> I'm curious about your experiences.

Well, let me tell you first my personal experiences with a non-terminal but severe and potentially life-threatening illness before I move on to my two relatives who died of cancer. I've had two excruciating episodes of acute pancreatitis that sent me to the ER this past 18 months. One was quite severe and left me in the hospital for a week. Pain control wasn't a problem in the hospital, but once I was discharged it become a huge problem. I got multiple other episodes of similar severe abdominal/back pain the past year but my amylase/lipase weren't elevated sky-high as they were during the two hospital stays. The whole situation lasted so long I'd assume I would be considered a chronic pain patient, and yet I can quite assure you I wasn't looking comfortable, I had elevated HR and BP, I was nauseated from either the pancreatitis or the pain (sometimes it was hard to tell). And yet the gastro I was seeing was loathe to prescribe me adequate pain relief, nor would he make a diagnosis of chronic pancreatitis all while farting around with tests like colonoscopy and gastric transit time testing. I got a months worth of pain killers from him after I was in the hospital for a week, then I was on my own though the pain was sometimes just as bad.

Finally, I fired him after getting nowhere for a year, went to a pancreas center of excellence a few hours away where they quickly ordered an EUS and found it was a bad gallbladder that was causing it (the old gastro had ordered a CAT scan and ultrasound but neither showed the sludge that my GB was packed with, although it should have shown some other issues with the gallbladder according to the pancreas expert). Had gallbladder removed a month ago and am feeling much better now, finally able to eat normally for first time in 18 months and out of severe pain.

Unfortunately, because of the pain and sickness, I've been unable to work for most of the last 18 months. Along with my considerable hospital bills (dozens of procedures, a surgery, two hospital stays), this has left my family in a precarious financial position. Luckily, so I'm now looking to return to work.

My story is not even what I was thinking about above, since I'm not 100% sure if I'd be considered a chronic or acute pain patient, but your attitude struck a nerve with me so I thought I'd share. Frankly, it pisses me off to hear you describe your patients thus, because my guess is that some of them are like me over the past 18 months.

By the way, although I certainly wasn't comfortable when I was in moderate-to-severe pain from the pancreatitis over the past 18 months, I would watch movies in a sometimes vain attempt to distract myself from the pain. I mention this just to clue you in as to what might be happening with your patients. And yes, some of your patients are malingering, I'm sure. But the fact that you make blanket generalizations about all your chronic pain patients tells me all I need to know about how many true cases of severe pain you're discounting.

On to my two relatives who passed away from cancer. One (my uncle, 45 of age, with lymphoma) wanted to die at home and so took home hospice care. Vastly under-treated for pain, with my aunts and uncles constantly reminding the doctors that he was terminal and pleading for more/better pain meds for him. The man was dying and his main goal, as explicitly explained to the doctors, was to die at home and do so as comfortably as possible, so I don't understand why concern over addiction, respiratory depression, or hypotension should have played a major role.

My other relative (grandfather) who passed away from cancer was a paragon of his community, retired fire chief, in-patient hospice care, 80 years old, and still struggled to get adequate pain relief for his terminal cancer pain. Luckily, after 3-4 weeks of unnecessary suffering, he had enough connections to influential people in the community that the situation was rectified, but what happens to other people without connections? Well, if they were at that hospice, then they probably suffered.

Honestly, this whole situation pisses me off so badly this will be my last comment on the matter. Think what you want, but tons of people, both acute and chronic pain patients, out there are suffering, and yet what's currently causing most opiate deaths are illegal drugs, not prescription pain killers. And many of the prescription pain killers are diverted from overseas, and not diverted from bona fide pain patients.

> But in my circle, I'm pretty frank with patients that we generally won't use opioids for chronic pain outside of cancer-pain [...] Yes, it means the few that do have a good indication for chronic opioid therapy will suffer.

Glad you recognize this. In addition to my verifiably organic condition, I have a friend with phantom limb pain (actually missing a arm, pretty fucking organic!) who is not helped much by the usual neuropathic pain drugs while opioids helped him tremendously. But he can't get them anymore, like yourself, all his doctors refuse, and so he suffers and is on disability when before he worked. Another casualty from our war on drugs, I suppose.

If you're like most doctors, I'm guessing that this won't make a damn bit of difference to your perspective, so I'm not sure why I spent the time writing it up. But I did, so I'll hit submit.