I'm on medicaid need script for oxycontin,need doc,or free from company chronic pain

I suffer from an inherited syndrome named Marfan syndrome that is highly lethal if left untreated. Marfan syndrome is a connective tissue disorder caused by a faulty gene named FBN1 located on the 15th chromosome pair; the defective version of FBN1 causes the body to create an insufficiently elastic version of a key protein named fibrillin-1, which is an essential component of connective tissue. Marfan syndrome also causes overactivity of a hormone named Transforming Growth Factor beta (TGF-beta); the results of this are that organs throughout the body suffer structural defects, and persons with Marfan syndrome frequently present with unusual height, high myopia, highly arched palates, "crowded mouth" problems, skeletal abnormalities, sinus hypertrophy, and other problems that cannot be attributed to the defective version of fibrillin-1 coded for by the damaged version of FBN1 alone. Marfan syndrome is autosomal dominant -- if one parent has this syndrome, each of that parent's children has a 50% chance of inheriting the syndrome; if both parents have this syndrome, each of that couple's children will definitely inherit the syndrome.

The most serious, life-threatening complication of this syndrome with which I present is an ascending aortic aneurysm; the aorta is the largest artery in the body, and an aortic aneurysm is a weak spot in the wall of the aorta that can disintegrate ("dissect") over a period ranging from a few seconds to several days. It can also rupture abruptly as opposed to dissecting; when this happens, the patient is usually dead within seconds. Very few people survive aortic dissection or rupture without surgery. When the weak spot reaches a size with which the cardiologists and other doctors are no longer comfortable, the standard of care consists of surgery to section the damaged aorta and to replace the aortic valves (if necessary) with artificial valves, or valves from the heart of a pig. The latter valves wear out and have to be replaced after a number of years, whereas artificial valves last a lifetime.

Up until recently, there was not much that patients could do other than take beta blockers (which act indirectly, by reducing the pressure applied to the wall of the aorta with every heartbeat) and carefully monitoring the size of the aortic aneurysm. Recently, however, Dr. Harry Dietz (of Johns Hopkins) established that overactivity of TGF-beta is also at the heart of pathogenesis of this syndrome. Commonly prescribed drugs named angiotensin-II receptor blockers (or antagonists) (ARBs) can reverse the effect of TGF-beta, and administration of ARBs such as losartan, candesartan, and irbesartan has been shown to reverse aortic wall damage in pediatric cases (clinical trials with adults are yielding very promising results too). Consequently, I now take losartan 200 mg daily in divided doses of 100 mg; this finding has revolutionized the treatment of Marfan syndrome, and it is entirely possible that my aortic aneurysm will never require surgical correction.

Unfortunately, there is nothing that can be done about the severe and permanent damage to my spine and joints that has already occurred. I suffer from levoscoliosis, facet joint arthropathy, disc compression, multilevel annular bulges, prominent spur formation, prominent Schmorl's nodes, disc desiccation, bone marrow signal changes, prominent osteophyte formation, marrow edema, and other indicia of severe degenerative changes; and I present with bone infarcts above and below each of my knees. I also suffer from osteoarthritis, which causes me severe and unremitting pain when not appropriately medicated. I also suffer from osteoporosis, which renders me an unsuitable candidate for treatment with rods inserted into my spine (as has been done in the case of many other patients suffering from osteoarthritis).

In 1995, my primary care physician (PCP) in New York City prescribed OxyContin. We titrated the dose until I obtained excellent pain relief at 80 mg twice daily (total dose of 160 mg every 24 hours). This dose remained effective for many years; I have been lucky in that I have developed tolerance relatively slowly. My PCP also prescribed Norco 10 / 325 for breakthrough pain; Norco 10 / 325 consists of 10 mg hydrocodone mixed with 325 mg acetaminophen. My PCP was very generous, and I received 240 Norco tablets every month; in addition, my Norco prescriptions were almost always written with five refills.

I moved to the UK about two years ago, and over the course of this timeframe, my doctor here in the UK increased my dose from OxyContin 120 mg twice daily to my current dose of 200 mg twice daily (total dose of 400 mg every 24 hours). This is definitely a high dose - I am receiving high dose opioid therapy. I cannot overemphasize the fact that I do not abuse my medications. My doctor here in the UK trusts me with an eight-week supply of my medications, which means that I take home a total of 224 OxyContin 80 mg tablets and 112 OxyContin 40 mg tablets every eight weeks. She also prescribes OxyNorm (named OxyIR in the US) 10 mg and 20 mg capsules for breakthrough pain, and gives me a total of 168 OxyNorm 10 mg capsules and 168 OxyNorm 20 mg capsules every eight weeks. In addition to this, she prescribes the UK equivalent of Tylenol #3 with codeine; I receive a total of 448 Co-codamol tablets every eight weeks. When the breakthrough pain is relatively mild, I take the Co-codamol tablets; on the other hand, when the breakthrough pain is severe, I take the OxyNorm 10 mg and OxyNorm 20 mg capsules.

If these quantities sound excessive, it is because doctors in the US are notorious for UNDERTREATING chronic pain. This is not news; several studies have confirmed that there is an appalling tendency on the part of doctors in the US to avoid prescribing opioids and opiates, even in those cases where the prescription of such drugs is clearly indicated. The terms "opiophobia" has been coined to describe the shocking tendency of so many doctors in the US to avoid prescribing drugs from this class; about 20% of family practice physicians do not even bother to order the triplicate prescription blanks that are required in the US for the prescription of drugs from this class! Doctors in the US wrongly assume that addiction and physical dependence are the same thing; they are NOT the same thing, and the fact that doctors, of all people, fall into this trap is testament to the ignorance that plagues so many doctors with respect to pain management and the prescription of drugs from this class.

This is not entirely the fault of the doctors. The "war on drugs" has been conflated with the legitimate prescription of powerful analgesics from the opioid and opiate classes of drugs, and many doctors feel under constant threat of being audited by the respective state boards of health and by the Drug Enforcement Administration (D.E.A.) whenever they contemplate prescribing opioids and opiates. This situation is both ludicrous and tragic; politicians and petty bureaucrats, uninhibited by wisdom, knowledge, or experience, make decisions as to what constitutes the "excessive" prescription of opioids and opiates, and then impose these determinations on medical professionals who have spent seven years or more obtaining hard-earned professional qualifications. It is little wonder that so few doctors are willing to prescribe as many Schedule II painkillers as they deem necessary.

(Schedule II painkillers include pure codeine, pure dihydrocodeine, pure hydrocodone, pure oxycodone, and other opiates and opioids that are not compounded with acetaminophen. Schedule III painkillers include many of the weaker opioids and opiates compounded with acetaminophen. For example, pure codeine is a Schedule II medication, whereas Tylenol with Codeine #3 is a Schedule III medication. Schedule II prescriptions may not be issued with refills; every time the patient needs another month's supply of the medication concerned, the doctor has to issue an entirely new prescription. Schedule III prescriptions, on the other hand, may be issued with up to five refills. Schedule II prescriptions have to be written up on triplicate prescription blanks - one copy of the prescription is retained by the doctor, one copy is retained by the pharmacy, and one copy is retained by the state department of health. Schedule III prescriptions, on the other hand, may be written up on ordinary prescription blanks. There is therefore an understandable, but very unfortunate, tendency on the part of doctors in the US to prescribe large quantities of weak opioids and weak opiates compounded with acetaminophen, as opposed to prescribing more powerful opioids and opiates unadulterated with acetaminophen; the result is that a large number of patients end up taking large quantities of acetaminophen that, at best, are useless to them, and at worst, are damaging to their livers.)

When prominent personalities such as Rush Limbaugh and (possibly) Michael Jackson are found to have abused OxyContin, they do an incalculable disservice to those men and women who are in genuine need of this particular medication, as well as to concerned friends and relatives of patients who take this medication. Following Michael Jackson's death, and the questions raised about OxyContin (including newspaper articles describing OxyContin as "hillbilly heroin" and articles describing the "struggle" that various persons have had trying to wean themselves from OxyContin), well-meaning members of my immediate family badgered me for weeks, trying to get me to stop taking OxyContin, and describing the articles that they had read about the bad press that OxyContin has received, and the "chokehold" that OxyContin has had on the lives of other men and women. THANK YOU, I GET THE POINT - when an irresponsible fool abuses a drug such as OxyContin, the results are bound to be tragic and unfortunate. When Sonny Bono skiid into a tree at high speed whilst in a Vicodin-induced stupor, his wife insisted that Vicodin (hydrocodone mixed with acetaminophen) was a "dangerous" drug that "robbed people of their thought process" - without regard to the fact that the dumb fool should never have been performing high-speed physical exertions whist under the influence of hydrocodone in the first place!

But I reserve unfettered, open contempt for Rush Limbaugh - an abusive, vicious bully, who had repeatedly and savagely mocked people suffering from substance-abuse problems, and who had attacked the Americans with Disabilities Act (ADA) precisely because this Act protects people whom Limbaugh refers to as "defectives" (his word to describe people addicted to drugs). This mealy-mouthed hypocrite had the effrontery to seek refuge in a drug rehabilitation center when news of his dalliance with OxyContin and hydrocodone preparations hit the fan. Instead of accepting personal responsibility for his behaviour (bullying his housekeeper, Wilma Kline, into diverting her husband's post-operative Vicodin prescription), Limbaugh actually blamed OxyContin and Vicodin for his downfall, insisting that there was something inherently dangerous about these particular drugs that forced him to abuse them. This variant of "the Devil made me do it" is particularly stomach-turning when it is uttered by moralistic bigots who hurl accusations against gay Americans (for example).

To those persons who have become addicted to OxyContin - you have my sincere sympathy. However, please do not make the assumption that all people who take OxyContin will necessarily become addicted to this drug. I have encountered this mentality with depressing frequency, and it is frankly both arrogant and ignorant.

PHILIP CHANDLER

Karen,

You state that very few doctors would prescribe 80 mg OxyContin for sustained, long-term use.  I must interject here.  I have written, above, about my condition in considerable detail -- but what is relevant to your reply is that I am currently taking 200 mg OxyContin every 12 hours (a total of 400 mg every 24 hours).  This is actually the British National Formulary's recommended maximum daily dose -- but it is essential to mention that there is no upper ceiling associated with opiates and opioids.  Many people -- including doctors -- do not know this.  The fact is that a person on high-dose opioid therapy can take massive doses -- doses that would kill an opioid-naive patient -- without any ill effects whatsoever.  It is not unusual to read about patients taking OxyContin 800 mg daily -- in fact, I think that this is the maximum amount that Medicaid will pay for.

You state that very few doctors would prescribe 80 mg OxyContin for sustained, long-term use. Respectfully, I must interject and strongly disagree here. I have written, above, about my condition (Marfan syndrome) in considerable detail -- but what is relevant to your reply is that I am currently taking 200 mg OxyContin every 12 hours (a total of 400 mg every 24 hours). This is actually the British National Formulary's (BNF's) recommended maximum daily dose -- but it is essential to bear in mind that there is NO UPPER CEILING associated with pure opiates and opioids. Many people -- including doctors -- do not know this. The fact is that a person on high-dose opioid therapy can take massive doses -- doses that would literally kill an opioid-naive patient -- without any ill effects whatsoever. It is not unusual to read about patients taking OxyContin 800 mg daily -- in fact, I think that this is the maximum amount that Medicaid will pay for in some states.  I refer you to http://www.gao.gov/new.items/d04110.pdf, where it is stated (about OxyContin) that "Like all pure opioid agonist analgesics, with increasing doses there is increasing analgesia, unlike with mixed agonist/antagonists or non-opioid analgesics, where there is a limit to the analgesic effect with increasing doses. With pure opioid agonist analgesics, there is no defined maximum dose; the ceiling to analgesic effectiveness is imposed only by side effects, the more serious of which may include somnolence and respiratory depression."

Back in 1995, I started on OxyContin 80 mg twice daily (a total of 160 mg OxyContin every 24 hours), with hydrocodone / APAP 10 / 325 for breakthrough pain. I developed tolerance very slowly (gradually increasing to 200 mg twice daily over a period of 14 years). When I moved from the US to the UK, I started taking OxyNorm for breakthrough pain (hydrocodone is not available in the UK), so in addition to the OxyContin 200 mg twice daily, I also take OxyNorm 10 mg and OxyNorm 20 mg as needed for breakthrough pain.

You state that it will do a person no good to make a scene at a hospital ER, and I completely agree with you. There have been times when I have suffered such excruciating pain that I have gone to the ER -- and by asking for an injection of diclofenac (which is a particularly painful and unpleasant injection), I have obtained more appropriate pain relief with a fentanyl patch or with an injection of meperidine -- by asking for a non-opioid injection, I have established my good faith intentions with the hospital staff, and have obtained more appropriate pain relief.  That is truly perverse.  This was NOT a ploy on my part; I go through utter hell when my back acts up (please see my above message about Marfan syndrome)...

I have written above about the problem with the D.E.A. -- doctors in the UK are much, much more willing to prescribe powerful opiates / opioids than are doctors in the US, precisely because they do not have to worry about a Sword of Damocles hanging over their heads every time they write out prescriptions for drugs such as OxyContin. I have NEVER abused my prescriptions and have NEVER sold them -- this would be such shabby treatment of my doctor here in the UK, who is a kind and decent person who has bent over backwards to help me, and who is a wonderful clinician; I am shocked and upset when I learn of patients who sell their doctors down the river like that...

Thank you,

PHILIP

Philip,

Thank you for your input on this question.  You are correct in saying there is no ceiling on prescribing opioids.  In this case, however, I was concerned that the person asking the question had gone from taking Percocet (of which the highest single dose available contains 10 mg of oxycodone) to taking 80 mg of someone else's OxyContin.  That big of an increase can be extremely dangerous.  While there is no ceiling on the amount of oxycodone that can be taken, it's essential that the patient be titrated up slowly to avoid overdose. 

Currently in the U.S., the highest dosage of oxycodone available in a single tablet is 80 mg.  We used to have a 160 mg tablet, but that has been discontinued.  I didn't mean to imply that 80 mg was the most that could be taken in a day or even at one time – just that that is the largest single-tablet dosage available.  I wanted to impress upon the person asking the question how dangerous it was to suddenly take that strong of a dosage that hadn't been prescribed for him.

As for my statement that it is difficult to find doctors who will prescribe large doses of OxyContin for long-term use, I stand by that.  Most general practitioners in the U.S. will not prescribe anything stronger than hydrocodone on a long-term basis because of their fear of the DEA.  Many refuse to prescribe any kind of opioid for any reason.  Sadly, even many pain management specialists are hesitant to prescribe high dosages of opioids because they know they're being watched.  Unfortunately, the FDA is currently considering putting even more restrictions on the use of opioids, so I don't expect the situation to improve any time soon. 

You were fortunate to have a PCP in the U.S. that was willing to work with you and provide the pain relief you needed.  If you could read my mail each day, you would see that your experience was the exception rather than the rule.  For every one person who has found a doctor willing to help them, I hear from more than a hundred that can't find anyone who will help. 

I'm also very happy to hear you have a good doctor in the UK and you don't have to worry about the DEA there.  Although the percentage of people who abuse opioids compared to the number of people who need them for real pain problems is fairly low, here in the U.S., the attention seems to be on preventing the abuse rather than helping those in pain.  Sad but true.

Thanks again for your contribution to this question and this site!  –  Karen

Dear Karen,

Thank you for this clarification.  I agree with you entirely that it is dangerous and irresponsible for any person to switch from oxycodone 10 mg to OxyContin 80 mg without doing so under careful medical supervision, and without careful titration of the dose in a proper clinical context.

I read recently that an FDA advisory panel has just recommended banning all compound analgesics that combine acetaminophen (APAP) with low-potency opioids and opiates such as hydrocodone, codeine, dihydrocodeine, etc., ostensibly because too many patients are taking too much APAP by stepping up their intake of these combination analgesics.  The stated goal of the advisory panel is to reduce the unnecessary intake of APAP by patients suffering from chronic pain.  If the FDA acts on the recommendations of its own advisory panel, it will effectively ban almost all of the Schedule III drugs that currently act as at least partial remedies for those patients suffering from chronic pain, whose doctors are either opiophobic or whose doctors live in fear of being prosecuted by the D.E.A. (or by state health departments) for prescribing "too many" Schedule II drugs.  If the FDA follows the advice of its own panel, then drugs such as Tylenol with Codeine #3, Tylenol with Codeine #4, Norco 10 / 325, Vicodin, etc. will all be banned.

Is this what you referred to when you stated that the FDA was considering placing even tighter restrictions on the prescription of opioids?

The results of such a ban will almost certainly be grotesque, and may well lead to a surge in the number of suicides caused by inadequately controlled chronic pain.  I do not make this statement lightly - many patients in the US who are unable to obtain adequate pain relief turn to suicide in their efforts to alleviate the pain.  At the present time, doctors who treat patients suffering from chronic pain have at their disposal a number of at least partially effective drugs that combine low-potency opioids / opiates with APAP.  These drugs are inadequate in the context of chronic, severe pain, but they are better than nothing at all.  Almost all of the Schedule III analgesics will be banned should this recommendation be implemented.

Unless the FDA issues clear, unambiguous guidelines, made binding on the D.E.A. and on state regulatory agencies, recommending that doctors be given a much freer hand in prescribing Schedule II painkillers to patients suffering from chronic pain, without having to worry about being harassed by the D.E.A. and / or by state regulatory agencies, this proposal is a recipe for utter disaster, and human suffering and misery on an appalling scale (made socially acceptable because it would be "legal").

This is an object lesson in the shambles that invariably results when the US government declares a "war" on something (whether that something be drugs, terrorism, etc.).  Whenever America declares a "war" on something, the result is invariably human misery on a massive scale.  This misery is invariably made even more grotesque by another American tendency, which is the refusal of politicians (and many of the people who they represent) to recognize and to acknowledge when such as "war" has failed.  To this day, many politicians continue to insist that the "war on drugs" is working, despite the fact that most illegal drugs are cheap, easy to obtain, and freely available.

It is working, all right.  It is working to ensure the continued and irreversible erosion of rights and liberties that we once took for granted - particularly in the realm of Fourth Amendment jurisprudence.  Searches and seizures that were considered by state and federal reviewing courts to be utterly impermissible just 20 or 30 years ago are now considered to be perfectly acceptable - and citizens who protest are frequently harassed and branded as "trouble-makers".  A generalized "drug exception" to the US Constitution (and to state constitutions) now exists, just as a generalized "gay exception" to the US Constitution existed right up until June 2003 (when the US Supreme Court handed down Lawrence v. Texas, 539 U.S. 558 (2003), thereby explicitly and bluntly overturning an earlier decision (Bowers v. Hardwick, 478 U.S. 186 (1986)) that permitted the states to criminalize gay sex even when this occurred in entirely private contexts in the homes of gay persons).  The "war on drugs" makes it acceptable for state and federal government officials to fly over the homes of law-abiding citizens at low altitudes to determine whether or not the occupants of those homes are growing marijuana (see Florida v. Riley, 488 U.S. 445 (1989), in which case the dissent invoked George Orwell's dystopian novel "1984" by hoping that "...it will be a matter of concern to my colleagues that the police surveillance methods they would sanction were among those described forty years ago in George Orwell's dread vision of life in the 1980's:

"The black-mustachio'd face gazed down from every commanding corner.  There was one on the house front immediately opposite.  BIG BROTHER IS WATCHING YOU, the caption said. . . .  In the far distance, a helicopter skimmed down between the roofs, hovered for an instant like a bluebottle, and darted away again with a curving flight.  It was the Police Patrol, snooping into people's windows.").  The "war on drugs" is also working to gut the Eighth Amendment, with its prohibition against cruel and unusual punishment (the Rockefeller drug laws in the State of New York mandate grossly disproportionate, lengthy terms of incarceration for both users and sellers of illegal drugs).  The "war on drugs" is also working to gut the Fifth and Fourteenth Amendments' guarantees of due process of law (see United States v. Salerno, 481 U.S. 739 (1987), in which case the US Supreme Court upheld the so-called Bail Reform Act of 1984 in the face of a due process challenge; this statute provides for the incarceration prior to trial of persons charged with certain offenses on very broad and shaky grounds of potential dangerousness to the community.  In short, the "war on drugs" has taken a wrecking ball to the constitutional structure of checks and balances that exists to protect the individual from the (virtually limitless) resources of the state.

There is a shocking tendency in America to confuse a procedure or medication with its abuse.  The furore that surrounded the abuse of a particular, very effective and useful sleeping pill is instructive in this regard.

I was born and raised in South Africa.  When the sleeping problems plagued me as a young adult, my doctor in private practice in Johannesburg prescribed a sleeping pill marketed as Rohypnol (its generic name is flunitrazepam).

May readers will recognize this drug.  It has acquired a reputation as a "date-rape" drug, because it has been used to spike the drinks of women (and sometimes men), in order to render them powerless to resist sexual assault.  However, flunitrazepam is an extremely effective sleeping pill - I know this from personal experience.  I took flunitrazepam for about two years, before immigrating to the US, and it gave me solid, uninterrupted sleep every night without fail.  However, when young men in states such as Florida imported this drug and started using it to sedate and sexually assault women, common sense flew out the window here in the US.  Whereas other nations (including South Africa) opted to impose tighter controls over this drug (it was moved from Schedule 5 in South Africa to Schedule 6 (there are a total of eight schedules in South Africa, with Schedule 8 representing illegal drugs)), the US government is currently trying to ban this drug outright!  Again, we see a tendency to confuse abuse of a drug with its entirely legitimate usage - current efforts to move flunitrazepam to Schedule I under US drug laws fly in the face of reason and definition - Schedule I drugs are by definition drugs that have no accepted medical usage and that are highly addictive.  In fact, flunitrazepam continues to enjoy usage as a powerful sleeping pill all over the world, and it is no more addictive than diazepam, lorazepam, temazepam, or any of the other benzodiazepines (I now take lorazepam for panic attacks and insomnia).

If the FDA follows the recommendations of its own advisory panel, patients who now obtain partial relief from pain may find themselves utterly without remedy.

I am glad that I no longer live in the US.  As you mentioned, my doctor in New York City was unusual in that he did not hesitate to prescribe OxyContin 80 mg and Norco 10 / 325 in generous quantities for me.  When I moved to Chicago on assignment, I found a pain management specialist who agreed to continue the regimen - but I realize that I was lucky, and that many people who suffer from chronic pain are left without medications, to suffer and to lead lives of genuine misery.

This is a national tragedy.

Only when those people who suffer from chronic pain mobilize politically and apply pressure to their political representatives will anything change.  Prior to this FDA advisory panel recommendation, it appeared that the US was slowly relenting and acknowledging the seriousness of chronic pain.  Now this has happened.

God help those ordinary men and women who are left to fend for themselves and to suffer.

PHILIP

I couldn't agree with you more, Philip.  Our government here gives lip service to wanting to help pain patients, but then does everything in their power to make it more difficult for us to get adequate pain relief.  And you're right – the "war on drugs" has been a catastrophic disaster.  It's done little to nothing to reduce drug abuse but has created a multi-billion dollar bureaucracy that we can't seem to get rid of.

Actually, when I mentioned that the FDA is considering placing even tighter restrictions on the prescription of opioids, I wasn't thinking of the possibility of removing drugs with acetaminophen in them – although that is certainly a serious concern.  But an even greater concern to me is the fact that they are developing "Risk Evaluation and Mitigation Strategies" to try to put tighter controls on the use of opioids.  Here's an article I wrote about it:  URGENT:  FDA May Remove or Limit Access to Opioid Pain Medications

As you'll see when you read the article, this could be a disaster for chronic pain patients.  If they follow through with these ideas, I'm afraid we'll see a significant increase in suicides as you mentioned.  What is sad is that these kinds of restrictions never seem to deter those who are determined to abuse drugs.  They just make life miserable for honest people who are in pain and just trying to have some quality of life. 

I'll be interested to hear your thoughts on this.

Karen

Dear Karen,

I read the proposed FDA changes with a growing mixture of disbelief, horror, and revulsion.

Patients suffering from chronic pain already have terrible difficulty obtaining access to opioids and opiates that they need in order to function.  The proposed changes could make it impossible for the majority of doctors who currently prescribe such medications from doing so in the future.  Already, the state health departments and the D.E.A. point a loaded gun to the heads of doctors who prescribe Schedule II narcotics -- now, they would seek to make it virtually impossible for these doctors to prescribe these drugs.

I had hoped that the proposed elimination of the compound analgesics would be accompanied by a loosening of the restrictions currently imposed on doctors in terms of their abilities to prescribe Schedule II narcotics -- how incredibly naive I was in thinking that the US government would act in a manner that would help its vulnerable and suffering citizens.  It is almost as though our politicians are TRYING to make persons who suffer from chronic pain live in utter misery.

When the FDA was slow and reluctant to approve AZT (now known as zidovudine) to persons suffering from HIV infection, activists literally shut down the FDA building, barricaded the offices of prominent lawmakers, and resorted to illegal activities to force the issue.  Ultimately, these activists succeeded -- the FDA listened, adopted a fast-track process for the approval of anti-retroviral drugs, and made these drugs available to those patients who needed them.  I am now beginning to think that the only way of making it clear to the US government that patients suffering from chronic pain need their opiates and opioids is to resort to such illegal activities.

I am very, very glad that I no longer live in the US, and have no plans to return to the US.  I have watched those who oppose President Obama's plans to implement a universal health care package that would ensure that all Americans have access to healthcare describe the President's proposal as "socialized medicine", and I have seen some protestors actually display placards depicting President Obama as Adolph Hitler, complete with a small moustache.  These bastards seem to think that merely using the phrase "socialized medicine", and portraying President Obama as Hitler, somehow makes the problem of 50 million uninsured Americans go away.  There is a reflexive response to the phrase "socialized medicine" that shows just how ignorant those who use this phrase really are.  I now rely on the British NHS to help me deal with chronic pain, numerous medical complications of Marfan syndrome, physiotherapy, MRIs, CT scans, echocardiograms, etc.  - and I am both appalled and disgusted by the American attacks on the NHS - attacks that utterly misrepresent the NHS, using scare tactics invoking the spectre of healthcare rationing - completely overlooking the fact that healthcare is already rationed in the US, and that only those who are either independently wealthy or who have very generous health insurance actually have access to healthcare.  America may indeed have the best medical technology in the world, but it most certainly does NOT have the best healthcare system in the world, and those ignorant fools who keep banging the drum and insisting that America has the best healthcare system in the world are utterly misguided and utterly misinformed.  Commercials in the US currently defame the NHS, grossly and criminally misrepresenting the NHS and indoctrinating the American people with horror stories about long waiting lists and substandard medical care.  I have relied on the NHS for several years now, and have nothing but praise for a system that has taken care of me and addressed all of my medical needs without my having to pay a single penny - yes, I pay taxes, but my taxes in the UK are substantially lower than the taxes I used to pay in the US.

If the NHS represents "socialized medicine", then LET'S HEAR IT FOR SOCIALIZED MEDICINE!

Should the FDA succeed in forcing these two changes upon the American people, I foresee a growing trend in which people suffering from chronic pain will turn to fraud and misrepresentation to obtain their medications, probably by travelling to Canada and / or Mexico to obtain their medications.  I would personally support these patients without hesitation.  Nobody should be forced to suffer from excruciating pain, day in and day out, because a nation has lost its way with respect to the "war on drugs", which has increasingly turned into a war on people.

I watch those who oppose President Obama demonize the NHS, and it makes me sick to my stomach to watch these false and ugly misrepresentations.  The visceral hatred that so many conservatives harbour for President Obama is unlike anything I have ever seen before in American politics - clearly, the neoconservatives cannot stomach the fact that THEY LOST, and lost BIG TIME!  The American people voted for a man named Barack Hussein Obama over the neoconservatives - something that the latter group cannot deal with and simply cannot handle.  THEY LOST, to a black man (horror!), whose name sounds like Osama! - and they cannot deal with this loss!

Karen, I can only say that I am deeply saddened, but am not in least surprised, by the materials to which you referred me.  Now, we have to decide how to respond to this.  If persons with HIV were able to obtain AZT and other much-needed drugs by resorting to civil disobedience, then person suffering from chronic pain may wish to resort to the same tactics.  When persons who suffer from chronic pain appear in court, as defendants, and tell juries about the excruciating suffering and pain to which their governments have condemned them, without due process and without an adequate reason, they may well receive sympathetic hearings (and equally sympathetic verdicts).

Try to imagine a world without Tylenol #3 with codeine, without Vicodin, without Norco, without Darvocet, without Percocet, and without generic versions of these drugs.  Then try to imagine a world in which almost no doctors would be authorized to prescribe drugs such as OxyIR, OxyNorm, OxyContin, Morphine Sulphate, MS-Contin, hydromorphone, oxymorphone, dipipanone, and the other Schedule II narcotics.  Then try to imagine suffering from chronic, unremitting pain of the severity that causes people to kill themselves.  This is indeed a form of legalized torture, made possible by another American "war on" something - in this case, drugs.

Let us both keep our ears to the ground and report back to each other on whatever we hear.  My email address is philipchandler domain earthlink dot net.

I look forward to hearing form you.

PHILIP CHANDLER