Victorian Square in Sparks, Nevada: a public plaza with no public

Early on an autumn morning I walked around Sparks (contiguous to Reno) a bit, just the area around the Nugget casino. The Nugget is about the biggest thing in this low-rise town; the original casino and one of its newer hotel towers are pictured below.

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Across the thoroughfare is what seems to be an extensive public area, called Victorian Square,

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with a bandshell-like gazebo.

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But alas, the constantly-flowing music comes from speakers mounted on the lightpoles, and the only other living creatures I saw were a man picking cans out of a garbage bin, and a lonely pigeon.

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The lack of pigeons emphasized to me the lack of public use, since wherever people congregate outdoors for any period, pretty soon they start dropping bits of food. When pigeons can’t find any reason to flock around, then the area is really unused.

But there was a sundial showing the correct time, just in case you’d hocked your watch and lost the money the night before.

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If I’d been there a month earlier, on a Thursday between 4 and 9 pm, I could have caught this event:

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The sign promises a “family activity park”––whatever can that be? Probable answer: one without “adult activities” like drinking and gambling. (I’m so behind the times, when the TV tells me a movie contains “Adult themes” I always have a micro-instant of thinking, Oh, it’s going to be about philosophy, or honoring one’s commitments, or solving world problems.) Anyway, as far as I could see the plaza itself included no play structures, no kid-sized statuary of animals to swarm over and sit on, no tile chess boards, no fountains, no picnic tables, few green areas to sit by…in fact for a while it seemed designed with the idea of clearing a defensible space around the casino where machine guns could command an open line of fire. Or it may be a disembarkation place for gamblers arriving by bus from California.

Along the edges there were a few survivors of the older buildings that must have been cleared for this big paved plaza area. One was the Victorian Penny Park Casino, closed.

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And an old brick building, maybe a former hotel, with a vivid exterior including painted roses under the windows.

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Looking back toward the Nugget I spotted these women: a few other wanderers who’d gotten bored and turned to stone? no, it’s a really incongruous effort at public statuary.

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I didn’t cross the street for a closer look, but a good guess would be that they are either four of the muses, or figures representing Nevadan history and industry. The two female figures in the middle seem less than pleased: one gathers her skirts up as if recoiling from her surroundings, while the other has a melodramatic “You’re breaking my heart” look. The third is holding something bulky to her stone bosom, probably part of the day’s take from the casino, while the last (on the left) stands erect, leg akimbo, and has thrown back her outer garment. Her I can place, with the aid of a taxi sign seen later; she’s inviting you to the world-famous, umm, museum that is nearby.

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Total knee replacement surgery, the second time around: learn from our experience

Nearly three years ago my husband had Total Knee Replacement (TKR) surgery. It’s drastic and major surgery, which people usually only choose when the pain from osteoarthritis becomes intolerable. And, it was not done properly so that last month it had to be re-done! Perhaps our experience can be useful to others.

Why do knees need to be replaced?

Generally because of pain and restricted motion caused by loss of cartilage (which cushions and separates the bony parts of a joint) and growth of bony “spurs”. This is labelled osteoarthritis. Other causes, like trauma, rheumatoid arthritis, and infection, account for a minority of the 300,000+ TKRs each year in the US.

As to what causes osteoarthritis, that is less understood than previously thought, when it was all blamed on “wear and tear”. The knee is the largest joint in the body, and bears the complete weight of the body at each step we take, so it is indeed subject to lots of “wear and tear”. Common-sense risk factors include types of high-stress activity in work or sports, injury, obesity, infection, stiffness from lack of activity, and age (since cartilage becomes more brittle with age). However, not all elderly people develop arthritis and some who do have no significant pain. This is why I said above that knees need to be replaced, not because of osteoarthritis, but because of pain and reduced range of motion.

The biologic factors leading to the deterioration of cartilage in osteoarthritis are not entirely understood. Many experts believe that osteoarthritis results from a genetic susceptibility that causes some biologic response to injuries to the joint, which in turn leads to progressive deterioration of cartilage. In addition, the ability to make repairs becomes progressively limited as cartilage cells age.

Although osteoarthritis generally accompanies aging, osteoarthritic cartilage is chemically different from normal aged cartilage. As chondrocytes (the cells that make up cartilage) age, they lose their ability to make repairs and produce more cartilage. This process may play an important role in the development and progression of osteoarthritis. [Emphasis mine. Source: www.healthcentral.com ]

What’s involved in Total Knee Replacement surgery?

The x-rays below, from the site of a prosthetics manufacturer,

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show views of a knee before and after surgery. On the left, cartilage loss has caused bone-on-bone contact: very painful. Bone spurs or bits of broken bone floating around can also cause pain in the deteriorated joint. On the right, an artificial knee joint (prosthesis) is in place. (These are not x-rays of the same knee; in fact, looks to me like one’s a left leg and the other is a right leg.)

Here are some views of prostheses. To install them, the ends of the two long-bones of the leg, tibia and femur, are sawed off (removing “usually between 2 and 12 mm” according to one source) and the artificial joint is affixed with cement, screws, etc. The work involved in removing bone and attaching the prosthesis involves considerable force and power tools. Note that the knee-cap, as well as muscles and ligaments, must be carefully moved aside to install the prosthesis. [Picture sources: 1, 2, 3 ]

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There are many patented designs for artificial knee joints, and these illustrations are for general example only. Surgeons have their preferred models; many were developed by orthopedic surgeons, and those surgeons tend to prefer the ones they have an interest in. Choice of prosthesis isn’t something the patient can weigh in on, we don’t know enough, but you may want to find out if your surgeon has a financial interest in the one he is going to use; if so, perhaps a second opinion would be valuable on the pros and cons of various types as applied to your individual case. Most insurance will pay for a second opinion for major surgery.

Research continues for better, longer-lasting designs and breakthroughs are regularly announced with fanfare––but some don’t fulfill their original promise, as with teflon-lined joints which wore away much faster in practice than lab tests had predicted. You will have to rely on the experience of your surgeon.

You can see photos of the stages of knee surgery (not for the faint-hearted) here, on a prosthesis company ‘s site.

Our experience

Surgery #1, 2006

Now, back to my husband’s case. Dan had knee pain for years that ruled out unnecessary walking, as in hiking or walking for enjoyment, and interfered with sleep. There was bone on bone contact and perhaps bone spurs or growths from osteoarthritis. In August 2006 he underwent total knee replacement surgery by an established older orthopedist in our area. Afterwards, the surgeon came out to me in the waiting room and told me that the operation had taken half again as long as planned because they had “run into something unexpected”. Later, when we knew more, that remark would have much more significance to us. The “something unexpected” was apparently the result of a broken leg at age ten, that had caused greater reliance on the other leg (the one that received the TKR).

The surgery was brutal, with terrible bruising all over the leg, and post-op pain and swelling were severe. From the beginning, the prosthesis felt loose and insecure, sometimes the knee buckled, and after the post-surgical pain subsided, he was still in pain sufficient to make walking difficult. At each visit with the surgeon Dan raised these issues and was told to exercise more, and that it would get better with time. Two years on, that hadn’t happened, and the surgeon then agreed that the knee was a bit loose and offered to go back in and “put a shim in it”.

At some point after the 2006 operation, when it became apparent that it had been unsuccessful, I began to research the subject. Immediately I found that it’s common practice now to use Magnetic Resonance Imaging before TKR, rather than merely relying on x-rays. MRIs provide an exact and minutely detailed three-dimensional picture of the joint. The data can be used to make a 3-D visualization that can be rotated. This way the surgeon knows exactly what to expect; the prosthesis is customized, if necessary, beforehand; the surgery is generally shorter and the incision may even be smaller. (Other advances, such as computer-assisted orientation systems to guide the surgeon in positioning the prosthesis during surgery, may also be used.) Nothing like this was done in Dan’s case, and we didn’t know to ask about it. We know now that the original surgeon does have access to an MRI, in the hospital across the street from his office, and used it to look at Dan’s hip after the bad artificial knee began to cause a lot of pain in his hip, back, and other knee. But he didn’t use it for the knee needing replacement.

Surgery #2, 2009

Finally, after the remark about putting in a “shim”, we began to look for another surgeon. I searched online for someone who used MRIs and computerized techniques for joint replacement and who was experienced in what I learned is called “revision” (re-do) of TKRs. (Some surgeons, including the only other ones in our area, won’t touch someone else’s failures.) I found a surgeon who met these qualifications, about 4 hours drive from where we live, and we went to see him. The first thing he did was to get a full-leg digital x-ray, which surgeon #1 had never done. He showed us the x-ray, and used software to examine the precise alignment of the prosthesis. It was 7.5° out of alignment. In effect, his lower leg-bone had been detached and then put back on at a different angle from the upper leg. For over two years the first surgeon had taken no steps to examine the results of his surgery, other than feeling the knee.

We liked what we saw here, added to what we already knew about Surgeon #2’s experience, and proceeded with the preparations for a revision.

In late May Dan went through the revision surgery. Pry off the old, shave off a little more bone, affix the new.

When the surgeon met with me afterward in the waiting room, he had troubling things to report but they weren’t about what had just taken place. He told me that the prosthesis he had removed was badly installed. He actually used the word “sloppy”––and you know how rare it is for doctors to criticize one another’s work! The lower part was out of alignment both front-to-back and side-to-side; the upper part was supposed to be stabilized by the bone growing into it on all sides, but this had not taken place (he remarked that he did not use this model because sufficient bone regrowth often failed to occur). So this artificial joint had been loose and seriously mis-aligned, with every step stressing both parts of the prosthesis, the ends of the bones, the muscles/ligaments/tendons, and the other joints involved in walking (back, hip, other knee). It was clear, said the surgeon, that this had been causing Dan considerable pain, and he felt confident that the new prosthesis was going to be a great improvement.

Today is post-op day 19, and there is no comparison between the two post-op experiences. The day after the surgery they got Dan on his feet, and the first time he put his weight on the new knee he said that it felt more solid than the old one ever had. The next day he was walking the hall, slowly, and walking without hip pain for the first time in ten years. Bruising of the leg is minimal, the incision is shorter, and pain is less. The first time he was using fentanyl patches, very heavy opioid painkiller, and was still in too much pain. This time it is Tylenol-3 every 4 hours, and ultram (tramodol) occasionally when needed.

The incision is closed with superglue, covered with crossways lengths of what looks like strapping tape: no staples to distort the skin and then have to be removed. He was able to take a short shower on post-op day 5. Last time the first shower was not permitted nearly so soon and he was in so much pain he had to sit down on a plastic bench in the shower. This time, he was easily able to stand and feel secure. He’s in pain, but not nearly as much as last time, and the solidity of the knee makes it possible for him to get around the house carefully but confidently, only occasionally using his walking stick for stability (and to keep the dogs from bumping him).

Like the first time, the anesthesia was a spinal block (not general anesthesia) but the new surgeon added a femoral nerve block. As I understand it, the spinal keeps pain messages from reaching the brain during surgery; the femoral block keeps the nerves immediately affected by the surgery from registering pain which gets the nerves excited even though the brain doesn’t hear about it. It’s supposed to lessen post-op pain and it certainly seems to do that, especially for the first 24-36 hours.

There is swelling, but it’s not bad unless he keeps his leg bent too long while sitting; last time he was still mostly in bed for at least 2 weeks, and the swelling was severe from above the knee to the foot. Perhaps this is related to another difference in surgical procedure: this time a drain was placed near the incision with a receptacle attached which had to be periodically emptied of fluid, partly blood. Before the drain was removed, 1200 cc of fluid had been collected. The first surgeon did not place such a drain, the leg continued very swollen, and at the two-week check-up the surgeon had to use a syringe to remove at least 200 cc from the still very swollen knee. Doing this is risky because in raises the risk of infection, which would be a dire complication.

At this point the future looks very good for this new knee, and we are talking about being able to get out and hike with our dogs again. I still have limited energy (fibromyalgia) but more than I used to, since getting off of methadone which I took for pain.

Lessons learned

The parts of our experience that I think may be useful to everybody facing joint replacement surgery are these:

Research and ask questions. Get a second opinion.
This is major surgery which will shape your everyday life for the next decade or more. Revisions are to be avoided: not only because of pain and expense, but each surgery removes a little more bone. Don’t be afraid of getting a second opinion, even if your orthopedic surgeon seems great. Believe me, if your orthopedist were going in for brain or heart surgery, he or she would ask around, not just take the first name in the phone book! Insurance generally covers second opinions for major surgery.

Educate yourself about the surgery in general: what can go wrong, and why? what are the different methods?

In choosing a surgeon, standard advice is to find someone who has done this particular surgery a lot and does it regularly. That’s good advice, but incomplete. Our first surgeon had lots of experience and he performs knee replacements regularly. But based on results and what we’ve learned since, this fellow has not kept up with new methods: MRI’s, femoral nerve blocks, post-surgical drains, etc.

Of course nothing is better just because it is new. Some things provide an advantage even the layperson can evaluate, such as the use of MRI’s to see exactly what the joint and surrounding bone look like, so that the operation can be planned using that information. There’s no real downside for the patient in providing better information to the person doing the cutting and sawing. As for the high-tech implantable prostheses used in TKR, there’s always something new coming out, which may or may not be better. You can at least ask a surgeon how long he has been using the device he intends to implant into your body, what the failure rate is, and when and why it fails. Does it fail to be stabilized by bone growth, or do components or surfaces wear out? Does it loosen in 2 – 5 years, for whatever reason? Do particles get ground off and act like grit in a bearing?

Read up on the subject and you’ll get an idea of what to ask. Take notes on your reading and your concerns, and bring them with you; then take notes on what the doctor says. Have someone else come along to help by writing things down, reminding you of questions, and in general giving you moral support. The doctor is the expert, but your body is what’s at risk; don’t be timid about asking. In my mind, a doctor who won’t answer my questions fully, as fully as I want, doesn’t get my business.

Also ask what to expect after the surgery. Surgeon #1 kept stringing us along, telling us that things would get much better. Now we hear from others that isn’t really true, that you “know” right away. And indeed the bad job felt loose from Day 1 and never changed; the recent revision felt solid from Day 1. Certainly, telling us for 2 years that there would still be improvement, was unrealistic (charitable interpretation) and dishonest (blunt interpretation).

More information on Total Knee Replacement

There’s an encyclopedia-style summary of the procedure, risks, failures, etc. here that looked good to me, and another page on this site deals with TKR revisions (re-doing the TKR).
Wikipedia also has good information.

How to reduce the chances that you’ll need knee replacement surgery

It’s no fun, really. And you’ll get stopped by airport security for a special check, every time.

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Photo from Wikimedia Commons.

Here’s the advice from the National Institutes of Health––

How Can People Prevent Knee Problems?

Some knee problems, such as those resulting from an accident, cannot be foreseen or prevented. However, people can prevent many knee problems by following these suggestions:

Before exercising or participating in sports, warm up by walking or riding a stationary bicycle, then do stretches. Stretching the muscles in the front of the thigh (quadriceps) and back of the thigh (hamstrings) reduces tension on the tendons and relieves pressure on the knee during activity.

Strengthen the leg muscles by doing specific exercises (for example, by walking up stairs or hills or by riding a stationary bicycle). A supervised workout with weights is another way to strengthen the leg muscles that support the knee.

Avoid sudden changes in the intensity of exercise. Increase the force or duration of activity gradually.

Wear shoes that fit properly and are in good condition. This will help maintain balance and leg alignment when walking or running. Flat feet or overpronated feet (feet that roll inward) can cause knee problems. People can often reduce some of these problems by wearing special shoe inserts (orthotics).

Maintain a healthy weight to reduce stress on the knee. Obesity increases the risk of osteoarthritis of the knee.

What Types of Exercise Are Best for People With Knee Problems?

Ideally, everyone should get three types of exercise regularly:

Range-of-motion exercises to help maintain normal joint movement and relieve stiffness.

Strengthening exercises to help keep or increase muscle strength. Keeping muscles strong with exercises – such as walking up stairs, doing leg lifts or dips, or riding a stationary bicycle – helps support and protect the knee.

Aerobic or endurance exercises to improve function of the heart and circulation and to help control weight. Weight control can be important to people who have arthritis because extra weight puts pressure on many joints. Some studies show that aerobic exercise can reduce inflammation in some joints.

If you already have knee problems, your doctor or physical therapist can help with a plan of exercise that will help the knee(s) without increasing the risk of injury or further damage. As a general rule, you should choose gentle exercises such as swimming, aquatic exercise, or walking rather than jarring exercises such as jogging or high-impact aerobics.

So there it is, same old thing: exercise and lose weight. If you really really do not want a titanium and plastic knee, losing weight is probably the best thing you can do. “Data from the first National Health and Nutrition Examination Survey (HANES I) indicated that obese women had nearly 4 times the risk of knee osteoarthritis as compared with non-obese women; for obese men, the risk was nearly 5 times greater.” Moreover, if you already have knee pain, losing even ten pounds can significantly reduce both pain and the ongoing deterioration of the knee. Being only 10 pounds overweight increases the force on the knee by 30-60 pounds with each step. You don’t need to reach your ideal weight; any reduction will help. And maybe that will be encouragement enough to keep going, slowly, losing weight and feeling better. (Thorough discussion of weight loss and osteoarthritis, here.)

More about credit cards, debt, pyramids, and eschatology

My recent post “Why I’m canceling my Bank of America credit card” brought a comment pointing out that cancelling credit cards can adversely affect one’s credit score, perhaps making it difficult to borrow for cars and houses. That may well be true, but it seems to spring from a view of credit and debt quite different from mine. Rather than dump this on the hapless commenter as a reply, I’ll say it here.

First, the companies have no incentive to restrict credit, and I expect they’ll soon be back to sending out credit apps to dogs and kindergartners. When the banks lose money through extending credit unwisely, they raise rates on the rest of us to recoup. Worst case, as now, the taxpayers bail them out, they buy each other up, write off debt, get tax breaks for losses. So I think people can safely cancel all but one or two cards, and still be able to use credit to make major purchases.

Second, I’m hoping that ordinary people, who DO have an incentive to learn from the present debacle, may start restricting their debt to large necessary items. Cars and houses usually do require going into debt. But I’m old enough to remember life without credit cards; my mom had a metal “charge-a-plate” for Macy’s, and there was layaway at some stores, but no credit cards. If you wanted something you saved up for it. If you couldn’t afford to go out to dinner, you didn’t go. To those accustomed to incurring chronic credit-card debt for indulgences, such a life may seem a bleak prospect. But actually I recall very few people growing despondent for want of cruises, concert tickets, and designer handbags.

Back in the 1980’s when I saw items at an Oregon department-type store bearing tags that said “Want me? Buy me!” and a credit card logo, I viewed it as a dangerous & selfish attitude to cultivate. Along with it came the re-definition of human beings as “consumers”.

The present economic system is a pyramid scheme because it is predicated on continual growth. We do not live in a world of infinite resources and space, therefore neither population nor consumption/production can continue to increase forever. Business interests, and even the administration, expect increased consumption to get us out of this depression. If it does, it can be only a temporary fix.

I know there are a lot of optimists out there who say not to worry about dismal stuff like the economy, climate change, and all that, because the world is going to end in 2012 (Mayan Calendar theory) or “soon” (some Christian fundamentalist theories). But I just can’t be that optimistic. Call me crazy, but what if we’ve got those Mayan numbers just a little bit wrong? Or some translator introduced an inaccuracy into the Book of Revelations? What if God has changed His mind, and now thinks it might be amusing to see how His little creatures manage with these challenges? We just can’t know. Better to keep our eyes on the ball, as it were (in this case the planet & its inhabitants) and not count on the Umpire calling the game on account of End of Time.

Oregon’s “Puppy Mill” bill: ineffective and wrongly aimed

In an earlier post I discussed some of the problems I see with two bills now in the Oregon legislature, HB 2470 the supposed anti-puppy mill law, and HB 2852 which is ostensibly aimed at increasing public safety from “dangerous dogs”.

The latter bill may be dead, and that is a good thing. But HB 2470 lives on, and I have closely examined the available version and have more to say about why it should also be forgotten. [I am still commenting on the original version. I have heard that changes have been made in committee but apparently the text of those changes is not available to the public. However, the bill is so fundamentally flawed that it would need to be rewritten completely to become both effective and beneficial, in my opinion, and I doubt that that has happened.]

What’s wrong with Oregon’s “anti-puppy mill” bill

We already have the laws needed to shut down puppy mills

Oregon animal cruelty laws currently contain requirements which would put puppy mills out of business, if enforced.

 (6) “Minimum Care” means care sufficient to preserve the health and well-being of an animal and, except for emergencies or circumstances beyond the reasonable control of the owner, includes, but is not limited to, the following requirements:

(a) Food of sufficient quantity and quality to allow for normal growth or maintenance of body weight.

   (b) Open or adequate access to potable water in sufficient quantity to satisfy the animal’s needs. Access to snow or ice is not adequate access to potable water.

   (c) For a domestic animal other than a dog engaged in herding or protecting livestock, access to a barn, dog house or other enclosed structure sufficient to protect the animal from wind, rain, snow or sun and that has adequate bedding to protect against cold and dampness.

   (d) Veterinary care deemed necessary by a reasonably prudent person to relieve distress from injury, neglect or disease.

   (e) For a domestic animal, continuous access to an area:

    (A) With adequate space for exercise necessary for the health of the animal;

    (B) With air temperature suitable for the animal; and

    (C) Kept reasonably clean and free from excess waste or other contaminants that could affect the animal’s health.
[ORS Chapter 167 – Offenses Against Public Health, Decency and Animals. 167.310 Definitions for ORS 167.310 to 167.351. As used in ORS 167.310 to 167.351]

I’ve never heard of a puppy mill that could come anywhere close to meeting these requirements. Hard to make a profit following those rules. Yet the existing criminal law has not been effective in ending puppy mills in this state. Why not?

1. Puppy mills hide in rural areas.
2. There is no funding for enforcement.
3. There is apparently no requirement for licensing of breeding establishments, so their location can remain unknown to authorities. Without licensing, there is no possibility of a regular inspection program like that for, say, food-handling establishments; and of course there’s no funding for such an inspection program either. Hence enforcement of the existing law depends on law enforcement rather than inspectors. Unless violations are reported by a witness or are visible from outside the property, law enforcement may not be able to enter the premises legally.

So what do we need? To do it right, licensing of breeding facilities (at a nominal cost), and funding for inspection. A couple of the provisions in HB2470 would provide some help, notably the requirement that “puppy dealers” provide purchasers with written documentation about the health, and origin of the dog––but the negatives in the bill far outweigh the positives. And “puppy dealers” as defined in the legislation wouldn’t apply to pet stores which sell the product of puppy mills!

HB 2470 is wrongly aimed

As far as I can tell, it systematically exempts pet stores, the main sales points for puppy mill “product”, from the standards of care and the health and documentation requirements, as well as from responsibility if a puppy turns out to have a health problem. The bill distinguishes between a pet store

SECTION 1. (1) As used in this section:

(b)(A) “Retail pet store” means a retail establishment open to the public that sells, or offers to sell dogs.
(B) “Retail pet store” does not mean a person that sells or offers to sell only dogs:
(i) That were bred or raised by the person; or
(ii) Are kept primarily for the purpose of reproduction.

and a pet dealer

SECTION 2. As used in sections 2 to 12 of this 2009 Act:

(3)(a) “Pet dealer” means a person that during a 12-month period sells, offers for sale, barters or exchanges more than the greater of:
(A) Twenty dogs; or
(B) Three litters of dogs.

All the subsequent requirements of the bill apply to pet dealers and not to pet stores.

Pet stores are not required to provide documentation to buyers giving the mill-produced puppy’s vet record, name and address of breeder or broker, and a guarantee of current health. Why not? What possible justification can there be for this?

HB 2470 also exempts pet stores from the “lemon law” portion of the bill. This part requires breeders, but not pet stores, to reimburse pet owners for dogs that have certain problems within two years of purchase. Sometimes that would be fair. But it makes the seller responsible for any “disease, illness or condition adversely affecting the health of the dog that existed in the dog before or at the time the customer acquired the dog”, or “a congenital or hereditary defect adversely affecting the health of the dog or requiring hospitalization or nonelective surgical procedures”. There is no provision here as to whether the condition or defect could reasonably have been known to the seller. The most careful screening of breeding stock, whether of a pure-bred dog or a cow or horse, cannot rule out every single genetic (hereditary) defect. Similarly, a puppy from a responsible breeder can receive all vaccinations, be checked by a veterinarian, and still possibly have some undetected condition that will affect its health in future.

Exemption of pet stores makes a mockery of the claim that the bill is aimed at shutting down puppy mills. Reducing demand, from the pet stores, is crucial to making puppy mills less profitable. Instead, those most affected will be the responsible breeders who are most easily located, not the secretive puppy mills, whether in Oregon or in the Midwest, which hide behind brokers, internet sales, and pet stores.

Unintended consequences

For boarding kennels:

”SECTION 1. …(2) A person may not possess, control or otherwise have charge of at the same time more than 25 sexually intact dogs that are four months of age or older.”

Foreseeable consequences

I’m not going to get into the motivations of some of the supporters of this bill, including allegations that it is part of PETA’s agenda to eliminate the “animal slavery” of pet ownership by driving breeders out of business. But it is predictable that HB 2470 will have far more effect on responsible breeders than on puppy mills. The responsible ones are out in the open, easy to find, unlike puppy mills. You are much less likely to have a problem with a dog from a responsible breeder, few of whom make a profit from their hobby. These breeders welcome potential puppy buyers to their homes to see the parents of the puppies, to interact with the puppies before they are 8 weeks old and ready for new homes, and to watch puppy temperament testing; they also choose male and female carefully when planning a breeding, with specific goals for the breed, do testing (genetic, x-ray, etc.) so as to avoid breeding dogs that carry heritable defects, and keep extensive records on their dogs.

An article in the Oregonian featured a woman who had purchased a puppy which turned out to have severe health problems due to bad care and bad breeding. That is a heartbreaker for the owner and the dog. But she bought it from a broker. Try to find that broker, probably in another state, and get him to comply with the bill’s “lemon law” provision. So, how much of the problem of true “lemon” puppies will be addressed, and how many good local breeders will be harassed by owners when a problem develops months or years later? I can leave my puppy outside 23 hours a day, and when it turns into a barking unsocialized dog, claim that it had an inherited genetic defect causing this behavior. Under the law, there’s no provision for evaluating claims against breeders.

I have some personal experience over two decades with breeders of two different dog breeds. They taught me right away that it is not simply a transaction to them: they decide if my household is suitable for one of their puppies, they require spaying or neutering to keep ill-bred or surplus pups of their breed out of the shelters and out of the wrong hands, they urge me to keep in touch and call with questions, they have me sign a contract which includes notifying the breeder if I can no longer keep the dog––even if it is 10 years later––so that they can accept it back for placement in a suitable home.

What happens at a pet store if I go in and buy a puppy? None of this, that is for sure! Those “doggies in the window” are there for a reason, to promote impulse buying of a live animal which will be a serious commitment for a decade or more. Pet store employees have no reason to talk a customer out of buying, say, a high-energy pup when the person says they want a quiet couch potato to watch tv with. If those cute puppies go unsold too long, they certainly do not go back to the breeder for placement; they get dumped or drowned or sold out out of the back of a truck. Yet this industry isn’t required to change one bit by HB 2470.

I know not all AKC breeders are so responsible as the ones I have dealt with and known. I have some ideas about that, which I’ll put in another post. But to burden this group with new legal restrictions under the guise of shutting down puppy mills, while exempting the pet stores which market the pups bred under cruel and unhealthy conditions, this makes no sense. And the lack of funding for enforcement ensures that breeders out in the open will be the actual subjects, while the unspeakably vile and carefully hidden puppy mills continue to grind out misery.

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In the couch potato class, our beloved English Mastiff Bart was a champion, as in all else. We lost him in February to consequences of old age (he was 11 and a half).

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Back to the past: Return of the percolator

Over three decades our household has averaged a new coffee-maker every three or four years. We’ve had Braun, Gevalia, Black and Decker, Krups, and other brands I’ve forgotten. A couple of times we got the $90 model but mostly they’ve been about half that price. Either way, eventually they quit working and this big non-repairable piece of plastic and electronics goes into the garbage.

As years have passed they’ve gotten more complicated, and that seemed to be the downfall of last week’s purchase. It was a Krups with an added water filter (good for us, with mineral-rich well water, but also one more thing to have to find, buy, and replace––profit’s big on consumables, like printer cartridges!). It also had an extra idiot light feature: a “low water” display and override which would keep it from running if it thought there was not enough water. This was not a feature we wanted, in fact we did not discover it until it malfunctioned on the third day of use. Push ON and all that happened was a cryptic pattern flashing on the display.

In the morning, when you want your coffee, reading a coffee-maker manual is not on your list of desired activities. Before consulting the manual we tried the chimpanzee approach, pushing the four control buttons in various combinations. Luckily we did not happen to activate any of the more arcane features, which can only be guessed at, nor (since we live in such a remote location) did the machine’s electronic calls for help manage to bring its plastic comrades jetting to its aid in time to defend it from our mishandling. Nor did we fix it, even after we deciphered the display message. We plugged and unplugged it, emptied and refilled it, all to no avail. Then we called the Customer Service number and listened to music for 20 minutes before a polite woman with a southern accent came on, heard our story, and informed us that by unplugging it and plugging it back in, we had “done all the troubleshooting” that we could do and our next step was to pack it up and ship it to their service center. Or, she said, we “might be able” to return it to the point of sale for a “straight-across trade”. Yes, I said, thinking “But not for another one of your brand!”

By then, we had made our morning’s coffee using a kettle and a flat-bottomed gold filter set in a sieve over a large pyrex measuring container. It was good. Caffeinated, we discussed our next step. Something simpler, not plastic and electronic, would be good; perhaps it would even have been Made NOT in China. We decided on a percolator, since Dan said he’d seen one on the shelf when he chose the Krups, and I remarked that when I was a kid people had the same percolator for 20 years, perking on and on. We marvelled that the coffee-makers of our childhood were still being sold. Maybe we weren’t the only people tired of having to read a manual for something that should be simple, and tired of the (planned or unplanned) short life-span of the new coffee-makers.

For $45 we got a shiny stainless steel West Bend percolator. It has no controls. Fill with water (there is a clear water gauge on the side, one new feature); insert the tube up which the hot water flows; put coffee in metal basket, put on lid, place basket on tube, put coffee-maker lid on, plug in. Less than a minute later hot water is flowing up into the clear knob on top and down onto the coffee basket. There is no possible programming, no clock, and only one “feature”, a plastic light on the base. I thought the thing was already broken, when the light did not come on after the percolator was plugged in. But no: the light comes on when the coffee is done. It keeps the coffee hot until unplugged, so you have to remember to do that to avoid cooked-all-day coffee remains. Unlike all the coffee-machine carafes we have ever had, the percolator does not drip when you pour too fast. Also, it takes up less space on the counter.

And the coffee? We like it better than what we were drinking before. The perking noise is pleasant, unlike the hissing and puffing of the previous type. Only one part didn’t turn out as we hoped: it was “Made in China”. But we hope it’s the last coffee-maker we buy for a long long time.

Listen up, retailers and retail employees!

You know you can’t afford to lose customers these days. We’re having an economic situation/blip/slowdown/downturn/recession/crisis/depression, ah––cut to the end: when the train finishes pulling into the station, it’ll be “Economic Disaster”.

Businesses spend money and effort on advertising, but often are oblivious to how they treat the customers themselves. When I walk into the tiny local florist to send condolence flowers and the person greets me coolly, asks only “How much do you want to spend?”, has no prices posted on anything, and no pictures or samples to show me, does it seem likely I will return? If there’d been another similar business within 15 miles I’d have walked out and gone elsewhere.

This subject has been on my mind for a few years, because my experience at the florist is far from an isolated incident. I fantasized about making my million with a company issuing videos and doing workshops about how to treat customers. But that’s not likely, and American business needs this now, so I’m going to write a little about it. Maybe it’ll be worth more than the traditional value of free advice.

Keep in mind, much of what I will say may seem obvious. It is. But if you work with the public and you aren’t practicing this, you need to hear it. And more than just hear it; consciously work at it and get some sort of feedback on how you are doing. My plan for teaching “customer service” included video illustrations of right and wrong; role-playing; and finally videotaping “students” for them to see themselves, because in all aspects of life we need a mirror, an objective reporter, to show us what we really do and say, as opposed to what we believe we do and say. Think about how true that is of other people you know. And it is just as true of you. And me.

Attitude

If you are going to work with the public, in a gas station, a library, a restaurant, a retail store, behind any sort of service desk, accept these basic realities:

  • No customers, no job.
  • Every customer advertises you to people they know, with praise, condemnation, or silence.
  • Making a repeat customer is like gaining a new customer without the expense of buying ads or running special deals.
  • You’re “on” every minute.
  • Customers get to act tired, cranky, stupid, and demanding, but you do not. You must be polite, helpful, inoffensively cheerful, and competent.

These are habits of thought and action like any others, and you can learn them and make them mostly unconscious and routine. Even virtue, Aristotle said, is a habit.

If you absolutely can’t accept and act on these realities, then public service/retail is the wrong place for you. You won’t be effective or happy in your job. And eventually it may catch up to you, as your boss decides you don’t add anything to the business, or your own business fails.

Attentiveness and Greeting

If you’re otherwise engaged when a customer arrives, you must show that you know he or she is there. Maybe you’re on the phone or helping someone else when Joe walks up to the counter. Make eye contact with Joe, smile, return to what you are doing.

Don’t keep him waiting more than a couple of minutes unless it is clear to him that your current transaction has a clear end coming up, as for instance ringing up the customer ahead of him. (This doesn’t apply to a grocery checkout line, or other situations where customers know they are waiting and know their place in line. Although even there, send a smile to the customer who’s waiting behind that person sorting through a zillion coupons, and it will be appreciated.)

If your transaction may go on and on, use your judgment; probably you should say to the customer in front of you, “Excuse me just a moment,” turn to Joe, and say “Hi, can I answer a question for you?” He asks whether your store has Acme Widgets in stock, you tell him yes (and where they are) or no (adding, but if he can wait a moment, we have something very similar) then turn back to your current customer. Or if there is another employee available, get that person over to help Joe. Joe doesn’t walk out thinking you don’t care about his business, and you may have a customer.

On the other hand, don’t let attentiveness to the newly arrived customer make you abandon the one you were working with. Same with phone calls; that’s what the Hold button is for. Fairness is important to us humans, and the person who was there first can reasonably expect you to finish his or her transaction before going on to another. If Joe’s “quick question” turns into something longer, you must gently interrupt and promise to help him just as soon as you’ve finished with the other person’s business.

[Supervisors, take note: should your sales desk people really be answering all the incoming calls, too? You think you’re saving money but it means someone who is right there with money to spend has to wait while the clerk answers questions and routes calls.]

Do not do personal business in front of customers. Everybody needs to make a phone call at work sometimes, or talks to other employees during a slow period about non-work stuff, but make it a rule: never when a customer is present. Tell your babysitter you’ll call right back, quit discussing the weekend, the hot new clerk in Shipping, or the prospect of layoffs. Even if the call or conversation is really work-related (informing another staff member that the new shipment of extra-large widgets hasn’t arrived yet so we don’t have any on the shelves right now), the customer needs to come first. Make eye contact (as above) and end the other matter at once.

Each customer should feel that they have been noticed, that they will have your attention soon, and that during that time they will be your primary focus.

Helpfulness

All of us have had the experience, on the customer side of the counter, of being either smothered with attention or wandering lost and alone. We want someone to pick up on our signals and act appropriately.

As a salesperson (or library assistant, waitperson, etc.) you can learn to read minds. Yes, it can be done. Offer initial assistance, then ask if you can help; if the answer is “No, I haven’t quite made up my mind,” or the old standby “I’m just looking around,” then say “Just let me know when you’re ready” or “Let me know if I can help you find something.”

And then, you don’t forget about this customer. If I sit staring at the menu for ten minutes maybe I need to be asked, “Would you like to hear about our specials today?” or “Can I tell you more about any of these lunches?”––and not in a tone of “Would you please get on with it!” Restaurant staff are usually much better at this than retail staff, since turning the tables over in restaurants is so important. In a store, people searching the shelves or aisles in vain for what they need have a certain look, which you don’t have to be a master of human expression to recognize.

Make your interchanges genuine. What you say, how you say it, body language, all can have a positive or negative effect. One of my pet peeves is the “drive-by wait-person” who asks, while rushing past our table, “Everything okay here?” And if it’s not? If my hamburger is raw inside or I need more water, do I have the impression that this person has time to care? Waiting table can be a high-stress job with a lot of things to juggle at once, but if you’re going to talk to me, please stop, face me, make eye contact, and then talk.

At the store’s cash register, as you are asking me whether everything was okay, and did I find what I needed, same thing: make eye contact, take that extra 5 seconds to see me, and then listen and respond to what I say. I like it better, and you may get valuable information: there’s no ground beef left at the meat counter, I couldn’t find what I came in for and am heading elsewhere for my main purchase, the directional signage is wrong and I’m ticked off, somebody spilled coffee all over your bin of blue widgets.

When there’s “nothing to do”

Most jobs have slow times: no customers, no calls, waiting for a part to arrive or for someone else to do something. In work that’s mentally or physically demanding you need little bits of rest. But, especially in retail or public service, there really are things to do even when––especially when––the store or restaurant is quiet and the phone isn’t ringing. This is your chance to make the coming busy times easier for yourself, and improve the service you are able to offer. Some of it’s obvious: fill the condiment containers, put away the unsold merchandise that has made its way to the counter, check your supplies, replace the cash register tape, tidy things up. That’s the kind of thing a boss will be pleased not to have to remind you about.

There’s more that’s not as obvious: you need to know a lot about whatever goods or services you are in charge of, so look over the stock, check out the new stuff, notice that you now have some of those special items someone asked about last week, ask the cook about today’s soup (or even taste it!). Find the answers to questions you haven’t been able to answer, and next time you won’t have to consult someone else or confess ignorance. Have the answer that will help the customer, and result in a sale. “I need something for a baby shower, but she already has 2 kids.” “How do you use this chutney stuff, can I use it for a marinade?” “All these dry dog foods are confusing, what are the differences?” “Can I do my taxes online here at the library?” “What’s a good flowering plant for a shady location?” “I need some left-handed scissors.” This can be an enjoyable part of your job, learning more to help people toward what they are looking for.

And if your store hasn’t got those left-handed scissors, or your restaurant doesn’t have a wide vegetarian menu, you’ll earn the customer’s gratitude by being able to suggest an alternative, or even another place that has what’s needed. I had to return a plastic lap desk (for a laptop) to an office store because it just wasn’t adequate, and nothing else they had was any better. I won’t forget that the staff person recommended a big book store to me as a good place to look; I would never have thought of going there and was getting tired of the search. I followed the tip and found what I wanted. Now, I think of that office store as a more helpful place, and I’m more likely to go there instead of to their competitor. An interchange can be very successful (in terms of your business) even if it doesn’t result in a sale.

Personal Satisfaction

This is the part about what’s in it for you, if you change your attitude and behavior so customers leave feeling good about their experience in your workplace.

Now, it’s obvious that you are very likely to increase your own chances of success at work by doing this, whether you own your own business or are an entry-level employee someplace.

What if your boss is an SOB who only cares about the bottom line, treats customers and staff poorly, and is never going to die or retire in time for you to benefit? Sounds like a good place to move on from, and if you understand and can express good principles of customer service, you have an advantage in the coming job interviews. The surly or spaced-out shirker isn’t at the head of anyone’s hiring list.

Deciding to look for ways to be better at what you do is not equivalent to resigning yourself to being at your present job forever. Just the opposite, in fact; bad attitude and bad performance are not attractive to potential new employers. Nor are they conducive to promotion (except in the financial industry and high-level corporate management).

Beyond that though, is another realm of benefit entirely. It actually is true that if you work at doing your job well you are very likely to feel better about it. That is not a falsehood spread by the capitalist bosses, it’s a psychological fact. If you don’t think your own job is worth doing well, then you are telling yourself that every moment at work is a waste of time, something to be resented and avoided. In other words, “Over half of my waking life is worthless.” If you don’t have any sense of satisfaction except when you manage to work as little as possible, you go home feeling pretty crappy about all those hours and effort, and about yourself.

And now, a word to the “capitalist bosses”

Most of what I have written has been addressed more to employees, but it is employers who set the tone of their businesses, and they have a lot to lose if staff are providing poor customer service. If that is the case at the business you run, don’t blame your the people who work for you––train them, encourage them, and set a good example including in your behavior to the employees themselves.

This may only be possible in small businesses, since larger ones get drawn astray by greed, ego, and isolation of management from the product and customers. Management starts to think that the end product is money, and they start viewing everyone else in the world as either tools or fools. Employees are tools to be used, customers are fools to be scammed. But we always hear that small businesses generate most of the new jobs in the US, so if they can accept a model based on good products, good customer service, good treatment of employees, then that will be a significant change.

Our current economic debacle can be directly traced to poor practices on the part of those in charge, whether they were causing bad loans to be made, or failing to listen to consumers when designing cars. Greed is always a pyramid scheme: it pays off only if you bail out at the right time. A risky business model, that: it’s really just gambling (with other peoples’ money).

If you’re in business, you have customers. Act toward their greater satisfaction, strive to do what you do better than anyone else, take a long-term point of view, keep your debt down, and invest in your employees. You may not end up with the biggest widget company in the world, but you are likely to be still operating when the big guys have vanished in debt and disgrace.

Dr. House’s writers betray pain patients

As a chronic pain patient who took methadone for years, and experienced a lot of misunderstanding from medical professionals and laypersons about addiction, I greeted the House series with hope when I first saw it. It’s smart and interesting as tv goes, and Hugh Laurie is a fine actor who has done well with the unusual role. But beyond that, I thought having a chronic pain sufferer as a main character presented a great opportunity to break the stereotype that “taking pain meds longterm = addiction”. Dr. Gregory House is certainly well-informed about medical science as opposed to drug war hysteria, and no one can deny that he’s assertive!

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Source unknown, appears only on generic odd picture sites. Found with Google image search.
House’s halo may fade as you read on.

However, the writers and producers are promoting the familiar hackneyed clichés about addiction–––worse, these clichés are false and are no longer accepted in current medical thought. And House, of all people, is represented as knowing no better, and accepting the label of “addict”.

Two of the doctors House works with (his boss Cuddy and his friend Wilson) say frequently that House’s professional and personal abilities are being damaged by his “addiction” (his everyday use of vicodin for constant severe pain in his leg), and this conflict has played out in many episodes in the first three years. [We never seem to watch the Fox channel, so we see House in reruns on other channels; if there has been a drastic change in the last season I wouldn’t know about it. But I doubt there’s been a change in a theme which has been used so often.]

I was moved to write this by seeing again the old episode titled “Detox” (episode 11, season 1, 2005). Cuddy challenges him to go a week without vicodin to “prove he’s not an addict”. House accepts the challenge, his prize being a month of no clinic duty, and he also accepts the premises: that if he shows signs of physical withdrawal it means he is addicted. He does show these signs, though he tries to hide or deny them, and he also suffers greatly increased pain. Feeling nauseated, he’s told that it’s withdrawal, and replies “No, I’m in pain. Pain causes nausea.” Maybe so, but withdrawal from opioids does too. Finally the pain and withdrawal symptoms make it impossible for him to function as his usual professional self: hyper-smart and intuitive diagnostician. A patient is depending on him, and so are his diagnosticians-in-training, and one of the latter gives him some vicodin and tells him to take it because he’s not able to do what needs to be done.

At the end, asked what he has learned, House says (close paraphrase): I’m an addict….But I’m not going to quit…I pay my bills, I work, I function.

His friend Wilson says, You’ve changed, you’re miserable and you’re afraid to face yourself…Everything’s the leg, nothing’s the pills?

House: They let me do my job, and they take away my pain.

So, House won’t abandon the vicodin because he cannot function without pain relief, but he caves to the notion that he is an addict.

There are so many things wrong with this, and the writers of a medical show ought to know better.

Addiction Versus Dependence

The refusal to distinguish between these two terms has cursed our management of pain for fifty years or more. But in the last couple of decades medicine has, at last, officially separated the two. Here is a discussion of the terminology from an authoritative source, a Consensus Document issued jointly by The American Academy of Pain Medicine, The American Pain Society and the American Society of Addiction Medicine, called Definitions Related to the
Use of Opioids for the Treatment of Pain
. [I quote at length, so it will be clear that this represents exactly and completely the sense of this document. Emphasis is added.]

BACKGROUND

Clear terminology is necessary for effective communication regarding medical issues. Scientists, clinicians, regulators and the lay public use disparate definitions of terms related to addiction. These disparities contribute to a misunderstanding of the nature of addiction and the risk of addiction, especially in situations in which opioids are used, or are being considered for use, to manage pain. Confusion regarding the treatment of pain results in unnecessary suffering, economic burdens to society, and inappropriate adverse actions against patients and professionals.

Many medications, including opioids, play important roles in the treatment of pain. Opioids, however, often have their utilization limited by concerns regarding misuse, addiction and possible diversion for non-medical uses.

Many medications used in medical practice produce dependence, and some may lead to addiction in vulnerable individuals. The latter medications appear to stimulate brain reward mechanisms; these include opioids, sedatives, stimulants, anxiolytics, some muscle relaxants, and cannabinoids.

Physical dependence, tolerance and addiction are discrete and different phenomena that are often confused. Since their clinical implications and management differ markedly, it is important that uniform definitions, based on current scientific and clinical understanding, be established in order to promote better care of patients with pain and other conditions where the use of dependence-producing drugs is appropriate, and to encourage appropriate regulatory policies and enforcement strategies.

RECOMMENDATIONS

The American Society of Addiction Medicine (ASAM), the American Academy of Pain Medicine (AAPM), and the American Pain Society (APS) recognize the following definitions and recommend their use:

ADDICTION

Addiction is a primary, chronic, neurobiologicneurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

PHYSICAL DEPENDENCE

Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist…

TOLERANCE

Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time.


DISCUSSION

Most specialists in pain medicine and addiction medicine agree that patients treated with prolonged opioid therapy usually do develop physical dependence and sometimes develop tolerance, but do not usually develop addictive disorders. However, the actual risk is not known and probably varies with genetic predisposition, among other factors. Addiction, unlike tolerance and physical dependence, is not a predictable drug effect, but represents an idiosyncratic adverse reaction in biologically and psychosocially vulnerable individuals. Most exposures to drugs that can stimulate the brain’s reward center do not produce addiction. Addiction is a primary chronic disease and exposure to drugs is only one of the etiologic factors in its development.

Addiction in the course of opioid therapy of pain can best be assessed after the pain has been brought under adequate control, though this is not always possible. Addiction is recognized by the observation of one or more of its characteristic features: impaired control, craving and compulsive use, and continued use despite negative physical, mental and/or social consequences. An individual’s behaviors that may suggest addiction sometimes are simply a reflection of unrelieved pain or other problems unrelated to addiction. Therefore, good clinical judgment must be used in determining whether the pattern of behaviors signals the presence of addiction or reflects a different issue.

Behaviors suggestive of addiction may include: inability to take medications according to an agreed upon schedule, taking multiple doses together, frequent reports of lost or stolen prescriptions, doctor shopping, isolation from family and friends and/or use of non-prescribed psychoactive drugs in addition to prescribed medications. Other behaviors which may raise concern are the use of analgesic medications for other than analgesic effects, such as sedation, an increase in energy, a decrease in anxiety, or intoxication; non-compliance with recommended non-opioid treatments or evaluations; insistence on rapid-onset formulations/routes of administration; or reports of no relief whatsoever by any non-opioid treatments.

Adverse consequences of addictive use of medications may include persistent sedation or intoxication due to overuse; increasing functional impairment and other medical complications; psychological manifestations such as irritability, apathy, anxiety or depression; or adverse legal, economic or social consequences. Common and expected side effects of the medications, such as constipation or sedation due to use of prescribed doses, are not viewed as adverse consequences in this context. It should be emphasized that no single event is diagnostic of addictive disorder. Rather, the diagnosis is made in response to a pattern of behavior that usually becomes obvious over time.

Pseudoaddiction is a term which has been used to describe patient behaviors that may occur when pain is undertreated. Patients with unrelieved pain may become focused on obtaining medications, may “clock watch,” and may otherwise seem inappropriately “drug seeking.” Even such behaviors as illicit drug use and deception can occur in the patient’s efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated.

Physical dependence on and tolerance to prescribed drugs do not constitute sufficient evidence of psychoactive substance use disorder or addiction. They are normal responses that often occur with the persistent use of certain medications. Physical dependence may develop with chronic use of many classes of medications. These include beta blockers, alpha-2 adrenergic agents, corticosteroids, antidepressants and other medications that are not associated with addictive disorders.

How important are definitions?

Few things are more important. We interact with the world through language. Words cause emotional reactions, compose our thoughts, represent us to others. Would you want to be introduced to a group of strangers as an “addict” or as a “pain patient”?

Let’s look at the decision to replace “addiction” with “dependence” in the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). This thick volume is the official dictionary and guide for defining mental disorders, including addictive behaviors. (Change in the DSM can contribute to profound social and legal change––as when, after a series of redefinitions, homosexuality was finally removed from the list of disorders in 1987.) An editorial in the American Journal of Psychiatry (2006) discusses this decision to use “dependence” not only to describe physical dependence, but also for addiction, as differentiated in the document quoted above.

All of the authors of this editorial are involved in the next revision of the DSM (DSM-V), and one has been part of the revisions since the 1980’s. They favor changing back to a distinction between “addiction” and “dependence,” and describe how the decision was made to merge both into “dependence”:

Those who favored the term “dependence” felt that this was a more neutral term that could easily apply to all drugs, including alcohol and nicotine. The committee members argued that the word “addiction” was a pejorative term that would add to the stigmatization of people with substance use disorders. A vote was taken at one of the last meetings of the committee, and the word “dependence” won over “addiction” by a single vote.

It was a victory for Political Correctness!

The authors criticize the widening of the term because of the negative effect on pain patients:

This [redefinition] has resulted in confusion among clinicians regarding the difference between “dependence” in a DSM sense, which is really “addiction,” and “dependence” as a normal physiological adaptation to repeated dosing of a medication. The result is that clinicians who see evidence of tolerance and withdrawal symptoms assume that this means addiction, and patients requiring additional pain medication are made to suffer. Similarly, pain patients in need of opiate medications may forgo proper treatment because of the fear of dependence, which is self-limiting by equating it with addiction.

A Canadian article (2006) describes the reluctance of many physicians to prescribe opioids for pain, and why they are reluctant:

In a recent national survey, 35% of Canadian family physicians reported that they would never prescribe opioids for moderate-to-severe chronic pain, and 37% identified addiction as a major barrier to prescribing opioids. This attitude leads to undertreatment and unnecessary suffering.

This is over one-third of Canada’s doctors who will never “prescribe opioids for moderate-to-severe chronic pain” no matter what. We cannot know how many would do the ethical thing and refer such patients to someone more experienced in treating pain, and how many just leave the patients to their own devices. If 35% would never prescribe opioids, some additional percentage would fall into the “rarely” category, which also results in undertreatment of pain.

Why does medical opinion on a fictional TV show matter?

Current medical “best practices” and principles regarding the differentiation of addiction from dependence have been slow to reach doctors and other medical professionals, let alone the public. Of course doctors should not be getting their medical information and attitudes from television, but television has a strong influence on viewers who know little about the topic presented–that’s all of us who are not medically trained. A person who believes that taking opioids results in addiction is far less likely to push for adequate pain treatment for him/herself, or family, and may even reject it if offered. If friends, relatives, and employers of pain patients share the confusion about addiction, they will exercise social pressure or threaten loss of employment. So the attitudes promoted by a popular TV show––in the US, House was the most-watched scripted program on TV during the 2007–08 television season––can have profound effects on the health care people receive.

When House stops taking the vicodin, he suffers headaches, sleeplessness, nausea, inability to concentrate, and irritability. All are symptoms of physical dependence, as in the definition paper cited above. That these same symptoms are felt by addicts is beside the point: addicts and chronic pain patients both are physically dependent, and both will suffer similar withdrawal symptoms as a result. For the pain sufferer, the symptoms of increased pain are added.

As a pain patient, I have experienced withdrawal from methadone. It is hell. It gave me much more compassion for addicts. Yet, in trying to get off methadone “cold turkey” when my doctors claimed they could not assist me, I went through seven days and nights of absolutely no sleep, intense physical and mental suffering from the withdrawal, and increased pain. There’s the pain you were medicating, and in addition the cessation of methadone makes all your bones ache, worse than any flu. And all this time the methadone was on the shelf. Untouched. Not typical addict behavior. On the eighth day with no sleep I realized that there had been no lessening of my symptoms, and that I could not endure it another 24 hours, so with distaste and reluctance I began taking the methadone again. I resolved then that I needed to find different doctors, who would help me through this, and subsequently did so with complete success. (I wrote about this in an earlier post.)

In my case the pain being treated had changed (improved, by a nerve block) during my time on opioids; the increased pain I had during withdrawal was nothing like that which House suffered from his leg. He showed great fortitude and self-control, but while dramatic it was medically pointless. The man has pain so bad he cannot function if it is not controlled; if nothing else works other than opioids, then that’s what he needs to use. Current medical thought recognizes this; the writers of the show do not.

Some of the behaviors relative to pain medication shown by House are reprehensible, such as stealing medication and forging prescriptions. This seems like classic drug addict behavior. But see the paragraph above on Pseudoaddiction, including the statement “Even such behaviors as illicit drug use and deception can occur in the patient’s efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated.” In fact, much of House’s often-criticized behavior has to be considered in light of the fact that even the vicodin never adequately relieves his leg pain. Irritability, mental and physical restlessness, combativeness, and harsh remarks can be the signs of unrelieved physical pain.

pain behavior chart.jpg

Chart from “Pain Assessment in Older Adults” (2006). The source references mentioned at the bottom of the chart are : 8. The management of persistent pain in older persons. American Geriatric Society (AGS) panel on persistent pain in older persons. J Am Geriatr Soc. 2002;50:S205-S224; and 9. Ferrell BA, Chodosh J. Pain management. In: Hazzard WR, Blass JP, Halter JB, et al. Principles of Geriatric Medicine and Gerontology. 5th ed. New York: McGraw-Hill Inc; 2003:303-321.

We have been told that even before his leg injury, House wasn’t a sunny sociable person. But he’s gotten worse since then, and in the show the doctors around House nearly always blame his pills––his addiction–not his pain.

Addicts and pain patients, differences and similarities

I intended to include some data here about the low actual rate of addiction (not dependency) in pain patients as a result of taking pain meds. I remember reading figures that ranged from 5% to 10%. When I did a quick search for substantiation I found that many of the research articles online are only available for a fee. The rates I did see varied so much, I must assume that the studies are not all using the same standards. Different researchers have different definitions of addiction vs. dependence; there is also an overlap of characteristics or symptoms between addicts and those who are physically dependent. If I had had no legal access to relief when I was in extremis after seven days of no methadone, I probably would have lied or stolen, if necessary to end the withdrawal. Nothing violent; I would have gotten myself somehow to the emergency room instead. But if turned away there, who knows?

This is the sort of mental and physical suffering that confronts the organism with a stark choice: solve this, or die. (If you are too debilitated to protect yourself or find food, you will die, as far as the primitive part of our brain is concerned.) Once physical dependency has been established, both addicts and pain patients are motivated to get their drugs, driven more powerfully than anyone can imagine who has not experienced it. The distinctions between addict and dependent patient must be made on criteria other than the evidence of physical dependence, since this is the same for both.

The chart below presents some criteria that seem to square with my experience and reading, although the source does not give scholarly or research citations for it.

Chart,addict-patient.jpg

[The last item under Addicts should read “The life of an addict is a continuous downward spiral.”]

Individual responses to potentially addictive drugs vary. Not everyone who tries heroin becomes addicted. Different responses are based on biological and psychological factors we are only beginning to glimpse: everything’s neurological in the end, I suppose, but increasingly it appears that experience (from conditions in utero to nutrition, upbringing, and exercise) can cause physical changes in the brain and nervous system, and therefore in thinking, emotion, and behavior [see note 1]. Even the physical brain, where our sense of “I” resides, is changeable throughout our lives: adapting, adding complexity, growing (or shrinking) based on what happens to us. The activity of our genes themselves can be enhanced, reduced, suppressed entirely, depending on outside conditions from before birth to the day we die.

How should society regard people with chronic pain?

When a starving person steals bread, we do not say that he should have simply endured his hunger, or that he is “addicted” to food. Believe me, the situation of a person in great pain, or even moderate chronic pain, is also desperate and unbearable, and the organism will get relief.

The compassionate and socially responsible action is to meet these needs in an appropriate way. Can we assist this starving person in earning money so as to feed himself or herself? If not, most of us agree that the helpless, the elderly, the people so injured by life as to be unemployable, should receive aid rather than be allowed to starve or freeze to death. The pain patient deserves the same action: the question to be asked is: How can the pain best be alleviated? There may be surgical options, transfer to a different job, physical therapy, use of TENS units and the like, as appropriate. Meditation, mild exercise, and cognitive training may offer some relief too. But the response to pain must not be limited to only non-drug approaches.

The patient is the final judge of what works, and how much pain is too much, and the patient should not be silenced with threats and accusations of addiction.

A question that needs to be asked about drug addiction is Why? Why do so many of our fellow citizens seek out heroin, cocaine, methamphetamine, illegal prescription drugs, too much alcohol? What is their pain? Not physical, perhaps, but certainly psychological or spiritual: despair, lack of meaning in life, lack of true positive connexion to other human beings and to the natural world. Until we approach drug addiction in this way we will never understand how to reduce its occurrence. Neither after-the-fact tactics (punishment, ostracism, rehab), nor prevention (education and interdiction) have worked very well. But asking Why? about addiction would reveal aspects of our society that are senseless and cruel to many, but pleasant and profitable for a few. Danger, ssssshh!

We have been so cowed and brainwashed by the continually failing War on Drugs and our native streak of puritanism that we even permit medical professionals to deny adequate pain relief to terminal cancer patients. Is it really because they “might get addicted” in the weeks before they die? Or is it the imposition of society’s fears and prejudices upon the most helpless among us? Clearly, we have made little progress in reducing the numbers of illegal drug users over the past forty years––but law-abiding people who go to doctors, they can be denied and controlled.

And so, apparently, can Dr. Gregory House, who is pitched to us as the independent thinker extraordinaire, smart and brave, ready to track truth to its lair and drag it out into the daylight. I wish his writers would let him do exactly that on the issue of pain and addiction.

1. Further reading on the “plasticity” of the brain (an unsystematic quick gathering)

  • Scientists map maturation of the human brain (2003), a short overview
  • Brain changes significantly after age 18 (2006), “The brain of an 18-year-old college freshman is still far from resembling the brain of someone in their mid-twenties. When do we reach adulthood? It might be much later than we traditionally think.”
  • Research finding persistent physical and functional changes in human brains caused by smoking, chemotherapy,
  • Empirical research on structural brain changes affecting social cognitive development after childhood (2007);
  • Various environmental factors can cause “epigenetic changes…reversible heritable changes in the functioning of a gene can occur without any alterations to the DNA sequence. These changes may be induced spontaneously, in response to environmental factors…” and be associated with development of schizophrenia and other psychiatric disorders or the quality of an individual’s performance as a parent
  • Childhood lead exposure can predict criminality(2008), even after controlling for factors such as socioeconomic status of the family; “Lead can interfere with the brain by impairing synapse formation and disrupting neurotransmitters, such as dopamine and serotonin. It also appears to permanently alter brain structure.”