, you know, kind of despairing because they don't have jobs and they're miserable and they're in ice solitary confinement and whatnot and drugging themselves, and you lose you know, 35-year-olds, it's different circumstance.
• 53:46
  Um, I don't know if you want to talk, you know, we we have about uh five more minutes.
• 53:51
  I don't know if you want to talk about uh some of those kind of general issues from your perspective, and or touch on, you know, if you notice any kind of differences with the MAHA, the Maha movement, and what are the answers?
• 54:03
  Um, kind of on a policy basis for either your problem or kind of health problems, such as you see nationwide anyway.
• 54:10
  Well, it's interesting because I don't see things getting any better for the honest pain patient.
• 54:14
  Um, you know, just uh since since I've got an association with the pharmaceutical industry, a little bit of background is when I started, um, I was good friends with a Purdue representative, and the representative was selling oxycontin at the time, which is the extended release uh form of oxycodone.
• 54:35
  And I was given that in the hospital prior to my release, and it was recommended that I continue to take this medication post-discharge.
• 54:45
  And I told the hospitalist, I said, I'm not gonna be able to get it.
• 54:49
  And she says, What do you mean?
• 54:50
  And I said, it's regulated, nobody's allowed to write that drug anymore in the in the pain management practices.
• 54:55
  All they have to do is write the short acting ones.
• 54:57
  And so that blew her mind because there's a little bit of a disconnect still between hospital and the reality out there.
• 55:04
  And so my dosing regimen immediately post getting two brand new hips was a you know, six four to six hour dosing schedule, which means that you've got to set an alarm in the middle of the night to take a pill, whereas the very, very useful oxyc oxycontin, which was a you know, just you know, it would it would uh um dispense over 12 hours taking a single pill would have allowed me to sleep through all night.
• 55:31
  And the the bigger joke of it is is you know, Purdue, the pharmaceutical company that invented the useful drug, and even though it was misabused by you know, smashing up and people were snorting it and defeating the time release purpose.
• 55:45
  Um, they just reorganized into a generic company called Rhodes Pharmaceuticals.
• 55:50
  And so the exact same company is making generic oxycodone, but just in the short acting version, which is available to patients, even though it would be much more beneficial uh to utilize the 12-hour formulation, uh oxycontin, uh that received so much stigma.
• 56:07
  Uh so it's difficult out there, and I don't see it getting any better under the Trump administration.
• 56:13
  Um, but then again, I don't know how it could get much worse.
• 56:17
  Um, I mean, the various states have their own uh legal.
• 56:23
  I mean, there's there's a lot of going after pharma as the bad guy here.
• 56:28
  And the reality of it is a lot of the drug abuse out there is with counterfeit medications.
• 56:36
  So I appreciate it.
• 56:37
  Uh that's all for today.
• 56:38
  Uh remember, every myth has a solution, every truth has the power to transform your health.
• 56:43
  Find us on America Out Law Pulse Radio every Friday at 5 p.m.
• 56:47
  Eastern or on demand, wherever you get your podcast.