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America’s Opiate War: The Medical Luddites vs. People in Pain – By Robert Wilbur – Truthout – June 3, 2012

Even way back in 2012, the DEA was interfering with the medical practice of pain management.

When I published my first paper in clinical psychopharmacology in 1980 with a psychiatrist collaborator, the physician-patient relationship was still virtually sacrosanct.

But with frightening hubris, narcs from the Drug Enforcement Administration (DEA), are now muscling into the practice of medicine.

At this writing, politicians are preparing to launch what may turn into a witch hunt on the medical profession and the medical professionals at the FDA.

Specifically, the May 16, 2012, issue of Pharmalot reports that the Senate Finance Committee is cranking up to probe “an epidemic of accidental deaths and addiction resulting from the increased sale and use of powerful narcotic painkillers.” The targets are drug manufacturers, physicians and patient advocacy groups.

It’s odd that he mentions patient advocacy groups specifically, but these groups set themselves up for this by taking so much money from the pharmaceutical industry.

There are only a few small groups, like ATIP, that don’t take such funds.

The Centers for Disease Control (CDC) claims that, in 2008 alone, 15,000 people died from prescription opiate painkillers.

To get some perspective on a number like this, Truthout spoke with one of most respected forensic pathologists in the country, Michael Baden MD. Dr. Baden, formerly chief medical examiner for the City of New York

Baden made several points.

First, CDC statistics for mortality are predicated on poor data, namely death certificates. There are no uniform diagnostic standards for filling out death certificates and, indeed, the certificates themselves vary from jurisdiction to jurisdiction.

The situation is all the more dismal because,

in the US these days, only 5 percent of bodies are autopsied – the only definitive way to arrive at the cause of death.

A corollary is that, absent an autopsy, we don’t know how much drug – if any – is present in the body. Usually, Dr. Baden suggested, when the signer of the death certificate finds a bottle of an opiate, he or she then attributes the death to its contents.

What makes the CDC’s reliance on death certificates even more problematic is that the signer of the death certificate in many jurisdictions need not even be a physician: he or she can be a non-physician coroner (generally an elective office), an emergency medical technician, an undertaker or even a cop.

Dr. Baden observed that a death may be caused by several factors and, indeed, most death certificates list a line for the putative primary cause and several lines for even more putative secondary causes. This applies with particular force to opiates, because most people are not junkies; they are taking opiates for an illness and that illness may be a primary or contributory cause of death … but we’ll never know without an autopsy.

so long as cops and undertakers can play pathologist and autopsies are the exception, the certificates’ accuracy is problematic

There is one cause of death from opiates that Baden considers very important, but which you can’t identify from the CDC data: Suicide.

Even if the signatory recognizes that they have a suicide on their hands, they often do not record it to spare the feelings of the dead person’s loved ones.

So, it just goes down as an opiate death, even though many suicides are accomplished with a potpourri of opiates, sleeping pills, anxiolytics and – to wash it all down – alcohol. Dr. Baden thinks that suicide is underestimated to a significant degree.

the lethality of opiates requires examination.

One revealing recent study found that most deaths from prescription opiates occurred when the patient was also taking methadone – though CDC statistics fail to reflect drug interactions. The opiate is usually fingered as the culprit.

The other major toxic effect of opiates is respiratory depression, but this effect only occurs in much higher doses and is the cause of death by suicide.

Adding alcohol, in particular, potentiates the respiratory depression, and throwing in sleeping pills and sedatives doesn’t help. Much is being made in the press of death by accidental overdose, but it seems likely that many of these cases are suicides.

Unfortunately, people can develop tolerance to the analgesic effect of opiates, but not to its potentially lethal effect on the breathing center of the brain.

John D. Loeser’s career spans 46 years as a neurosurgeon and pain specialist, most of that time at the University of Washington (UW). Loeser wears his laurels lightly, but he is a man of firm views.

Maria A. Sullivan MD, PhD is associate professor of clinical psychiatry at Columbia University and New York State Psychiatric Institute (NYSPI). She is both a psychiatrist and a psychologist and is board certified in addiction psychiatry and in adult psychiatry and neurology. Like Dr. Loeser, she gave of her time both generously and authoritatively.

Loeser made it emphatically clear that he does not welcome the increasing “policing” of medicine by the DEA.

He believes that the proper body for regulating opiate prescribing practices is the FDA because its scientists possess the knowledge of pharmacology and medicine that DEA agents and politicians lack.

This is precisely the problem: politicians and DEA agents have no clue how opioids work, how much legitimate doses can vary, how many people have a genetic inability to metabolize opioids.well.

Dr. Loeser said that he would not sit in judgment on the dose a particular patient might need, provided the medication was prescribed appropriately. For example, many patients with cancer require substantially higher doses, or more powerful narcotics like Fentanyl.

Dr. Loeser’s criterion: “Is an opiate the best available treatment for this patient at this time?”

Feelgoods – physicians who derive their livelihood from writing prescriptions for controlled substances – are not the problem, he said – there aren’t enough of them around to make a dent in the body count, and the average person in pain probably wouldn’t know how to find one.

That is so true. Neither I nor many other legitimate pain patients know of these doctors that supposedly hand out opioids freely. Instead we’re stuck with doctors reluctant to prescribe, pain contracts, and constant suspicion.

A related and real problem, Dr. Sullivan told me, is diversion: one person gets a prescription for OxyContin, Percocet, or Vicodin and sells the pills at a profit.

Pain medicine specialists aren’t the problem either. They are highly trained, board certified specialists who work with the patient’s primary care physician or specialist (an oncologist or an orthopedist, for example) to solve tough pain problems.

Yes, they prescribe opiates, but also nonsteroidal anti-inflammatory agents, muscle relaxants, Neurontin, cortisone injections, relaxation training and some use acupuncture.

The problem, said Loeser, is the “primary care docs” who know little about pain and bought into a “huge push” from drug companies to hand out pills, most notoriously OxyContin, for chronic conditions. It is well known that many doctors learn about new drugs from drug company sales reps, not respected journals like JAMA or the New England Journal of Medicine.

So, what’s the right way? A careful history. A thorough examination and appropriate tests and radiology when indicated. An attempt to correct the cause of the pain. A trial of non-opiate pain medicine before resorting to opiates.

This is the norm for us legitimate patients. We’ve tried all the other methods of pain management but they did not work for us. Opioids do.

Dr. Loeser told Truthout that opiates are actually underutilized by physicians and hospitals for treating acute conditions with adequate doses owing to the unfounded fear of getting patients hooked. Acute means 30 days or fewer on an opiate for situations such as postoperative pain, injuries healing, awaiting an operation or lab work, dental work, and so forth. Within a time frame of 30 days, a patient should have no trouble tapering off the opiate.

And this is what hundreds of thousands of Americans do every year. They have surgery, get opioids prescribed for post-op pain, take however much they need and then stop.

Of course, these leftover pills can fall into the wrong hands, but if opioids were as addictive as they are made out to be, there would never be “leftover” pills. If there are really so many leftover pills causing all the overdoses, it proves that the vast majority of people who get prescriptions do NOT become addicted.

Dr. Sullivan said that uncontrolled pain leads to adverse outcomes, especially in elderly patients who comprise a majority of postsurgical patients.

For instance, pain-induced tachycardia (abnormally rapid heart beat) can cause a heart attack. Uncontrolled pain also increases the risk of delirium (Morrison, 2003), prolongs hospital stays and makes it difficult for the patient to resume a normal life.

Human laboratory studies have shown that administering opiates does not precipitate an addiction in patients without a history of drug abuse (Corner et. al, 2010); such folks were found to use an opiate only when they felt pain.

Dr. Loeser said, “We don’t know why, but a subgroup of chronic pain patients doesn’t respond to recognized treatment for their condition.” This is the fraction that needs opiates and Dr. Loeser thinks it is small – certainly fewer than 50 percent of chronic patients.

But as Dr. Loeser said, Big Pharma taught willing general practitioners and primary care providers that opiates were the answer to all pain symptoms. Such prescribing papers over symptoms (and complaints) and clears demanding pain patients out of the office.

Dr. Loeser readily agreed with the statement that the majority of chronic pain patients who require opiates, sometimes for years, sometimes for life, use them responsibly, without jacking up the dose and continue to experience sustained relief. So, I asked why some people became junkies; why, specifically, that very first pill is “like discovering Heaven,” a description I had encountered about a first drink in my research on alcoholism.

Dr. Loeser said that, just as there are a fraction of chronic patients, probably small, for whom therapy with opiates is appropriate, so there is another fraction, also probably small, for whom opiates are “a disaster.”

Dr. Loeser thinks the reason is genetic and pointed to the example of Native Americans, who disproportionately become disinhibited and violent on alcohol.

The anti-opiate (or pro-pain) crowd that Dr. Loeser and many of his distinguished colleagues oppose would have us believe that every patient is a potential junkie.

It simply is not so, any more than that every person who has a couple of drinks with dinner is a drunk.

In 1995, the small drug company Purdue Pharma marketed a long-acting formulation of oxycodone under the brand name OxyContin.

It came in a generous variety of strengths, and one capsule[?] would maintain a reasonably constant blood level for 24 hours.

I’m surprised the author didn’t know that OxyContin is a tablet, not a capsule.

The time-delay chemistry was poorly conceived. The capsules could be chewed up and the contents ingested – one whole day’s supply of oxycodone swimming to the brain in a single heavy hit.

And aficionados of OxyContin soon found faster, more gratifying ways of experiencing the drug: snorting the powder; rubbing it in the gums; dissolving it in water and mainlining it.

Intentional abuse did not come to light right away, but another problem with OxyContin was apparently obvious to FDA medical officers, because it is reflected in the package insert

OxyContin was approved for moderate to severe pain in chronically ill patients who required round-the-clock pain medication.

The latter stipulation is important because many patients with chronic pain have good days and bad days, in which case they might need only one or two Percocet, or perhaps even none at all

With OxyContin, on the other hand, the patient is exposed to a relentless 24-hour opiate assault. This increases the likelihood of developing tolerance and physical dependence.

This is why I never took opioids “round-the-clock” or at scheduled intervals. I believe that taking pain medication constantly is inappropriate for many pain patients who experience varying levels of pain.

By letting my opioids wear off each night I believe I developed much less tolerance than expected.

Within a few years of OxyContin’s introduction, it was becoming clear that Purdue Pharma’s spokespeople were lying in a big way about the safety of Purdue’s only big seller.

in 2007, Purdue paid a fine of $600 million and three of its top executives shelled out $24.5 million to stay out of jail.

Everybody had pleaded guilty to “misbranding,” defined as lying or making claims not approved by the FDA, as reflected in the official labeling. To cap it off, the FDA required Purdue Pharma to come up with a new, long-acting formulation that is no more vulnerable to tampering than ordinary oxycodone tablets; such a product was approved by the FDA in April 2010.

When the FDA considers whether to approve a drug for marketing, it must balance a drug’s safety against its efficacy.

The noisiest con is Sidney M. Wolfe MD, formerly director of Ralph Nader’s Health Research Group and now director of its umbrella organization, Public Citizen

Wolfe is a medical Luddite, who would weight the scales so heavily in favor of safety that we would get few effective new drugs.

He is proud to be known as the FDA’s nemesis and boasts that he killed 14 drugs. Wolfe and other activists like him seem to crave a world of perfect safety, but the reality is that the best a regulatory agency can do is predicate its decisions on the evidence in front of it

While it is perfectly proper for Wolfe to testify before the FDA as often as he wishes, it is another matter for him to testify in the House and Senate for the purpose of trying to get from the politicians what he can’t get from the FDA.

One physician who isn’t the least bit shy about his views is Andrew Kolodny.

At the mention of Kolodny’s name, Dr. Loeser laughed: “Kolodny occupies the far end of the spectrum” of the anti-opiate fringe, and he added, “He believes nobody should have opiates unless they’re about to die.” And if you want opiates from Kolodny, you’d better be dying of cancer.

Kolodny was the subject of a puff-piece interview in Pharmalot (May 16, 2012), where he betrayed an abysmal ignorance of pharmacology, and Pharmalot failed to ask for documentation of his more outré assertions, such as this one:

“There’s increasing evidence that opioids are neither safe nor effective for the majority of people with non-cancer pain.”

Kolodny seems to be afraid that even cancer patients were in danger of getting too much relief, as he told Pharmalot: “To increase use of opiates for cancer care, Purdue paid thought leaders to encourage prescribing more opioids.” Cancer pain is the most important indication for OxyContin.

Kolodny condemned the FDA for having “no teeth” because it declined to impose Draconian restrictions on opiate prescribing after hearing testimony from pain specialists and patients with chronic pain who required opiates for relief.

Jane C. Ballantyne MD, professor of anesthesiology and pain management at the University of Washington, …as well as a member of PROP, shared some of her thoughts with me in an exchange of emails

I asked her if she thought cancer was the only indication for opiates. Her reply: “Cancer only is a little too narrow, but pain should be severe and intractable (in other words, failed all attempts with non-opioid and non-medical treatments) before opioids are used.”

This is the common course for legitimate pain patients who explore every other avenue of relief before taking opioids.

I asked Dr. Ballantyne whether she thought the FDA, not the DEA or Capitol Hill, is the appropriate agency to regulate opiate prescribing. Her reply: “The FDA has not heeded early warning signs that prescription opioid abuse is becoming a public health problem in the US, so I do not agree that the FDA alone has been or can be effective.”

Ballantyne also contravened the view that opiates are being underprescribed for acute pain, the evidence notwithstanding. She insists that opiates are “grossly overutilized” and reiterates that they should only be utilized for pain that is “severe and intractable.”

This is a physician with responsibility for training future doctors in pain management.

And her PROP leader’s voice has inspired some very unhealthy comments, like this one from Original Industry Insider in the pages of Pharmalot: “Maybe if we let them go cold turkey in a basement shooting gallery and puke their guts out for three days, the addiction problem might change for the better.”

There is no doubt that opiates are addictive, but to what degree? In her email, Dr. Ballantyne wrote: “… opioids are much more addictive than alcohol, which puts opioid users at higher risk than alcohol users.”

Except for a patient who has been treated with an opiate for only a few days or a week – for something like dentistry, some types of post-op pain, injuries etc. – it is best to taper the dose down gradually at the rate of 10 percent per day.

I’m glad it’s now recognized that this speed of tapering is ridiculous. The reduction should be 10% per week or more.

Dr. Sullivan told Truthout that opiate detoxification can be accomplished on an inpatient or outpatient basis using buprenorphine, a synthetic opiate with which Dr. Sullivan has done extensive research, for just one injection daily to mitigate the withdrawal syndrome.

Dr. Sullivan notes that clonidine, a blood-pressure-lowering medication, is a useful addition to the treatment regimen. Probably the reason is that clonidine can relieve the “physical” symptoms of withdrawal, such as anxiety, tremor, palpitations, sweating and so forth

Dr. Sullivan found that naltrexone substantially increases the rates of abstinence – as much as 60 percent at six months, a figure that is much better than methadone maintenance.

This article invites several conclusions:

Narcs and politicians are not qualified to meddle in the practice of medicine because, as Dr. Loeser put it, they don’t know enough. By contrast, the medical officers at the FDA are specialists in various categories of drugs; they have the expertise to draw evidence-based conclusions from the available data. It follows that the regulation of drugs must be the province of the FDA, not the DEA or Capitol Hill

No worthwhile purpose is served with hysterical rhetoric about an “epidemic” of prescription opiate abuse because, as Dr. Baden explained, the CDC’s conclusions are predicated on dubious data. It is unquestionably true that, in recent years, there has been an upward trend in opiate prescribing and a parallel trend in deaths from these pain killers. However:

Opiates are underutilized for people with acute pain;

Opiates are inappropriately overprescribed for chronic pain, mainly by primary care providers who use these drugs as a Band-Aid to cover symptoms instead of seeking and treating the cause of the pain, although an unknown fraction of chronic patients are going to require long-term or permanent opiate therapy;

The only predictable consequence of policing and politicizing the prescribing practices of physicians will be to intimidate them, thereby depriving patients with real pain issues of the medications they need; it follows that physicians and patients must join forces and kick back hard at those would diminish the role of the FDA as the only appropriate regulatory agency for drugs and challenge the heated rhetoric, errors and misrepresentations of PROP and it members;

The overwhelming majority of patients on opiates for chronic pain use their medication responsibly. As Drs. Loeser and Sullivan attest, that unknown but small fraction of patients who get hooked from their first dose probably have a genetic deficit;

It is essential to get Big Pharma out of the lucrative racket of “educating” physicians by reps and complicit doctors.

Dr. Sullivan drew Truthout’s attention to evidence-based guidelines for the appropriate prescribing of opiates, and continuing medical education credits could be offered by medical societies to doctors who master these guidelines;

Perhaps most important, the politicians should increase the FDA’s budget, and the medical Luddites should eschew pronouncements on matters for which they evince a major paucity of knowledge.
Author: Robert Wilbur did research in biological psychiatry for many years. He also writes for popular magazines and newsletters. He is active in progressive politics, especially opposition to the Middle East wars and capital punishment, and fighting for animal rights.

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Denied medical care while detoxing, Texas woman died in a rural Nevada jail

https://www.rgj.com/story/news/2018/08/31/kelly-coltrain-death-nevada-mineral-county-jail-denied-treatment/1145643002/

Locked away in the Mineral County Jail for failing to take care of her traffic tickets, 27-year-old Kelly Coltrain asked to go to the hospital. Instead, as her condition worsened, she was handed a mop and told to clean up her own vomit. She died in her jail cell less than an hour later.

Despite being in a video-monitored cell, Mineral County Sheriff’s deputies did not recognize that Coltrain had suffered an apparent seizure and had not moved for more than six hours. When a deputy finally entered her cell and couldn’t wake her, he did not call for medical assistance or attempt to resuscitate her. Coltrain lay dead in her cell until the next morning when state officials arrived to investigate­­.

Details of Coltrain’s death 13 months ago came to light this week with the release of a 300-page report compiled by state investigators. The investigation found that Coltrain’s jailers violated multiple policies when they denied her medical care after she informed them she was dependent on drugs and suffered seizures when she went through withdrawals.

The investigators also asked the Mineral County District Attorney to consider criminal charges in the case, after finding evidence the Mineral County Sheriff’s Office may have violated state laws prohibiting inhumane treatment of prisoners and using one’s official authority for oppression.

To avoid a conflict of interest, the investigation was forwarded to Lyon County District Attorney Stephen Rye for review. Rye declined to press charges in the case.

“The review of the case, in our opinion, did not establish any willful or malicious acts by jail staff that would justify the filing of charges under the requirements of the statute,” Rye said.

Coltrain’s family feels otherwise.

On Wednesday, Coltrain’s mother, father and grandmother filed a wrongful death lawsuit, accusing the sheriff’s office of ignoring her life-threatening medical condition despite knowing that she was suffering withdrawals and had a history of seizures.

“(Jail staff) knew Kelly Coltrain had lain for days at the jail, in bed, buried beneath blankets, vomiting multiple times, refusing meals, trembling, shaking, and rarely moving,” lawyers Terri Keyser-Cooper and Kerry Doyle wrote in the lawsuit. “Defendants knew Kelly Coltrain was in medical distress.”

“Kelly Coltrain’s medical condition was treatable and her death preventable,” the lawyers wrote. “If Ms. Coltrain had received timely and appropriate medical care, she would not have died. Kelly Coltrain suffered a protracted, extensive, painful, unnecessary death as a result of defendants’ failures.”

RELATED:The Reno Gazette Journal’s investigation into jail deaths in Washoe County

‘The worst I have ever seen’

Keyser-Cooper, who has a decades-long career of successful civil rights lawsuits against Northern Nevada police agencies, said this case is “the worst I have ever seen in 33 years. I’ve never seen anything like this.”

Mineral County Sheriff Randy Adams referred questions to the county’s lawyer but did say he is in the process of updating the jail’s policies.

“Obviously it’s terribly unfortunate and it’s tragic,” Adams said. “That’s really all I can say.”

The county’s lawyer, Brett Ryman of Reno, also described Coltrain’s death as a tragedy, and said the sheriff has hired the Legal and Liability Risk Management Institute to update the jail’s policies and provide training for deputies. He declined to answer any specific questions about the investigation because of the family’s lawsuit.

“It’s just really difficult for a small rural county like this to handle what is just a massive problem,” Ryman said. “There are so many people addicted to substances who end up going through withdrawal in the jail.”

Mineral County is a tiny rural county southeast of Washoe County. Its population is just under 4,500.

Keyser-Cooper described Coltrain as a “successful student, a friendly outgoing girl, and an exceptionally talented soccer player,” who was close to her family. She developed depression and a drug addiction after a knee injury as a teenager living in Las Vegas, the lawsuit said.

RELATED: Death follows Washoe County Sheriff’s decision to award a $5.9 million no-bid contract to NaphCare

The day she was arrested

Although she was living in Texas, Coltrain had visited Reno and Lake Tahoe for a family reunion to celebrate her grandmother’s 75th birthday. 

After the celebration, Coltrain was pulled over for speeding outside Hawthorne on July 19, 2017, according to the investigation by the Nevada Division of Investigation. Because she had failed to take care of previous traffic violations in Clark County, the officer who stopped her decided to book her into the Mineral County Jail.

While being booked, Coltrain initially refused to answer questions about her medical history and next of kin. But soon after she learned she wouldn’t be able to make bail, she informed Sgt. Jim Holland that she was dependent on drugs and had a history of seizures when she went through withdrawals, according to the investigative report.

After Coltrain came forward with her medical history, Holland did not follow a jail policy that requires inmates with a history of seizures to be cleared by a doctor before being held at the jail. Nor did jail staff follow medical protocol of carefully monitoring the vitals of a person undergoing withdrawals.

In fact, the jail had no on-site medical care, relying instead on the hospital across the street to attend to inmates’ medical needs and prescriptions.

RGJ INVESTIGATES: The stories that made a difference in Northern Nevada

Deputy denied her access to hospital

About four hours after she was booked into the jail, Coltrain told the night deputy she needed to go to the hospital right away for medication. Instead of following the jail’s medical care policy, he told Coltrain she couldn’t get help unless he determined her life was at risk.

“Unfortunately, since you’re DT’ing (referring to the detoxification process), I’m not going to take you over to the hospital right now just to get your fix,” Deputy Ray Gulcynski told Coltrain, according to the investigation report. “That’s not the way detention works, unfortunately. You are incarcerated with us, so … you don’t get to go to the hospital when you want. When we feel that your life is at risk… then you will go.”

Coltrain spent the next three days in her cell, eating almost nothing and drinking a little bit of water. She spent most of her time curled in the fetal position underneath blankets.

Early on July 22, 2017, her third day in the jail, Coltrain began vomiting, trembling and “making short, convulsive type movements,” according to the investigative report. A little after 5 p.m. that day, Holland brought Coltrain dinner and water and tried to talk her into eating a little bit of food. She ate a few bites.

Holland then brought her a new set of jail clothing to replace her soiled uniform and a mop, asking her to clean the vomit from her floor, according to the investigative report. Coltrain sat still for a few minutes until Holland returned and asked her again to mop.

According to video reviewed by the Reno Gazette Journal, Coltrain then began mopping her floor while still sitting on her bed. She was trembling during the process and stopped often to rest. A few minutes later, Holland returns to point out the spots she had missed. Coltrain wipes up the spots and Holland leaves with the mop.

Holland later told an investigator that he thought it was odd Coltrain didn’t get out of bed to mop the floor.

“Sgt. Holland advised he thought Coltrain was just ‘lazy’ and that she just didn’t want to stand up to clean the floor,” the report said. “Sgt. Holland advised he just wanted the floor to be cleaned and he didn’t care how it got done, just that it got cleaned up.”

This was the last time Coltrain was seen alive.

Hours pass before deputies realize she is dead — paramedics not called

Less than an hour later, Coltrain was shown on the video lying in the fetal position when her body suddenly goes rigid and her legs straighten. While on her stomach, her face slowly rises toward the back wall and her arm stretches out and hangs off the bed. Her head lowers back onto the mattress and for the next several minutes her body appears to go through periodic convulsions.

Coltrain then stops moving entirely about 6:26 p.m. The video shows her lying still in the same position until about 12:30 a.m. when Gulcynski arrives to move her to a different cell and finds her unresponsive.

According to the investigation report, the 20-minute section of video depicting Gulcynski entering her cell was missing entirely from the files the state obtained for its investigation from the sheriff’s office. But a Reno Gazette Journal reporter found the video in files provided by Keyser-Cooper.

The video shows Gulcynski walk into the cell and nudge Coltrain’s leg with the tip of his boot. When she didn’t respond he enters the cell, looks at her face, briefly touches her arm and then quickly exits the cell.

According to the investigative report, Gulcynski notified his supervisors that Coltrain appeared dead and was cold to the touch. The video then shows him re-enter the cell and check for a pulse on Coltrain’s neck before leaving again.

The sheriff’s office then left Coltrain’s body locked in the cell until a Washoe County forensic technician arrived at 5:48 a.m. to begin the investigation.

No one on staff called for paramedics after finding Coltrain lying unresponsive and cold on her bed, according to the investigation. The lawsuit said the sheriff’s office had no policy for what to do after discovering an unresponsive inmate.

The Washoe County Medical Examiner labeled Coltrain’s death accidental, caused by “complications of drug use.” The toxicology results showed she had heroin in her system.

Investigator: Had deputies followed policy, she may not have been in danger

Gulcynski told investigators that he had periodically looked at Coltrain from the video monitor outside her cell but thought she was asleep. The sheriff’s policy requires deputies to physically check inmates under observation at least twice an hour if they are lying under blankets. That didn’t occur, according to the investigation.

Holland told investigators that Coltrain “never looked good,” but that he couldn’t “force medical attention” on inmates.

The state investigator assigned to the case, Detective Damon Earl, noted in his report that had Gulzynski and Holland adhered to some of the department policies in place, Coltrain may have not have been in as much danger.

“There were a limited number of times where Coltrain had actual contact with the staff,” Earl wrote. “This may be significant because had more contact been made with Coltrain, indicators of Kelly’s medical condition may have been observed. These indicators may have alerted staff therefore prompting medical attention to be rendered to Coltrain.”

At one point in his investigation, Earl timed his walk from the jail to the hospital across the street. It took “a little over two minutes.”

Ryman, Mineral County’s lawyer, said he couldn’t comment on the specifics of the investigation, including why no one called for emergency medical help when Coltrain was discovered unresponsive. He also wouldn’t comment on whether any disciplinary action was taken against either Gulcynski or Holland.

The lawsuit, however, said both men were disciplined but that Holland opted to retire early.

In June, the Mineral County Commission voted unanimously to buy Holland an additional year toward his service for a cost of $17,853. The buy-out allowed Holland to retire with a higher annual pension and health care benefits than if it had been denied.

District Attorney didn’t find ‘cruel, oppressive or malicious treatment’

In reviewing the case for criminal charges, Rye, the Lyon County District Attorney, said he couldn’t find evidence that the two jailers acted maliciously.

“Based on my review, they did not notice any signs warranting any medical intervention based on their training or experience,” Rye said. “They were provided information related to her, and it appeared to me that was taken into account in her housing and monitoring. The officers did not ignore information provided to them. And, based on the reports by NDI, it did not appear that they exhibited any cruel, oppressive or malicious treatment.”

Keyser-Cooper, however, believes policies and training are less than adequate at the Mineral County Jail. The lawsuit by Coltrain’s family seeks not only compensation for their loss, but also for Sheriff Adams to improve the conditions at the jail. Keyser-Cooper said the family won’t settle their lawsuit without that.

Ryman said such changes are already underway, but within the small county’s limited resources.

“The policies of the jail in regard to people who have addictions and are undergoing withdrawals have the full attention of the sheriff and the county, despite the fact of the lawsuit,” Ryman said. “Even outside the lawsuit, the sheriff will go forward with this kind of training. Everything will be done to the best ability of this small county. They don’t have the resources of someone like Washoe County.”

Read the Reno Gazette Journal’s investigation into jail deaths in Washoe County:

 

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DEA Proposes Reduction in US Opioid Manufacturing Quotes

https://www.natlawreview.com/article/dea-proposes-reduction-us-opioid-manufacturing-quotes?

Yesterday, in a joint statement by the US Department of Justice and the US Drug Enforcement Administration (DEA), the government proposed a reduction in the Aggregate Production Quotas (APQ) for certain controlled substances that may be manufactured in the United States next year. The government indicated that its intent was to “cut nationwide opioid prescription fills by one-third within three years.” The proposal decreases manufacturing quotas for six opioids (oxycodone, hydrocodone, oxymorphone, hydromorphone, morphine and fentanyl) by an average of 10 percent, as compared to 2018 quotas.

As the government noted, the action marks the third straight year of proposed reductions. Although the reduction was not formally tied to diversion statistics, the government stated that the reduction was consistent with its announcement earlier this year of a rule amending DEA’s regulations to improve the agency’s ability to consider the likelihood of whether a drug can be diverted for abuse when it sets annual opioid production limits.  

The APQ is designed to control the quantities of basic ingredients needed for the manufacture of controlled substances. The APQ is the first step in determining allocations made available for individual US manufacturers to produce controlled substances. Once the APQ is set, the DEA allocates individual manufacturing and procurement quotas to those manufacturers that apply for them. The DEA noted that these individual manufacturer allocations may be subject to further revision during the course of a year based upon a number of factors, including increased or decreased sales or exports, new manufacturers entering the market, new product development or product recalls.

This is where the DEA “found” their opinion(s) on abuse

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I have the photo.This is from a pt from WA.  ”Last night after a bad bicycle accident with lacerations down to the bone they gave me two Tylenol in the ER as I was screaming through my clenched teeth.
“We can’t give you anything else.” Why? Because doctors are afraid of losing their licenses if they prescribe pain medication”. This is happening all over the country folks. You better get up and do something or you and your children will be next.************

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Prescription Drug Monitoring Program May Not Cut Opioid Use

https://www.clinicaladvisor.com/pain-information-center/prescription-drug-monitoring-program-may-not-cut-opioid-use/article/791479/

HealthDay News — Implementation of a mandatory prescription drug monitoring program (PDMP) does not necessarily reduce the overall rate of opioid prescribing or the mean number of pills prescribed for patients undergoing general surgical procedures, according to a study published online Aug. 22 in JAMA Surgery.

Ryland S. Stucke, MD, from Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and colleagues conducted a prospective observational cohort study at an academic hospital among 1057 patients undergoing representative elective general surgical procedures from July 1, 2016, to June 30, 2017. Beginning Jan. 1, 2017, new state legislation mandated the use of a PDMP and opioid-risk assessment tool for all patients receiving an outpatient opioid prescription.

The researchers found that there was no significant reduction in the percentage of patients prescribed opioids after surgery before versus after the new requirements (80 vs 77%; P = 0.29). In the six months before the mandatory PDMP requirement, the mean number of opioid pills prescribed decreased from 30.8 to 24 (22.1%); in the 6 months after the legislation, the decrease was less, from 22.8 to 21.9 pills (3.9%). No high-risk patients who subsequently were not prescribed opioids were identified by the new requirements.

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https://www.clinicaladvisor.com/pain-information-center/odds-of-death-up-with-exposure-to-pregabalin-opioids/article/789877/

HealthDay News &,dash; Concomitant exposure to pregabalin and opioids is associated with increased odds of opioid-related death, according to a research letter published online Aug. 21 in the Annals of Internal Medicine.

Tara Gomes, Ph.D., from the University of Toronto, and colleagues conducted a population-based nested case-control study and identified a cohort of persons aged 15 to 105 years who received publicly funded opioid prescriptions between Aug. 1, 1997, and Dec. 31, 2016. Case patients (1,417), defined as those who died of an opioid-related cause, were matched with up to four controls based on age, sex, index year, history of chronic kidney disease, and Charlson comorbidity index (5,097 participants).

The researchers found that, compared with opioid exposure alone, concomitant exposure to pregabalin in the preceding 120 days correlated with significantly elevated odds of opioid-related deaths (adjusted odds ratio, 1.68). Results were consistent in sensitivity analyses assessing pregabalin use overlapping the index date and after matching on prior use of central nervous system depressants (odds ratios, 1.81 and 2.00, respectively). A high dose of pregabalin correlated with increased odds of opioid-related death compared to no pregabalin exposure in the dose-response analysis (adjusted odds ratio, 2.51), while the odds of opioid-related death were lower but still significantly elevated with a low or moderate dose of pregabalin (adjusted odds ratio, 1.52).

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These pharmacies topped J.D. Power’s 2018 survey

https://www.drugstorenews.com/pharmacy/these-pharmacies-topped-j-d-powers-2018-survey/

The pharmacy industry continues to provide superior levels of customer satisfaction in the brick-and-mortar and mail-order segments, according to the J.D. Power 2018 U.S. Pharmacy Study, released Tuesday. Health-and-wellness services available in brick-and-mortar pharmacies and the timeliness of delivery for mail order pharmacies are among the key factors driving customer satisfaction.

Good Neighbor Pharmacy ranked highest overall among brick-and-mortar chain drug stores, with a score of 903. Health Mart (890) ranked second and Rite Aid Pharmacy ranked third (846). Sam’s Club ranked highest overall among brick-and-mortar mass merchandiser pharmacies, with a score of 892. Costco (860) ranks second and CVS/pharmacy inside Target (859) ranks third. Among brick-and-mortar supermarket pharmacies, Wegmans ranked highest overall, with a score of 906. H-E-B (897) ranked second and Publix (891) ranked third.

Humana Pharmacy ranked highest overall in mail order with a score of 885. Kaiser Permanente Pharmacy (866) ranks second and Express Scripts (862) ranks third.

The 2018 study is based on responses from 10,749 pharmacy customers who filled a prescription during the three months prior to the survey period of May-June 2018.

“The retail pharmacy business has been in the spotlight ever since Amazon announced in June 2018 that it’s getting into the space,” J.D. Power senior director and healthcare practice leader Greg Truex, said, in a press statement. “Amazon, or any other organization looking to disrupt the $100 billion U.S. mail order pharmacy market, will have their work cut out for them. Legacy pharmacy players have invested heavily in delivering superior service, while brick-and-mortar pharmacies are starting to reap significant customer satisfaction gains from retail-style clinics offering health and wellness services.”

The study also found the following:

•  The average customer satisfaction score for brick-and-mortar pharmacies was 847 on a 1,000-point scale; mail order was 859, which is favorable when compared to h other high-scoring industries evaluated by J.D. Power, such as direct banks (863), property and casualty insurance companies (860) and full-service investment advisors (839). Among the different pharmacy segments, supermarkets have the highest levels of overall satisfaction (863).
• Among brick-and-mortar pharmacies, the key driver of overall customer satisfaction is the availability of health and wellness services. Availability of these services is associated with a 66-point improvement in overall satisfaction. Such services are currently present in 86% of chain drug stores, 83% of supermarket pharmacies and 75% of mass merchandiser pharmacies.
• Among mail-order pharmacies, the key driver of overall customer satisfaction is having a prescription ready/delivered when promised. Delivering prescriptions on time is associated with a 78-point increase in overall customer satisfaction. Customers also evaluate the speed of delivery, adding 42 points to overall satisfaction scores when prescriptions are received within five days of completing an order.
• •Some of the most significant drivers of customer satisfaction in all pharmacy segments include friendly, engaging service. Among brick-and-mortar pharmacies, the second-most effective driver of overall satisfaction is “non-pharmacist staff greeted you in a friendly manner,” which is associated with a 64-point increase in customer satisfaction. Even in the mail-order segment, a “thank you” from non-pharmacist staff is associated with a 17-point increase in satisfaction.

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