“The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped.” – Hubert Humphrey
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Pharmacist Steve steve@steveariens.com 502.938.2414
A shocking documentary is shedding new light on just how far the Nazis and Allied soldiers went in an attempt to win World War II — including the use of performance-enhancing drugs.
“Secrets of the Dead: World War Speed,” which airs June 25 on PBS, reveals that Nazi soldiers were given the methamphetamine Pervitin, manufactured by Temmler Pharmaceutical, while American and British forces used everything they could get their hands on, including coffee, Pervitin obtained from Nazi forces and the amphetamine Benzedrine.
“In 1940, the British army discovered Pervitin in a downed German plane in the south of England, unlocking the secret to the German troops’ boundless energy, and leading the Allies to consider the same tactic for their troops,” PBS representatives wrote in a statement.
The representatives continued: “The Allied troops decided to use the amphetamine. Both drugs make users intensely alert by flooding them with a sense of euphoria. With its added methyl-group molecule, Pervitin races across the blood-brain barrier a bit faster than Benzedrine. Otherwise, the two drugs have virtually the same impact.”
Military officials (including U.S. General and future President Dwight Eisenhower, who ordered 500,000 tablets of Benzedrine) were anxious to gain an edge in the war. They wanted to push the soldiers past their limits, hoping the drugs would “defeat not just the need for sleep, but anxiety and fear among troops” as well.
(Courtesy of Brave Planet Films)
LiveScience reports that in 1940, the year of the Nazis’ relentless attacks against Britain (also known as the Blitzkrieg), approximately 35 million Pervitin tablets were sent to 3 million German soldiers, seamen and pilots, citing data from the British War Office.
The findings were compiled by Nicolas Rasmussen, a professor at the University of New South Wales in Australia and published in 2011.
However, the implications of the drugs were largely overlooked, PBS reports.
According to the National Institute on Drug Abuse (NIDA), methamphetamine is chemically similar to amphetamine and can be used in a variety of different ways, including smoking, pills, snorting or injecting the powder after it is dissolved in water or alcohol.
Some of the long-term consequences of methamphetamine use include extreme weight loss, addiction, memory loss, violent behavior, paranoia and several others.
“In addition, continued methamphetamine use causes changes in the brain’s dopamine system that are associated with reduced coordination and impaired verbal learning,” NIDA writes on its website. “In studies of people who used methamphetamine over the long term, severe changes also affected areas of the brain involved with emotion and memory. This may explain many of the emotional and cognitive problems seen in those who use methamphetamine.”
Inside the German Pharmacy Museum, James Holland meets with medical historian, Dr. Peter Steinkamp of Ulm University. (Credit: Courtesy of Brave Planet Films)
The organization even cited a recent study that people who once used methamphetamine “have an increased the risk of developing Parkinson’s disease.”
And though Benzedrine was determined not to be as dangerous as Pervitin (it was administered in tablet and inhalant form), the drug was still harmful to soldiers, documentary consultant James Holland told Live Science.
“It stops you from sleeping, but it doesn’t stop you from feeling fatigued,” he told the news outlet. “Your body has no chance to recover from the fatigue it’s suffering, so there comes a point where you come off the drug and you just collapse, you can’t function.”
German soldiers battling in the Stalingrad region, Russia, World War II, on Sept. 6, 1942. (De Agostini Editorial/Getty)
Holland added that the full extent of the addiction and the devastating effects were not “properly understood” and that there was “very little help” given to the people who became addicted.
“By the end of the Second World War, you saw increasing knowledge of the side effects of these drugs,” Holland said. “What you don’t see is what to do with people once they become hooked — that’s something that had to be learned the hard way in the years that followed.”
SALT LAKE CITY — While Utah and the country take aim at the opioid epidemic, many with chronic pain have suffered as doctors take away or taper them off their medications, a lobbyist told legislators Monday.
There are people having trouble getting their prescriptions from pharmacies and others being “force-tapered” or having their opioid prescriptions suddenly discontinued, which can cause severe opioid withdrawal symptoms, said Amy Coombs, who has worked with substance use patients and serves as executive director of Prestige Government Relations and Consulting Group.
Coombs presented to members of the Health Reform Task Force as the group discussed opioids, health care costs and Medicaid expansion during a Monday legislative interim meeting.
In April, the Centers for Disease Control and Prevention announced its 2016 opiate guidelines have been “widely misapplied” to include those using opioids for palliative care, chronic pain and illnesses such as cancer, Coombs said.
There’s been a “broad brush stroke” of tapering or cutting people off of opioids, according to Coombs, but opioids should be considered on a person-to-person basis.
Also in April, the Food and Drug Administration issued a warning and required labeling changes after receiving “reports of serious harm in patients who are physically dependent on opioid pain medicines suddenly having these medicines discontinued or the dose rapidly decreased. These include serious withdrawal symptoms, uncontrolled pain, psychological distress and suicide.”
Many do benefit from opioid therapy, Coombs said, and she’s heard “more and more of those particular stories” about people in Utah who have taken their lives or suffered severe setbacks in their pain management because of their opioid prescriptions changing too quickly.
Some have turned to illegal drugs, according to Coombs. “People are not getting the care that they need.”
Those who need opioids now face more difficulty finding access to quality care and providers willing to treat their chronic pain, she said. People who have been on opioids for years often have to wait for pharmacists to reach their doctors before dispensing prescriptions — and suffer withdrawal symptoms while they wait, she said.
Rep. Jim Dunnigan, R-Taylorsville, asked what could cause that delay.
Senate Majority Leader Evan Vickers, R-Cedar City, himself a pharmacist, explained that there’s a “disconnect” between decisions being made by health plans and pharmacy benefit managers that “aren’t necessarily medically based” but are instead often “financially based.“
Health insurance plans have taken the fight against the opioid crisis as “a hard, fast rule and they don’t allow a lot of leeway,” Vickers said.
Opioid patients prescribed high quantities of opiates need to be tapered off slowly to get long-term results, according to Vickers. But health plans often don’t allow for slower tapering.
“And that forces (the patients) into making choices that they probably normally wouldn’t make,” including finding drug sources on the streets, Vickers said.
Sen. Allen Christensen, R-North Ogden, noted that the opioid issue has been “beat to death.” But opioids are “miracle drugs,” he said.
“We have to move the pendulum back and forth a little bit. … We have to regulate it, but don’t overreact with it. … We’re trying to find that healthy medium in the middle,” he said.
Coombs said patients have also suffered because doctors have been incentivized to taper patients off opioids and de-incentivized to treat pain patients with opioids.
She urged the task force to work on creating a palliative care definition or exemption to help those who need opioids long term receive them. She also encouraged creating “bridge” opportunities for patients to receive supplies of two to four days so as not to suffer withdrawals while doctors and pharmacists work out issues such as authorization.
Several of the legislators agreed that Coombs brought up a real problem, but a potential course of action was not discussed in the meeting.
“I think it’s a problem. You have to find someone who thinks it’s enough of a problem to try and do something about it,” Christensen said, quipping that “a pharmacist” legislator would be a good person to tackle it.
Rep. Suzanne Harrison, D-Draper, said, “I think this raises the issue of: We need to make sure that we’re providing evidence-based care and enough access to those care providers who have the qualifications.”
New York resident Mickey Saxbury worked on a General Motors assembly line for 25 years before sharp, throbbing back pain from an on-the-job injury forced him to retire.
A back operation failed. A device to block his pain gradually became ineffective. The only thing that’s consistently worked, he says, is pain medication.
But a judge overseeing his New York State Workers Compensation Board disability case ordered that his opioids be sharply reduced.
“They dropped me so far down that I can’t even get off the couch anymore,” said Saxbury, 61, who lives near Buffalo.
Chronic pain patients such as Saxbury are becoming increasingly vocal about what they say is a medical community that’s shutting them out. The Centers for Disease Control and Prevention issued guidelines in 2016 to cut back prescriptions after years of liberal opioid dispensing contributed to addiction and overdose deaths.
Those guidelines not only influenced doctors – state regulators, health insurers and even disability administrators also have cited these federal guidelines to justify policies that limit pain pill prescriptions.
Last month, the CDC clarified its position, saying that the response to the opioid crisis went too far. In a New England Journal of Medicine editorial, a panel of experts cited examples such as inflexible thresholds on dosages, abrupt tapering and misapplication of the guidelines for people with cancer, sickle cell disease or recovering from surgery.
Dr. Joshua Sharfstein, a former health secretary of Maryland and health commissioner of Baltimore, said he supports how CDC’s clarified guidelines reconcile the risk of opioids with their need.
“The right thing is to follow that balance,” said Sharfstein, who is now a professor and vice dean at Johns Hopkins Bloomberg School of Public Health. The guidelines “shouldn’t be used as a kind of cudgel to reduce appropriate prescribing.”
Many chronic pain patients question whether the revised policy will bring them relief.
Saxbury took a powerful opioid, oxycodone, to manage throbbing lower back that radiates down his left leg. His prescription remained steady for several years: 30 milligram pills, four times each day.
But the New York State Workers Compensation Board, which oversees his case, tapped a medical expert to review Saxbury’s medical chart. The expert, Dr. Chris Grammar, who never physically examined Saxbury, concluded he was being prescribed unsafe levels of opioids.
In his report to the New York board, Grammar cited the state’s non-acute pain medical treatment guidelines and CDC data on overdose deaths linked to opioid prescriptions. He added that Saxbury’s pain doctor’s high-dose opioid prescriptions are “no longer supported.”
“This is not to be critical of his treating physician as this approach is relatively new,” Grammar wrote. “However, in the absence of functional improvement, this patient is undergoing extraordinary risk with little benefit.”
A judge agreed and ordered Saxbury’s pain medication reduced.
Based on the judge’s decision, Saxbury said his doctor cut his daily pain prescription by half. He cannot muster the energy or tolerance to do many daily activities. And his planned move to Arizona to escape a cold climate that makes his pain worse and live near family seems more daunting than ever.
Saxbury said he has unsuccessfully pleaded with his doctor to reconsider the pain pill reduction.
“My pain-management doctor said they cannot give me the medication because they could lose their license,” Saxbury said. “I’m between a rock and a hard place.”
Grammar declined to discuss the specifics of Saxbury’s case with USA TODAY. But, in general, he said medical evidence does not support long-term opioid use for chronic pain patients.
He said pharmaceutical companies such as OxyContin maker PurduePharma have not proved in medical studies that long-term opioid use alleviates chronic pain.
Patients who have become dependent on opioids now feel scapegoated as more doctors scrutinize the use of the pain medications.
“With few exceptions, the patients are innocent,” Grammar said. “They’re not writing the prescriptions.”
State laws created a ‘chilling effect’ on pain prescriptions
States have responded to the addiction crisis by passing laws that aim to reduce opioid prescriptions.
As of October 2018, 33 states have passed laws that limit or impose requirements on opioid prescriptions, according to the National Conference of State Legislatures.
Most of these states limited initial pain pill fills to seven days, with some states imposing even more aggressive cutbacks that limit fills to three or five days.
Last July, Florida passed a law requiring physicians to register as chronic pain clinics to prescribe more than three days worth of opioids. Dr. Melanie Rosenblatt, who is a pain doctor and certified in addiction medicine, said the law has had a “chilling effect” on prescribing. Many of her new patients were dropped by their former physicians or “would doctor shop until they got what they want.”
Federal statistics show total U.S. opioid prescriptions have declined each year since 2012. However, that trend accelerated since the CDC issued guidelines and has caused for many to land in an addiction recovery program.
Total prescribing dropped from 46 billion morphine milligram equivalents in March 2016 to 32 billion morphine milligram equivalents in September 2018. MMEs are a measure of the amount and potency of opioids.
John Downey, a pain doctor in Augusta, Georgia, argues that the “damage has been done” from restrictive state laws and reluctant prescribers.
Family doctors who fear disciplinary action from medical boards have dropped chronic pain patients. Those pain patients have crowded the lobbies of pain clinics seeking relief.
Downey served a three-year term on the Georgia Medical Board through mid-2018 and chaired the board’s pain committee. He told colleagues he was not interested in another term because his medical practice was so busy with patients turned away by other doctors.
One Monday morning, he had 50 referrals for new patients “just because doctors are saying they are fed up,” Downey said.
While he was on the medical board, he developed a point-based worksheet for family doctors who treated pain patients. The goal: Help doctors determine whether pain patients are willing to complete therapy and try non-opioid therapies such as injections, rather than only seeking pain pills.
Medical board investigators who see patients taking the same prescription every month might see signs of abusive prescribing or a “pill mill,” said Downey.
But he said such patients often are able to maintain regular activities such as working, spending time with family or going to church.
“From a pain perspective, that is a well-managed patient,” Downey said. “They are stable.”
Doctors are ‘terrified of addiction’
Sharfstein, the former health secretary of Maryland, said “there’s been a big whiplash” as doctors react to the opioid epidemic which was fueled by years of permissive prescribing.
“Doctors were told they should treat pain as much as possible and now might be hearing the message they they could get in trouble for any opioids,” he said.
Sharfstein and his wife, Dr. Yngvild Olsen, an addiction medicine physician, wrote the book The Opioid Epidemic: What Everyone Needs to Know. In it, they argue that doctors need to be trained to detect and treat addiction. Most medical residency programs don’t teach how to care for patients who misuse substances.
Doctors are “terrified of addiction and need to understand it and treat it,” said Sharfstein.
Garrett Greene, 27, was dropped as a patient by his pain management doctor last month. He said the doctor told him he wasn’t comfortable seeing a cystic fibrosis patient.
Greene said he was taking about a 90 milligram dose of the opiod Percocet every day to control pain since he had surgery seven years ago after his left lung collapsed twice. He’s had many other surgeries and blood clots.
“I spent the better part of my twenties cooped up in the hospital watching firsthand how this monster of a disease can rear its ugly head,” said Greene.
Late last month, Greene went through what he calls “a horrific detox” while he was “losing my mind” trying to find a new pain doctor. When he found Rosenblatt, she switched him to buprenorphine, which is also an opiate but one that is used to help wean people off heroin and other opioids. Percocet, said Greene, wasn’t good for his lungs long term and could suppress his breathing.
Rosenblatt finds she often has to change new clients to longer-acting opioids, as well as combinations of physical therapy, antidepressants, muscle relaxants and therapy to help improve sleep.
“Most of the time it works out really well and there is a silver lining in many cases because people get the appropriate specialist,” said Rosenblatt. “For other people, not so much, because they go through crazy withdrawal after doctors just cut them off, go to jail or retire with no exit plan.”
Former Food and Drug Administration Commissioner Dr. Scott Gottlieb said regulators “arguably had to play catch up” with the opioid crisis, which he calls the “biggest public health crisis in modern history.”
Regulators “had to take dramatic action to intervene,” he said. “It was inevitable there were going to be public health consequences at the margins.”
As for doctors, they have been “overshooting in both directions” – first over- and now often under-prescribing.
“You are seeing doctors too reluctant” to prescribe opioid painkillers now, said Gottlieb, now a resident fellow at the American Enterprise Institute. “It was inevitable they were going to land there.”
Dr. Mary Jeanne Kreek on Tuesday said that Congress should “absolutely” remove marijuana from the Controlled Substances Act list, arguing that such a move would help facilitate more medical research.
Kreek, a senior attending physician Rockefeller University, said her lab has struggled over the past two years to get permission to study two key active ingredients derived from the cannabis plant: tetrahydrocannabinol (THC) and cannabidiol (CBD) because marijuana is still considered a Schedule 1 drug, which is defined by the Drug Enforcement Administration (DEA) as having a “high potential of abuse.”
Cannabis remains scheduled alongside heroin, LSD and Ecstasy.
“We have what they call a DEA [Drug Enforcement Administration] laboratory license for research in rodent models in my lab and it took us over a year to get that permission for Delta-9-THC — that’s the active ingredient of marijuana,” Kreek said in an appearance on Hill.TV’s on “Rising.”
“There’s a second ingredient in the plant called cannabidiol — CBD — and there’s evidence shown, very credible research — both in this country and particularly in Israel — that this compound may be beneficial for certain kinds of disorders, including seizure disorders and possibly some inflammatory disorders,” she continued.
“This, we all know as scientists, does not bind to the marijuana receptor, it does not alter brain function, it does not alter behavior but it’s scheduled as Schedule 1 in DEA and my lab is still under process of getting approval to purchase and study CBD in rodent models,” she added.
Kreek’s comments come amid a broader push to legalize marijuana in several states across the country as public support for legalization hits a record high. Thirty-three states and Washington, D.C. have legalized marijuana in some form.
In 2017, Booker introduced the Marijuana Justice Act, which would eliminate marijuana’s status as a Schedule 1 drug under the Controlled Substances Act. Harris, Gillibrand and Warren co-sponsored the bill.
MORGANTOWN – The Northern District of the West Virginia U.S. Attorney’s office has opened 81 methamphetamine cases that involve 101 defendants. Those statistics are about 45 percent of the total case load.
The case load has prompted U.S. attorney Bill Powell to label methamphetamine as the most problematic drug in the Mountain State and request money from the federal government via the High Intensity Drug Trafficking Area program to help fund the campaign.
Investigators of personal injury attorneys have formed task forces across the state comprised local police, FBI and DEA agents.
In Morgantown, police chief Ed Preston says, “Methamphetamine is starting to replace and overtake opioids for quantity of abuse because of the changing international drug markets and availability. The greater the availability, the lower the price, the more it becomes abused locally.” Preston served for two years in the Appalachian Hideout Drug Task Force the covers West Virginia, Tennessee and Kentucky.
Preston says tips from the public help detectives identify, investigate and hopefully remove dealers and their drugs from the streets.
In 2018 police seized 206 grams of heroin and 790 grams of methamphetamine from a Star City home. Two men from Philadelphia were arrested in that case.
Anyone hearing about pharmacy layoffs happening today? It seems that some techs got axed – not sure how reliable the info is, chime in if you have any info…
WHAT IN GOD’S NAME IS HAPPENING????!!!!! HAS WAL-MART PUBLICLY ADDRESSED ANY OF THIS HORSE S**T?
Laid off today. Pharmacy tech. 11 months with the company. Was given the reorg rah rah as well. They blamed ‘the computer’ (something like your name popped up, it was not us selecting you which is stupid, why would you even say that)
Got the axe as Staff Pharmacist today. Same BS Restructuring, bla ,bla.The disingenuity is too much.That you may apply for other positions that may arise well knowing there will be none.Promising 60 days pay and an undetermined severance package.Heartless
my pharmacy manager was cut today
They fired my pharmacy manager today sadly.
It’s true, my wife just got laid off today.
Talked to a staff pharmacist that got laid off today. He said Walmart is cutting 1000 pharmacist across the company. Not sure how accurate.
Not just pharmacists, but PICs (which is generally a safe position).
Pharmacists, techs, cashiers affected. H&W also in a hiring freeze.
Could it be that Walmart’s reported new policy of reducing the quantities of all opiate Rxs for new/acute prescriptions and their use of Narxcare that creates a “abuse score” – much like a “credit score” from one of the credit rating companies – on any pt that is attempting to get a controlled substance Rx filled.. has impacted their prescription business and a number of pharmacists and technicians are finding themselves UNEMPLOYED from Walmart… just more collateral damage of the war on drugs ?
Officials say cocaine is making a comeback in Pennsylvania after more than $1 billion in cocaine was seized from a container ship in Philadelphia Tuesday.
Six people have been charged in connection with the raid, which saw about 35,000 pounds of cocaine seized from the ship. According to an affidavit, members of the crew admitted to loading “bales of cocaine” onto the ship. U.S. Attorney William McSwain called it “one of the largest drug seizures in United States history” in a tweet.
The seizure coincides with a rise in cocaine prevalence across the United States, Philadelphia-based DEA Special Agent Patrick Trainor said. He attributed the resurgence to abundant harvests in South America, where he said the drugs originate. Methamphetamine has also been abundant and cheap, Trainor said.
“We certainly have noticed an increased in both drugs over the past few years,” Trainor said.
While opioids like heroin and fentanyl have dominated the conversation in Pennsylvania, Dauphin County Coroner Graham Hetrick said he’s seeing a local rise in deaths involving stimulants like cocaine.
“I see a resurgence of it,” Hetrick said.
The number of times cocaine and methamphetamine were detected during an autopsy increased in Dauphin County from 2017 to 2018, according to data from the coroner’s office. Cocaine is mentioned 24 times in 2018, and only eight times in 2017. There were also more drug-related deaths in 2018 than in 2017, according to the data.
Deaths related to cocaine and other stimulants have been on the rise for several years. A recent CDC report showed that deaths involving cocaine and other stimulants have been on the rise across all age groups. Nationwide, nearly 14,000 drug overdose deaths involved cocaine in 2017, a 34-percent increase from 2016, the CDC reported.
Opioids still have an impact on the rise in stimulant use, as Trainor and Hetrick said illicit fentanyl is being combined with stimulants cocaine with deadly effects. Trainor attributed some of those deaths to users not knowing what is in the drugs they’re taking.
“We’ve seen cases where drug traffickers themselves don’t necessarily know what they’re selling,” Trainor said.
The increase of cocaine and meth has ties to the opioid crisis, Trainor said. He noted that in some cases, opioid users take an “upper” to stave off the effects of withdrawal.
Hetrick said the rise in stimulants might have to do with the amount of resources being put toward reducing opioid use. He likened the focus on specific types of drugs to “whack-a-mole” and said that much of the money and resources going toward the opioid crisis should be instead treating addiction as a whole.
“We have an addiction crisis, we don’t have an opioid crisis,” Hetrick said.
Education and a better understanding of addiction would be more impactful on driving down the prevalence of drug use, Hetrick said. He said specific drugs are simply “tools” in a substance use disorder.
“Whether it’s stimulants, a combination of cocaine and fentanyl, or heroin itself, they’re all tools,” Hetrick said. “The conditions for addiction are within the person, and the drugs are the tools. That’s what we have to concentrate on.”
Another reason these drugs are prevalent in Pennsylvania is its location, Pennsylvania State Police Communications Director Ryan Tarkowski said.
“Pennsylvania’s unique geographic location and converging highway system make it a natural conduit for the trafficking of illicit drugs and other contraband – providing access to major cities and airports, as well as one of the largest seaports on the east coast,” Tarkowski said.
Tarkowski said collaboration between state, federal and local agencies in key in combating the flow of illegal drugs through the state.
Not every coroner across the state has seen an increase in stimulants and deaths around them.
“I’m not seeing any significant increase with stimulants in our deaths,” York County Corner Pam Gay said.
“The nine most terrifying words in the English language are: I’m from the Government, and I’m here to help. “President Ronald Reagan
It’s an oft cited quote. Some might say overused. But these words have proven to be eerily prophetic when it comes to how the governments, state and federal, have dealt with the opioid crisis. And as with most crises, there are victims. The victims can be defined as those left in the wake of all who have died from overdoses. Those who have lost loved ones or are living with someone who has become addicted. The many press reports recount the typical outcomes of an illicit drug epidemic. The numbers of deaths are staggering. The streets of once great cities are littered with hypodermic needles, and homeless encampments are rife with illicit drug dealers and addicts who use the deadly poison that they peddle. But also, the chronic pain patient who has followed all the rules, been treated by licensed medical doctors, has submitted to ever growing demands for urine, for pill counts, for actual compliance contracts and been subjected to stigma. The patients who have been totally compliant yet cut off forcibly from the only medications that have enabled them to live a quasi-normal life. These are the victims not well represented in the media. So, a group of chronic pain patients, who have gathered in closed Facebook groups for several years, decided to bring awareness to these untold stories, and the march towards the CDC in Atlanta was launched.
Last week, a group of chronic pain patients, began their trek towards Atlanta, Georgia. Folks from all walks of life, and all 50 States, unwitting allies, all headed towards the Center for Disease Control (CDC). Their mission: to raise awareness to the plight of the chronic pain patient in the wake of the fallout over the government’s handling of the opioid crisis. The location was chosen because it was the CDC who began their plummet from well controlled pain patient with an ability to perform activities of daily living, to victims of the opioid crisis, many left writhing in unfathomable pain. On Friday, they pushed their pain aside, and made their stand in the shadows of the CDC headquarters. A diverse crew, some in wheelchairs, or using walkers, or canes and others with no visible disability or injury holding signs and chanting “don’t punish pain” and “pain patients vote.” A rallying cry of desperation from a mostly forgotten group from varying socioeconomic roots but with the common history: all had been impacted by this war on opioids and the CDC’s own “guidelines for prescribing opioids for chronic pain.” To this group, the guidelines had effectively become law and the pain had become unbearable. Still, they were there to stand for those of us who couldn’t be there, either due to disability, distance, or because a growing number, unable to live with the pain, had committed suicide. They stood for all of us even though some could literally not stand.
It began seemingly benignly to the casual observer. In 2016, the CDC issued guidelines for prescribing opioids for Chronic Pain. In its entirety, the statement discusses numerous medical factors intended for the clinician under the guise of helping the physician decide how much, if any, opioid pain medication should be prescribed to his patient. Though the text of the guideline is lengthy, to the layperson who even noticed, it probably seemed innocent enough: “CDC developed and published the CDC Guideline for Prescribing Opioids For Chronic Pain to provide recommendations for the prescribing of opioid pain medication for patients 18 and older in primary care settings. Recommendations focus on the use of opioids in treating chronic pain (pain lasting longer than 3 months or past the time of normal tissue healing) outside of active cancer treatment, palliative care, and end-of-life care.” In essence, the CDC recommended that chronic pain patients not be given doses of opioids over 90 morphine medical equivalents and warned of doses above as low as 50 MMEs. I was not the casual observer. I am both a political junkie and a chronic pain sufferer, and I knew immediately there would be trouble. The fallout and the harm has been swift and vast, and has only proven to increase in the three years since publication. The government overreach in the name of these guidelines began almost immediately. And it continues to this day.
The punishment meted out for having a chronic pain condition requiring opioid medications under these circumstances has been overwhelmingly draconian. Facebook groups, gathering places for the disenfranchised, have become virtual halls of knowledge for advocates and pain patients alike. Doctors, pharmacists, and other pain patient advocates as well as pain patients use them to organize. One of our groups has nearly 10,000 members, and our membership grows daily. And the few of us with any experience on how to fight city hall, never mind the federal government, are also pain patients fighting our own battles. The challenges are many, but we’ve begun to garner attention and gain some traction.
The cost in dollars is not insignificant, either. Virtually all pain patients have suffered a similar fate. Their prescriptions have been cut or cut off. Even if they were not on the higher than 90 MME per day dosage as cited in the original CDC guidelines, they’re being cut. It’s come down from on high that opioid medications that are virtually the same as those which has been used to treat moderate to severe pain for centuries is persona non grata in America circa 2019. It’s become all too much for the average physician to deal with. It’s also more than the average chronic pain patient can deal with. There is now a group that keeps count of the suicides due to intractable, untreated or undertreated pain. I personally know of three people who have committed suicide. And several of the Facebook group administrators, myself included, have been in the position of having to deal with a suicidal chronic pain patient. That we are ill equipped for this is an understatement. Perhaps worst of all is this, it’s not working. The numbers of opioid prescriptions has decreased, and overdoses have increased. Predictably so for those in the trenches of advocacy, since this is an illicit heroin and fentanyl crisis. And it’s not going to work; prohibition never does. If it did, alcohol would not be killing more people than all opioid deaths combined.
A Dispatch analysis of prescription drug prices for the poor and disabled since the state’s latest stab at reform turns up one simple fact: No matter what laws or regulations are changed, as long as pharmacy benefit managers control Ohio Medicaid’s $3 billion drug-pricing mechanism, it will be difficult to make sure that both Ohio taxpayers and pharmacies are getting a good deal.
The analysis of more than 400,000 prescriptions from about three dozen pharmacies across the state in the first quarters of 2018 and 2019 produced four major conclusions:
• Ohio’s largest Medicaid pharmacy benefit manager, CVS Caremark, increased its rates for specialty drugs at the beginning of this year, even though the cost of many of them was dropping nationally. Along with raising the price for Ohio taxpayers, CVS benefits from the inflated cost because its PBM directs many of these prescriptions to CVS specialty-drug pharmacies. The price increases took effect as Ohio eliminated the old “spread pricing” system in which pharmacy benefit managers, a middlemen in the drug supply chain, walked away with as much as $200 million a year in profit.
• The state’s new “pass through” system has generated better results for Ohio pharmacists. The amounts they are receiving from PBMs above the pharmacies’ costs to buy Medicaid drugs more than tripled after the sweeping changes this year. The bad news: That $6.25 margin per prescription still falls well short of the standard $9.48 deemed by pharmacies as their break-even point.
• CVS Caremark’s reimbursements to Ohio pharmacies for Medicaid prescriptions are well under half those of the other pharmacy benefit manager handling Ohio Medicaid money, UnitedHealth Group’s OptumRx. Many of CVS’ reimbursements fluctuated wildly from year to year for the same drug, seemingly without relation to the actual cost of that drug.
• A plan added to the proposed state budget by the Ohio Senate last week that would earmark $100 million to ailing Ohio pharmacies might end up enriching the PBMs instead.
Pharmacy benefit managers operate as middlemen between pharmacies that dispense drugs to Medicaid recipients and Ohio taxpayers, who pay for the drugs through five private managed-care organizations that run Medicaid and hire the PBMs.
The analysis actually produced a fifth finding: Nearly six months after implementing a much-touted “pass through” drug-pricing system, the Ohio Department of Medicaid still doesn’t have basic figures on how much PBMs and pharmacies are making — or whether the new arrangement is working as planned. The system is called “pass through” because whatever amount the PBMs charge the state is supposed to be passed through to pharmacies.
The results of an analysis by a state consultant are expected next month.
Changes on the way
Ohio Department of Medicaid spokesman Kevin Walter said changes are coming.
“As Governor (Mike) DeWine stressed from the outset of his administration, ODM is committed to creating as much transparency as possible. Switching from spread pricing to the pass-through model was a first step, as are changes that will be implemented in (Medicaid) provider agreements that take effect July 1, and in the procurement process that began last week with the release of ODM’s first request for information seeking public input on the current managed care program.”
Spread pricing happened when the PBMs charged the state more than they paid pharmacies, a total that reached nearly a quarter billion dollars in the one year studied.
State Sen. Dave Burke, a Republican from Marysville who also is a pharmacist, said Medicaid officials are saying the right things, but the time has come for action on behalf of Ohio taxpayers and pharmacies, several of which are teetering on the edge of going under.
“Simply watching someone crush a business is not a policy,” he said.
Like many other pharmacists, Burke said they and the state will never get a fair shake until those who profit from Medicaid are removed from the process that sets prices.
“The entity that tells me it’s fair is the same one that sends me the bill,” he said.
The lack of information from the state about whether the Medicaid changes are working provided the main impetus for The Dispatch to obtain drug-pricing information — with all patient-identifying information removed — from pharmacies large and small across Ohio.
The analysis included only solid medications taken orally, because listed amounts for liquids, gels, creams and the like are sometimes not recorded in the same units. Of course, caution is necessary in projecting the results from fewer than 40 pharmacies in the Dispatch study to all 2,000 in Ohio that dispense Medicaid drugs.
The Dispatch conducted a similar study a year ago that showed how PBMs were making substantial money from “spread pricing,” which is the difference between what PBMs charge the state and what they pay pharmacies to dispense drugs. Later studies by the Medicaid agency’s consultant and the state auditor’s office confirmed the practice.
When asked about the large discrepancy in payments to Ohio pharmacies between the PBMs for CVS and UnitedHealth, Drew Krejci of UnitedHealth’s OptumRx corporate communication office said, “The data you have on increased OptumRx reimbursements to pharmacies speaks for itself.”
Mike DeAngelis, senior director of corporate communication for CVS, would not answer why CVS Caremark is paying pharmacies so much less than OptumRx is, nor any other questions about the company’s practices in Ohio generated by the pharmacy data.
“It is not reasonable or fair to be asked to comment on data we have not had an opportunity to review and validate. The Dispatch has spent an inordinate amount of time and effort attempting to discredit the work we do to reduce health care costs and improve health outcomes. While the paper continues to focus on context-free data pushed by other interests, we’ll continue to focus on the $145 million pharmacy benefit managers like CVS Caremark save for Ohio taxpayers annually,” he said.
The $145 million in “savings” frequently mentioned by CVS already has been debunked. It’s merely the price difference the Medicaid consultant found last year between Ohio’s current managed-care setup and a prospective fee-for-service model, and did not account for drug rebates in the latter.
A 2,300% markup?
CVS made an estimated $37 billion from specialty drugs last year — a quarter of its prescription revenue and easily the most in the country. These drugs are typically used to treat such complex conditions as hepatitis, cystic fibrosis, HIV and some cancers.
Perhaps the most egregious example is the generic form of Gleevec, known as imatinib mesylate, which is used to treat leukemia and other kinds of cancer. It’s not cheap: about $83 in 2018 for a single 400-milligram tablet, which is taken daily, per the federal government’s National Average Drug Acquisition Cost. Last year, CVS Caremark charged a 45% markup, to about $120 per pill, the pharmacy data provided to The Dispatch showed.
In early 2019, the national average dropped dramatically — as prices of drugs often do soon after a generic form hits the market — to about $14.50 a pill. But instead of reducing its price in Ohio, CVS Caremark more than doubled it. The PBM charged the state $270 per tablet — raising the markup to more than 1,700%, or more than $250 per pill — the pharmacy data show.
Antonio Ciaccia, lobbyist for the Ohio Pharmacists Association, describes what CVS did this way: “The state slapped their hand and said, ‘Stop taking money from us this way.’ They say, ‘OK, we’ll take it another way.’”
While the profit from raising the price for a big-dollar medication is obvious, a large enough markup on even a relatively inexpensive drug can add up, too. The national average was only 24 cents last year for a 20-milligram tablet of Sildenafil, which is used to treat high blood pressure in the lungs (pulmonary hypertension). But CVS Caremark charged $3.45 for each pill, a markup of more than 1,300%.
This year, the national average price of Sildenafil dropped by a third. But CVS raised its price in Ohio, generating a 2019 markup of more than 2,300%, the pharmacy data show.
Increasing revenue from specialty drugs is an explicit part of CVS corporate strategy. In a June 4 call with investors, CVS Health Corp. President, CEO and director Larry Merlo said the company is “focused on winning in the fastest-growing market segments, specifically government-sponsored programs and specialty pharmacy.”
Derica W. Rice, president of CVS Caremark, noted that the PBM’s growth has been aided by “increased utilization in specialty” drugs.
Walter of the state Medicaid agency such maneuvers by CVS will be limited starting next year.
“In order to eliminate conflicts of interest, reduce costs and expand access, ODM is requiring, beginning January 1, (managed care organizations) to accept any specialty pharmacy that meets their specific quality and service standards and can provide services at the same or lower cost compared to other in-network specialty pharmacies.”
“The boat is still sinking”
Frustrated by the Medicaid department’s failure for years to ensure that Ohio pharmacies are being reimbursed adequately, state senators allocated $100 million to the pharmacies last week.
Sen. Burke said the money is not so much a pharmacy bailout as an effort to make sure that Ohioans in inner cities and rural areas have access to neighborhood pharmacies. Without a local drugstore to provide needed medications, sick Ohioans are more likely to wind up in a hospital emergency room — the most expensive option. Besides, the federal government mandates that state Medicaid programs ensure local access to medical care, a requirement Ohio violates when, for instance, a town’s only pharmacy is allowed to close.
“Leaving your county to get a prescription filled is a ridiculous notion in the year 2019,” he said.
But Burke acknowledged that any attempt to help local pharmacies financially might be gobbled up by PBMs that manipulate their drug price list so they can pocket the money.
The House also went after PBMs in its version of the budget, albeit using a much different approach. So the two chambers’ proposals must be reconciled in a House-Senate budget conference committee this week.
Rep. Mark Romanchuk, a Mansfield-area Republican who chairs the legislature’s Joint Medicaid Oversight Committee, said that despite the substantial Medicaid changes this year, “I’m not convinced the problem’s fixed.”
Noting the tide of drugstores across Ohio that are closing, he said: “That was job one, let’s shore up our pharmacies, especially our small, independent ones. …
“We haven’t plugged the hole. The boat is still sinking; the pharmacies are still going out.”
Radiology technologist Jeff Dettbarn, alleges thousands of tests at the Iowa City VA were improperly canceled, potentially risking veterans’ lives. USA TODAY
WASHINGTON – Three Veterans Affairs health care professionals who reported patient care issues say the agency continues to try to silence them, jeopardizing veterans and undercutting a key Trump promise of whistleblower protection.
They work at different sites – in the Phoenix area, Baltimore, and Iowa City, Iowa – yet the VA response has been similar. All were stripped of assigned patient-care and oversight duties, and they suspect VA managers are retaliating against them for speaking out, and sidelining them to prevent them from discovering or disclosing any more problems with veteran health care.
In exclusive interviews with USA TODAY, their assertions contradict proclamations by agency leaders and President Donald Trump that VA employees who disclose wrongdoing at the agency are being celebrated and not scorned.
Mitchell is scheduled to testify at a congressional hearing Tuesday examining the treatment of whistleblowers at the VA. She will be joined by Iowa City CT technologist Jeffrey Dettbarn, who blew the whistle on mass-cancellations of diagnostic test orders, and Baltimore VA psychologist Minu Aghevli, who reported veterans had been removed improperly from wait lists for opioid-addiction treatment.
Mitchell said the retaliation against her and others who speak out sends a signal to other employees to keep their mouths shut and “jeopardizes the health and safety of every veteran in the system.”
“Whistleblowers who are brave enough to report problems serve as a vital safety net for veterans,” she said. “If people can’t identify problems, veterans will suffer and die. That’s what it boils down to.”
But the VA inspector general has since launched a wide-ranging investigation of the office’s handling of whistleblower cases and reports of problems.
The Government Accountability Office issued a report last July that said the office allowed officials accused of wrongdoing or retaliation to be involved in investigations of the accusations – calling into question their independence and findings. And leadership at the office has turned over multiple times, causing confusion and disruption.