Left Eye Blind

Is LA Times an OXY-Moron?
Posted by Jeffrey Fudin – September 19, 2016 – Dr. Jeffrey Fudin Posts, Guest Blog, Opioids & Politics
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Let’s take a look. to see if the LA Times is in fact an oxymoron.

Merriam-Webster’s online dictionary defines moron as “a very stupid or foolish person”, but since this country treats corporate entities as people, I’d say LA Times qualifies. Their legal definition is “a person with a mild or moderate intellectual disability —used formerly — see also idiot.”

Other OXY-morons include anti-opioid zealots in the lay press, some propagandists, and politicians who persistently call OxyContin “synthetic heroin”. One who is skilled in the art and science of pharmaceutics knows this to be untrue. In fact, oxycodone is a precursor to oxymorphone, a CYP2D6 metabolite of the former. Oxymorphone is one substituent on the tertiary amine (nitrogen) different in chemical structure to naloxone as pointed out in a previous post Breaking Bad 2.0: Is it possible to synthesize Oxycodone from Naloxone?. That said, OxyContin, oxycodone, and oxymorphone are synthetic congeners of naloxone, an opioid receptor blocker with virtually no medical dangers and an antidote to what anti-opioid zealots otherwise describe as “synthetic heroin”: morphine, fentanyl, and heroin itself. Naloxone actually saves people from respiratory depression from opioid overdose. In fact, OxyContin is more similar in chemistry to over-the-counter dextromethorphan (the ‘DM’ in Robitussin DM) than it is to heroin. Truth be told, heroin is semi-“synthetic morphine” because heroin is essentially two morphine molecules synthetically sandwiched together by an acetyl group, more commonly known as vinegar. But alas, I suppose not knowing this science doesn’t make someone a moron; professing to know something you know nothing about is certainly short-sided, idiotic, and without a doubt approaches moronism.

On May 5, 2016 LA Times printed an OxyContin dosing article, “You want a description of hell?’ OxyContin’s 12-hour dosing problem” by Rion and Girion (two potential OXY-morons).1 In rebuttal, I wrote an editorial with Drs. Mena Raouf and Erica Wegrzyn in a highly regarded refereed periodical, the Journal of Pain Research, entitled “OxyContin was submitted and justifiably approved by the Agency as a twelve-hour dosage form”, to clarify the idiocy of LA Times authors Rion and Girion and the editorial staff that allows such nonsense to be published.2

I encourage anybody that is interested to look at the JPR article mentioned above by clicking HERE. But, as an educational exercise, I thought it would be nice to engage an up and coming Student Pharmacist Lindsay Worthmann to summarize our JPR editorial and the various issues by posting a guest blog. Overseeing Lindsay’s writing was Dr. Erica Wegrzyn, my current PGY2 Pain and Palliative Care Resident. Here for your information and entertainment is what both of these young professionals had to say…

Ms. Lindsay Worthman and Dr. Erica Wegrzyn:

As we all know, just about every aspect of life is governed in some way, shape, or form by Big Brother and/or the letter of the law. Fortunately, there is some degree of leeway in medicine. Behold, the off-label use function.

When OxyContin came to market, it was intended for every 12-hour dosing (Q12H). This is how the product was approved by the FDA and what the manufacturer (Purdue Pharma) marketed and subsequently endorses. The recent article in the LA Times, mentioned above, called Purdue out for “knowing” that some patients experience an end-of-dose effect as the12-hour mark approaches.1 Now, if this is true (which it sometimes is), patients would be experiencing pain or perhaps mild opioid withdrawal before the next scheduled dose. This can result in additional immediate release medications (like oxycodone) prescribed to cover that time-span, i.e. breakthrough pain. More medications may affect other risks such as overdose, opioid craving, and the like. So what exactly is all the fuss about? It appears that the LA Times is upset that Purdue is not formally addressing this presumed “lack of efficacy”, or what is commonly known as “end-of dose failure” of a 12-hour dosing interval and isn’t promoting its use at 8-hour intervals. This is because Purdue is a pharmaceutical company and is LEGALLY prohibited from promoting off-label uses.

If a patient is experiencing this lack of benefit at Q12H dosing intervals, a Q8H dosing interval sounds like a plausible option. Logically, it makes sense: prevent return of pain, prevent withdrawal, avoid adding additional medications, and maybe even diminish the risk for diversion. The concern expressed by some, with dosing OxyContin Q8H, is that the patient could potentially experience a higher oxycodone plasma level, therefore increasing the risk for side effects such as a loss of consciousness or a decrease in respirations. There is no evidence to support this.

Off-label use is not an uncommon scenario. For example, fentanyl patches are marketed as Q72H, but may be used for Q48H as indicated in the label3. Tricyclic antidepressants (TCAs) such as amitriptyline for neuropathic pain are commonly used off-label4,5.

Can the pharmaceutical companies that make these drugs legally and openly support off-label uses? No.

Is fentanyl often dosed Q48H? Yes.

Is amitriptyline used for neuropathic pain? Yes.

Can oxycodone ER be usedQ8H? Yes.

Obviously, there are always risks associated with off-label use. There are also risks associated with any medication even when taken as prescribed. It is the responsibility of the medical provider to discuss risks vs. benefits of any treatment plan. The further a medical provider deviates from the intended use, the higher the liability. Many antidepressants and anticonvulsants without a pain indication are routinely used to treat neuropathic pain syndromes. Cancer drugs are frequently used for malignancies for which there is poor evidence. In the grand scheme of things, whether or not Purdue Pharma openly supports or endorses OxyContin Q8H is irrelevant, other than their obligation to follow the law and not promote for off-label use.

n closing, it is noteworthy that newspapers should provide accurate information by honest journalists who do their homework and provide each side of a controversial story. Perhaps the term Newspaper here is an oxymoron too, since the definition of oxymoron is “a combination of words that have opposite or very different meanings”.

Just a heads up. I will be publishing articles here wherein I will be interviewing people with pain and pain care specialists. I expect to publish 2 monthly.

For the last 4 weeks, I’ve had a net another yet another Behcets’s lesion in my mouth. This one stayed the longest, and is still present though less painfully combustible. As it began to recede I had the utterly stupid, as history should note, idea that I would be able to spend a few weeks without some part of my mouth on fire. Right. Yes, to believe in this is to believe in white bunnies bringing me candy every day.

Just as the one began to slip away, another sprouted its painful self of lower left side of my tongue. This is a strategic location because it causes pain no matter what my mouth does.

This should not be such a surprise as I”ve lived with this for nearly 40 fucking years. If it’s not one lesion in my mouth it’s a lesion elsewhere causing the same or worse pain.

This disease is designed, at least for me, to cause the maximal pain. Not simply physical pain, but the pain of one onslaught upon the next. It waits until I’m almost ready to accept a leison free few days when it detonates a new one. This is designed for maximal demoralization.

Lesions and their attendant pain, sometimes agony, are designed to inflict maximal psychological torture. Just when you think you’ve escaped, the fucker tracks you down before you reach freedom at the gate and pulls you back in. All the while laughing manically in my ear. My ear, so no one else hears the agonizing protest gargling up my throat.

Yes, the life of the chronically ill, the chronically painful existence, is quite frankly, the last laugh of Beelzebub. His chared tongue and split lips laughing up brimstone, brimstone he laves over our writing bodies.

It makes me murderous.

For over 25 years I have gone almost everywhere with my cocobolo wood cane that my mother gave me to replace the standard issue Walgreen’s cane that had no character that I hastily bought the day before my wife and I were off to Paris. My right knee had swollen badly after a steroid injection that was supposed to dial back the pain so I could walk when in Paris.

If I was going to spend the rest of my life accompanied by a cane, I should, according to my stylish LA mother, at least have one with artistic definition, panache, and “character” that she was convinced would enhance my physical visage even as the Behcet’s disease mindlessly assaulted me with rapacious, nay, vicious glee.

It was immediately apparent that toting my cane around with me in the Loop, on the subway and in airports was a thing of silent questioning and occasional poorly disguised approbation by those who would first look at me, then the cane I was carrying and not using to walk. “What,” the silent appraisal seemed to say, “are you doing with that cane; you’re certainly healthy enough not to need that.”

I hasten to add that I’m more than a little aware of the possibility of projection on my part. It is a possibility that I’ve attended to more than once, the possibility that people who appraise me in this matter are not critical but curious. I’m aware that the old critical “voice” I acquired in my youth might well be the operative motivation in this.

I’m quite aware that, in psychoanalytic parlance, I’m engaged in something known as psychic equivalence: to wit; what I think is equivalent with reality.

This is a regression on my part to a very early way of being in the world while trying to learn the difference between what is in my mind and what is out there beyond me in someone else’s mind, which may be very different than what is in mine. This is a developmental step we all need to make if we are to be able to distinguish our thoughts and feelings from those of others.

This equivalence is a way to externalize the disquieting voice in me that doesn’t yet believe-after all these years-that I really do suffer from grinding pain. In other words, I may be attributing the wheedling voice in me to those who pass me in the streets.

Come with me a quarter of a century into the present day. I am in my mid sixties once again working in Chicago as I did the 25 years ago. There is no mistaking me for a man in his 40s. I am now “elderly” and a cane for a man of my age isn’t surprising.

There is more to this story. For the 1st time in over 20 years I am able to work once again, even if only part-time. I have not had use for a Winter coat since leaving New York in ’03 to spend the next 10 years in the unreal balmy weather in LA and San Francisco.

Back here in the cold climate of Chicago I had to improvise on a long winter coat. Out of the back of our packed front hall closet I retrieved a 35 year old duster still in good condition with it’s length below my knees, flaps and hidden pockets and a black leather collar. With this distinctive coat that is now quite rare but still fashionable, I wear a black leather baseball style cap.

Walking to and from the subway stations with my bag slung over my shoulder, coat and cap topped off with me striding down the sidewalk with my carved wood cane in my right hand that I look rather like a dashing, newly minted senior citizen. I may be getting on in years but I’m still Stylin’ I reply when I can.

When coming and going from work dressed like this I do get my share of “looks” from other denizens of the Loop. I find that other pedestrians openly survey me as they close down on me from the opposite direction. They look first at my face, then coat and hat followed by a sometimes furtive but lingering look at my cane: the one instrument not on me, but held by me in case of need, or for some, a feeble attempt by me to raise concern and pity.

As these circumstances happened more & more I began to notice that after surveying my cane these polite people looked again at my face as if trying to come to some sort of conclusion about me and my motivations in this very brief, fleeting encounter with my rather, I’m told, striking presence. I say striking since a number of young African American men and older women compliment me on my coat &/or my “look.”

But what am I to make of this rather frequent fleeting appraisal of me as I make my way to and from the Red Line, to and from work I can finally do again? I don’t want to leave the impression that these brief encounters only happen in Winter. I get them year round, but admittedly, more often in the cold months, where I must be honest, I am more covered and “incognito” than I and others are during the warmest months.

Living in a large city it’s a common daily occurrence to come across differently abled persons. It seems a human quality to look furtively at the persons who exhibit “diabledness” and to look away before the person who embodies that difference can look back in humor, anger or righteous indignation at being deemed nothing more than a type, an “other” who can, &, most often, should be ignored.

I think that our brothers and sisters who negotiate the world from the sitting position in variously tricked out wheelchairs are the ones who attract the most frequent furtive glances. I think our comrades in the seating position are the easiest for the healthy to somehow look down on if not comprehend; those who glide by on wheels and are given a measure of deference by the among us.

I think that what is connoted is varied. To wit: there but for the grace of god…can they really have wheelchair access whenever they need it…I wonder what forces combined to put them in that chair…what is it like to always have to look up to others when in conversation.

In short, those of us who display our “disabledness” through the contraptions that allow us mobility and some sense of “living in the world” move us unsteadily through that world as societies “other.”

We are needed, not for our individual attributes and consciousness, but for our ability to embody a trope, a meme, an idea that can be accepted within limits or rejected out of hand depending on how much empathy has been inculcated in the observer.

As outliers/others we seem to be societal benchmarks for the dividing line between those upright and able and those “otherwise.” In many ways we become a starting point for the able among us to gauge what it would be to move them into our world, a world which they despise as a world not just otherness, but a world of reduction. A world or body not bargained for nor easily imagined and easily discarded.

When I get that look, the look that begins with my face then bends quickly to the cane in my right hand and back to my face I know a judgement was in hasty production. Certainly a judgement about me, for example: he’s not crippled, what’s he doing with that cane? Or maybe they see me descend the stairs into the subterranean transit system.

A descent for which I do not use my cane. Ubiquitous observers see me take up my waiting position on the platform and see me twirl my cane in my right hand before dropping the rubber tipped end of it to the anonymous platform.

That link between platform and cane that life thrumming through my hand as a 95th Street bound train heaves into view, a leviathan who for just a few moments sings my song, our song whose jagged notes like jagged breath floats above the Leviathan’s staccato wash, a wash that sings to no one, but whose melody is heard only by the chosen few, the few who must stand still to listen long after the behemoth has lurched away and away…after which the hand and arm I lean on, the ones that let me live upright, if only for a time, clasp around my heart, the heart of all differently abled who your gaze can not but linger long enough to form a recognition.

I get it.

I can walk walk most of the time for hours without the need for my cane. I can not stand, for example, at a Loop intersection where I have to stand and wait my turn. I immediately employ my cane onto which I, like others, lean, to reduce the pressure on my spine and the quickly assembled crashing pain.

No one sees my anguished drama at every stop light, on every platform waiting on trains, standing…standing in an ever deeper pool of pain while others watching me, yes watching me as they come to whatever conclusions they can muster from their brief encounter with a stylishly dressed man who surely must be hiding something, right? Why else doesn’t he use that cane all the time?

I refuse to explain myself, to explain why a seemingly robust, well dressed man uses his cane intermittently while looking like an otherwise sturdy elderly man.

In many ways I have encountered the same suspicious “looks” when I displayed my handicapped card on the windshield shield of my car. Once a cop actually followed me into a grocery store to enquire about my disability. The same happens when I carry my cane. There is no end of suspicion however wrongly assumed.

I may not look like the average differently abled person, but looks deceive just as our prejudices deceive.

All I ask, as many of us would be happy to be asked, is that the able bodied ask with humility, with a certain trepidation, a notion that your suspicions might be prejudiced and depraved.

Approach me. Ask in genuine interest, get to know me and more importantly, come to know my cane and its role in the lives of so many, so many in need of support for which they never wanted.

I won’t be offended.  We won’t be offended, we’ll be grateful.

Yesterday I squeezed onto a red line subway train headed for the Loop. At the next station people, healthy looking people got up from the “Designated Seats” for the elderly and disabled and a young woman standing next to me quickly, ignoring me and my cane, sat her self satisfied ass in the seat meant for people like me; you know, the disabled senior citizen? We’re everywhere and we are her future.

She and the young woman seated next to her feigned complete blindness to my presence standing right in front of them. This may not have been my best moment, but I really, and I mean really, wanted to smack their self-satisfied heads together.

Eventually, our train pulled into the 1st station in the Loop, where I always step off the train to walk to my office. The woman sitting right in front of me, the one who so completely ignored the plight of the disabled senior standing directly in front of her made motions indicating she was readying herself to get up and leave the train.

Being the bastard I can sometimes, be I, I feigned that I didn’t notice her and, therefore, didn’t budge an inch even though it was my stop. I stood still as she tried to get up from the disabled’ persons rightful seat. I didn’t budge. I ignored her.

When in exasperation with my studied indifference to her, she said “Excuse me,” I replied with as much saccharine as I could muster: “Oh, now you see me. For the last 10 minutes I didn’t exist. Maybe next time a disable or senior citizen requires the “Designated” seat, you will gather as much empathy as your parents, in their miserable failure, tried to instill in you and you will cheerfully give up your seat.” I turned and walked away from her with just the slightest bit of satisfaction, but knowing, realistically, my words fell on the deaf ears of a cemented, self-involved blockhead.

For those who’ve never before encountered me in my writer’s persona, I should describe who, or what I am. How’s that for a small project? In brief, my age is closer to 70 than to 60. I am a creature of initial old age. I used to be a young man, healthy, vital, energetic, involved. But early on something happened. A small, but easily handled, so I thought, disaster befell my very young body while playing high school basketball. As some would say, no biggie, a bit of a setback, but so what, I was young and, yes, as a cliche, I was invulnerable. Not being able to get out of bed without the assistance of a persistent friend, was, I naively thought, was a small bump in my road to adulthood.

One morning a week I have to catch the CTA subway at my elevated station in Lincoln Park on Chicago’s north side. If you’ve ever scene footage of the same in Tokyo, you have an idea how much like a cattle car these trains are. Though there is no one behind we boarding passengers shoving us onto an over filled car, those scenes evoke what it is like to be a passenger/sardine in a hurtling metal box. My station is only about 20 minutes from my destination in the Chicago’s Loop, but it is 20 minutes of a jostling, jolting wrestling match for people like me. The unseen, the fellow passenger you don’t want to talk with.

Why, you may rightfully ask? My cane. Yes, my 30 year old cocobolo wood cane. A thing of beauty, a thing of otherness. A thing of passing interest, but not me, the person on the business end of that cane. I am often not an object of interest at all. I am symbol, a meme, if you will, of something to be, for many, avoided. I am their unsettling fantasy, their bad dream. Afflicted. I am Disabled. I have to rely on that exquisite cocobolo wood my mother bought for me 30 years ago, it is an unsettling calling card. a sign hung around my neck.

I am a harbinger of loss. I am resolved into a singular, Greek Chorus. A chorus who most don’t, and I can’t really blame them, want to see or hear from. I am the glitch in the mirror, the bad penny. I know, I live in the darker regions of that dream.

This is my prolix entry into a recurring experience, an experience that I long ago decided would not lay its border around me, define me, relegate me to insignificance. I am vertical, and for all my brothers and sisters who aren’t I refuse to give into the waif, the of the borderlands, the graying outskirts of empathy. No.

No.

But truth to tell…I’m not always up to the battle.

This morning I caught the Red Line into the Loop. Like others, I squeezed into the smallest cleft in the press of passengers, turned to face the closing door and, left hand clutching my cocobolo resigned myself to a harrowing ride of pain, pain dark and silent to others, but a chorus of complaints marching up and down my ruined spine. Nothing to do, it was what it was. Bear it. I’ve always borne it so I knew I could. Just 20 minutes. 20. Five minutes later we pulled into the North & Clyborn station and several people behind me exited before the press of new passengers climbed aboard.

I seen my chances and I took ‘em, a quote said to have been spoken by the 1st Mayor Daley. I slipped through a vacant space, excused myself as I made my way to stand in front of the two seats designated for the elderly or disabled. As I’m both, I thought my chances of sitting might be good when stepping up I was confronted by 2 very attractive blond haired women. I arranged my body and cane for the coming lurch of the trains acceleration hoping that one or both, seeing my dual eligibility for the designated seats would offer me hers.

Of course, dear reader, you know what happened. Yes, that’s correct…nothing. The woman on my left looked at my cane, then up at me with a blankness I knew only too well. The young beauty on my right buried her face even further into her frayed book pretending that in her concentration, she hadn’t noticed me at all.

As the train lurched into sudden motion, the jagged movement snarled up my spine to explode in my head. I gritted my teeth and tried not to show my vulnerability. As the train’s hurly burly motion assaulted me, I felt a tap on my left hand. Looking down I was met with the smile of a slightly older young woman offering me her seat. Usually, I gracefully accept the proffered relief. But something in my head said nope. I smiled & responded that I’d be okay.

At the next station, the blond on my left got up to move towards the exit. With my howling spine and increasing anger, I did not budge an inch to let her by. I stood still and made her scramble around me and the man on my right. As soon as she moved away, I gratefully sat. The young woman who offered me her seat smiled at me as I settled next to the blond studiously engrossed by her novel. I wanted to bang her about the head and shoulders with my cane. I rather smartly resisted the temptation.

When we arrived at the 1st Loop station all 3 of us got up to leave and I realized with a start that the young lady who offered me her seat was well into a pregnancy. She wanted to give up her seat to me and she was pregnant! I fell in love with her and felt humbled by her previous offer. I thanked her as we left the car.

My point? Those two women sitting comfortably in the designated seats were neither elderly or disabled. They were clearly experienced riders and knew in what seats they were sitting yet ignored me and my obvious discomfort almost as if I simply didn’t exist.

Ordinarily I ask if someone sitting in those seats to give up their comfort for me. I am always met with a kind, if somewhat reluctant response. But more often I am met with studied indifference as if I am an apparition to insubstantial to believe exists.someone who is simply invisible, nothing more than a spooky wraith to be ignored.

What I don’t understand is this: Most often when we show kindness towards others we feel good, like maybe we just deposited a chit in the bank, a chit that might be matched in the future by a kindness shown to us. A small kindness that temporarily lightens the load that we incur as we live longer.

These two women by passed that. They must, I tell my more hopeful self, have felt uneasy or low, possibly unkind. That’s what I tell myself when this happens, but in reality I know they feel nothing of the kind. They feel, in my mind, that they got away with sitting beneath my obvious discomfort. They overcame a slight tinge of guilt and comfortably rode out my presence. For them, a small transit victory.

For me? Not so much. I was treated as invisible. A beautiful cocobolo wood cane often elicits admiration, usually from very young men just starting out in life. I am always pleased to give them a bit of the history of my pal, my upright strong friend. Those young me remind me that I am, indeed, not invisible.

I am me. Right here, right now. I won’t fade away from the uneasy fantasies of those not yet afflicted with disability or on-rushing age. We all, if we’re lucky, live long enough to very often encounter both.

It’s our encounters of empathy and kindness that pulls us out of the ineffable into the the substantial, the body that is seen. The body acknowledged, acknowledged in kindness, respect.

Cliche though it is, what goes around comes….

http://www.alternet.org/culture/dear-kylie-jenner-my-wheelchair-isnt-prop-stop-playing-dress-games-my-reality

This is an interesting piece by a woman whose disability requires a wheel chair responding to the picture of Kylie Jenner in an Interview magazine spread using a wheelchair as a prop in the photos of her nearly naked sitting in a wheel chair. As did the author of this piece, I found the photo tastelessly using disability as a prop through which both the magazine and Jenner decided to use an undeniable symbol of disability to titillate the reader, inviting the person looking at the photo to objectify both the chair and the young woman.

I have had to use a cane for the past quarter of century. While I can walk long distances for up to 1 1/2 hours, I cannot stand still without rapidly spreading pain up my spine and across the muscles of my back. The way people viewed me with the cane when I was 40 are qualitatively different now that I’m in my mid 60s.

People will look at me openly trying to fit the cane with my appearance. When I step onto a crowded subway car and move towards the seats designated for the elderly and disabled I am frequently studiously avoided by a much younger healthier looking person or offered a seat by someone not in the designated seats.

I am frequently looked upon with frank mistrust by people who see me walking along an el or subway platform holding, not using my cane until I either come to a stop to wait or enter an open car. I have even taken verbal abuse on elevators by people who seem genuinely disgruntled by both my appearance and my use of my cane. Unlike most people on the streets in Chicago’s Loop I am hardly ignored. I can watch, without frequently knowing reactions and judgments related to my cane use. I suspect this is largely the result of my general healthy appearance combined with the manner in which I rely on my cane.

While I certainly don’t have the need for a wheelchair I have used them from time to time in airports when my spine and I are at odds with each other.

Regardless of what alerts others to noticeable disabilities, we do not have the luxury of anonymity, the ability to go about our business without the accompanying snap judgments..