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Time for change's Journal
Posted by Time for change in General Discussion
Sun Nov 01st 2009, 08:01 PM
People have an unalienable right to have their pain treated. If your doctor doesn’t agree with that; if s/he doesn’t talk with you about it or doesn’t believe you when you talk about your pain, then it’s time to consider switching doctors.
The under-treatment of pain in the United States is a public health problem of great magnitude. (It is also a major problem in several other countries as well)

It has been estimated that from 50 to 76 million Americans currently suffer from chronic pain. In the good majority of instances, the suffering is unnecessary, since medical science has the knowledge to successfully treat the great majority of cases of pain. One example of this is a study that showed that one quarter of nursing home residents received no pain medication at all for their persistent pain. Another study showed that 70% of patients showing up in emergency rooms for the treatment of fractured bones received no pain medication while in the emergency room.


My involvement in a Wisconsin pain management project

In the late 1990s I worked for the Wisconsin Peer Review Organization, which had a contract with the state of Wisconsin to encourage Wisconsin health care providers to provide better health care to its Medicare patients. In that capacity I became involved in a pain management project, which led to a research study, which was published under the title “Evaluation of a Local Cooperative Project to Improve Postoperative Pain Management in Wisconsin Hospitals”.

More important than the specific results of this study were the conditions that led to it. The initial impetus for the project was the results of a questionnaire survey that showed that most Wisconsin acute care hospitals had no policies in place to ensure that postoperative patients received pain management consistent with existing standards of care. As one example, only 12% of hospitals had policies that required that postoperative pain management plans be developed in cooperation with patients prior to their surgery. And a review of 100 patient medical records showed that most post-operative patients did not receive adequate pain management.

Our research study concluded, in part:

This study demonstrated significant improvement in six of the seven indicators used to measure the quality of the processes used to control postoperative pain in 15 acute care Wisconsin hospitals after the implementation of quality improvement plans…


Why pain control is so important

Actually, the reasons why it is so important to control pain should be obvious to anyone who has ever experienced severe pain. Chronic pain destroys the quality of life for tens of millions of Americans. And it is not just the pain itself. Severe pain also interferes with or eliminates the ability of people to perform myriad functions required in their work or their home lives.

When postoperative patients are inadequately treated for their pain they tend to heal slower and end up staying in the hospital longer. Nor is it sufficient to wait until pain becomes severe before treating it. By delaying treatment until it becomes severe, the patient ends up requiring more drug treatment to provide the necessary pain relief, and therefore acquires a greater risk of serious side effects:

Pain medication should be given on a regular schedule so that there is a stable amount of medicine in the body to keep the pain away. By taking medication before the pain becomes unbearable, the patient can get better relief with lower doses and fewer side effects.

The under-treatment of pain in children is recognized as a world-wide problem that:

can lead to patient anger, frustration, depression, low self-worth, anxiety, mistrust, isolation, or even suicide… In an effort to quell this "public health problem," the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) developed standards that deemed… pain treatment to be a patient right.


Some personal experiences

My mother, when she was alive, suffered from severe rheumatoid arthritis for the last 40 years of her life. My wife has long suffered from chronic back pain due to a condition called spondylolisthesis, which is a displacement of the lumbar vertebra. Consequently, they both required large doses of pain medication, including narcotics, for control of their pain.

So when they required surgery for various unrelated conditions, management of their pain presented an especially challenging problem. Not only did they have to contend with the chronic pain that they normally were plagued with, but added to that was pain associated with their post-surgical status.

On those occasions I don’t believe that their pain was ever handled adequately. Often or usually, for one reason or another, they were taken off even their routine chronic pain medication upon admission to the hospital. Because of their weakened condition, they were in a poor position to fight with the doctors and nurses to demand adequate pain relief.

These were some of the most frustrating periods of my life. Throughout much of their hospital stays I would have to beg the doctors or nurses to provide adequate pain relief. They would tell me that they wanted to see if lower doses of medication were adequate before going to higher doses, and I would attempt to assure them that the lower doses that they contemplated wouldn’t even begin to control their pain. It was always a constant struggle and a constant fight. And my mother and wife suffered great amounts of unnecessary pain in the process.


Reasons for under-treatment of pain

There are many reasons why pain is under-treated, and these reasons have been written about in great detail. One obvious reason is the lack of access to medical care. But even after medical care is accessed, pain is much too often under-treated. Here, I’ll address two reasons that I have found to be especially important in my own experience:

Systemic lack of empathy
A certain high degree of empathy is often required to treat severe pain adequately. The treatment of severe pain requires spending a good amount of time with the patient – to evaluate the pain, initiate a treatment plan, and then follow the patient closely in order to determine the effects of the treatment.

The fact of the matter is that there is only one good way to determine how much pain a patient is having: talking to the patient about it. That takes time and effort, and it is not encouraged or well rewarded by private insurance companies.

Furthermore, when I attended medical school there was very little time devoted to the subject. And then there are cultural issues. There are many who consider the endurance of pain, even when unnecessary, to be a virtue. The end result is that patient pain is often not considered a high enough priority by too many doctors.

Over-concern about drug addiction or “drug abuse”
I encountered this problem all through medical school and during my residency training. And I accepted the “common wisdom” at the time, as I didn’t know any better, or I just didn’t think about it enough. The general attitude seems to be in many quarters that it’s better to let a hundred patients suffer in pain than to risk the possibility that someone may “abuse” the drugs they’re given and become addicted to them. I find that authoritarian attitude abhorrent.

One thing that physicians generally are not taught in medical school, but which is very important to keep in mind is that drugs used for the relief of pain cannot simultaneously cause euphoric effects and the addiction that accompanies those euphoric effects. Is it possible that a patient may continue to demand narcotic drugs after s/he has no more pain? Sure. Is it possible that drugs taken for the relief of pain may continue to be needed for the relief of pain indefinitely? If the underlying cause of the pain continues, then sure it is. Do patients sometimes ask for pain medication when they have no pain at all? Sure they do. But do all these considerations justify 50-76 million Americans living in chronic pain for large periods of their lives? Absolutely not!


The role of the U.S. government’s “War on Drugs”

A large part of the blame for this belongs with our government’s stupid “War on Drugs”. Some doctors live in fear that they could be arrested for providing large amounts of pain medication to their patients who need it. Efforts by the Drug enforcement Agency (DEA) to “crack down” on narcotic abuse have resulted in denying nursing home patients the pain relief that they need. Senators Kohl and Whitehouse recently objected to that:

The lawmakers wrote to Attorney General Eric H. Holder Jr. this month, urging that the Obama administration issue new directives to the DEA and support a possible legislative fix for the problem, which has bothered nursing home administrators and geriatric experts for years…

The law "fails to recognize how prescribing practitioners and the nurses who work for long-term care facilities and hospice programs actually order prescription medications," Kohl and Whitehouse write. They conclude that delays can lead to "adverse health outcomes and unnecessary re-hospitalizations, not to mention needless suffering."

Katherine Addleman explains how drug paranoia in the United States has interfered with providing adequate pain relief to chronic pain patients:

Paranoia about prescribing opiates has been intense in the US. With the highly restrictive regulatory climate, many American doctors fear that they could be arrested as pushers if they prescribe opiates… US Doctors who treat pain aggressively risk investigations by state medical boards, police and agents from the Drug Enforcement Administration who sometimes pose as patients, as well as loss of license and criminal prosecutions….

The feds filed the Lethal Drug Abuse Prevention Act, a law that made any physician prescribing a controlled substance subject to prosecution, unless he or she could prove the prescription was justified. But the backlash came swiftly. Fearing that doctors would be unwilling to take on pain patients, over 50 medical and patient groups got together and stopped implementation of the bill. They were right to worry. A study later found that after the feds threatened Oregon doctors suspected of assisting in patient suicides, pain under-treatment spiked in the state.

But… a directive on controlled substances was passed by the American Federation of State Medical Boards, after the American Medical Association and other professional medical societies put pressure on the government to stop harassing doctors who were prescribing appropriately. The new directive clearly declares that under-treatment of pain is just as unacceptable as overtreatment. Since then, medical boards in Oregon and California have disciplined doctors for inadequate pain management….

And of course, in addition to the chilling effect that our “War on Drugs” has had on the use of legal drugs for the relief of pain, it has also criminalized some drugs that are quite useful in the treatment of pain – most notably marijuana.


Some advice to pain patients

People have an unalienable right to have their pain treated. It’s in our Declaration of Independence. If your doctor doesn’t agree with that; if s/he doesn’t ask you about your pain and then talk with you about it when you want to talk about it; if s/he seems reluctant to prescribe sufficient pain medication because of a fear that you will “abuse” the drugs; or if s/he doesn’t seem to believe you when you talk about your pain, then it’s time to think about finding a different doctor.
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U.S. Democracy in Crisis
Time for change


The Democratic Underground was born on one of the worst days in U.S history – The day that the worst President in U.S. history took office.

Now, here we are 8 years later, and we’ve managed to remove that cancer from our nation and replace it with something much better. Notwithstanding my many ambivalent feelings towards President Obama, I have no doubt that he will be infinitely better for our country than his predecessor.

Yet despite that, our country has been terribly scarred from the events of the past eight years, and it continues to suffer from all of the root problems that brought us the worst President in our history in 2000 and 2004. Therefore, it is worth taking a look at the root problems that brought us to this sorry state of affairs.


MAJOR IMPEDIMENTS TO DEMOCRACY IN THE UNITED STATES

One thing that we must keep in mind when considering our current problems is that they are not new. They were greatly exacerbated by eight years of Bush administration misrule, but they did not start with George W. Bush and Dick Cheney.


Money in politics

All but the most naïve of the American citizenry know that the wealthy and powerful in our country routinely influence our local and national elections through huge campaign contributions. And they also know that they are generally well rewarded for their “contributions”. And they also know that bribery is presumably against the law in our country. Yet, on the rare occasion that our politicians are actually accused of bribery, our news media makes a great big deal over it, as if bribery is actually a rare event in American politics.

The end result is that a great many of our politicians do everything they can to make their wealthiest constituents happy with them, at the expense of everyone else. They do that with the knowledge that the voters they lose in doing so will be more than compensated for by the disinformation that will be paid for by their wealthiest constituents. I discuss this situation in more detail here, here, and here.

There are a few dots to connect here, but any reasonable assessment of American politics tells us that bribery is routinely used to buy and sell elections in our country. So routine is it that it is actually built into our system and legalized. But that fact is never overtly spoken of. To do so would imply that our system of government is as much or more an aristocracy than it is a democracy.

Bill Moyers, in his book “Moyers on Democracy”, explains the situation bluntly:

We have lost the ability to call the most basic transaction by its right name. If a baseball player stepping up to home plate were to lean over and hand the umpire a wad of bills before he called the pitch, we’d call that a bribe. But when a real estate developer buys his way into the White House and gets a favorable government ruling that wouldn’t be available to you or me, what do we call that? A “campaign contribution”.

Let’s call it what it is: a bribe.

The legality of contributing money to political candidates, with the implicit (though not explicit) understanding that that money will buy political favoritism, has been defended by both our courts and our Congress by sanctimoniously pointing to the free speech provisions in the First Amendment to our Constitution and claiming that money is speech. But the absurdity of that contention should be obvious to anyone with some primary school education. Speech is of value from a political standpoint (or any other standpoint) only when it is heard. But if one billionaire has one thousand times as much opportunity to speak through a medium which reaches millions than several thousand other people added together, the speech of that one billionaire will drown out the speech of most other people, thereby interfering with their right to free speech.


Election fraud

Electronic vote switching with DRE (direct-recording electronic) machines poses a great danger to the integrity of our election system – by virtue of its ability to switch a voter’s vote without being noticed by the voter. In other words, someone tries to vote for John Kerry, and the machine registers a vote for George Bush instead. What makes matters worse is that many or most of these machines don’t even produce a piece of paper with the vote on it, which can then later be used for a recount. So, if fraud is suspected there is no recourse. And worse yet is the fact that most of these machines use proprietary (secret) code to determine who the voter voted for.

We know for a fact that vote-switching occurred in the 2004 election. One study, based on voter reports to the national Electronic Incident Reporting System (EIRS), showed that vote switching incidents favored Bush over Kerry by a ratio of 12 to 1 nationally. A similar study showed that these vote switching incidents that favored Bush were 9 times as common in the heavily contested “swing states” than in non-swing states. To make the point that the EIRS reports represent only a small fraction of actual Election Day problems, an investigation by the Washington Post identified about 25 electronic voting machines in Youngstown, Mahoning County, Ohio, that were said to have been switching votes all day long. Yet only eight incidents of this nature from Mahoning County (all in favor of Bush) were reported to EIRS that day.

Clint Curtis, a computer programmer working in Florida prior to the 2004 election, testified before the Democratic staff of the House Judiciary Committee that he was requested in 2000 by his boss (at the request of a high level Republican operative, Tom Feeney) to “develop a prototype of a voting program that could alter the vote tabulation in an election and be undetectable”. Curtis’ testimony was followed by the death of Raymond Lemme, who while investigating Curtis’ allegations was found dead in a Georgia hotel room, just a couple weeks after telling Curtis that he had traced the corruption “all the way to the top”,

Another type of election fraud is the illegal purging of registered voters from the voter rolls. Like vote switching, the increasing computerization of voter registration is no doubt making it much easier to perpetrate this type of fraud on a mass basis.

This article describes a great deal of evidence that voter registration fraud played a major role in the 2004 presidential election, and in fact was probably the deciding factor in Ohio, which gave George Bush his electoral victory. Similarly, although the 2000 presidential election was stolen by a variety of means, voter registration fraud was quantitatively the most important method used. In 2000, the Florida Governor’s office used a computer program to purge tens of thousands of mostly black and Democratic voters.

There are many other means of election fraud that have been used in our country to destabilize our democracy. I discuss this issue in more detail, along with means for preventing election fraud, in this post.


Our corporate news media

If cash donated to their political campaigns is not enough to carry them through to victory, and if election fraud doesn’t happen to play a significant role, the corporate news media serves as another valuable tool for those seeking to sabotage our democracy. This problem overlaps with the role of money in politics, since those who own and control the corporate media are uniformly wealthy, and since it was their money that led to the acts that enabled our corporate media to become what it is today – Ronald Reagan’s veto of Democratic legislation to enforce the Fairness Doctrine in 1987, and the Telecommunications Act of 1996. This legislation allowed the monopoly consolidation of our news media to the point where today it is controlled by a very small number of extremely wealthy individuals.

Several excellent books have been written about the extent to which wealthy corporate interests control our news media today. I would highly recommend “Lapdogs – How the Press rolled Over for Bush”, by Eric Boehlert, “What Liberal Media – The Truth About BIAS and the News”, by Eric Alterman, and “Into the Buzzsaw – The Myth of a Free Press”, edited by Kristina Borjesson. And I have ranted about pseudo-journalists such as Tim Russert, who have made a largely successful, but hypocritical effort to appear unbiased to their viewers.

The bottom line, as Bill Moyers points out, is that the protection offered us by our First Amendment is based on the assumption of a separation of our government and a free press, which is supposed to protect us from government abuses. Moyers wrote this during the Bush administration:

What would happen, however, if the contending giants of big government and big publishing and broadcasting ever joined hands, ever saw eye to eye in putting the public's need for news second to free-market economics? That's exactly what's happening now under the ideological banner of "deregulation". Giant media conglomerates that our founders could not possibly have envisioned are finding common cause with an imperial state in a betrothal certain to produce not the sons and daughters of liberty but the very kind of bastards that issued from the old arranged marriage of church and state.

Consider the situation. Never has there been an administration so disciplined in secrecy, so precisely in lockstep in keeping information from the people at large and -- in defiance of the Constitution -- from their representatives in Congress. Never has the powerful media oligopoly ... been so unabashed in reaching like Caesar for still more wealth and power. Never have hand and glove fitted together so comfortably to manipulate free political debate, sow contempt for the idea of government itself, and trivialize the peoples' need to know.


Secrecy in government

Democracy suffers terribly when a nation’s citizens are uninformed – especially when they are uninformed with respect to the actions and motivations of their own government. If we don’t know what our government is doing, then how can we be expected to vote them out when they do something that we would consider deeply immoral had we known about it?

Consider war for example. If Americans understood the real motivations for its nation’s wars, they would probably be much more likely to strenuously object to those wars. That would make war much less politically feasible, and our country would therefore be led into war much less frequently than it has been in the past.

That is why I so hate the “national security” excuse for withholding information from us, the American people – which has become so routine that it is willingly or passively accepted by the good majority of Americans. I very much doubt that the “national security” excuse for withholding information from the American people has anything to do with national security more than 5% of the time. Rather, the reason for withholding such information from us is almost always something totally different. It is to blind us to the real reasons for war or other nefarious acts, so that we will accept them and willingly support or even risk our lives in their cause.


Rampant U.S. nationalism and the GAME

Two months ago I wrote a DU post that I titled “The GAME”, which I began by discussing “Unmentionable things in U.S. politics” – including such things as the stealing of a U.S. presidential election, calling American military or covert actions immoral rather than merely “misguided”, and imputing bad intentions rather than mere incompetence to a U.S. president.

I find this to be terribly repressive, not because I personally can’t mention these things, but because our elected representatives are under tremendous pressure not to discuss them. We elect them to represent us and our nation, and except for some rare courageous exceptions such as Dennis Kucinich, Cynthia McKinney, and Robert Wexler, they refuse to even talk about some of our very most important issues.

It has occurred to me that this provides the backdrop for a huge GAME that has been foisted upon us. A prerequisite of the GAME is to create an alternate reality that must be believed by a critical mass of people in order for the GAME to proceed. Why is that necessary? I believe it’s necessary because the reality is so terrible that if enough people consciously recognized it they would rise up and simply refuse to play the GAME.

Although the GAME’s masters set the rules, there are two related character traits of many Americans that cause them to play along: Rampant nationalism and a propensity for denial. Rampant nationalism is the attitude that our country is inherently better than any other country – so much so that it can do no wrong. This attitude is drummed into the American people from the time that most of us learn how to talk. We are made to feel that to believe or speak otherwise demonstrates a dangerous lack of “patriotism”, which makes us deserving of being shunned – or worse.

The other character trait that persuades too many Americans to play the GAME is denial. Believing terrible things about one’s country can be very painful. Accepting reality as it is, rather than as one would like it to be, can be very painful. To make this point, in a recent post titled “12 Things that Never Happened in American History”, I discuss the following official stories that we have been told (or not told):

The U.S. is not an imperialist country; FDR’s New Deal was not instrumental in ending the Great Depression; the Cold War was just about fighting totalitarian Communism; JFK was assassinated by a lone gunman; bribery is infrequent in American politics; Iran-Contra was not a criminal abuse of presidential power; U.S. presidential elections cannot be stolen; Bush and Cheney did everything they could to protect us against the 9/11 attacks; the Bush administration’s crimes are not serious enough to warrant impeachment or prosecution; and, we’re barely told about our nation’s killing of more than a million Iraqi civilians, the October Surprise, or Operation Northwoods.


CONSEQUENCES

These impediments to democracy work together to surrender great amounts of power into the hands of a small number of elites, who use that power in the cause of increasing their wealth and power at the expense of everyone else. It is a vicious cycle that is very difficult to break. Here are some of the major tragic consequences.


Rampant militarism and illegal aggression against sovereign nations

We are so often told how good and pure our nation and its people are that only a minority of Americans are aware of the extent of our many illegal and immoral activities. Many or most who aren’t aware of these activities would be shocked to learn about them and quite resistant to accepting that information as the truth.

In myriad instances we have overthrown or assisted in the overthrow of sovereign nations. In the good majority of these instances we have substituted a repressive right wing government for one that was much more responsive to the needs and desires of the nation’s citizenry. Sometimes genocide was used to accomplish our goals. The purpose of these activities has most often been to create a government that is friendlier to the desires of American businesses or corporations – though we always have some sort of rationalization for our actions.

In “Excuses for War” I discuss many of the phony excuses that the United States government has used to lead us into war, including its Indian wars, the Mexican-American War, the Spanish-American War, and the Vietnam War.

In “The Roots and Consequences of U.S. Overseas Imperialism” I note or discuss our covert and overt illegal and immoral overthrowing of the sovereign nations of Hawaii (1893), Cuba (1898), Puerto Rico (1898), the Philippines (1899-1902), Nicaragua (1910), Honduras (1911-1912), Iran (1953), Guatemala (1954), South Vietnam (1963), Chile (1973), Grenada (1983), Panama (1989), Afghanistan (2001), and Iraq (2003).

In “The Meaning of U.S. Imperialism, Genocide and Militarism” I note U.S. perpetrated genocides, as described in “State of Darkness” by David Model, including our atomic bombing of Japan (1945), those perpetrated against Guatemala (1954), Vietnam (1954-73), Indonesia (1965), Cambodia (1970-75), Laos (1969-74), and East Timor (1975), and our two wars against Iraq.

Other atrocities include our invasion of Cuba in 1961; U.S. Marine invasion of the Dominican Republic in 1965 to put down a rebellion against their repressive right wing government; U.S. military support of Haitian tyrant and mass murderer, Francois Duvalier; and numerous brutal interventions in several Latin American and African nations.


Massive Income and wealth inequality

Inequality of wealth in the United States is truly astounding – and it is increasing at a fast rate. In the United States in 2001, 1% of the population controlled 38% of the wealth, whereas the bottom 40% owned just 1%. That means that, on average, individuals in the top 1% owned about 1,500 times more wealth than individuals in the bottom 40%.

The rising level of income inequality in our country recently exceeded the point where it stood just prior to the stock market crash of 1929, which led to the worst depression in U.S. history. There are many who see a connection between the income inequality preceding that depression and our current situation. This graph, which plots income inequality measured as the ratio between the average income of the top 0.01% of U.S. families compared to the bottom 90%, over time, makes that point.

I discuss the subject of income and wealth inequality here, here, and here.


The loss of the rule of law

During the Bush Presidency I often argued that he should be impeached for his many crimes. Now that he can no longer be impeached, I have argued that our Justice Department should prosecute him for those crimes, and if it fails to do so then the International Criminal Court (ICC) should step in.

While Bush was still President, President Obama weighed in against impeachment, saying that impeachment should be reserved for only the most serious crimes. Now that he is President he has thus far given little or no indication that he intends to have his Justice Department prosecute George Bush or any other high level Bush administration official for their crimes. But if widespread torture, an illegal war of aggression, spying on American citizens, suspending of the right of habeas corpus, and numerous other violations of our Constitution don’t constitute serious crimes, then what does?

What would people say if a prosecuting attorney failed to prosecute a rapist and murderer simply because he had high level political connections? Who would accept that? Then why when far more serious crimes are committed by a President of the United States are there so many people who seem to think that it is ok to sit passively by and make no attempt to hold the perpetrators accountable for their crimes?

I’ll tell you why. It’s like I said earlier in this post. Saying that a former U.S. President might be guilty of prosecutable crimes is simply against the rules of the GAME. Given that and the failure to hold the Reagan administration accountable for its Iran-Contra crimes, George Bush and Dick Cheney connected the dots and thought that they might be able to get away with just about anything. Testing that assumption by moving ahead with prosecutions might be politically risky for the Obama administration. The Republican Party would no doubt raise holy hell if there was an attempt to prosecute high level Bush administration officials.

Consequently, we live in country in which, protestations to the contrary notwithstanding, certain people are indeed above the law. That fact, taken together with all of the impediments to democracy discussed in the first part of this post, means that democracy and the rule of law in our country are in grave danger. Indeed, some believe that we narrowly averted a military coup perpetrated by the Bush administration.

The American people and their leaders need to reassess what our country stands for. Is our democracy important enough to take steps to remove the role of money in politics, reform our election system, break up the corporate monopoly on our news media, require government actions to be much more transparent than they now are, and dare to look more objectively at who we are and what we do? Can we give up imperialism and warfare for the sake a world in which nations live and work together to further the cause of peace and justice? Can we make our nation one in which all of its citizens truly have the opportunity for life, liberty and the pursuit of happiness? And do our laws apply to all people, not just to those who lack the political influence to avoid them?

If we think that these things are important we have a great deal of work to do, lest our country sinks into a tyranny from which it may never recover.
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