As Wyoming tries to control supply of opioids, patient, prescriber complications emerge

https://www.cowboystatedaily.com/2019/09/05/as-wyoming-tries-to-control-supply-of-opioids-patient-prescriber-complications-emerge/

Through decades of numerous, unpredictable illnesses, pain has become a constant for Cody resident Dawn Scott.

But with the opioid epidemic raging in Wyoming and throughout the U.S., obtaining painkillers has become as unpredictable as epithelioid hemangioendothelioma, the rare cancer she fought in the late 1990s. 

The guarantee of a doctor prescribing opioids can be as uncertain as her thoracic outlet syndrome, the illness that resulted in 21 surgeries between 2014 and 2016, which left her with most of her collarbone removed and muscles that had been attached to the clavicle reattached to other parts of her body. 

“Once I tell them the amount of opioids I’m going to need to get relief — which is significant after 21 years of surgeries — I’m almost instantly labeled a seeker,” she said. “Unless it’s an ER doctor who knows me and knows my history. Newer doctors or loaner doctors don’t offer any form of pain control.”

As state leaders try to control the flow of opioids in Wyoming, complications have emerged. Chronic pain patients have had trouble getting the medicine they need to be comfortable and live productive lives. Physicians and other prescribers – already under watch by private insurers and government health care programs – have new laws to consider in their practice. 

But state leaders, concerned about addiction and its effects on families and communities in Wyoming, felt it necessary to change the law and make it harder to dispense and obtain opioids.

Last month, the Cowboy State Daily reported more than 100 million painkillers were shipped to Wyoming pharmacies between 2006 and 2012. The state, local governments and Indian tribes have sued drug makers and distributors, saying they aggressively marketed the medicines and downplayed their addictive tendencies. 

In February, the Wyoming Legislature passed Senate File 46 and Senate File 47 – its own response to the opioid epidemic. 

S.F. 46 prohibits prescribing and dispensing more than a 7-day supply of opioids in a 7-day period to an acute pain patient, with the Wyoming State Board of Pharmacy to establish “reasonable exceptions” for chronic pain, cancer treatment, palliative care and other clinical exceptions.  The pharmacy board is working on rules. 

The 7-day law is similar to restrictions in about 15 other states. 

S.F. 47 requires licensed health care professionals to take continuing education courses in the responsible prescribing of controlled substances, which includes opioids. 

The law also requires prescribers to upload controlled substance prescriptions electronically to the Wyoming Online Prescription Database by Jan. 1, 2021, so that doctors, pharmacists and other professionals can review what drugs a patient is on — and prevent abuse or adverse side effects.

The federal government has touted state-level prescription drug monitoring programs as a way to spot and close down “pill mills,” and reduce addiction and overdose deaths. Wyoming physicians — who feel they don’t have a problem with over-prescribing, save for a few extreme examples – say the new state laws are heaping on more regulations on top of various insurance and government health care programs, said Sheila Bush, the Wyoming Medical Society’s executive director.

For instance, Medicare encourages physicians to check the prescription drug monitoring program when writing opioid scripts. One private insurer may prohibit opioids for patients under a certain age, another may limit patients to three days of opioids. There are federal laws, and now state laws, she said. 

“Separate from all of this, you still have good clinical knowledge – the ability for a physician to look at a patient and know the history and say, ‘This is the best care for you today,’” Bush said.  “They’re inundated. There’s no consistency.”

The Medical Society was supportive of the Wyoming legislation because it knew the public had asked for changes in the law. The organization felt that having a seat at the table and providing doctors’ expertise could make the measures better, she said. 

But Wyoming patients with serious medical issues may suffer as a result of these policies. 

Scott, the Cody chronic pain patient, had a miscarriage in a 2016. She asked the physician for painkillers for her cramping. She received just one pill – two milligrams of the opioid Dilaudid. 

“My normal dosage to give me maximum relief is between 12-16 milligrams of Dilaudid,” she said, describing the following days as agonizing. 

Scott has since found a pain specialist in Billings, Montana, who has reduced her trips to the emergency room when migraines, cluster headaches and other pain flares up. 

Scott, who as an attorney has represented people with chronic pain, believes opioids aren’t addictive for everyone. Some patients use them responsibly to relieve pain, she said. Scott said she’s gone through periods in which she didn’t have to take any painkillers. 

“It’s sad, and I’ve watched addiction first-hand, not with opioids – but my dad died of alcoholism,” she said. “I understand the power of addiction. I understand there needs to be control. But there also needs to be a case-by-case basis, not just a blanket decision that, ‘I’m not going to ever offer over 2 milligrams of Dilaudid.’ They feel like their discretion is being scrutinized because of regulations. Some doctors want to help people and they’re limited.”

 

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JIM WATERS: Will the Real AARP Please Stand Up?

https://www.surfky.com/index.php/179-news/kentucky/143349-jim-waters-will-the-real-aarp-please-stand-up

KENTUCKY (9/5/19) — “To tell the Truth,” a popular TV game show from the annals of history, featured a panel of celebrity judges who would try to correctly identify contestants with unusual jobs or life experiences.

The twist was that while one of the contestants was sworn to tell the truth, two other impostors were also on the show and it was their job to fool the panelists by pretending to be the real contestant.

At the end of each show, panelists would vote on who they thought was the truth-teller.

Then the host would say to the three contestants: “Will the real circus performer please stand up?”

The three contestants would bob up and down; one would act like he was going to stand and then quickly slide back into his seat and then they would all do that until finally, the real circus performer stood up and was revealed.

It’s what needs to happen with AARP which promotes itself as a simple advocacy group looking out for the interests of older Americans yet harms seniors by supporting policies like Obamacare – which resulted in making one in three Kentuckians dependent on Medicaid – or opposing changes such as a recent proposal to lower out-of-pocket prescription-drug costs.

What gives?

Why would AARP oppose a rule requiring rebates paid by pharmaceutical companies to insurers through middlemen known as pharmacy benefits managers be shared with patients in a way that reduces their out-of-pocket costs for prescription drugs?

How could they oppose such a basic idea if they’re really just a simple advocacy group whose sole mission is to advocate for seniors’ best interests?

Follow the money and find an answer.

What very few Kentucky seniors know is that AARP receives most of its revenue from UnitedHealth rather than membership dues.

AARP in 2017 collected $627 million from UnitedHealth, the nation’s largest health insurer which pays the seniors’ group royalties for the right to market its insurance plans using AARP’s name and logo, compared to $301 million in membership dues.

Chris Jacobs, founder and CEO of Juniper Research Group, reviewed AARP’s financial statements and reported the group made more than $4.5 billion in income since 2015 just from selling health insurance plans and generating investment income from UnitedHealth plan premiums.

Which explains why AARP paid folks to run around at this year’s Fancy Farm political barbecue as part of its #StopRxGreed propaganda campaign, which blames only drug companies for those higher out-of-pocket prescription costs which affect seniors on fixed incomes the most.

There’s certainly enough blame to go around when it comes to higher healthcare costs in general and prescription medicines in particular.

This columnist recently expressed disapproval of some of the practices of pharmaceutical companies – particularly when it comes to brand-name drug manufacturers attempting to keep cheaper generics off the market.

Still, it’s dishonest for AARP to claim advocacy for seniors yet oppose policies that would lower up-front prescription costs, all because it would cut into insurers’ profits, which UnitedHealth – AARP’s deep pocket – and its middlemen oppose.

In a recent op-ed, AARP Kentucky state president Charlotte Whitaker admonishes: “No Kentuckian should be forced to choose between putting food on the table or buying a lifesaving medication.”

I couldn’t agree more.

Unfortunately, Whittaker can’t go all the way with her argument; she can only blame one party – “Big Pharma,” as she puts it – and will, understandably, not bite the hand that feeds her group by even mentioning insurers or their middlemen as significant contributors to higher out-of-pocket prescription costs.

Currently, I’m being inundated with mail from AARP wanting me to join their organization.

For me, the bobbing and weaving has ended; the real AARP has stood up and my response: No thanks.

Jim Waters is president and CEO of the Bluegrass Institute for Public Policy Solutions, Kentucky’s free-market think tank. Read previous columns at www.bipps.org. He can be reached at jwaters@freedomkentucky.com and @bipps on Twitter.

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Who is really behind a proposed new definition of pain?

https://www.statnews.com/2019/09/05/pain-new-definition-proposed/

A new definition of pain is out for comment from the International Association for the Study of Pain, an influential global alliance of researchers.

When I heard about it, my hair stood on end. Some people think a new definition could lead to new therapies. But as a 23-year veteran of serious pain from a progressive disorder, I dread losing the old therapy: opioids.

Prescription opioids have lost favor since the national opioid crisis, when a growing number of people fell victim to an increasingly unrelated supply of these drugs. Prescribed drugs, illicit drugs — the distinction between the two, and their respective contributions to overdoses, hasn’t been widely grasped. And so there’s much ado about opioid replacements such as ineffective drugs, “mindfulness,” chiropractic, cognitive behavior therapy, “coping and acceptance,” acupuncture, virtual reality, and more. The problem is that none of these has been proven or even properly tested. New drugs likely to work on severe pain aren’t anywhere near the pipeline. And most of us already know what we’d pick for a broken bone or a kidney stone.

As someone who lives with a lot of pain, I care deeply about pain treatment. In the last two years, I’ve lost care twice, without warning, because of the thoughtless, often self-interested policy that’s fueling the fad to get everyone off pills. My longtime primary care doctor, threatened by her regulator, suddenly stopped prescribing opioids. Next, the government abruptly closed my pain specialist’s practice.

As a writer, I care as deeply about words. Here’s the old definition of pain that the International Association for the Study of Pain (IASP) laid out in 1994: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

It ain’t broke. Why fix it?

Here’s the proposed new definition: An aversive sensory and emotional experience typically caused by, or resembling that caused by, actual or potential tissue injury.

Look what the cat dragged in. Something only resembling damage might cause pain. Despite disclaimers in the notes attached to the new definition, here’s the slippery slope: Pain might result from a verifiable injury, or it might not. It might be an illusion, an inconvenient mental trick. If it’s all in your head, pain obviously won’t need a Percocet.

And there’s more — or in this case, less. Treatment, which was declared a must in the notes accompanying the old definition, goes unmentioned in the notes accompanying the new one.

The IASP is accepting comments on the new definition until midnight on Sept. 11.

One thing I notice about the opioid crisis is this: the more talk, the less pain care. Will a new definition help, or will it harm?

How did we get here? The IASP always seemed to be a good guy in the conversation about pain relief — by whatever methods it takes. Since 2010, the organization has been associated with what was long considered one of the world’s best pain clinics, at McGill University in Montréal. The clinic’s former director is past president of IASP. He’s written thoughtfully about untreated pain, even mourning Spain’s Philip II, a 16th-century Catholic who died in needless agony from cancer while refusing all help but God’s.

Back in 2010, IASP issued its “Declaration of Montréal,” after the city in which it was crafted during the group’s 13th world congress. It’s strong stuff. “Recognizing,” it says, “the intrinsic dignity of all persons and that withholding of pain treatment is profoundly wrong, leading to unnecessary suffering which is harmful; we declare that the following human rights must be recognized throughout the world:

• The right of all people to have access to pain management without discrimination
• The right of people in pain to acknowledgment of their pain and to be informed about how it can be assessed and managed
• The right of all people with pain to have access to appropriate assessment and treatment of the pain by adequately trained health care professionals.”

Who could argue with that?

Almost everyone, it turns out: governments, prescribers, insurers, news media, the public. It’s wonderful that professionals who really know pain once declared these rights for people like me — for all of us, actually, since at some point we’ll all have pain. But who’s listening now? The deprescribing whirlwind has battered many like me beyond repair. However carefully chosen the words of the declaration, they’re not binding in the least.

Dr. Yoram Shir, the current director of the McGill clinic, has said that pain patients on opioids “hate” the drugs. Prescription pills feed overdoses. Doctors should be dissuaded from prescribing them and patients from taking them.

IASP has changed, too, and some of the changes unnerve me. For instance, Christine Chambers, a psychologist, is championing a new IASP initiative called the North American Pain School. Health Canada ponied up $1.6 million for her work to “bridge the gap between current treatments and evidence-based solutions.” At the annual conference of Canada’s pain specialists last year, Chambers brought in her colleague Dr. Jane Ballantyne, the enduring president of the opioid-averse lobbying group Physicians for Responsible Opioid Prescribing, as the conference keynote speaker — and then declined to comment to the media on her choice.

PROP’s executive director, Dr. Andrew Kolodny, has called medical opioids “heroin pills.” Ballantyne famously recommends “coping and acceptance” over drugs for intractable pain, and has been a paid consultant to states suing drug manufacturers, whom they blame for overdoses.

Ballantyne also helped craft IASP’s 2018 Position Statement on Opioids. It advises caution “when prescribing opioids for chronic pain, focusing instead on strategies that integrate behavioral and physical treatments,” because, we’re told, opioids are good only for acute pain, cancer pain, and end-of-life care. When used “indiscriminately” (meaning for chronic pain, according to the statement), we’re also told that the use of opioids has led to “high rates of prescription opioid abuse, unacceptable death rates, and enormous societal burdens.”

Recent research, and much of IASP’s own work, says otherwise. Take, for example, the largest study to date, of 2.2 million North Carolinians, which pegs the risk of dying due to medical use of opioids at just 0.022%.

What, exactly, is pain? It’s not something I need spelled out. But as the IASP rejiggered its answer to that question, did these colleagues weigh in? Another PROP director, Dr. Mark Sullivan, sits on the definition task force, where opinion lists the ship by favoring “nonnarcotic methods” and “risk containment for opioid misuse, abuse and addiction associated with medical prescribing.”

The IASP and its task force comprise many points of view. But even if the rewrite were less trendy, I’d question the need for it.

In our new no-opioids culture, pronouncements like the IASP’s lead to more resources going to “innovations” and “emerging research” that disparage and displace proven therapies, leaving nothing for people living with pain.

What matters is what’s done, not what’s said. George Orwell wasn’t the first to observe that what’s said can be designed to obscure what’s done. Funding attaches to words. Will more parsing mean more mindfulness and acupuncture for victims of head-on car crashes? And more advantage for opioid detractors, whose opinions spell opportunity in the form of research grants, publishing records, jobs, media prominence, speaking engagements, paid testimony and other consulting for law firms, as well as promoting alternative analgesics and addiction drugs for pharmaceutical companies?

Let’s look at who is behind new declarations and definitions, and who isn’t — understanding the players helps us understand the argument. Let’s watch the data, not the news, and check facts and sources. The IASP’s rewrite is on the way to kicking medical opioids to the curb. Maybe we will do that someday, and maybe that will be fine.

But until then, I’ll stick with opioids … if I can.

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Death Certificate Project Accuses 64 Calif. Doctors

https://www.medpagetoday.com/painmanagement/opioids/81954

The so-called Death Certificate Project initiated by the Medical Board of California that began in 2015 has now resulted in formal accusals of wrongdoing filed against 64 physicians related to their drug prescribing, primarily involving opioids, newly updated records show.

Five of the 64 have surrendered their licenses; six others were put on probation, and eight received public reprimands.

These are out of a total of 469 physicians investigated for excessive prescribing because of patients’ overdose deaths in 2012 or 2013.

Two of the 64 accusations were withdrawn, according to statistics released by the board last week.

The remaining 43 physicans of the 64 accused still await final decisions; half of these have been hanging more than 7 months and five for nearly a year.

Beyond the 64 doctors against whom an accusation had been filed, another 11 of the 469 are still under investigation. It remains to be seen whether a round orange gavel signifying a disciplinary action will mark any of their profile pages.

The agency’s investigators continue to prowl the state Department of Justice’s prescription drug database to identify doctors who prescribed opioids to a patient who, according to a death certificate, fatally overdosed in 2012 or 2013, even as long as three years after that doctor wrote that script, and not necessarily from the same drug the doctor prescribed.

Separate investigations were conducted of 72 nurse practitioners, physician assistants, and osteopathic physicians — who are governed by different state boards — but the results of those were not immediately available.

In the next leg of the investigation, the medical board, which licenses some 140,000 physicians, will scrutinize practices of doctors whose patients fatally overdosed in 2016 and 2017, when presumably far more conservative opioid prescribing had replaced more liberal practices and as the extent of addiction potential and lethality of these drugs was better understood.

‘Witch-hunt’

The project is intended to stop overdoses and save lives. But it has been harshly lambasted by some doctors as a “witch hunt.” It also has disrupted practices by many physicians who — prior to 2014 — were abiding by the now outdated mantra that patients’ pain complaints should be aggressively treated with whatever it takes.

Many representatives of organized physician groups said the project is now hurting patients in pain trying to get relief. Pain specialists’ waiting lists have backed up and increasing numbers of primary care providers refuse to prescribe opioids in fear that years later, a patient death — even by suicide — may put their licenses under public scrutiny as well.

But Kimberly Kirchmeyer, the medical board’s executive director, defended the project. In an e-mailed statement, she said it “is helping the board meet its mission of consumer protection in a proactive way.” She added that her agency “will continue to find ways to improve this process.”

In remarks to the board during its January meeting, Kirchmeyer gave more detail. She said expert reviewers looked for high-dose opioid prescribing patterns that included morphine equivalencies greater than 90 mg, opioids in combination with sedating drugs like benzodiazepines, Soma, sleeping pills, and other unsafe combinations of medications. Additionally, the reviewers zeroed in on doctors who prescribed dangerous drugs frequently, “and other red flags.”

A welcome change?

Perhaps not surprisingly, consumer advocates have applauded the Death Certificate Project for calling out doctors with reckless prescribing habits.

Carmen Balber, executive director of Consumer Watchdog, spoke from “the injured patient’s perspective,” saying, “Doctors in this state are accustomed to weak or non-existent regulatory oversight. For patient safety, it’s about time that the medical board started acting to proactively investigate the opioid crisis.”

In many accusations she’s read, dangerous prescribing practices are obvious. “Patients are not getting medical exams. Doctors are not confirming the injuries the patients came forward with. Doctors are prescribing wildly excessive doses of medications. Even to a lay person it seems blatantly obvious that action should have been taken,” Balber said.

Patient safety activist Eric Andrist of Los Angeles, who started the newer Patient Safety League which posts stories about medical harm and patient experiences, travels around the state to every medical board meeting to complain that the agency is too soft, allowing hundreds of dangerous doctors to get off with no more than a slap on the wrist. He said he’s pleasantly surprised the board tackled the opioid issue in the first place.

“They’ve always said that they don’t and won’t look for cases themselves … and only act on complaints brought to them,” he said. Without this initiative, these doctors would never have been punished or called out. He also praised the yield of 19 accusations resulting in disciplinary action to date — even with 43 more to go — because by his count the agency’s average is much lower.

Five licenses surrendered

Among the most egregious cases, those that prompted five physicians to surrender their licenses, departure from the standard of care was especially well documented.

In the longest accusation, a 63-page petition to revoke the license of Frank D. Gilman, MD, of San Diego, the board listed hundreds of prescriptions written for four patients. He prescribed 370 prescriptions for one of them, and of those more than 200 were for oxycodone. Two of his patients died from overdoses. Gilman was accused of gross negligence, repeated negligent acts, incompetence, repeated acts of clearly excessive prescribing, and failure to maintain adequate and accurate medical records.

John Winthrop Pierce, MD, of San Francisco, surrendered his license after one of his patients died of an overdose of hydrocodone. The board’s 28-page accusation said that he had prescribed a long-acting combination of fentanyl and morphine for another patient who had exhibited suicide ideation, and overall prescribing behavior that constituted gross negligence and repeated negligent acts.

Robert M. Littman, MD, of San Diego, also surrendered his license after the board’s accusation said that his treatment of a patient, who was found dead at her home from “carisoprodol, lorazepam, oxycodone, zolpidem and trazodone toxicity” with traces of amphetamines and clonazepam, constituted “gross negligence.” The patient had received prescriptions from multiple doctors, and “doctor shopped,” but Littman had failed to conduct toxicology screenings and had not checked the prescription database to see what other prescriptions she had been getting.

Philipp Leo Bannwart, MD, of Zermatt, Switzerland, surrendered his license after the board found fault with his treatment of a patient in Concord, near San Francisco. She died of “acute methadone intoxication.” The board accusation says that Bannwart wrote combination prescriptions for her, including methadone, Percocet, Norco, and promethazine-codeine syrup, constituting what the board called “gross negligence, repeated negligent acts/incompetence/improper prescribing without an appropriate prior examination and medical indication.”

Daniel George Clark, MD, of Auburn, surrendered his license after the agency found that a patient died after Clark increased dosages of fentanyl, which it labeled “gross negligence.”

Probation and public reprimand

Six accused physicians were placed on probation for periods of 3-7 years: Ashmead Ali, MD, of California City; Jay Milton Beams, MD, of Susanville; Harold Budhram, MD, of Shasta Lake; William Lee Matzner, MD, of Simi Valley; Michelle Anne Orengo-McFarlane, MD, of Martinez; and Ilona Sylvester, MD, of Thousand Oaks.

Another eight physicians were formally reprimanded and ordered to take courses on prescribing practices and, in most cases, medical record-keeping: Alyn Gary Anderson, MD, of Huntington Beach; Michael S. Basch, MD, of Temecula; Jose Rosendo Cesena, MD, of El Cajon; Vorakiat Charuvastra, MD, of Los Angeles; Moshe Miller Lewis, MD, of San Francisco; Diana Maria Prince, MD, of Rohnert Park; Charles Yang, MD, of Huntington Beach; and Tahir Yaqub, MD, of Atwater.

Still-pending accusations against the remaining 43 physicians can be read here.

The California Medical Association did not respond to a request for comment about the current status of the Death Certificate Project. But in an interview late last year, David Aizuss, MD, CMA president and an ophthalmologist from Encino, criticized the board for going after doctors because of how they prescribed controlled substances before 2014. “I don’t think it’s appropriate to apply our current clinical guidelines to what was going on six or seven years ago,” he said then.

Asked why the investigations take so long, medical board spokesman Carlos Villatoro replied that for the latest fiscal year ending June 30, 2018, it took an average of 322 days after an accusation was filed for the case to conclude without compromising due process. He added that the process involves the Attorney General’s office and the office of administrative hearings, both of which are outside the board’s control, he said.

Other MedPage Today stories about the California Medical Board’s Death Certificate Project:

‘Death Certificate Project’ Terrifies California Doctors

Provider Groups Hit Back at California’s Death Certificate Project

Calif.’s ‘Death Certificate Project’ Nabs 11 More Physicians

Foundation Wants Revamp in Calif.’s Death Certificate Project

Methodology Fixes Coming for Calif. Death Certificate Project

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For Immediate Release:

September 2, 2019

PainWarriorsUnite.com Announces its official website launch in observance of Pain Awareness Month.

At long last, we are extremely excited to announce the official launch of our “community”website which has been in development since April of 2018.

Patients, physicians, and professional advocates have made their presence known throughout the country since the release of the CDC’S controversial opioid prescribing guidelines.

Hundreds of pain groups who exist on social media & the web have focused on different strategies to garner attention from policy makers and media, and have made significant progress in fighting for our collective cause. However, we need to expand our numbers and reach the patients/advocates who are not tech savvy or do not have access to social media. 

Our website was created BY pain patients FOR pain patients and will serve as an invaluable tool to UNITE each and every group by providing a free page on the website for everyone who wishes to participate & use this resource to amplify their unique missions.

We hope that this website will help streamline the process of sharing information and actionable steps, and save enormous amounts of time by eliminating the repetitive posting of the same redundant information being dissected in different ways.

We’re all fighting for the same goal at the end of the day, so this solution will allow everyone to retain administrative control, yet it gives our community a singular platform to stand as ONE united front for media and lawmakers to see just how many of us are being affected by their misguided policies. This should encourage them to work with us to enact public policies that balance attempts to reduce addiction while protecting patients who depend on individual treatment plans that include pain medication to maintain their function and quality of life.

We’re hopeful that this community effort will help to dispel the STIGMA attached to the responsible use of prescription pain medications for legitimate medical purposes, and quickly reverse the government’s overarching approach which is interfering with individualized treatment, eroding the doctor patient relationship,  and hindering their ability to prescribe such medications as they see fit.

Respectfully submitted, 

Andrea Patti

Tamera Stewart

Co Founders, Pain Warriors Unite 

Website: PainWarriorsUnite.com

Phone (202) 792-5600

Email: info@painwarriorsunite.com

Twitter: @PainWarriorTeam

Facebook:  https://m.facebook.com/PainWarriorsUnite 

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Suicide rates rise across Michigan, with few answers

https://www.bridgemi.com/michigan-health-watch/suicide-rates-rise-across-michigan-few-answers

Even as Michigan’s suicide rate rose by a third over two decades -‒ and climbing even higher among young people, rural residents and military veterans -‒ a fundamental question has yet to be fully answered.

Why?

“We need to get to the bottom of why this is happening,” said state Sen. Jim Runestad, R-Oakland County. “I don’t hear that’s being done.”

Runestad contends a commission on suicide can provide at least some answers, and could lead to a rapid, statewide approach to suicide prevention. In May, the Senate unanimously approved his bill authorizing a suicide commission, sending it to the state House Health Policy Committee.

A near-identical version of that measure is slated for a likely vote in committee Thursday. Health Policy chairman, state Rep. Hank Vaupel, R-Fowlerville, said he is “optimistic” of committee approval and that he anticipates a vote by the full House this fall.

“Very definitely we need to look at some of the causes of what’s going on and see what we can do to prevent it. I think it’s vitally important,” Vaupel said.

Under the House bill, a 27-member commission would work with state departments and agencies and nonprofit organizations to study the underlying factors of suicide in Michigan and produce guidance quickly. The measure seeks preliminary findings and recommendations to the legislature in six months, and a report highlighting promising suicide prevention programs in the state within a year. 

The commission is to include suicide prevention researchers, members of the mental health, substance use disorder and medical treatment communities, law enforcement, suicide loss and suicide attempt survivors as well as the ombudsman for Michigan’s veterans’ facilities.

Runestad said he is hopeful the commission’s recommendations would lead to immediate action, including legislative measures if needed. “The thing I want to emphasize is not to delay,” he told Bridge. “There are people dying every day.” 

The measure would place the commission within the state Legislative Council, a bipartisan arm funded by the state Legislature. According to the House fiscal agency, the measure would raise costs by an “unspecified amount,” depending on how much extra staff time it consumes.

While no one’s sure why the suicides are rising, University of Michigan research suggests part of the problem is linked to opiate use. Others point to a lack of medication assisted treatment in Michigan for opioid addiction that advocates say could help to lower the suicide rate.

Runestad could point to a stack of grim statistics that argue for urgent action:

According to the U.S. Centers for Disease Control and Prevention, the overall suicide rate in Michigan spiked 33 percent from 1999 to 2016, compared to a nationwide rise of 25 percent over the same period.

For those ages 15 to 24 in Michigan, suicide is now the second leading cause of death, with the rate jumping nearly 50 percent in less than a decade in this age group, state health data show.

 

Deadly toll

Rural Michigan counties led the state in suicide rates from 1999 to 2017. Click on a county to see the rate.

Source: U.S. Centers for Disease Control and Prevention

And in parts of rural Michigan, suicide rates are twice the state average.

Sparsely populated Alcona County, 100 miles north of Bay City, charted the highest cumulative suicide rate in the state from 2000 to 2017 ‒ at 26.6 per 100,000 people, far above the state average. Its rural neighbor to the west, Oscoda County, was second highest with 25.5 suicides per 100,000.

Four counties in the Upper Peninsula ranked among the top 10 statewide in suicide rates. That includes Gogebic County in the west fringe of the U.P., which had the 10th highest suicide rate in the state.

Ironwood resident Pat Gallinagh has made it his mission to prevent suicide in this rural area, decades after he tried to take his own life. Retired from Ironwood Area Schools after three decades of teaching, he now steers a nonprofit area suicide prevention organization.

Gallinagh said he would welcome any initiative that might reach more people before they end their lives. 

“There are lots of things we could do for prevention,” he said. “The question is whether the state legislature would act on any of the recommendations. You have to look at a statewide effort to do it.”

Gallinagh said he would grade Michigan’s current suicide prevention efforts as a “D.”

“It’s not that people don’t care. It’s just that the money isn’t there.”

As a starting point, Gallinagh said, Michigan can require depression screening for Michigan school students. Research has found that up to 65 percent of adolescents report depressive symptoms, but only a third to a fourth receive treatment. About half of all those who commit suicide nationwide have a current or known mental health problem, according to the  CDC.

“That’s an expensive proposition. A lot of poor school districts couldn’t afford to do that screening,” Gallinagh said.

Adding to the challenge, Michigan schools have the nation’s second-worst ratio of students to school counselors, with 741 students for every counselor, according to the American School Counselor Association, which recommends a 250-to-1 ratio.

Two years ago, the CDC issued a series of recommended strategies to help states reduce suicides. They include housing stabilization programs to keep people on marginal incomes in their homes, improved mental health care in rural areas, advocacy for safe firearm storage, broadened peer support programs in schools and community-based policies to reduce alcohol use.

As disturbing as suicide rates are in Michigan’s rural counties, rates can be far higher among Michigan’s estimated 580,000 veterans, especially younger veterans.

According to the U.S. Department of Veterans Affairs, Michigan veterans had a suicide rate of 26.2 per 100,000 in 2016, well above the overall state suicide rate of 16.9. Among veterans age 18 to 34, the rate was a grim 44.4 per 100,000; with rates at 33 per 100,000 for those age 35 to 54.

The V.A. recorded 159 suicide deaths among all Michigan veterans that year – nearly one every other day. Nationally, an average of 20 U.S. veterans and active duty service members commit suicide a day.

Kellie Cody, the current Michigan veterans ombudsman, said he was instructed not to comment directly on the legislation since he serves within the Legislative Council.

But he said the toll of suicide among veterans underscores the need for action, especially given the rate among young veterans.

He said the rise among younger veterans may be linked to multiple deployments by U.S. troops to Iraq and Afghanistan that followed the terrorist attacks on Sept. 11, 2001.

 

Michigan Health Watch is made possible by generous financial support from the Michigan Health Endowment Fund, the Michigan Association of Health Plans, and the Michigan Health and Hospital Association. The monthly mental health special report is made possible by generous financial support of the Ethel & James Flinn Foundation. Please visit the Michigan Health Watch ‘About‘ page for more information.

Cody said that in turn is tied to high rates of post traumatic stress disorder and traumatic brain injury among those veterans, as a V.A. study found veterans with multiple brain injuries were twice as likely to consider suicide as those with one or no injury. 

“I’m a Vietnam veteran. In that era, you didn’t have multiple deployments. You went once, you did your time and you were out,” Cody said.

He added that rural veterans may be especially vulnerable, because they can be socially isolated and a long distance from mental health care.

In the meantime, school districts have been stirred to action by multiple student suicides, some in the course of a year.

That includes Cedar Springs Public Schools north of Grand Rapids, where three young students took their life over a one-year period in 2015 and 2016. That included an incident where students on a morning bus to school watched in horror as they rode past an eighth grader who had killed himself, the boy’s mother cradling his body near the roadside.

Those incidents prompted the district to invest $400,000 from its $38 million budget to add six mental health professionals to its staff, including three counselors and three other mental health specialists hired in 2018.

“It’s an issue we take very seriously,” Cedar Springs Superintendent Scott Smith said. 

Thus far, a bill has stalled that would provide teachers training to help them spot students at suicide risk. State Sen. Sylvia Santana, D-Detroit, introduced a bill In January that directs the Department of Education and Department of Health and Human Services to develop a course for teachers on “mental health first aid.”  

The bill hasn’t made it out of the Senate Education and Career Readiness Committee. More than two dozen states already require some form of suicide prevention training for teachers and other school personnel.

And aide to committee chair Lana Theis, R-Brighton, told Bridge in late August she was unavailable to discuss the bill. 

But as suicide rates remain high, veterans ombudsman Cody said the issue cries out for a unified system that brings all suicide prevention players together.

“Different counties have their approach to it. But there is no coordinating body to address it statewide,” he said. “When you have a lack of overall coordination, it gets piecemealed.”

Suicide prevention resources 

Call:National Suicide Prevention Lifeline, at 800-273-8255. It’s a network of more than 150 crisis centers that provides a 24-hour hotline to anyone in suicidal crisis or emotional distress.

Text: Crisis Text Line: 741741, is a national service that connects the texter with a live, trained crisis counselor 

Connect: To Michigansuicide hotlines, located in many communities across the state.

Reach out: ToOK2SAY, a state-funded student safety program which allows students to confidentially report tips on potential suicide and other risks to student safety. The tips can be reported by phone, at 8-555-OK2SAY (855-565-2729); by text message at 652729 (OK2SAY); or by email, at OK2SAY@mi.gov

Communicate: People can be hesitant to approach someone showing signs of despair. But experts say getting a friend or loved one to talk openly of suicidal thoughts can save a life. 

If you are a military veteran in crisis — or you’re concerned about one — the V.A. offers 24/7 confidential support. Call the Veterans Crisis Line at 1-800-273-8255 and Press 1, send a text message to 838255, or chat online.

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Fraud Alert: Genetic Testing Scam

https://oig.hhs.gov/fraud/consumer-alerts/alerts/geneticscam.asp

The U.S. Department of Health and Human Services Office of Inspector General is alerting the public about a fraud scheme involving genetic testing.

Genetic testing fraud occurs when Medicare is billed for a test or screening that was not medically necessary and/or was not ordered by a Medicare beneficiary’s treating physician.

Scammers are offering Medicare beneficiaries “free” screenings or cheek swabs for genetic testing to obtain their Medicare information for identity theft or fraudulent billing purposes. Fraudsters are targeting beneficiaries through telemarketing calls, booths at public events, health fairs, and door-to-door visits.

Beneficiaries who agree to genetic testing or verify personal or Medicare information may receive a cheek swab, an in-person screening or a testing kit in the mail, even if it is not ordered by a physician or medically necessary.

If Medicare denies the claim, the beneficiary could be responsible for the entire cost of the test, which could be thousands of dollars.

Protect Yourself

• If a genetic testing kit is mailed to you, don’t accept it unless it was ordered by your physician. Refuse the delivery or return it to the sender. Keep a record of the sender’s name and the date you returned the items.
• Be suspicious of anyone who offers you “free” genetic testing and then requests your Medicare number. If your personal information is compromised, it may be used in other fraud schemes.
• A physician that you know and trust should assess your condition and approve any requests for genetic testing.
• Medicare beneficiaries should be cautious of unsolicited requests for their Medicare numbers. If anyone other than your physician’s office requests your Medicare information, do not provide it.
• If you suspect Medicare fraud, contact the HHS OIG Hotline.

Related Material: Senior Medicare Patrol’s Information on Genetic Testing Fraud

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FDA Changes Opioid Labeling to Give Providers Better Information on Tapering Noting that the agency remains focused on striking the right balance between policies that reduce the rates of opioid addiction while still allowing patients and health care providers access to appropriate pain treatments, Food and Drug Administration (FDA) has announced required changes to the prescribing information for all opioid analgesic medications used in the outpatient setting. The changes, announced in a Drug Safety Communication, provide expanded information to health care providers on how to safely decrease the dose in patients who are physically dependent on opioids. FDA intends for this information to be used when health care providers and patients have decided together that a decrease in dose or discontinuation of opioids is appropriate. “Rapid discontinuation can result in uncontrolled pain or withdrawal symptoms. In turn, these symptoms can lead patients to seek other sources of opioid pain medicines, which may be confused with drug-seeking for abuse,” the agency said in the communication. “Patients may attempt to treat their pain or withdrawal symptoms with illicit opioids, such as heroin, and other substances.”In addition to these changes, an FDA press release also announced that additional policies related to the opioid crisis are forthcoming. These include a requirement for immediate-release formulations of opioids to be made available in fixed-quantity packaging that contain doses more typical of what patients may need for common acute pain conditions and procedures. The full press release is available in the News and Events section of the FDA website

https://nabp.pharmacy/wp-content/uploads/2016/06/Kentucky-Newsletter-September-2019.pdf

 

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U.S. judge approves CVS purchase of insurer Aetna

https://www.reuters.com/article/us-aetna-m-a-cvs/u-s-judge-approves-cvs-purchase-of-insurer-aetna-idUSKCN1VP2WO

WASHINGTON (Reuters) – A federal judge reviewing a Justice Department decision to allow U.S. pharmacy chain and benefits manager CVS Health Corp (CVS.N) to merge with health insurer Aetna said on Wednesday that the agreement was in fact legal under antitrust law.

Judge Richard Leon of U.S. District Court for the District of Columbia had been examining a government plan announced in October to allow the merger on condition that Aetna sell its Medicare prescription drug plan business to WellCare Health Plans Inc (WCG.N). Both deals have already closed.

Leon had initially balked at approving the merger conditions and insisted on hearing from critics of the deal, but finally decided to grant the motion to approve the consent agreement.

But he took aim at the common practice of companies’ closing multibillion-dollar deals while the court review, required by the Tunney Act, was still in process.

“If the Tunney Act is to mean anything,” Leon wrote, “it surely must mean that no court should rubberstamp a consent decree approving the merger of ‘one of the largest companies in the United States’ and ‘the nation’s third largest health-insurance company,’ … simply because the Government requests it!”

In December, Leon said he was “less convinced” than the government that the asset sale to WellCare would resolve antitrust concerns. Since then, Centene Corp (CNC.N) agreed to acquire WellCare for $15.27 billion.

Assistant Attorney General Makan Delrahim, head of the Justice Department’s Antitrust Division, said he was pleased with Leon’s decision.

CVS said the judge’s decision reinforced that CVS and Aetna have already merged.

“CVS Health and Aetna have been one company since November 2018, and today’s action by the District Court makes that 100 percent clear. We remain focused on transforming the consumer health care experience in America,” CVS spokesman T.J. Crawford said in an emailed statement.

Critics of the CVS-Aetna deal included the American Medical Association and the AIDS Healthcare Foundation.

Another critic, U.S. PIRG, expressed skepticism that savings from the merger would end up in consumers’ pockets.

“Again and again, CVS Caremark has used its market power to both increase the cost of medications for consumers and rip off the government, instead of passing on savings its promised to consumers,” PIRG said in a statement.

Pending Leon’s approval, CVS agreed to temporarily allow Aetna to independently make critical product, pricing and personnel decisions.

CVS has been in the process of converting itself into a healthcare company and said in June that it would offer expanded health services such as nutrition counseling and blood pressure screenings in 1,500 stores by the end of 2021.

Most consent agreements that the antitrust agencies strike with companies to resolve competitive concerns are approved by federal courts with little fuss under the 1974 Tunney Act, which requires courts to ensure the agreements are in the public interest.

Companies generally do not wait for final court approval before closing their transactions.

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