this was just posted on www.youtube.com on 04/14/2019 – so in less than 48 hrs – this has a 50:1 ratio of THUMBS UP to THUMBS DOWN and has nearly 7000 comments  Does that suggests that the actual feelings of the general public about pain management or that John Oliver has a rather young audience that probably has not had much experience with chronic pain and get most of their “news” via social media.

Notice in the transcript of one of the Sackler family they asked if anyone became “dependent or addicted”… as if they are the SAME ?

The only thing that I can sort of agree with Oliver is that the company that put out Insys Fentanyl oral spray… was the “poster child” of very bad marketing of that product.  Fentanyl being dosed via a oral spray has only one valid medical use – end of life cancer because a oral spray will  have a very short onset and a very short duration of action.  This medication – in this route of administration – would put a chronic pain pt on a “pain roller coaster” and likewise this med in this application should NEVER BE USED as the primary pain management med for ANYONE.

It is too bad that John Oliver and his staff are not as smart as they are smart asses.

Filed under: General Problems | 4 Comments »

Torture and Cruel Treatment in Health Settings

https://www.hrw.org/news/2010/01/20/torture-and-cruel-treatment-health-settings

Human Rights Watch has reported on a wide range of abuses against patients and individuals under medical supervision – in medical facilities, juvenile detention centers, orphanages, drug treatment centers, and social rehabilitation centers. Often in these settings, health providers may be forced to withhold care or engage in treatment that intentionally or negligently inflicts severe pain or suffering for no legitimate medical purpose.

Medical care that causes severe suffering for no justifiable reason can be considered cruel and inhuman, and in some cases, where there is state involvement and specific intent, it can be considered torture.

Prohibitions in international human rights law forbidding torture and other cruel, inhuman or degrading treatment (CIDT) or punishment apply to conditions of confinement, including in medical and other institutions. The International Covenant on Civil and Political Rights (ICCPR), the first international treaty to address torture and CIDT explicitly, provides, in article 7, that: “No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment. In particular, no one shall be subjected without his free consent to medical or scientific experimentation.”

The UN Human Rights Committee emphasizes that article 7 “protects, in particular … patients in teaching and medical institutions.” The UN Manual on Reporting also notes: “Article 7 protects not only detainees from ill-treatment by public authorities or by persons acting outside or without any official authority but also in general any person. This point is of particular relevance in situations concerning … patients in … medical institutions, whether public or private.”

The United Nations Human Rights Committee has stated that prohibitions against torture and CIDT apply “not only to acts that cause physical pain but also to acts that cause mental suffering to the victim.”^[1] Article 16 of the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Convention against Torture), and interpretations by the European Court of Human Rights and the United Nations special rapporteur on torture and other cruel, inhuman or degrading treatment or punishment suggest that, at a minimum, CIDT covers “treatment as deliberately caus[ing] severe suffering, mental or physical, which in the particular situation is unjustifiable.”^[2] The special rapporteur, Manfred Nowak, suggests that CIDT is distinguished from torture in that it may occur out of intentional and negligent actions.”^[3]

Human Rights Watch research into torture and CIDT in health settings includes  health care providers’ involvement in forcible anal and vaginal exams, female genital mutilation, and failure to provide life-saving abortion, palliative care and treatment for drug dependency.

The Human Rights Watch 2010 World Report essay, “Abusing Patients: Health Providers’ Complicity in Torture and Cruel, Inhuman or Degrading Treatment” summarizes recent research by Human Rights Watch on the abuse of patients in health settings.

Other Human Rights Watch research related to this theme, in various institutional settings:

• 1. Prisons/Pre-Trial Detention
• 2. Immigration Detention
• 3. Health Care Institutions/Hospitals
• 4. Psychiatric Institutions
• 5. Drug Treatment Facilities
• 6. Social Rehabilitation Facilities
• 7. Orphanages/Juvenile Detention Centers

Prisons/Pre-Trial Detention

“Barred from Treatment: Punishment of Drug Users in New York State Prisons,” March 2009: Details lack of drug dependence treatment, Medication-Assisted Therapy, and harm reduction services in New York state prisons.

“Torture and Impunity in Jordan’s Prisons: Reforms Fail to Tackle Widespread Abuse,” October 2008: Documents torture in Jordan’s prisons and notes lack of adequate health care, especially psychiatric care.

“Locked Up Alone: Detention Conditions and Mental Health at Guantanamo,” June 2008: Describes deteriorating mental health of detainees held at Guantanamo Bay, Cuba, as a result of conditions of confinement.

“In a Time of Torture,” February 2004: Documents the human rights abuses suffered in Egypt  by men suspected of engaging in homosexual activity, which is unlawful under Egyptian moral codes. The systematic abuse imposed on suspected individuals  by police officials includes forcible “anal exams,” conducted by forensic physicians. These exams, which involve anal molestation and penetration, are used to establish whether an individual has violated the moral code against “debauchery.” But examining physicians admitted to HRW that the tests are not conclusive despite official reliance on results for conviction.

[See also: News Release, “Egypt: Court Upholds HIV Sentences, Reinforces Intolerance,” May 2008; News Release, “Egypt: New Indictments in HIV Crackdown,” March 2008; News Release, “Egypt: Spreading Crackdown on HIV Endangers Public Health,” February 2008; News Release, “Egypt: Stop Criminalizing HIV,” February 2008: Series of pieces detailing abuses suffered by men arrested and tried on the basis of suspected HIV positive status, including HIV testing without consent by Ministry of Health doctors and forced forensic anal examinations designed to “prove” that they had engaged in homosexual conduct].

“Undue Punishment: Abuses Against Prisoners in Georgia,” September 2006: Details conditions of detention in Georgian prisons and substandard or absent medical care, including lack of medicines and other treatment and wholly inadequate mental health care.

“Guinea – “The Perverse Side of Things”: Torture, Inadequate Conditions, and Excessive Use of Force by Guinean Security Forces,” August 2006: Describes prison conditions in Guinea, including severe overcrowding, and policy of releasing individuals who are near death so that they do not die in custody.

“Ill-Equipped: U.S. Prisons and Offenders with Mental Illness,” October 2003: Documents the disproportionate number of mentally ill individuals in prisons. Three times as many  mentally ill people are in prisons as in mental health hospitals; and prisoners have rates of mental illness  two-to-four times greater than the rates for the general public. Seriously ill prisoners often receive little or no meaningful treatment because prison mental health services are woefully deficient, crippled by understaffing, insufficient facilities, and limited programs. The role of psychiatric personnel is limited, and includes stabilizing those who suffer psychotic episodes so that they can be returned to the conditions that provoked the attack.

[See also: Letter to Representative Julie Hamos, “Human Rights Watch Supports HB 2633,” April 2009; Article, Jamie Fellner, “Prevalence and Policy,” Correctional Mental Health Report, January 2007; News Release, “U.S.: Number of Mentally Ill in Prisons Quadrupled,” September 2006; News Release, “Prisons No Place for Mentally Ill,” February 2004].

“Long Term Solitary Confinement for Political Prisoners,” July 2004: Describes Tunisia’s prolonged isolation of selected inmates, most of them leaders of the banned Nahdha Party, which seems driven less by legitimate penological motives than by a political will to punish and demoralize these individuals and to crush the Islamist trend they represent.

“Nowhere to Hide: Retaliation against Women in MI State Prisons,” September 1998: Describes  retaliation by attackers against  women inmates who have been raped by guards in Michigan prisons.

“Cold Storage: Super Maximum Security Confinement in Indiana,” October 1997: The first comprehensive assessment under international human rights law of super-maximum security facilities in the United States, which house prisoners who will someday be released back into society.

Immigration Detention

Report, “On the Margins: Rights Violations against Migrants and Asylum Seekers at the New Eastern Border of the European Union,” November 2005: Describes detention conditions  for migrants in Ukraine, including lack of access to medical services.

“Chronic Indifference,” December 2007: Documents HIV/AIDS care for detained immigrants; death of HIV-positive detainee in federal custody immigration facility; and failures in the system that lead to insufficient medical care, discrimination and harassment.

 “Detained and Dismissed,” March 2009: Documents health care conditions in  US immigration and Customs Enforcement Service facilities, where as of 2007,  more than 320,000 people were in its custody. Individuals are detained for administrative infraction but suffer health care conditions worse than prison settings. Documents  many instances of facilities ignoring sick call requests, not delivering necessary medication, losing medical records, failing to provide translation services, impeding access to specialist care, and  denying access to needed treatment. Documents instances in which women were denied gynecological care, mammograms and adequate care during pregnancy.

Health Care Institutions/Hospitals

“Please, do not make us suffer any more…,” March 2009: Examines the chronic  worldwide problem of under-treatment for pain. Despite the universal consensus that palliative care should be  part of the national response to AIDS and cancer treatment, 80 percent of the world’s people do not receive adequate pain treatment. Government passivity is a key reason for under-treatment  in both the developed and developing world.

“A High Price to Pay: The Detention of Poor Patients in Hospitals,” September 2006: Examines the effects of user fees and the practice of routinely detaining poor patients who are unable to pay their hospital bills in Burundi, one of the poorest countries in the world.  Documents inadequate, often inhumane, living conditions for  detained patients, who often go hungry, sleep on the floor and are refused appropriate medical treatment. The abuses  discourage similarly situated people from seeking health care and exacerbate health problems of recovering patients.

“Hated to Death: Homophobia, Violence, and Jamaica’s HIV/AIDS Epidemic,” November 2004: Notes discrimination faced by men who have sex with men in Jamaica by health workers, who refuse to treat the men, make abusive comments and disclose their sexual orientation, putting them at risk of homophobic violence.

“Over Their Dead Bodies,” October 2007:  Documents  deaths that result from a blanket ban on abortion in Nicaragua, one of three remaining countries that ban abortion for women in all circumstances and a country in which a doctor who performs abortions may face criminal charges. The deaths include those that result from the “chilling effect” of the law, described by women reluctant  to seek medical care for obstetric emergencies, including heavy bleeding, for fear of being suspected of inducing abortion.

“No Bright Future,” July 2006: Details the practical impossibilities for HIV-positive individuals in Zimbabwe  in accessing necessary antiretroviral therapy (ART), whose cost can be prohibitive. The government grants waivers for health user fees  but the  system is rife with flaws. Hospitals turn away patients who have been granted exemptions, for example,  requiring payment  up front instead. Such provider abuse denies life-saving care  and disrupts ART, which can result in the patient’s developing drug resistence.

“Decision Denied,” June 2006: Documents the difficulties  Argentinian women have gaining access to abortion.

“Mexico: The Second Assault,” March 2006: Documents difficulties girls and women face in Mexico if they seek abortions  as a result of rape. Mexico’s laws permit legal abortion after rape. But for many rape survivors, actual access to safe abortion procedures is made virtually impossible by a maze of administrative hurdles as well as official negligence and obstruction. At the core of this issue is a generalized failure of the Mexican justice system to provide a solution for rampant domestic and sexual violence, including incest and marital rape.

“Rhetoric and Risk,” March 2006: Describes discrimination by health  care providers  against people living with and at high risk of HIV/AIDS in Ukraine. People living with HIV/AIDS and injection drug users have been turned away from hospitals, summarily discharged when their HIV status became known, or provided poor quality care that was both dehumanizing and debilitating to their already fragile health status.

“Positively Abandoned,” July 2005: Documents discrimination for HIV-positive mothers and their children in healthcare settings (as well as in other sectors).

Psychiatric Institutions

News Release, “Speaking Up for Vietnam,” June 2008: Notes the legally sanctioned practice in Vietnam of committing political dissidents to “social protection centers” and psychiatric facilities involuntarily without trial.

News Release, “Turkmenistan: New Leader Should End Rights Abuses,” December 2006: Urges Turkmenistan to end practice of forcible detention of political prisoners in psychiatric hospitals

News Release, “Uzbek Activist in Eighth Day of Detention,” November 2005: Describes arrest of Elena Urlaeva, a member of the Human Rights Society of Uzbekistan,  in the waiting room of the office of the human rights Ombudsman in Tashkent while trying to deliver a complaint.

News Release, “Uzbekistan: Dissident Forced into Psychiatric Detention,” September 2005: Describes  politically motivated detention of individuals in psychiatric facilities and forced psychiatric treatment as punishment.

[See also: News Release, “Uzbekistan: Dissident in Psychiatric Detention,” April 2001].

News Release, “Russia: EU Policy Should Address Human Rights,” March 2004: Notes need for reform of psychiatric institutions given serious problems with procedures for committal for involuntary treatment.

“Dangerous Minds: Political Psychiatry in China Today and Its Origins in the Mao Era,” August 2002: Details the practice of politically motivated psychiatric diagnosis and institutionalization in China. Inside a secret network of state run psychiatric facilities, accused political dissidents are detained indefinitely, alongside those who are truly mentally ill. Political dissidents receive “treatment” for disobedience in the form of electroshocks, public humiliation, force feeding, and forcible injections of anti-psychotic drugs.

[See also: News Release, “China: No Medical Reason to Hold Dissident,” March 2006; News Release, “China: Political Prisoner Exposes Brutality in Police-Run Mental Hospital,” October 2005; News Release, “China: WPA Action on Psychiatric Abuse Falls Short,” August 2002; News Release, “China: End Political Abuse of Psychiatry,” August 2002].

Drug Treatment Facilities

“‘Skin on the Cable’:The Illegal Arrest, Arbitrary Detention and Torture of People Who Use Drugs in Cambodia,” January 2010: Documents the treatment of   people who use drugs  by law enforcement officials and staff  at government drug detention centers  claiming to provide drug “treatment” and “rehabilitation.”  These centers  hold  people rounded up by police or arrested at  the request of family members, who sometimes pay for their care,   without  judicial oversight.  In 2008 over 2,300 people were detained in such centers, including many children under 15 and people with mental illnesses.

“Where Darkness Knows No Limits,” January 2010: Documents how China’s June 2008 Anti-Drug Law compounds the health risks of suspected illicit drug users by allowing government officials and security forces to incarcerate them for up to seven years without trial or judicial oversight.  The law fails to  define clearly mechanisms for legal appeals or to report abusive conduct and does not ensure evidence-based drug dependency treatment.

“An Unbreakable Cycle: Drug Dependency Treatment, Mandatory Confinement, and HIV/AIDS in China’s Guangxi Province,” December 2008: Details the range of human rights abuses suffered by identified drug users in China. Detained in drug rehabilitation centers for indefinite periods of time, drug users are forced into unpaid labor, exposed to environments with  an unnecessary and heightened risk of disease infection, inadequate medical services and rampant abuse  by prison guards.   Describes human rights violations resulting from a  national drug policy that shirks universally recommended methods for rehabilitation in favor of a punitive system.

“Rehabilitation Required: Russia’s Human Rights Obligation to Provide Evidence-based Drug Dependence Treatment,” November 2007: Finds that treatment offered at state drug treatment clinics in Russia is so poor as to constitute a violation of the right to health and further notes breaches of confidentiality.

“Deadly Denial,” November 2007:Documents the repeated failures of the Thai government in extending the success of its universal ART program to HIV- infected drug users. Although the law has extended  provision of  ART to drug users, discriminatory practice continues without state censure. Health care  providers interviewed admitted  they did not know of a change in the law, were uncertain about potential interactions between ART and methadone or other illicit drugs, or feared that extension of ART to drug users would be “asteful” given the group’s “unreliability.”

“Not Enough Graves: The War on Drugs, HIV/AIDS, and Violations of Human Rights,” July 2004: Details inadequacy of drug treatment and HIV prevention programs in prisons in Thailand, coerced substandard drug treatment, discrimination in hospitals, and drug users’ exclusion from government-sponsored HIV/AIDS treatment programs.

“Locked Doors,” September 2003: Documents the urgent needs of persons living with HIV in China  for healthcare, legal aid and community support.  Instead, widespread discrimination by state and private actors and the lack of redress are forcing many people with HIV/AIDS to live like fugitives. 

Social Rehabilitation Facilities

“Libya: A Threat to Society? Arbitrary Detention of Women and Girls for ‘Social Rehabilitation‘” February 2006: Details the inhuman and degrading treatment of women  suspected of transgressing moral codes – often involving extramarital sex and rape –  in state run “rehabilitation centers.” Women and girls identified as “vulnerable to engaging in moral misconduct” can be detained indefinitely at these  centers. A majority of women interviewed reported undergoing invasive “virginity exams,” by health care personnel when they entered  the facility. Results from such exams not only inform the prosecutorial process but also affect the family’s decision on whether to abandon the woman to the facility’s care.

Orphanages/Juvenile Detention Centers

“Real Dungeons: Juvenile Detention in the State of Rio de Janeiro,” December 2004: Describes abuse and inhumane conditions in Rio de Janeiro’s state juvenile detention centers, including poor hygiene and healthcare (lack of water and frequent scabies outbreaks).

“Abandoned to the State: Cruelty and Neglect in Russian Orphanages,” December 1998: Details the egregious abuse and inhumane conditions that abandoned and orphan Russian children experience in state-run orphanages. . Inhumane conditions include prolonged use of restraints and light deprivation, inadequate medical attention, isolation, and abuse by supervising medical staff.

“Custody and Control,” September 2006: Examines two large, prison-like facilities in which girls in New York state are confined, and concludes that, far too often, girls experience abusive physical restraints and other forms of abuse and neglect and are denied the mental health, educational and other rehabilitative services they need.

“Death by Default: A Policy of Fatal Neglect in China’s State Orphanages,” January 1996: Documents the pattern of cruelty, abuse, and malign neglect which has dominated child welfare work in China since the early 1950s, and that constitutes one of the country’s gravest human rights problems.

“Romania’s Orphans: A Legacy of Repression,” December 1990: Shortly after Nicolae Ceaucescu was overthrown on December 22, 1989, the world was exposed for the first time to the shocking images of Romania’s orphans, expecially its handicapped children and babies with AIDS. These children, numbering over 100,000, lived for the most part in Dickensian institutions – bleak, understaffed orphanages built by the Ceaucescu government to deal with the consequences of its policy of coercively raising the birth rate. The orphans are the grisly legacy of an oppressive regime in a country that lacks both democratic traditions and independent associations of professionals.

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Pain Management Best Practices Inter-Agency Task Force Third Meeting

https://www.hhs.gov/ash/advisory-committees/pain/meetings/2019-05-09/index.html

Agenda

The meeting will occur on Thursday, May 9, 2019 from 10:00 a.m. to 5:30 p.m. and Friday, May 10, 2019, from 9:00 a.m. to 12:00 p.m. Eastern Time (ET). The agenda will be posted soon.

I was looking at this website and while I do not want to discourage anyone from making comments to this… but..  everyone needs to read this and see who you are making comments to—> HHS  Health and Human Services.

When is the last time – or first time – that someone from HHS came in and raided a prescriber’s office and shut the practice down, walked off with all the office computers and other records ?

When is the last time – or the first time – have you seen HHS make the determination that a prescriber’s practice is a “pill mill” and making the determination that the prescriber is prescribing controlled substance in excess of what is considered  “outside of best practices and standard of care ” and declares that the prescriber is functioning as a “pill mill” and facilitating controlled substances to be diverted to “the street”

HOW ABOUT NEVER ?

So apparently, there is going to be NO ONE FROM THE DEA present at this meeting or reading any submitted comments…and that would be BECAUSE ?  Could it be that the DEA has no interest in changing their current policies and procedures and continue to raid prescribers’ offices and using the Civil Asset Forfeiture Act to confiscate all their assets?   Yes the Supreme Court has been making some changes to that act and other states have shown a interest in changing the law. People who have had their assets confiscated… may at some point in the future may be their assets back but what if the DOJ has liquidated the hard assets… at a FIRE SALE… the person may get back what the DOJ got in cash for their seized assets.

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Is Our Government Ready to Listen on Chronic Pain and Suicide?

www.nationalpainreport.com/is-our-government-ready-to-listen-on-chronic-pain-and-suicide-8839557.html

The recent discussion on chronic pain and suicide on the National Pain Report has elicited some significant and candid responses from our readers. The temptation is to look at the issue in a binary way—people are being denied care and many are choosing to either contemplate or actually take their own lives.

But there’s more—as Dr. Terri Lewis asked on Twitter recently–Are policy makers, clinicians, patients, and payors sharing the same mental models?

The answer is most assuredly not yet.

That’s why Lewis has been leading a conversation about suicide with our readers and the pain community. People have been reaching out to her—and we caught up with her over the weekend to find out what she’s been learning—and what she plans to do with what she’s learning.

National Pain Report: “You have received a lot of responses from people who either have actively contemplated suicide or loved ones who shared their stories about people ending their lives. What are all those responses telling you?”

Dr. Terri Lewis: “These responses are telling me that the health care system that serves persons with multiple chronic conditions is not working. And it sure isn’t working for effective governance either. Whether by policy design or through overspecialization, the lack of adaptation to the needs of persons at whatever life stage they find themselves operating within has created significant disruption in ways that are not good for communities, health care systems, government services, or families.”

The words folks use to describe their feelings of helplessness and disempowerment to regain control over the quality of their days are consistent, palpable. I have several longer-term objectives that include documenting that suicide is often (not always) a considered choice in this underserved population of people, and that this choice is being made against transformative changes within our health systems across the nation.

These transformative changes amount to serious encroachment by the legal system into the practice of medicine through the application of surveillance tools that are engendering decisions which reallocate resources away from health care and toward enforcement controls processes that are unrelated to managing health outcomes. We need to seriously examine the costs to the system that this is inserting into the entire system and the long-term impacts of building to a system that has so little positive return for communities. The current course is unsustainable. It prematurely moves people into positions of disability and reduced economic circumstances. This has all kinds of downstream consequences.

National Pain Report: “You have gathered an unbelievable amount of information through the survey—What are you going to do with it and how will you distribute it?

Dr. Terri Lewis: “I’ve concluded that I’m engaged in a process of studying the intersection of social justice and healthcare anthropology. The current medical, social and cultural context is very impacted by political influences working on changing population characteristics. These exert a large, and under-addressed influence on policy development.

If our system is being transformed in ways that have negative consequences, we need to understand what that might mean for those who are affected so that they can become more informed and can advocate for more participation in personal choices and public processes. The information gathered will be shared with respondents, advocates, public officials using a variety of push techniques. Above all I want it to be accessible and to help us push toward asking the right questions, allocating the right decision resources.

The emerging patterns reflect enough data to support inquiry in several areas:

• Who are the people affected by this problem?
• What are their characteristics?
• What are the characteristics of the context in which this problem is occurring?
• What role do various parts of the system (government, medical professionals, insurers, law enforcement, families, community) serve in contributing to the overall observable problem?
• How should this information inform the decisions we make to manage our systems?

National Pain Report: Final question—it feels to me in reading the conversations that our stories inspire that there are so many things that need to happen–more patient centered care—more access to mental health services–affordability—It feels to me like for the first time in a long time, federal policy makers are beginning to realize “Houston We Have a Problem.”  How can we create more momentum around that?

Dr. Terri Lewis: “The large problem of social justice research in this area is confirming the personal voice. We’ve all been trained to shield our privacy which means we have lots of layers of profoundly ‘ableist’ designs that get in the way of figuring out what we are dealing with. We have to ask ourselves who is affected? How? Are there harms and what kind of harms? What are the systemic barriers that are getting in the way of choice-making and control of personal resources? What works and what doesn’t work? What other actions influence outcomes of decisions made within multiple political processes? How can we use this information to inform public policy decisions while breaking down faulty beliefs? Person centered policy requires us to ask these questions and design systems which continuously assert the rights of full participation by persons who are most affected by the outcomes.

Importantly, how does the individual with limited resources influences processes in their own communities using the tools at their disposal? They can do this with their voices and by working with others who share their needs and concerns. They have to be informed, they need to understand that they can make a difference by speaking out and by giving notice that they expect to participate and to be accounted for.

I’m really excited by the people who have responded to this tool. They are frustrated, brave, and have just had enough. They seem to fully understand that their future and the future of their children are in serious trouble. This is moving them to action. And we need to magnify their voices.

I’m in the same boat. It has moved me to this course of action. So I intend to keep paddling. The alternative is to do nothing, and that makes no sense to me.”

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Colorado enacts ‘red flag’ law to seize guns from those deemed dangerous, prompting backlash

https://www.foxnews.com/politics/sheriff-fires-back-after-colorado-enacts-red-flag-law-to-seize-guns-from-individuals-deemed-dangerous

Colorado became the 15th state on Friday to adopt a “red flag” gun law, allowing firearms to be seized from people determined to pose a danger — just weeks after dozens of county sheriffs had vowed not to enforce the law, with some local leaders establishing what they called Second Amendment “sanctuary counties.”

The law didn’t receive a single Republican vote in the state legislature, and has led to renewed efforts from gun-rights activists to recall Democrats who supported the measure. In a fiery and lengthy statement on Facebook on Friday, Eagle County, Colo., Sheriff James van Beek slammed the law as a well-intentioned but “ludicrous” throwback to the 2002 film “Minority Report,” and outlined a slew of objections from law enforcement.

Van Beek charged that the law treats accused gun owners like “criminals,” discourages individuals from seeking mental health treatment, and ignores the reality that “a disturbed mind will not be deterred by the removal of their guns.”

Noting that cities with strict gun laws still experience high murder rates, van Beek asserted: “By removing guns from someone intent on committing suicide or murder, we still have the danger of someone who may be unbalanced, now, angrier than before, and looking for another means … explosives, poisons, knives, car incidents of mowing down groups of unsuspecting innocent.”

Colorado’s law, approved by Democratic Gov. Jared Polis, allows family, household members or law enforcement to petition a court to have guns seized or surrendered based on a showing that someone poses a danger under the “preponderance of the evidence,” a civil standard which means that the defendant is more likely than not to be a threat.

“In other words, there is just over a 50/50 chance of accuracy,” van Beek wrote, noting that someone’s guns could be seized even without a mental health professional making a determination of any kind. “Like the flip of a coin. Couldn’t that apply to just about anything a person does?”

A subsequent court hearing could extend a gun seizure up to 364 days, and gun owners can only retain their guns if they meet a burden of demonstrating by “clear and convincing evidence” — a much higher standard — that they are not in fact a threat. Gun owners, van Beek said, are “guilty until proven innocent” under this framework.

Minority Republicans in the legislature had unsuccessfully tried to shift the burden of proof to the petitioner.

The law’s passage marked a personal victory for first-term Democratic Rep. Tom Sullivan, whose son, Alex, was gunned down in the 2012 Aurora theater massacre that killed 12 people and wounded 70 others. The bill is slated to take effect in January.

“Three hundred and fifty one Fridays since Alex was murdered,” Sullivan began, wearing his son’s leather bomber jacket at the signing ceremony for the bill he sponsored.

“Being the parent of a murdered child, everything is stunted,” Sullivan said, prompting knowing, tearful nods from several other shooting survivors standing behind him. “I am elated, believe me. It just can’t come out because there is just too much work in front of us to get done.”

Alex Sullivan was celebrating his 27th birthday at the theater. Tom Sullivan, elected to the House in November, has devoted his life since Aurora to counseling survivors of other mass shootings around the country and campaigning for gun control.

CALIFORNIA GUN SEIZURE PROGRAM HITS HURDLES

Responding in part to Sullivan’s remarks, van Beek emphasized his own county’s work on establishing partnerships to combat mental illness, which he characterized as a practical solution. The Aurora theater shooter, James Holmes, long suffered from mental illness.

“The Red Flag Law can remind one, of the movie ‘Minority Report’; regulating against what we think someone might do,” van Beek wrote. “It’s like regulating via clairvoyance, but in this case, we actually take away someone’s property and require them to go to court to prove their innocence of a crime that hasn’t been committed, yet they were punished because someone thought they might be thinking about it.”

The sheriff continued: “I find no mental health programs associated with this law. Just a possible overreach of well-meaning citizens, with no infrastructure for addressing the primary intention of the law: mental health as it relates to public safety.”

Van Beek’s post concluded by arguing that Colorado’s law violated the Second Amendment. However, van Beek explicitly stopped short of declaring sanctuary county status, and suggested his office would enforce the law.

“Removing the guns in a constitutionally questionable manner, without notice, denying the accused the ability to defend charges, then requiring medical services that are not available, in order to reinstate private property rights, afterward, is like putting a Band-Aid on the probability of a wound, and not allowing its removal until an injury has occurred,” he wrote. “In other words, the entire process is ludicrous.”

Van Beek added: “I stand with other Sheriffs in opposition to the Red Flag law on constitutional grounds as well as its failure to address the true issues, which are behavioral and mental health. In addition, it places fiscal hardships on county budgets, places law enforcement officials in imminent danger, violates citizen’s rights, and actually works against the mental health concerns that it was originally designed to aid.”

“The entire process is ludicrous.”

— Eagle County, Colo. Sheriff James van Beek

Florida passed its own “extreme risk protection order” law after the 2018 Parkland school massacre. Others with versions of the law include California, Connecticut, Delaware, Illinois, Indiana, Maryland, Massachusetts, New Jersey, New York, Oregon, Rhode Island, Vermont and Washington state, as well as Washington, D.C.

“Colorado has endured more than our fair share of tragedies,” Polis said Friday. This law will not prevent every shooting, but it can be used in a targeted way to make sure that those who are suffering from a mental health crisis are able to temporarily have a court order in place that helps make sure they don’t harm themselves or others. Today we may be saving the life of your nephew, your niece, your grandchild.”

Gun rights activists pushed for Polis and some Democrats who supported the legislation to be recalled. Senate President Leroy Garcia, a Democrat, voted against the bill — primarily, observers said, because his predecessor was recalled in 2013 for supporting the state’s last major gun control push.

That 2013 legislation implemented background checks and ammunition magazine limits, following the Aurora and Sandy Hook Elementary School shootings. In all, two Democratic lawmakers were recalled and another resigned for supporting those laws.

About half of Colorado’s 64 counties — most in rural areas — passed resolutions opposing the new bill and declared themselves “Second Amendment sanctuaries.”

Opposition from rural sheriffs elicited a warning last month from Democratic Attorney General Phil Weiser, who has said those who won’t enforce the law should resign.

The law is named after Douglas County Sheriff’s Deputy Zackari Parrish III, a 29-year old husband and father who was killed on New Year’s Eve 2017 by a man who had exhibited increasingly erratic behavior.

Parrish’s boss, Douglas County Sheriff Tony Spurlock, and Boulder County Sheriff Joe Pelle attended. Pelle’s son, a Douglas County sheriff’s deputy, was wounded in the shooting that killed Parrish.

Pelle said he was working with Spurlock and other law enforcement chiefs to develop protocols for executing protective orders safely.

Co-sponsor Alec Garnett, a Democrat and the House majority leader, noted that Colorado’s law stands out for providing legal representation for gun owners.

“We have come a long way in this state from Columbine,” Garnett said, referring to the upcoming 20th anniversary of the April 20, 1999, Columbine High School massacre.

CLICK TO GET THE FOX NEWS APP

Separately, a prosecutor refused to approve criminal charges Friday against Pittsburgh’s mayor and six City Council members over the passage of firearms restrictions that gun rights advocates say are blatant and deliberate violations of state law.

Seven city residents tried to file private criminal complaints against Democratic Mayor Bill Peduto, who signed the legislation into law this week, and council members who voted to approve the bills. The complaints charge the mayor and council with official oppression and other counts.

Fox News’ Andrew O’Reilly and The Associated Press contributed to this report.

Filed under: General Problems | 1 Comment »

Susan lost her doctor to suicide. She wants to know why.

www.idealmedicalcare.org/susan-lost-her-doctor-to-suicide-she-wants-to-know-why/

Susan Kreischer is one in a million.

One of a million Americans to lose their doctor to suicide—each year.

She is still devastated years later.

“I had awful back pain—was barely walking when I met Dr. Ortiz and right away we bonded. Every time I went in, he’d give me a huge bear hug, lifting me off the floor (and I’m a heavy woman). He always had a big smile on his face. He was it. He was the man. He didn’t just hand me another pill. He actually got in there and solved my problems.”

Dr. Ortiz was a man who never gave up on his patients.

“Later when I had more back problems, he said I’d need my hip fused and he’d look for another surgeon since that wasn’t a procedure he was familiar with. Next time I saw him he told me that he didn’t find anyone he could trust so he was going to do it himself—and that’s exactly what he did. He learned that procedure for me! I was in awe that he did that for me.”

Staff in the operating room were in awe as well. Nobody could believe how perfectly Dr. Ortiz performed her fusion.

“I saw that man five times in a day and a half in the hospital, plus he went to see me another four or five times when I was in recovery. He called me every night at home to make sure I was okay—and I was.”

Susan wonders how she’ll ever replace him.

“I don’t trust other orthopedic doctors around here. I had some very bad experiences. I had so much faith in Dr. Ortiz because I knew he was being truthful—giving me his honest opinion. I adored him. He was a saint to me. He took so much of my pain away. He changed my life.”

Now all Susan has left of her doctor is this picture she snapped of a framed photo that hangs in the hallway of the hospital where he once worked.

Dr. Ortiz was clearly one of the most thoughtful, compassionate, and ethical men one could ever hope to meet—especially when needing back surgery.

Once when Ortiz was on a vacation, his patient became sick and Ortiz flew home early to take care of her. What kind of surgeon does that?

A patient case was cancelled one day because the hospital did not secure an assistant for the surgery. However the patient had already been sedated with Versed to calm her anxiety so she couldn’t drive home. Ortiz held her hand and explained the situation to her. He then decided to drive her home in her car more than an hour away. He took a cab all the way back to the hospital.

Who was Steven Ortiz?

As a child, Steve was a hard worker who put all his efforts into school. His teachers were impressed by his intelligence. He never got into trouble, always did his homework and turned in all his assignments without prodding from his parents.

Steve had beautiful blue eyes and at a very young age he starting receiving unsolicited attention from older women. One day, after a doctor’s appointment, he was thirsty so he asked his mom to buy a drink. She parked in front of a store and gave him a dollar. He came back out with his drink and handed his mom the dollar. Steve told her that the lady in the store said, “I have beautiful blue eyes and I don’t need to pay.”

“We marched back into that store and told the woman he had to pay for his drink and he did,” says his mom. “Oh the trouble he could have gotten into with those eyes.”

Though we never met, I feel I know Steve Ortiz. Maybe it’s because he grew up down the street from me in Eugene, Oregon. He attended Sheldon High School where he played on the football team and never lost a game. He kept up his grades and was an all-around good kid.

After high school, Steve was a sprinkler fitter for 10 years, then became a fire sprinkler engineer for his father’s company. He also worked in construction. One day at work he stepped off a curb and tore his meniscus. He had surgery immediately and on follow-up when the doctor showed him his x-ray he almost passed out and had to be helped to sit down by the nurse. He literally couldn’t stand looking at his own x-ray.

He returned to school at 28 earning a chemistry degree from Fullerton Community College then a full scholarship to UC Irvine and Stanford Medical School before completing orthopedic residency in New York and spine surgery fellowship in Minneapolis—19 years of medical education!

Despite the demands of nearly two decades of medical training, Steve never forgot birthdays, holidays, or special occasions. He moved his family to Stanford for medical school just before his daughter turned 13. She hadn’t made many friends so she didn’t know how to celebrate her birthday. On her birthday her dad came home and told her he rented the entire medical school auditorium for the afternoon and he invited her whole soccer team to watch a movie and help her celebrate. He even rented a popcorn machine and bought everyone candy.

“He was very observant, always watching, always listening, and always learning,” says his daughter Alyssa. “Once I saw a string of pearls in a picture and I commented that they were very beautiful. I never said I wanted them. A few months later a package came in the mail with the same type of pearls. These surprises happened many times in my life. He was a wonderful man.”

Yet Steve—such a devoted family man—had to sacrifice relationships with the very people he loved the most so he could help heal others. With his kids and wife finally settled in California, he was distraught having matched in New York for orthopedics. During his five years of residency he only got to see his kids once per year. That marriage eventually failed and he remarried a woman who wanted to be near her family in Florida. So, of course, Steve agreed. (With loved ones he had trouble saying no!) So after fellowship, he set up his practice in a Florida hospital where he was adored by patients and staff.

“I want you to know the nurses were drooling over this man. The nurses always said, ‘He is so hot!’ and once I even tried to hook him up with my daughter,” claims Susan Kreischer. “I told Dr. Ortiz, ‘If you ever need any jewelry for someone special, let me know. I make jewelry.’” For Susan, he was more than a doctor; he was her friend.

In the aftermath of his suicide, I’ve received a constant stream of emails from his patients, colleagues, even his college girlfriend. They all want me to know what a truly special man he was.

Kind and generous, Steve helped anyone who needed it. He showed up at a colleague’s house unannounced when she was moving. He brought boxes, tape, wrapping paper, and marking pens and spent his weekend helping her move.

When not attending to patients, Steve adventured in the outdoors. He was a certified scuba diver, a hunter, a motorcycle enthusiast, a fisherman, he even hurt his knee again skateboarding around Florida. Yet his top priority was always caring for his patients.

Typical of doctors, Steve spent his time helping others and rarely asked for help.

Working 80-100 hours each week, surgeons often experience marital distress, and divorce is not uncommon. Back when I was in medical school, surgical residency programs bragged about having 100% divorce rates—as if total devotion to the surgical profession and absence of any personal life would make the best doctor.

Steve did confide in Sherry Cleveland, his surgical nurse. “He called me the annoying little sister he never had because we would goof off and pick on each other during OR days,” says Sherry. “He was in the midst of his second divorce and the Friday before his death he came out with a bunch of us and stayed longer than usual. We were talking about doing the VIP area at the brewery. He was very popular with the ladies and we joked about hosting a ‘Date Dr. Ortiz’ event there. He laughed. When he left he hugged tighter and longer than he ever had before.”

The most unforgettable story about Steve—the ultimate fix-it-guy—is the way he dealt with the giant pothole in the hospital parking lot. No spine surgeon wants patients bouncing up and down in potholes. Since the hospital didn’t have a plan to repair it, Dr. Ortiz went to the hardware store, bought several bags of cement and gravel and he fixed it himself early one morning—before a full day of surgery.

Imagine a sweaty spine surgeon repairing potholes on the hot Florida asphalt before scrubbing in for his next case.

Yet Steve’s problems with the hospital were deeper than parking lot potholes. Due to irreconcilable differences with hospital leadership, Dr. Ortiz was considering moving on to another practice.

Everything changed on Tuesday morning, February 7, 2017, when Steve got a phone call in the doctors’ lounge. Staff said he was white as a ghost and he must have been threatened or something. Nobody knows what happened on that phone call.

He then texted Sherry Cleveland asking for her personal email address. She thought that was strange.

That evening at 5:00 pm, he called his mother for the last time. He told her, “They are greedy; that’s all they care about.” His mom said he was very upset.

During that 30-minute call, he shared the challenges he faced every day. His mom knew none of his struggles prior to that conversation.

He had already planned it.

On Wednesday, February 8, Sherry Cleveland got up for work shortly after 4:00 am. Though she doesn’t usually check her email, she thought Steve might have sent her something. His goodbye letter arrived at 12:09 am. She was in her bathroom getting ready for work when she read it:

Sherry was numb. In her heart she knew what it meant. But she was hoping it wasn’t true. She emailed Dr. Ortiz and asked if he was moving back to California. “Please tell me you’re okay. Please respond to me,” she wrote. Sherry wanted to call him, but was afraid she was going to wake him up. She didn’t want to wake her husband up, so she finished getting ready for work.

Sherry rushed to the hospital and pulled into the parking lot just after 5:00 am when she saw the police cars.

“I was on the phone with one of my really good friends, because I just needed to talk to someone. When I saw the lights, I was numb. I didn’t know what to think. I didn’t know what to do. I went to work that day, because I didn’t want to be alone. I didn’t want to go home and be by myself, but I really just didn’t know what to do. I was shocked because out of everyone that he worked with, everyone that he knew, I was that person that he felt comfortable enough with to share that information, and to tell me, and have me be his messenger to let everyone know that he appreciated us, and goodbye.”

Dr. Ortiz was found dead in his truck.

Wednesday morning at 2:00 am, Steve Ortiz checked in on all his patients and wrote orders to make sure they were okay. At approximately 3:00 am, he went out to the hospital parking lot where he repaired the pothole, sat down in his truck, and shot himself in the heart.

Steve’s dad and brother flew to Florida. His dad met with another doctor who said he was struggling with the same issues as his son. That doctor, like Steve, felt bullied—pulled into all sorts of illegal shenanigans that undermined the care of his patients.

In the aftermath of Steve’s suicide, flyers were taped on hospital walls naming three doctors responsible for his death and demanding justice for Dr. Ortiz. When removed, new flyers were taped back up. This continued for a month until a doctor was caught affixing them to the walls.

“He was 47 when he finished his fellowship and was very naïve having spent most of his life in school,” says his mom Gloria. “Steve was glad his training was over so he could be a real doctor. He felt alone in Florida. He had only been out of training for three years and was very disillusioned. He was not a quitter. He just could not deal with the corruption at his age.”

I first learned of Dr. Ortiz when an online Florida news headline reported a possible suicide of a local surgeon found deceased at a hospital. The article became an online tribute to Steve’s life and death with more than 155 comments from adoring patients (and curious citizens) wanting to know why a successful orthopedic surgeon would be found dead in a hospital parking lot. One woman commented:

“I called his office this morning to schedule an appointment with Dr. O. for my husband when I was told he was no longer with the practice. They would not give me any information. I found [this article] on Google just few minutes ago. If it were not for your report I would not have known. I am so saddened with this news of his loss. He was such a wonderful caring doctor.”

Others were furious with the journalist for reporting on the suicide of Dr. Ortiz: “I think it is disgraceful and disrespectful that this is blasted all over the web. This is not responsible news reporting or journalism; it is potentially hurtful gossip that has not been confirmed by any agency.”

Some argue that it is nobody’s business why Dr. Ortiz died. Others are still searching for answers years later.

The fact is without a proper investigation of his suicide, people will remain confused—many like Susan grieving in isolation.

Yet Dr. Ortiz is one of tens of thousands of doctors trapped in corrupt US health systems, caught between for-profit insurers, unethical administrators, and shareholders demanding maximum profit extraction from the sickest, most vulnerable patients. Physicians are the extraction device.

Without a proper investigation of the corruption leading to this surgeon’s suicide, there is no way to protect patients or prevent the next doctor suicide.

After posting a comment on the article, I got a call from Steve’s mom. We spoke for hours. I asked if she wanted to connect with an Emmy-winning filmmaker so her son could be honored in the forthcoming film, Do No Harm—a documentary exposing the doctor suicide crisis that ends with a scrolling list of nearly 100 names and photos of doctors we’ve lost to suicide. Dr. Steven Ortiz is now one of them.

News reports are an anomaly in the aftermath of a doctor suicide in the United States. Most are just a paragraph or two. The “article” on Dr. Ortiz was just 133 words. Reporters (as in Dr. Ortiz’s case) promise to “bring more on this story as it develops.” They never do. I have never seen a follow-up story or a detailed investigation into any of these physician suicides since I began tracking them in 2012. I now have 1,243 doctor suicides on a confidential registry—all cases that I’ve personally investigated since nobody in the media or medicine seems willing to launch an honest investigation into why so many of our doctors are dying by suicide.

High doctor suicide rates have been reported since 1858—and seem to be accelerating. Yet more than 160 years later the root causes of these suicides remain uninvestigated and unaddressed.

Of my 1,243 cases, I’ve learned that for every woman who dies by suicide in medicine, we lose four men.

Male surgeons are the second highest risk group after male anesthesiologists. Many are found dead at hospitals. Doctors jump from hospital windows or rooftops. They shoot or stab themselves in hospital parking lots. They’re found hanging in hospital chapels. Physicians often choose to die where they’ve been wounded.

Doctors choose suicide to end their pain (not because they want to die). Suicide is preventable. We can help doctors who are suffering if we stop suicide secrecy and censorship.

Medical institutions lie (or omit the truth) to cover up suicides—even when media and family report the cause of death. Instead we hear euphemisms such as “passed away unexpectedly.”

Ignoring doctor suicides leads to more doctor suicides.

Steve is just one of the 1,243 doctors I know who have died by suicide.

Sadly, the original article about his death is no longer live on the Internet.

I’m beyond appalled at the lack of investigation of these suicides.

One month after his death, Susan called the office for an appointment. “I was told that would not be possible. Then the person on the phone said, ‘He passed.’”

“Excuse me. What did you say?” asked Susan.

“Dr. Ortiz has passed away.”

“I started crying hysterically,” Susan explains. “I kept asking, ‘What happened to him?’”

“We don’t know. We think it was an accident,” the receptionist said.

Susan kept crying.

The receptionist kept saying how sorry she was.

“I found out later they lied to me. They knew what happened to my doctor. I was completely devastated that nobody called me before to let me know. I need to know what would make such a wonderful and successful doctor feel that suicide was his only way out. I don’t understand why he was put in such an awful position. People should be held responsible for what they’ve done to him. I hope they will be. I just wish that you had been around before my doctor died. I really think you could’ve helped him.”

Susan’s sentiment is shared by Steve’s mom. “Since his death I have thought several times that had he been able to go to an advocates group for help or talk to someone like you that he may have lived, but apparently there wasn’t any help available to him.”

Since 2012, I’ve offered a free physician suicide helpline. Click here for help.

Susan still remembers his final words.

During my last appointment I begged, “Please don’t ever give up on me.” He looked at me and smiled. “I won’t give up on you. I’ll be here for you.”

“When I found out about you, Dr. Wible, I was in heaven. I thought maybe I can find out what really happened to my doctor,” Susan said.

Why would such a beloved orthopedic surgeon die by suicide?

Dr. Ortiz couldn’t play the game of corruption—harming patients for profit. He asked other physicians for help—even met with the Hospital Board of Directors—and he was told he should just “go with the flow.” He sought out government officials and the FBI. He never heard back from them. He explored in his own head all the options (and documented it all). He was at a dead end. Exhausted, he saw no solution. He would rather “tap out” than play the game by someone else’s rules. He was not depressed. He was frustrated, pissed, and stuck. His suicide was well-planned. He was a truth teller and was biting his tongue just to survive. Dr. Ortiz died as a whistleblower. He gave it his best shot. He truly felt that his suicide was the only way to draw attention to—and end —the corruption.

Justice for Dr. Ortiz?

Absent an investigation by authorities, with legal repercussions and penalties, the status quo continues.

“I used to like to drive by and see Dr. Ortiz’s car in the parking lot,” says Susan. “After he died, they left his truck there for three months. People would leave flowers. Now when I drive by I can’t look at the place. I went to get my wrist looked at and It was hard being there. We would wave to each other through the glass door. I sat there and I didn’t see his smiling face. I kept looking expecting to see him. He did not deserve what he got. I am disgusted with the way this absolutely gifted surgeon was treated.”

Steve’s first wife, a fundraiser at Stanford, is trying to start a program about doctors like Steve. Medical institutions are starting to finally grasp the severity of our doctor suicide crisis.

“I don’t even do spine cases anymore, because I just can’t,” says Sherry Cleveland. “I can’t be in the room. I can’t. It hurts too bad. I see certain things or think certain things and I have to walk away, because it’s painful.”

The Do No Harm documentary honoring Dr. Steve Ortiz is now on an international film tour screening at health systems and film festivals.

I continue to investigate doctor suicides in between attending to my own patients.

As for Susan, it’s been more than two years and she still has no doctor.

In 2019, one million more Americans like Susan will wonder why they can’t see their doctor

 

Filed under: General Problems | 3 Comments »

Alabama Cops Raided Their House, Seized Their Cash, and Ruined Their Lives Over $50 of Marijuana

http://https://www.reason.com/2019/04/12/alabama-cops-raided-their-house-seized-t/

Greg and Teresa Almond lost their house after a financially devastating drug raid involving civil asset forfeiture.

Filed under: General Problems | 2 Comments »

Too Little, Too Late: US Government Backtracks on Opioid Discontinuation

https://www.practicalpainmanagement.com/resources/news-and-research/too-little-too-late-us-government-backtracks-opioid-discontinuation

Jeffrey Fudin, PharmD, and Jeff Gudin, MD, PPM Co-Editors-At-Large:

Thousands of patients have been dispassionately forced into tapering their opioids, often inappropriately, due to fear from regulatory agencies following initiation of the 2016 CDC Guideline on Prescribing Opioids for Chronic Pain. In addition to unnecessary suffering, this has resulted in opioid withdrawal due to due either rapid or misguided or inexperienced taper regimens. The sad irony here is that three years later, the FDA is saying exactly what nationally recognized pain experts have been saying all along. In a safety announcement on April 9, 2019, FDA announced that it “has received 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.” (Update: The next day, the CDC came out with its own follow-up, not to the full HCP community, but to one doctor in particular. See the agency’s response here which states that the CDC “does not endorse mandated or abrupt dose reduction or discontinuation” and that the CDC is “working diligently to evaluate the impact of the Guideline and clarify its recommendations.” )

The 2016 CDC guideline was born from an “expert” panel mostly consisting of addictionologists and non-pain experts, many of whom had conflicts of interest and strong partiality as anti-opioid zealots. Many of these panel members were affiliated with PROP (physicians for responsible opioid prescribing) who submitted a petition to the FDA in 2012 requesting harsh and unreasonable restrictions on opioids; this was rejected by FDA in 2013. [PPM covered FDA’s rebuttal in PROP versus PROMPT: FDA Speaks].

Just recently, the article “International Stakeholder Community of Pain Experts and Leaders Call for an Urgent Action on Forced Opioid Tapering” cited forced tapering and opioid dose reductions as a large-scale humanitarian issue. The authors pointed out that “…no data exist to support forced, community-based opioid tapering to drastically low levels without exposing patients to potentially life-threatening harms.” Consensus guidelines were also publishedm, led by Kroenke and colleagues, titled “Challenges with Implementing the Centers for Disease Control and Prevention Opioid Guideline.” This paper outlined a “failure to appreciate the importance of patient involvement in decisions to taper or discontinue opioids.”

A group of Pharmacy Pain Clinicians recently surveyed over 100 opioid prescribers throughout the United States to determine the level of variation within and between clinicians in opioid tapering methods (data pending presentation/ publication). Outcome analysis overseen by Amelia Persico, PharmD, suggested that although the majority of providers surveyed were pain specialists, 15% were not comfortable tapering opioids at all; morphine daily dose influenced taper confidence; and taper-motivation was largely motivated by CDC guidelines rather than medical reasons or patient specific factors.

As clinicians, we hopefully recognize the complexities of opioid prescribing. We recognize that because of tolerance, metabolic and pharmacogenetic factors, patients respond differently to different molecules of opioid and not all patients will respond to low doses. Practitioners who prescribe opioids and are comfortable assessing the benefits and potential harms should recognize the above factors and appropriately titrate analgesics the way any class of drug should be titrated to effect in the appropriate patient.  

More thoughts from PPM Editorial Advisors & Contributors:       

Jennifer Schneider MD, PhD:
As a result of the 2016 CDC guideline on opioid prescribing, which has all too often been treated as regulations rather than a guideline, a huge number of patients with chronic pain have suffered increased pain, decreased function, desperately turning to illicit opioids to treat their pain, and a large number finally committing suicide. It boggles the mind that the CDC never followed up their guideline with any information about how to appropriately taper opioids in patients on chronic opioids. Three years after publication of the guideline, the FDA (not the CDC) has now figured out that there have been significantly negative consequences. Three years! That’s 3 years too late for many patients. 

The most pertinent information from the FDA announcement for health professionals, which should be widely disseminated, includes:

“In general, for patients who are physically dependent on opioids, taper by an increment of no more than 10-25% every 2-4 weeks. It may be necessary to provide the patient with lower dosage strengths fo accomplish a successful taper.

“If the patient is experiencing increased pain or serious withdrawal symptoms, it may be necessary to pause the taper for a period of time, raise the opioid analgesic to the previous dose, and then once stable, proceed with a more gradual taper.”

Every professional who has prescribed opioids should become familiar with this Drug Safety Announcement in its entirety, as there are other important elements. A change in opioid tapering practices is the only way to prevent more patients from suffering because their prescribers did not know enough about opioids and the consequences of sudden stopping or rapid tapering.”(See Dr. Schneider’s take on tapering from 2012, even before the CDC guideline came out,  as well as and a more recent look at safe tapering practices with Courtney Kominek, PharmD.)

I’ve gone through the press release.  And the devil is in the details. There’s less here than meets the eye. I don’t want to appear ungracious in the face of “success,” but… I’m not convinced these two recent announcements actually change policy in any fundamental way.  I sense this is a political delaying action to avoid having to admit that CDC was fundamentally wrong when they bought into … fraudulent claims about dangers of opioids.  It’s  not a change of heart and there’s a long way to go before practical improvements arrive in doctor treatment of patients denied opioid therapy.  

The Director of CDC letter has doubled down on several “initiatives” which appear to assume that the original assumptions and declarations of the guidelines were correct – which they weren’t, and for which there is abundant published proof that they weren’t.  You’ve seen many of the themes in my published work, both in single-author and dual-author papers.   The myth of over-prescribing is still alive and well.  We need to kill it conclusively.

Specifically:

• CDC claims to be doing a review with AHRQ of literature published since March 2016.  Among the areas of review are non-pharmacologic non-invasive therapies.  AHRQ published what may be the definitive systematic review of this area in June 2018 – but they tried to rig their summary level findings to put the best possible face on the very weak medical evidence behind this area of medicine.  There’s a lot of harmful quackery hiding in the many small-scale “trials” of “alternative therapies” which don’t directly compare with opioid analgesics or properly document protocols for the addition of such therapies as adjuncts to “usual therapy – namely NSAIDS and opioids.  Steve Nadeau and I have written in Practical Pain Management on this topic.
• CDC  also claims to be doing reviews for the Quality Improvement Collaborative.  But the underlying assumption of that Collaborative is that “safety improvements” are needed in prescribing practices.  And that premise is highly debatable.

From publications that go back as far as the Cochrane review of 2010, we know that incidence of substance abuse associated with medically managed opioid analgesics is possibly as low as 0.5%.  Incidence of substance abuse or overdose diagnoses in post-surgical patients  treated with opioids for pain is on the order of a maximum of 0.6%, and incidence of chronic opioid prescribing in post-surgical patients is less than 5% in even the most failure prone surgical procedures (total knee replacement), and shows no increase above background prescribing rates in non surgical patients, in some common procedures.   With such low incidence rates, I rate the chances of “improving safety” of opioid prescribing as zero to nil.  It’s just another camouflage for discouraging opioid prescribing and threatening doctors with sanctions if they prescribe high amounts.

So my instinct is to acknowledge incremental progress, and then get busy forcing the immediate recall and repudiation of the entire guideline document and all state legislation or regulation that incorporates it.  We likely won’t be able to avoid a rewrite effort for “some” kind of guideline, because doctors won’t reenter pain management practice without a shield from sanctions;  they’ll want to be “guided”.  The HHS Task Force draft points in many of the right directions if they can translate it into actionable recommendations to Congress that allow doctors to use their judgement, and give them meaningful education to develop that judgment. 

David Cosio, PhD, ABBP:

Rather than further policing the actions of some prescribers, it may be more important to ask why they are discontinuing in this manner. It is not only the regulations that have been imposed but also the general fear that comes with using opioids that has led to this problem. So, the first thing needed is further education on appropriate opioid prescribing and reimbursement for support staff that is necessary to provide a multimodal approach.

The FDA does seem to offer some guidance, but it is confusing and incomplete. They first say, for example, there are no standard opioid tapering schedules, but then propose a general 10 to 25% reduction every 2 to 4 weeks? They also suggest that a multimodal approach to pain management, including mental health support, be in place prior to initiating an opioid analgesic taper. If about 50% of patients who suffer from chronic pain obtain their care from a primary care provider, then a multimodal approach may not be accessible due to insurance regulations or may not be available in the clinic where they seek their care. Furthermore, many patients may not embrace this approach and thus this holds the prescriber hostage.

The FDA also recommends frequent follow-up appointments, again not recognizing that in some clinics there is a wait of up to three months to see a general practitioner.

Norm Shealy MD, PhD:
“t is becoming more and more clear that the FDA is responsible for the opioid epidemic. Any physician who is not caught up in pharmaceutical ties knows to withdraw their patients from opioids slowly.

Srinivas R. Nalamachu, MD:
Typical FDA, nothing new and very generic with no guidance.

Add your thoughts on our LinkedIn conversation or email the editors at ppmeditorial@verticalhealth.com

Filed under: General Problems | 3 Comments »

When did people’s feelings start mattering more than patient safety?

www.kevinmd.com/blog/2019/04/when-did-peoples-feelings-start-mattering-more-than-patient-safety.html

As an elder millennial physician, I’ve been straddling two worlds, that of the “old-school” mentality of training and this newer one of “wellness.” I’ve become disheartened with new physicians being increasingly unable to tolerate any criticism by teaching faculty, even when patient harm is at risk. However, it wasn’t until I was accused of bullying and bullying exclusionary by a group of colleagues — not trainees — that I grew completely fed up.

Merriam Webster defines bullying as the abuse and mistreatment of someone vulnerable by someone more powerful. By definition, there is no power differential between my colleagues and myself. I am in no position of power — purely clinical physician at a community-based teaching program. I have been told that while there is no “factual evidence” to base these claims off of that it is, perhaps, the “perception of my tone” and my “intimidating nature” that are to blame.

It is known to most of my colleagues that I have exceptionally high standards when it comes to patient care, my signouts are very detailed, I pose lots of questions and ask about exam findings, etc. This style of signout is not only targeted at those who have been known to miss things or have cases go before our performance-improvement committee but extends to my close friends and physicians I would trust with my family’s lives. Patient handoff is the most dangerous time for the patients, and I take it seriously. My intent is not to intimidate others, and there is no subtext of criticism. At what point am I in control of the perceptions of others and at what point are others projecting their own insecurities onto my clinical questions? I welcome all clinical questions about my patients as I want to ensure the same focused care for them after I leave. If residents ask about changes I suggest to their management, I let them know if things they were doing could or did cause patient harm — because that is a paramount part of their education.

When did people’s feelings start mattering more than patient safety? If the goal is to create a work environment where everyone feels safe, including patients, where does that leave me?

I have been told many that I am intimidating, but never before in a negative light. I have exemplary blinded resident evaluations. I have been told that my high expectations push residents to be better, more thorough and efficient clinicians. Many a female resident has told me what an inspiration I have been to them as a strong female role model. Many a colleague, as well as nursing and support staff, have told me they would entrust or have entrusted me with the care of their loved ones to me, so I have to assume I’m not that intimidating — right?

People would also not describe me as a social butterfly. I have a small group of friends at work I socialize with outside the hospital. I have courteous professional relationships with the other faculty. I work similar shifts as these close friends, does that mean we exclude others? I would argue that by a group of us working a similar typically undesirable shift, we have developed excellent teamwork and ways to support each other as we work with limited resources. When people who do not typically work these shifts join us occasionally, they are welcomed and sit with us and enjoy this same support. Does my special bond with a few attendings really cause distress for others?

Does being demanding now equate with me being a bully? I would argue not. Does that give the others I work with the right to associate this HR terminable phrase with my name without any evidence — definitely not. The same people claiming I am contributing to their “toxic work environment” are essentially creating that for me. What recourse do I have? It seems that everyone’s feelings about this matter except mine. I have asked for ways to improve perceptions of others and my superiors had nothing to offer.

Interestingly, now I am the one who feels targeted, under a microscope and unsure how to proceed. If I were in extremis, I’d hope the doctors taking care of me cared more about my care and less about their feelings towards each other.

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CDC Issues Key Clarification On Guideline For Prescribing Opioids For Chronic Pain

https://www.news-line.com/PH_news28551_enews

The American Society of Clinical Oncology (ASCO), the American Society of Hematology (ASH), and the National Comprehensive Cancer Network® (NCCN®) are pleased to acknowledge receipt of a key clarification from the Centers for Disease Control and Prevention (CDC) on prescribing opioids to manage pain from certain conditions. The clarification regarding CDC’s Guideline for Prescribing Opioids for Chronic Pain—issued in a letter from the agency to ASCO, ASH, and NCCN—comes as a result of a collaborative effort by these organizations to clarify CDC’s opioid prescribing guideline in order to ensure safe and appropriate access for cancer patients, cancer survivors, and individuals with sickle cell disease.

CDC’s clarification letter notes that the agency’s guideline was developed to provide recommendations for primary care clinicians who prescribe opioids for patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care.

The letter conveys that CDC’s guideline is not intended to deny clinically-appropriate opioid therapy to any patients who suffer acute or chronic pain from conditions such as cancer and sickle cell disease, but rather to ensure that physicians and patients consider all safe and effective treatment options for pain management with the goal of reducing inappropriate use.

“This clarification from CDC is critically important because, while the agency’s guideline clearly states that it is not intended to apply to patients during active cancer and sickle cell disease treatment, many payers have been inappropriately using it to make opioid coverage determinations for those exact populations,” said ASCO Chief Executive Officer Clifford A. Hudis, MD, FACP, FASCO.

The CDC’s clarification further notes that clinical practice guidelines addressing pain control for survivors of cancer, such as the American Society of Clinical Oncology Clinical Practice Guideline on Management of Chronic Pain in Survivors of Adult Cancers and the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Adult Cancer Pain, which were published and/or updated more recently than CDC’s guideline, provide important guidance on the unique considerations when using opioids to control pain in cancer survivors without worsening the current opioid crisis.

“Pragmatic approaches for pain management exist at the intersection of multiple health concerns,” said NCCN Chief Executive Officer Robert W. Carlson, MD. “Our guidelines help clinicians to assess the risk of inappropriate substance use, while still ensuring people with cancer don’t suffer unnecessary, severe pain. CDC’s acknowledgement that clinical decision-making should be based on the relationship between physicians and their patients is important and in the best interest of people with cancer and sickle cell disease.”

In November 2018, ASCO, ASH, CDC, and NCCN representatives met in-person to discuss concordance and variation among current guidelines for chronic pain management and develop a strategy to resolve inconsistencies as well as improve communication of existing recommendations. External reviews had previously identified perceived inconsistencies among existing guidelines and had noted concern that such inconsistencies may be causing inadvertent confusion in the healthcare community.[1] The organizations also discussed issues related to the CDC guidelines and agreed jointly to seek clarification of the guidelines regarding their applicability to patients with cancer and sickle cell disease. Following the meeting, ASCO, ASH, and NCCN sent a letter to CDC urging the clarification.

“People with sickle cell disease suffer from severe, chronic pain, which is debilitating on its own without the added burden of having to constantly appeal to the insurance companies every time a pain crisis hits and the initial request is denied,” said ASH President Roy Silverstein, MD. “We appreciate CDC’s acknowledgement that the challenges of managing severe and chronic pain in conditions such as sickle cell disease require special consideration, and we hope payers will take the CDC’s clarification into account to ensure that patients’ pain management needs are covered.

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