Place opioid blame where it belongs

https://www.postandcourier.com/opinion/commentary/place-opioid-blame-where-it-belongs/article_0e924542-9ca1-11e8-88e3-6fd45e5a5c25.html

The physicians of the Charleston County Medical Society welcome the attention brought to the rising death rate from opioid overdoses. Concern over the loss of life and impact on our communities has reached the tipping point where action is needed and being demanded. Legislators have answered in kind — over 60 bills have been introduced at the federal level, including some sponsored by our own Sen. Tim Scott. In South Carolina, the governor recently signed nine bills into law with one of the stated goals of the Opioid Emergency Response Team being to “bring down the opioid prescription rate,” as reported in this newspaper.

The liberalized medical prescription of painkillers as mandated in the late 1990s by the independent Joint Commission and federal Centers for Medicare and Medicaid Services put many opioids into circulation, which increased the opportunities for misuse and abuse. Around 2010, law enforcement’s focus on unscrupulous “pill mills” and the bad doctors who ran them marked the peak in number of prescriptions written. Since then, legislation imposing limits on prescriptions and prescriber monitoring programs and sanctions have contributed to a decrease in number of prescriptions written for medical use by nearly 30 percent, with a decrease in 2017 alone of over 12 percent. Legal medical opioid production quotas have been cut by 45 percent by the federal government. Yet, the death toll from all opioids — over 600 last year in South Carolina — continues to climb.

Contrary to the narrative that the current death-by-overdose crisis is the result of doctors over prescribing opioids to our patients in pain are the facts. There is no correlation between the number of prescriptions written and a state’s death rate by opioid overdose. Although the District of Columbia had the lowest prescription rate in the nation in 2016 it had the fourth-highest death rate by overdose; Alabama, with the highest prescription rate had an average death rate. In 2016, just fewer than 5 million opioid prescriptions were filled in South Carolina — about 89 opioid prescriptions per 100 persons compared to the national rate of 70 opioid prescriptions per 100 persons — and the death rate due to opioid overdose was under the national average. Why, then, are so many people dying?

As pharmaceutical grade medical opioids became harder to obtain due to regulatory efforts, sales on the “street” and “dark web” spiked. Predictably, as with any prohibited substance, an alternative market materialized to meet the demand. In this black market, however, the drugs are far more dangerous and of dubious composition. Fentanyl and other synthetic opioids tainting fake prescription tablets, with potencies hundreds to tens of thousands of times more powerful than morphine, along with heroin, are being taken by unsuspecting people who then accidentally die. Importantly, the vast majority of those dying are not those for whom the medicine was legitimately prescribed — it is not our original pain patient who typically goes on to use and then die from illicit drugs. They are her friends and relatives who steal the pills or to whom they are being diverted and who statistically are already more likely to be misusing alcohol, cocaine and other drugs. In fact, most “opioid deaths” involve a combination of several drugs and alcohol.

The overdose rate for medically prescribed opioids for acute pain (such as kidney stones or surgery) is less than 1 percent and around 8 percent for long-term, chronic non-cancer pain management in recent very large studies. The vast majority of chronic pain patients use opioid therapy successfully to be able to function in life. It is evident from many sources that restricting prescriptions does not lower overdose death rates but merely pushes non-medical users to more dangerous drugs. Notwithstanding the evidence, our patients, who are being arbitrarily cut off or having doses limited to insufficient levels for their acute and chronic pain in response to these policies will, literally, suffer.

To be crystal clear, one overdose is a tragedy. However, pinning the blame on legitimate prescriptions for opioids is not evidence based. As doctors, we wholeheartedly support and will participate in professional and public educational efforts, medical alternative therapies for pain, harm reduction efforts and treatment of addiction without stigma or prejudice. However, we believe that the blunt, broad tool of restrictive legislation will not cure the death rate by opioid overdose and is fraught with unintended consequences for our patients. The right medication, in the right dose, for the right duration, for a given condition in an individual patient can only be resolved by the finesse of the doctor-patient relationship.

Marcelo Hochman, M.D., is chairman of the Legislative Committee and president-elect of the Charleston County Medical Society. William Simpson, M.D., is chairman of the Public Health Committee/Opioid Task Force.

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Medicare Finalizes Opioid Restriction Plan That Will Massively Impact Pain Patients

https://www.thefix.com/medicare-finalizes-opioid-restriction-plan-will-massively-impact-pain-patients

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Now Seriously?? So I’m at Walmart buying a bag of dog food. While in the check-out line, a woman behind me asked if I had a dog. Why else would I be buying dog food, RIGHT???
So on impulse I told her that no, I didn’t have a dog. “I’m starting the dog food diet again. I probably shouldn’t because I ended up in the hospital last time. I lost 50 pounds before I woke up in intensive care with tubes coming out of most of my orifices and IVs in both arms.”
I told her that it was essentially a perfect diet. “All you do is load your pockets with food nuggets and simply eat one or two every time you feel hungry. The food is nutritionally complete so it works well, and I am going to try it again.” (I should add that practically everyone in line was now enthralled with my story.)
Horrified, this chick asked if I ended up in ICU because the dog food poisoned me. I told her, “no, I stepped off a curb to sniff a poodle’s ass and a car hit me.” I thought the guy behind her was going to have a heart attack he was laughing so hard.
Now that you’ve read this I have to confess, I copied it. Now copy and share. Make someone else laugh.

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Down The Rabbit Hole

By: Suzanne Stewart

(8-11-18)

I want to inform the pain community about my situation because this is happening to many chronic pain patients. I’ve been a voice in the pain community and now I too, am going “down the rabbit hole”! Before I become possibly incapacitated; I want you to know what is happening. For those who believe that we should “get beyond the pill bottle”; I say, unless or until you are in my shoes and live with my experiences, stop saying silly things like “pain acceptance”, will help. It cannot help all of my pain conditions combined. Stop acting like you are better, mightier or stronger than me because you might feel better from “grounding” (which is in essence, touching the earth with your feet, being “one with the ground/nature”, to make your pain lessen or disappear). The bottom of my feet are covered with open sores due to the stage of CRPS that I live with. This has become insane, while there are individual cases in which opioids are the preferred treatment and they do continue to reduce our pain.

*A bit of history if you want it: I won’t start at the very beginning because that would be much too long. I will tell you that I’ve been on SSDI since 1999 and initially for PTSD (*they said that I was the “worst case of childhood trauma/abuse they’d seen in 36 years) and kidney failure. Then I was hit by a car that ran through a red light. One minute my husband & I were sipping lemonade at an art fair.  The next minute, (as we travelled through a green light to have dinner afterwards) he was really bruised & shaken and I was unconscious & strapped to a back board, on route to the hospital. That experience is a story for another day. The entire auto insurance bullying and fear mongering was another traumatic debacle. These experiences have continued, one after another; which brings me to today and this article. 

After our accident in 2002 and upon being discharged from the hospital; I was sent to doctor after doctor. I was also sent to TBI rehabilitation, PT/OT and also to Tri-County pain clinic in MI. I was totally new at all of this & it was my first experience with this type of physical pain. Although, I have had 2 C-sections and I’ve lived through childhood, ex-spousal & other abuse throughout my entire life. At the pain clinic, I received various epidural nerve blocks, trigger point, cortisone and other injections. I also saw a Pain Psychologist, did Biofeedback and did many other types of therapies. The Pain Psychologist wrote in his report, by the way, that I “do not fit the profile for an addictive personality.” He attached me to an EMG type of machine where he can “see” your pain spiking via a red line going upward. Mine went off the charts. This was prior to my diagnosis’ of: systemic CRPS, EDS-4/vascular (aka Polyneuropathy in Collagen Vascular Disease), R.A., Dysatuonomia/POTs, Gastroparesis, S.I.B.O., Chiari and more. At that time though, I was diagnosed after the auto accident with: many physical injuries and a TBI. I went through 8 surgeries, 2 screws in my left shoulder, metal in my jaw, 2 AFO’s, prisms in my glasses, 2 hearing aids, a dual chamber pacemaker and a hospital bed in my home. I have a walker, loft-strand crutches, wheelchair, motorized scooter, leg braces and also knee, neck, hand and shoulder type of braces.

After going through all of the “hoops” at the pain clinic, I was found not to be a candidate for an SCS (spinal cord stimulator) nor a pain pump (intrathecal). I was diagnosed with CVID or “Combined Immune Deficiency” disease. They informed me that I would be sent back to my primary dr. because they could not give me the medication that I needed. In 2005, they were already saying that they could not prescribe pain medications (which they felt I needed) because they had to “stay under the radar of the DEA”. I went back to my PCP and for the next 10 years he prescribed pain medications.  Until one day in December of 2014, I arrived at my PCP’s office and was told that it was his last day working there. I received no other information and I was terrified because I did not know where to go or what to do. Dr. Pete Bullach, Jr., MD, promised me that he would personally make a call to my former pain clinic and Dr. Dennis Dobritt, my former pain physician. He also promised me that my treatment would remain the same under his partner. I returned the next month to see his partner and was teased, put down, called names and told that “all of the other dr’s patients were “drug addicts”, “drug seekers” and unworthy people seeking pain medications. He promised to see me for a couple of months because he had known me “to be a good person” since my children were small. But over the next 6 months I had to put up with derogatory remarks.

I sought out a pain physician and found one near my home. He told me that if I could take myself off of the medication that had been prescribed to me since 2005, that he would “accept me as his patient”.  I was very ill for about 11 days and for up to 6 months, I was not feeling well aside from the pain issues. But I got through it and would not ever want my worst enemy to go through that experience. I did it with my loving husband by my side because I was not addicted to it. My mind did not care at all, but my body was dependent. When that ordeal was over, I saw my current pain dr; the one I still see today. Things had been going well and I have had some semblance of a life. He had told me that I was a “complicated patient” and that I did not have to worry about my medication being stopped.

For several days prior to these appointments, I became very apprehensive, nervous and had many of the PTSD symptoms recurring monthly. Then his attitude towards me changed from a mutual respect to him being the “Wizard with a magic wand” and Me being a peasant “needing his magic”. Thats the only metaphor I can come up with. It was bazaar. I had a routine urine drug screen test in April 2018 and he knew before I left his office that something was not “right” with it, but he failed to inform me prior to leaving. At my next appointment he informed me that I had had a positive urine test and so he sent it into a lab for more testing. It came back as a “false positive” because of the migraine medication that HE KNEW WAS PRESCRIBED to me for many years. I take very little, but he knew it was in my records; he knows that I take it.  In the end, we got stuck with a $265.00 bill for testing that I did not agree to pay for. We got stuck with this large bill for something that I did not do and would never have done. It was his mistake, not mine that he forgot the medications that I am taking and that it can show up as something else, as he explained later.

He has had an “edge” to his treatment of me since that date. I am literally ill prior to each monthly appointment. Nothing changes in 30 days anyways? Why in the world do we need to go so often? This is ridiculous.  Just as a person with diplopia or myopia needs glasses; just as a diabetic needs insulin and a depressed person needs anti-depressants; I am a chronic intractable pain patient and I need pain medications.  I’ve never done anything wrong as far as I always pick up my meds on time, I’m never late for my appointments and I’ve never been a “no-show”. But I showed up on July 9th, 2018; and was suddenly without explanation, cut down to 75% of my LA/ER pain medication. He was going to stop it abruptly that day, but I did not get hysterical. I reasoned with him, adult to adult. I reminded him of my prior heart attack, the CVA (stroke) and my complicated medical history with multiple co-morbidities. He agreed reluctantly to taper me a bit. He informed me that he was doing this to get me “psychologically ready” and that next month I would get zero.  I’m not “Psychologically addicted” so that made no sense at all, but I went with it for my own comfort and safety.  He went on to tell me that suddenly the patch is  now “only for cancer patients”, which he does not treat. He also told me that I was “not heavy enough” for the patch and “I was probably only really getting 30% of the medication”. I did not say a word as I was prescribed down from 100 mcg per hour, every 48 hours (due to hyper metabolizing), to 75 mcg every 72 hours. So not only 25% less medication, but now being stretched out a full 24 hours longer each patch. The first few days were difficult as I had a few withdrawal symptoms. But the rest of the month, I’ve had increased pain, exacerbation of my CRPS, and fatigue. Also, every 3rd day I was in bed, very ill. We all know that for especially those of us who hyper-metabolize (due to the types of pain illnesses that we have), the patch never works on the 3rd day!  

I have a loving, supportive husband and my support “team” online which consists of a few people who have been there for me throughout this ordeal. I had websites, stories and ideas sent, all in an effort to help me reason with my pain dr. On 8-10-18, I showed up well prepared.  I had with me, the 2013 FDA’s response to Andrew Kolodny, when he wanted Fentanyl labelling changed for non-cancer pain. They told him this, in their 2013 letter (Docket No. FDA-2012-P-0818):  “It is FDA’s view that a patient without cancer, like a patient with cancer, may suffer from chronic pain, and PROP has not provided scientific support for why labeling should recommend different treatment for such patients.  In addition, FDA knows of no physiological or pharmacological basis upon which to differentiate the treatment of chronic pain in a cancer setting or patient from the treatment of chronic pain in the absence of cancer, and comments to the Petition docket reflect similar concerns.  FDA therefore declines to make a distinction between cancer and non-cancer chronic pain in opioid labeling”. My dr responded that “this was not about Fentanyl” and that I am educated and should be able to find out about this?

Next, I brought to his attention, a letter that I received a copy of, from a good friend of mine on LinkedIn. He had written to the CDC and asked about the horrific state of affairs within the chronic pain community. We covered his name and I showed this to my dr as well. This letter, which is directly from the CDC and dated 4-8-18, states these things:

• chronic pain patients deserve safe and effective pain management

• physicians should continue to use their clinical judgment and base their treatment on what they know about their patients. That includes the use of opioids if they are determined to be the best course of treatment.

• The Guideline does not support involuntary tapering. 

• Obtaining patient buy-in before tapering is critical to successful dose reduction.

• The Guideline is not a rule, regulation , or law.  

• The Guideline is not intended to deny access to opioid pain medication as an option for. pain management.

• The Guideline is a set of voluntary recommendations intended to guide primary care providers as they work in consultation with their patients to address chronic pain.

• The Guidelines are not intended to take away physician discretion and decision-making.  

• Specifically, the Guideline includes a recommendation to taper or reduce dosage only when patient harm outweighs patient benefit of opioid therapy.

In the end, none of the information that I presented, made any difference to my pain dr.. He just kept repeating “the guidelines, the guidelines, the guidelines”. He told me that in all reality, I was not worth saving, because if I look at his waiting room, he has all of those other people to serve, who also live with pain. If he helps me, he risks losing his practice and then he would not be able to help all of them. He informed me that “everyone is looking at him the same way” and they are also “pleading with him” for their medications.  I told him that he’s told me that I am “different” and that I am a “very complicated case with multiple co-morbidities”.  I told him that I researched Michigan Law and that there are no changes in the care or plans for chronic pain, only acute pain. None of this mattered because he just looked at me, after I showed him the letter from my G.I. dr.. A letter written by him on my behalf, states that “Suzanne has been stable while she received the fentanyl patch”. It goes on to say that I have “RSD and severe Gastroparesis and this could “exacerbate the illness of a patient who was difficult to stabilize” due to Q-T prolongation, her allergies and intolerance for oral medications”. He said that “he strongly recommends that my pain management not be altered unless there is a strong medical reason.”

My pain dr looked at me and said “This is bullshit! His license is not any better than mine! If he wants you to have the fentanyl patch then let him prescribe it for you. You’re also welcome to find another dr and get a 2nd opinion. I won’t be upset if you do that, although Im not kicking you out or anything.” He repeated that “the CDC guidelines are specific for fentanyl” and there was no way in hell I was ever getting that from him ever again, an neither is anyone else; no matter what! He pretty much told me if there was an exception, I would be it, but there are no exceptions. He repeated to me that I am educated, and have access to the internet. If I do my research, I will know that what he’s saying is true. I have done a ton of research and I know that what he’s saying is not true. He is violating his Hippocratic oath “to do no harm”. Many other physicians are also doing this instead of defending the fragile people who need them during this opioid hysteria

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https://youtu.be/WTKfFeg11ng

This is the first in a series depending on the response this one receives. If people do these steps and are interested in the addresses needed to serve subpoenas on the VA and DOJ, I’ll make part II. In the second part, I will also include the language needed to make your case(s) the strongest possible by eliminating what the defense attorneys can use in their motions to dismiss. Together, we will destroy these policies of DENY till DEAD. Thank you, take care and may God bless you in all your endeavors to the right the wrongs being done to veterans each day we are silent. SF-95 CLAIM FOR DAMAGE, INJURY, OR DEATH https://www.va.gov/OGC/docs/SF-95.pdf

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Compensating The Spouse and Family of The Injured: Loss of Consortium Claims

http://www.alllaw.com/articles/nolo/personal-injury/compensation-spouse-family-loss-consortium-claim.html

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UPDATE: Hagerstown police sergeant who faced drug charges dies by suicide

https://www.heraldmailmedia.com/news/local/update-hagerstown-police-sergeant-who-faced-drug-charges-dies-by/article_6f199e52-9c0f-11e8-87f2-a740ab07e8ed.html

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Suit: Woman killed herself after Olathe doctor got her hooked on opioids, cut her off

https://www.kansascity.com/news/business/health-care/article216457440.html

Some time around Jan. 19, Jacquelyn Spicer sent one last email to her Olathe doctor, the man who had treated her back pain with opioids for a decade before he suddenly stopped, according to court documents.

Then she killed herself.

In a lawsuit filed Thursday in Johnson County court, Spicer’s family accuses Douglas Brooks of getting her hooked on pain medicine and then leaving her with no way to get off it safely after the Kansas medical board ordered him to stop treating chronic pain patients because of his dangerous prescribing patterns.

Brooks didn’t respond to a phone message left Friday at his Olathe clinic, Brooks Family Care. An attorney who represented him before the Kansas medical board didn’t either.

The order issued by the Kansas Board of Healing Arts in October stated that Brooks, a primary care doctor, was supposed to refer all of his chronic pain patients to specialists “without abandoning the patient in need of care.”

But according to the lawsuit, Brooks didn’t do that for Spicer.

Instead, he allegedly cut her off cold turkey, and ignored her requests for a referral to a methadone clinic or other provider who could help with withdrawal symptoms. The lawsuit says Spicer warned him that she was very concerned about withdrawal and contemplating suicide.

“I have had several patients get off high doses very quickly without issues so don’t predetermine your outcome,” Brooks responded on Jan. 13, according to the suit. “It won’t be as bad as you can imagine.”

About six days later, after sending Brooks a final email, Spicer committed suicide.

According to his website, Brooks was the chairman of the department of obstetrics and pediatrics at Olathe Medical Center from 2004 to 2006, before starting a primary care practice.

The suit brought by Spicer’s family says she started seeing Brooks in 2007. From then until the end of 2017 he prescribed her between 240 and 450 tablets of 60-milligram morphine sulfate every month.

The family’s lawyers wrote that Spicer showed signs of opioid addiction and, at one point in 2016, told Brooks she wanted to get off the painkillers. But he didn’t refer her to an addiction specialist and kept prescribing the morphine.

According to the suit, the staff at Brooks’ clinic called him “The Candy Man” because of his “history of freely prescribing addictive controlled medications.”

Last year the Kansas medical board said that an investigation revealed Brooks was negligent or grossly negligent in his treatment of five chronic pain patients.

“He improperly and inappropriately prescribed and refilled excessive doses of opioid/controlled medications, failed to properly monitor the patients’ adherence to treatment, failed to address the red flags for opioid/controlled medications abuse, failed to properly treat/modify his treatment plan, failed to refer to appropriate specialists, failed to address a patient’s presenting illness and failed to properly document within the patients’ medical record(s),” the board’s attorney wrote.

The board ordered Brooks to hand off his chronic pain patients to specialists, submit monthly reports of his narcotic prescribing for a year, complete continuing education courses on proper prescribing and medical record-keeping and pay some of the costs the board incurred in hearing his case.

Brooks’ current clinic advertises itself as a direct primary care practice, a model in which the medical provider doesn’t take insurance but instead charges patients directly.

Unlike some other direct primary care practices, though, Brooks’ website says that his patients are bound to 12-month contracts, rather than being able to opt out of membership on a monthly basis.

According to the lawsuit, Brooks’ patients were charged by the minute. That’s also different from most direct primary care practices, which charge a flat monthly rate for unlimited office visits.

The suit also names Price Chopper Pharmacy as a defendant, alleging that staff at the Price Chopper at 2101 E. Santa Fe St. in Olathe was negligent in continuing to fill and refill Spicer’s prescriptions without warning her of the risks of addiction or notifying authorities about the “excessive opioid/controlled medications” Brooks was prescribing her.

Staff at that Price Chopper pharmacy declined to comment, citing medical privacy laws.

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