Thursday, October 17, 2013

Walgreens and Taking Action


"Don't Call Us, We'll Call You" 


Dr. Jeffrey Fudin's blog, PainDr, recently hosted an article written by him and and his recent guest poster Dr. Ernest Dole, who spoke out about Walgreens Good Faith Dispensing Policy in, 'Is Walgreens Opiate Policy Deceptive'?



American Medical Association

Dispensed As Written lambastes Walgreens and the conduct that individual pharmacists have exhibited, operating under the deceptive and intrusive GFD policy.  After the American Medical Association (AMA) introduced a resolution, at it's last House of Delegates meeting, "AMA response to drug store intrusion into medical practice, resolution 218 (A-13)."  Dr. Melvyn Sterling, Orange County delegate, representing the AMA in a public statement had a message for pharmacists: "Don't Call Us, We'll Call You."  The AMA resolution is specifically directed at Walgreens Corp.


If you were one of the many legitimate patients who attempted to fill your medications at a Walgreens pharmacy and had a problem of any type, please read this insightful article and leave your experiences on Dr. Fudin's blog or the Drug Topics website, where the article ran on October 15, 2013.  It may be easier for you to copy and paste what you wrote if you left a comment on my Walgreens experience.  The corporation is taking notice of these complaints across the nation.  Someone from a Walgreens Facebook group left a comment on my post asking me to contact them on a general email address or through Facebook.  Shortly after I filed a formal complaint with the California State Board of Pharmacy.  Leaving a short comment a midst multiple horror stories from patients is not the way a national pharmacy chain should handle business.

A compassionate Pain Management specialist informed me that Walgreens is the top pharmacy that gives them problems filling the patients scripts.  This is a large Orthopedic group with multiple offices and established, respected doctors in many specialties.  They tell every patient when they leave, to call the doctor's (wonderful) medical assistant directly if they experience any problem filling their medication at any pharmacy.  The last time I was in Pain Management, this was never an issue.  The pharmacy calls requesting further documentation from the doctor are unnecessary, very time consuming, and may breach the privacy rights of the patient.


How You Can Take Action 

Many have written of being denied fills of legitimate pain medications by Walgreens Pharmacy, some refusals--such as mine for the muscle relaxer Carisoprodol--did not include opiate medications.  The corporation is losing customers, patients are driving farther, to other pharmacies (albeit inconvenient) that want to be an integral part of our health care.  The pharmacy is usually the end-stop for all compliant and very tired patients who are simply trying to complete what the doctor's visit that day began.  Along with taking our dollars away, we need to stop and make sure these negative events are documented with the governing board of both pharmacies and the pharmacist.

I filed a complaint with the California State Board of Pharmacy against the pharmacist that denied my prescription, all on the basis of the company's Good Faith Dispensing Policy.  I did this online, there is a specific page for this on the Board's site.  This takes approximately 20-30 minutes.  If you do not have computer access, you may file a complaint by phone.

I was contacted by an investigator from the Board, who is assigned to my case.  It has not been long since the online complaint was filed.  I was surprised at the quickness of his response.  He will investigate (among other things) if the pharmacist acted within his scope of practice.  He will investigate if there was harm done to the patient, and if the corporation's GFD was the basis for the action the pharmacist took when he neglected to complete the plan of my treating doctor when he refused to fill the doctor's prescription written for me.

The good pharmacists and other pharmacy employees who are caught in the middle of this corporate debacle, as I noted on Dr. Fudin's blog, are innocent and I feel for them.  Not all pharmacists are acting outside the scope of their practice.  All pharmacists are, however, aware that they have never been licensed nor trained to perform any prescribing.  Prescribing by omission is doing just that.

There are compassionate, conscientious physicians, nurses, dentists, surgeons, etc., etc., and there are those who are not.  Compassion does not override professionalism, it lies within it.  One can not work with patients, with people that are ill, who are in any state of illness, without having and exhibiting compassion.  Illness means the body is not in a state of wellness.  The last thing that anyone that is ill needs to deal with is a holdup of their doctor's plan for their treatment, and the stress that stems from being denied their medication.

Please go to your state's Board of Pharmacy site online, and file a complaint.  The American Medical Association also wants to hear from you.  Those who have been wronged need to stand up and be heard, and more important, take a step towards rectifying the injustices done to innocent patients.

A little compassion can go a long, long way.



Gentle Hugs....and a tolerable pain day.



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Sunday, August 25, 2013

Treating Cluster Headaches

Today I am pleased to bring some information about a different type of pain than I usually write about.
Pain is pain, no matter where it occurs, and I have been experiencing very challenging pain from various areas of my body--all at the same time.

I need a professional pain management physician to treat me.  I realize the specialty of pain management is one of great insight, with interest in the patient's well-being, of their quality of life, and in keeping their patients educated along with a life of tolerable pain levels.  

A guest post concentrating on the treatment of the Cluster headache follows, with some great information.  My heart goes out to those whose pain is always in their heads.  I know people who suffer with migraines, I used to, and they are absolutely debilitating.


How to Treat Cluster Headaches

Cluster headaches occur in cycles and typically develop on one side of the face behind the eye. These are some of the most painful headaches, which can last for several weeks or even months. Fortunately, there are remission periods when the attacks stop for varying lengths of time.

If you experience frequent cluster headaches, there are some treatment options that can reduce the frequency of your attacks and intensity of your symptoms. These treatments fall into three different categories, and they are abortive medications, preventative medications and surgery.

Abortive Medications

Abortive medications are those treatments that are used during an attack to help relieve existing symptoms. While there are many of these medications, the most effective include sumatriptan, other triptans and oxygen therapy. In addition, you may wish to try intranasal lidocaine, anti-inflammatory medications, dihydroergotamine injections and ergotamine drugs.

Preventative Medications

As their name implies, preventative medications are used to help prevent cluster headaches from developing in the first place. However, it is essential to note that results may vary among patients, and some patients may still experience mild cluster headaches even after taking these medications. The most common drugs in this category are listed below:
  • Ergotamine tartate
  • Lithium
  • Prednisone
  • Divalproex sodium
  • Beta blockers
  • Calcium channel blockers
  • Cyproheptadine
  • Amitriptyline
  • Topiramate or valproic acid

Surgical Treatments

On very rare occasions, doctors may recommend surgery for patients who experience chronic cluster headaches that cannot be relieved through any of the above treatment methods. Surgery may also be an option for people who cannot tolerate various medications or who are experiencing too many side effects from medications.
The goal of surgical procedures is to block the nerve pathways that are responsible for cluster headache pain. However, there is a risk of complications with surgery that can include muscle weakness of the jaw or sensory loss in various areas of the face and head. It is for this reason that surgery is rarely considered.

Preventative Steps You Can Take

There are some things you can do on your own to help prevent cluster headaches. By keeping a headache diary, you can identify what may be triggering your attacks. Once you know what your triggers may be, you simply need to avoid them. There are many things that can trigger cluster headaches, such as smoking, alcohol, various foods, unusual sleeping patterns, overexposure to the sun and poor nutrition.

Occipital Nerve Stimulation

Currently, researchers are studying a new potential treatment for cluster headaches known as occipital nerve stimulation. For this procedure, specially-designed electrodes are implanted in the back of your head. These electrodes are then connected to a tiny pacemaker-like device. When necessary, the electrodes send impulses to encourage the stimulation of the occipital nerve, which may relieve or even block the pain from cluster headaches. While several studies have found the procedure to be effective in small groups of people, it has not yet been established as a viable treatment method.
Although cluster headaches are some of the least common types of headaches, they are also some of the most painful. While there are no exact cures for cluster headaches, there are a number of treatments to help reduce or relieve the symptoms. If you experience cluster headaches, speak with your doctor to find the best treatment option for you.


Julian Kahn works at the Migraine Relief Center. Their treatments help headache sufferers cope with the pain of cluster, sinus, tension and migraine headaches.


Gentle Hugs....and a tolerable pain day.

Tuesday, July 9, 2013

DEA Settles with Walgreens for a Record $80 Million

It was not a judgement call when a Walgreens Pharmacist refused to refill a medication two months ago that I had filled (at Walgreens) 30 days prior.  And 30 days before that....etc.  It was nothing new on my profile of medications.

I wrote Farewell to Walgreens about this experience, and received comments and emails from all over the states, which all mirrored my experience with Walgreens Good Faith Dispensing Policy.

While researching this, I discovered a plethora of information that finally explained why this is happening to so many compliant, legitimate patients.

In 2011, Walgreens stores and distribution centers in Florida ordered more than 2.2 million dosage units of Oxycodone/Oxycontin.  That same year, the average pharmacy in the U.S. ordered approximately 73,000 oxycodone dosage units. The DEA investigated, and fined Walgreens $80 million.  The largest ever for a violation of the Controlled Substances Act.

I came across Dr. Jeffrey Fudin's blog, PainDr, and was delighted to find a post by a guest author, Dr. Ernest Dole, a Clinical Pharmacist and Professor.  Titled, 'Is Walgreens Opiate Policy Deceptive?', Dr. Dole looks into the 'Good Faith Dispensing Policy' or GFD in relation to the State Board of Pharmacy and the oath of the Pharmacist.  Are they beginning to 'prescribe by omission?' was a question posed by Dr. Dole, and this caught my eye, as my prescription had been axed by a pharmacist-- standing in the role of a doctor.

I relayed my experience with Walgreens on Dr. Fudin's blog, and was pleased to see him, and Dr. Dole show up with a response.

Dr. Dole's post brought in multiple comments full of the same stories of legitimate, well-established patients, being refused medication fills/refills by Walgreens.  What the cameras don't see, are the faces of patients in pain, that rely on certain medications to function.  Walk.  Stand up.  No one sees or wants to really know about the bleak horror of opiate withdrawal.  Unplanned and sudden, the cessation hurts the body and the mind.  This is not correct patient care.  This is an interruption of a physicians plan that may have taken months- even years of work.  Trial and error.  Doctor and patient together, working with the physical and the pharmaceutical; successful pain management does not happen overnight.  Is a corporation now telling me (and in turn, my physician) that we are unable to complete the plan for my chronic pain management?

All medical professionals take an oath.  Usually beginning with, .....First, do no harm......

And it's up to the patient once again, to protect and heal themselves.  It is in a patients best interest to ask for written evidence of any claim by a pharmacy that they can not fill a legitimate prescription due to a 'DEA rule/law'.  This is vague and unprofessional.  Whoever says this to you without anything to support this statement, is lying and making a fool out of the patient.  As a nurse I would never consider lying to a patient to save face.  My own or a company I work for.  I realize here that many innocent employees of Walgreens Pharmacy may be caught in the middle of this huge corporate debacle, not realizing themselves what exactly they are supposed to tell patients, or what their revised 'Good Faith Dispensing Policy' even means.

Some of the patient's stories I read were heartbreaking.  A woman who was a long-time, faithful Walgreens Pharmacy customer was suddenly refused her regular monthly medication, and she could not find another pharmacy to fill her medications at, the small town she lives in has no other options.  One must also consider various disabilities, financial stressors, and other factors that accompany the body in disease or pain.  Suddenly, abruptly left without any pain medication, her pain increased to levels that were intolerable, and she began to experience unpleasant (and unnecessary) withdrawal symptoms.  She was sent to the ER by her pain management physician.  The ER doctor (and her pain physician) in an effort to bring her constant high pain levels down and allow her to become somewhat mobile again; treated and released her with a prescription for a different opiate.

And then she had to fill it.
~~~~~~~~~~~~~~


California Medical Association talks about Walgreens pharmacists refusal to fill.

Do you need help with a pharmacists refusal to fill your legitimate prescription?

In California:  If you or your patients have difficulties filling prescriptions for controlled substances at any pharmacy in California, please report problems to CMA's Center for Legal Affairs at legalinfo@cmanet.org or (800) 786-4262.  (From the California Medical Association)

In Other States: Contact your State Board of Pharmacy.



Gentle Hugs....

**Thanks to my friend C -an amazing PharmD- for the exchange of ideas.

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Saturday, June 22, 2013

Adar Scrub Top Review

Look As Professional As You Are*
     

Uniformed Scrubs asked me to review a medical scrub top from Adar Uniforms.

I ordered a size medium (quick arrival, via UPS) that came in black.  The first thing that I noticed was the quality of the fabric.  The feel is one of crispness, like fresh cotton sheets.  This Adar scrub top is 65% polyester and 35% cotton.  Washing is simple, with the directions stating to machine wash in warm water, and tumble dry low, no bleach.  The weave is tight, yet breathable.  For a polyester base, it feels more like cotton.  This is one of those scrub tops that stays looking new, despite repeated washing.  

Scrubs must be durable and easy to take care of.  Repeat--easy care.  Anyone in the medical profession knows how important that is at the end of a busy day.  I will never forget one of my nursing instructors relating to us in class that each day she got home from her shift in the ER, she stripped down in the garage, tossed her scrubs in to the wash and immediately took a shower.  That has always stuck in my mind as she was getting across to us the plethora of bacterial transfer that occurs when working in direct patient care, and teaching us that each patient we come into contact with, lab coat or not, may transfer bacteria not only to our skin (ergo the constant hand washing) but also to our uniforms.  Unless there is protective wear over nurses scrubs, this seems inevitable.  

The fit is roomy, a refreshing change to the trend of tighter scrubs that are so popular.  I know nurses who were never interested in the body-conscious designs.  These are not overweight people.  Everyone has a personal comfort factor, knowing what works best for them and the specific job being performed.  We all have an overall preference towards a certain fabric, a favorite fit, and color.

I have a slender build, and the width of this particular style is a bit too large for my frame.  I would wear this top however; I have others that are of the looser style, and they are very comfortable.  A couple of the tighter scrubs I have feel a bit too tight and restrictive.  It’s all about personal comfort in our profession.  An uncomfortable nurse makes for an unhappy nurse.

This scrub top style also considers function of the job being done.  What nurse is not completely lost without a pen?  (Oh the arguments I've seen over lost/stolen pens)  Within the top left pocket is a separate stitched pocket for pens, penlights, etc.  One of those small but much needed and appreciated features.

For my readers, here is a deal for 15% off from Uniformed Scrubs!   Use the coupon code ‘trueblue’.  This is good through July 31, 2013.

Visit Uniformed Scrubs:  Facebook-https://www.facebook.com/uniformedscrubs
                                      Blog-http://uniformedscrubs.wordpress.com
                                      Google Plus- https://plus.google.com/102649430487593258176/about
                                      Pinterest-http://pinterest.com/uniformedscrubs
                                      Twitter- @UniformedScrubs


Gentle Hugs....

*Adar Uniform's slogan
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Sunday, June 16, 2013

Missing Mr. Small

I completely forgot today was Fathers Day.

No longer needing to remind my son to call his dad on this day and his birthday, no longer having my dad around to say things to, this becomes just another day.  Mothers Day is a bit different (my mom died 5 years before my dad) because I have my precious and only child, my son, who always makes Mothers Day something special.

Each time there is a special day that many people celebrate, I am reminded over and over just how fortunate those are that have their loved ones here with them.  I lived in Taiwan in the 80's, and both my parents (who were divorced) and I stayed as close as when I was in the U.S.  We made it happen.  No computers, texting, no instant anything.  Long-distance (expensive) phone calls from land lines, and snail mail was it.  Taiwan is 15 hours ahead of California, calling was challenging and had to be prearranged to work for each side of the world.

I felt like the most fortunate daughter in the world when my dad called and told me that he was coming over to Taipei for business.  He worked for Ford Aerospace his entire life as a contract administrator, overseeing billion dollar defense contracts with U.S. allies.  (I was the only fourth grader I knew that brought a reel to reel film of a tank shooting ballistic missiles for show and tell).

Taiwan straight out of the camera
(Photo credit: Lif...)

I was busy studying Mandarin Chinese and working as a model in Taiwan and Hong Kong when my dad came over, along with some other Ford employees, and took great delight in telling me about going to a local department store.  They were all going up the escalator and one of his coworkers said something about 'the pretty American girl in the poster'.

My dad looked over and said, "That's my daughter", and when
he was telling me this, the gleam in his amazing green eyes was bright.  That was in 1986. I had my son that year in Taiwan.  He sure loved his 'Papa Web'.  

In 1995, I was a Hospice nurse by profession and a full-time nursing student when I took care of my father when he was put on Hospice.  He had colon cancer (as his mother did) that had metastasized to his liver.

I was given the amazing gift of taking care of both my mother and my father during their last days here.  Once, after gently wrapping my dad's swollen, weeping legs, I leaned over and said, "you're the best patient I've ever had", and my dad responded in a soft whisper, "you're the best nurse I've ever had honey".

These words I will treasure forever.

Inscribed on the granite stone with a bodysurfer on a wave, remembering my champion athlete dad, my younger brothers and I chose: Our Friend, Our Father.

Miss you Dad.      


Gentle Hugs....(and give your father some on this day.... if it is possible)
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Tuesday, April 30, 2013

Farewell To Walgreens Pharmacy

The mortar and pestle, one of the internationa...

A Judgment Call


Walgreens Pharmacy has served me for years, been a partner in my medical care, and been a friend at times when I felt as if the entire system was against me simply because I live with pain every day.  (I have also been a long time customer of the entire store)  This connection has been built over many years, and as with any part of the management of my pain or other medical issue, is  very important.  I knew the various staff, I was comfortable.  It is sad to lose that.

I am not a 'pharmacy-hopper' or a 'doctor-shopper'.  I create long-lasting partnerships in my pain management, including the pharmacy at which I choose to fill prescriptions.  After decades of spine and knee surgeries, various procedures, trials and novel treatments, all performed by respected surgeons (Neuro and Ortho) Pain Management physicians and the well-known clinics they practice in; I am a credible and compliant patient with a medical history starting with severe trauma going back to my teens.

One thing that does change over the years is employment, health status, etc., and I have been a customer with various insurances, and also a cash pay customer.  One year I paid about $12,000 cash for prescriptions, and I did not spread that love around to other pharmacies, that was all for Walgreens.  Ouch.

So why am I leaving Walgreens pharmacy?

Let's start with the phone call.

I was returning a call from the Walgreens pharmacist who was refilling some medications I had submitted via the convenient text & email refill alerts they offer.  He had said on the message that there was a "problem with one of the medications" and needed to talk to me.  I thought I may know what he was referring to with one of the refills, and was shocked to find out what the 'problem' really was.

Asking what he wanted to talk to me about, the pharmacist said something about a new Walgreens policy regarding pain medications and that he couldn't refill the Soma prescription.

Soma, or Carisoprodol, is a muscle relaxer.  Granted, it definitely helps with the deep pain and the movement restriction of severe muscle spasms (ergo why it has been prescribed to me for years) but I beg to differ on his wording.  I asked him if he could repeat what he had said.

"We at Walgreens in an effort to protect ourselves and our customers, have a policy regarding certain medications and in all good faith, I cannot dispense this medication at this, or any other Walgreens."  I was a bit taken aback and asked him to please repeat himself, and I grabbed a pen & paper.  He stated this again, and was definitely reading this statement off a paper.  I asked him if this meant that no Walgreens now would fill Soma, and the pharmacist read the same thing to me.  He chose to do this instead of talking to me like a person.  He was completely ignoring my pertinent, non-argumentative questions.  This was very aggravating and I felt it necessary to be 100% clear on what the pharmacist was attempting to get across to me.

I said that I need him to clarify this.  He began a another script-reading and I stopped him.  I told him I am a nurse, I am not arguing with him, I just needed to understand exactly what he was telling me.  Had Walgreens implemented a new rule that certain medications were not to be filled?  That doesn't make much monetary sense.  Was there some problem with my profile on their system?

Or was this a judgment call?

He refused to speak to me on a human level, and began to re-read the same thing.  At this point, I realized there was no getting through to this Pharmacist on the phone.  I asked him for his name, and he gave me his first name, which I already had from his voice mail.  I asked for his full name, and he hesitated, saying, "I don't usually give my last name", and proceeded to tell me.  I asked him to spell it, and he did.  I thanked him and hung up.  I was never angry or rude, I was calm and respectful.

Speechless, I began writing down everything that was said.  I looked his name up on the licensing board, and he looked to be related directly to Walgreens.  My friend then called the store and asked for the name of the store manager, who was not in at the time.  The assistant manager was eager to help, and gave the name of the Pharmacy manager when asked.  The Pharmacy manager is one and the same as the script-reading Pharmacist. Helpful assistant manager asked if he could do anything else, and at the time, that was all that was needed.

Recently, Carisoprodol was introduced into the DEA Schedule as a Schedule IV.  After January 11, 2012, Carisoprodol prescriptions are limited to 6 fills per prescription.  (Initial plus 5 refills)  I was aware of this change and my doctor's office also, letting me know last year that the doctor would need to write a new prescription to comply with the refill limits due to this change.  (The Walgreens I've gone to for years also alerted me to this)  Nothing else changed in the filling or refilling of this medication that affected me in any adverse way.

Until now.

Unable to find anything else that would clue me into why this one Pharmacist refused to refill this medication, I decided to go in person, and meet face to face.  We had spoken on the phone late, and I went in to his pharmacy the next day.  Unfortunately, he was not in, and would return after the weekend.  The Pharmacist there was not contracted with Walgreens, and was one of the nicest people I have met lately.  Smiling, he answered what he could of my many questions, letting me know that he could not fill the Soma because of what the other Pharmacist had done, and he was unable to override the manager.  I expressed my frustration with the pharmacy manager including his lack of communication skills and his inability to just talk to me and explain the situation.  It was recommended that the prescription be transferred across the street to another pharmacy, I agreed, and that was that.  The Soma was filled with no problem.  Yet I was not finished with this.  Too many unknowns.  I dislike unknowns in my own medical care.

A few days later, it was time to fill my monthly pain medication.  I have filled this same med at Walgreens Pharmacy for years, just as I have with my Soma.  I decided to take the security prescription to the same Pharmacist that had denied my Soma prescription.  I felt this would most likely not be a simple fill like usual, as this med is a Schedule II.  I was not looking for a challenge, I was hoping to simply meet the Pharmacist and let him see me, hear me, and understand that I am a stable and compliant patient, not a drug-seeker, or anything close to that.  If that was his reasoning for denying to refill the Soma, he made that call before he ever left me a voicemail that something was wrong with one of my prescriptions.  I could have easily filled this medication at the Walgreens by my physician's office where I have been a customer for years.

Again I went in, and again, the Pharmacy manager was not there, and again, the really nice Pharmacist that doesn't work for Walgreens was.  I had to laugh when handing him the prescription for my pain medication saying, "I imagine this will not go over very well considering what happened with my Soma."  He had more information this visit about the new rules that required the pharmacy to contact my physician, who then needed to write very detailed notes about my pain, if 'weaker' meds had been tried out, etc., and that this documentation would take a few days, leaving me without medication during this time.  I still wanted to speak to the manager.  My back was in severe pain and I was unable and unwilling to make a third trip back.  I realized then that I was not meant to meet the Pharmacist that had denied me a medication that allows my body some freedom of movement, some sort of help for the severe muscle spasms I have all day long.  I realized filling any type of medication related to pain was going to be a problem here.  I also realized that this Walgreens Pharmacy was not one that I wanted to be a customer of.  (Excluding the non-contracted Pharmacist from all of this-- he was so helpful, with excellent customer service skills and would be a perfect Pharmacy manager).

It didn't take long for me to decide that because of this one Pharmacist's judgment call, who has never met me, who only has a computer screen to 'know' me through, who never said, "why don't you come in tomorrow and I can explain this to you in person"; because of that I am now done with Walgreens Pharmacy altogether.

I recently moved just a few miles further south, and the Walgreens I speak of (with the Pharmacist and his interesting customer service style) would have gotten all of my business, both in the Pharmacy, and in the store.  It is convenient in location, it is the same familiar layout, all the little things that go with a place frequently shopped.  I did my best to try and establish a new and hopeful long-term relationship with the Pharmacist.  No attempt was made to contact me after I had gone in, and I made every effort to speak to him in person.

After my experiences in both nursing and as a patient, I understand there are some people that simply won't budge, who refuse to open up, and are all too quick to judge.  Decades of Pain Management have taught me to not waste time in any part of the treatment of my daily pain.  Let's all remember:  I live with severe spinal pain.  I am the patient here.  I am not the nurse, the manager, or the lawyer who must plead their case.  

When Walgreens Corporate receives my letter including my blogs address so they can read this, will they care?  Take note?  Respond?  Or am I just a person that really doesn't matter to them, even if I am a long-time loyal customer?  However it all shakes out, it took only one, one employee, one Pharmacist, one Pharmacy Manager; to quickly bring down what many other Walgreens Pharmacy employees have worked hard to build with me.  Tsk-tsk, Mr. B., you should be ashamed.

Oh, and when I filled my meds across the street, it definitely was personal.          



Gentle Hugs....



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Thursday, March 21, 2013

Costotransversectomy Video

The second Thoracic spine surgery I had was in 2001, called a Costotransversectomy, with discectomy and fusion.  At T-9/10, I had an anterolateral disc protrusion, causing severe upper back pain.  A highly respected and recommended spine surgeon in Arizona was doing a newer (at the time) anterior approach through endoscopy for cervical and thoracic spines.  I was excited at the thought of a few band-aid scars and the easier recovery from a spine surgery without the large paraspinal muscles being cut!

After reviewing my studies, he suggested that the surgeons go with a more traditional approach, and do open back surgery.  My Neurosurgeon chose Costotransversectomy, removing a piece of the rib (costectomy) the herniated disc material (corpectomy) and finishing with the hopeful added stability with a fusion of the T9/10 vertebrae.

Costovertebral articulations. Anterior view.
Costovertebral articulations. Anterior view. (Photo credit: Wikipedia)
Costotransversectomy was first performed in 1894, by Dr. Menard.  In this surgery, the spine is accessed through an open back incision, the proximal rib that attaches to the thoracic vertebrae creating the Costovertebral joints, is cut so as to allow a clear view and room to work on disc, tumor, spur, etc.  The simple fact that the ribs are 'in the way' for many thoracic procedures, lends to the use of this approach, and also used for surgery on anterior or lateral herniations, osteophytes, etc.  The transverse process of the vertebrae is then cut, leaving a nice view and area to work.  This surgery can only be done in the thoracic spine.  

Costotransversectomy is a combination word, like most medical terminology.  Costo: ribs.  Transverse: the transverse process of the vertebrae.  Ectomy: the act of cutting out.  ('ectomy' is usually preceded by the name of what is to be cut out, i.e., Tonsillectomy- here it is the rib and transverse process).

I found a video of a Costo, and may I note here that I have nothing to do with the soundtrack.  Thank the rockin' surgeons at University of Southern California Neurosurgery !!

In this operation, the patient is having work done at the same level as my surgery: T9 to T11.  There is also work done on this patient above at T7.  It is the approach via Costotransversectomy that is exactly like mine,  showing the cutting and resection of the rib and transverse process to visualize the needed area, and it is always interesting for me to see what my spine has had done to it!  Also in this video the surgeons insert hardware, and I did not have any put in.  Although twelve years later I feel as if the hardware shown in this surgery may give some feeling of stability to my spine.

Note the cut paraspinal muscles and the retractors necessary.  Minimally invasive surgery now completely eliminates the need for this, lessening recovery time, and even post-surgical pain.

Enjoy!!    Those of you that can watch surgeries that is.  ;)


Gentle Hugs....




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Friday, January 18, 2013

Over The Counter Medications in Chronic Pain

Many patients that suffer from chronic pain use a myriad of different medications, try various modalities, and will try almost anything in an attempt to obtain some sort of respite from the unrelenting assault to the body and mind.


Recently having ended nearly a decade of pain management physician-prescribed Morphine for the chronic pain in my spine, I find that the use of OTC (Over the Counter) medications are finding a definite place in my changing arsenal of treatments.


When opiates are prescribed and used as a part of your Chronic Pain Management program, it is common to see non-opiates either blended with the opiate, or used as an adjunct medication.


The most common OTC med found in opiates is Acetaminophen  or APAP.  (Brand name Tylenol)  Most people have had some experience with Vicodin, being the most widely prescribed medication in the U.S.  Vicodin (brand name) or Hydrocodone (generic) is mixed with APAP, and shown as the bottom number in all forms of the drug.  Example= 5/500 means that there is 5 milligrams of Hydrocodone, and 500 milligrams of APAP.  These are seen in the brands Loracet, Loratab and Norco.


There are dosage limits with any medication, and in the use of Acetaminophen, it is very important not to exceed 4,000 milligrams.  Especially with long-term use, damage to the liver can occur, among other issues.  I advocate patient education, and learning about the medications you use, including the dosage limits, is something everyone that is prescribed medication could benefit from.  Your doctor loves a well-educated patient!



Coated 200 mg ibuprofen tablets, CareOne brand...
Coated 200 mg ibuprofen tablets
(Photo credit: Wikipedia)
Also seen mixed into opiates is the OTC med Ibuprofen.  Commonly used with Hydrocodone, this medication can be found under the name brand 'Vicoprofen' for example.  The maximum dose per day of this OTC medication is 2.4 grams, or 2400 milligrams.  800 mgs. 3 times a day.


Used to augment a prescribed opiate, or alone as an adjunct to a non-opiate pain management program, these easy to obtain and relatively affordable over the counter medications are an excellent way to help manage your pain.  Along with many, many others who experience life with the constant companion called PAIN, I understand that my pain is managed, not obliterated.  That is reserved for after surgeries now, and living life without a long-term opiate pain medication is awesome--not only in it's clarity, but also in it's depth of my experience of pain.


I believe that when a chronic pain patient comes to a deep understanding that life will most likely be pain management vs. (total) pain relief, life will feel less on edge.  If we lower expectations, and move towards acceptance of the situation, what we are dealing with this day, this pain, this life, well, it may just seem a little more tolerable.


Even a little less pain is a very good thing.  



Gentle Hugs....
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