The US and the US Veterans Administration has no sense of good work.
Call the White House and tell them to call Ratner 718-823-5049.
Sam Stone is laughing at us all that his invention the neutron bomb was not widely used to save lives and
avoid or reduce the incidence of traumatic injuries, including idiopathic pain, as the US has persisted in killing the old fashioned way.
The Lancet p.106 Jan. 14, 1978 describes the treatment of the cause of causalgia.
Ratner's invention of a device or a variant device to turn off pain should be widely applied.
The US is a third world country in terms of pain management which by its own words of lesser value than curing idiopathic pain as Ratner has done.
Opiates are a useful adjunct to curing pain.
I commend to the powers that be the work of Dr. Eugene J. Ratner started at the US Veterans Administration at Fort Hamilton and continued thereafter.
The NY Times is remiss in a survey of work done in the US without studying Ratner's work.
The alternative of last resort is always the work of Dr. Hiram Maxim, the greatest Dr of all time.
His methodology is guaranteed to be safe, effective and everlasting.
Hot lead healthcare standing the test of time in every conflict since the invention of automatic weapons and variations thereon.
Saving Sergeant Savage
Four years and a lifetime ago, a new war began for Sgt. Shane Savage.
On
Sept. 3, 2010, the armored truck he was commanding near Kandahar,
Afghanistan, was blown apart by a roadside bomb. His head hit the
ceiling so hard that his helmet cracked. His left foot was pinned
against the dashboard, crushing 24 bones.
Sergeant
Savage came home eight days later, at age 27, with the signature
injuries of the conflicts in Iraq and Afghanistan: severe concussion,
post-traumatic stress and chronic pain. Doctors at Fort Hood in
Killeen, Tex., did what doctors across the nation do for millions of
ordinary Americans: They prescribed powerful narcotic painkillers.
What
followed was a familiar arc of abuse and dependence and despair. At one
point, Sergeant Savage was so desperate that he went into the bathroom
and began swallowing narcotic tablets. He would have died had his wife,
Hilary, not burst through the door.
Today
Sergeant Savage has survived, even prevailed, through grit, his family
and a radical experiment in managing pain without narcotics. When
off-duty, he pulls on cowboy boots and plays with his children, does
charity work and, as part of a therapy program, rides horses. The only
medication he takes for pain is Celebrex, a non-narcotic drug.
“You
have to find alternative ways to get out and do stuff to stay active,
to get your brain off the thought process of ‘I’m in pain,’ ” said
Sergeant Savage, whose ears push out from under a Texas A&M baseball
cap.
The
story of Sergeant Savage illuminates an effort by experts inside and
outside the military to change how chronic, or long-term, pain is
treated. By some estimates, tens of millions of Americans suffer from
chronic pain, and the use of opioids — drugs like hydrocodone, methadone
and oxycodone (the active ingredient in painkillers like OxyContin) —
to treat such conditions has soared over the last decade.
This
opioid boom was a result of a synchronized drumbeat sounded by
pharmaceutical companies, pain experts and others who argued that the
drugs could defeat pain with little risk of addiction. Insurers embraced
opioids as a seemingly effective and relatively inexpensive solution to
a complex problem that often involves psychological and emotional
issues.
In
recent years, sales of opioids have flattened because of their role in
16,000 overdose deaths annually in the United States, cases that often
involve abuse of the drugs. But a growing number of specialists have
sharply reduced or stopped their prescription of opioids for another
reason: their belief that the drugs have led doctors to focus on the
wrong goal in treating chronic pain.
Opioids
blunt a patient’s discomfort for a time. But the drugs can become a
barrier to improving how well a patient functions physically and
socially, goals that appear crucial in combating chronic pain, many
experts say. As a result, specialists are returning to strategies that
were popular before the opioid era, like physical therapy, behavior modification and psychological counseling. Others are exploring alternative treatments like acupuncture and yoga.
Many pain programs now use non-opioid drugs, including ones developed for conditions like epilepsy,
that are also effective in relieving pain. “We have to change the
paradigm and the culture,” said Dr. Karen H. Seal, who specializes in
pain treatment at the Veterans Affairs Medical Center in San Francisco
and has studied the use of opioids and other drugs in combat veterans.
These days, the biggest changes are taking place inside the military and the Department of Veterans Affairs,
organizations that have drawn criticism from lawmakers and others for
overprescribing opioids and other powerful medications. Physicians in
those organizations have more leeway than other doctors to use
alternative treatments because insurers do not govern their decisions.
Five
years ago, approximately 80 percent of the injured soldiers treated at
Walter Reed Army Medical Center in Washington were prescribed opioids.
That figure has since plummeted to 10 percent, and many patients are
benefiting from the change, said Dr. Christopher Spevak, a pain
specialist there.
“As
we decrease the amount of opioids, their healing and recovery has
gotten much quicker,” Dr. Spevak said. The implications go far beyond
the military because most patients at Walter Reed in recent years have
not been suffering from serious battlefield injuries but from problems
many civilians face, like back injuries.
As
long as a decade ago, some drug industry researchers questioned the
value of opioids in the treatment of chronic pain even as drug producers
promoted their widespread use, emails reviewed by The New York Times
show.
“The
important issue in the treatment of chronic pain is recognizing
patients with chronic and acute pain are different and require different
approaches,” Dr. David Hewitt, who was then the medical director of
Ortho-McNeil Pharmaceutical, a division of Johnson & Johnson, wrote
in 2003 to an academic researcher. “Employing a drug alone is unlikely
to lead to a successful outcome.”
Asked about the email, Dr. Hewitt, who later moved to Merck, declined to comment through a company spokeswoman.
A Vicious Cycle
All
Shane Savage wanted was to be a soldier. He joined the Marines in June
2001, a day after graduating from high school in Olive, Okla. He stood
6-foot-5, had six-pack abs and was ready for adventure.
After
the Sept. 11 attacks, his engineering unit was sent to Iraq, where he
served three tours before being honorably discharged in 2005. Nine
months later, he wanted back in.
“I
missed the uniform,” Sergeant Savage recalled. “I missed the
brotherhood, the camaraderie, getting to go places and do cool stuff.”
To
keep his rank, he enlisted in the Army and went back to Iraq in 2007
for a fourth tour. Then, in 2010, he was deployed again, this time to
Afghanistan.
He
soon asked for a transfer from a construction detail to one closer to
the action and was reassigned to lead a unit clearing roadside bombs.
Then came Sept. 3.
Once
Sergeant Savage was back at Fort Hood, doctors put him on an array of
medications; at one point, he was taking 12 different drugs, Hilary
Savage recalled.
“They put him on anything and everything,” she said. “They had him on pain blockers and narcotics, antidepressants, Concerta for A.D.H.D. They had him on stuff for tremors. Like, I mean, you name it, we had it in our cabinet.”
A
month after Sergeant Savage’s return, he and his wife went to pick up
their daughters, Jada, 13, and Ameliea, 11, from a neighbor’s house. On
the way, they ran into the young daughters of the Fort Hood soldier who
had been killed by a roadside bomb shortly after taking Sergeant
Savage’s place in Afghanistan.
“They just kind of peered into Shane’s soul, and Shane kind of turned into a completely different person,” Hilary Savage said.
For two days, Sergeant Savage sat in his home and cried. Then he reached for a handful of pain pills and tried to end his life.
After
a few weeks in a psychiatric hospital, he no longer felt suicidal, but
his pain and other problems persisted. He tried a program at Fort Hood
in which soldiers suffering from trauma learned tai chi, yoga and other
relaxation techniques. But he was not ready to change.
“I
was very naïve,” Sergeant Savage said. Today, most doctors remain
focused on treating physical pain, which is just one symptom of chronic
pain, experts say. And as a result, they also often “chase” pain,
increasing opioid dosages as lower amounts become ineffective, exposing
patients to more side effects.
“It becomes a vicious cycle,” said Roger Fillingim, a pain researcher at the University of Florida and a past president of the American Pain Society, a professional medical group.
A 2008 study
by the Mayo Clinic found that patients who were weaned off opioids and
put through a non-drug-based program experienced less pain than while on
opioids and also significantly improved in function. Other studies have had similar findings.
In
some cases, insurers will pay for such treatments, but the practice is
not widespread because there are few standards to judge their value,
said Dr. Jeffrey Livovich, a medical director at Aetna. Dr. Edward
Covington, the director of the Neurological Center for Pain
at the Cleveland Clinic, said he believed that companies like Aetna had
another incentive not to pay: Programs like his are initially more
expensive than opioids, and insurers are loath to invest in patients
when they do not know if they will be their customers next year.
“Their view is, why should they benefit another insurer?” Dr. Covington said.
Whatever
the case, physicians treating soldiers or veterans are free of
insurance industry dictates. And a growing number of doctors are largely
abandoning opioids for the same reason that Dr. Hewitt, the former
Ortho-McNeil medical director, suggested a decade ago: The drugs do not
seem to help many with chronic pain.
“I
think that the more appropriate use of opioids is in the acute pain
setting and the surgical setting,” said Dr. Seal, the expert in San
Francisco. “I am not convinced that opioids are any better than
non-opioids” for chronic pain, she said.
Kicking the Habit
For
three years, Sergeant Savage struggled to navigate through a drugged
fog. Surgeons repeatedly tried to fuse the smashed bones in his foot,
using metal screws and bone grafts, but each procedure eventually
failed.
There
were periods when he limited his use of opioids, but after each
operation, he started again. By last spring, he was taking over 300
milligrams of morphine daily, a very high amount. As his dosage
increased, he became more lethargic and detached.
“He
would just zone out on something, and he’d start looking at the
computer or whatever” for hours, Hilary Savage recalled. “The next thing
he knew, we were getting ready to go to bed.”
Sergeant
Savage’s relatives tried to intervene, but nothing worked. Then, last
summer, his older daughter, Jada, confronted him. She said she could no
longer bear the person he had become.
That
night, Sergeant Shane decided to wean himself off opioids and other
powerful drugs. Soon, he and his wife were hunting for pills to throw
away.
“I had some in my Jeep,” Hilary Savage said. “I had some in his car or his truck. I had some in my bedroom.”
To his surprise, Sergeant Savage soon felt better, not worse.
“The
pain medication, it might make me feel great and golden, you know, in
here,” he said, pointing to his chest. “But it didn’t do anything for
me.”
His
pain continued, however, and last fall he started to consider another
option: having his foot amputated. Around that time, he also heard about
a V.A. hospital in Tampa, Fla., that ran a multidisciplinary pain
treatment program. He arrived there in September. Some patients were
much older than him, and many in the program had been on opioids for
decades. Their pain and the drugs had left them housebound, disabled or
addicted.
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Despite
feeling like the odd man out, Sergeant Savage threw himself into the
program, which ran three weeks. When his first attempt to make a
Western-style belt in a crafts class failed because his hands were
shaking too much to control the stamping tools, he didn’t give up. He
got a new leather strip and tried again.
Jennifer
Murphy, a psychologist working in the Tampa program, said doctors are
often too quick to dole out pain pills rather than to take advantage of
alternative treatments. “What may be easy in the moment may not be the
right thing, now or down the road,” she said.
Two
months later, Sergeant Savage and his family visited a horse arena not
far from Fort Hood. It was a cool November evening, and he looked far
better than he had in Tampa. He was calmer, and his tremors, while not
gone, were less frequent.
He
had left the Tampa program with mixed feelings. He wished that there
had been more people his age in the program and wondered why the Army
didn’t run similar programs for soldiers who wanted to be able to work
after they left the service. Once back home, he began his own recovery
plan, one that involved volunteering with groups that helped soldiers
dealing with pain and trauma — work that he had done previously. But
now, having found ways to cope with his pain without narcotics, he was
able to throw himself into that work with new energy.
That
night at the horse arena, he took part in a therapy program in which
horses are used to help injured soldiers regain their sense of
self-control and trust. He also volunteered for a group that ran
off-road Jeep excursions for veterans and for another organization that
rescued wild mustangs from federal lands for adoption.
“They
can sense your emotions and feelings,” he said, patting a mustang. “If
you are tense, they are going to be tense. If you are anxious, they are
going to be anxious. Especially, if you are in pain, they are going to
sense you are in pain as well.”
A Permanent Companion
In
recent years, insurers have started cracking down on doctors who
overprescribe narcotics. But it is not clear when, or if, they will
embrace alternative pain treatments. Critics of the military and the
Department of Veterans Affairs say the pace of change in those
organizations has been too slow.
At
bases like Fort Hood, soldiers like Sergeant Savage can spend years
heavily medicated while awaiting a medical discharge, Ms. Savage said.
“I
call it purgatory — you are not in heaven, and you are not in hell,”
she said. “I can go in there and I can immediately spot people that are
on narcotics or on drugs.”
Changing
how doctors practice is not easy, but experts like Dr. Spevak and Dr.
Seal are trying to push alternatives to opioids further down the chain
of treatment so that patients will get them more quickly after an
injury. Dr. Spevak, for example, said he expected this year to give 130
lectures about such techniques to military doctors working worldwide.
In
January, Sergeant Savage underwent another operation to reconstruct his
foot. He took narcotic painkillers for only a few days, and initially
the procedure appeared to have stabilized his foot and reduced his pain.
Then, that procedure also failed. Now, after four years of struggle,
Sergeant Savage plans to undergo an amputation of part of his left leg,
from the midcalf down. He’ll use a prosthetic device in place of the
missing limb.
His
commanders at Fort Hood recently nominated him for an honor known as
the Meritorious Service Medal in recognition of his volunteer work. He
expects to leave the Army by the end of this year or in early 2015. Once
that happens, he said, he hopes to find a job that will allow him to
spend most of his time outdoors, such as running a therapy program for
other veterans.
Sergeant
Savage expects that even after the amputation, pain will be his
companion wherever he goes. But he believes he can deal with it.
“Am
I the person that I was four years ago? No. Will I ever be? No. Will I
ever be able to run down the street and chase my girls? I really don’t
know,” he said. “But you know what? I can get a bike and I can ride with
them.”
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