What Happened to All the Clanging Brass Balls?

Maude: You know, at one time, I used to break into pet shops to liberate the canaries. But I decided that was an idea way before its time. Zoos are full, prisons are overflowing... oh my, how the world still *dearly* loves a *cage.*

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It's a gritty morning.  I need to do a dozen things, eleven of them clamoring to have been accomplished yesterday.

For once I'll spare you.  I put the Maude quote up top to get that crap out of my system.

So let me tell you about the brief visit with my Hawaiian-shirted, sandal-wearing NeuroMan on Thursday.

By the way, he continues to throw his staff under the bus for having attributed my spasticity to cerebral palsy (though Thursday, he said MS).  He further maligned this poor staffer for having ordered him an artichoke and olive pizza when what he craved -- and he is clearly a man of cravings -- was anchovies and onion.

I forgave everyone again, assuring them that there was not even the opportunity for offense being taken, at which I got the usual strange looks.

I had written out a text for him, as it was also, on Thursday morning, a gritty morning and I needed to do a dozen things, eleven of them clamoring to have been accomplished on Wednesday.  The epistolary version of my appeal to him for help began:

today's visit has several goals and i'm not leaving without answers.
just kidding.

He let me down, he really did.  He made squeaky noises about my need for specialized researchers who have been dubbed by the Queen as acceptable distributors of drugs in off-label uses.  He said, this is something that PainManagement Dood should be in charge of... or anyone... anyone ELSE.  "But I don't know enough, I don't specialize..."

Alarms, sirens, bright lights made my brain hurt.  No one knows, no one specializes, you dimwit hawaiian-shirted, sandal-wearing pseudo-cool guy!  Even the moody medico brave enough to infuse me with vast amounts of intravenous ketamine knew that.

He dared start to lift a lip in a sneer at my exposé on neuroinflammation, neuroautoimmunity, and my multimedia presentation of the DVD "Why am I still sick?" which is about biofilm infections.  If you claim not to know, if you claim to be ignorant, then don't hint at an upper lip tic when presented with information.

So I hit him squarely in the nose and kicked him where his brass balls were supposed to be a-hanging.

Brass Big Boy Nuts

Okay, I either hit him squarely in the nose and kicked him where his brass balls were supposed to be a-hanging or I said, "I need you to step up."  It amounted to the same thing.

Turns out he yammers, too.  So I told him to step up, several times.  It turns out that the thought of my good MDVIP go-to-guy doctor sets off fireworks in my verbiage.  He always steps up.  He takes the risks.  He never yammers, never makes excuses, and the goddamn Queen curtsies to him.  And he doesn't get the money the specialists get (InfectiousDisease Dood?  Oh my God, I am still getting EOBs that are clearly built on the art of upcoding) -- nowhere near.

That may have been the persuasive part -- not my anger at NeuroMan's neutered attitude, but my admiration for MDVIP go-to-guy, and my desire to protect him.

I left the office with 3-months worth of memantine [a med used for Alzheimer's that is an NMDA receptor blocker], and a prescription for dantrolene, mostly used in MS patients for spasticity.  Add that to Tuesday's Mobic, and I strong-armed my way through a fucked-up medical system with some success.  I can now predict that October will not be the month in which I succumb to suicide's sexy call.  Should there be any improvements, you, Dear Reader, will be the first to know.

Low Dose Ketamine and Memantine for Neuropathic Pain

I recognize and respect the frustration that doctors and nurses must experience when patients delve into the internet to obtain medical information, and then bring that "research" in to appointments in full "eureka!" mode.

That said (ar! ar! ar!), one of my MedWorm news feeds, on ketamine, turned this up:
ultra-low dose ketamine and memantine treatment for chronic pain -- specifically, neuropathic pain. As usual, the non-malignant neuropathic pain is represented by diabetic peripheral neuropathy. This use of memantine is off-label (of course) -- the drug is usually used in moderate to severe Alzheimer's disease (Namenda).

In the October 2008 issue of Anesthesia and Analgesia, doctors from the Anesthesia Department of the University of Washington published "Ultra-low dose ketamine and memantine treatment for pain in an opioid-tolerant oncology patient."

This is the abstract of the article that the authors submitted to PubMed:

Patients taking high-dose opioids chronically for tumor-related or neuropathic pain may develop pain that is refractory to opioids. One option for control of such pain is the use of the N-methyl-D-aspartate (NMDA) receptor antagonist ketamine. We describe a case of opioid-refractory pain that responded to a low-dose IV infusion of ketamine in the inpatient setting. The patient was then successfully transitioned to oral memantine for long-term outpatient management, in a novel use of this oral NMDA receptor antagonist. We present recent findings from basic research on pain mechanisms to explain why opioid tolerance, as in this patient, may contribute to the analgesic benefit of NMDA receptor antagonists.


"Memantine Significantly Reduces Peripheral Neuropathy Pain in Diabetics" was the next thing I turned up -- yes! I released the hounds! I let the dogs out! And I dare to call it research... But will I dare to stalk my internist, neurologist, and pain management doctor-dude with the information that I have culled, and will continue to cull?

Yes, I think so. It has been several years, actually, since I have dragged in any articles. Mostly, I read and then present anything interesting in a very brief oral report that inevitably results in the same reaction of "uh-huh." That is not to say there is no interest -- no, the problem lies elsewhere. The problem is that "no one knows" how CRPS / RSD really comes about, sticks around, or is best treated. I feel myself on almost equal footing with some of the more speculative researchers out there, with the difference that I cannot afford -- neither by bank account nor by insurance coverage -- the treatments that are in the pipeline.

Bitter? Moi? Of course not.

Shoot, we just added Forteo as an off-label use -- why not give this ketamine-transition-to-memantine idea a go? I think sometimes that they give me way too much credit. There is this tacit assumption that Retired Educator, succored by Fred, the felines, and La Belle Bianca Castafiore, and living the luxe in Marlinspike Hall, Tête de Hergé, can handle any amount of pain.

Not so. More and more "not so" with each passing day.

(Oh -- for those who don't know, MedWorm is a "medical RSS filter engine" and proves *occasionally* helpful in turning up germane articles -- but only if you feed the worm with very specific and well-thought out search guidelines. You must then bring the full power of your intellect to bear upon the results and vett the weird and unfounded, the scientistic and the industry-driven.)