The General's Drug Problem

[SouthernDZ]

This was in USA Today as well. It's a long article but well worth the read. Apparently the medical establishment still does not have a handle on pain management and the aftermath.



The General's Drug Problem

TAMPA - Standing before a packed hall of 700 military doctors and medics here, the deputy commander of the nation's elite special operations forces warned about an epidemic of chronic pain sweeping through the U.S. military after a decade of continuous war.

Be careful about handing out narcotic pain relievers, Lt. Gen. David Fridovich told the audience last month. "What we don't want is that next generation of veterans coming out with some bad habits."

What Fridovich didn't say was that he was talking as much about himself as anyone."I was fighting the pain. And I was fighting the injury. And I was fighting the narcotics."

For nearly five years, the Green Beret general quietly has been hooked on narcotics he has taken for chronic pain - a reflection of an addiction problem that is spreading across the military. Hospitalizations and diagnoses for substance abuse doubled among members of U.S. forces in recent years. This week, nurses and case managers at Army wounded care units reported that one in three of their patients are addicted or dependent on drugs.

In going public about his drug dependency during interviews with USA TODAY, Fridovich, 59, echoes the findings of an Army surgeon general task force last year that said doctors too often rely on handing out addictive narcotics to quell pain.

An internal Army investigation report released Tuesday revealed that 25 percent to 35 percent of about 10,000 soldiers assigned to special units for the wounded, ill or injured are addicted or dependent on drugs, according to their nurses and case managers. Doctors in those care units told investigators they need training in other ways to manage pain besides only using narcotics.

"I was amazed at how easy it was for me or almost anybody to have access and to get medication, without really an owner's manual," says Fridovich, deputy commander of the nation's roughly 60,000 Green Berets, Army Rangers, Navy SEALS and secretive Delta Force teams.

For such a high-ranking military officer, publicly acknowledging drug dependency was unprecedented.

More...

http://www.theleafchronicle.com/arti...roblem-w-VIDEO

[kgoerz]

Doctors prescribe that stuff way to much IMO. When I was in you could get anything you wanted from the Bn Doc.

[mojaveman]

I understand that there was a similiar problem after the Civil War with wounded Veterans who experienced morphine for the first time.

[Red Flag 1]

Originally Posted by mojaveman

I understand that there was a similiar problem after the Civil War with wounded Veterans who experienced morphine for the first time.

The pain medicine of choice during the Civil War era was Laudanum. Laudanum was a opium alcohol mixture that was potent, very effective, and readily available. Not only was it the drug of choice for pain relief for Civil War Veterans, it was widely used by civilians. Narcotic addiction was very high in the immediate post Civil War period. There was a a letter titled, "Confessions of a Young Lady Laudanum-Drinker" dated 1889 by an unknown author http://www.druglibrary.org/schaffer/...y/laudlady.htm, written to a doctor describing her troubles with Laudanum. It is still available today by prescription. It was not until the 1914 Harrison Narcotic Tax Act that narcotics became regulated and subject to control.

There are many that deal with moderate to severe chronic pain every day, from a variety of causes. Using long acting narcotics is effective in dealing with such pain; however, it is not without drawbacks. All previous major armed conflicts have wrestled with this problem, and today we have a specialty that can address chronic pain management. A system that seems to offer the best hope are multidisciplinary approaches. This includes providers from General Medicine, Surgery, Orthopedics, Anesthesia, Psychiatry, and Physical Medicine. This combined approach may well be able to tailor an approach that reduces the need for narcotic use long term. Every major war brings advances in medicine. Perhaps we can see some advance in the chronic pain issue that has haunted us since before our Civil War. It is very difficult to look a wounded war veteran in the eye and say no to the request for pain meds that are clearly needed; perhaps that is why the problem has lasted so long.

RF 1

[mojaveman]

Originally Posted by Red Flag 1

The pain medicine of choice during the Civil War era was Laudanum. Laudanum was a opium alcohol mixture that was potent, very effective, and readily available. Not only was it the drug of choice for pain relief for Civil War Veterans, it was widely used by civilians. Narcotic addiction was very high in the immediate post Civil War period. There was a a letter titled, "Confessions of a Young Lady Laudanum-Drinker" dated 1889 by an unknown author http://www.druglibrary.org/schaffer/...y/laudlady.htm, written to a doctor describing her troubles with Laudanum. It is still available today by prescription. It was not until the 1914 Harrison Narcotic Tax Act that narcotics became regulated and subject to control.

There are many that deal with moderate to severe chronic pain every day, from a variety of causes. Using long acting narcotics is effective in dealing with such pain; however, it is not without drawbacks. All previous major armed conflicts have wrestled with this problem, and today we have a specialty that can address chronic pain management. A system that seems to offer the best hope are multidisciplinary approaches. This includes providers from General Medicine, Surgery, Orthopedics, Anesthesia, Psychiatry, and Physical Medicine. This combined approach may well be able to tailor an approach that reduces the need for narcotic use long term. Every major war brings advances in medicine. Perhaps we can see some advance in the chronic pain issue that has haunted us since before our Civil War. It is very difficult to look a wounded war veteran in the eye and say no to the request for pain meds that are clearly needed; perhaps that is why the problem has lasted so long.

RF 1

Correct on Laudanum, my father was offered it during the final weeks of his life while he was dying of cancer but he refused it.

[PRB]

have lots of friends with hiatal hernias (serious acid reflux) from all of the Motrin team guys used like aspirin.
They say serious pain killers are one of the most adictive things going.
Frido, from my experiences with him, is a very straight shooter...glad we have guys like him being successful. I watched him chew an 06 Inf type a new asshole when he was an LTC SF controller @ NTC. The 06 was the division ops officer and totally disregarded the SF intel until they got waxed...it was great to see. I admired his directness and honesty.

[mojaveman]

Could it be that a number servicemembers actually carry the gene for addiction but never had problems with it because they never used opiates until they were seriousely wounded? They start taking them for the pain and then they become addicted. Happens to a number of otherwise ordinary people. I read a book and then watched the movie about a female undercover narcotics officer who in her work had to occasionally use small amounts of cocaine. It turns out that she carried the gene, became addicted, and then had to go through rehabilitation and leave the narcotics field.

[alright4u]

Originally Posted by PRB

have lots of friends with hiatal hernias (serious acid reflux) from all of the Motrin team guys used like aspirin.
They say serious pain killers are one of the most adictive things going.
Frido, from my experiences with him, is a very straight shooter...glad we have guys like him being successful. I watched him chew an 06 Inf type a new asshole when he was an LTC SF controller @ NTC. The 06 was the division ops officer and totally disregarded the SF intel until they got waxed...it was great to see. I admired his directness and honesty.

In the late 60's no way did you get narcotics after the morphine, then initial debridgement. Within two days after that they were ripping clotted blood bandages off one to keep the infection out. The next time narcotics came around was after surgery for primary /delayed closure.. That was two days max for GSW's in the upper and lower leg even with a shattered bone. I will never forget when they took that short leg walker off in late July 69. I about screamed every step to the car. I went to the Smoke Bomb Hill Club. Drank plenty.

Now, I think these men are getting some different kinds of wounds these days? I certainly am no expert nor anyone's judge as every wound is different. I could not imagine a man I respected being burned terribly by WP.

[DoctorDoom]

Originally Posted by PRB

have lots of friends with hiatal hernias (serious acid reflux) from all of the Motrin team guys used like aspirin.

Slightly tangential but hiatal hernia is a different entity that can be aggravated by NSAID use, but really should not be a result of pain medications. A surgical consult and possible laparascopic repair would be advisable.

[PedOncoDoc]

Originally Posted by Red Flag 1

Using long acting narcotics is effective in dealing with such pain; however, it is not without drawbacks.

Great post RF1 - I am sure you are well versed in pain management from your medical field. For chronic pain (read - not acute on chronic) - do you feel methadone is underused? Extremely effective and long acting with minimal abuse potential. Titrating up the dose does take time, but gives a long steady state once you get there.

We tend to wait to use methadone for end-of-life care in my field (and our pediatric palliative team seems to support this practice).

(I hope this post isn't seen as a hijack.)

[Richard]

One of the best MDs I ever worked with was the ER Physician at Womack back in the mid-70s. He developed a case of nephrolithiasis and self-treated with oral morphine, became addicted, was rehab'd and lost his license to prescribe controlled meds.

I saw far too many get hooked on pain or other meds.

Richard

[Red Flag 1]

Originally Posted by PedOncoDoc

Great post RF1 - I am sure you are well versed in pain management from your medical field. For chronic pain (read - not acute on chronic) - do you feel methadone is underused? Extremely effective and long acting with minimal abuse potential. Titrating up the dose does take time, but gives a long steady state once you get there.

We tend to wait to use methadone for end-of-life care in my field (and our pediatric palliative team seems to support this practice).

(I hope this post isn't seen as a hijack.)

The short answer is maybe. Methadone has been around since the late 1930's, first synthesized in Germany, partly due to Morphine shortages. Introduced to the US around 1947. Methadone (Dolophine), a mu-agonist, has been well tested and has its primary use in treating opioid addiction, heroin in particular. Bulk of the data today about Methadone is written by the addiction community; so that is where Methadone is expected to stay. Methadone is a long acting opioid that can be used for moderate to severe chronic pain (www.rxlist.com/dolophine-drug.htm). The drug does have the advantage of reducing the euphoric high seen with other opioids, I see that as a plus overall. Conversion to Methadone dosages from other opioids is a bit difficult, in part because of the long acting nature of Methadone; 8-59 hrs in some cases, creating an unseen drug reservoir. Respiratory depressant effects of Methadone outlast the analgesic effects, and chasing pain with Methadone and other opioids can lead to apnea and death.

There is a roll for Methadone in pain management, and is seeing use in that roll. The same cautions and warnings of all opioids applies. Use of NSAIDS with Methadone can reduce the amount of opioid needed. There is also QT segment involvement that could lead to cardiac complications.

As Richard has noted, "I saw far too many get hooked on pain or other meds.", self prescription and administration is a horrible idea. The outcomes of such decisions are far from Rosey, and leads directly to diversion of controlled substances. With the safe guards in place, diversion will be discovered; just a matter of time.

RF 1