Why states might start taxing opioids

The next wave of state actions against the opioid crisis may focus on taxing them — depending on the outcome of an industry lawsuit against New York, the first state to try it.

Between the lines: Most of the bills that have been proposed would tax opioid painkillers and use the money for addiction treatment and prevention. But the health care industry argues that they’re bad policy and, at least in the New York law’s case, illegal. That case will be tested when oral arguments in the lawsuit begin Monday.

More than a dozen states saw the introduction of bills to tax opioids last year, but only New York’s made it into law.

• The New York law will collect $600 million over six years from drugmakers and distributors and use it to fund addiction treatment and prevention. These industry groups have responded with three different lawsuits arguing that the law is unconstitutional. Oral arguments for each lawsuit will be heard on Monday.
• Some groups are also arguing that the law is bad policy. “The fee itself could force a generic company, which is making a very low margin, to leave the market. And so a potential policy consequence is that patients are only left with the brand-name, high cost opioids when they have medical needs,” said Jeff Francer of the Association for Accessible Medicines, one of the plaintiffs.

Why it matters: If the industry is successful in its attempt to kill the law, that could influence whether other states follow New York’s lead or how they write legislation.

• “I think that the states see what’s going on in litigation,” Francer said. “No legislator wants to pass a law that a court finds to be unconstitutional.”

One state to watch is Minnesota, where Governor-elect Tim Walz has said he’s supportive of a fee on opioid prescriptions to help pay for treatment and prevention.

• Legislation that would have created such a fee failed to pass last year, but lawmakers have said they want to try again, per Kaiser Health News.
• Other states to watch include California, Delaware, Iowa, Kentucky, Maine, Massachusetts, Montana, New Jersey, Tennessee and Vermont, per KHN.
• Here’s a list of state opioid tax legislation that was introduced in 2018, as compiled by the National Conference of State Legislatures.

Proponents of opioid taxes argue that their value goes beyond just raising money. “If the actual price for these products reflected their true costs, I think we’d see a greater emphasis on reducing opioid use and encouraging use of pain treatments that are much safer and more effective,” said Andrew Kolodny of Brandeis University.

The other side: Opponents say these taxes could make it harder for people to get the pain medication they need. “We do not believe levying a tax on prescribed medicines that meet legitimate medical needs is an appropriate funding mechanism for a state’s budget,” said a spokeswoman for Pharmaceutical Research and Manufacturers of America.

The bottom line: It’s a unique new approach to the fight against the opioid crisis — but a ruling against New York could easily shut it down.

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Americans eat more French fries than any other country in the world and now a Harvard professor is saying you should not eat more than six fries at a time. Professor Eric Rimm at the Harvard T.H. Chan School of Public Health told The New York Times, “I think it would be nice if your meal came with a side salad and six French fries.” Potatoes, especially those cooked in oil, have been linked to obesity, diabetes, and heart disease.

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We’ve also contacted every civil rights attorney & organization here in Oregon & across the country. Their answers have been, across the board, via phone, snail mail, email, & in person, “we do not choose to get involved with this issue at this time.”

There is a lot going on in Oregon, for those not paying attention that local bureaucrats are hell bent on taking away all opiate pain management … initially from Medicaid pts.

Could the above response from the various law firm be for several reasons:

1.  those that have approached them, want them to take the case on … on a contingency basis and there is really no financial upside for a law firm in preventing laws, regulations, interpretations from being implemented.
2. It will be easier to challenge the constitutionality of whatever they implement after the fact.. because then it gets into the court system and in theory they can get an injunction promptly upfront and then move on with challenging its constitutionality
3.  They may never consider any of these actions because their is no financial upside to the law firm taking on such a legal challenge and until some group comes forward with a “boat load of $$$” to finance the legal challenge.

What we have seen over the last 2-3 yrs with these bureaucrats and their actions against chronic pain pts cannot be labeled as anything less than they are ZEALOTS.

From what I have read about the “going ons” in Oregon… these bureaucrats have their opinions and maybe they have reached the point where they believe that they are entitled to their opinions should actually be considered as FACTS.  Or they are basing their actions on “facts” from such entities like the CDC, which most realize that many are fabricated, embellished or just flat out lies.

Sooner or later… the chronic pain community is going to have to come to the conclusion that data/facts from some other entities than what the bureaucrats have formed their decisions from are most likely not going to be considered by the bureaucrats and they are going to move forward with their planned changes… they have devoted a lot of staffing time coming to their conclusions and perhaps no words or “other’s facts” are going to change their agenda and moving forward.

In the end, it may just boil down to the chronic pain community coming together FINANCIALLY and funding one or more law firms to challenge the constitutionality of what has been done against those suffering from chronic pain and their pain therapy is being reduced, stopped or not started in the first place to those new pts which are headed towards being a chronic pain pt.

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I filled my scripts last Wednesday at my mom & pops pharmacy. They were packed!!!!! Most people had come from Wal Mart…..

https://www.npr.org/sections/thetwo-way/2018/05/08/609442939/walmart-will-implement-new-opioid-prescription-limits-by-end-of-summer

Walmart announced Monday it is introducing new restrictions on how it will fill opioid medication prescriptions in all of its in-store and Sam’s Club pharmacies.

It is the company’s latest expansion of its Opioid Stewardship Initiative, intended to stem the spread of opioid addiction, prevent overdoses and curb over-prescribing by doctors. It follows a similar initiative by CVS that went into effect in February.

A March report by the Centers for Disease Control and Prevention found overdoses from opioids soared by nearly 30 percent between 2016 and 2017.

“We are proud to implement these policies and initiatives as we work to create solutions that address this critical issue facing the patients and communities we serve,” Marybeth Hays, executive vice president of Health & Wellness and Consumables said in a statement.

Over the next 60 days, the fourth-largest pharmacy chain will cap acute painkiller supplies to cover a maximum of seven days. It will also limit a day’s total dose to no more than the equivalent of 50 morphine milligrams. And, in states where prescriptions are restricted to fewer than seven days, Walmart will abide by the governing law.

Walmart said the new policies align with the Centers for Disease Control and Prevention recommendations established in 2016. Those rules were meant for doctors prescribing chronic pain medication and encourage primary care physicians to prescribe the “lowest effective dose.”

By the end of Aug. 2018, the company said its pharmacists will begin using NarxCare, a controlled-substance tracking tool with “real-time interstate visibility.”

Pharmacies will also carry naloxone, an opioid overdose antidote that has become instrumental in helping to decrease overdose deaths. The life-saving medicine will be offered over the counter, dispensed upon request, wherever it is legal.

As NPR has reported, “The medicine is now available at retail pharmacies in most states without a prescription.” Retail sales of naloxone, more commonly known by the popular brand name, Narcan, increased by tenfold between 2013 and 2015.

Dr. Steven Stanos, former president of the the American Academy of Pain Medicine told NPR the organization applauds “any action that seeks to limit the over-prescription of opioids.” But, he added, “That needs to be balanced with the very real need of patients.”

“Setting a mandatory limit without giving physicians the ability to explain why a patient might need a longer prescription, interferes with the relationship between that person and their physician, who knows them better than the pharmacist,” Stanos said.

He also explained requiring patients to obtain a new prescription after seven, or sometimes even three days, depending on the state, can become too costly because of mandatory co-pays.

Another of the company’s changes going into effect on Jan. 1, 2020, is a requirement that all controlled-substance prescriptions be submitted electronically. According to Walmart: “E-prescriptions are proven to be less prone to errors, they cannot be altered or copied and are electronically trackable.”

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I-Team: Opioid crisis: Crackdown fails to cut opioid overdoses; deaths on the rise

https://www.lasvegasnow.com/news/local-news/i-team-opioid-crisis-crackdown-fails-to-cut-opioid-overdoses-deaths-on-the-rise/1575669160

LAS VEGAS – A year ago this month, 8 News Now aired a multi-part, in-depth project called “#OurPain: The other side of opioids,” which explored the mostly untold stories of how a crackdown on prescription medications has affected millions of legitimate patients dealing with chronic pain.

#OurPain: Opioid crisis leaves legitimate pain patients struggling

The Centers for Disease Control started this ball rolling back in 2016 when it issued supposedly voluntary guidelines that have since been enacted into law across the country.  In the past 12 months, the crackdown has intensified, though it failed to put a dent in opioid overdoses. 

I-Team: Feds ask public for help with opioid crisis

Barby Ingle, the president of the International Pain Foundation, learned about chronic pain patients the hard way when she became one. Ingle lost everything to pain, then slowly rebuilt her life and became an advocate for pain patients. 

Since  2016, when the CDC initiated the great opioid crackdown by issuing supposedly voluntary guidelines, the suffering of millions of legitimate pain patients grew to be worse. 

“I’m hearing more desperation,” Ingle said.  “I’m hearing about more suicides, more loss of friends.”

Ingle says she hears the stories every day through her pain foundation, but now, the news is slowly seeping out.  

Suicides among pain patients, including veterans and seniors, have spiked.  Pain patients who could function and hold jobs have had to leave the workforce after being cut off. 

Forced reductions in the production of opioid medications is felt in hospital emergency rooms, even in hospices where end-of-life cancer patients have had to suffer.  

The crackdown on pain medications not only failed to cut opioid overdoses, but the deaths have also gone up.  Especially, in areas that cut down the most.  Death records, including in Nevada show that 80 percent of deaths are from illicit drugs like heroin and fentanyl, or a combination of drugs and alcohol, along with other underlying medical problems.

“Gunshot wounds; people who are taking multiple medications or mixing medications, even NSAIDs and opioids, It could have been the NSAIDs that gave you internal bleeding, but they blame it on opioids only,” Ingle said.

The annual pain week symposium held in Las Vegas was missing many familiar faces this year.  Pain doctors are shutting down their practices out of fear they will be prosecuted.  

Pain pioneer Dr. Forrest Tennant earned a lifetime achievement award one year ago. Now, his practice is shut down. Not because he was charged with any crime, but merely because he was served a search warrant. That kind of news spreads fast among doctors.

“We already know patients are having trouble finding doctors willing to treat them, especially in rural areas — pain management doctors are extremely hard to find,” said Pat Anson, Pain News Network.  “And if they are abandoning their practice and doing whatever they can do safely, who is going to treat the pain patient of the future from the standpoint of the patient, they are being abandoned.  From the standpoint of the doctor, they could be going to jail if they don’t stop prescribing, o what choice do they have?”

Since January when a new state law kicked in, Nevada doctors have sought clarification from the medical board about what the crackdown means here. At its most recent meeting, the board approved general guidelines that are far less Draconian than in other states, but the required paperwork is burdensome, and patients are being cut back regardless of their individual medical needs.

“I had my pain management physician involuntary taper me down to 90 MMEs and their entire amount of patient; they had like 300 patients and told me they were going to taper all of them down to 90. We’re all in pain because of it,” said Rick Martin, patient advocate.

Martin says the worst may come in January when new federal guidelines give pharmacies and insurance providers more power to overrule no matter what a doctor might prescribe,

“The insurance company is basically got a prescription pad and a white coat now, telling the legislators and doctors what to do,” Martin said. “The patient-doctor relationship is shattered.”

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Oregon along with 5-6 other states has a “death with dignity ” law. it is claimed that another 30 states will have similar bills on their legislative agenda over the next year.

According to https://www.newamericancentury.org/, changes in our social morals seem to be driven by MONEY… generally gambling was illegal, until the bureaucrats “did the math” and figured out the revenue stream attached to the Lottery and Casinos – now many states are licensing all sorts of gambling activities.

We are seeing the same “realization” by bureaucrats as to the tax revenue that can be generated by Marijuana and we now have some 30 states that have legalized it .. in some form or another and it is probably just a matter of time before at the federal level it will no longer be a C-I – illegal substance – after some 100 years of claiming that this substance has no valid use.

Over the years, I have worked with several non-profits and the brighter ones understand in the non-profit arena that it much easier to save money than beg/raise money.

For the first 140 years or so, the United States did not have a income tax, but a income tax was initiated to replace the tax revenue that was going to be lost by the 18th Amendment that make alcohol ILLEGAL.. that initial income tax was just 1% -2 % and it mostly hit those people who were considered “rich” at that time. 14 yrs later the 21st Amendment repealed the 18th Amendment, alcohol was once again legal and alcohol tax money starting flowing again.. but.. the Federal income tax … did not go away.

Is the bureaucracies finally “seeing the light” that it is going to be easier to cut expenses than to raise money and with us spending abt $10,000/person in healthcare taxes and much more on those who are handicapped/disabled, elderly.

Is Oregon the FIRST STATE to establish a processes that will make an increasing number of its residents to “qualify” for the parameters of utilizing the state’s death with dignity law ?   The state is not DIRECTLY forcing them to exercise their choice to utilize the “final act” to eliminate their pain ?  It is the choice of the pt and their prescribers as to what the pt wishes to do ?

I am not encouraging suicides… but.. already we have 50,000 suicides and ONE MILLION attempts every year.  As that number start climbing… as many of us believe that it will.. it may be time for those people who believe that suicide is their only option from unrelenting pain from intractable chronic pain to do some planning… It has been reported that many times a suicide note inexplicably disappears either by the family that is embarrassed that their family member has did this and/or some other person(s) would prefer that the death be labeled as a “opiate related death” to better serve their agenda.

Should a video by the “desperate person” be made… blaming/accusing those who have put them into the position that causes them to take this action.  Could they be charged with assisting suicide ?  Could an “agreement/understanding” be made by compassionate friends/relatives that the video could be sent to them and it would be understood that it would be “shared far and wide”.  Should those complicit in carrying out the actions of the bureaucracy be held accountable ?

Over the last decade, we have all seen the insidious actions of many bureaucracies and where they seem to be heading and it would appear that Oregon has stepped up the game plan and is seemingly taking very bold steps to take the “game’ to the end and declare VICTORY.

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Your Rights in the Emergency Room

https://www.webmd.com/special-reports/er-violations/20181129/patients-rights-in-the-emergency-room

Nov. 29, 2018 — The Emergency Medical Treatment and Labor Act, or EMTALA, guarantees a certain level of medical care to anyone who comes to an emergency department that accepts payments from Medicare or Medicaid.

Some labor and delivery units and psychiatric hospitals are also governed by EMTALA.

Under the law enacted in 1986, emergency departments must:

1. Offer patients a timely and appropriate medical screening exam.

• This exam is different from triage, in which a nurse or other provider takes vital signs to decide the order in which to see patients.
• Unlike with triage, a health care professional with a certain level of expertise — typically a doctor, advanced practice nurse, or physician assistant — must do the medical screening.
• Medical screening exams are done to find out the cause of a patient’s symptoms. They cannot be delayed or denied in order to ask about a patient’s ability to pay.
• Medical screening exams must make use of all the hospital’s relevant resources, for example, lab tests or CT scans.

Over the last 10 years, the most frequent EMTALA violation by hospitals was the failure to do an adequate medical screening exam.

2. Stabilize patients who have emergency medical conditions.

Failure to offer stabilizing treatment was the fourth most common EMTALA violation over the last 10 years.

3. If a hospital can’t stabilize a patient, it is required to arrange an appropriate transfer to another facility, including:

• Treatment to lessen the risks of transfer
• Getting consent from the receiving hospital to accept the transfer
• Ensuring the transfer involves qualified personnel and transportation (an ambulance)

Failure to do an appropriate transfer was the second most common way hospitals have violated EMTALA over the last 10 years.

4. Keep appropriate records on patients, including a central log of who came to the ER and what happened to them.

Failure to keep this log was the third most common EMTALA violation over the last 10 years.

5. Post signs in the ER letting people know about these rights.

6. Keep a list of on-call doctors who can see patients in case of an emergency.

7. Accept appropriate transfers from other hospitals if the receiving facility has special abilities or is able to care for an incoming patient.

8. Not punish any hospital employee who reports a violation.

9. Report any improperly transferred patients it receives within 72 hours.

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It  is claimed that there are 10 MILLION ESI given to pts every year in this country and that an estimated 5% of the ESI’s will cause Arachnoiditis       

That is described as a VERY PAINFUL and IRREVERSIBLE disease state/condition.

One of the medications that is typically uses is Depo-Medrol which is a suspension of Methylprednisone – but some physicians may be using other corticosteroids that are in the same class as Depo-Medrol.

Both the FDA and Pfizer – who manufacturers the medication – has come out and strongly recommended that this medication NOT BE USED in ESI’s. Many other countries have BANNED these medications being used in ESI’s.

Recently the FDA,  FDA Warns Against Off-Label Use of Implantable Pain Pumps

The only opiate that is approved for use in implanted pain pumps is INFUMORPH (Morphine) and often pain docs use a pharmacy compounded cocktail in the implanted pump in their pts.  BECAUSE.. it is claimed that the pain clinic can purchase the compounded product for 10%-25% of the cost of the commercial product.

The question has to be asked … why does Medicare/Medicaid and other health insurance companies pay for these product(s) and procedure(s).

What is even more questionable is that it was recently reported that Medicare was going to increase the allowable – what is paid physicians – on providing ESI’s.

I have also read statements from chronic pain pts that have indicated that their pain clinic refuse to prescribe oral opiates to pt who do not want to have ESI procedures, especially those pts who have had them in the past and they have received little/no benefit and/or benefit was very short lived, less than what would be expected. Some suggest that this may be in violation of a part of the Sherman Antitrust Act called Tying Commerce   which basically states that forcing someone to purchase something they don’t want/need in order to be able to purchase something that they want/need.

So do we have three federal agencies (FDA, DOJ, HHS) with policies in conflict.

What would happen if some pro-pain group(s) petitioned the FDA to  BAN or declare the use of these medications in these particular applications as EXPERIMENTAL. No insurance company will pay for experimental medications.

Has anyone noticed that when the DEA charges a prescriber with inappropriate (medically unnecessary) prescribing of opiates… that they are also charged with Medicare fraud ?

If the FDA won’t act, then Congress is always talking about getting rid of Medicare fraud and abuse.. maybe talking to members of Congress to get these specific medications no longer being reimbursed… may be an option.

What has the chronic pain community got to lose ?

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China agrees to make fentanyl a controlled substance after talks with US at G20 summit

https://www.cnn.com/2018/12/01/politics/fentanyl-us-china-g20-talks/index.html

(CNN)China has agreed to reclassify fentanyl as a “controlled substance,” in what the White House is calling a “wonderful humanitarian gesture” after the much-anticipated talks Saturday between US President Donald Trump and Chinese President Xi Jinping in Buenos Aires, Argentina.

In a statement, China’s Foreign Ministry said China has “decided to schedule the entire category of fentanyl-type substances as controlled substances, and start the process of revising relevant laws and regulations.”

China and the United States have “agreed to take active measures to strengthen cooperation on law enforcement and narcotics control,” including the control of fentanyl-type substances, it said.

The new designation for the synthetic opioid drug means people in China who sell fentanyl to the US “will be subject to China’s maximum penalty under the law,” according to a statement from the White House.

Trump and Xi met Saturday for dinner on the sidelines of the G20 summit in Buenos Aires.

Fentanyl’s new designation is one result from their meeting. The US also agreed to maintain the 10% tariffs on $200 billion worth of Chinese goods, instead of raising them to 25%, the White House said.

Fentanyl, an extremely powerful drug, is 50 to 100 times more potent than morphine and 30 to 50 times more potent than heroin.

What you need to know about fentanyl

According to the US Centers for Disease Control and Prevention, 5,500 people died of synthetic opioid overdoses in 2014, most of them related to fentanyl. That’s an 80% increase over the number of deaths reported in 2013. Last year, the Drug Enforcement Administration issued a national alert stating that “drug incidents and overdoses related to fentanyl are occurring at an alarming rate.” In 2013, the Drug Enforcement Administration made 942 fentanyl seizures; in 2014, it made 3,344.

In August, Trump claimed on Twitter Chinese suppliers are fueling America’s opioid crisis.

“It is outrageous that Poisonous Synthetic Heroin Fentanyl comes pouring into the U.S. Postal System from China. We can, and must, END THIS NOW! The Senate should pass the STOP ACT — and firmly STOP this poison from killing our children and destroying our country. No more delay!” the tweet said.

Yu Haibin, a senior official with China’s National Narcotics Control Commission, said in a press briefing at the time that Trump’s comments were “unacceptable” and “irresponsible.”

“The United States has no proof that most fentanyl in the country comes from China,” he said. “It’s highly irresponsible to draw such a conclusion based on some individual cases.”

Officials in Washington believe China is the primary source of fentanyl found within US borders, following a 2017 US Congressional report citing law enforcement and drug investigators.

Trump last year declared the opioid crisis a public health emergency in the United States and brought up the issue with Xi when the two leaders met in Beijing in November 2017.

CNN’s Kevin Bohn and Steven Jiang contributed to this report.

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