Migraine Art

Recovering from the debacle of TimesSelect, the New York Times is developing a superb repository of off-the-wall blogs.  I just discovered this one, devoted to migraines. 

The most recent post is a long essay by Jeff Tweedy, leader of Wilco (not one of my favorite bands, sorry to say).  His descriptions of the mysterious condition are compelling, especially to someone like me who’s never had one but has lived with people who have.  Tweedy now claims to have his migraines under control, but only after years of suffering, and a painkiller addiction that was a result of misguided care:

I had had a psychiatrist that was prescribing drugs to me without any conscience. I actually had a psychiatrist prescribe Vicodin to me as a way to alleviate anxiety. And I also had a therapist tell me that I needed the painkillers because I had migraines and that I didn’t need the antidepressants because they were just capping my creative energy. This guy was just a quack, an idiot. But when you’re in such a vulnerable and desperate state as I was, you want somebody to help you. I really wish I had been in a condition where I could have known and listened and understood that these people were out of their minds, but I wasn’t. I was vulnerable and I needed someone to help me. But I got really, really bad help.  

Also on this blog, a slide show of paintings by migraine sufferers.  Here’s an example:

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Blogger, Interrupted

Sorry for the delay in posting. I’ve been on two business trips this past two weeks, to Phoenix, Arizona and to Richmond, Virginia.  I didn’t bring my camera to AZ, but I had it in Richmond, a city I’d never seen before.   I spent most of my time there in the ER at Virginia Commonwealth University Hospital, which was not the plan, obviously.

After discharge and navigating through a Soviet-style pharmacy, I decided to walk back to my hotel. 

Here is a plaque on a building near the hospital.  It seemed strange that I would get a serious diagnosis at such an historical location:

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Then I saw this great old building, which wouldn’t look too out of place in San Francisco.  It was on Governor’s Road, not too far from the Virginia governor’s mansion:

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A little further away from all the Commonwealth’s majesty, I found this odd salute to the classical style of the old city:

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I rested up and reunited with my colleagues for dinner at a restaurant that unabashedly bears the name, “The Tobacco Company.”  You walk in, it smells like smoke.  It has cigarette girls.  You almost want to embrace and love all the tradition.  Almost. My own condition is the result of overyielding the seductive calls of bad food.  The evil of the American diet is in the vast amounts of sugar hidden in it. Tobacco is right out there, telling its users, “I’m killing you.”  Maybe that’s part of its appeal.  If James Dean had a chocolate-chip cookie hanging out of his mouth instead of a cigarette, how many posters would he sell?

So I told my dinner companions about my day at the hospital, then wandered out into the cobblestone street on a cool evening, immersing myself in this curiously timeless little city for the few minutes I had left to enjoy it. 

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I would have to get up at 3:30 a.m. to catch my flight — 12:30 a.m. Los Angeles time, which is my approximate bedtime.  The cab driver who took us to the airport is a local historian who regaled us with tales of the Byrd family and what a close call the ratification of the Constitution had been.  That unassuming plaque commemorates a pivotal moment in the nation’s history, it turns out.  Only fitting that a pivotal moment in my life take place on the same site.

Parents’ Nightmare: A Misdiagnosis of ADHD

chris-kaman.jpgThis story, from Tuesday’s LA Times, frightened and relieved me at the same time. 

Los Angeles Clippers’ center Chris Kaman is an exceptional person.  Only a few men at any given time are capable of playing center in the NBA.  There are hardly enough qualified centers to go around.  Physical gifts like size, speed and shooting accuracy must combine with the ability to process rapidly the flow of the game, the positions of all the players, the coach’s designs. 

Coming up as a ballplayer and student, Kaman had to learn all that, under the influence of powerful psycoactive medications he didn’t need — Ritalin and Adderall — from age 2 1/2 through high school for attention-deficit hyperactivity disorder (ADHD).  However,

Kaman, who had trouble remembering plays and concentrating on the court in college and in the pros, disclosed Sunday that he was misdiagnosed.

Kaman actually had an anxiety disorder that caused him to over-analyze situations and scenarios.

“Growing up, I had to take the medication my whole life,” said Kaman, who said he grew so frustrated taking the medication that he would come home from school and cry.

“I can’t take back time. I wish I could. But I can’t. It really bothered me to take the medication every day. I felt I had to take the medication to make me feel like a regular person. It was kind of backward.”

His misdiagnosis was discovered in July by Hope139, a 5-year old organization based in Grandville, Mich., that studies the brain. According to the National Institute of Mental Health, between 3% and 5% of children have ADHD, with symptoms that include hyperactivity and impulsiveness.

According to Hope139′s research of about 40,000 patients, up to 15% of those on medicine for hyperactivity do not have the affliction.

You got kids?  You get the impression as a parent that it’s a lot more than 3 to 5 percent of kids who are being diagnosed with ADHD. If your kid seems intelligent but gets bad grades, is rambunctious, talks too much, is forgetful, the ADHD diagnosis seems to linger in the air with every doctor visit.

Raising my son, I made up my mind to strap myself to the mast and get us through adolescent and not listen to any such diagnosis.  As frustrating as raising my son could be at times, I did not want him taking these medications.  I figured the cure to what seemed to be ailing him was merely to grow up.  Which, at 17, he’s showing signs of doing, to our relief.

What happened to Kaman is exactly what I worried would happen to my son:

The medication Kaman took had the opposite effect on him, said Dr. Tim Royer, the organization’s chief executive.

Kaman’s brain was already working in overdrive, and the medication provided an added stimulus. The dosage was increased to the point that Kaman’s mind became overloaded and he became less animated. “He stopped being a behavioral problem, but he got too much medicine and it shut him down,” Royer said.

Kaman stopped taking medication once he entered college at Central Michigan because he no longer had to sit in one place for more than a couple of hours.

But his concentration in college, and once he signed with the Clippers, was still lacking. He could focus on the man he was guarding but not on weak-side defense, or as Royer put it, “He could see the tree in front of him, but not the forest.”

How is this generation of parents, pediatricians and psychologists going to be judged?  Kaman’s story is going to become better-known soon, and we’ll all be taking a second look at how these medications were sold as the panacea to so many families.

Kaman is hoping to become a spokesman for children who are misdiagnosed or are simply looking for another alternative instead of taking medication for hyperactivity. “I’m using my resources as much as I can to try and help people,” he said. “I was trying to see if it worked first. I’m on a platform being in the NBA where I can help people.”
 

Gentlemen, Start Your Lobbyists

cheeseburger.jpgI’m sure the City Council is sincere about wanting to improve the diets and health of the residents of South Los Angeles. But they also have to know what will come of the proposal to impose a moratorium on new fast-food restaurants in that area of the city: A gig for every major lobbyist in town.

McDonald’s, Burger King, KFC, Jack-in-the-Box and all their franchisee organizations will all want to strangle this idea in the cradle. They will pay whatever it takes. From a legal standpoint, I don’t know how you distinguish a fast-food chain restaurant from an ordinary restaurant, or what careful balance between unhealthy and healthy menu items would qualify a restaurant for the moratorium, but they will be talking about it at City Hall for months if not years. For the lobbyists, all that talk will be billable.

When was the last time the Council tried to take on so many international corporations at one time? Start looking for a new rush of donations from franchise operators’ associations and restaurant-industry PACs.

Amid worries of an obesity epidemic and its related illnesses, including high blood pressure, diabetes and heart disease, Los Angeles officials, among others around the country, are proposing to limit new fast-food restaurants — a tactic that could be called health zoning.

The City Council will be asked this fall to consider an up to two-year moratorium on new fast-food restaurants in South L.A., a part of the city where fast food is at least as much a practicality as a preference.

“The people don’t want them, but when they don’t have any other options, they may gravitate to what’s there,” said Councilwoman Jan Perry, who proposed the ordinance in June, and whose district includes portions of South L.A. that would be affected by the plan.

In just one-quarter of a mile near USC on Figueroa Street, from Adams Boulevard and south, there are about 20 fast-food outlets.

That particular cluster probably has much more to do with USC kids’ late-night study/beer munchies than with any other part of the neighborhood. They might want to choose another area to make an example of.

“While limiting fast-food restaurants isn’t a solution in itself, it’s an important piece of the puzzle,” said Mark Vallianatos, director of the Center for Food and Justice at Occidental College.

This is “bringing health policy and environmental policy together with land-use planning,” he said. “I think that’s smart, and it’s the wave of the future.”

I think he’s right about the future. I’ve noticed lately the increasing link environmentalists are making between food choices and the health of the planet. I know I read recently something to the effect that one cannot consider themselves an environmentalist and still eat meat. Global warming is as much cow- as car-driven.

The dietary paternalism inherent in this proposal — the claim that City officials know what you should eat — hasn’t registered yet. Maybe it never will. Maybe we all see ourselves as the sheer victims of corporations, and believe it is corporations that are limiting our choices, not government. I’d be curious to see the results of an approval poll comparing the Los Angeles City Council with McDonald’s.

Perhaps the council would win. Maybe all the popularity that fast-food brands have paid so dearly for over the past 40 years will now crash around their deep fryers. But they will not go down without a fight, and in Los Angeles, that means writing a lot of checks.

Vogue Takes A Stand: If You Don’t Want Us to Advertise Cigarettes, Pass a Law

As this country ages away from its founders’ vision, we get more and more ambivalent about free speech.  Examples abound, but today’s story (possibly $$) about Vogue and Glamour‘s publishers’ statements supporting a refusal to stop running ads for cigarettes helps illuminate the labyrinth our culture is building to deal with unpopular speech. 

Magazine ads like this one from Camel have drawn the ire of Rep. Lois Capps.The leader of a group of U.S. representatives that has been asking women’s magazines to voluntarily give up cigarette advertising said she is unsatisfied with publishers’ response — or, more often, their lack of response.

“I am extremely disappointed with the decision of these 11 women’s magazines to continue running ads promoting cigarette smoking,” said Rep. Lois Capps, D-Calif., in her third and latest open letter. “These ads encourage a fatally addictive habit and are especially targeted at young women. It’s just flat-out hypocritical to run stories about becoming more beautiful and healthy while promoting a dangerous product responsible for killing hundreds of thousands of people a year.”

Vogue’s response was disturbing.  Despite his industry’s reliance on the First Amendment, publisher Thomas A. Florio wants Congress to punch a hole in it.  He objects to being pressured politically to withdraw the ad on his own, but he doesn’t object to being compelled to do so by law.   Continue reading

Iced Cappucino, Scourge of Starbucks

If you order an iced cappucino at Starbucks, the cashier will tell you “we’re not supposed to make iced cappucino, but we’ll make one for you.” I guess you’re supposed to feel like they’re cutting you a break but, shh, don’t tell everyone.

Perhaps inspired by the current book I’m reading, “The Curious Incident of the Dog in the Night-Time,” I had an overly literal reaction to this disclosure. I pointed to the menu on the wall above the barrista’s station. It listed all the coffee drinks including cappucino. Each one could be purchased “hot or iced.”

“You got us on a technicality,” one of the employees said, laughing like the jig was up.

A technicality? “It’s on your menu. It’s been there for years.”

Finally, they let me in on the real secret. Apparently, the Starbucks corporation is worried about the possibility of bacteria forming growing when the heated foam hits the ice cubes. So employees are instructed to say what the cashier said to me. I assume the company’s lawyers came up with this.  Perhaps they have gotten a ruling that the company would not be liable if I come down with food poisoning after such a dialogue.

If I keel over in the next few hours, Starbucks will be able to say, “We warned him, but he ignored us, the poor chap.”

It’s a weird way to manage a liability problem, to orchestrate a conversation between employees and customers that’s supposed to seem friendly, spontaneous and intimate.

Corporate practices like this tend to replicate themselves.  I’m already used to being asked at Pavillion’s whether I want help carrying my groceries to my car, even if I’m only buying a tube of toothpaste.  You’d think the clerks would have figured out by now that I’m perfectly capable of pushing a cartful of groceries.  I’ve been shopping there for years, and I don’t recall ever passing out from exhaustion in their presence. But, of course, “we’re required to ask,” so this charade of a friendly offer will continue, and I will continue to be forced to say, “No, but thank you.”

But the Starbucks variation — “We’re not supposed to make it for you” — is a new one.  Anyone else run into something like this?

Persecuting Pain*

We need to figure out a new way for American society to resolve ambiguous issues — an alternative to federal prosecutors making their bones by tossing individuals in prison via smear techniques designed to inflame rather than enlighten juries.

What prompted me to think about this was the cover story of this Sunday’s New York Times magazine, “When is a Pain Doctor a Drug Pusher?”  Author Tina Rosenberg tells two distinct stories here:  One is about Dr. Ronald McIver, a physician whose address is now a medium -security prison in Butner, North Carolina.   The other is about the never-ending quest people in severe pain go through to find relief, a quest that can inadvertently bring them or their doctors into gray legal areas. 

Certainly there are crooked doctors who write fraudulent prescriptions for opiates that drug addicts abuse and drug dealers sell.   Nobody objects when prosecutors pursue them.  It does not appear to me that Dr. McIver was one of those crooked doctors. As Rosenberg writes,

McIver was a particularly aggressive pain doctor. Pain can be measured only by how patients say they feel: on a scale from 0 to 10, a report of 0 signifies the absence of pain; 10 is unbearable pain. Many pain doctors will try to reduce a patient’s pain to the level of 5. McIver tried for a 2. He prescribed more, and sooner, than most doctors.

Perhaps knowing his intolerance for his patients’ pain, some unscrupulous people posing as patients tricked McIver into giving them drugs illegitimately, which they abused or sold.  There’s no evidence McIver ever recognized this or intended to aid them in their criminal schemes.  He comes off as a little credulous. But on at least one occasion, his suspicions about a particular patient led him to call the police to ask for background. 

Later, of course, prosecutors successfully twisted that call into evidence against him.  The logic — very familiar to me now — went like this:  You called the cops about this patient. Yes. What happened next?  The cop never called me back.  What happened next?  I assumed the lack of a return call meant my suspicions were unfounded, so I continued to prescribe medicine to this patient.  Ladies and gentlemen of the jury, you see what we have here.  Dr. McIver knew there was a problem with this patient.  Did he stop giving him dangerous narcotics?  No, he just went right on doing it.  The fact that the law officer was unable to reach him is irrelevant.  By this act, Dr. McIver demonstrated his criminal intent to provide drugs illegally.

Others of his patients were prescribed high doses of powerful opioids.  This is not necessarily a sign of abuse. As Rosenberg takes pains to explain, high levels can be safe if the patient’s dosage is increased gradually through a process called “titration to effect.”  McIver was one of many pain specialists who believed, it appears compassionately, that this was the correct course for some patients.  But prosecutors were able to make the jury quiver, apparently, at the sheer numbers associated with these dosages. 

One of McIver’s patients died with high levels of an opioid in his blood.  The drugs didn’t kill him — a heart problem did it.  But the patient’s death was a good data point in the case the government was able to build against him, a ghost story to frighten jurors.

To find out more about the blow-by-blow of McIver’s outrageous prosecution, please read the story.  For the remainder of this post, I want to focus on the bigger picture:

No one has analyzed the various prosecutions of pain doctors, so it is hard to determine how many of them look like McIver’s. The D.E.A.’s list is incomplete. There have been many cases like McIver’s, and most of these cases are not listed on the D.E.A.’s Web site. (One possible reason for this omission is that some of these cases are still being appealed.) And many cases that do appear on the list detail only vague crimes: convictions for prescribing “beyond the bounds of acceptable medical practice” or “dispensing controlled substances . . . with no legitimate medical purpose” — which is how the agency will most likely describe the McIver case if it ever includes the case on the list.

The D.E.A. claims that it is not criminalizing bad medical decisions. For a prosecutable case, Caverly, the D.E.A. officer, told me: “I need there to be no connection of the drug with a legitimate medical condition. I need the doctor to have prescribed the drug in exchange for an illegal drug, or sex, or just sold the prescription or wrote prescriptions for patients they have never seen, or made up a name.”

I read this statement to Jennifer Bolen, a former federal prosecutor in drug-diversion cases who trained other prosecutors and now advises doctors on the law. “That’s a good goal,” she said. “I don’t think they have yet reached that goal.” McIver’s case had no such broken connection, and in many cases the government has not produced testimony of intent to push drugs, providing evidence only of negligence or recklessness. In 2002, Bolen was one of the authors of a Justice Department document intended as part of a basic guide to prosecuting drug-diversion cases. The document, in the form of a reference card, dispenses with any need for a broken connection. It suggests that prosecutors need not prove a doctor had bad motives, that to be within the law a doctor had to prescribe “in strict compliance with generally accepted medical guidelines” and that doing an abbreviated medical history or physical examination is “probative” of lack of a legitimate medical purpose. The reference card was on the Justice Department’s Web site but was pulled, according to the Pain Relief Network, which provided the card to me. Bolen told me: “I have no problem saying that if the card was all there was, it was not acceptable. But it isn’t all there was.” She described the card as one piece of a more thorough training, but added that many prosecutors followed its theories.

Prosecutors are in essence pressing jurors to decide whether an extra 40 milligrams every four hours or a failure to X-ray is enough to send a doctor to prison for the rest of his life. One doctor, Frank Fisher, was arrested on charges that included the death of a patient taking opioids — who died as a passenger in a car accident. A Florida doctor, James Graves, is serving 63 years for charges including manslaughter after four patients overdosed on OxyContin he prescribed — all either crushed and injected their OxyContin or mixed it with alcohol or other drugs. “A lot of doctors are looking for safe harbor,” Caverly said. “They want to know as long as they do A, B, C, D or E, they’re O.K.”

The D.E.A. once thought that this was not an unreasonable desire. A few years ago, it worked with pain doctors to develop a set of frequently asked questions that set out what doctors needed to do to stay within the law. The FAQ recommended, for example, that doctors should do urine tests and discuss a patient’s treatment with family and friends. In October 2004, the FAQ were erased from the agency’s Web site. One reason was that one of their authors, who is a doctor, was about to use the list to testify on behalf of William Hurwitz, a pain doctor in McLean, Va. (Hurwitz was convicted on 50 counts of drug trafficking in 2004. His conviction was overturned, and he was recently retried and convicted on 16 lesser counts. He is awaiting sentencing.)

Caverly acknowledged the Hurwitz trial was one reason the FAQ were pulled, but said there were other reasons. He said such a checkoff list could tie the D.E.A.’s hands. “Some doctor’s going to pull that list of dos or don’ts out and say: ‘See, I’m O.K. I did these 10.’ But there’s a new wrinkle there — an 11th one the doctor didn’t do,” he said. Most important, he went on to say, the FAQ had stepped over the line to insert the D.E.A. into issues of medical practice. “We have to stay in our lane,” he said. “Those definitions are the professional community’s — not the D.E.A.’s.”

In a perfect world, such reasoning would make sense. But the agency is defining issues of medical practice in dramatic fashion — by jailing doctors who step over the line. It would not seem to be bothering, however, to draw the line first.

The dilemma of preventing diversion without discouraging pain care is part of a larger problem: pain is discussed amid a swirl of ignorance and myth. Howard Heit, a pain and addiction specialist in Fairfax, Va., told me: “If we take the fact that 10 percent of the population has the disease of addiction, and if we say that pain is the most common presentation to a doctor’s office, please tell me why the interface of pain and addiction is not part of the core curriculum of health care training in the United States?” Will Rowe, the executive director of the American Pain Foundation, notes that “pain education is still barely on the radar in most medical schools.”

The public also needs education. Misconception reigns: that addiction is inevitable, that pain is harmless, that suffering has redemptive power, that pain medicine is for sissies, that sufferers are just faking. Many law-enforcement officers are as in the dark as the general public. Very few cities and only one state police force have officers who specialize in prescription-drug cases. Charles Cichon, executive director of the National Association of Drug Diversion Investigators (Naddi), says that Naddi offers just about the only training on prescription drugs and reaches only a small percentage of those who end up investigating diversion. I asked if, absent Naddi training, officers would understand such basics as the whether there is a ceiling dose for opioids. “Probably not,” he said.

There is another factor that might encourage overzealous prosecution: Local police can use these cases to finance further investigations. A doctor’s possessions can be seized as drug profits, and as much as 80 percent can go back to the local police.

I think about people in my family who are, or were, in terrible pain.  Or who might be in the future.  I think of their doctors, reading about McIver and other doctors similarly persecuted.  It was bad enough when doctors’ treatment decisions were based on fear of civil malpractice litigation.  But now the federal prosecutors have joined the party, with all their incentives to win cases no matter what, and with punishments at their disposal that can destroy careers, even lives. 

It’s one thing for a doctor to wear a brave face and put his or her patient first in the face of potential lawsuits. But prison?  The suffering patient will just have to understand. 

The criminalization of gray-area medical decisions is the ultimate empowerment of ignorance, fear and innuendo as the driving forces of our civilization.  Despite miraculous medical and scientific advances, as long as we give power to prosecutors to go “booga-booga” to juries, some of those advances will be shelved. 

There are countless examples of this trend, but this one really turned my stomach.

*Edited and retitled, 6/18/07