Hypothetical – pt has been seen in a practice for several decades by one particular practitioner. The pt is a intractable/high impact chronic pain pt being on opioids and other controlled substances for several decades. The practitioner that as taken care of this pt and a couple of other thousands with individualized therapies. This practitioner is retiring and the 10-12 practitioners in the group have decided to create a “cook book formula ” for treating chronic pain pts. this one particular pt is facing having her stable opioid therapy cut by 33% if the pt wishes to remain as a pt in the practice. Apparently, there is going to be no appeal to dosing decision. Most all of these pts are disabled/handicapped. Isn’t there some Medicare/Medicaid, HHS, CMS or ADA rules about such discrimination against disabled people

---

Yes, there are protections under federal law—including the Americans with Disabilities Act (ADA), Section 504 of the Rehabilitation Act, and Centers for Medicare & Medicaid Services (CMS)/HHS rules—against arbitrary, discriminatory policies that target disabled patients, including those with chronic pain who are stable on opioid or controlled substance therapy.

ADA and Legal Protections

• ADA Prohibitions: The ADA prohibits discrimination against individuals with disabilities—including chronic pain patients—in places of public accommodation, including medical offices. Blanket policies refusing care or medication adjustments for all disabled/chronic pain patients, without individualized assessment, can constitute prohibited discrimination.

• Reasonable Accommodation: Medical providers must engage in an interactive process and provide reasonable accommodations for disabled individuals, unless doing so poses a direct threat or undue burden. This includes considering continued individualized pain management rather than enforcing a rigid “cookbook” protocol.

• Federal Examples: The ADA guidance explicitly states that, if a doctor’s office has a blanket policy of denying care or altering medication for patients with specific disabilities—such as opioid use disorder (OUD) or chronic pain—that blanket refusal may be illegal discrimination.

CMS/Medicare Rules

• Patient Rights: CMS and Medicare rules require that care be individualized based on medical necessity, and blanket downward adjustments in dosing with no appeal process may violate coverage and patient rights provisions.

• Appeals and Documentation: While Medicare Part D does allow safety edits and restrictions on opioid prescriptions, it also supports appeals, exceptions, and mandates careful documentation for patients requiring ongoing higher-dose opioid therapy for legitimate disabling pain.

• Chronic Pain Patient Focus: CMS encourages careful, documented, and medically necessary opioid use for chronic pain, and continued therapy for functionally impaired/disabled individuals is recognized when justified clinically.

HHS Guidance

• Discriminatory Impact: HHS and the Interagency Pain Task Force have warned that non-individualized, “formulaic” protocols for opioid therapy risk patient harm and can be seen as discriminatory towards disabled populations, particularly when patients do not have recourse to individualized review or appeal.

Summary

Blanket policies that cut opioid dosing for all chronic pain or disabled patients—especially with no pathway for individualized assessment or appeal—may violate the ADA and other federal regulations. Such practices could expose the practice or health system to legal action, enforcement by the Office for Civil Rights, complaints to Medicare/HHS, and even civil litigation.

If a patient or advocate feels discriminated against, filing an ADA complaint with the Department of Justice (DOJ), Office for Civil Rights (OCR), or CMS may be warranted—documentation of individualized medical need and the impact of the rigid policy will be essential.There are indeed federal rules that prohibit medical discrimination against people with disabilities, including those with high-impact chronic pain and functional impairment:

• ADA (Americans with Disabilities Act): It is illegal for medical practices to use blanket “cookbook” policies that deny access to individualized pain treatment for patients with disabilities, such as intractable chronic pain. The ADA requires reasonable accommodation and individualized assessment, particularly if a policy disproportionately impacts the care of a protected group and there is no medical justification based on individualized care.

• CMS/Medicare and Medicaid Rules: These programs mandate individualized medical necessity and allow for appeals or exceptions for beneficiaries needing long-term opioid therapy for legitimate disabling pain. While safety edits and monitoring exist, abrupt policy-driven cuts without clinical justification (and appeal rights) may violate patient protections under CMS regulations.

• OCR/HHS Guidance: HHS, through the Office for Civil Rights and the Interagency Pain Task Force, has specifically warned that policies which do not allow for individualized review of opioid and pain care can risk being discriminatory if they disproportionately harm disabled populations; complaints about such discrimination can be made to the federal government.

Blanket, non-individualized dosing policies—especially when targeted only at those with chronic disabling pain—are vulnerable to ADA and CMS complaints and could trigger civil rights investigations or legal action. Practices must provide a pathway to individualized assessment and appeal, or risk violating federal anti-discrimination law.

Filed under: General Problems | 1 Comment »

It has taken only a DECADE for the TRUTH TO SURFACE

 

 

 

 

 

 

 

 

 

 

Filed under: General Problems | 1 Comment »

In 2000 our National Debt was abt 5 trillion, today it is at 37+ trillion. The simple math, in the last 25 yrs we have added > ONE TRILLION/YR to our national debt. When during our first 175 yrs we only amassed 5 TRILLION in a national debt.

Now many of chronic pain pts who are now getting money for Medicare Disability, Medicaid or some other disability insurance, that if they had their opioid pain management back they could be employed and be a productive part of our society?

Medicare disability for people < 65 y/o started in 1972. So between 1965 & 1972, many benefits were added to the SS system – that it was not originally planned for paying out for. 

 

What would be expected in the change in the pt’s life expectancy under such circumstances of reduced/stopped opioid pain management and substantial increase in BP?

If a patient dies 7 years earlier due to abrupt opioid cessation and uncontrolled hypertension, the total expenditures from Social Security, Medicare, Medicaid, insurance, and the potential tax revenue they might generate if “healthy” and employed would decrease substantially over those lost years.

### Estimated System Savings Due to Early Death

#### Social Security
– Average annual Social Security benefit for retirees: ranges from $21,900 to $23,988 per year.[1][2][3]
– 7-year reduction: $$ 7 \times \$22,000 = \$154,000 $$ not paid by Social Security.

#### Medicare
– Average annual Medicare spending per elderly beneficiary: $10,000–$19,000 depending on age, increasing as patient ages.[4][5]
– Using an average of ~$15,000/year: $$ 7 \times \$15,000 = \$105,000 $$ saved in Medicare expenses.

#### Medicaid & Long-Term Care
– Average long-term care cost per year (Indiana): about $70,000 in a nursing facility; Medicaid pays when assets are exhausted.[6][7]
– If Medicaid coverage is used at any point: 7 years at full coverage $$ 7 \times \$70,000 = \$490,000 $$ saved for those in long-term care—less if not continuously institutionalized.

#### Private Insurance
– End expenditures for any ongoing insurance claims (variable, but typically much less than government spending unless catastrophic needs).

### Potential Lost Tax Revenue (If Healthy and Employed)

– Average annual federal taxes collected per person:
– Income tax: ~$7,900/year[8]
– Payroll tax: ~$4,500/year[8]
– Total: ~$12,400/year federal (not including state/local).
– 7 years of lost productivity: $$ 7 \times \$12,400 = \$86,800 $$ in direct federal tax revenue not generated, per working individual.

#### Additional Notes
– If the person was gainfully employed, additional state/local taxes, excise taxes (from consumption), and indirect contributions (e.g., Medicare/SS trust fund contributions) would add several thousand dollars more per year.[9][8]
– Healthier individuals also tend to incur lower annual health care costs, which further amplifies system savings, but the above focuses only on direct expenditure changes

 

 

Filed under: General Problems | Leave a Comment »

All the answers in this blog post was provided by perplexity.ai – all I did was to ask some questions!

While I am not an attorney, it is my understanding that many states have limits on malpractice settlements that are often below what amounts of  the legal fees to fund a case for malpractice.

It is my understanding, law firms look for people that have been harmed by some entity – especially a large corporations with “deep pockets”

It is well established/documented that the MME system has no real valid large double blind clinical studies with a control group to support its conclusions, especially when those conclusions are applied to treating chronic pain pts.

Since the vast majority of practitioners are employees of large hospital system, when all the practitioners are “persuaded” to follow some hard/cold opioid dosing guidelines that are well below the dosing ranges that are published in the FDA prescribing guidelines.

So a entity establishing dosing guidelines limits that are nothing but a FRACTION of the FDA’s prescribing guidelines for a specific medication, that would strongly suggest that SUBSTANDARD CARE IS BEING MANDATED.

Causing unnecessary pain & suffering, premature deaths and often suicides.

---

could find the original parameters for the establishing the original MME equivalents and I believe that was done during the 1970 and has there been any updates or revisions and if so what was those parameters?

The original Morphine Milligram Equivalent (MME) parameters were developed to standardize opioid prescribing by expressing potency relative to morphine, primarily for comparing different opioids and aiding in safe dosage adjustments. While the concept traces back to clinical pharmacology work from the 1970s, there is little evidence of a single formalized or universally adopted framework from that era; standardized MME conversion tables became prominent much later, especially with opioid prescribing guidelines in the 2000s and 2010s.[1][2][3]

Original MME Calculation Parameters

The standard formula for calculating daily MME is:

$$\text{MME}=(\text{Dose Strength per Unit})\times (\text{Units per Day})\times (\text{Opioid-specific Conversion Factor})$$

These conversion factors reflect the relative potency of each opioid compared to morphine.

### Updates and Revisions to MME Parameters

There have been significant updates and periodic revisions to the MME standards, particularly as reflected in CDC guidelines:
– The CDC and other regulatory bodies periodically revise MME conversion tables based on new evidence, observed clinical outcomes, and concerns about overdose risks.
– Notably, the CDC made updates in their 2022 guideline, reflecting adjusted conversion factors for certain opioids (e.g., methadone and tramadol had significant changes in their factors).[6][7][8]
– The parameters for calculating MME now emphasize more precise conversion factors, updated every few years, and stress caution in cross-opioid dose conversions due to incomplete cross-tolerance and patient variability.[5][6]

References and Further Information

Modern resources, including the 2022 CDC Clinical Practice Guideline, provide the authoritative conversion factors and detailed explanation of calculation methods. For full lists of current conversion factors and descriptions of methodologies, consult the CDC official guidelines or clinical documentation from NIH and state PDMPs.[2][7][8][5][6]

In summary, while the MME concept originated in the 1970s, robust and widely adopted parameters and tables are much more recent and have undergone several important updates, especially by the CDC in response to new evidence and evolving clinical needs.

[1](https://www.youtube.com/watch?v=KVoKRLWwduI)
[2](https://heal.nih.gov/files/2025-03/MME%20Calculator%20FAQ_508.pdf)
[3](https://www.eviq.org.au/clinical-resources/eviq-calculators/3201-opioid-conversion-calculator)
[4](https://pmc.ncbi.nlm.nih.gov/articles/PMC9477978/)
[5](https://health.maryland.gov/pdmp/Documents/Clinical%20Docs/MME%20Fact%20Sheet.pdf)
[6](https://www.albme.gov/press-release/changes-to-mme-conversion-calculations-reflected-in-pdmp-database)
[7](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm)
[8](https://archive.cdc.gov/www_cdc_gov/opioids/data-resources/index.html)
[9](https://meps.ahrq.gov/data_files/publications/rf45/rf45.shtml)
[10](https://apps.health.ny.gov/pub/ctrldocs/bne/nyosammeformulation.pdf)
[11](https://medicaid.alabama.gov/alert_detail.aspx?ID=16245)
[12](https://www.nj.gov/humanservices/dmahs/boards/durb/newsletters/34-01_DURB_Newsletter_MME.pdf)
[13](https://scholarlycommons.henryford.com/hfjhrs2025/2/)
[14](https://www.mbc.ca.gov/Download/Publications/pain-guidelines.pdf)
[15](https://www.cms.gov/files/document/methodology-comparison.pdf)
[16](https://www.sciencedirect.com/science/article/pii/S174868152400336X)
[17](https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/ambulatory-care/docs/2022-CDC-Opioid-Prescribing-Guideline-Updates.pdf)

So there has never been any double blind clinical trials with a control group to validate or update the MME standards since the 1970’s and these MME standards are mostly or totally observational and/or consensus of how many experts ?

There have never been any large-scale, double-blind clinical trials with a control group specifically established to validate or revise the core MME (Morphine Milligram Equivalent) standards since their introduction. The MME conversion factors used today are based almost entirely on a combination of observational pharmacologic data, literature review, single-dose studies, and expert consensus rather than rigorous randomized controlled trials.[1][2]

### Scientific Basis and Validation

– The conversion factors for MME are derived largely from early pharmacology work, single-dose potency studies, clinical experience, and expert panel discussions—not from systematic, blinded trials comparing equivalent clinical outcomes across opioids.[2]
– Validation efforts and updates, such as those led by the CDC, involve comparative effectiveness research, retrospective analyses of prescription data, and integration of available pharmacologic data, but not large prospective, double-blind, randomized studies.[3][4][2]
– The most recent changes and adjustments are made by consensus panels with periodic literature review, relying on the accumulated judgment of pain management and pharmacology experts rather than new interventional clinical evidence.[2]

 

 

 

 

 

 

Modern publications and patient-advocacy organizations confirm that MME limits and conversions are not based on formal, rigorous science or double-blind clinical trials, but remain consensus tools created for guidance and policy, with recognized limitations and substantial variability for individual patients.[2]

In conclusion, MME values remain an observational, consensus-based tool, not formally validated or updated with double-blind clinical trial data since the original rough potency estimates were established.No, there have never been any large-scale double-blind clinical trials with a control group specifically designed to validate or update the MME (Morphine Milligram Equivalent) standards since their development. The MME conversion factors and standards used today are almost entirely based on observational data, single-dose potency studies, and the consensus of clinical experts in fields such as pharmacology and pain management—not randomized controlled trial evidence.[1][2]

Nearly all updates and adjustments to MME values in guidelines (including CDC guidelines) come from panel reviews of the existing clinical literature, animal studies, case reports, and collective clinical experience of expert teams. These panels typically include pain management specialists, pharmacologists, and regulatory experts, but the precise number and selection process vary by group or guideline update.[2]

As a result, MME remains an expedient and widely used clinical tool, but its actual scientific validation is limited, and its reliability at the population level has sometimes been challenged. Blinding, randomization, and placebo-controlled methods—the gold standard for validating clinical interventions—have not been applied to the establishment or revision of MME standards.[2]

[1](https://pubmed.ncbi.nlm.nih.gov/39907478/)
[2](https://www.thedoctorpatientforum.com/debunking-lies/508-milligrams-of-morphine-equivalent-mme-and-mme-limits-are-a-scientific-concept)
[3](https://pmc.ncbi.nlm.nih.gov/articles/PMC9477978/)
[4](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm)
[5](https://clinicaltrials.gov/show/NCT00325377)
[6](https://www.clinicaltrials.gov/study/NCT00134524)
[7](https://heal.nih.gov/files/CDEs/2024-04/opioid-mme-crf.docx)
[8](https://www.frontiersin.org/journals/pain-research/articles/10.3389/fpain.2025.1612572/full)
[9](https://www.cms.gov/files/document/methodology-comparison.pdf)
[10](https://medinform.jmir.org/2024/1/e53625/)
[11](https://blueprintgenetics.com/tests/single-gene-tests/mme-single-gene-test/)
[12](https://apps.health.ny.gov/pub/ctrldocs/bne/nyosammeformulation.pdf)
[13](https://pmc.ncbi.nlm.nih.gov/articles/PMC8851821/)
[14](https://www.invitae.com/us/providers/test-catalog/gene-252961)
[15](https://www.communitycarenc.org/sites/default/files/2017-12/Opioid-Morphine-EQ%20Conversion%20Factors.pdf)
[16](https://clinicaltrials.gov/study/NCT04491175)
[17](https://www.albme.gov/press-release/changes-to-mme-conversion-calculations-reflected-in-pdmp-database)
[18](https://reporter.nih.gov/search/12E8CC0C488BC4D77598B8961CAA4A01A2FFCEB861BF/project-details/11240717)
[19](https://wa-provider.kaiserpermanente.org/static/pdf/public/guidelines/opioid.pdf)
[20](https://www.clinicaltrials.gov/study/NCT03847311)

So these conclusion were based on a SINGLE DOSE to pts dealing with surgically induced acute pain, thermal induced acute pain or some other induction of acute pain?

Yes, the foundational MME (Morphine Milligram Equivalent) ratios were mostly derived from single-dose studies given to patients with experimentally induced acute pain, such as surgical procedures, thermal injury models, or other controlled acute pain scenarios.[1][2][3]

### Methodology of MME Conversion Factors

– Early opioid equivalency tables depended on studies where a single dose of an opioid was administered, and pain relief was evaluated—often in patients with surgically-induced pain, experimental thermal injury, or dental pain procedures.[2][3][1]
– These studies were typically short-term and involved volunteers or patients without chronic pain histories or opioid tolerance, making the results less generalizable to populations with chronic pain or complex opioid needs.[1][2]
– The conversion ratios measured analgesic potency using standardized pain scales and sometimes crossover designs but did not account for individual variation, chronic dosing, tolerance development, or metabolic differences over time.[2][1]

### Limitations and Generalizability

– The relative potency data from these acute pain models serve as the basis for the equianalgesic tables that underpin MME conversion, but these do not translate perfectly to chronic pain, nor do they account for risks such as opioid tolerance, incomplete cross-tolerance, or individual pharmacodynamics—limitations which are widely acknowledged in recent guidelines and literature.[4][2]
– There is widespread recognition that these tables can lead to imprecision and even risk when applied to chronic pain management practices, especially for opioid rotation; most expert consensus recommends significant caution and clinical judgment.[4][1]

In summary, MME conversion standards are based on single-dose research in acute pain models and were not validated for chronic pain, repeated dosing, or complex clinical scenarios. They remain a tool with substantial limitations and should be used with clinical caution.[3][1][2][4]

[1](https://www.sciencedirect.com/science/article/pii/S0885392409006307)
[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC3555047/)
[3](https://bpspubs.onlinelibrary.wiley.com/doi/10.1111/j.1365-2125.2009.03456.x)
[4](https://pmpawarxe.zendesk.com/hc/en-us/articles/41323540381587-Morphine-Milligram-Equivalency-MME-Insights-into-a-Complex-Metric)
[5](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm)
[6](https://www.ncbi.nlm.nih.gov/books/NBK537482/)
[7](https://www.eviq.org.au/clinical-resources/eviq-calculators/3201-opioid-conversion-calculator)
[8](https://www.mdanderson.org/documents/for-physicians/algorithms/clinical-management/clin-management-post-op-pain-web-algorithm.pdf)
[9](https://heal.nih.gov/files/CDEs/2024-04/opioid-mme-crf.docx)
[10](https://academic.oup.com/painmedicine/article/13/suppl_1/S12/1909004)
[11](https://www.mbc.ca.gov/Download/Publications/pain-guidelines.pdf)
[12](https://www.sciencedirect.com/science/article/pii/S174868152400336X)
[13](https://www.ncbi.nlm.nih.gov/books/NBK526115/)
[14](https://emedicine.medscape.com/article/2138678-overview)
[15](https://attcnetwork.org/wp-content/uploads/2024/07/Acute-Pain-Post-op-Pain-MPATTC_23July2024.pdf)
[16](https://clincalc.com/opioids/)
[17](https://pmc.ncbi.nlm.nih.gov/articles/PMC7736143/)
[18](https://ascopubs.org/doi/10.1200/JCO.22.02198)
[19](https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/opioid-prescribing.html)
[20](https://mn.gov/dhs/opip/opioid-guidelines/pain-phase/acute-pain.jsp)

Since pain is a subjective issue with a pt, how could any consistent results be expected. How many pts were involved in these observational studies?

The early studies underpinning MME conversion factors often involved small patient groups, and most were single-dose studies using subjects with experimentally induced acute pain rather than chronic pain patients. Pain, as a subjective experience, naturally introduced wide variability in responses—making consistent results challenging and the data less reproducible across patient populations.[1][2][3]

### Typical Sample Sizes

– Many foundational opioid equivalency studies involved fewer than 100 participants, sometimes as few as 10–40, with some larger efforts occasionally reaching 100–200 subjects, but these were exceptions rather than the norm.[2][4]
– More recent prospective cohort studies for acute pain may include hundreds or up to 1,550 participants, but these do not specifically validate the classic MME conversion tables used for equianalgesic calculations.[5]
– Pilot and comparator studies in the last decade on specific opioids still often report “relatively small sample size,” making robust statistical conclusions difficult.[6]

### Impact of Subjectivity

– Because pain reporting relies on individual patients’ subjective assessment using numeric or visual analog scales, the resulting potency ratios are averages that mask considerable patient-to-patient variability.[3][2]
– Equianalgesic dose tables are therefore widely recognized as starting points and must be adapted for each individual, particularly in cases of underlying opioid tolerance, comorbidities, and other unique clinical factors.[7][2]

In conclusion, the evidence base for MME ratios comes from observational and single-dose studies with limited sample sizes and high interpatient variability, meaning consistent results are not guaranteed and individualized adjustments are required in real-world practice.Consistent results from MME conversion studies were always limited because pain is inherently subjective and highly variable between patients. The original research often involved relatively small sample sizes—many studies included dozens to, at most, a few hundred subjects—and almost all relied on acute pain models with single-dose exposures.[1][2][7][3]

Most classic equianalgesic studies used fewer than 100 participants per group, and even some more recent prospective observational studies or cohort studies with hundreds of participants have not specifically focused on validating or updating the basic MME conversion tables themselves. This means the results cannot be viewed as universally consistent—the experts themselves acknowledge that variability and individual response differences are significant.[4][2][5][1]

So, the underlying data for opioid potency and equivalency, and thus MME tables, come from small single-dose studies where pain was usually induced experimentally, with results averaged across patients who may respond very differently. This creates a tool that is useful for starting clinical decisions but is not a precise or universally reliable metric.[2][3][1]

[1](https://www.sciencedirect.com/science/article/pii/S0885392409006307)
[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC4590088/)
[3](https://pmc.ncbi.nlm.nih.gov/articles/PMC3555047/)
[4](https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21823)
[5](https://bmjopen.bmj.com/content/12/7/e058782)
[6](https://scholars.uky.edu/en/publications/relative-potency-of-intravenous-oxymorphone-compared-to-other-%C2%B5-o)
[7](https://apm.amegroups.org/article/view/38250/29318)
[8](https://www.sciencedirect.com/science/article/pii/S0885392401002949)
[9](https://www.ncbi.nlm.nih.gov/books/NBK458655/)
[10](https://academic.oup.com/painmedicine/article/17/1/85/1752837)
[11](https://pmc.ncbi.nlm.nih.gov/articles/PMC8514134/)
[12](https://www.ohsu.edu/sites/default/files/2019-01/Opioids_final_report_update-6_Jul_11.pdf)
[13](https://www.nature.com/articles/s41372-024-02121-z)
[14](https://www.ncbi.nlm.nih.gov/books/NBK607985/)
[15](https://www.ncbi.nlm.nih.gov/books/NBK535402/)
[16](https://www.sciencedirect.com/science/article/pii/S0039606021000349)
[17](https://academic.oup.com/painmedicine/article-pdf/17/5/892/6845415/pme.12920.pdf)
[18](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2786200)
[19](https://www.dovepress.com/practical-management-of-opioid-rotation-and-equianalgesia-peer-reviewed-fulltext-article-JPR)
[20](https://emedicine.medscape.com/article/2138678-overview)
[21](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm)

Consensus among experts and guidelines acknowledges significant limitations in the use of MME tables for managing chronic pain, particularly in patients with high-intensity or complex chronic pain. While MME tables may offer a rough framework for opioid rotation or initial dosage considerations, their accuracy and safety for chronic pain management—especially high-dose, long-term cases—are widely debated, and their generalizability remains questionable.

### Evidence and Expert Consensus

– Recent consensus statements and systematic reviews confirm that MME tables are subject to high variability among individuals and across different opioids, making them vulnerable to misapplication in chronic pain populations.[3]
– The CDC and other organizations have acknowledged that recommendations for MME-based dosing thresholds (e.g., limits at 90 MME/day) are not based on high-quality evidence, and that rigid adherence can be harmful to certain chronic pain patients who have benefited from higher doses.[4][1]
– Professional guidelines urge clinicians to use MME tables with caution for chronic pain, reduce reliance on arbitrary limits, and instead adopt individualized, patient-centered approaches when considering opioid therapy and tapering.[2][5]

### Clinical Reality

– Many chronic pain specialists and panels advise that MME conversions do not address incomplete cross-tolerance, pharmacokinetics, metabolic differences, nor the long-term adaptation seen in high-intensity chronic pain.[2]
– For chronic pain, especially severe cases, judicious, individualized opioid management is key—using MME tables only as approximate guides, not absolute rules.[3][2]

 

 

 

 

 

 

 

In summary, current expert consensus and available research strongly suggest that MME tables, while useful for standardization, are not reliably viable as stand-alone tools for chronic or severe pain management—especially in high-intensity, long-term opioid therapy contexts. Clinicians are urged to employ individualized methods and clinical judgment rather than strict MME-based controls.Most studies and expert consensus now agree that MME tables—originally designed for standardization and acute pain—have significant limitations and only limited viability for chronic pain management, especially for patients with high-intensity, complex pain.[7][1][2][3]

Recent guidelines and reviews highlight these key issues:
– There is high variability and limited accuracy in using MME for chronic pain patients, due to differences in tolerance, metabolism, cross-tolerance, individual drug effects, and the adaptive changes seen with long-term opioid exposure.[2][3]
– Rigid MME-based dosing limits can be harmful—for example, the CDC acknowledges that the 90 MME/day threshold is not rigorously supported by science and that forced tapering or strict adherence to MME protocols can negatively impact patients who have benefited from higher doses.[1][4]
– Specialist societies and consensus panels recommend using individualized clinical judgment, careful patient monitoring, and shared decision-making when managing chronic pain with opioids, rather than relying exclusively on MME tables.[5][7]

In summary, while MME tables may provide a baseline for comparison or initial prescribing, the evidence and expert opinion clearly indicate they should not be used as rigid standards for chronic pain management in high-intensity patients. Instead, tailored, nuanced approaches are strongly recommended.[7][1][3][2]

[1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5135486/)
[2](https://mn.gov/dhs/opip/opioid-guidelines/pain-phase/chronic-pain.jsp)
[3](https://www.nature.com/articles/s41598-025-17979-y)
[4](https://www.aafp.org/pubs/afp/issues/2020/0415/p458.html)
[5](https://www.aafp.org/pubs/afp/issues/2020/0915/p335.html)
[6](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm)
[7](https://pubmed.ncbi.nlm.nih.gov/38117465/)
[8](https://www.painphysicianjournal.com/current/pdf?article=Nzc3Nw%3D%3D&journal=157)
[9](https://pmc.ncbi.nlm.nih.gov/articles/PMC10949542/)
[10](https://www.sciencedirect.com/science/article/pii/S174868152400336X)
[11](https://www.medicaid.gov/sites/default/files/Medicaid/Prescription-Drugs/Downloads/Drug-Utilization-Review/DUR-FFS-Reports/AR-DUR-FFY17.pdf)
[12](https://www.mbc.ca.gov/Download/Publications/pain-guidelines.pdf)
[13](https://jamanetwork.com/journals/jama/fullarticle/2503508)
[14](https://wa-provider.kaiserpermanente.org/static/pdf/public/guidelines/opioid.pdf)
[15](https://www.ncbi.nlm.nih.gov/books/NBK535402/)
[16](https://www.fda.gov/media/147152/download)
[17](https://www.mirecc.va.gov/VISN16/docs/pain-management-pocket-guide.pdf)
[18](https://www.ncbi.nlm.nih.gov/books/NBK458655/)
[19](https://www.aafp.org/pubs/afp/issues/2016/0615/p982.html)
[20](https://pmc.ncbi.nlm.nih.gov/articles/PMC7139205/)

 

Could it be considered malpractice if a practice or large hospital system established hard/cold dosing limits based on the MME system for all pts

It could be considered malpractice—or at least a form of substandard care—if a practice or hospital system imposes strict, non-individualized MME-based dose limits for all patients, especially when these policies disregard patient-specific needs and established evidence regarding chronic pain management.[1][2]

### Legal and Ethical Risks

– Current clinical guidelines from the CDC and other authorities clearly emphasize that MME limits should not be rigidly enforced, and care should be individualized.[3][1]
– The CDC specifically warns against forced or abrupt tapering based only on MME thresholds, acknowledging potential harm and risk of legal liability for providers who follow overly strict protocols without clinical justification.[2][1]
– Professional consensus and several recent publications have stated that blanket application of dosing ceilings not supported by patient-specific evaluation can pose real risks, sometimes leading providers to face malpractice claims if patient harm occurs as a result.[4][2]

### Regulatory and Case Precedent

– There is growing documentation of adverse events, such as unmanaged pain, withdrawal, and even suicide, when strict MME-based limits are imposed without individual assessment.[1][2]
– Malpractice is defined in part as failure to meet the standard of care, and most authorities now recognize that rigid, unmodified MME limits fall short for chronic and complex pain patients, possibly amounting to negligence if harm follows.[2][4]

|

 

 

 

 

In summary, health systems and practices implementing hard MME limits without regard for individual patient assessment and clinical judgment may risk accusations of malpractice—especially if patients are harmed and current best-practice guidelines have been ignored.[3][4][1][2]

[1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5135486/)
[2](https://www.aafp.org/pubs/afp/issues/2020/0415/p458.html)
[3](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm)
[4](https://www.aafp.org/pubs/afp/issues/2020/0915/p335.html)

Filed under: General Problems | 1 Comment »

By reducing a pt’s opioids to manage their  chronic pain. Could reduce their life expectancy by upwards of 7+ yrs.

Most of those estimated 100 +/- million chronic pain pts are no longer able to be employed, they produce NOTHING, they pay nothing toward our Social Security or Medicare “trust funds”.

They probably get some monthly money from Medicare disability, maybe from state’s Medicaid. From the bureaucrat’s perspective, we have nearly 30% of our population that are considered “takers”.

In 2000 our national debt was ~ 5 TRILLION and today it is 37+ TRILLION. Keep in mind that the 5 trillion national debt was after abt 225 yrs as being a country and involved in our Civil War, WW-1, WW-2, Korean, Vietnam wars.

Since 1965 we have been fighting the war on poverty- spending some 1 trillion/yr and today some 20% of our population is on Medicaid and since 1970 we have been fighting the war on drugs – spending a some 120-140 billion on that.  40% of households pay NO FEDERAL INCOME TAXES.

At the federal level, our country did not start imposing income taxes until the 1940’s.

So I asked perplexity.ai how having reducing/eliminating a chronic pain pt’s opioid therapy could impact the pt’s life expectancy

---

What would be expected in the change in the pt’s life expectancy under such circumstances of reduced/stopped opioid pain management and substantial increase in BP?

Abrupt reduction or discontinuation of opioid pain management in chronic pain patients, especially when accompanied by a substantial and treatment-resistant increase in blood pressure, dramatically increases the risk of early mortality and can severely decrease life expectancy.[1][2][3]

### Life Expectancy Effects

– **Acute Harm and Mortality Risk:** Studies consistently show that opioid tapering—even when gradual—can lead to increased emergency department visits, hospitalizations, and poor control of chronic conditions like hypertension and diabetes in vulnerable patients. When opioids are withdrawn suddenly, uncontrolled pain and severe sympathetic activation (raising BP) set in, and mortality risk spikes even higher.[3][1]
– **Resistant Hypertension:** If heightened blood pressure becomes resistant to usual medications due to uncontrolled pain or withdrawal-induced sympathetic overdrive, the result is a compounded risk for fatal cardiovascular events (stroke, heart attack, heart failure) and accelerated end-organ damage.[4][1]
– **Excess Mortality:** The risk of death during the period out of opioid agonist treatment is roughly double compared to the period during stable treatment for opioid dependence; these findings translate to chronic pain populations as well, given their overlap in risk profile.[2]
– **Psychosocial and Suicide Risk:** Unrelieved chronic pain and withdrawal both dramatically increase the risk for depression, suicidal ideation, and suicide.[5][3]

### Expected Reduction in Life Expectancy

– **Case-Based and Cohort Data:** Some analyses suggest life expectancy is reduced by several years for patients with uncontrolled pain and resistant hypertension, potentially 5–7 years or more less than peers with controlled pain and BP.[1][2]
– **Instant Risk Increase:** Mortality risk from acute sympathetic crises (severe hypertensive emergencies) rises immediately; risk of fatal cardiovascular events can spike in weeks to months if pain is left uncontrolled and BP remains refractory.[3][1]

### Summary Table

| Scenario | Expected Life Expectancy Change |
|————————————————|—————————————-|
| Stable opioid/pain control + managed BP | Baseline for age, condition |
| Abrupt/tapered opioid stop, uncontrolled pain | 2–7 years reduction if prolonged[1][2][3] |
| Pain-induced resistant hypertension | Increased immediate cardiovascular risk |
| Suicidal ideation/suicide | Markedly increased sudden death risk |

In summary, life expectancy under these circumstances can decrease dramatically due to the dual impact of uncontrolled pain and resistant hypertension—often by several years, and sometimes more if acute events or suicide occur. This underscores the vital importance of safe, effective pain control and careful opioid management, particularly for vulnerable older adults with comorbid cardiovascular conditions.[2][1][3]

[1](https://health.ucdavis.edu/news/headlines/tapering-may-have-negative-impacts-for-patients-taking-opioids-long-term/2023/02)
[2](https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2780655)
[3](https://www.fda.gov/drugs/drug-safety-and-availability/fda-identifies-harm-reported-sudden-discontinuation-opioid-pain-medicines-and-requires-label-changes)
[4](https://www.mayoclinic.org/diseases-conditions/back-pain/in-depth/chronic-pain-medication-decisions/art-20360371)
[5](https://journalofethics.ama-assn.org/article/nonconsensual-tapering-high-dose-opioid-therapy-justifiable/2020-08)
[6](https://www.sciencedirect.com/science/article/pii/S003335062400146X)
[7](https://www.ncbi.nlm.nih.gov/books/NBK458655/)
[8](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm)
[9](https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf)
[10](https://pmc.ncbi.nlm.nih.gov/articles/PMC4036624/)
[11](https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/OUD%20issue%20brief%20final%20508%20compliant%204-19-18.docx)
[12](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2734070)
[13](https://www.ncbi.nlm.nih.gov/books/NBK549202/)
[14](https://www.sciencedirect.com/science/article/pii/S0885392402004116)
[15](https://www.ncbi.nlm.nih.gov/books/NBK526012/)
[16](https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/Pain_Opioid_Taper_Tool_IB_10_939_P96820.pdf)
[17](https://pmc.ncbi.nlm.nih.gov/articles/PMC7854020/)
[18](https://www.cms.gov/about-cms/story-page/cdcs-tapering-guidance.pdf)
[19](https://www.acofp.org/news-and-publications/journal/article-detail/vol-16-no-3-fall-2024/opioid-use-elderly)
[20](https://www.who.int/news-room/fact-sheets/detail/opioid-overdose

 

Filed under: General Problems | 1 Comment »

If you can’t fill in the graphic on the blog post, click on the hyperlink to go to original form

https://pbsnewshour.formstack.com/forms/chronic_pain

Filed under: General Problems | 4 Comments »

Medicare to Pilot AI in Coverage Decisions, Starting January 2026, Impacting Six States

https://demstate.com/article/medicare-to-pilot-ai-in-coverage-decisions-starting-january-2026-impacting-six-states

Medicare will pilot AI for prior authorization decisions in six states starting January 2026, aiming to revolutionize healthcare efficiency while maintaining CMS oversight. This transformative initiative could reshape medical coverage as we know it.

 

Filed under: General Problems | 2 Comments »

How long can bureaucrats, politicians and law firms ignore how the American with Disability Act is being violated and pts being harmed?

As before, all of this was generated by asking questions to perplexity.ai.

 

 

 

I have a pt bringing to me a situation which does not sound entirely kosher.  A office practice operated by a large hospital system in two separate states involving multiple hospitals and numerous office practices that involves upwards of a 1000 practitioners/prescribers. One of the offices of 10-12 practitioners/prescribers have apparently created an agreed upon opioid dosing guidelines as a “standard of care and best practices” for all practitioners working for this particular practice. It may as well be for all office practices owned by the hospital system, at this point that is unknown. As far as I can find out, the “standard of care and best practices” dosing limits are dramatically below what the FDA’s dosing limits are for all oral opioids. Since these guidelines are directed to pts that are mostly disabled/handicapped. Could this “agreement” be considered a form of collusion and discrimination under the Americans with Disability Act, which would be a civil rights violation and Medicare/Medicaid rules about discrimination?

The described situation raises significant legal and ethical concerns. In summary: if a physician group or hospital system imposes opioid prescribing limits that systematically restrict access to adequate pain management for disabled patients—especially if these policies are not rooted in individualized clinical judgment and contradict FDA labeling—this could potentially constitute both unlawful **collusion** and **disability discrimination** under the Americans with Disabilities Act (ADA), and may also violate Medicare/Medicaid anti-discrimination rules.

### Opioid Prescribing Agreements and Collusion

– When a group of providers collectively agrees to restrict opioid prescribing below FDA-approved dosing regardless of individual patient needs, this could be construed as **collusive** behavior if it results in patient harm or disrupts the standard of individualized care.
– Collusion, in the medical and legal sense, often involves agreements or coordinated activity that undermines competition or patient choice and may violate antitrust laws in certain scenarios.

### ADA and Civil Rights Concerns

– The **ADA** prohibits healthcare providers, including hospital systems and their affiliates, from adopting policies that have a “disparate impact” on persons with disabilities, including chronic pain patients. Ensuring effective pain management is often a reasonable accommodation required under ADA if supported by legitimate medical need.
– If such policies result in systematically under treating pain, especially for those with disabilities, this may be considered a form of **discrimination** and a civil rights violation.
– The Department of Health and Human Services’ Office for Civil Rights (OCR) and the Department of Justice (DOJ) have pursued claims where care was denied or unduly limited because of disability status, particularly in cases involving blanket policies that restrict care.

### Medicare/Medicaid Anti-Discrimination Rules

– Providers participating in Medicare and Medicaid are prohibited from discriminating against beneficiaries on the basis of disability, including through practices that restrict access to needed pain medications without clinical justification.
– Reimbursement or participation in these federal programs may be at risk if the institutional guidelines systematically result in discriminatory care.

### FDA Dosing Guidance vs. Standard of Care Policies

– The **FDA labeling** for opioids sets the maximal approved dosage and titration guidance, but “standard of care” is typically determined through clinical consensus and evolving best practices.
– However, if the local standard is set arbitrarily low for non-medical reasons (e.g., legal risk aversion, blanket risk management), conflicting with FDA labeling and national specialist guidelines, and results in under treatment specifically for disabled patients, this can shift from clinical discretion to potential discrimination.

***

If the practice-wide or system-wide guidelines result in **blanket limits** rather than individualized patient assessment, affected patients may have grounds to:
– File a complaint with the OCR (HHS) or DOJ under the ADA.
– Complain to CMS for Medicare/Medicaid discrimination.
– Pursue a civil lawsuit under state or federal civil rights laws.

Cases have been brought in recent years alleging precisely these harms, and regulators have issued warnings against rigid opioid prescribing limits that ignore patient-specific factors.

###

### References

– U.S. DOJ and HHS resources on ADA and healthcare discrimination
– Analysis of CMS and OCR guidance on disability discrimination in opioid prescribing
– Legal commentary on antitrust, civil rights, and medical collusion issues in group practice opioid policies

If specific patient harm, or a pattern of discrimination, can be documented, this situation should be reviewed by legal counsel familiar with healthcare civil rights and reported to relevant regulatory authorities.

---

what if the practice or hospital system say this standard of care and best practices are following CDC 2016 or 2022 opioid dosing guidelines. When it has been widely stated that the 2016 guidelines have been misinterpreted and abused and/or the 2022 was suppose to provide more individualized pt care when being prescribed opioids and neither one of these guidelines provide for any provision for using PGx results and/or consideration for high intensity pain levels – like CRPS and/or sickle cell flares and other such disease/health issues?

The hospital system or practice cannot justify rigid, below-FDA opioid dosing thresholds solely by citing the CDC 2016 or 2022 opioid prescribing guidelines, since both the CDC and leading medical organizations have repeatedly emphasized these guidelines are intended to support—not supplant—individualized and patient-centered care.[1][2][3][4]

### CDC 2016 Opioid Guideline Misapplication

– The 2016 CDC guideline recommendations were widely misinterpreted and sometimes abused, resulting in unintended patient harm, especially for those on chronic opioid therapy for high-intensity pain or complex, disabling conditions.[5][6][7][1]
– Many policies extrapolated rigid dose caps and blanket restrictions that were not present in the CDC’s recommendations, leading to abrupt discontinuation, undertreatment of pain, and even increased risk for withdrawal or suicide among affected patients.[8][9][1]
– The CDC has since clarified the misapplication, affirming that the guideline was not meant to be a mandatory, inflexible policy or a substitute for FDA-approved labeling or clinical judgment.[9][1][8]

### CDC 2022 Opioid Guideline: Individualized Care Emphasis

– The 2022 CDC guideline specifically calls for flexibility, shared decision-making, and individualized pain management—rejecting one-size-fits-all policies.[2][3][4]
– The updated guidance also clarifies that it is not to be used as an inflexible standard or law, but to empower clinicians and patients to make person-centered decisions according to clinical judgment and patient needs.[3][4][2]
– Severe conditions like sickle cell disease and CRPS (complex regional pain syndrome), in particular, require careful exceptions and individualized approaches, not blanket dose restrictions.[10][11][12][13]

### Lack of PGx (Pharmacogenetics) or High-Intensity Pain Consideration

– There are no specific CDC guideline provisions for pharmacogenetic (PGx) testing or unique dosing for patients with high opioid requirements due to severe conditions like CRPS, sickle cell crises, or other rare disorders—the guidelines acknowledge that unique cases require individualized management beyond standard recommendations.[4][10][3]
– Several professional organizations have criticized the lack of such provisions and emphasize the necessity for tailored care using clinical discretion, not blanket limits.[12][10]

### Discrimination and Regulatory Risk

– Policies that impose rigid opioid limits based on misapplied guidelines, especially for disabled populations, can constitute discrimination and expose providers to ADA, civil rights, and Medicare/Medicaid compliance violations.[1][2][4]
– Regulators have explicitly warned systems, insurers, and practices against adopting rigid policies and urged flexibility for those with complex pain.[2][3][4][1]

***

In conclusion, using the CDC 2016 or 2022 guidelines as justification for rigid opioid dosing standards that ignore individualized patient needs—including pharmacogenetics and severe pain syndromes—contradicts the CDC’s intent and may constitute discrimination under the ADA and Medicare/Medicaid rules. Such practices should be reviewed for compliance risks and patient harm.[10][3][4][1][2]

[1](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm)
[2](https://www.pharmacist.com/Blogs/CEO-Blog/cdc-releases-new-pain-management-guidelines-advocating-tailored-care-for-patients)
[3](https://www.cdc.gov/overdose-prevention/hcp/clinical-guidance/index.html)
[4](https://www.cdc.gov/overdose-prevention/hcp/clinical-guidance/recommendations-and-principles.html)
[5](https://news.harvard.edu/gazette/story/2022/11/new-cdc-guidelines-a-corrective-for-opioid-prescriptions-specialist-says/)
[6](https://www.ama-assn.org/public-health/behavioral-health/time-revamp-cdc-s-problematic-2016-opioid-rx-guideline)
[7](https://www.npr.org/sections/health-shots/2022/11/03/1133908157/new-opioid-prescribing-guidelines-give-doctors-more-leeway-to-treat-pain)
[8](https://archive.cdc.gov/www_cdc_gov/media/releases/2019/s0424-advises-misapplication-guideline-prescribing-opioids.html)
[9](https://www.mbc.ca.gov/Download/Publications/pain-guidelines.pdf)
[10](https://www.hematology.org/newsroom/press-releases/2022/ash-statement-on-new-opioid-prescribing-guidelines)
[11](https://www.uspharmacist.com/article/cdc-opioid-guidelines-impact-on-patients-with-sickle-cell-disease)
[12](https://pmc.ncbi.nlm.nih.gov/articles/PMC10928539/)
[13](https://www.the-hospitalist.org/hospitalist/article/37990/addiction-medicine/opioid-prescribing-and-outcomes-in-patients-with-scd-post-2016-cdc-guideline/)
[14](https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm)
[15](https://www.ncbi.nlm.nih.gov/books/NBK458653/)
[16](https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/ambulatory-care/docs/2022-CDC-Opioid-Prescribing-Guideline-Updates.pdf)
[17](https://pubmed.ncbi.nlm.nih.gov/38466269/)
[18](https://www.medcentral.com/pain/chronic/what-do-cdc-guidelines-mean-patients-long-term-high-dose)
[19](https://www.regulations.gov/document/CDC-2022-0024-5551)
[20](https://stacks.cdc.gov/view/cdc/122248/cdc_122248_DS1.pdf)

Filed under: General Problems | 2 Comments »

It would appear that the various state AGs suing the 3 major drug wholesalers over their involvement in contributing to our fabricated opioid crisis.  This lawsuit did not go to trial, it was handled by a committee of state AGs and a Federal judge and mediation. Everyone was on salary paid for by the taxpayers, and all the negotiations/mediation was done BEHIND CLOSED DOORS. It looks like they may have done things this way, so that they would not have to “split the loot” from the lawsuit with some law firm.

 

 

who was the law firm involved with the 45 state AGs that acted as prosecutor law firm?

The law firm that acted as the prosecutor or lead coordinating counsel for the 45 (or 55) state attorneys general in the major multistate opioid settlements—such as those involving Purdue Pharma and the Sackler family—was not a single private law firm, but rather the legal teams within the offices of the state attorneys general themselves, often coordinated by an executive committee of AGs from several key states. These AG-led teams collectively acted as “the law firm” representing the states, exercising their powers to prosecute civil enforcement actions against opioid manufacturers and distributors.[1][2]

In some other opioid litigation, specific private law firms such as The Lanier Law Firm were retained by certain states, or worked closely with AGs and trial lawyers in supporting roles, but in the broad, coordinated actions on behalf of the 45 or more state AGs, prosecutorial authority resided within the AG offices and their appointed committees—not an outside firm.[2][3][1]

[1](https://www.troutman.com/wp-content/uploads/2018/06/The20Robust20Use20of20Previously20Ignored20States20Powers.pdf)
[2](https://www.naag.org/issues/opioids/)
[3](https://www.lanierlawfirm.com/practice-areas/pharmaceutical-liability/opioid-lawsuits/)
[4](https://www.tn.gov/attorneygeneral/news/2025/6/16/pr25-36.html)
[5](https://ag.ny.gov/press-release/2025/attorney-general-james-announces-every-state-has-joined-74-billion-settlement)
[6](https://www.mass.gov/news/55-attorneys-general-sign-on-to-74-billion-purdue-settlement)
[7](https://www.attorneygeneral.gov/taking-action/ag-sunday-announces-historic-settlement-with-purdue-pharma-and-sackler-family-regarding-manufacture-distribution-of-opioids-that-fueled-addiction-epidemic/)
[8](https://www.law.alaska.gov/press/releases/2025/061625-Purdue.html)
[9](https://journals.law.harvard.edu/jlpp/wp-content/uploads/sites/90/2021/01/Cordova-Parens-Patriae.pdf)
[10](https://ag.ny.gov/press-release/2024/attorney-general-james-secures-150-million-multistate-settlement-principle-hikma)
[11](https://oag.ca.gov/news/press-releases/attorney-general-bonta-signs-74-billion-purdue-settlement)
[12](https://www.doj.state.or.us/media-home/news-media-releases/attorney-general-dan-rayfield-secures-720-million-from-eight-opioid-drug-makers/)
[13](https://goultralaw.com/tools/opioid-settlement-calculator-for-individuals/)
[14](https://oag.dc.gov/release/attorney-general-schwalb-secures-21-million-purdue)
[15](https://legislativeanalysis.org/wp-content/uploads/2024/12/Opioid-Litigation-Proceeds-Summary-of-State-Laws.pdf)
[16](https://attorneygenerallynnfitch.com/opioidsettlement/)
[17](https://ncdoj.gov/55-attorneys-general-sign-on-to-7-4-billion-purdue-settlement/)
[18](https://www.nbcnews.com/politics/elections/opioid-firms-kept-donating-state-ags-while-negotiating-settlements-n1050671)
[19](https://www.texasattorneygeneral.gov/news/releases/attorney-general-ken-paxton-and-multistate-coalition-reach-74-billion-settlement-purdue-pharma-its)
[20](https://illinoisattorneygeneral.gov/news/story/attorney-general-raoul-secures-720-million-from-eight-opioid-manufacturers)

 

 

 

tobacco lawsuit/settlement and the states took the risk of cost of carrying the overhead of the lawsuit, so that they took the case to federal court – where everyone (judge, state AGs, etc) on the “prosecutor’s” side of the lawsuit – was basically on the payroll… the only extra money that may have to be spent is for some ancillary para-legals. So there was really no “trial”, just mediation, so it was sort of a bench trial? So this legal proceeding was basically “behind closed doors”?

State attorneys general did adopt elements of the tobacco litigation approach, but with important differences in structure, risk, and legal process. In tobacco cases, many outside law firms were retained on contingency contracts and took substantial financial risk to carry litigation overhead, with states depending on fee arrangements negotiated beforehand. In the opioid litigation, most states relied primarily on their own AGs’ offices and internal legal teams, sometimes supplemented by outside counsel, but the risk and cost were largely handled by state legal infrastructure—rather than private firms.[1][2]

Most opioid proceedings were centralized in federal court (MDL 2804, Northern District of Ohio) under Judge Dan Polster, who organized the process around settlement negotiations rather than extended jury trials. These negotiations were generally conducted through mediation and “negotiation classes,” often without the public or traditional trial proceedings, meaning much of the key decision-making was effectively “behind closed doors” among judge, AGs, defense, and mediators. The result was less a bench trial and more a series of court-facilitated mediations and settlements, with federal oversight, documentation requirements, and some limited open proceedings, but very few actual contested trials.[3][4][5]

Unlike jury trials, these legal actions did not feature public evidentiary hearings or cross-examination; instead, settlements were brokered through judicial mediation efforts, negotiations, and sometimes approval by a federal judge, reflecting a process that was not very transparent to the public, with key decisions occurring in judicial chambers and closed mediation sessions. Thus, while the structure echoes parts of the tobacco template, opioid litigation by state AGs was a more internally managed, mediation-oriented process that often lacked the open adversarial features of conventional trials.[6][4][3]

[1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5871135/)
[2](https://www.classaction.com/news/opioid-lawsuits-big-tobacco/)
[3](https://www.congress.gov/crs_external_products/LSB/PDF/LSB10365/LSB10365.2.pdf)
[4](https://law.stanford.edu/2019/10/01/opioid-negotiation-class-may-be-organic-procedure-evolution/)
[5](https://www.ohnd.uscourts.gov/mdl-2804)
[6](https://www.npr.org/2021/09/01/1031053251/sackler-family-immunity-purdue-pharma-oxcyontin-opioid-epidemic)
[7](https://nashp.org/understanding-opioid-settlement-spending-plans-across-states-key-components-and-approaches/)
[8](https://legislativeanalysis.org/wp-content/uploads/2024/12/Opioid-Litigation-Proceeds-Summary-of-State-Laws.pdf)
[9](https://www.naccho.org/uploads/downloadable-resources/OpioidSettlementsPDFFinal.pdf)
[10](https://nationalopioidsettlement.com/executive-summary/)
[11](https://www.tn.gov/attorneygeneral/working-for-tennessee/filings-of-interest/opioids.html)
[12](https://www.naag.org/issues/opioids/)
[13](https://www.attorneygeneral.gov/wp-content/uploads/2021/07/2021-07-21-Final-Distributor-Settlement-Agreement.pdf)
[14](https://goultralaw.com/tools/opioid-settlement-calculator-for-individuals/)
[15](https://lawecommons.luc.edu/context/luclj/article/2776/viewcontent/4_Art_Aaron__11_87_.pdf)
[16](http://law.stanford.edu/wp-content/uploads/2022/07/Engstrom-Rabin-73-Stan.-L.-Rev.-285-1.pdf)
[17](https://legislativeanalysis.org/wp-content/uploads/2023/01/Opioid-Litigation-Proceeds-Summary-of-State-Laws.pdf)
[18](https://www.tn.gov/attorneygeneral/news/2018/3/21/pr18-09.html)
[19](https://www.sciencedirect.com/science/article/pii/S0955395923000464)
[20](https://attorneygenerallynnfitch.com/opioidsettlement/)

 

being paid out, when these wholesalers did not have any first hand information on who prescribed these controlled meds, no first hand medical/healthcare information on the pts who were prescribed these medications. Did anyone involved in these negotiations have any medical education/backgrounds or review of the medical records on these same pts that would end up with less controlled meds that they had been receiving previously for years or decades.

The final opioid settlement agreements with the three major drug wholesalers—AmerisourceBergen, Cardinal Health, and McKesson—did result in new distribution controls for controlled medications, which have led to reports of patient access limitations, including for people with longstanding, medically justified needs for these drugs. Many chronic pain patients, some of whom are disabled, have expressed that these restrictions are causing hardship and could be seen as discriminatory. There is an ongoing legal and ethical debate about whether such blanket policies run afoul of the Americans with Disabilities Act (ADA), which prohibits discrimination against individuals with disabilities, including those treated for conditions requiring opioids. However, courts have generally found it difficult to prove that these policies exclusively or disproportionately deny access to people with disabilities—official rulings so far have not held the wholesalers’ new policies to be ADA violations.[1][2][3][4][5]

Regarding the use of medical expertise in mediation negotiations, available documentation indicates that negotiations relied heavily on public health officials, attorneys general, government lawyers, and some outside counsel, but did not feature systematic review of the medical records of individual patients affected by reduced opioid access. Instead, settlements and compliance policy changes were focused on population-level distribution data, reporting, and aggregate public health harms rather than individual review or medical necessity determinations. There is no evidence that prescribers’ clinical records or individual disability claims were substantively reviewed during the final settlement processes.[6][7][5]

For shareholders, the settlements did have substantial financial impacts on the companies as billions in payouts reduced available profits, created legal risk, and depressed stock prices at times, even though the companies themselves did not handle prescribing decisions or have patient medical records access. The legal theory of liability was based on distribution and reporting failures rather than individual patient harm or prescriber intent.[8][5][9]

In summary:
– Many disabled patients are experiencing reduced access, but legal obstacles remain in proving ADA violations by distributors.[2][3][4]
– No systematic review of affected disabled patients’ medical records occurred in settlement mediation.[7][6]
– Financial harm to shareholders has been significant, despite distribution companies not prescribing or directly managing patients.[9][8]

[1](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)
[2](https://www.pharmacytimes.com/view/patient-alleges-chain-s-opioid-policy-violates-antidiscrimination-statutes)
[3](https://www.ada.gov/resources/opioid-use-disorder/)
[4](https://adata.org/factsheet/ada-addiction-and-recovery-private-businesses)
[5](https://www.nytimes.com/2021/07/21/health/opioids-distributors-settlement.html)
[6](https://www.expertinstitute.com/resources/insights/mdls-to-watch-national-prescription-opioid-litigation/)
[7](https://www.propublica.org/article/pharmaceuticals-pay-doctors-drugs)
[8](https://www.morningstar.com/sustainable-investing/what-investors-should-know-about-26-billion-opioid-settlement)
[9](https://www.hbs.edu/faculty/Pages/item.aspx?num=61311)
[10](https://www.justice.gov/archives/opa/pr/justice-department-secures-settlement-resolve-disability-discrimination-against-people-opioid)
[11](https://pmc.ncbi.nlm.nih.gov/articles/PMC7859880/)
[12](https://www.lac.org/news/doj-settlement-with-skilled-nursing-facility-excluding-people-on-addiction-medication-violates-the-ada)
[13](https://www.kaplangrady.com/first-court-ruling-clarifying-that-title-ii-of-the-ada-protects-individuals-engaging-in-illegal-drug-use/)
[14](https://goultralaw.com/tools/opioid-settlement-calculator-for-individuals/)
[15](https://www.bmj.com/content/368/bmj.m409)
[16](https://www.opioidsettlementtracker.com/globalsettlementtracker)
[17](https://pmc.ncbi.nlm.nih.gov/articles/PMC6140023/)
[18](https://www.justice.gov/usao-ma/pr/us-attorneys-office-settles-disability-discrimination-complaint-skilled-nursing-facility)
[19](https://jm-aq.com/opioid-litigation-settlements-remediating-the-harms-caused-by-the-opioid-crisis/)
[20](https://www.afslaw.com/perspectives/alerts/opioid-use-and-the-ada-eeoc-issues-new-guidance)

Filed under: General Problems | 2 Comments »

Filed under: General Problems | 2 Comments »