“Our healthcare system should reimburse doctors and hospitals for patient’s health outcomes”

Does this suggest that Kennedy is in favor of treating chronic pain patients to optimize a patient’s QOL?  Could we bring back “pain is the 5th vital sign”? Could a lot of practitioners who are now “uncomfortable” in writing for opioids for pain management have a change in their belief of treating pain if their reimbursement was based on optimizing the pt’s level of pain and QOL?  Will the DOJ/DEA get muzzled in raiding practitioners’ offices based on some nebulous statistical data? Should chronic pain pts reach out to RFK Jr to support his new patient treatment goals?

RFK Jr. Says the Medical System Has ‘Perverse Incentives’ for Doctors

https://www.medpagetoday.com/publichealthpolicy/healthpolicy/115141

We have to change that,” says Kennedy, who also praised the CDC’s work on the measles outbreak

HHS is trying to change the “perverse incentives” in the medical system, including the way doctors are paid, HHS Secretary Robert F. Kennedy Jr. said Tuesday.

“A lot of the negative behavior and self-destructive behavior in both the medical system — how we pay for healthcare — and how we eat is driven by perverse incentives,” Kennedy said at a press conference at the Indiana State Library in Indianapolis.

“Today, we have a healthcare system that reimburses doctors and hospitals for procedures rather than for health outcomes. We have to change that.”

On another front, Kennedy also said that the CDC “has done a very good job at controlling the measles outbreak. We’ve had about 700 cases nationally and in Europe, they’ve had 127,000 cases and 37 deaths.” That number contrasts with 2024, in which 285 measles cases were reported in the U.S. for the entire year, according to the CDCopens in a new tab or window.

“People get measles because they don’t vaccinate. They get measles because the vaccine wanes — the vaccine wanes about 4.8% per year, so you know that problem is always going to be around,” he continued. “We need to also make sure that doctors know how to treat measlesopens in a new tab or window and how to treat the associated diseases, the pulmonary disease that often comes with measles, and [the] bacteriological [ones] — we can’t rely simply on the vaccine.”

In contrast to Kennedy’s remark, experts say that the measles vaccine provides lifelong immunityopens in a new tab or window, which is how the U.S. achieved elimination status.

It’s “outrageous” that the government doesn’t have a better surveillance system for vaccine injuries, Kennedy said in response to a question from the audience — which was not audible on the livestream — that apparently raised the issue of a possible connection between vaccines and autism, a relationship that has been widely debunkedopens in a new tab or window.

The CDC did a study on HHS’s surveillance system, the Vaccine Adverse Event Reporting System — which allows for self-reporting of possible vaccine-associated injuries but does not verify them — in 2010, “and [found that] it captures fewer than 1% of vaccine injuries,” he said, noting that at the time, the CDC had a “machine counting” system for such injuries but they “put it on a shelf.”

“We are going to improve the surveillance,” Kennedy said. “We’re going to get the data sets from everybody we can. We’re going to make data-sharing agreements with scientists all over the world, with the best scientists, and we’re going to find out what contribution vaccines and everything else make — mold, EMF [electromagnetic fields], food, all of these other exposures — which one of those are the culprits? I suspect we’re going to see that there’s a lot of culprits, but we need to know.”

“People don’t have informed consent [for vaccination], and people don’t trust our agency anymore,” he added. “And the way to improve vaccination is to make the agency trustworthy, and that’s what we’re going to do.”

HHS is trying to change the “perverse incentives” in the medical system, including the way doctors are paid, HHS Secretary Robert F. Kennedy Jr. said Tuesday.

“A lot of the negative behavior and self-destructive behavior in both the medical system — how we pay for healthcare — and how we eat is driven by perverse incentives,” Kennedy said at a press conference at the Indiana State Library in Indianapolis. “Today, we have a healthcare system that reimburses doctors and hospitals for procedures rather than for health outcomes. We have to change that.”

On another front, Kennedy also said that the CDC “has done a very good job at controlling the measles outbreak. We’ve had about 700 cases nationally and in Europe, they’ve had 127,000 cases and 37 deaths.” That number contrasts with 2024, in which 285 measles cases were reported in the U.S. for the entire year, according to the CDCopens in a new tab or window.

“People get measles because they don’t vaccinate. They get measles because the vaccine wanes — the vaccine wanes about 4.8% per year, so you know that problem is always going to be around,” he continued. “We need to also make sure that doctors know how to treat measlesopens in a new tab or window and how to treat the associated diseases, the pulmonary disease that often comes with measles, and [the] bacteriological [ones] — we can’t rely simply on the vaccine.”

In contrast to Kennedy’s remark, experts say that the measles vaccine provides lifelong immunityopens in a new tab or window, which is how the U.S. achieved elimination status.

It’s “outrageous” that the government doesn’t have a better surveillance system for vaccine injuries, Kennedy said in response to a question from the audience — which was not audible on the livestream — that apparently raised the issue of a possible connection between vaccines and autism, a relationship that has been widely debunkedopens in a new tab or window.

The CDC did a study on HHS’s surveillance system, the Vaccine Adverse Event Reporting System — which allows for self-reporting of possible vaccine-associated injuries but does not verify them — in 2010, “and [found that] it captures fewer than 1% of vaccine injuries,” he said, noting that at the time, the CDC had a “machine counting” system for such injuries but they “put it on a shelf.”

“We are going to improve the surveillance,” Kennedy said. “We’re going to get the data sets from everybody we can. We’re going to make data-sharing agreements with scientists all over the world, with the best scientists, and we’re going to find out what contribution vaccines and everything else make — mold, EMF [electromagnetic fields], food, all of these other exposures — which one of those are the culprits? I suspect we’re going to see that there’s a lot of culprits, but we need to know.”

“People don’t have informed consent [for vaccination], and people don’t trust our agency anymore,” he added. “And the way to improve vaccination is to make the agency trustworthy, and that’s what we’re going to do.”

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Short-sighted: Why the administration’s opioid plan won’t work

https://thehill.com/opinion/5247116-opioid-crisis-prevention/

by Chris Fox, opinion contributor  chris@nonopioidchoices.org  https://nonopioidchoices.org/

Last week, the Trump administration released a five-step plan to address the country’s opioid addiction crisis. The administration’s new drug czar’s plan focuses largely on attempts to prevent opioid-related overdose deaths.

It won’t work. Here’s why: The plan continues a years-old downstream focus on overdose death prevention and neglects the opportunity to prevent addiction in the first place.

In 2023, the last year for which we have full-year overdose data, 81,000 Americans died from an opioid-related overdose — an average of more than 220 deaths per day. Despite these staggering numbers, the administration’s plan primarily focuses on stopping the flow of illicit fentanyl into the U.S., relying on border control and punitive measures against drug cartels.

While addressing fentanyl trafficking is important, this approach tackles only one part of a far more complex problem. The reality is that overdose deaths remain high not only because of illegal fentanyl but also because millions of Americans continue to receive prescription opioids to manage postsurgical pain, whether they need them or not. In fact, as many as 90 percent of all surgical patients in the U.S. today receive an opioid prescription for post-operative pain.

The administration’s approach also touts increasing access to naloxone and medication-assisted treatment for opioid-use disorder, which are essential components of addiction treatment and overdose prevention. However, these measures are reactive, not proactive. They miss an important opportunity to prevent addiction before it starts by expanding non-opioid pain management options.

Current pain treatment protocols incentivize the use of generic prescription opioids. They do so because such medicines are cheap and well-known to health care professionals, and most patients will tolerate these medicines without incident.

However, some —  estimates show between 6 percent and 20 percent —  will misuse these medicines. Some may become addicted and move on to other illicit forms of opioids. Some will overdose. Some will die.

This overreliance on prescription opioids strips patients of real choices and unnecessarily increases the risk of long-term dependency. We have the tools to change the status quo.

We must change how we treat pain in this country and ensure that patients and health care providers have options when it comes to treating acute pain. The passage of the Non-Opioids Prevent Addiction in the Nation Act in 2022 was a major step forward, ensuring that non-opioid alternatives are available in outpatient surgical settings.

But there is more work to do.

We must ensure that all patients in all settings can easily access non-addictive pain treatment options. This is especially true for patients covered by Medicare Part D plans.

Earlier this year, legislation was introduced in Congress called the Alternatives to Prevent Addiction in the Nation Act. This critical legislation would make sure that patients can easily access non-opioid medications at the pharmacy counter.

The opioid addiction epidemic is far from over. Hundreds of Americans still die every day, and the crisis is evolving in ways that demand urgent action. Focusing solely on border control and fentanyl supply reduction ignores the deeper issue: how we manage pain in our health care system.

If we are serious about preventing addiction and saving lives, we must prioritize non-opioid choices — before it’s too late.

Every day we delay action, more patients are denied access to a non-opioid pain management tool. Recently, a major insurance company announced that it was making it more difficult for Americans to access non-opioids. We cannot stand idly by and let this happen.

This proposal would ensure that all patients can access non-opioid treatments in all settings. It can prevent addiction before it starts.

Congress has a chance to get ahead of this crisis — but only if they act now. Passing the act is a concrete step toward ensuring that patients have real choices in pain management. If we are serious about preventing addiction and saving lives, we must prioritize non-opioid choices.

We cannot afford to fight the opioid crisis with half measures.

Chris Fox is executive director of Voices for Non-Opioid Choices.

https://nonopioidchoices.org/about/members/

This article was appropriately noted as provided by: by Chris Fox, opinion contributor. I find the adjective OPINION very true, unfortunately, his opinion has very little to do with reality.

Generally, addiction is not caused by Opioids or some other substances that the person with pre-existing mental health issues. They have unknown- to them- “monkeys” on their back and/or “demons” in their head, and their interaction with some substance or activity will silence those “monkeys” or “demons”. They experience a “mental peace” they had no idea was possible. Depending on what statistic one wishes to believe, 0.6% to 3% of the people prescribed an opioid for acute or chronic pain will become addicted. It appears that this organization, Voices for Non-Opioid Choices believes that >97% of anyone dealing with acute or chronic pain should be denied effective, FDA-approved medications.

Recently, I asked www.perplexity.ai the following question: What comorbidities issues are generally involved 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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Just imagine when a private equity company buys a company whose primary function is to provide medical care to mostly pts who are high acuity, complex, and most likely disabled. However, the primary function of private equity companies is to generate profits. One can only imagine what happens to the healthcare companies that they buy.

Private Equity’s Growing Role in Disability Care Demands Urgent Oversight

Patients are not lines on a balance sheet

https://www.medpagetoday.com/opinion/prescriptionsforabrokensystem/115074

Private equity (PE) has become a powerful and often invisible force reshaping how care is delivered across the country. A recent report from the Private Equity Stakeholder Projectopens in a new tab or window shines a light on one of the latest, and most concerningopens in a new tab or window, developments: the growing role of PE in services for people with intellectual and developmental disabilities (IDD).

This trend is alarming not just because of the populations involved, but because of what it reveals about how healthcare is increasingly being treated — not as a social good, but as a business opportunity ripe for financial exploitation.

The Lifeline of Medicaid-Funded IDD Services

Many of the services supporting individuals with IDD — residential facilities, home care, adult day programs, physical and occupational therapy, and more — are funded primarily through Medicaidopens in a new tab or window. For nearly 10 million Americans with IDD, these programs represent far more than care: they are the foundation of daily life, independence, and survival. Historically, these services have been provided primarily by non-profits and religious organizations.

And yet, as PE firms continue to acquire companies that provide these services, we must ask a difficult question: What happens when profitability becomes harder to maintain, especially when Medicaid dollars are cut or restrictedopens in a new tab or window? The answer, based on past precedent in other areas of healthcare, is not promising.

The PE Playbook: High Returns, Low Transparency

PE firms generally operate on a 4-to-7-year investment horizon. Their goal is generally to double or triple returns during that short window. In order to get results quickly, PE firms often resort to significant cost-cutting, rapid scaling, and creating “operational efficiency.” In sectors with strong commercial margins, this approach might be sustainable. But in IDD care — an underfunded, labor-intensive space that relies heavily on government reimbursement — this model could result in real harm.

According to the Private Equity Stakeholder Project’s report, PE firms are already applying their traditional cost-saving strategies in IDD. They are reducing staffing levels, relying on lower-paid and less-trained workers, eliminating oversight roles, and prioritizing rapid expansion. The result? Allegations of substandard care, including abuse and neglect, abound and are being investigated by federal and state lawmakers.

The changes put in place by PE firms might boost margins in the short term, but they undermine quality, safety, and continuity — the very pillars of care for individuals with IDD.

And let’s not forget: these significant policy changes will affect vulnerable individuals with lifelong needs, who are often unable to advocate for themselves and are reliant on stable, skilled, and compassionate care teams. Additionally, people with IDD already experience significant health and social inequities. They face shorter life expectancies, higher rates of chronic illness, increased mental health challenges, and greater risk of pregnancy complications. These disparities are rooted in structural barriers, including difficulty accessing care, lack of provider training, and social marginalization.

Now layer on top a business model that prioritizes efficiency over empathy and returns over relationships, and the risks become unacceptable. Indeed, the shift from mission-driven nonprofits and religiously affiliated organizations to profit-maximizing investors represents a fundamental change in how care is conceptualized and delivered — and it is a terrible shift.

We Have Seen This Before

As I have written in MedPage Todayopens in a new tab or window, private equity is not inherently bad. When firms are responsible and transparent, they can fuel innovation, expand access, and help modernize outdated systems. But when left unchecked, firms’ incentives are often misaligned with the core mission of healthcare: to care for people.

This argument is not speculative.

In fact, we have seen the negative effects of PE in emergency medicineopens in a new tab or window, where PE-backed staffing firms have contributed to burnout and dissatisfaction among clinicians. We have seen it too in nursing homesopens in a new tab or window, where aggressive cost-cutting has coincided with drops in quality and oversight. And we are seeing PE expand into behavioral healthopens in a new tab or window, where providers under financial strain are already stretched too thin to meet patient needs. Health policy researchers, patient advocacy groups, and providers worry that similar quality declines will be seen in mental health care with PE acquisitions.

What is unfolding in the IDD space has all the same warning signs, but with even higher stakes.

If we are serious about protecting people with IDD and about ensuring our healthcare system upholds the dignity of those who need it most, we must act now. We must:

• Require PE firms to disclose ownership structures and report quality outcomes in IDD settings
• Strengthen federal and state oversight to ensure that care quality, not just financial returns, is being measured
• Mandate regulatory review before PE firms can purchase entities serving vulnerable populations
• Set minimum staffing ratios and require specialized training for caregivers in IDD services
• Encourage financial firms to invest with integrity, prioritizing people over profits in high-impact areas like disability care

Healthcare is not a commodity, and people with disabilities are not lines on a balance sheet. When profit is prioritized over people, we do not just lose efficiency, we lose trust, compassion, and the fundamental integrity of care. If we are not vigilant, the most vulnerable will pay the highest price for someone else’s financial gain.

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It is claimed that there are some 50,000 new chronic pain pts every year – that is about 140/day… that is about SIX EVERY HOUR – 24/7/365!

How many of your family, friends, or neighbors will become a chronic pain pt in the next day?  Could you become a chronic pain pt in the next 24 hrs?  All it takes is one serious accident that may or may not be your fault. What is even worse is that most of those 50,000 people will discover that our healthcare system doesn’t want to be the intensity of the pt’s pain nor will be willing to treat their pain for more than MAYBE just a few days.

Today, many chronic pain pts have been basically put under HOUSE ARREST because they receive inadequate pain management that most of their days, they spend laying in bed or a couch and/or sitting in a chair. 

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The Era of Compounded GLP-1 Drugs Is Over. What Now?

https://www.medscape.com/viewarticle/era-compounded-glp-1-drugs-over-what-now-2025a10008kq

Now that the US Food and Drug Administration has removed both tirzepatide and semaglutide from its Drug Shortages List, the widespread compounding of these drugs is ending. Tirzepatide’s deadline has already passed, while physicians and pharmacies have until April 22 for semaglutide. An estimated 2 million Americans have been using these more affordable copycats every month.

Even with direct-to-consumer discounts, monthly doses of brand-name versions cost hundreds more than compounded ones, putting them beyond the reach of many people. This means a significant number of compounded glucagon-like peptide 1 (GLP-1) users will be forced to go cold turkey — but studies consistently show weight regain when patients stop taking them abruptly. So how can you help your patients?

Forced Off GLP-1s

While published research into best practices for discontinuing the use of GLP-1s is scant, accessibility and price issues have already forced physicians and patients to devise workarounds. Not everyone was willing to rely on the compounded versions, after all. And some who succeeded on a brand name were reluctant to spend that much money every month for the rest of their lives.

As a result, anecdotal information already exists about tactics like stretching out the time between injections, tapering the dosage, and adding strength training to patients’ exercise routines.

“Anecdotally, some doctors and patients are being forced into this,” said Jennifer Manne-Goehler, MD, a researcher at Harvard Medical School, Boston, and the lead author of a paper in JAMA Internal Medicine that looked at what we know about off-ramping these drugs.

“I get messages from people saying, ‘Do you think microdosing is okay?’ or, ‘I had a patient who ran out, or they couldn’t get more tirzepatide, so they started taking it every other week,’” she said.

So far, success seems to be dependent on the individual patient’s level of motivation and their ability to commit to lifestyle changes. Regular communication with the patient goes a long way toward determining what might work.

“Subjectively, patients know when things are working for them or not,” said Jeremy Korman, MD, medical director of the Cedars Sinai Marina Weight Management Center in Marina del Rey, California. “That’s a way, without any concrete algorithm, that I work with my patients who’ve reached a target weight. We start using those subjective measures of hunger and cravings and tapering in that way, whether it’s tapering on time interval or tapering on dose.”

Slow Tapering May Work

Last year, researchers presented findings on a slow tapering method at the European Congress on Obesity. When participants reached their goal weight, their dosage was gradually reduced over an average of 9 weeks while they continued with coaching on diet and exercise. Data was available for 85 participants — 6 months after tapering to zero, and their weight remained stable.

“Because they’ve engaged in some of the lifestyle changes, when they eventually taper off, they keep the weight off without semaglutide,” lead researcher Henrik Gudbergsen, MD, told Medscape Medical News at the time. “I think there’s a strong linkage between the initial phase of using this medication with lifestyle changes and actually being capable of keeping the kilos off once they’ve stopped.”

Given the small number of participants, more research is necessary. But those initial results are promising, Korman said.

“The European study, tapering over 9 weeks, is very interesting,” Korman said. “The original studies just stopped the medication, and all the weight came back. We still have to be a little skeptical, even if we taper properly, that it’s going to be as durable as we hope. It could be, but it’s very early on.”

Of course, the end of mass-produced compounded GLP-1s is less than 9 weeks away. But in Reddit discussions among compounded tirzepatide users, many said they have stockpiled a supply, enough to last for months. A slow taper could work for them. For those without a ready supply, a short-term prescription for a brand-name GLP-1 might do the trick.

Turn to Older Generation Weight-Loss Drugs

Another option that shows potential is simply migrating from a GLP-1 to an older generation, generic version of an anti-obesity medication. A study in the December issue of Obesity followed patients on this protocol. Out of an initial group of 105 participants, 40 used a GLP-1 medication for 12 months to reach a body mass index of less than 30, then transitioned to generic phentermine, phentermine/topiramate, topiramate, metformin, bupropion, and/or naltrexone. They maintained their initial weight loss for up to 2 years when the study ended.

Gitanjali Srivastava, MD, medical director at Vanderbilt Obesity Medicine in Nashville, Tennessee, co-authored the study. She compared this approach to cancer treatment: If a patient comes in with an aggressive tumor, the oncologist might use expensive therapies to decrease the size of the tumor burden. Once that’s achieved, the oncologist can move the patient to less intense, less costly therapies.

“In the same way, when we think about obesity as a disease process, patients with severe obesity have a very high disease burden,” she said. “With GLP-1 medications, you’re shrinking the size of that disease burden, then exposing them to the older generation armoire.”

She’s been using this approach in her practice for several years.

“Even though the GLP-1 drug classes have created hype, I don’t think we should forget some of these older-generation medications that are less expensive, that patients still do really well on and respond very favorably to, if there are no contraindications,” she said. “For instance, metformin is free at Publix. Topiramate is just a few dollars. A combination of phentermine and topiramate, which is sold under the brand name Qsymia, you can get for less than $20 a month.”

Discoveries Still to Come

With so many patients being forced off compounded GLP-1s at once, we’re likely to learn a lot about what helps — and what does not — to maintain a substantial weight loss. One thing will almost certainly be a crucial factor: Guiding patients toward a healthier lifestyle in general.

“Regardless of what treatment we give a patient, even with surgery, our weight loss outcomes and the durability of them depend on lifestyle modification,” Korman said. “That has to be the foundational concept. If we’re just going to rely on the meds, and we’re not going to commit to that, nothing is going to work.”

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I shared this article on April 7, 2025, referencing our Fed AG Jan 31, 2019 decision. This was during President Trump’s administration. It is typical for these things to take some time to reach a conclusion. But preceding this date, several people held the office of AG or acting AG, which led up to this conclusion.   Jeff Sessions, Rod Rosenstein, Matthew Whitaker   Below that link to the article, I am sharing the information provided by perplexity.ai when I asked it: what comorbidities issues are generally involved with addiction.

I asked perplexity.ai what the DOJ has done regarding discrimination of pts with SUD/OUD since Jan 2019, and it came up with NADA. With our new Fed AG Pam Bondi, I doubt if she will pursue anything as well. I guess we have another law that is enforced at the discretion of  “who is in power.”

DOJ Considers Opioid Use Disorder an ADA Covered Disability and Pursues Claims Against a Provider for Refusing Medical Services to Opioid Users

what comorbidities issues are generally involved with addiction

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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Beyond Medical Paternalism: Restoring Control to the Individual

https://www.cato.org/free-society/spring-2025/beyond-medical-paternalism-restoring-control-individual

Heavy-handed government policies often undermine patient autonomy, restricting the medicines they can take, the doctors they can see, and the information they can access.

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According to this article, Selma Medical had a policy to not prescribe narcotic controlled substances to any pts. This was SIX YEARS ago, why has there not been a lot of lawsuits against practitioners that refuse/decline to treat pts whose health issues require the use of  opioids?

DOJ Considers Opioid Use Disorder an ADA Covered Disability and Pursues Claims Against a Provider for Refusing Medical Services to Opioid Users

https://www.healthlawadvisor.com/doj-considers-opioid-use-disorder-an-ada-covered-disability-and-pursues-claims-against-a-provider-for-refusing-medical-services-to-opioid-users

The U.S. Department of Justice reached a January 31, 2019 settlement of an American with Disabilities Act (“ADA”) Title III complaint against health care provider Selma Medical Associates relating to provision of medical services to an individual with opioid use disorder (“OUD”).  The settlement is notable for health care providers and employers as it makes clear that DOJ considers OUD as a disability under the ADA thereby triggering the full panoply of ADA rights for those with OUD.

The DOJ complaint was premised on the alleged refusal of Selma Medical to schedule a new patient family practice appointment after the patient disclosed he takes Suboxone.  Suboxone is a prescription medication approved by the Food and Drug Administration for treating OUD.  The complaint further alleged that Selma refused to treat patients with narcotic controlled substances, including Suboxone, thus imposing “eligibility criteria that screen out or tend to screen out individuals with OUD.”  The compliant also alleged a failure to make reasonable accommodations to policies, practices or procedures when necessary “to afford such goods, services, facilities, privileges, advantages, or accommodations to individuals with disabilities.”

Under the settlement, Selma agreed to:

1. Not discriminate or deny services on the basis of disability, including OUD;
2. Not use eligibility standards, criteria or methods of administration that tend to deny benefits on the basis of disability including OUD;
3. To modify its policies as necessary;
4. To draft and submit within 30 days for DOJ approval a non-discrimination policy and to remove any inappropriate existing policies;
5. After DOJ approval, to adopt and disseminate to all employees the new non-discrimination policy;
6. To train all management and employees within 60 days and annually for three years as to the new policy and ADA compliance with the initial training conducted live, with a Q&A opportunity, and by a trainer to be approved by DOJ;
7. Submit compliance reports to DOJ for three years; and
8. To pay compliant $30,000 in damages and a civil penalty to the U.S. of $10,000.

The DOJ-Selma Medical settlement is highly significant in an environment where in 2015, OUD affected 2 million people aged 12 and over (Drug and Alcohol Dependence, Vol. 169, Dec. 2016, pp. 117-127) and .6 million persons aged 12 or over had heroin use disorder (id.) and the lifetime percentage of individuals with Diagnostic and Statistical Manual-IV prescription OUD among adults 18 and over had more than doubled from 1.4% in 2001-2002 to 2.9% in 2012-2013 (id.), and likely higher today.  And, of course, this does not include those who are OUD for reasons other than prescriptions.  This means that health care providers are highly likely to encounter significant numbers of potentially challenging OUD patients.  DOJ has now made clear that providing the full range of care and services to such patients is required under the ADA – and that any failure to do so can lead to litigation, costly settlements and adverse publicity.

All employers, not just health care providers, should take note of this settlement as it clearly means that employers will also need to reasonably accommodate employees who seek time off for treatment or other accommodations unless the employer cannot show the requested accommodations would be an undue hardship.

The Selma Medical settlement is also a reminder that health care providers should make sure they have appropriate non-discrimination policies in place as required pursuant to Health and Human Services regulations for compliance under Title III of the ADA, the Rehabilitation Act of 1973, and the non-discrimination requirements of Section 1557 of the Affordable Care Act.  We can assist with any questions regarding the required policies and other issues as to compliance with the ADA, the Rehab Act and Section 1557.

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I asked www.perplexity.ai the following fairly (IMO) complex question. It looked at 58 different sources to come up with this answer/explanation.  It has been several years since the DEA has published what they were spending to fight the war on drugs. Recent estimates are that it is 120 – 140 million/yr. I have read recently that the 1970 CSA directed the DEA to deal with the diversion of pharma opioids. That might explain why we don’t see the DEA involved with all the illegal opioids and various illegal substances showing up on our streets. Our DEA is part of our FED DOJ, and they have an array of laws they are in charge of enforcing, and sometimes their interpretation(s) of the laws. Which our SCOTUS declared a year ago that Fed agencies do not have the statutory authority to make new interpretations of the laws they are in charge of enforcing. SCOTUS has no authority to enforce our laws. That is the duty of the DOJ. Unfortunately, many bureaucrats and politicians seem to work under the premise that “no one is above the law… except those who are in charge of enforcing our laws”. So, those entities that choose to enforce or ignore our laws can pretty much establish their own agenda. Their agenda prevails, and the FACTS are just ignored, and “experts” come forward to contradict and deny the facts are untrue and/or meaningless.

Most of your footnotes reference the use of opioids and treating SUD. Little/no deal with treating chronic pain. A couple of years ago the DEA stated that < 1% of pharma opioids were being diverted, but followed up by reducing pharma production quota. The National agreement was a mediated agreement – no court case. It would seem that there was no consideration of those agreements causing chronic pain patients to have access to their prescribed, medically necessary medications. Who determines what adequate pain therapy is? The vast majority of OD/poisoning is with opioids. The illegal opioids are known to be coming primarily from China & Mexican cartels. Over the last decade, pharma opioid production quotas have been reduced > 50%, and yet OD/poisoning is up 6-7 times. Are politicians & bureaucrats ignoring the real source of OD/poisoning – illegal opioids?

The opioid overdose crisis has shifted dramatically toward illicit synthetic opioids like fentanyl, yet policy and regulatory responses often lag behind this reality. Here’s an analysis of the disconnect between the current overdose drivers and policy focus:

—

### **1. Overdose Trends vs. Policy Focus**
– **Illicit opioids dominate deaths**: Over 80% of opioid-related deaths now involve illicitly manufactured fentanyl, with China supplying precursors and Mexican cartels producing/distributing the drug ([4][5][8]). Meanwhile, pharmaceutical opioid prescriptions have declined by over 50% since 2012 ([9]).
– **Policy emphasis persists on prescription opioids**: Recent settlements (e.g., 2022 distributor agreement) and 2025 DEA regulations ([3]) continue targeting pharmaceutical supply chains, despite <1% diversion rates for prescription opioids ([8]). These policies risk restricting access for chronic pain patients without addressing the primary overdose driver: illicit fentanyl.

—

### **2. Chronic Pain Patient Challenges**
– **Stricter quotas and oversight**: The DEA’s 2025 opioid production quotas and CMS care coordination edits (90 MME/day threshold) prioritize reducing prescription volumes ([3]). However, guidelines still emphasize **individualized care**, noting opioids may be appropriate for some chronic pain patients when benefits outweigh risks ([1][2]).
– **Documentation burdens**: Physicians face increased administrative requirements to justify opioid therapy, which can delay or deter treatment for legitimate patients ([1]).

—

### **3. Political and Regulatory Blind Spots**
– **Partisan divides**:
– **Democrats** increasingly focus on pharmaceutical accountability and treatment access ([10]), which risks overemphasizing prescription opioids’ role.
– **Republicans** prioritize border security and illicit drug interdiction ([10]), but underfund harm reduction strategies (e.g., naloxone distribution, overdose prevention centers) proven to save lives ([6][7]).
– **International policy gaps**: While China and Mexico are central to fentanyl production, U.S. efforts to disrupt supply chains remain inconsistent. China’s 2019 fentanyl ban reduced direct exports but not precursor flows, and Mexican enforcement varies by administration ([4][5][8]).

—

### **4. Data vs. Action**
– **Overdose deaths vs. prescription trends**: Between 2012 and 2025:
– Pharmaceutical opioid prescriptions dropped by ~60% ([3][9]).
– Overdose deaths increased 6-7x, driven by illicit fentanyl ([7][8]).
– **Misaligned solutions**: Funding from opioid settlements often supports law enforcement rather than addiction treatment or pain management programs ([7][10]). For example, only 12% of settlement funds in 2023–2024 were allocated to harm reduction or patient care ([7]).

—

### **5. Who Decides “Adequate Pain Therapy”?**
– **Guidelines vs. reality**: The CDC’s 2022 guidelines ([2]) and state policies ([1]) delegate decisions to clinicians but impose structural barriers (e.g., dosage caps, prior authorization). This creates a “chilling effect,” where physicians avoid opioids even for appropriate cases due to liability concerns.
– **Patient exclusion**: Chronic pain advocacy groups report being sidelined in policy discussions, with settlement negotiations ([3][8]) and legislation ([10]) prioritizing public health agencies and law enforcement over patient representatives.

—

### **Conclusion**
Politicians and regulators are disproportionately focused on legacy issues tied to prescription opioids, despite overwhelming evidence that illicit fentanyl drives the overdose crisis. Chronic pain patients face collateral damage from restrictive policies, while harm reduction and international supply-chain interventions remain underprioritized. Effective solutions require:
– Reallocating settlement funds to **patient access programs** and **illicit drug interdiction**.
– Pressure on China and Mexico to disrupt precursor networks ([4][8]).
– Revisiting CDC/DEA guidelines to prevent nonmedical opioid use without penalizing legitimate patients ([1][2][3]).

Until policymakers confront the synthetic opioid pipeline and balance supply-side enforcement with patient-centered care, overdose rates will likely remain elevated.

Citations:
[1] https://www.mbc.ca.gov/Download/Publications/pain-guidelines.pdf
[2] https://www.cdc.gov/overdose-prevention/hcp/clinical-guidance/recommendations-and-principles.html
[3] https://titangroupdea.com/blog/new-opioid-regulations-pain-management-specialists-need-to-know-about-2025?hsLang=en
[4] https://www.brookings.edu/articles/the-fentanyl-pipeline-and-chinas-role-in-the-us-opioid-crisis/
[5] https://www.npr.org/2025/02/02/nx-s1-5283957/fentanyl-trump-tariffs-china-canada-mexico
[6] https://www.thinkglobalhealth.org/article/how-overdose-prevention-centers-became-political-scapegoats
[7] https://www.npr.org/2023/12/28/1220881380/overdose-fentanyl-drugs-addiction
[8] https://www.cfr.org/backgrounder/fentanyl-and-us-opioid-epidemic
[9] https://pmc.ncbi.nlm.nih.gov/articles/PMC5565130/
[10] https://ldi.upenn.edu/our-work/research-updates/partisan-politics-and-the-opioid-epidemic-a-social-media-analysis/
[11] https://www.humhealth.com/blog/chronic-pain-management-cpt-codes-and-billing-guide-2025/
[12] https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
[13] https://www.aafp.org/family-physician/patient-care/care-resources/pain-management/aafp-chronic-pain-management-toolkit.html
[14] https://docrx.com/2025-billing-updates-for-non-opioid-pain-treatments-key-takeaways-for-healthcare-providers/
[15] https://www.ncbi.nlm.nih.gov/books/NBK92054/
[16] https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/opioid-prescribing.html
[17] https://nacns.org/wp-content/uploads/2025/02/Pain-Management_2025_02_04_FINAL-.pdf
[18] https://www.azdhs.gov/documents/prevention/womens-childrens-health/injury-prevention/opioid-prevention/appendix-b-state-by-state-summary.pdf
[19] https://end-overdose-epidemic.org/wp-content/uploads/2020/07/Principles-of-Evidence-Informed-Pain-Care-FINAL_template-1.pdf
[20] https://painmed.org/clinical-guidelines/
[21] https://www.ncbi.nlm.nih.gov/books/NBK572085/
[22] https://www.ncbi.nlm.nih.gov/books/NBK553030/
[23] https://www.ncbi.nlm.nih.gov/search/research-news/19707
[24] https://www.congress.gov/event/118th-congress/house-event/115371/text
[25] https://www.dea.gov/sites/default/files/2020-03/DEA_GOV_DIR-008-20%20Fentanyl%20Flow%20in%20the%20United%20States_0.pdf
[26] https://www.wilsoncenter.org/article/lab-overdose-synthetic-opioid-crisis-shaping-us-mexico-agenda
[27] https://www.dea.gov/sites/default/files/2024-05/NDTA_2024.pdf
[28] https://www.pa.gov/agencies/ddap/overdose/opioid-overdose.html
[29] https://www.cbp.gov/border-security/frontline-against-fentanyl
[30] https://www.samhsa.gov/find-help/helplines/national-helpline
[31] https://www.whitehouse.gov/presidential-actions/2025/02/imposing-duties-to-address-the-flow-of-illicit-drugs-across-our-national-border/
[32] https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates
[33] https://fsi.stanford.edu/sipr/fentanyl-blame-game
[34] https://www.dea.gov/resources/facts-about-fentanyl
[35] https://pmc.ncbi.nlm.nih.gov/articles/PMC9838196/
[36] https://www.azag.gov/issues/opioids
[37] https://www.cdc.gov/overdose-prevention/about/understanding-the-opioid-overdose-epidemic.html
[38] https://www.naccho.org/programs/community-health/injury-and-violence/overdose/health-equity-drug-overdose-response
[39] https://www.hhs.gov/overdose-prevention/
[40] https://www.cbo.gov/publication/58532
[41] https://siepr.stanford.edu/publications/policy-brief/opioid-crisis-tragedy-treatments-and-trade-offs
[42] https://calmatters.org/explainers/california-opioid-crisis/
[43] https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2022/01/07/an-equitable-response-to-the-ongoing-opioid-crisis
[44] https://journalofethics.ama-assn.org/article/how-fda-failures-contributed-opioid-crisis/2020-08
[45] https://publichealth.jhu.edu/2024/nearly-one-third-of-us-adults-know-someone-whos-died-of-drug-overdose
[46] https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm
[47] https://www.asahq.org/~/media/sites/asahq/files/public/resources/standards-guidelines/practice-guidelines-for-chronic-pain-management.pdf
[48] https://www.dir.ca.gov/dwc/DWCPropRegs/2025/MTUS-Evidence-Based-Update/Chronic-Pain-Guideline.pdf
[49] https://www.va.gov/painmanagement/docs/cpg_opioidtherapy_summary.pdf
[50] https://www.healthquality.va.gov/guidelines/pain/cot/
[51] https://nida.nih.gov/research-topics/opioids
[52] https://www.bbc.com/news/articles/cvg93nn1e6go
[53] https://www.canada.ca/en/health-canada/services/opioids/overdose.html
[54] https://medlineplus.gov/opioidoverdose.html
[55] https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0236815
[56] https://pmc.ncbi.nlm.nih.gov/articles/PMC9261968/
[57] https://www.ama-assn.org/system/files/ama-overdose-epidemic-report.pdf
[58] https://pmc.ncbi.nlm.nih.gov/articles/PMC5846593/

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Answer from Perplexity: pplx.ai/share

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