The VA, Vanity and Duragesic

The VA, Vanity and Duragesic

Dr. Marc regularly answers readers’ questions on matters relating to medicine, healthcare and politics. To send a query, click here.


I suppose I shouldn’t be surprised by drug-war rhetoric from both the left and right, but why on earth would you worry about an 83-year-old becoming addicted to Duragesic? Don’t you know that the research is clear that iatrogenic addiction is extremely rare among people (in the single digits, according to most data) without a history of substance abuse and that long-lasting, slow-acting medications like patches are among the least likely to produce addiction? Don’t you know that among older people, such addiction is even rarer? And that even among young people who try heroin, for goodness, sake, for recreational purposes, only 10-20 percent get hooked? If you don’t, I would be happy to provide citations.

You claimed that all analgesics can hurt the kidneys, but this is not true of opioids. When used as directed in a steady dose, their only side effects tend to be constipation. They are actually far safer than NSAIDS because they don’t cause bleeding.

Why can’t we tell the truth about opioids? And why can’t we let patients make an informed choice based on the data, rather than paternalistically presupposing that all humans are incipient dope fiends?

New York City

Dear Maia,

You are right that decisions about pain medication should be made pharmacologically and on a patient-by-patient basis. However, you are wrong to say that opiates don’t have a long-term addictive potential and aren’t likely to be abused. These feel-good drugs are great pain medications, but they are abused routinely, even if not by the majority of those who use them responsibly. And I do not say this simply because I can’t bear Rush Limbaugh’s radio show.

I have received information warning against freezing water in plastic water bottles; then adding water as it thaws, and using it for drinking. This is exactly what I do when I go out golfing! The gist was that when the ice thaws the bottle releases toxins into the water making it unsafe to drink. Is this true?

Gold Canyon, AZ

Dear Bobbi,

It is a fair question. It actually depends on the bottle. Acutely, though, I don’t think there’s a problem. However, prolonged exposure to plastic, especially when the exposure is then transferred to your stomach, could conceivably act as a low level carcinogen. I wouldn’t worry about it if you only use the water bottle on the weekends, but you might want to consider bottling water, rather than ice, as a general practice.

I’m writing because I saw you on “Help Me Howard” from the Channel 11 news. The topic was about herbal dietary supplements. I took an interest because I need help finding out about an herbal product. The product is called Vanity. It is used to increase breast size. I would like to try the product but I am scared that it may contain something that can hurt me and I am also scared it won’t work. I wanted to try breast implants but I am also terrified of that, so I figured that breast-enhancement pills were better. However, I feel that I can’t buy it unless I receive all the information I need. Thank you so much for taking the time to read this.

New York City

Dear Valerie,

I am concerned about the risks of any herbal supplement that is used to increase breast size–it is bound to have unregulated amounts of active hormone that can cause other effects on the body. In terms of breast implants, many people are happy with the results, but there are still many unproven questions related to silicone, and saline implants–the safer alternative–aren’t as effective. But how about accepting yourself as you are? I am not a big fan of cosmetic changes, because I think we all have to work harder to accept who we are rather than to fulfill the image that someone else may have of us. Many other writers have taken on this issue with great eloquence, including The Nation’s Katha Pollitt.

I’m 73 years old, a type-two diabetic (fairly well controlled), and otherwise in good health. My knees are not in good shape, though. My orthopedist told me I am almost devoid of cartilage. He suggested that I have knee implantations, but I’m not sure if I want to go that route. From what I have been reading, there can be complications. Perhaps I should wait for modern medicine to come up with something else for repairing bad knees. Is there anything in the works?

Beacon, NY

Dear Virginia,

What is truly in the works is too much of a push for knee replacements. It’s a cottage industry, and we would all be better off if modes of physical therapy, dietary supplements, and specific medications were exhausted first. Having said that, I would also add that there is a definite role for the procedure in cases of severe arthritis, or a knee completely devoid of cartilage, which means that bone is essentially grinding against itself. You may be in that category if your overall health is good. Diabetics tend to heal more slowly, but can also tolerate this procedure. I would encourage you to strongly consider the procedure if you’re satisfied that your cartilage is truly gone.

This is more an anecdote than a question. I am a disabled veteran and so receive medical care from the Veteran’s Administration (VA). The nearest VA clinic is eighty miles away, in Eureka, and the nearest VA hospital is in Roseburg, Oregon, 155 miles away. I do not have a car, so of course when I got sick with SARS-like symptoms during that epidemic in the late summer of 2002, I simply stayed in bed–having no insurance or money for a visit to the local urgent-care clinic run by Sutter Coast Hospital. I was in bed for two weeks, and my mother says I was unconscious and delirious most of that time. I finally woke so sick that I decided to spend the $88 to go to the clinic, but once there I was told my 104.8 temp was dangerously high and that I had to go to the ER across the street (I am 46, by the way).

I went to the ER, as instructed, fearing the eventual billing. The nurse took my temperature and I was given a Tylenol, then left by myself for more than three hours in a small surgery room. A lab tech took some blood along the way, and simple tests were ordered. Eventually a doctor came in and asked how I felt. I said awful, but my temp was down to 100 by then, so he said to go home, but return the next day if my temperature was back up. The next day it was again near 105, so I did as I was told and went back to the ER. This time I was given a Tylenol and left for hours freezing in the little room. Again the temp went down and I was sent home. The next day I was mending, though it took another two weeks to recover fully. I still limp with pain in my left knee, which swelled to twice its normal size.

At the end of that month I got the bill for this episode: $1,978. They even added insult to injury by billing me $88 for the original visit to the clinic where I was not seen but sent to the ER. I filed for bankruptcy the next week; this was the straw that broke me. In all, I spent less than twenty minutes with a physician, and the blood work was so routine and simple that it was barely charged. The meat of the bill was $890 just to walk through the door.

This was a billing that was not paid; it was discharged in bankruptcy court. The next time, God forbid, I will just have to lie in bed praying I do not die, since I no longer have the option of bankruptcy.

It is obvious to me that low compensation by MediCal is the culprit. The hospital expected me to file for coverage, and since reimbursements are so low, they inflate the charges in order to come close to what they feel they should be getting. Also, all unpaid charges must be totaled and divided among those that do pay. I was not eligible for Medicaid/MediCal since I had VA coverage. The VA would not pay since they said the illness did not result in death, so was not “life-threatening,” which is their standard for paying non-VA billings. In California you may not apply for MediCal unless you also apply for food stamps, general relief and other social services.

The irony here is that before I lost my home in Florida, and my career in 2000, I was a financial analyst at Florida Medicaid, which handled reimbursements for nursing home care. I was ostracized at work for being both gay and rather outspoken about the fraud and abuse in provider cost reporting. I say in full confidence that more than ten percent of the $2 billion we disbursed each year was fraudulent. This is the number the government estimates, but my estimate is double that. Prescription-drug reimbursement is even worse. I could write a book about the claims providers tried to slide by us; like the Marriott facility that claimed a $47,000 acquisition cost for a Lincoln Town Car. Or a string of three facilities that claimed property taxes paid to Broward County on the property tax pass-through no less, and for which they had applied and received years before an exemption as a nonprofit organization. The tax was paid on the part of the property that was a highrise condo with yacht marina and theater, and that was not to be claimed in their Medicaid cost report for their nursing home. For pointing out this example to my bosses I was passed over for promotion as a “troublemaker.”

I contend that if you took all the health insurance premiums paid by all employees and businesses, and all the unpaid billings, and all the cash payments by the uninsured for care, and all the government outlays for health in all the programs–state, federal and local–and all the money lost due to the total absence of care for the uninsured, and the money wasted in redundant and poorly distributed facilities/providers, you could fund a model single-payer system that was both innovative in research and equal in delivery to all people.

Not only that, there would be money left over, and cost would begin to actually decline. There is no earthly reason for the industry to be 17 percent of our total economy. We will never get control of healthcare costs as long as healthcare is treated as a luxury to be dispensed to those with the most money. Capitalism has no place in such a basic need. Greed must be removed from the system and will be in a few short years, when the system bankrupts America the way it did me.

Thank you for permitting me to vent my 2 cents’ worth (that is $61,544 in medical dollars).

Crescent City, CA

Dear Mark,

Thanks for a great letter. There is no doubt in my mind that the healthcare industry is a cash cow for private interests. It is tragic that the heart of the healthcare system–patients–are the ones who are marginalized and serve as sources of profit. The original idea of insurance was based on a cost-effective plan, where you get back essentially what you put in. Perhaps we could see that in a single-payer system, if it were administered properly. The current system doesn’t lower prices based on competition, it insures profits based on cronyism, as I don’t need to tell you.

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