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I had an interesting conversation today. Our PCP called in Barb’s opioid Rx in Monday or Tuesday. The independent pharmacy that we patronize called us and said that their drug wholesaler – one of the BIG THREE MAJORS – did not have her particular med in stock & it was in back order.
I know who the drug wholesaler that they use. So I called their corporate HQ. I got to someone in their customer service area. I told the gentleman that I was trying to confirm that they had no inventory of a particular C-2. He first told me that I was not a customer of the wholesaler, and he could not tell me if they had inventory.
I asked if he could transfer the call to someone who is his supervisor and could share that information? Surprisingly, this young man suddenly had the authority to provide me if they had any inventory on hand.
He stated that they had no inventory on hand. I asked him how many pharmas that makes this particular product, did they normally have it in inventory ? I was told that they normally had the product from NINE DIFFERENT PHARMAS. I asked if they had an inventory on the next higher strength. I knew that even though this was a extended release – long acting – dose that they could be split in half without interfering with the long-acting property. I then called our pharmacy and they checked the wholesaler’s inventory for the higher strength – but they only had CAPSULES – which you can’t split.
This guy had no information on when any of the strength that Barb needs would become available.
I have no way to check, but the THREE MAJOR DRUG WHOLESALERS control some 80% of the entire Rx marketplace. So I would not be surprised if all three of these wholesalers are also without inventory.
Barb has a implanted pump, so she can “survive” without one of the two oral opioids that she takes. I feel sorry if all those chronic pain pts that can’t refill their Rxs more than two days early and will soon be thrown into cold turkey withdrawal.
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The FDA does not routinely use Morphine Milligram Equivalents (MME) in its professional literature for opioid
dosing for several key reasons:
– **Variability in Conversion Factors:** MME conversion tables are based on data from small clinical studies
in limited populations, and different resources (tables, calculators) may use different conversion factors for the
same opioid. This lack of standardization can lead to inconsistencies and potential dosing errors when applied
broadly[5].
– **Patient and Drug Differences:** The pharmacokinetics and pharmacodynamics of opioids can vary widely
among individuals due to factors like opioid tolerance, genetics, age, organ function, and concurrent
medications. Some opioids (e.g., partial agonists like buprenorphine or novel agents like tapentadol) do not fit
neatly into the MME system, making it unreliable for all clinical scenarios[5].
– **Intended Use of MME:** The original purpose of MME was to provide a rough guide for clinicians when
converting from one opioid to another, not as a precise tool for dosing or setting rigid prescribing thresholds[5].
Over time, MMEs have been increasingly used by policymakers and payers to set limits, but these uses may not
reflect the nuances required for individual patient care.
– **Risk of Misapplication:** The FDA and CDC have both cautioned that applying MME thresholds as rigid
standards can lead to unintended consequences, such as under-treatment of pain or abrupt discontinuation of
opioids in patients who may benefit from them. Clinical guidelines now emphasize individualized care and warn
against using MME cutoffs as inflexible rules[1][5].
– **Epidemiologic vs. Clinical Use:** While epidemiologic studies have shown that higher daily MME doses
are associated with increased overdose risk, there is no universally agreed-upon MME threshold that defines
“safe” versus “unsafe” prescribing. The FDA recognizes that MME is useful for population-level risk
assessment but not as a precise clinical dosing tool[5].
Citations:
[1] https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm
[2] https://www.ncbi.nlm.nih.gov/books/NBK458653/
[3] https://www.fda.gov/media/147152/download
[4] https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
[5] https://www.fda.gov/media/150436/download
[6]
https://www.fda.gov/drugs/news-events-human-drugs/morphine-milligram-equivalents-current-applications-and
-knowledge-gaps-research-opportunities-and
[7]
https://www.fda.gov/drugs/drug-safety-and-availability/fda-updates-prescribing-information-all-opioid-pain-me
dicines-provide-additional-guidance-safe-use
[8] https://www.fda.gov/media/126835/download
[9]
https://www.fda.gov/drugs/fda-drug-safety-podcasts/fda-updates-prescribing-information-all-opioid-pain-medici
nes-provide-additional-guidance-safe-use
[10] https://www.healthvermont.gov/sites/default/files/document/reg-prescribing-opioids.pdf
[11] https://www.ncbi.nlm.nih.gov/books/NBK551720/
[12] https://www.ncbi.nlm.nih.gov/books/NBK572085/
[13] https://health.ri.gov/addiction-overdose/safe-opioid-prescribing
[14] https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/019813s033lbl.pdf
[15] https://www.ncbi.nlm.nih.gov/books/NBK458654/
[16] https://mn.gov/dhs/opip/opioid-guidelines/pain-phase/acute-pain.jsp
[17] https://healthandwelfare.idaho.gov/providers/opioid-use-disorder/opioid-prescribing
[18] https://mn.gov/dhs/opip/opioid-guidelines/pain-phase/chronic-pain.jsp
[19]
https://www.fda.gov/drugs/food-and-drug-administration-overdose-prevention-framework/timeline-selected-fda
-activities-and-significant-events-addressing-substance-use-and-overdose
[20] https://www.hca.wa.gov/assets/billers-and-providers/opioid-policy.pdf
—
Answer from Perplexity: pplx.ai/share
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The hyperlink below is just a link to a 557-page report from the WHITE HOUSE on the COVID-19 Crisis. Of course, the highlight of the entire 4 yrs crisis and a copy of the pardon that President Biden gave Anthony Fauci for his contributions to the COVID-19 crisis.
https://www.whitehouse.gov/lab-leak-true-origins-of-covid-19/?utm_source=wh_social_share_button
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https://www.acsh.org/news/2025/04/14/morphine-milligram-equivalents-metric-obscures-mission-49415
Generated by AI
“You can’t manage what you can’t measure.”
While this statement by business sociologist Peter Drucker is certainly true, in some scientific or regulatory instances, it is impossible to measure what you seek to manage. Proxies are measurable and, when strongly correlated with our goal, useful. Proxies can simplify complex problems, allow for performance tracking, and deliver faster feedback. But poorly chosen proxies derail the very goals they’re meant to support.
A Poorly Chosen Proxy
In the opioid wars, Morphine Milligram Equivalents (MMEs) became the proxy of choice. Easily measured, easy to regulate, and track—MMEs appear whenever a prescription is filled. So, it made sense, on the surface, to use MMEs to simplify the goal of reducing opioid prescribing.
Unfortunately, the goal of reducing opioid prescribing is, in fact, a proxy for an even more difficult goal: the reduction of prescription-related substance use disorder.
MMEs, now a proxy for a proxy—lose their strength of correlation and usefulness, succumbing to the proxy’s pitfalls: misalignment, unintended consequences, and oversimplification. More specifically, the use of MMEs in the war on opioid addiction and overdoses has resulted in unintended harm to individuals afflicted with chronic pain, oversimplifying the clinical nuances of addiction allowing bureaucrats to count pills instead of understanding patients.
It is a painful demonstration of Goodhart’s Law,
“When a measure becomes a target, it ceases to be a good measure.”
A new study in JAMA Network Open drives home the disconnect between proxy metrics and meaningful outcomes.
The Law That Capped Judgment
In 2016, New York implemented a limit to the initial prescription of opioids for acute pain to 7 days, stripping any discretion, i.e., clinical judgment, by physicians. The New York law, known as Section 3331, joined 39 other states in state opioid cap laws (SOCLs) aimed at:
The research involving Medicare beneficiaries looked at prescribing behavior before and after implementing New York’s SOCL Section 3331 for individuals undergoing total joint replacement (TJR). As they write,
“Adequate post-TJR pain control is a key marker of successful surgery, and inadequate control is associated with impaired recovery, resulting in delayed or unmet physical therapy milestones, increased health services use, and reduced quality of life.”
California, which had the highest number of Medicare TJRs and no SOCL, served as a control. The primary endpoint was the total MMEs filled after discharge. They considered the first 7 days after surgery and 30- and 90-day intervals consistent with the law and “key clinical practice milestones.” [1]
The patient cohort included 85,000 Medicare beneficiaries undergoing 93,000 total joint replacements, roughly a third being treated before New York’s SOCL implementation. The mean age was 73; 60% were women, and 89% were White.
The Data Speaks
“Overall, our findings suggest that Section 3331 may have achieved its intended objective of reducing opioid prescribing for acute pain in the short-term 7-day post-TJR period.” [emphasis added]
However, that’s where the success story ends. The unstated but actual goal, reducing prolonged opioid exposure, addiction risk, and leftover meds for diversion—remained unmeasured and possibly unmet. Exposure was longer in New York when those later refills are counted. And we have no data on addiction, diversion, or patient satisfaction.
What’s Missing from the Metrics
Most critically, the focus on the proxy, MMEs prescribed, left “meaningful changes in the pain needs of patients, morbidity, or mortality for future research.” The increase in refills after the initial 7 days is ambiguous. Do they suggest the persistence of pain requiring longer treatment or reflect misuse or diversion? Refills tell us nothing about “risky” behavior.
We don’t know—because the measure we chose can’t tell us.
Goodhart’s Law In The Real World
Goodhart’s Law manifests itself in many ways, as this study demonstrates. MMEs are too simple a measure of the complexity of real-world prescribing that is a confluence of practitioner beliefs, institutional protocols, and policy environment. California’s trends in prescribing behavior were nearly identical to New York’s, without the benefit or limitations of SOCL. MMEs fail because they are correlates, not causes. MMEs are a rough measure of opioid exposure, at best, a risk factor among many for substance use disorder.
They are neither a measure of pain management nor relief. MMEs also allow for gaming the system. Prescribers might under-treat pain out of fear—or overprescribe to avoid complaints—neither of which addresses patient well-being. Proxies distort behavior and, as Goodhart suggests, undermine intended outcomes.
Recognizing these pitfalls, one might hope for mitigation strategies. That could include:
Unfortunately, legislation is drawn in blacks and whites, and rarely are clinicians invited to the table. Researchers are equally culpable for using available data rather than more costly, in time and money, bespoke data. These researchers write that “much work remains to restrict opioid prescribing in the later post-TJR period, suggesting there is an opportunity to refine Section 3331 to reduce perioperative prescribing.” This refines the proxy and does little for the clinical outcomes of safe pain management and lowered addiction risk.
Proxy metrics like MMEs were never designed to bear the weight of legislation, yet we keep piling on. In chasing numbers, we lose sight of patients—of pain that goes untreated, of addiction risks that go unmeasured, of policies that solve for optics instead of outcomes.
Real patients suffer when we treat metrics as medicine.
If we want better results, we need better questions, metrics, and a better understanding of what and who we’re actually trying to heal.
[1] Secondary endpoints included MMEs per prescription and day, number of refills and the likelihood of at least one opioid fill, the likelihood of an opioid prescription longer than 7 days, and total opioids prescribed.
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I asked www.perplexity.ai several questions concerning a pt’s concurrent prescribed use of an opioid, benzodiazepine, and muscle relaxant. It kept giving me answers that might, could cause respiratory suppression. It was obvious all the answers were based on – IMO – sloppy documentation of a death from a person taking the three meds together, and maybe – maybe not – took prescribed meds as directed in mgs dose and frequency, and what other substances – legal or illegal – the person had taken.
Statistics can be your friend or your enemy. When someone has an agenda and they are in the position to choose which particular pieces of data they can use to support the conclusion that will serve their agenda. One can just figure out which pieces of data are ignored or discarded, and which ones are used to match the conclusion that they want.
Below is my final question, trying to get Perplexity to find some definitive data. The last sentence in Perplexity’s answer pretty much says and clarifies it all.
So what you are saying is that no one bothered to document any evidence that confirmed ODs that the person was taking their prescribed meds, in the doses and frequency prescribed and had taken no other legal or illegal substances concurrently. Published statistics have stated that the typical OD involved 4 to 7 different substances, with alcohol and marijuana typically being in the polysubstance OD. While all three classes of meds will suppress respiration, but is suppression at therapeutic doses typically fatal – can you provide clinical studies that shows a high probability of it being fatal
The user raises valid concerns about confounding factors in overdose statistics, but clinical and pharmacological evidence confirms that fatal respiratory depression can occur even when opioids, benzodiazepines, and muscle relaxants are taken as prescribed, without other substances. Here’s the breakdown:
FDA’s 2016 Analysis (prescribed regimens):
Veterans Health Study:
Respiratory Depression Mechanism:
Opioids (µ-opioid receptors) and benzodiazepines (GABA-A receptors) synergistically suppress brainstem respiratory drive710.
Muscle relaxants like carisoprodol further amplify GABA-A receptor activity, eliminating the “ceiling effect” of partial opioids (e.g., buprenorphine)109.
Animal/human studies show synergistic hypoxia even at sedative (not overdose) doses810.
Polysubstance Overdose Prevalence:
Indirect Evidence from Hospitalizations:
Human Experimental Trial:
Fentanyl (opioid) + midazolam (benzodiazepine) at sedative doses caused severe hypoxia in 100% of subjects vs. 50% with fentanyl alone8.
Buprenorphine/Methadone Patients:
82% of buprenorphine-related deaths involved benzodiazepines, often at prescribed doses9.
Postoperative Mortality:
Combined preoperative opioids + benzodiazepines (as prescribed) increased short- and long-term mortality vs. either drug alone7.
While polysubstance use dominates overdose statistics, mechanistic and cohort studies confirm that respiratory depression from triple therapy can be fatal at therapeutic doses, particularly in high-risk groups (e.g., sleep apnea patients, elderly). The FDA and CDC warnings are grounded in this evidence, though isolating “pure” cases remains methodologically challenging 1 4 10.
Answer from Perplexity: pplx.ai/share
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More than 90% of people taken to federal court in the United States are found guilty. The most recent data shows that in fiscal year 2022, 89.5% of federal defendants pleaded guilty, while only 0.4% went to trial and were acquitted, and 1.9% went to trial and were found guilty. An additional 8.2% of cases were dismissed at some point in the judicial process
When combining those who plead guilty with those found guilty at trial, the overall conviction rate in federal court exceeds 90%—and is often cited as being around 93% or higher in recent years
. This high rate is largely due to the prevalence of plea bargains, which account for the vast majority of convictions in the federal system
In summary, the percentage of people taken to federal court who are found guilty is typically above 90%, with most convictions resulting from guilty pleas rather than trials
Overview:
Dr. Neil K. Anand, a Pennsylvania-based pain management specialist, was convicted by a federal jury in April 2025 on multiple counts related to healthcare fraud and violations of the Controlled Substances Act (CSA).
Key Charges and Findings:
Healthcare Fraud and Wire Fraud:
Dr. Anand was found guilty of conspiring to submit false and fraudulent claims totaling approximately $2.3 million to Medicare, the U.S. Office of Personnel Management (OPM), Independence Blue Cross (IBC), and Anthem. The fraudulent activity centered around “goody bags”—pre-packaged sets of prescription medications dispensed by his in-house pharmacies. Patients were required to accept these unnecessary “goody bags” in order to receive prescriptions for regulated drugs23.
Distribution of Controlled Substances:
Anand distributed over 20,000 tablets of oxycodone, a highly addictive opioid painkiller, to nine patients, often without a legitimate medical purpose and outside the usual course of professional practice. He also signed blank prescription letterheads and allowed unlicensed medical interns to write prescriptions for controlled substances23.
Money Laundering and Unlawful Monetary Transactions:
After the investigation began, Anand attempted to conceal his fraudulent activities by transferring nearly $1.2 million into an account in his father’s name, purportedly for the benefit of his minor daughter2.
Conspiracy to Distribute Controlled Substances:
The evidence showed Anand conspired with others to distribute controlled substances without a legitimate medical purpose, using the goody bag scheme as a cover for the unlawful distribution of opioids23.
Potential Penalty:
Dr. Anand faces a maximum statutory penalty of up to 130 years in prison. Sentencing is scheduled to begin on August 19, 2025, with the final sentence to be determined by a federal district court judge in accordance with U.S. Sentencing Guidelines and other statutory provisions2.
Summary Table of Charges
| Charge | Description |
|---|---|
| Healthcare Fraud & Wire Fraud | False claims to Medicare, OPM, IBC, Anthem via unnecessary “goody bags” |
| Distribution of Controlled Substances | Unlawful prescription and distribution of over 20,000 oxycodone tablets |
| Money Laundering & Unlawful Transactions | Concealing proceeds by transferring $1.2 million to a family account |
| Conspiracy to Distribute Controlled Drugs | Collaborating with others to distribute opioids without legitimate medical purpose |
Dr. Anand’s conviction highlights ongoing federal efforts to combat opioid-related healthcare fraud and the improper distribution of controlled substances by medical professionals23.
Answer from Perplexity: pplx.ai/share
While according to asking three different AI programs what was in the “goody bag,” the only one that mentioned was Oxycodone
One of the people that I know told me that a plastic bag with some writing on the outside like “EVIDENCE” contained one or more tubes of Diclofenac Topical (Voltaren)- which is an OTC medication.
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Some people (DOJ, DEA, Fed prosecutors, politicians, media, and others) believe and state that opioids are VERY ADDICTING. Many things in our day-to-day life can be dangerous or even kill us. Vehicles are/can be very safe – yet some 42K people die in vehicle accidents every year. Some 100K people die from using many alcohol products, the death rate from people using tobacco products is in the 400 range, and some claim that both of those products are addictive. Gasoline, Kerosene, and Propane are safe, as long as they are used properly, and a simple spark or some ignition source can turn an otherwise safe product into a potentially dangerous or catastrophic outcome.
Below is what perplexity.ai suggests are preexisting ( undiagnosed ) health issues in a person, and when they interact with some substance (opioid, alcohol, cocaine, etc), they – LIKE THE WAY IT MAKES THEM FEEL – and they start down the road to some degree of addiction.
Basically, people who are labeled as dealing with SUD or OUD have some degree of undiagnosed or under/untreated mental health issues that collectively is a form of addictive personality.
So here we are, 55 yrs after our bigoted, racist President Nixon got Congress to pass a bill that was basically directed at putting hippies and black people in jail. We are still chasing down addicts, because President Nixon, by education, was an ATTORNEY, and we still have attorneys interfering with the practice of medicine, but they have expanded their scope that they are raiding practitioners’ offices and throwing thousands of people who have a valid/legit medical needs to be prescribed a controlled med. Not to mention that they are ruining thousands of practitioners’ lives and discouraging other practitioners from properly treating millions of pts who have a valid need to take a controlled substance.
Besides violating this federal law that has been on the books since 1935 – 35 yrs before the CSA was signed into law.
https://uscode.house.gov/view.xhtml?req=(title:42%20section:1395%20edition:prelim)
Nothing in this sub chapter shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer or employee of any institution, agency, or person providing health services; or to exercise any supervision or control over the administration or operation of any such institution, agency, or person.
(Aug. 14, 1935, ch. 531, title XVIII, §1801, as added Pub. L. 89–97, title I, §102(a), July 30, 1965, 79 Stat. 291 .)
Here is something interesting: What comorbidity issues are generally involved with addiction? I suggest this as well: DOJ Considers Opioid Use Disorder an ADA Covered Disability and Pursues Claims Against a Provider for Refusing Medical Services to Opioid Users https://www.pharmaciststeve.com/doj-considers-opioid-use-disorder-an-ada-covered-disability-and-pursues-claims-against-a-provider-for-refusing-medical-services-to-opioid-users/
Comorbidities associated with addiction, also known as substance use disorders (SUDs), are common and can significantly complicate treatment and recovery. These comorbidities span mental health disorders, medical conditions, and behavioral issues. Below is an overview of the most prevalent comorbidities:
### *Mental Health Disorders*
1. *Depression and Anxiety Disorders*: These are among the most frequent comorbid conditions. Many individuals use substances to self-medicate, which can create a vicious cycle of dependency[1][2].
2. *Bipolar Disorder*: Substance abuse often exacerbates mood instability in individuals with bipolar disorder[1][3].
3. *Post-Traumatic Stress Disorder (PTSD)*: Trauma survivors may turn to substances to cope with distressing memories and emotions[1][2].
4. *Personality Disorders*:
– *Borderline Personality Disorder (BPD)*: Impulsivity and emotional dysregulation in BPD increase vulnerability to substance use.
– *Antisocial Personality Disorder (ASPD)*: Individuals with ASPD are more likely to engage in substance abuse due to impulsivity and disregard for societal norms[1][3].
5. *Psychotic Disorders*: Schizophrenia frequently co-occurs with SUDs, complicating treatment adherence and symptom management[1][3].
### *Medical Conditions*
1. *Infectious Diseases*: Injection drug use is linked to a higher risk of HIV/AIDS and hepatitis.
2. *Cardiovascular Issues*: Stimulant use can lead to hypertension, arrhythmias, and heart attacks.
3. *Liver and Gastrointestinal Problems*: Chronic alcohol or drug use can cause liver damage and gastrointestinal disorders.
4. *Diabetes and Cancer*: Addiction may exacerbate these systemic conditions by hindering proper management[4][6].
### *Behavioral Disorders*
1. *Eating Disorders*: Conditions like anorexia, bulimia, and binge eating disorder often co-occur with SUDs due to shared risk factors such as low self-esteem[1][3].
2. *Gambling Disorder*: Both behaviors share underlying vulnerabilities in brain reward systems[1].
### *Challenges in Diagnosis and Treatment*
Diagnosing comorbidities is challenging due to overlapping symptoms, stigma, and limited integration between mental health and addiction treatment services. Untreated comorbidities often worsen outcomes by increasing relapse risks and reducing treatment effectiveness[2][6].
### *Integrated Care Approach*
Effective management requires a multidisciplinary approach that simultaneously addresses addiction and comorbid conditions through personalized treatment plans. This includes pharmacological interventions, psychotherapy, and social support systems tailored to individual needs[1][2].
Addressing these comorbidities holistically improves recovery outcomes and enhances quality of life for individuals struggling with addiction.
Citations:
[1] https://www.serenityspringsrecovery.com/blog/common-comorbidities-with-substance-use-disorders/
[2] https://www.euda.europa.eu/spotlights/comorbid-substance-use-and-mental-health-problems_en
[3] https://www.unodc.org/documents/drug-prevention-and-treatment/UNODC_Comorbidities_in_drug_use_disorders.pdf
[4] https://footprintstorecovery.com/comorbid-medical-conditions-addiction/
[5] https://www.youtube.com/watch?v=5RbEotf0jqI
[6] https://thephoenixrc.com/blog/addiction-recovery/handling-comorbidities-with-substance-use-disorder/
[7] https://www.ncbi.nlm.nih.gov/books/NBK571451/
[8] https://nida.nih.gov/research-topics/co-occurring-disorders-health-conditions
[9] https://altacenters.com/addiction-resources/comorbidity/
[10] https://www.helpguide.org/mental-health/addiction/substance-abuse-and-mental-health
—
Answer from Perplexity: pplx.ai/share
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