I agree. Interesting article in that Tylenol and Vicodin work well for me. Ibuprofen on the other hand does nothing at all. Even 800 milligrams is no better than drinking water. But the doctors wouldn't believe me, even when I was shaking and in tears in the post-surgery torture bed.

Doctors need to learn to treat the individual in front of them, not the case study they read about in med school.

OhJoy - When I had my gallbladder out earlier this year, the doctors didn't take into account the fact that I've been on long term pain medication due to my auto-immune disease and had built up a tolerance. I was in agony, thrashing around on the bed, until they finally gave me a shot of something in addition to the Vicodin. And then the nurse chased my mother around for an hour talking about how I needed to get a handle on my drug problem! She was so pissed, she complained to her supervisor. I don't have a drug problem, I have a pain problem.

ah Matt... sounds awful and thank goodness you did get relief... and are finished with Vicodin.

There's codeine in Vicodin and Norco so we must be careful not to take more than we need and especially never longer than we need. Codeine is addictive... and worse, from what I have read, messes up thought processes... like using our brain cells, which affect everything... any smarts and good judgment we may have, it screws up emotions, and in a few cases I have read about even makes some of us physically clumsy.

Still, that in mind... for screaming type pain, it is a good temporary help. As it was in your case.

I personally hate the thought of messing with my brain cells... they're all I have to get through this very challenging life of ours. Want them wide-eyed and bushy-tailed and awake to all the good stuff that is part of true reality. (And able to deal with the not-so-good with any normal intelligence I might have.)

vicodin is a great painkillier,

Unfortunately it is mind altering, habit forming, with some dangerous side effects (respiratory depression for one)

Also, if dr's prescribe it willy-nilly, then the govt will not hesitate to revoke their medical licenses...

Matt, I agree. I live with debilitating chronic pain, and I've been on every painkiller, over-the-counter and prescription, that there is. Surprisingly, hydrocodone, which is one of the weaker opiates, is the best painkiller for me. I've been on much "stronger" ones that don't work nearly as well.

The fears of addiction are severely overblown. Numerous studies have proven that only 2-3% of pain patients prescribed opiate painkillers go on to abuse them. The most dangerous part of hydrocodone is that it's mixed with high doses of Tylenol, which is far more toxic and dangerous than the hydrocodone. I've never experienced any kind of problems with judgment or brain processes, and I've been on it for years. But everyone's body is different. You need to find what works for you.

The article just made me laugh, as do those commercials for Aleve and Advil that claim that two pills will leave you pain-free all day. I wish!

I also have severe chronic pain from injuries received in an automobile accident. Hydrocodone was one of the drugs I have taken that proved absolutely worthless in my case. Everyone is different. For me, Neurontin has proven to be the best painkiller other than morphine.

I do agree with you that Tylenol is a dangerous drug that should not be on the market, let alone OTC. And how about those Aleve & Advil claims! Two aspirin or a glass of wine does more in the way of pain relief than either of those products.

megidoloan,

Where are you getting your data? Its completely inaccurate. Please post your source. Here's some true (and cited) data:

Nonmedical use of prescription drugs doubled in the US between 1992 to 2003, from 7.8 to 15.1 million

In 2008, an estimated 6.2 million Americans (2.5 percent of the US population) reported using prescription drugs nonmedically in the past month

Results from the 2008 National Survey on Drug Use and Health: National Findings. Substance Abuse and Mental Health Services Administration, Rockville, MD, 2009

Emergency department visits involving controlled prescription drugs increased 79 percent in the US between 1994 and 2002, with the sharpest increase (168 percent) involving prescription opiates

Prescription drug abuse has a large economic burden. One study estimated the direct and indirect costs of prescription opioid abuse in 2001 to be $8.6 billion, including workplace, health care, and criminal justice expenditures

Hardly an overblown problem...

I metabolize pain meds faster than the medical textbooks say I should. Surgery is a nightmare for me. When doctors prescribe adequate (usually, MORE) pain meds, healing is actually faster. Our bodies tense up when we are in pain, which reduces circulation to essentially injured sites. And who can sleep while in pain?

I firmly believe that our bodies simply metabolize pain meds differently when we are actually experiencing pain. I for one have NEVER experienced any kind of high from taking them.

Jean, I also use Neurontin, and it's helped tremendously with my pain. It's like a fabulous multi-purpose med for me - it helps several of my conditions. I love it.

Eric, your information simply is not true for chronic pain patients. Your sources cite the behaviors of the general population - not pain patients. Here are some of my sources:

WHO: Achieving Balance in National Opioids Control Policy.

The WHO Expert Committee on Cancer Pain Relief and Active Supportive Care states that, "studies have shown that, while withdrawal syndrome and tolerance do occur in patients who take opioids over a long period, [drug] dependence is extremely rare."

Fishbain DA, et al. What Percentage of Chronic Non-Malignant Pain Patients Exposed to Chronic Opioid Analgesic Therapy Develop Abuse/Addiction and/or Aberrant Drug-Related Behaviors? A Structured Evidence Based Review. Pain Medicine. 2008;9(4):444-459.

Fishbain's article states that, "For the abuse/addiction grouping there were 24 studies with 2,507 CPPs [chronic pain patients] exposed for a calculated abuse/addiction rate of 3.27%."

I can tell you, as can several other chronic pain patients, that when you take opioids for pain, you don't feel any kind of high. I have no idea what this "high" feels like, and I've been on opioid therapy for years. The medication simply leaves me able to (somewhat) function and takes the edge off the debilitating pain. Trying to make us out to be drug addicts is very insulting. We're just trying to live like normal people.

Megidolaon, Please do not confuse Eric with the facts. He gets a little upset. He is just doing what he is PAID to do, which is comment on blogs to make a few points then he leaves. If you follow several blogs on health care issues, like I do, you will see him or his buddies, try and baffle everyone with BS. If you go toe to toe, with them on the facts, they usually shut down the postings. So lets give Eric and his buddies a round of applause! By the way I have been in pain, every day, for the last 40+years!!!!!!

so I just wanted to say

1) I apologize sincerely if I offended you, I did not intend to

2) It was my belief that this thread stemmed from the original poster, who stated vicodin worked "100%" of the time--especially in the acute setting, to which he was referring

3)Thanks for posting your source--it was interesting reading

But on the subject of chronic pain, I must disagree. I really do not like opiods chronically, for the reasons I desribed above

As for your article, it was interesting, and well designed, in addition to being well written. The biggest problem is that it is a meta-analysis, which while is the strongest form of evidence, it is also the hardest to analyze because it combines multiple studies, and it is difficult to analyze the methods

For example, even the authors state that there was not 1 accepted method for diagnosing addiction across the various studies. That is significant, and does weaken the overall argument the article is trying to make

However, your conclusion from the article is not totally correct

While it is true that the PHYSICIAN diagnosed addiction rate was 3.27%, the authors themselves conclude that this is an underestimate

In fact, the rate of aberrant drug related behaviors (ADRBs) {suggesting addiction} was 11.5%--quite a bit higher

In addition, the rate of illicit drug use is chronic pain patients is 14.5%--a very high number that would suggest addictive natures in these patients

In fact, urine toxicology found that over 20% of all chronic pain patients had opiods in their systems other than the ones prescribed

What you did was find the statistic that supported your point the most, and disregarded the rest

I actually think this study demonstrates the addictive potential of these patients

wow

Mr know it all,

I resent your implication, and challenge you to give any, ANY evidence for your claims

I do not get paid to write on here (although if msnbc wants to...)

I take part in no blog

I also am happy to respond to facts, which I think I have demonstrated.

Now let's contrast this with YOUR behavior

You list NO facts of your own. You are only capable of mocking others and making sarcastic remarks that remind me of an unfortunate child that has suffered head trauma

Now lets see who comes with facts or shuts down postings

Way to go Eric! You just answered my question. You will do anything for money. And what about that "unfortunate child" comment. PLEASE!

Eric, don't worry - you didn't offend me. This is just one of those issues that sets me off a bit because so many of us chronic pain patients are seen as drug addicts because we rely on narcotic painkillers to function. NSAIDs are also widely used in chronic pain treatment, but I'm allergic to them, so they aren't an option for me.

There are lots of other therapies to help with pain, such as physical therapy, other classes of drugs (like I mentioned, Neurontin is a godsend for nerve pain), acupuncture (never tried it, but lots of people swear by it), nutrition, and so forth. A good pain management physician will incorporate all of these in your treatment plan. While narcotic medications work, I personally don't think it's a good idea to rely solely on them. In addition to them, I also do yoga and water exercises and keep a healthy diet.

So yeah, I'm really not offended. It's just that we face that mistaken stereotype so much that it's easy to take it personally and want to clear up any wrong ideas.

Chronic pain patients who take opioids generally do NOT become addicted to them. I took vicoprofin for years (combined with neurontin) and never ONCE experienced any sort of "high". For acute pain, the only thing that works is Percocet (oxycodone/aceitominaphen). I have been taken off the opioids for chronic pain relief and am on neurontin only. I can't take hydrocodone (vicodin/vicoprofin/lortab) for acute pain because it upsets my stomach and MUST be taken with Benedryl in order for me to keep it down (I knew this while taking it for chronic pain and any time the doseage was increased I had to take benedryl for at least a week and a half before my body would tolerate it).

Chronic pain patients are NOT addicts. We may become DEPENDENT on a medication for pain relief, but that does not mean we are ADDICTED to it. Generally, we do not go out and "doctor shop" to get MORE pain medications to "get high". There are obviously people with chronic pain who DO become addicted and go to extraordinary means to get MORE, but the numbers of those people are smaller in the Chronic Pain "community" than in the general population.

While it is true that the PHYSICIAN diagnosed addiction rate was 3.27%, the authors themselves conclude that this is an underestimate.

Facts to back up the *underestimate*?

In fact, the rate of aberrant drug related behaviors (ADRBs) {suggesting addiction} was 11.5%--quite a bit higher

WTF are ADRBs, other than an acronym?

W/ the lg pool of side effects than *may* affect anyone, everyone, or no one at all, I don't even see how *drug related behaviors* (whatever those may be) could be termed *aberrant* when everyone's reaction isn't the same. Of course there will be *aberration*.

In addition, the rate of illicit drug use is chronic pain patients is 14.5%--a very high number that would suggest addictive natures in these patients

I call BS. By *illicit drug use* I shall assume you mean marijuana used for medicinal purposes (which is all the chronic pain patient urine testing is trying to *catch*).

That doesn't suggest an *addictive nature*. It suggests a patient who is not receiving sufficient relief thru conventional methods b/c the *war on drugs* is even in the dr's office. That's why there's now the specialty of *pain management* (which you'll note is not called *pain eradication*).

In fact, urine toxicology found that over 20% of all chronic pain patients had opiods in their systems other than the ones prescribed

That would probably be for 2 reasons.

• 1, the hit & miss nature of prescription pain relief & nasty side effects thereof, necessitating several switches in medication b4 the *right one* is settled upon (not necessarily by the patient, but by the dr), which means there are often *leftovers*. They were legally prescribed at one time, pd for, ppl aren't throwing them away *just in case*.
• 2, the prescribed pain relief is insufficient & therefore, supplemented from time to time w/ these *leftovers*.

What you don't seem to get is that there is a huge difference btwn *acute pain* (I hurt but it's just temporary, ie, injury or post-surgical pain) & *chronic pain* (I hurt & it's permanent, ie, autoimmune disorders & other chronic illness that cause constant pain, pain which will never subside & in most cases only gets worse). Percocet will take away 90% of the pain of a cracked rib, but it won't do much for severe arthritis (& not everyone who has severe arthritis is 80 yrs old), fibromyalgia, lupus, pick your chronic ailment & insert here.

Pain mgmt drs consider it *successful* if their treatment can alleviate just 30% of chronic pain. No ppl in acute pain would accept that statistic, but it's a fact of life for ppl in chronic pain. 70% of it is unrelieved.

In that context, everything you've had to say is invalid.

i think its more complicated than that for a few reasons

1) There are a LOT of drug-seekers--people want to get high, and they will say anything to a doctor in order to get narcotics. Some will go as far as looking up in a textbook what to say or how to respond to certain tests on physical exam in order to recieve pain meds

Here is a site I found within 10 seconds of looking online entitled "easiest way to get pain meds":

http://www.hipforums.com/newforums/showthread.php?t=284340

2) There are no tests to determine your pain level, or where its coming from (some of the time)

3) Its frustrating to treat

You obviously are approaching the subject from an academic standpoint. I hope you never experience the other side of the coin. Believe me, it is hell on earth.

youre right on both counts. I feel truly bad for people who are in constant pain without relief

However, I do still disagree with the orignal poster. Most doctors are jaded by all the fakers out there who ruin it for the few who are truly suffering

Most doctors are jaded by all the fakers out there who ruin it for the few who are truly suffering

You have that backwards. There are many suffering & only a few who *ruin it* for the vast majority of legitimate chronic pain patients.

You're no better than ppl who rail against all the ppl who are somehow *cheating the system* in order to live off *their* tax dollars. In both cases, pain mgmt & social programs, the % of bad apples is extremely low, not much more than 2-3%. That means there are 97-98% of ppl legitimately in need.

*Most* doctors won't touch a chronic pain patient b/c of restrictive fed regs, ins interference, frequent random testing, & mtns of pw. That's why they're referred to *pain mgmt*. At least educate yourself b4 you spout off.

Distraction didn't work for me. The pain was constantly there. It was so bad that I couldnt even stand to do the dishes. I couldnt concentrate on reading a book. I couldnt even pick up my infant son. I needed real pain medication. They stopped giving it to me, because they didnt want me to get addicted. Back to several months of living in hell, and not even being able to get out of bed.

I respectfully disagree...

Firstly, almost all pain meds are generic--think aspirin, ibuprofen, hydrocodone--No drug company sells those anymore as brand name, so drug reps are a non-issue

In addition, drug reps never bring docs to a strip club--that's ridiculous. Furthermore, would you sell out your patient for a nice dinner? If not, then how can you accuse most doctors of doing that?

Secondly, our health care system does not rank 37th in quality of care. It was PERFORMANCE of our health care system--subtle difference. In fact, what made up a large majority of their rankings was equity of distribution and payment of services, as well as overall health of the population. Believe it or not, those factors are not really influenced by doctors to a large degree. Its a little off topic, but I would be happy to discuss why I think our system is the BEST in the world..

The stripper club comment wasn't meant to be literal. If someone were to think that drug company reps and drug company TV commercials don't influence which drugs that are prescribed by physicians, I would have to classify that person as naive, at best.

The latest figures for infant mortality (in wiki) is that the USA ranks 34th in the world. 33 other countries, who spend way, way less on health care have better outcomes on births. Yeah we the best health care system, if you're rich and can afford to pay. Try to get health insurance in you have diabetes or heart disease, or anything. Pre-existing conditions often prevent you from getting health insurance. In EVERY other industrialized country in the world you get FREE health care. NOBODY else in the industrialized world goes bankrupt except Americans. Unpaid health care bills is the #1 cause of bankruptcy in America.

Yeah, we got the best....

And to address your first point, Vicoden, Lortab, Norco, etc.are all brand name prescriptions that sell millions and millions of dollars/year over generic hydrocodone, which is much cheaper.

Those drugs (norco, vicodin) are automatically exchanged for generic equivalents by most insurance companies. Again, there are NO norco drug reps, I promise you...

If you have evidence to support the claim that the brand name of those drugs sell for "millions" a year I would love to see it...

I don't think drug reps and certainly not TV commercials affect dr's prescription habits.

First, again, I ask you, would you sell out your patient in return for a free dinner? Would you make grandma pay more for a less efficacious medicine for a couple of pens and a smile from a pretty lady? Then how can you accuse doctors of doing that? Especially since theyve devoted a good portion of their lives to medicine, presumbly at least in part to help people? I think that viewpoint is unfair without any convincing evidence

Secondly, its important not only to look at the final data, but also at the methods in which it was collected, and how it is analyzed.

Infant mortality is a great example, Im glad you brought it up. Those data you cite come from telephone interviews--hardly a reliable data gathering technique. Also, in Cuba for example, an infant born at 32 weeks that dies 24 hours after delivery would be counted as a miscarriage--here in the US we count that as infant mortality--probably correctly

In addition, we have some of the best data tracking in the US--one reason behind our higher infant mortality is that we keep track better, not necessarily that there are actually more deaths than other countries

Finally, we have a very unhealthy population. We don't really look it from the outside, but if you could see inside, you would see all the atherosclerosis, coronary artery disease, diabetes, hypertension, etc...The responsibility for that is squarely on the population, not the health care sector. And of course sicker mothers have sicker babies. So the infant mortality statistic is really more reflective of our overall health (largely in the hands of the patients) rather than a condemnation on our health care system

To your last point, no health care is free. Those countries pay taxes orders of magnitude more than us.

But I do agree that denial based off pre-existing conditions is wrong, as well as bankruptcy because your insurance company doesn't want to pay

But to think that you can trade this in for "free" health care is a pipe dream.

speaking of getting out more, why don't you take some of your own advice and not use a phrase that has been repeated on the internet since people were using AOL...

ON a more adult note, just show me some evidence instead of tired old phrases and I would be happy to debate them with you

I thought the "looking out of your plexiglass belly button" or "the dropping bread crumbs, so you could keep up" comments were funny! HAHAHA

I guess I don't get it...maybe I do need to get out more?

The problem with marijuana is that it is still illegal in most places. It's ridiculous, but that is the fact. Even though I have chronic pain that is only lessened by Neurontin, I'm not really ready to risk even a tiny bit of jail time. I also love to travel and would be at a loss to make a connection for marijuana in a foreign country even if I dared to try. At 70 years of age, I think I'll just wait for death to take the pain away.

jean:

I'm very sorry that you are suffering. I understand your position, but if I were you I would say screw the law and toke up. If you did get busted with a small amount of weed I very seriously doubt you would see any jail time. Now if you got busted a second time...

You are 70 now. You could live another 10 years or more. That's a damn long time to be in chronic pain. Give weed a try. It may or may not work for you. But if it does, I bet you would move to a state that had medical marijuana.

Thats the only thing that takes the pain away fully. I am so glad to live where I do!

Key word, 'nearly'. Seriously, don't speak for others. Have an agony-free day, hope you aren't ever in need of a 'specific' med for intense pain. 'Walk a mile in another man's moccasins...'

Wusses? Really? All this time I thought I was in tremendous pain because my spine is slowing fusing together. But come to find out I'm just a wuss. Good to know.

I know there is no actual treatment for fibromyalgia, so the best doctors can do right now is treatment for symptoms, especially pain, but it is another example of treating the symptoms rather than the actual disease. Hopefully someday they will find a way to treat the cause of the pain and fatigue rather than just give pain meds.

I wouldn't be surprised if someday they found fibromyalgia, autoimmune forms of arthritis, and many other simular diseases have related roots as so many times one person will have several of these types of diseases.

EAE - a lot of other people I know who have Fibro have joked about it being "MS-light". I do have an auto-immune form of arthritis - psoriatic arthritis (along with the psoriasis). I don't think they are related because my mom's family shows the predisposition to Fibro and my Dad is where I inherited the psoriasis.

And you are part of why chronic pain patients are "labeled". Great job doc. Keep helping those in need. Ever heard of a pain contract? Look it up. Pain is personal and CANNOT be quantified. I hope someday you end up in chronic pain and are labeled a "seeker." Turn in your license and go practice third world medicine. They could use you.

I really hope you are NOT a doctor. Because if you are you have failed your patients by failing to take continuing medical education. If you are a doctor then you are a SHAM. If you are a nurse you are a SHAM. Doctors and nurses are bound by ETHICS to continue to further their education in medicine as it is a DEVELOPING field. It does not stand still. There are new diagnostics, new medications, new illnesses and new treatments being discovered all the time. I highly doubt that you ARE "in the medical field" unless you are either a) someone with a "god complex" who thinks they know it all because they passed medical school or went to medical school because of the complex, b) someone who has RETIRED because they are so old that they can no longer perform their medical duties, c) a drug rep, d) a sociopath who enjoys the suffering of others or e) a veterinarian.

There IS a diagnostic criteria for Fibromylagia. There are 18 tender points on the body and someone MUST have 11 of them in order to be diagnosed. There are a number of diagnostics that are used to rule out other similar illness (like Multiple Sclerosis).

http://www.nfra.net/Diagnost.htm

http://onlinelibrary.wiley.com/doi/10.1002/acr.20140/pdf

http://www.mayoclinic.com/health/fibromyalgia/AR00056

http://www.mayoclinic.com/health/fibromyalgia/DS00079

Cat- "It's" moniker alone suggests "it" is NOT a doctor. MAYBE a P.A. at most. ANY physician who thinks real pain is faked is deluded. Yes, there ARE drug seekers, but YOU as a "Doctor" are supposedly trained to figure that out. Ever think elevated BP? flushed skin? rapid respiration? There are plenty of indicators. I pity your patients Fake Pain Syndrome. Personally, I tend to think that you are NOT a licensed physician simply based on your obvious misunderstanding. You give the REAL physicians who care about their patients' well-being AND comfort a horrible name.

On other words "Fake Pain Syndrome"... Put up, or shut up. Then change your moniker to "Real Pain In The A$$ Syndrome." You're as much an M.D. as I am an astronaut. PFFFFFFTTTTT!!!!!!

The real problem is that there are too many people that fake pain to get their fix of narcotics.

Got statistics on that? B/c the majority of studies I've seen abstracted say it's 2-3 ppl out of every 100 who *want a fix*. Believe me, a competent medical professional knows how to weed those ppl out & even if 1 slips by, fed regs on frequent random testing will catch tme eventually.

Drs are almost always initially skeptical of anybody that comes in seeking "the best pain medication you have."

I've never heard anyone say such a thing LOL It's not like they're ordering steak.

For those of you outside of the medical field,

Of which I think it's safe to say you'd be one of them.

there are a lot of patients that will even claim they are allergic to a laundry list of medications,

Some ppl are. Non-narcotic indomethecin made me so loopy I couldn't keep my eyes open, yet I couldn't sleep b/c of how it made my brain race, & after 2 doses I was told to discontinue it immediately b/c my lips were numb & tingling, my tongue was thick, I was slurring speech, & those things can signal the start of anaphylactic shock.

except of course their drug of choice.

Yes, b/c all patients go to the dr w/ a list of meds they must.have.now.

It puts us in a horrible position legally. Do we give them what the actually need, give them what they want, or make the judgement call and kick them the heck out of the office?

No, 1st you'd verify the allergic reaction.

Duhhh. You're not a dr.

And don't even get me started on Fibromyalgia. It's a disease with no diagnostic criteria, no lab abnormalities, and no common symptom besides "pain."

You're wrong. There is certainly diagnostive criteria.

Besides the previously referenced tender pts, FMS can also be diagnosed from a simple sleep study. No one who has FMS gets to delta stage sleep. That's the restorative stage of very deep sleep where the body gets to *heal*. This is what causes the extreme fatigue & unrelenting pain.

Can't *fake out* electrodes.

Nor can you *fake* blood work.

If a patient's C-reactive protein factor is abnormally high, there's inflammation going on in the body. That's a prime marker for FMS.

You're as much an M.D. as I am an astronaut. PFFFFFFTTTTT!!!!!!

Agreed.

Yeah ... I went through a NUMBER of tests in order to be diagnosed with FMS. Some NEUROLOGISTS think that I may have both FMS and MS ... I just may be one of the few who never show demyelinization on an MRI. I also have CTS (diagnosed by an EMG), peripheral nerve damage in my feet, psoriasis and psoriatic arthritis, MPS, CFIDS ... and the list goes on. Percocet/oxycodone (as I've mentioned before) is the ONLY pain med that works for me on acute pain. Dilaudid/hydromorhpone (which is STRONGER than Percocet) does NOTHING. T-3's do no better than M & M's, and I have the aforementioned GI problems with hydrocodone.

I *have* known people who claimed higher levels of pain in order to get more medication, but they also DOCTOR SHOPPED in order to get them and had meds filled at different pharmacies in order to foil the feds. I have ONLY seen Doctors I've been referred to and use only one pharmacy. My pain levels on a daily basis are between 7 and 8 ... pain that "normal" people would be at their doctor's office crying about. For a Fibro person to say they're even at a 6 ... that's pain that most "normal" people would rate somewhere about an 8 or 9. We have to learn to LIVE with pain that others would drive to the ER to alleviate so our "pain level" scale gets adjusted up and most REAL health care professionals know that when a Fibro patient says they're at a 7 it's REAL pain.

To give an example, my labor pains for me never went above what I live with on a regular basis ... it was just in a different area. I was up and standing on a chair taking pictures of my husband and son within 14 hours of a c-section.

Also my doctor evaluated my metabolism, blood pressure, and weight to find out my correct pain dosage. They did not just say, "Oh here's 600 mg, hope this works."

I know another person who just had their wisdom teeth extracted by another dr. and they were just given random dosages of pain meds.

So obviously alot of drs. DON"T seem to really investigate into each patient's uniqueness.