From a short websearch – MO Healthnet – seems to be the state of MO Medicaid program. Will many of the practitioners in MO just pull out of the Medicaid program or will they end up just applying Medicaid prescribing rules to all their pts… so that they will not accidentally exceed the dosing limit on Medicaid pts ? with this and the other post from today that applies to SC and Arkansas New law lets South Carolina providers deny care that conflicts with personal beliefs Is it time for some law firms that deal with civil right violations to step up to the plate ?
Steve Corsi, Psy.D., Director of Department of Social Services
Randall Williams MD, Director of Department of Health
Mark Stinger, Director Department of Mental Health
This message is intended to reach the people listed above as the heads of their respective Departments. If they have since been replaced please forward it to the new Director(s). No disrespect to anyone else that may read this, but I need to reach those with the power to effect change. Since the website for the Great State of Missouri is extremely difficult to navigate, I am sending this to the address listed on the March 9, 2018 letter to prescribing physicians. At the end of this message I will attach the response that I have already received from the Administrator of the MO Bureau of Narcotics and Dangerous Drugs. In his letter he was clear that doctors should use their best medical judgement in prescribing and that the CDC Guideline does not hold the effect of law. What it has done is frightened physicians to the point of abandoning, forcing tapers and refusal to accept any new pain patients.
As you are well aware on March 9, 2018 physicians that accept MO HealthNet were issued a letter that can only be described as a direct threat to their livelihood, ability to properly treat patients, and even their freedom in the form of incarceration if they did not dramatically reduce the doses of chronic pain patients on opioids to an arbitrary amount of 90mmed. There is no medical evidence that this threshold in anyway protects the lives of chronic pain patients as we are the most responsible patients a doctor could have. It also discounts the fact that the enzymes in the livers of each individual metabolize opioids at extremely different rates so much so that a dose of 50mmed in one patient may suppress their pain, but another patient may require 1,000mmed or more to control the same amount of pain.
This has forced doctors in MO to taper their patients that have been on high dose long-term opioid pain medications, sometimes for decades, against the patients wishes and their thoroughly considered medical decisions. This has been disastrous for Missourians and across the country where this guideline has been applied as policy or law. Whether your intent was to force doctors to do this it has been the effect. My personal physician has received regular visits by the BNDD to monitor the tapering of opioids of legacy patients. It is impossible that an agency that denies this guideline has the force of law, would take it upon themselves to do these edits without being directed by one of your Departments.
Factors you may not be, but as a governing body should be aware of, is that the authors of the CDC Guidelines were from a radical group of anti-opioid crusaders known as PROP physicians for responsible opioid prescribing, or as many in the industry call them PROPaganda. (They will be mentioned again in this letter many times) In 2012 PROP petitioned the FDA, which is the appropriate regulating agency for prescription drugs in the United States, with the very recommendations they later used as the anti-opioid guideline. The FDA of course rejected their petition because it was not based on solid science. The FDA did agree with them in part and introduced new labeling requirements. Again this is the ONLY measure that was approved by the FDA, which again is the governing and regulating body for all prescription drugs. The buck stops with them.
In the published abstract from the authors of the guideline they readily admit they used low quality evidence as a basis for their recommendations and I quote…
EVIDENCESYNTHESIS Evidence consisted of observational studies or randomized clinical trials with notable limitations, characterized as low quality using GRADE methodology. Meta-analysis was not attempted due to the limited number of studies, variability in study designs and clinical heterogeneity, and methodological shortcomings of studies. No study evaluated long-term (1 year) benefit of opioids for chronic pain. Opioids were associated with increased risks, including opioid use disorder, overdose, and death, with dose-dependent effects.
IMPORTANCE Primary care clinicians find managing chronic pain challenging. Evidence of long-term efficacy of opioids for chronic pain is limited. Opioid use is associated with serious risks, including opioid use disorder
Underlined in the above information (top) provided directly by the authors of the guideline shows that they used poor quality studies to reach their conclusions. In the next underlined part (bottom) it is clearly stated that this information is directed SOLELY to Primary Care Physicians who may find treating chronic pain challenging. It is not intended to apply to ANY specialists, particularly those who specialize in diagnosis and treatment of chronic pain disorders. The bold and italic portion indicates the opinions of the writers with very limited scientific evidence. While some studies suggest an increased effect of mortality with higher doses, they are of the same limited numbers and poor quality. The bold portion indicates that there is limited evidence of long-term efficacy of treating chronic pain with opioids. This is due to the fact that an ethical clinician cannot take patients that have been treated long-term with high dose opioids and replace them with placebo. The patients receiving placebo would suffer from excruciating pain and withdrawals within 1-2 days maximum. Therefor any patient that received the placebo would immediately know they were receiving it and drop out of the study rendering it useless. This may suit the authors of this guideline as the studies that they site as evidence are similarly useless. All of this information is in the guideline itself if someone took the time to read the complete report, a responsibility that would fall directly on the shoulders of each Director.
The following is a link to the suicides resulting from tapering or abruptly stopping opioids based on the CDC Guideline compiled by a compassionate and caring physician named Dr. Kline. These do not represent all of the suicides do to the CDC and regulatory bodies such as yours but is a list the great doctor has composed in his spare time when not treating or advocating for the rights of chronic pain patients, followed by some excerpts.
https://medium.com/@ThomasKlineMD/opioidcrisis-pain-related-suicides-associated-with-forced-tapers-c68c79ecf84d
Dr. Kolodny (the founder of PROPaganda) commented on the pain related suicides cases: “ There is good evidence the majority were suffering from opioid addiction”. He was not familiar with the cases.
Dr. Kolodny is not a specialist in pain medicine. He is a trained psychiatrists who benefits financially from every “addict” he assumes care for. He has also made over $500,000 as a self proclaimed expert for the prosecution in cases where well intentioned, caring and compassionate doctors were put on trial for their prescribing habits without regard to the conditions of their patients. He alone has been responsible for imprisoning doctors who faithfully executed their Hippocratic Oath. Dr. Kolodny also stands to make untold millions and possibly billions as an “expert” witness for the prosecution in the lawsuits against opioid manufacturers and suppliers.
Doctors across the country actually believe the CDC/PROP manifesto of pain medicines not working and too dangerous to use, a false assumption. Their belief that “addictions and overdoses” are being prevented by eliminating opiate pain medicine is a failure of science, reason, and common sense. These people are no longer with us due to the policy of “you are better off without pain medicines”
No case has been reported of true addiction suddenly occurring while taking pain medicine in the 10 million with long term pain disease, belying the governments’s belief that addictions will be prevented if the population as a whole does not take them.
Suicide prevention in the ten million noted by NIH requiring daily pain medicine is pain care. Not providing suicide prevention is negligence. Not treating a person in pain is negligence. Abandoning people with painful disease to the streets with no doctor, is negligence. Believing you can addict the general population is ignorance. Believing serious pain can relieved with Tylenol, meditation, expensive injection therapy, anticonvulsants, and physical therapy — is ignorant. The longer you wait to treat pain the more serious it becomes. Opiates remain the treatment of choice for serious pain, no matter what a few extremists purport.
This nihlist medical view is not accepted by most U.S. practicing physicians, nor in other countries, nor by the World Health Organization. The CDC and its PROP consultants have an extreme view, a pain nihilism manifesto, with unfounded near shrieking polemics, a bizarre “lunatic fringe” (FDA senior official) plan for the earth riding through every doctor office in the land with warnings not to addict or kill using “heroin pills” in the words of Thomas Frieden CDC director allowing the Guideline to be published by an Agency not tasked with opiate recommendations.
Allison Kimberly, age 30, of Colorado was denied treatment for her intractable pain from interstitial cystitis and several other painful conditions. Interstitial cystitis can end in suicide from the failure to treat it properly as it is an extreme form of agonizing discomfort. It is said that the University of Colorado emergency room in Aurora refused her treatment for her pain.
deceased
Allison posted on Instagram describing how she was treated as an addict and sent away without pain medicine. “I was rushed to the ER because my pain was so out of control I couldn’t take it anymore, I got ZERO help. After 7 hours I was discharged. The nurse has the nerve to say that my kind of pain shouldn’t be that bad and basically I was faking for medication. I am so beside myself I am shaking as I type this. Screaming and begging in pain, needing any kind of help they’d give me and I was just sent home. As soon as I am able I’m reporting my whole experience.” Allison did not have time to file a complaint against the hospital as she violently ended her life while her mother walked her dog, the animal companion that had made her anguish less lonely. No doctors appear to have been charged. The Colorado Hospital Association was in the process of piloting a no-opioid policy for the state. She died in June, 2017.
How any human being can read these stories and fail to take appropriate measures to keep it from happening again is gruesome, scandalous, repugnant, outrageous, obscene and nefarious. No longer can you claim ignorance of the harm and dangers this is causing. Lack of action at this point would be gross negligence and dereliction of duty. The purpose of having an agency to regulate medical treatment is there to safeguard patients not to commit negligent manslaughter. Instead the focus has been driven not only to the treatment of addicts but to treat anyone suffering from chronic pain AS addicts.
The ADA prohibits government agencies that receive any federal funding from discriminating against Americans with Disabilities. Chronic pain is a leading cause of disability in the United States. Denying proper and adequate medical treatment that effectively reduces pain to those of us that are disabled by chronic pain is a clear violation of law. Hiding behind a guideline produced by an agency with NO authority to regulate prescription drugs in the United States is not a valid excuse. A strong case could be made for malicious intent.
With the swipe of a pen almost all of the harm that was caused can be reversed. This will not bring back Allison and the others that have died due to the overzealous application of an invalid guideline, but their deaths do not have to be in vein. If it were to effect change the circumstances for the rest of us I believe their families would be happy knowing their loss has helped millions of others. I don’t wish to make any threats as I believe that the appropriate agencies will do what’s right for those of us suffering in MO, however if a remedy can not be reached by communication I will be forced to gather all my struggling brothers and sisters together to file an ADA claim against Steve Corsi, Psy.D as the director of the Department of Social Services, Randall Williams, MD as the director of the Department of Health, and Mark Stringer, as the director of the Department of Mental Health.
In addition you will find attachments of the press releases by the CDC and FDA that discourage forced tapering and stress that the guidelines have been wildly misinterpreted. You will also find the FDA’s refusal to accept the recommendations of PROP that later formed this grotesque unlawful guideline.
From: “Boeger, Michael” <Michael.Boeger@health.mo.gov>
> Date: November 12, 2019 at 8:33:12 AM CST
> To: “‘ff5863@yahoo.com'” <ff5863@yahoo.com>
> Subject: Your email about opioid milligrams and enforcement
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> November 12, 2019
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> Dear Dr. Pezzani:
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> As a result of the opioid abuse epidemic, the CDC issued and published an educational guideline relating to the prescribing of controlled drugs.
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> Our department made it a specific point to let practitioners know that this was an educational guideline and that it was not a law that could be enforced. If doctors choose to prescribe more, this is not a direct violation of law or regulation. The guideline wanted to stress that doctors review their patient charts and look to see how much they are prescribing, then make their own decisions.
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> During the past several years, our bureau has not revoked or suspended any doctors merely for prescribing too many opiates.
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> Upon reviewing our records, the Board of Healing Arts and the Dental Board have not revoked or suspended anyone from over-prescribing.
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> Doctors are allowed to review their own practices and make their own decisions. The CDC guidelines are not being enforced upon them
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> as a law.
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> Our current studies we have seen online show that about 30% of the overdoses are from prescription drugs and 70% are from “street drugs.”
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> However, of the 70% addicted and abusing street drugs, the study showed that 80% of them started off with a prescription drug problem.
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> At this point, that only action taken is that the CDC has asked the doctors to review and make their own decisions.
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> Michael R. Boeger, Administrator
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> Missouri Bureau of Narcotics and Dangerous Drugs
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> P.O. Box 570
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> Jefferson City, MO 65102-0570
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> Phone: (573) 751-6321 Fax: (573) 526-2569
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> Website: www.health.mo.gov/BNDD
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