Anticoagulation Guidance Emerging for Severe COVID-19

https://www.medpagetoday.com/infectiousdisease/covid19/85865

Pragmatic choices dominate as guidelines are shaping up

Systemic clotting problems emerging in severe and critically-ill COVID-19 patients are pushing centers to make tough decisions on anticoagulation with a dearth of information.

Disseminated intravascular coagulation has been noted by Chinese physicians on the initial front of the pandemic. Autopsies showing clots in “not only the lungs but also including the heart, the liver, and the kidney,” were described on a webinar co-sponsored by the Chinese Cardiovascular Association and American College of Cardiology in March.

Elevated D-dimer, a fibrin degradation product indicating thrombosis, at admission has also been linked to substantially higher odds of death in hospital among COVID-19 patients in Wuhan, China.

“What really has become clear in the discussions in the last 2 weeks is that the COVID-19 disease is much associated with thrombosis: large vessel clots, DVT/PE [deep vein thrombosis/pulmonary embolism], maybe arterial events, and potentially small vessel disease, microvascular thrombosis,” said Stephan Moll, MD, of the University of North Carolina at Chapel Hill Hemophilia and Thrombosis Center.

As U.S. cases have skyrocketed, it has also become clear that hospitalized patients often develop blood clots despite being on prophylactic anticoagulation, he told MedPage Today.

“The question is whether everybody with COVID-19 in the hospital should be on blood thinners, and the answer is probably yes,” he said. “Should they be on higher than usual prophylactic doses? And the answer is possibly yes.”

Now, full-dose anticoagulation is being considered even if patients don’t have documented blood clots, he said, “because it may be microvascular thrombosis in the lung, in the kidneys that lead to pulmonary failure and renal failure and eventually death.”

Clinical Challenges

“Even the diagnosis of thrombotic events is difficult in this population because of the risk of exposure when performing testing as well as the difficulty testing for microthrombotic events,” commented Ajay Kirtane, MD, SM, director of the cardiac catheterization laboratories at Columbia University Irving Medical Center/NewYork-Presbyterian Hospital in New York City.

Without knowing the true incidence of events, he told MedPage Today, “empiric anticoagulation with either full dose or partial dose antithrombotics is such an interesting question.”

Physicians are having to dive in, though, with pragmatic guidelines being released by many centers and some professional societies and more on the way, according to Moll.

The International Society on Thrombosis and Haemostasis recently recommended that all hospitalized COVID-19 patients, even those not in the ICU, should get prophylactic-dose low molecular weight heparin (LMWH), unless they have contraindications (active bleeding and platelet count <25×10⁹/L).

Recommendations from Britain also call for VTE prophylaxis for all high-risk patients as well as considering PE for patients with sudden onset of oxygenation deterioration, respiratory distress, and reduced blood pressure. It suggested LMWH rather than oral anticoagulants, including switching patients who normally take a direct oral anticoagulant (DOAC) or vitamin K antagonist.

Many institutions are choosing threshold values upon which to start systemic anticoagulation around a D-dimer >1,500 ng/mL and fibrinogen >800 mg/mL, noted Jason Katz, MD, director of cardiovascular critical care at Duke University Health System in Durham, North Carolina. “For now, we [at Duke] are taking things on a case by case basis – which I think is reasonable in light of the small (albeit growing) evidence base.”

Long chain (unfractionated) heparin would theoretically be preferable among anticoagulants because of their anti-inflammatory effects, Moll noted, while LMWH has less of an anti-inflammatory effect and DOACs have little. “And inflammation plays a big role in COVID-19.”

IV unfractionated heparin also has an advantage in that it can be stopped quickly if bleeding occurs, Katz noted. While there has been some suggestion that heparin may influence SARS-CoV-2 binding, “this construct needs to be validated, of course.”

However, practical matters may dominate. In New York City, Montefiore and many other hospitals have chosen DOACs, Moll noted. “They don’t want the nurses to go into the patients’ room to give the unfractionated heparin two or three times a day or to adjust the IV unfractionated heparin. It’s much easier to just give an oral anticoagulant with a huge number of patients.”

Mechanism

Exactly why the virus causes such extensive coagulation isn’t clear.

Three ICU patients with COVID-19 in China showed antiphospholipid autoimmune responses, reported Yongzhe Li, MD, of Peking Union Medical College Hospital in Beijing, and colleagues in a letter to the New England Journal of Medicine published Wednesday.

All three tested positive for anticardiolipin IgA and anti-β2-glycoprotein I IgA and IgG.

“The presence of these antibodies may rarely lead to thrombotic events that are difficult to differentiate from other causes of multifocal thrombosis in critically patients, such as disseminated intravascular coagulation, heparin-induced thrombocytopenia, and thrombotic microangiopathy,” they wrote.

D-dimer was over 21 mg/L in the first patient, who “had evidence of ischemia in the lower limbs bilaterally as well as in digits two and three of the left hand. Computed tomographic imaging of the brain showed bilateral cerebral infarcts in multiple vascular territories.” Lab results also showed leukocytosis, thrombocytopenia, an elevated prothrombin time and partial thromboplastin time, and elevated levels of fibrinogen.

D-dimer was around 3 mg/L in the other two patients, both had multiple cerebral infarctions in the right frontal lobe and other locations in the brain on imaging, and other findings were similar as well.

Lupus anticoagulant was not detected in any of them.

However, Moll cautioned against drawing any causal conclusions, as antiphospholipid antibodies are well known to be transiently positive at the time of acute infectious illness. Also, antiphospholipid antibody titers and lab assay used were not reported.

Endothelial damage leading to subsequent clotting has been promoted as the mechanism by Bin Cao, MD, of the National Clinical Research Center for Respiratory Diseases in Beijing, who helped develop treatment strategies there from the beginning of the epidemic.

The SARS-CoV-2 virus that causes COVID-19 disease enters cells via the angiotensin converting enzyme 2 (ACE2) receptors, which are most commonly found in the alveolar epithelial cells, followed by endothelial cells, Cao noted on the CCA/ACC webinar last month. When the virus binds to these cells, it may damage the blood vessel, especially the microcirculation of the small blood vessels, and thus spur platelet aggregation, he said.

Autopsies have also shown inflammatory changes in the heart with fine interstitial mononuclear inflammatory infiltrates, but no viral inclusions in the heart, Yundai Chen, MD, of the Chinese PLA General Hospital in Beijing, added during the webinar. Other potential mechanisms for the cardiac damage are hypoxia-induced myocardial injury, cardiac microvascular damage, and systemic inflammatory response syndrome.

Which of these mechanisms is dominant matters a lot in treatment approach, Moll noted. “If the thrombosis is the major reason for multiorgan failure, then the anticoagulation is really important. Anticoagulation obviously leads to higher risk of bleeding, so you don’t want to give it if that’s not the main mechanism.”

Further autopsy studies will be important in sorting this out, along with studies correlating those findings to clinical course, he said.

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https://youtu.be/NjjybyJ59Lw

I have felt uneasy on many of the statements that Dr Fauci has made in regards to treating COVID-19 pts.  He has been big about having full vetted double blind clinical trails before he is willing to endorse any therapy particularly Plaquenil (hydroxychloroquine).  while pts are dying on vents and once a pt is on a vet there is around a 10% chance they will come off ALIVE.  Yes this med can be troublesome when used long term for Lupus and Rheumatoid Arthritis but the recommended therapy for COVID-19 is 5-10 days.

I have seen many such statements from pharmacist FB pages… and when I posted a challenge that pharmacists routinely dispense meds that are prescribed off label.. a get a couple of “thumbs up” but there is no disputing that statement but a lot of “crickets”

This doc suggest a LOT OF MIS-CODING of diagnostic codes and cause of deaths… to justify an agenda ? Maybe the community needs to uses these facts in the future when the COVID-19 epidemic has come and gone and the fabricated opiate crisis is back in the news

Have we seen this before… with the fabricated opiate crisis ?  A 90 y/o chronic painer dies… heart attack, stroke or natural causes and toxicology shows opiates and we have a “opiate related death”

Could it be that every cancer pt in hospice – or even every hospice pt’s death … could be coded as a “opiate related death ”  because of their toxicology  or just the fact that they have been prescribed a opiate ?.. no sense in wasting resources on toxicology ?

Are we inching toward more and more socialism with every crisis or maybe a George Orwell’s type world ?

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Below is a link to a post I made a few days ago..  as I often do, I cut/paste things that I see on the web and make it as a post on my blog.  I typically do not share the name of the person who originally made the post… just as I did this time.  Apparently Claudia thought that someone was posting about her.  But she took 20 minutes out of her busy day to attempt to give me a rip.  Except she apparently didn’t read the post itself, must have read just what ended up being posted on FB.. as a share from my blog… where post graphics are not included.  Which in using her myopic point of view and inferring information not included… she went on this video diatribe focusing on lies about me ,my professional Pharmacist status , my activity as a chronic pain advocate and negative comments concerning the spelling and grammar in the text that I ONLY SHARED  !

Below is the only comment on this video before comment section was closed… it pretty much says it all

if anyone is interested, here is a website about the cost of juvederm  https://www.realself.com/question/juvederm-cost

Someone defrauding those in the chronic pain community for their own personal gain ?

Funny how she claims NOT to know who he is, as she tries to belittle and mock him by calling him a “Little man”……….
Yet like 30 seconds later she starts talking about his blog post’s from over 4 months previous and knows all about him ……….
Showing once again that she is lying through her teeth here……….

The other irony is that in the Blog post of his that she is attacking him over, He himself never actually wrote anything about her at all ……….
And he did NOT even mention her by name……….
Funny as neither did the patient whose comment he had shared………….

So essentially Claudia put herself out here once again…….

Guess she really should take her own advice about posting “Crazy Shit”
Like all that madness she posts about the DEA and those doctors she thinks are innocent………
You know the ones that are actually guilty and have killed patients……..
Like the two she has promoted repeatedly over the past year ……….
One of them lost a patient on the table while he was performing a procedure ……….
And the other was found guilty of manslaughter in the death of his patient whose “Tooth” he was extracting ………..
Those are some real stand up pillars of the community there ……………

Just as here she is shown smearing a member of the pain community taking pot shots, snipes and swipes at him……
Trying to call him out and bait him into giving her what she wants…………
This seem’s to be her “Go To” response anytime her horrible behavior is exposed by someone…………
Put then down, Mock them, Then try to insinuate that they have done nothing to help the pain community, Simply because they do not constantly do live streams praising and patting themselves on the back like she does on a regular basis …………. It’s always “What have you done” ???
Meanwhile nothing she has done has actually come to any fruition, well other then inflating those GoFrundMe accounts that she set’s up under other patients names, You know instead of setting them up under the 501c3 tax exempt non profit she is running …….. Talk about odd ……
Wasting all those patients donations to GoFundMe fee’s………
Of coarse the person whose name they are under will have to pay income tax on all the $$$ donated by the sick and disabled …………
Why waste 25% of that money on needless fees and taxes when she is tax exempt ???

And funny but I though she had “”Evolved”” and learned from all those other videos in which she smeared, slandered, and attacked other advocates and patients ???
Talk about not a good look and needing to put on a better face because as she says “Big brother is watching” …………

Once again patients and advocates were actively doing many different things to fight for their rights BEFORE you came along in 2018 ………
You had nothing to do with that Legislation in Oklahoma which actually got voted through and signed into law ……..
Unlike that Legislation of yours that you have been touting for over 2 years now and that was poorly written that still has not been able to get through your state Senate ………..
Remember that “Rally” in Washington DC ???
Yea the one that you sniped the idea for holding Rally’s from to begin with ……..
Just like how you also sniped the original group Name Don’t Punish Pain that the Award winning advocate Ken McKim had been using for over 4 years BEFORE you came along………….
Sad that he had to retain an attorney and threaten legal action as you tried to trademark his pages name ………………

As to the video game thing that you find so weird…….
That sure is an odd thing to be so in a huff and worked up about. ???
I can’t see how playing a “Video Game” is somehow such a bad look for the community ……
Can’t be worse then the attack / smear videos you make ………
Funny that you would try to “Mock” them over something like this ???
Especially as nobody has ever seen the two men your talking about actually play any video games “Together” ever ……..
I have a feeling they will get a kick out of this specific bit of information when I pass this along to each of them …………
Just so you know ….. I don’t think many of the people you call trash troll haters actually “Hate” you ……..
I think they simply hate how horrible you act and treat other people in the pain community……………..

Seem’s you have some really bad sources providing you information …………….

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Small business employees more people than large businesses, but big business donate many more $$$ to politicians and political campaigns. Small business is ran by your neighbors, all of their profits are typically reinvested in the local community. The net profits from big business quickly are taken out of the town they were generated in. This national virus shutdown is going to change how we shop and even maybe who is left open to buy products/services from. If big business is the winner, after all is said/done and you end up having to travel longer distances to get what you need or you end up in a BIG BUSINESS with no one around to ask a question or provide a service. This political decision could be the genesis.

Once again, are politicians trying to designate who is going to be the winners and losers out of this current crisis ?

Dems block McConnell bid to swiftly approve $250B more for small business fund

https://www.foxnews.com/politics/gop-effort-for-250b-in-small-business-help-fails-in-senate

A $250 billion urgent request to shore up a depleting small business fund failed to pass the Senate Thursday after Democrats objected to the measure pushed by the White House and Senate Majority Leader Mitch McConnell.

With lawmakers home and social distancing, McConnell sought to pass the cash infusion swiftly Thursday by unanimous consent with a skeleton group of senators, but Democrats blocked the effort because they want add-ons to help businesses in disadvantaged communities and an additional $250 billion in funds for other priorities.

The extra funding is being sought amid concerns that the original $350 billion program to help businesses stay afloat during the coronavirus pandemic could run dry in the near future in the face of an enormous demand.

The stalemate in the Senate comes as a record-breaking number of Americans have filed for unemployment with the economy shutting down nationwide under stay-at-home orders. New jobless numbers out Thursday morning show a total of 16.8 million Americans have filed for unemployment benefits in the last three weeks.

McConnell pleaded with Democrats to pass a measure that would change the funding for the program from $350 billion to $600 billion total in a “clean” emergency measure.

“My colleagues must not treat working Americans as political hostages. This does not have to be, nor should it be, contentious.” McConnell said, adding that lawmakers can pass other COVID-19 legislation in the future.

“Please do not block emergency aid you do not even oppose, just because you want something more,” McConnell implored.

But Democrats say they’ve got a better plan, and want additional provisions and protections to help businesses in disadvantaged communities. Their proposal would cost roughly double the Republicans’ and include an additional $100 billion for hospitals and $150 billion more for state and local governments as well as increases to food assistance benefits.

Democrats called McConnell’s move a “political stunt” because the Senate leader knew his plan didn’t have bipartisan support but put it forward anyway, knowing it would fail.

“I’m afraid that this unanimous consent is basically a political stunt because it will not address the immediate need of small businesses in the legislation that we have passed,” Sen. Ben Cardin, D-Md., said.

Democrats said small businesses have been seeking fixes in the loan program already that could have garnered bipartisan support if McConnell had worked with them.

“Yes, we know we need more money for this program,” said Sen. Chris Van Hollen, D-Md. “But for goodness sakes, let’s take the opportunity to make some bipartisan fixes to allow this program to work better for the very people it’s designed to help — small businesses, nonprofits. That’s what they are asking us to do.”

During a brief Senate session Thursday morning, McConnell sought unanimous consent for the small business funding boost. But Cardin objected. And McConnell formally rejected the Democrats’ alternative proposal — creating an impasse.

And even if it had passed the Senate, House Speaker Nancy Pelosi warned Wednesday the narrow McConnell plan couldn’t pass the House by unanimous consent. Meanwhile, Kentucky Rep. Thomas Massie, R-Ky., again threatened to block anything passing the House during the pandemic without lawmakers returning to Washington to vote in person.

The disarray at the Capitol leaves small business owners in the balance as Treasury Secretary Steven Mnuchin warns the popular program is on track to be depleted as struggling businesses rush to apply for aid.

The Paycheck Protection Program helps businesses with under 500 employees obtain loans that can cover eight weeks of their payroll, benefits, rent and other expenses.

The loans will be converted to grants and fully forgiven if 75 percent of the loan is used to keep employees on the payroll. The program was created as part of the $2.2 trillion CARES Act that passed last month.

McConnell said at least $100 billion in loans for small businesses — roughly 30 percent of the fund — has already been approved under the program since it started accepting applications April 3.

McConnell accused Democrats of trying to hold paychecks “hostage” and blasted them for trying to push programs that have “zero” chance of passing the House and Senate.

“We cannot play games with this crisis,” McConnell said.

Instead of a $250 billion replenishment for the existing Paycheck Protection Program, the Democrats only offered $125 billion. But Democrats proposed an additional $125 billion for new small business funding targeted at disadvantaged businesses that may not have pre-existing relationships with certain banks that put them last in line for the first-come-first-served program, Pelosi said.

The Democrats’ $125 billion proposal breaks down with $60 billion for community-based lenders; $50 billion for the Small Business Administration’s Economic Injury Disaster Loans and $15 billion for the SBA’s Emergency Economic Disaster Grant Program.

“There is a disparity in access to capital in our country,” Pelosi said Thursday.  “We do not want this tragedy of the coronavirus to exacerbate that disparity, or to ossify it.”

The Democrats’ plan also made some changes to the $400 million in election funding to states that passed in the original CARES Act, after a bipartisan group of state elections officials petitioned Congress for help. The plan would have eliminated the 20 percent state match requirement to access the funds and lengthen the spending and reporting requirements that state leaders said were too onerous.

In all, the Democrats’ alternative proposal cost at least $500 billion and affected multiple programs, compared to McConnell’s narrower $250 billion cash infusion for a signal small business fund.

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Since the outbreak, things we have been saying for years about the CDC are proving true. CDC manipulates data and numbers. Look at previous years of pneumonia deaths. Then at current deaths. Dr. Birx admitted the CDC wants Drs to list cause of death as Covid-19. Now is the time to inform people, again, that this is what was done to us. The CDC does this alot. My opinion it needs to be shut down. It has 0 oversight. If it cant be shut down, then its scope reduced to contagious virus/bacteria. Now is the time to add millions more voices to ours.

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Yes, in June 2019, she became a registered lobbyist. Now, she’s asking for funds for lobby services for a “firm”, when she has had this planned out for 2 years. She also has spent over $40k in go fund me donations for a “commercial”. How I became aware was that my family and friends raised $650, sent the money in, two weeks after she started the first fundraiser, she did a live video, telling people she was closing it and withdrawing the funds. I asked sonething in the comments about,”what about the receipts that were going to be provided”, because she showed up fresh off a car wreck with her daughter, with 8 shots of Botox in her face. The woman is on ssd. (She doesn’t take pain medication, btw. Says it’s a “bad look” for her in her video, so unsure why she’s so passionate about it) she’s got no business to withdraw nine thousand dollars (in the first of 5 commercial fundraisers) and come on live video, saying she’s getting her daughter a bmw and complaining how bad her face hurt after 4 thousand dollars worth of Botox injections. I was so confused and just felt wronged. I asked where our $650 went, if she could provide receipts to the donors like she had originally promised. She started tossing anyone asking anything about the money, telling people they need to trust her. How can we trust her when she won’t even answer simple questions to people she should be respectful of that did give money to her? Things were very wrong and I felt like I was in the twilight zone with this lady, because her fraud is so obvious, especially to anyone whose been watching her talk since January 2018

I don’t know who is being referenced in this FB post, nor the accuracy of the information that was posted.  However, all of those in the chronic pain community should be aware of those who will take advantage of the community for their own personal gain.

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CBP intercepts thousands of fake IDs coming in from China: “Can be associated with terrorist activity.”

https://www.lawenforcementtoday.com/cbp-intercepts-thousands-of-fake-ids-media-is-silent-on-seizure/

U.S. Customs and Border Protection must be butter, because they’re on a roll. Dad jokes aside, CBP agents managed to intercept nearly 2,000 fake IDs during the week of March 23^rd in Memphis, Tennessee.

While folks may think this only prevented numerous youngsters for buying a six-pack of beer, CBP officials say false documents present more trouble than just underage drinking.

CBP officers assigned to the Area Port of Memphis got their hands on approximately 2,000 phony driver’s licenses as well as two fake passports from what was described as a express consignment facility.

Gee, I wonder why we’re only hearing #crickets from @AOC over @CBP seizing almost 2000 fake IDs in just one week?? No doubt AOC somehow wants to call the CBP ‘racist’ and wants to disband the CBP, but the more AOC opens her yap, the more #Americans realize she’s full of sh-t. https://t.co/J53l1QunuA

— WakeTheFup (@USMSS99) March 29, 2020

Officials stated that these faux IDs had made their way over from China and were likely headed to numerous destinations throughout the United States.

Several of the seized documents were smuggled via containers that were made to look as though they only carried tassels crafted into Chinese knots.

Smuggled in the bottom of boxes containing a single tassle, and were manifested as a Chinese knot, CBP seized 2000 fake IDs and 2 passports originating in China and bound for different parts of the US.
https://t.co/ydgq9JOidG

— 🇺🇸⚡Red Hoss⚡🇺🇸 (@RedHoss44) March 28, 2020

The Fraudulent Document Analysis Unit of the CBP determined that the IDs were all fake after the agents handed them off to them for review. From here, Homeland Security Investigations is going to be working the discovered contraband case.

The agency noted that these types of documents often garner anywhere from $250-$500 a piece on the black market.

Yes, these may be used by underage students in order to purchase items like booze or tobacco products, but CBP Area Port of Memphis Director Michael Neipert said it goes deeper than just some beers:

“Fraudulent IDs can also be associated with identity theft and terrorist activity. With all the uncertainty currently facing our nation, it is inherent that CBP Memphis Officers/Agriculture specialists remain steadfast in securing the nation’s borders.”

Meanwhile, the Border Patrol have been knocking it out of the park at our southern border, so to speak. 

Border Patrol agents have been fairly busy over in Texas, even with the pandemic in high-gear. From human smuggling, enormous groups of illegal immigrants, to even some nabbed sex offenders, these Texas agents are protecting our community one solid arrest at a time.  

The substantial busts all started out in Del Rio, Texas between March 23^rd and 24^th. Agents assigned to the Del Rio Sector managed to arrest two illegal immigrants who carried previous convictions of sexual offenses.

On March 23^rd, agents from the Uvalde Station were in the midst of conducting freight inspections when they encountered a 40-year-old Mexican national believed to be illegally present.

When processing the individual at the station, records indicated that he’d been previously convicted of sexual battery in St. Lucie County, Florida in 2009. Furthermore, he’d already been removed from the states back in 2018. He’s now facing charges for re-entry after deportation.

The day following, agents from the Comstock Station were conducting “line watch” operations, which is essentially staking out a particular area known for various criminal activity.

During said line watch, agents apprehended a 33-year-old male citizen of Mexico who carried a past that’s every parent’s worst nightmare.

Records checks revealed that this subject had a prior conviction of enticing a child in Houston back in 2011. He too had been previously deported back in 2018. Much like the March 23^rd arrest, this individual is facing charges under re-entry after deportation. Either of the two sex offenders could land 20 years in prison if convicted.

Del Rio Sector Acting Chief Patrol Agent Doyle E. Amidon, Jr. noted the amazing work by the agents within his sector:

“Agents within Del Rio Sector work tirelessly to maintain the security of our nation’s borders and protect the American public. Due to our agents’ tireless work ethic, two more violent predators have been stopped from doing further damage in our communities.”

Between March 25^th and the 26^th, Border Patrol agents in Edinburg, Texas were able to thwart not one, but two human smuggling attempts. One attempt was stopped via a checkpoint, whereas the other was halted via vehicle stop.

The March 25^th incident happened when agents were alerted about a vehicle that was suspected of loading illegal immigrants not far from Los Ebanos. Once agents made their way to the described location, the driver of the suspected vehicle sped off after catching wind of the Border Patrol.

During the chase, the driver of the suspected vehicle stopped and four passengers from the vehicle fled. An orchestrated multi-agency effort aided by the Texas DPS Troopers, La Joya PD officers, and agents from other Border Patrol stations managed to round up the driver and the four vehicle occupants that fled earlier on in the chase.

Not even 24 hours after agents in Edinburg pulled that off, they landed another win while working the Falfurrias Checkpoint. A Nissan Pathfinder had caught the attention of K9 units and was referred over to secondary for a closer inspection.

What agents discovered was two adult illegal immigrants inside of a luggage compartment, one from Mexico and another from Guatemala. Travelling with the two was also an unaccompanied minor from Guatemala as well. Who knows what would’ve become of the smuggled minor had they entered the country undetected?

Then on March 26^th, agents stationed at the Javier Vega Jr. checkpoint in Sarita, Texas were able to apprehend a whopping 48 illegal immigrants in one shot.

Agents had taken notice of a tractor/trailer that appeared to be hauling some grain aboard over to the secondary inspection area in the early morning hours. When the Kingsville agents brought forth the K9 unit to inspect the load, they’d gotten a positive alert.

Upon further inspection of what this trailer was hauling, agents happened upon 48 illegal immigrants inside, where they were hidden atop the stored grain in the load. Agents arrested the vehicle’s driver and proceeded to process all the concealed persons aboard.

The discovery falls in line with Rio Grande Valley Sector’s “Operation Big Rig,” which has aimed to address the sort of smuggling attempts.

Healthcare professionals are basically FORCED to accept the ID that is presented to them from a pt. Especially a pharmacist, who then fills a Rx and it is sent to the states’ PMP database. So those who are in the “business”of diverting legal opiates… they could have a different ID for each prescriber they go to and pharmacy they have a prescription fill at and as long as they get their 30 days supply of one or more controlled substances 30 days apart … they will never show up on any PMP report as a potential abuser or diverter.

This article was from a LAW ENFORCEMENT website, so is law enforcement, in general, aware of this issue ?  If they are, are they intentionally ignoring it ? Fake ID’s can contribute to the diversion of legal opiates.  Could law enforcement and our judicial system being putting up the facade of fighting the war on drugs – since 1970 – and yet ignoring what could be a serious factor contributing to the diversion of legal opiates.

At the same time the DEA continues to profess that the prescribing of legal opiates is the primary driving force behind opiate/controlled substance addictions and OD’s.

As I have stated before, the primary function of a bureaucrat is to perpetuate and grow the bureaucracy and this could be just one part of the DEA/judicial system meeting that task/goal.

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Oath of a Pharmacist

https://www.pharmacist.com/oath-pharmacist

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I recently moved back to xxxxxxxxxx. When looking for a pain management doctor I found I had to go out of the area to see a doctor. When the #campfire took everything I owned I moved to a rental for 16 months. Now that I am back and settled into my new home in xxxxxxxx I looked for an inexpensive place to fill my prescriptions. I did reduce my high opiates with this doctor leaving me to only take and try to live with my chronic pain with Cymbalta, Tramadol and Subutex. As you probably know the subutex is expensive. Raleys happened to be the cheaper choice and 13.1 miles from my home. Upon turning in my doctors prescriptions the associate took all of my info and all of mt goodrx coupon info and said there should be no problem and will text me when my prescriptions are ready for pick up. By the time

I got home I recieved a message from the pharmacist that he can not complete my order because my doctor is more than 30 miles away.

The DEA has stated that it is a RED FLAG for a pt to travel a “long distance” to see a physician or go to a pharmacy to get a Rx filled.  To the best of my knowledge the DEA has never DEFINED what is a “long distance”  This came from the period years ago when people were going to pill mill clinics in FL and showing up in pharmacies states away wanting to get those Rxs filled.

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