Denial of care… continuing and growing ?

Posted on November 21, 2019 by Pharmaciststeve

Dear Steve,

I have pudendal neuralgia (on my right side) and interstitial cystitis. I’ve been following your work for awhile and I was one of the patients who spoke to the Department of Health & Human Services Pain Task Force in DC last year. I also follow Red Lawhern, (along with other excellent researchers on this topic), and have been an advocate on behalf of myself and others for the last 3 years or so. 

I’ve been fortunate that I’ve been able to maintain a good medical team, though I must admit I live in fear of my pain management doctor being raided by the DEA even though he does all the due diligence possible. 
I ran into an interesting problem the other day and I’m not sure if I have any recourse. I would appreciate it if you can weigh in. I’ve been taking 2 schedule 3 pain medications along with a very, very low dose of Klonopin daily. I’ve been taking this combination for awhile with no concern expressed by my doctors office or pharmacy. In fact, all of the doctors on my team are supportive of my protocol. 
My doctor tried to call my Klonopin in to Wegmans pharmacy  last week, as we have in the past. My doctor was told that they will no longer fill a benzodiazepine with an opioid pain reliever. My 3 doctors were surprised and I decided to call the pharmacist myself. After talking with the pharmacist at length to reassure him about my medical condition and explain that I’m one of the patients that takes my medication as prescribed… he acquiesced that they could continue to fill them as long as I kept my dose low. 
He told me that the pharmacy had been harrassed by the medical board and were all in fear of losing their license if they filled a benzodiazepine and pain medication together. He also cited the CDC guidelines that discourage (but do not entirely prohibit) the combination. 
Red Lawhern provided me with some research from UNC Chapel Hill that proved that the drug combination was generally safe when used as directed, but the pharmacist was not swayed. They simply had too much fear of the regulatory bodies that could take their license. My pain management doctor showed the pharmacist research that suggested that my incredibly low dose could not possibly cause an overdose, but again, the pharmacist was not swayed. 
Do I have any recourse? I felt uncomfortable when I realized I needed to disclose my diagnosis in order for him to fill the prescription. I also felt uncomfortable that my pharmacist was allowed to question the sound judgment of 3 different doctors who know me well. I certainly don’t mind my pharmacist asking questions and verifying things with my doctor, but I think that creating an overall rule that they will not fill this combination of medication goes too far. 
However, they seem to be embolded by the current CDC recommendations. I am having a hard time understanding this when those guidelines were only created for primary care doctors and not meant to be used by specialists or pharmacists. 
Can you give me some advice? I do understand my pharmacist feels stuck in the middle of a regulatory mess. I am trying to be empathetic but I think I need to report the situation if you think it would help other patients. 
Best regards, 
This pt has been going to a grocery store chain pharmacy and it would seem what they are running into is that the corporate HQ has been intimidated by some part of some bureaucracy and/or they are concerned about being drug into the law suits that are currently going after the pharmas and wholesalers. I suspect that the chain pharmacies and the insurance/PBM industry can’t be far behind in the law firms going after more money ..because they will claim that they facilitated the opiate crisis by providing and/or paying for opiates for pts who had a valid medical necessity.
This seems to confirm what I have suspected for some time,  some corporations have went so far as to turn their employee pharmacists into nothing more than puppets to the corporate demands on what meds or combinations of meds will or will not provide to certain pts.   Has these corporate demand being instigated by the DEA or by their legal council ?
From what this was stated by this pt… this corporation has taken upon itself to basically revoked the professional discretion of their employee pharmacists and impose their opinions,  Which since the corporation can only have a permit to operate a pharmacy not the practice of pharmacy they have appeared to exceed their legal authority.
However, we have a very serious and growing Pharmacist surplus and it is claimed that the 140 odd pharmacy schools are graduating 15,000 new pharmacist each year and there are MAYBE 10,000 open job slots to be filled.  Many of these new Pharmacists having SIX FIGURE student loans hanging over their heads.
So those Pharmacists who have a job, know that they can be easily replaced by young and eager – in debt – Pharmacists may accept a lower hourly rate.
To date, the corporations that are taking such actions have no reason to fear pts being denied care… no one has sued them…  Actions that have no consequences, typically are repeated until there are consequences.
Here is a website to help pts find independent pharmacies  http://www.ncpanet.org/home/find-your-local-pharmacy where they will be dealing with the Pharmacist/owner and unlike the corporate pharmacist that collects a paycheck every couple of weeks… regardless if they deny filling valid Rxs or not … only get paid when they fill legit prescriptions for pts with valid medical necessity.  The over whelming majority don’t have “deep pockets” … so there is nothing for the bureaucrats to fine…  if they do fine the independent it would probably mean a closing of the store because they cannot afford to pay the fine.

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ACLU supporting illegal immigrants while ignoring the inhuman treatment and discrimination of our handicapped/disabled citizens ?

Posted on November 21, 2019 by Pharmaciststeve

Three years of the Trump administration, Steve.
We told President Trump that if he acted on any of us his unconstitutional campaign promises, we would see him in court.

And we did – filing 140 lawsuits and 100+ other legal actions. We’ve won many of them, but the fight is ongoing.

In fact, next year may be the toughest yet. Trump is doubling down on his agenda, abusing power, and behaving more erratically in hopes of winning reelection.
But what we’ve accomplished together in these three years gives me hope. Here are just a few reasons why:
• Separating families seeking asylum is perhaps the cruelest out of all of Trump’s anti-immigrant policies. So we sued and got a court ruling barring the practice. We’ve helped reunite more than 2,000 families since then. The legal fight continues as we press the administration to reunite the thousands of others that remain separated. We won’t rest until we’ve reunited them all.
• As a candidate, Trump promised to overturn Roe v. Wade, and in response, seven states have enacted laws banning abortion. We’ve challenged five of these bans, and got injunctions on every single one. Thanks to our collective action, abortion remains legal in all 50 states. We anticipate more state bans in the year to come, and we’ll be ready.
• The president tried to rig the census by adding a question about citizenship to intimidate immigrant participation. The impact would have been dire: By deterring tens of thousands of immigrants from filling out the form, the question would have resulted in congressional under representation and less federal support for districts where immigrants live. But we fought the administration all the way to the Supreme Court, and won. Together, we preserved the integrity of our democracy.
Wins like these are powerful. But what gives me the most hope are the people behind this work: our relentless team of lawyers, organizers, policy analysts, and our supporters – you’re a big part of this.
Steve, you allow all of this to happen – whether you’ve made a donation or a phone call to Congress, showed up at a rally, or spread the word about the most pressing civil rights battles we face.
So when Trump doubles down on his attacks in the coming year, we have the team ready to fight back – to defend our right to abortion, seek asylum, vote, or exercise any of our constitutional rights and liberties. We will continue to secure our freedoms and advance equality.

David Cole
ACLU Legal Director
P.S. It’s tough to capture all that we’ve done together in the past three years, but I attempt to in this piece I wrote. Give it a read and learn more about how we fought the Trump administration together.

Doesn’t this email, that showed up in my email inbox, give you the warm fuzzies ?  ACLU filing 140 lawsuits and 100+ other legal actions…  I am not aware If any action initiated by the ACLU to provide assistance or protect anyone in the chronic pain community or other pts that are dealing with subjective diseases.

millions of pts dealing with human rights violations and civil rights violations and some pts given no choice but suicide because of their under/untreated unrelenting pain.

How many chronic pain pts have reached out to the ACLU to only be told that they don’t have the resources to provide any help ?

According to this letter apparently illegal immigrants well being is a much higher priority than many of our country’s own citizens.

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what can happen when you deal with a nameless/faceless mail order pharmacy ?

Posted on November 20, 2019 by Pharmaciststeve

An example of why not to use Mail Order Pharmacies…

“Patient’s niece wanted me to help her uncle since he was so confused about his meds. Saw this and nearly fainted.

Those fridge items you see were just sitting on a table by the bed.


Unopened boxes from AMAZON PILLPACK. “They have tried to tell them not to send any more but they keep coming” she says.”

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What Are Medicare Opioid Guidelines?

Posted on November 19, 2019 by Pharmaciststeve

What Are Medicare Opioid Guidelines?

https://www.verywellhealth.com/medicare-and-the-opioid-epidemic-4684180

The opioid epidemic affects people of all ages. The Centers for Disease Control and Prevention (CDC) estimates that 130 Americans die from an opioid overdose every day. While drugs like heroin and illicitly-manufactured fentanyl account for the majority of cases, 35% of deaths were attributable to prescription opioids like methadone, hydrocodone, and oxycodone in 2017.

Interestingly, that same year, there was a 10.5% increase in opioid-related deaths due to prescription opioids for people 65 years and older (i.e., people eligible for Medicare). That is why the Centers for Medicare and Medicaid Services (CMS) is introducing new Medicare opioid guidelines to curb the trend.

Opioid Use in Medicare Beneficiaries

Multiple studies have shown a rise in prescription opioid use in Medicare beneficiaries in the past decade.

A 2018 study in the British Medical Journal looked at opioid use data from 2007 through 2016 for 48 million people covered by either commercial insurance or Medicare Advantage plans. The researchers teased apart data for those who were eligible for Medicare based on age compared to those who qualified based on disability.

Age-eligible Medicare beneficiaries had a 12% to 15% increase in prescription opioid use over that time compared to a 26% to 39% increase for disabled Medicare beneficiaries.

Overall, the prevalence of opioid use increased by 3% for people on Medicare but showed no change for people on non-Medicare commercial plans.

A study in the Journal of Managed Care and Specialty Pharmacy in January 2019 focused on claims data for more than 15.5 million beneficiaries on traditional fee-for-service (FFS) Medicare between 2010 and 2011. The researchers used diagnostic codes from these claims to identify cases of misuse and abuse of prescription opioids. Approximately half of all Medicare beneficiaries used at least one prescription opioid during that time. Misuse and abuse were seen at a 1.3% rate and was more prominent in disabled Medicare beneficiaries, accounting for 76.2% of those cases. 

Overall, these rates were higher than previously recognized data for commercial insurance (0.65%), Medicaid (0.87%), or the Veterans Health Administration (1.1%).

The data seems to suggest that Medicare beneficiaries, whether they are on traditional Medicare or Medicare Advantage, are more likely to be prescribed opioid therapies and are at higher risk for abuse. Medicare opioid guidelines may help to decrease opioid use in at-risk individuals.

The Federal Government Targets Opioid Use

The federal government is taking steps to address the opioid epidemic by introducing Medicare opioid guidelines. The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act was passed in October 2018. The legislation is multi-pronged and aims to decrease opioid abuse in a number of ways.

This includes, but is not limited to, creation of new and expansion of existing programs to treat substance use disorders, increasing funding for residential treatment programs for pregnant and postpartum women, authorization of grants for states to improve their prescription drug-monitoring programs, expanding the use of telehealth services, and funding research and development of new non-addictive painkillers and non-opioid drugs and treatments. 

For Medicare beneficiaries, SUPPORT may have significant implications. The legislation allows CMS to refuse payments for opioid medications if it is determined that someone is at-risk for abuse. This involves looking at the dose of opioid medications relative to morphine (morphine equivalents), the number of medical providers prescribing an opioid drug to a given person, and the number of pharmacies used to fill those prescriptions for that person.

Looking at data in six-month intervals between 2011 and 2014, CMS noted that opioids were overutilized by 0.37% to 0.58% of the Medicare population and were associated with a mortality of 3.91% to 7.55% over that time.

Unfortunately, the method CMS uses to identify those people at risk for opioid abuse may not be very sensitive, meaning that it can miss a lot of cases.

Also, many people were flagged as being high-risk even when they never came to develop a substance abuse disorder.

Medicare Part D Policy Changes in 2019

New Medicare Part D policies have been introduced in 2019 to further address prescription opioid use. People with chronic pain syndromes will especially want to take note.

  • If you are receiving a new opioid medication for acute pain, you will be limited to a seven-day supply. If more medication is needed, a medical provider will need to seek Part D approval through a “coverage determination”.
  • If you are prescribed long-term opioid medications, you may be required to get your prescriptions from a designated medical provider(s). The goal is to improve care coordination and to decrease the risk of overprescribing.
  • A safety alert will be triggered at the pharmacy if you take an opioid medication and a benzodiazepine at the same time. Both classes of medication have addictive potential. Taken together, there is also an increased risk of overdose.
  • A safety alert will be triggered at the pharmacy if you receive a dose or quantity of opioid medication that exceeds a certain limit, depending on the drug in question.

These rules will not apply to everyone. Residents of long-term care facilities, people being treated for cancer-related pain, and beneficiaries in hospice, palliative, or end-of-life care will be exempt from these Part D policy changes.

A Word From Verywell

The federal government is taking steps to curb opioid abuse. CMS is not only refusing to pay for opioid medications in high-risk cases but they are also changing several Part D policies as they relate to prescription opioid coverage. While these Medicare opioid guidelines won’t apply to people residing in nursing homes, people receiving treatment for cancer-related pain, or people receiving end of life care, there are many people who rely on long-term opioid therapies for chronic pain.

These policy changes could make it harder for them to get the treatment they need. If this applies to you, be sure to speak with your healthcare provider to explore your best options.

I have a lot of VERY MIXED EMOTIONS about this… there are a number of  VAGUE STATEMENTS in this article… It all depends on someone who has the ability to enforce these things make a decision as to what they mean.

what does a designated medical provider(s) actually mean ? Does this mean that CMS – or some other entity – determines by some statistical number docs who a pain pt can see ?

This is something that Medicaid has done for a long time for verifiable pt who is a doc/pharmacy shopper.

This whole process maybe a pilot program for how if/when we go to a national health insurance and how they will be able to control cost – think ration care.

They already are putting in this process that they are going to use the MME calculators which I recently posted about The Myth of Morphine Equivalent Daily Dosage   that basically stated that those calculators are basically  CRAP !  But things that are incorrect or flat out bad… has never interfered with the government  following thru with its agenda.

This is just another good example of until the chronic pain community comes together and puts their dollars together and create a non-profit and hire a law firm, PR firm and lobbyist firm to be on the lookout and possible prevent such things from being implemented… various parts of the bureaucracy is going to STEAMROLL over the community.

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Sens. Kamala Harris, Bernie Sanders, Cory Booker and Warren 100 billion to treat ADDICTION

Posted on November 19, 2019 by Pharmaciststeve

‘Missed Opportunity.’ Warren’s Opioid Plan Has a Major Blind Spot, Experts Say

https://fortune.com/2019/05/22/elizabeth-warren-opioid-plan-care/

Massachusetts Senator and 2020 presidential candidate Elizabeth Warren proposed a $100 billion plan to address the opioid epidemic earlier this month, earning praise for recognizing the scale of response the crisis requires. Drug policy experts, however, say that while her proposal is a step in the right direction, it overlooks the opportunity to fix a broken healthcare system and address substance use more effectively.

“Because it is so focused on opioids, there are blind spots for where you need to expand access to low cost health coverage, and expand access to housing, and address the underlying issues which fuel problematic substance use and overdoses in the first place,” Northeastern law and health sciences professor Leo Beletsky, an expert on the U.S. opioid crisis, told Fortune.

This “missed opportunity,” like other opioid-related legislation, adds more funding to a substance use treatment system that is “fundamentally flawed and broken,” said Beletsky.

Warren’s CARE Act—cosponsored by a number of other 2020 Democratic candidates, including Sens. Kamala Harris, Bernie Sanders, and Cory Booker—proposes $100 billion in federal funding over the next 10 years to address early intervention, harm reduction, and long-term support services for those struggling with addiction.

Of this $100 billion, funded through her proposed ultra-millionaire tax, $4 billion would go to states, territories, and tribal governments; $2.7 billion to the counties and cities hit hardest by the opioid epidemic; $1.7 to public health surveillance, research, and health professional training; $1.1 billion to public and nonprofits on the front lines; and $500 million to expand access to naloxone, a drug used to reverse opioid overdoses.

In 2017, drug overdose deaths in the nation reached an all-time high of nearly 72,000, a 6.6% increase from 2016. Warren’s bill comes just months after a new report named dying of an opioid overdose the leading cause of preventable death in the United States.

In a Medium post announcing her plan, Warren said that along with addiction treatment, “the CARE Act would ensure access to mental health services and help provide critical wraparound services like housing support and medical transportation for those who need them.”

While many agree on where Warren wants to put the money—Beletsky in particular applauded her dedication to harm reduction, a sometimes controversial area—some argue the funds are already in the system.

“She is a champion of healthcare and I think that she’s got a lot of things right,” Michael Cartwright, CEO and co-founder of American Addiction Centers, told Fortune.

“I don’t know that you need any new money,” he added, noting he doesn’t believe Warren’s ultra-millionaire tax is necessary. “The reason I say that is the health plans alone could fund this $100 billion over the next ten years if they just simply followed the Parity Act.”

The Mental Health Parity and Addiction Equity Act, passed in 2008, states that if health insurance companies provide mental health or substance use disorder benefits, the financial requirements and treatment limitations that apply to them must not be more restrictive than the medical or surgical benefits provided.

Despite being more than a decade old, the Parity Act is rarely enforced. According to a coalition of nonprofits who analyzed several major health plans in 2015 and 2016, documents frequently lack necessary details about coverage. Moreover, many patients are not aware of their rights under the Parity Act.

“Critical details about coverage and access to treatment are often missing from plan documents. It would be challenging—if not impossible—for an average consumer to know whether a plan violates the Parity Act,” Paul Samuels, director and president of the Legal Action Center and spokesperson for the Addiction Solutions Campaign (the group that conducted this study), said in a statement.

“Yet, the current system relies on consumers to report problems to insurance regulators,” Samuels continued. “When regulators don’t receive complaints, they assume the plans are in compliance. Our analysis reveals that most parity violations cannot be identified through consumer complaints nor can they be identified via form review.”

The issue has not gone unnoticed: Warren has long advocated for the Behavioral Health Coverage Transparency Act, which, if passed, would strengthen enforcement partially through random audits of insurance plans and a consumer web portal to file complaints.

Since such legislation has not yet been passed, however, the Parity Act continues to be rarely enforced, allowing insurance companies to get away with placing barriers both in policy and practice, preventing some patients from seeking treatment for substance use disorder.

“The Parity enforcement is abysmal and it’s definitely hurting people,” said Beletsky, adding that this act “arguably is more important” than the episodic funding of Warren’s plan and past legislation addressing the opioid epidemic.

“The bottom line is that the more barriers you create for people to get coverage, the better” for the insurance companies, said Beletsky. “And the stigma around addiction is such that this has been an issue that has received too little attention. As long as something is stigmatized and hidden, it makes it easier for insurers to get away with not covering it properly.”

Like Warren’s CARE Act, past legislation—including the 21st Century Cures Act of 2016 and the SUPPORT for Patients and Communities Act of 2018—have attempted to address the opioid epidemic in other ways. The SUPPORT Act, passed under the Trump administration, allocated roughly $6 billion in new funding to address the opioid epidemic through addiction prevention, medication assisted treatment, and support services.

Much of this funding, however, went into the pockets of pharmaceutical companies. The SUPPORT Act required state Medicaid plans to provide coverage for medication assisted treatment, or the use of drugs like methadone and buprenorphine to aid the recovery of those addicted to opioids.

According to Beletsky, the risk of a patient overdosing goes down by 80% when they’re treated with one of these medications. Abstinence-based rehabilitation programs, on the other hand, actually increase the risk of overdose: the program causes the patient’s tolerance to drop, meaning if they relapse and take a dose similar to what they took prior to treatment, it may be too much.

Thus medications like methadone and buprenorphine are a “critical tool,” said Beletsky, but it does “introduce this element of cognitive dissidence” for those who view the pharmaceutical companies manufacturing them as the villain.

Warren’s plan, for example, advocates for the expansion of naloxone. This drug saves lives, but by virtue of being produced by pharmaceutical companies, promoting its expansion puts more money in the pocket of big pharma. (Unlike other bills, however, Warren’s plan addresses the “criminal negligence” of major drug companies, promising to hold them accountable with actual criminal penalties.)

Cartwright argues the money dedicated to these medications would be better spent on learning more about the cause and treatment of addiction.

“I totally believe in using pharmaceuticals when necessary,” he told Fortune, but he’s bothered by the fact past legislation left us “pouring billions of dollars into old, antiquated medications versus billions of dollars into Harvard and MIT to find the answers for the cure.”

Warren’s CARE Act provides $700 million annually to the National Institutes of Health from 2020 to 2029 for the purpose of researching exactly this. The funds are designated for “research on addiction and pain, including research to develop overdose reversal drug products, non-opioid drug products and non-pharmacological treatments for addressing pain and substance use disorder.”

Meanwhile, the medications being used—while beneficial—are outrageously priced. Vivitrol, another medication used for opioid addiction treatment, costs over $1,000 per monthly shot. Naloxone, the drug used to reverse overdoses, reportedly costs about $1 to manufacture, but with insurance it costs around $40 per dose. Warren’s bill requires any federal contract with a naloxone manufacturer to include negotiations for a discounted price.

“We’ve got to ask ourselves, ‘Why are we paying so much—more than every other country on the planet—for pharmaceuticals?’ That’s a serious problem.” said Cartwright. Along with forcing drug prices down, he said “we ought to take a hard look at the money that’s already in the system and ask, ‘Is it being used efficiently?’”

Cartwright argues more should be spent on prevention and telemedicine, the latter of which could have a major impact on rural areas with few resources. Prevention is effective, he says, but according to the Center on Addiction, just two cents of every state and federal dollar spent on addiction and substance use goes towards prevention and treatment.

A truly effective solution to the opioid epidemic, however, will require a restructuring of the way problematic substance use is treated.

“There’s a consensus [among experts] that we really need to be working to integrate substance use treatment into mainstream medicine and reduce the barriers between substance use treatment, mental health, and primary care or other kinds of healthcare,” said Beletsky.

While policymakers are addressing the opioid epidemic, it’s important not to cut out those suffering from related conditions, he added. Warren’s policy is modeled off of the Ryan White CARE Act, which in 1990 allocated significant funding to address the AIDS epidemic that killed more than 100,000 people. The program is celebrated for its positive impact on HIV/AIDS treatment, but it also created this idea of “HIV exceptionalism” where those with HIV were privy to benefits that those at risk of HIV were not.

“You don’t want to create a system where if you’re using opioids, you have access to certain services and if you’re using meth, you don’t,” said Beletsky.

While Warren’s bill addresses the opioid epidemic specifically in some parts, its overarching aim is to provide complete support for all types of substance use disorder. The bill’s text says the grants are to address “substance use,” not specifically opioids.

To prevent a similar crisis in the future, however, any solution to the opioid epidemic should address root causes of problematic substance use. Warren’s plan begins to move in the right direction, but overall “there’s a lot more that needs to be done in terms of recalibrating existing systems,” said Beletsky. “It isn’t just about the healthcare system and it isn’t just about public health prevention. It’s also about the fact that we sink a lot of resources and really emphasize criminal justice approaches and we really need to move away from that.”

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Ask to share 11/19/2019

Posted on November 19, 2019 by Pharmaciststeve

https://youtu.be/rWHnb9QyH9k

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Sacred Medicine Stories: Chronic Pain 10_28_2019_ Mike

Posted on November 18, 2019 by Pharmaciststeve

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St. Joseph County Drug Unit being shut down amid uptick of violence

Posted on November 18, 2019 by Pharmaciststeve

St. Joseph County Drug Unit being shut down amid uptick of violence

https://wsbt.com/news/local/st-joseph-county-drug-unit-being-shut-down

St. Joseph County Prosecutor Ken Cotter said that even thought the Drug Investigation Unit is being shut down, that doesn’t mean the fight against drugs is over.

Cotter said it’s a combination of Drug Unit success and resources and that with the uptick of violence in Saint Joseph County, they needed the Drug Unit officers to be able to focus on other issues, too.

“In 2016 we had 58 overdose deaths,” said Cotter.

But now so far in 2019, St. Joseph County has had 12 overdose deaths, so the Drug Investigation Unit will be shut down beginning January 1.

“There are fewer drugs throughout our community today than there were five years ago,” said Cotter. “People are still overdosing. People are no longer dying in the manner that they were before.”

Cotter says that Narcan, a lifesaving treatment, has also had a huge impact on reducing overdose numbers.

“The difference is that folks are taking seriously that these drugs kill,” said Cotter, “and so more and more people are having Narcan. Our first responders five years ago did not have Narcan, now they all carry it. Family members are carrying Narcan.”

Now the officers in the Drug Unit can be used for an even more pressing issue.

“Everything is a priority to us,” said Scott Ruszkowski, South Bend Police Chief. “And right now, we have an overwhelming amount of violence in our city, and we are going to concentrate those resources there.”

Drugs remain an issue, but gun violence is even more concerning.

“I would love to have the unit remain, but I also have to be realistic,” said Cotter, “because there is only so many taxes that folks want to pay to be able to supply those law enforcement officers to do all the things that we want them to do.”

Their number one priority in allocating resources is avoiding more deaths.

“Because nothing is more important than a person’s life,” said Cotter. “You can recover from anything else except death.”

The prosecutor’s office wanted to make clear that overdoses will still be investigated, but that the goal is to get more of the people committing violent crimes behind bars or prevent them in the first place.

This is one of those stories that what is said … could only be a portion of the full story…  So now this Indiana county has a increased violence and increased gun violence..

Across this country we are having a increase in meth, cocaine and since MJ – in all forms – is illegal in Indiana … so is all of this street violence mostly involving “street gangs” fighting over turf to sell these illegal products ?

Just because someone is a addict does not mean that they are STUPID… surely they have seen how LETHAL the “Heroin” that is being sold on the street because most of it contains an illegal fentanyl analog.

So they have switched substances which they are abusing… typically addicts have a favorite substance,  but often finances forces them to use what is most available or they can afford.

For at least 100 yrs, our country has had some sort of substance abuse issues…. the difference from time to time is the primary substance that is being abused will change from time to time.

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The Myth of Morphine Equivalent Daily Dosage

Posted on November 18, 2019 by Pharmaciststeve

The Myth of Morphine Equivalent Daily Dosage

Michael E. Schatman, PhD; Jeffrey Fudin, PharmD

May 24, 2016

https://www.medscape.com/viewarticle/863477

For far too many years, pain researchers and clinicians have relied on the concept of the morphine equivalent daily dosage (MEDD), or some variant of it, as a means of comparing the “relative corresponding quantity” of the numerous opioid molecules that are important tools in the treatment of chronic pain. This concept dates back to the mid-1980s, first appearing in the cancer pain treatment guidelines by Portenoy and colleagues,[1] and has subsequently been used empirically and clinically for a variety of purposes.

For example, researchers have relied on non-empirically derived “equivalent dosages” as a means to facilitate research in which opioid consumption serves as a dependent variable. Clinically, opioid “conversion” tables have been routinely used when switching a patient from one opioid to another. And, most unfortunately, opioid prescribing guideline committees have relied on this concept as a means of placing (usually arbitrary) limits on the levels of opioids that a physician or other clinician should be allowed to prescribe. Although these guidelines typically bill themselves as “voluntary,” their chilling effect on prescribers and adaptation into state laws[2] makes calling them “voluntary” disingenuous.

Although some scientists and clinicians have been questioning the conceptual validity of MEDD for several years, a recent study[3] has indicated that the concept is unequivocally flawed—thereby invalidating its use empirically and as a tool in prescribing guideline development. This analysis determined that a fundamental inadequacy of the MEDD concept is the lack of a universally accepted opioid-conversion method. The authors used survey data from pharmacists, physicians, nurse practitioners, and physician assistants to estimate daily morphine equivalents and found great inconsistency in their conversions of hydrocodone, fentanyl transdermal patches, methadone, oxycodone, and hydromorphone—illustrating the potential for dramatic underdosing or, in other cases, fatal overdosing.

Regarding the use of MEDD in research, our suspicion is that many pain investigators have known about the problems with this prodigiously flawed concept for many years. For example, in a 1991 Australian review of the polymorphic metabolism of opioids,[4] the authors concluded that “Pharmacogenetics may play an important role in explaining the wide variability of the clinical response to many opioid drugs.” Yet, a quarter of a century later, MEDD remains routinely used in pain research worldwide. Given that invalid dependent variables in research result in invalid findings, our hope is that investigators will begin to conduct studies comparing morphine with morphine, hydrocodone with hydrocodone, and so on—as opposed to relying on the standard (and far more convenient) approach of MEDD.

Clinically, prescribers need to use this information regarding the flawed MEDD concept to begin practicing dosage-switching and opioid rotation in a more thoughtful and scientific manner. Thus, even if the charts suggest that 1 mg of oxycodone is the “equivalent” of 1.5 mg of morphine, the practice of opioid rotation based on the concept of pharmacogentic homogeneity needs to be seriously reconsidered.

Furthermore, the evidence supporting pharmacogenomic differences among patients is mounting[5,6] and needs to be carefully weighed before labeling a patient who requires 30 mg of morphine rather than the prescriber’s “standard” of 10 mg in order to achieve adequate analgesia as an “addict.” Patients with chronic pain (particularly that of noncancer origin) who are reliant on opioid analgesia are already sufficiently stigmatized and marginalized[7] to allow this type of practice to continue to be the norm.

Although the use of MEDD in research and, to a greater extent, in practice, is probably due to unawareness of its inaccuracy, we posit that the use of MEDD by recent opioid guideline committees (eg, the Washington State Opioid Guideline Committee[8] and the Centers for Disease Control and Prevention Guideline Committee[9]) in the drafting of their guidelines is based more heavily on disregarding available evidence rather than ignorance. Furthermore, their misconduct in doing so has been more pernicious than the use of MEDD by researchers and individual clinicians, because these guidelines widely affect society as a whole as well as individual patients with persistent pain syndromes. We opine that these committees are strongly dominated by the antiopioid community, whose agenda is to essentially restrict opioid access—irrespective of the lack of data indicating that opioids cannot be a useful tool in the comprehensive treatment of carefully selected and closely monitored patients with chronic pain.

Although we emphatically agree that opioid analgesia should not be the first-line treatment for chronic noncancer pain, when other nonopioid treatments have either failed, are contraindicated medically or owing to behavioral and emotional factors, or are inaccessible because of the health insurance industry’s refusal to cover them (irrespective of their established evidence-bases), opioids should be considered. Guidelines that contain language suggesting that alternative treatments are regularly available when this is not the case are shortsighted and troubling.

Recently, we published an article in the Journal of Pain Research titled “The MEDD Myth: The Impact of Pseudoscience on Pain Research and Prescribing-Guideline Development,”[10] with Dr Jacqueline Pratt Cleary as our coauthor. This article goes into considerably more detail regarding the clinical and ethical imbroglio that we address in the current brief article, and as an open-access publication, the Journal of Pain Research encourages readers to access the full text at no cost here. We feel that the healthcare community must learn more about the need to work toward a paradigmatic revision in the consideration of opioids in research, clinical practice, and prescribing guideline development.

I can’t remember how long that I have been saying that any practitioner or entity that uses any of these MME conversion programs should be charged with unprofessional conduct or malpractice.  Besides the inaccuracies of these conversion calculation at face value… We have the fact that without throwing into the decision making process of changing a pt from one opiate to another  without considering the pt’s CYP-450 opiate enzyme metabolism status. Makes the entire conversion process INACCURATE at best.

Before everybody jumped on board of these MME conversion programs and before the CYP-450 opiate enzyme metabolism was in the mix… the standard of care and best practices when switching a pt from one opiate to another… was to use one of these calculator and whatever answer was produced – cut the pt’s starting dose IN HALF and start titrating the dose up or down …depending on the pts self-assessment of their level of pain and quality of life.

We have insurance companies, Prescription Benefit Managers, chain pharmacies, CDC, DEA and others making mandates on what level of opiate therapy a chronic pain pt should be provided.

Here we are dealing with treating subjective diseases and we as Homo sapiens  and we are individuals… we each have 50 odd enzymes in our livers that metabolizes various substances  along with numerous other systems that helps our body functions… some of us better than others.

We are not baking cookies here… we are dealing with a pt’s quality of life and yes we are dealing with medication that can POTENTIALLY BE ADDICTING to some 1.3% of the pts who are prescribed these medications for valid medical necessities.

Yet it would seem like every bureaucrat, politician and others believe that they have the authority to determine the appropriate level of opiate therapy all pts should receive by some cookie cutter formula… IMO… that seems to be like the PRACTICE OF MEDICINE…

Where is the various state medical licensing boards… isn’t it their responsibility to make sure that only licensed practitioners practice medicine ?

Where are the law firms, besides practicing medicine without a license… they are directly or indirectly discriminating against all of these pts and violating the Americans with Disability Act and the Civil Rights Act ?

Many pts have called law firms seeking representation, but apparently many have failed to explain to the law firm that they are not talking about malpractice, but civil rights discrimination, denial of care, pt abuse and in some incidents … intentionally throwing a pt into cold turkey withdrawal and elevated pain (torture).  If the pt’s problems involve a large healthcare corporation… the law firm needs to be aware that there is possibly some very DEEP POCKETS to go after and hundreds or thousands of pts involved.

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CVS: reducing more man hours in their Rx depts ?

Posted on November 16, 2019 by Pharmaciststeve

If you patronize a CVS pharmacy and already believe that their Rx dept staff is understaffed and overworked  this appears to be a chart of MORE REDUCED MAN HOURS in their Rx depts.

Common sense suggests that when a staff is already over worked and understaffed and total man hours are reduced… in the pharmacy depts… that generally means two things… pts will typically have much longer wait times to get their prescriptions filled and the staff will most probably make more errors in filling prescriptions

You might want to ask yourself…. is it time to fine a new pharmacy ?

Here is a link to find a independent pharmacy by zip code  http://www.ncpanet.org/home/find-your-local-pharmacy

Filed under: General Problems | 1 Comment »

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