“The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped.” – Hubert Humphrey
passionate pachyderms
Pharmacist Steve steve@steveariens.com 502.938.2414
“The guideline is intended to ensure that clinicians and patients consider safer and more effective treatment, improve patient outcomes such as reduced pain and improved function.”
“Clinicians should consider the circumstances and unique needs of each patient when providing care.”
“Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient’s clinical situation, functioning, and life context.”
“This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.”
We all know that subjective disease are covered under The Americans with Disability Act and Civil Rights Act and discriminating against person in their protect class is consider a civil right violation.
We all know that the majority of the studies that the CDC used to come to the opiate dosing guidelines were rated “3′ or “4”… where “1” = good/excellent, “4” = poor/crap.
We all know that dosing for all disease states – except for subjective diseases – is based on adequate therapies that will return the diagnostic lab values to as close to acceptable values as clinically possible without inducing other adverse side effects. With subjective disease the only therapeutic outcomes can be based on input from the pt.
We all know that healthcare professionals will not use – or depend upon – testing equipment or any means of testing that will produce inconsistent results.
We all know that <1% of chronic pain pts treated with opiates will become addicted.
It would appear by this letter that the DOL has determined that does above 90 MME/day is a “concerning level of medication” and that will be working on “… curtailing (all) opiate usage …”
When it comes to prescription drugs, an error at the pharmacy can put a patient’s health at risk.
The Troubleshooters have uncovered hundreds of prescription error complaints filed with the Department of Consumer Protection over the last two years. Some mistakes were so severe that the patients received the wrong drug or an incorrect dose.
Lauren Kagan, of Avon, was prescribed a medication that was supposed to help calm her nerves during a medical procedure, but she says what she received from the pharmacy put her life in danger.
“A trip to the ER would have been definite, for sure,” Kagan said. “But it was not definite that I would have survived.”
Kagan was scheduled to have an MRI, but she can become claustrophobic. She was nervous about getting body scans in such a confined space, so she says her doctor prescribed an anti-anxiety medicine. The recommendation was to take one to two of the pills. Shortly after she had the MRI, Kagan says the medical staffers became concerned about why she was suddenly becoming so groggy and confused.
“They were just curious to know how many of the pills I had ended up taking,” Kagan said.
She said she took the minimum dose — one pill. That decision may have saved her life.
“The doctor had meant for it to be a quarter of a milligram pill, but the pharmacist prescribed a two-milligram dosage,” Kagan said.
Kagan says her husband had to keep her from falling asleep. Taking the recommended two pills would’ve been sixteen times stronger than the dosage she was supposed to be getting.
“I feel like there should be no such thing as a mistake with prescriptions because life or death is on the line,” she said.
Between 200 and 300 prescription error complaints are filed with the Department of Consumer Protection per year, according to state data obtained by the Troubleshooters. In cases where people complained about getting the wrong medications, DCP data shows that nearly 78 percent of complaints were found to be valid. These patients were indeed given an incorrect prescription.
“It could be really simple but it could also be something very severe,” said Lora Rae Anderson, Director of Communications for the Department of Consumer Protection.
Searching through two years of data from the Drug Control Division of DCP, the NBC Connecticut Troubleshooters identified several complaints including:
A woman in Enfield who had foot surgery who said she was prescribed 10-milligram opioid pills for pain, but received 80-milligram pills instead.
A West Hartford patient who was supposed to get a prescription for an over-active thyroid, but said she received a medication for Alzheimer’s.
An elderly man in New Haven who said he was prescribed what was supposed to be an anti-depressant but found out that, for two weeks, he was really taking a blood thinner.
A man in Hartford who said he was prescribed an antibiotic but ended up with medication to treat seizures.
“If you’re talking about 50 milligram instead of 15 in say, an infant, that can be really very serious,” Anderson said.
In most cases, when a prescription error complaint is substantiated, the pharmacist will pay a civil penalty to the state to avoid potentially having his or her license revoked. Those fines could be hundreds or even thousands of dollars.
“If there is a routine problem, if the issue is really severe, the long and short is that the fine gets bigger and their license could be at stake,” Anderson said.
Since her medication scare, Kagan said she has learned to follow up by taking a number of steps, including to report a problem not just to the pharmacy, but also to DCP. She said she now double-checks prescriptions – both the labels and the pills.
“We take for granted what’s written on the label because we assume that’s what the doctor has wanted for us,” Kagan said.
The Department of Consumer Protection offers tips to protect yourself against medication errors:
Open the bag at the counter. Check to be sure that you’ve been given is what you’ve actually been prescribed.
Don’t sign too quickly. The agreement you sign acknowledges that you’ve gotten the information you need. Don’t sign it without checking first.
Read the label carefully. Read every word. Check the name of the drug and directions for use. If the directions are unclear, ask the pharmacist to explain them. If the name on the label isn’t the name of your doctor, notify the pharmacist.
Look at the drug itself. If it’s a refill, does it look the same as the previous prescription? Is it the same shape and color? If not, ask the pharmacist.
Ask for printed information sheets. Ask the pharmacist if you need any additional counseling on the medication.
If you have issues with your prescription, complaints can be sent to DCP.DrugControl@ct.gov.
The various state pharmacy practice acts were created in a era when all pharmacies were owner/operator… in fact many of the earliest days of pharmacy, the local physician also served as the local pharmacist.
The “chain pharmacy” concept mostly evolved starting in the early 20th century. When I graduated from Butler University in 1970 there was more independent pharmacies in Indianapolis/Marion county than the ENTIRE STATE of Indiana has today. Back then there was a chain “Hooks Drugs” that was the TENTH LARGEST chain pharmacy in the country – with 243 stores – all WITHIN the state of Indiana, and there was about 75% of all pharmacies – in the country – were independents.
Today, abt 65% -75% of all community pharmacies are designated at “chain pharmacies” and there is two chains (CVS & Walgreens) have abt 10,000 chain store outlets – EACH.. with a total of community pharmacies being in the 65,000 area.
Several years ago Kevin McCoy published in the USA TODAYChains’ ties run deep on pharmacy boards showing that the vast majority of the Boards of Pharmacies are dominated by chain pharmacy employees.
When the various state practice acts were law, the typical pharmacy was owned/operated by a pharmacist and thus the law focused on a “Pharmacist in Charge”… the person who was responsible to the board of pharmacy ( BOP) for the legal operation of the pharmacy.
Today, we have a situation where the ownership of the pharmacy – a minority part of the time – is the pharmacist in charge (PIC)… since the vast majority of pharmacy ownership is by a major publicly held corporation.
Today, the PIC has no say over the operation of the Rx dept… which he/she has the legal responsibility for its operation. Here is an example in Connecticut where the BOP are going to fine or suspend a Pharmacist for a medication error… which the vast majority of time can be traced back to a “failure of the system” within the Rx dept work environment.
When a entity (BOP) that is in charge of protecting the public’s health and safety and looks to blame individuals within that system..when it is common knowledge that the design of the system itself is the real underlying cause.. suggests that the BOP’s loyalty may be to some entity other than the general public ?
discussing the FDA, sex being a CPP, state Law Acts concerning opiates and any call-in questions you have for Dr. Kline.
Questions? (415) 915-2291. Please tune in atwww.cawnation.com. Click on “Listen” or listen and chat live with the audience on our YouTube Channel: Conspiracies Against Wellness Live Stream.
Admitted drug addicts and dealers were among the hundreds of thousands of people and businesses the Drug Enforcement Administration (DEA) licensed to manufacture, distribute or prescribe pharmaceuticals over the past 12 years, a Daily Caller News Foundation investigation has found. The agency stripped only 240 licenses for wrong-doing over the same period.
The DEA’s Office of Diversion Control, which is responsible for issuing and revoking the permits, is, by law, fully funded by the licenses’ application fees. More than 1.7 million individuals and organizations held licenses as of March 2018 — an increase of more than 510,000 since August 2006, the earliest publicly available data, TheDCNF’s review found.
“The office … has not been very aggressive in hunting down doctors [who] are prescribing in inappropriate ways,” said Carnegie Mellon University Professor Jonathan Caulkins, who’s worked extensively in drug policy. “The DEA does not aggressively try to find corrupt or incompetent health care providers in the health care system.”
Effective enforcement is especially important given the growing opioid epidemic, Caulkins added. More than 200,000 Americans died from prescription drug overdoses between 1999 and 2016, according to the Centers for Disease Control and Prevention. Most heroin users begin their addiction with such prescriptions, studies have shown.
The DEA ruled on 430 investigations into licensed individuals and groups since March 2006. The agency only revoked 240 licenses and denied applications for another 106, according to a DCNF review of the investigations.
“It is not really believable from my perspective that if they had proper enforcement … that that number [of revocations] would be so low,” Public Citizen’s Health Research Group Founder and Senior Adviser Sidney Wolfe told TheDCNF. “We don’t have adequate, serious law enforcement that musters all of the evidence they have and then acts appropriately. If we did, that number would be in the thousands.”
Most states maintain databases with information about how prescription drugs are dispensed, Wolfe also noted.
“I would bet DEA itself does not collect the data from these states that could be useful in deciding if it’s safe to re-register someone,” Wolfe added. “It’s poor law enforcement. These are crucial, life-challenging things that are going on.”
Meanwhile, the DEA gave out licenses to people who admitted to having been addicted to or dealt drugs in the past.
One dentist, for example, admitted to helping “an outlaw motorcycle gang” manufacture methamphetamine in the early 2000s, which resulted in two years of jail time, a DEA document said. He’d previously been caught with meth several times and admitted to “a history of substance abuse with alcohol, marijuana, methamphetamine and cocaine.”
The DEA gave him a license to prescribe certain drugs in September 2013.
A doctor was caught distributing cocaine in 1981 but wasn’t prosecuted because he cooperated with authorities, another DEA document shows. He was arrested again in 2001 with cocaine and two prescription drugs — an opioid and a minor tranquilizer — and pleaded guilty to related charges in 2003.
The DEA gave him a license to prescribe drugs in February 2009.
“The number of doctors themselves [who] have opioid problems is probably higher than the number of [revocations],” Wolfe told TheDCNF. “If you have an opioid addiction, the last thing you should be doing is prescribing opioids.”
However, “doctors have a relatively high risk of addiction” and there is rehabilitation specifically designed for physicians, Caulkins said.
Also, 72 percent “of all substances identified in physician arrests since 2003 were opioids,” according to a recent Detox.net study that analyzed DEA data.
Government watchdogs have also repeatedly criticized the DEA’s Office of Diversion Control.
Even when the DEA revokes a license or denies an application or renewal, the decision-making process can be lengthy, the Department of Justice’s inspector general (IG) found in 2014. It took the agency an average of nearly two years to make a final decisions on cases in 2009, though that decreased to just one year by 2012.
“Such delays can create risks to public health and safety by allowing noncompliant registrants to operate their business or practice while the registrant action is being adjudicated,” the IG wrote. For example, a doctor can keep writing prescriptions — even after the DEA proposed revoking his license — until a ruling is made.
Just one doctor prescribing medications in an abusive manner could harm hundreds of patients, according to Wolfe.
Just one percent of special agents’ investigative time in 2005 was spent on drug diversion probes, according to a 2006 IG report. Intelligence analysts, likewise spent just over five percent of their time on such investigations that same year.
The report cited a 2004 survey that found 2.4 million people “used prescription pain relievers non-medically for the first time within the past 12 months. This number was the largest number of new users for any type of illicitly used drug during that same time period.”
Additionally, the number of people who admitted to abusing prescription drugs between 1992 and 2003 nearly doubled, according to another study the IG cited.
Still, the DEA provided little instruction in the way of investigating prescription drug trafficking.
“DEA special agents have received minimal diversion control training,” the report stated. At the time of the report, only 98 special agents had taken a week-long course, while the rest had only received a two-hour session during basic training that consisted of a video from 1996.
The video was produced the same year OxyContin was made publicly available, which critics have widely blamed for initiating the opioid epidemic. The prescription painkiller’s manufacturer — Sackler Family owned Purdue Pharma — launched an aggressive and deceptive marketing campaign promoting the drug.
In fact, company representatives downplayed OxyContin’s addictiveness and consequently paid nearly $635 million in 2007 — just one year after the IG report was published — Purdue and three top executive admitted in court.
Doctors can spend years in jail if they’re caught overprescribing opioid medications, but the Purdue executives only had to pay a fine, Wolfe pointed out.
Purdue, which is now facing hundreds of lawsuits around the U.S., raked in $35 billion in OxyContin sales between the time of its release and 2015, helping The Sacklers become one of the nation’s wealthiest families with a $13 billion net worth, according to Forbes.
The Government Accountability Office (GAO), a congressional watchdog, also found problems with the diversion office — specifically regarding its ability to monitor individuals with licenses to prescribe drugs.
More than 760 people of the then-1.4 million registered with the DEA “were potentially ineligible” for licenses because the Social Security Administration reported them as dead, they did not have state-level permission to prescribe or distribute controlled substances or “were incarcerated for felony offenses related to controlled substances,” the 2016 GAO report stated.
Also, nearly 700 Social Security numbers in the DEA’s database were registered to multiple names or variations of names, “which can be a risk indicator of potential fraud,” the report showed.
Another nearly 42,000 entries in the DEA’s database listed an employer identification number rather than a Social Security number, the GAO found, which makes it more difficult to conduct background checks and prevent fraudulent identities.
In fact, one person convicted of defrauding Medicare in June 2013 was still actively registered with the DEA to dole out drugs as of January 2016, the GAO pointed out. The drug agency had no notes about the crime in its system.
Additionally, the DEA doesn’t conduct criminal background checks after an individual receives their license unless the crime is either self-reported or if the state of practice informs the agency, according to the GAO report.
Although the DEA’s diversion control office is supposed to be fully funded through the fees people pay to acquire the drug licenses, it’s faced periods of especially tight budgets, according to a 2008 IG report.
“I do think it is odd that the office has to be funded out of licensee fees,” Caulkins told TheDCNF. “It should be funded at whatever level it takes to get the job done. Perhaps that is less than the license fee revenue. Perhaps it is more.”
“It seems quite arbitrary to imagine that license fee revenue would end up magically providing just the right level of funding,” he continued. “But DEA would have to revoke an awful lot of licenses to seriously hurt that revenue stream (and it could presumably increase the size of the license fee by one percent to offset the losses).”
The DEA, for example, raised registration fees for the first time in 10 years in October 2003 in part to respond “to the threat of OxyContin abuse,” according to the IG report.
The DEA expected to rake in $238 million in 2006 but fell short by $75 million — or about one-third of the agency’s projection — the IG found. In 2007, the DEA settled a lawsuit that increased the amount the agency had to pay diversion investigators for overtime, which put additional financial restrictions on the diversion control office.
Consequently, the diversion office was forced to tighten its purse strings, according to the IG report.
“We found that overtime, travel and equipment purchases had been limited during the period of our review” as a result of the lawsuit and the revenue shortfalls, the report stated.
The DEA collected $235 million in fees in 2009, which increased by about 40 percent — or $93 million — by 2013, according to a 2015 GAO report. The number of registrants, meanwhile, increased by roughly 15 percent over the same period, TheDCNF’s review found.
The DEA’s role and effectiveness in fighting the opioid epidemic has also recently come under fire.
One West Virginia county with a population of less than 3,000 was flooded with nearly 21 million opioid pills from two pharmaceutical wholesalers over roughly a 10-year period, a House Committee on Energy and Commerce investigation found. Republicans and Democrats alike scrutinized the DEA for failing to stop the pill dumping.
Lawmakers have also grilled the DEA for its lack of cooperation in the committee’s investigation, and the agency has faced subpoena threats for slow-walking the release of related documents.
Additionally, pharmaceutical companies hired high-ranking DEA officials after leaving the agency, a joint Washington Post and “60 Minutes” investigation found. The agency also began to limit how often it immediately suspended pharmaceutical distributors that were shipping suspiciously large volumes of pills.
The DEA ultimately didn’t oppose a 2016 bill pharmaceutical industry-backed members of Congress sponsored and co-sponsored that essentially eliminated the agency’s ability to use such suspensions, the investigation found. The legislation consequently passed with unanimous consent, and then-President Barack Obama signed it without question.
Both Caulkins and Wolfe noted the power pharmaceutical companies hold in forming policy and legislation, which has helped bind the DEA.
“There’s enormous influence in this industry,” Wolfe told TheDCNF.
The DEA did not respond to requests for comment.
Andrew Kerr and Grace Carr contributed to this report.
NEW YORK — With one completed suicide every day, US physicians have the highest suicide rate of any profession. In addition, the number of physician suicides is more than twice that of the general population, new research shows.
A systematic literature review of physician suicide shows that the suicide rate among physicians is 28 to 40 per 100,000, more than double that in the general population.
Physicians who die by suicide often suffer from untreated or undertreated depression or other mental illnesses, a fact that underscores the need for early intervention, study investigator Deepika Tanwar, MD, Psychiatric Program, Harlem Hospital Center, New York City, told Medscape Medical News.
“It’s very surprising” that the suicide rate among physicians is higher than among those in the military, which is considered a very stressful occupation, Tanwar told Medscape Medical News.
The findings were presented here at the American Psychiatric Association (APA) 2018 annual meeting.
Stigma, Access to Lethal Means
Using MEDLINE and PubMed, the investigators conducted a systematic literature review of physician suicide that included articles published in peer-reviewed journals during the past 10 years.
The review showed that the physician suicide rate was 28 to 40 per 100,000; in the general population, the overall rate was 12.3 per 100,000.
The results also showed that although female physicians attempt suicide far less often than women in the general population, the completion rate for female physicians exceeds that of the general population by 2.5 to 4 times and equals that of male physicians.
Experts are trying to understand why physician suicide rates are so high, said Tanwar. She pointed out that their review shows that some of the most common diagnoses were mood disorders, alcoholism, and substance abuse.
One study showed that depression affects an estimated 12% of male physicians and up to 19.5% of female physicians, a prevalence that is on par with that of the general population.
Depression is more common in medical students and residents, with 15% to 30% screening positive for depressive symptoms.
The investigators note that mood disorders in the medical profession is not restricted to North America. Studies from Finland, Norway, Australia, Singapore, China, and elsewhere have shown an increase in the prevalence of anxiety, depression, and suicidality among medical students and practitioners alike.
Stigma, said Tanwar, is a major obstacle to seeking medical treatment. She pointed to a study in which 50% of 2106 female physicians who completed a Facebook questionnaire reported meeting criteria for a mental disorder but were reluctant to seek professional help because of the fear of stigma.
The new review showed that poisoning and hanging are among the most common means of physician suicide. The findings also suggest that greater knowledge of and easier access to lethal means account for the higher rate of suicide completion in physicians.
The review also showed that of all medical specialties, psychiatry is near the top in terms of suicide rates.
There is growing awareness of physician suicide, and initiatives to prevent it are increasing.
Tanwar noted that several sessions at this year’s APA meeting address physician wellness and burnout, which may help reduce suicide rates.
Alarming Rates
Commenting on the findings for Medscape Medical News, Beth Brodsky, PhD, associate clinical professor of medical psychology in psychiatry at Columbia University and the Irving Medical Center, New York City, who is an expert in this field, said the very high rate of physician suicide is “alarming.”
However, she added, it is not surprising, given the stressors physicians face.
The stress starts in medical school and continues in residency with the high demands, competitiveness, long hours, and lack of sleep. This may contribute to substance abuse, another risk factor for suicide, said Brodsky.
This high stress is exacerbated by dwindling healthcare resources and residency positions, she noted. There are many stories of individuals dying by suicide after not securing one of these coveted spots.
When medical students graduate and enter the profession, they face different but equally challenging stressors, said Brodsky.
As more women enter the medical profession, they are becoming increasingly vulnerable to the fallout from work stressors. As a result, their rate of suicide is also increasing, said Brodsky.
Brodsky is among the experts advocating for better ways of addressing these problems, which may start with simple semantics. People do not “commit” suicide but “die by suicide,” she said. She noted that suicide is an “illness and not a crime.”
Brodsky welcomes the APA’s focus on physician suicide because it raises awareness of the issue and will ultimately lead to improved prevention and intervention initiatives.
Openly discussing suicide as an illness helps “bring it out of the darkness” and shed the stigma shadowing this problem, she said.
The investigators and Dr Brodsky have disclosed no relevant financial relationships.
American Psychiatric Association (APA) 2018. Abstract 1-227, presented May 5, 2018.
A woman who had been physically active for all of her life, who had been a law enforcement officer and who also suffered from intractable chronic pain killed herself recently.
Her name was Jennifer Adams and she lived in Helena, Montana.
She had a career in law enforcement, working as a deputy sheriff, and as a member of the Helena Police Department. She was a remarkable athlete who loved to run marathons, ski, snowboard and many other things. She loved the lifestyle of Montana.
Jennifer Adams
She also was a visible member of Montana’s increasingly public (and angry) pain community. One of her colleagues, Gary Snook, remembered her simply as a very good person who tried to fight her chronic intractable pain but was overwhelmed as doctors she visited left their practices either because they were suspended or retired.
She started to see Dr. Mark Ibsen in Helena in 2014 who he said had to convince her to use a “moderate dose” of opioids in order to help deal with her pain. Her law enforcement background made her skeptical of opioids and downright adamant about using cannabis, which she refused to do.
When Ibsen ran afoul of the Montana Medical Board (his license was suspended), she began to see Dr. Forest Tennant of West Covina, California who is known as a staunch advocate of using opioids for the treatment of intractable chronic pain. Then Tennant himself became a target of the DEA which raided his office late last year. Tennant announced he was closing his pain clinic in March of this year.
According to her friend and fellow Montana chronic pain patient, Gary Snook, Jennifer felt isolated, alone and finally determined she couldn’t take it anymore.
For Dr. Terri Lewis, who is a Montana native and has been a leading voice in what she believes is a failure of the health care system to treat chronic pain, this should be a wake up for states who she believes are failing their patients. She thinks her home state is a particularly negative example—she calls it a “pain care desert”. She also said that Montana leads the nation in suicides of persons with complex care needs, like chronic pain.
Here’s what she told the National Pain Report.
“We lack a cohesive unified understanding of the pain experience across the nation. Across the disciplines of care, pain is inconsistently conceptualized and therefore responded to differently. Each state has implemented different regulatory processes, some confusing addiction prevention with the care for pain and long-term support for chronic, complex illnesses,” she said.
Some states, like Montana, have no functioning pain law at all, relying on the application of guidelines of various types or the courts to determine the limits of care. Montana’s situation is especially grievous as there is no cohesive plan for resourcing the care of persons who struggle with pain, and the state Board of Medicine has abdicated its duties to plan for or recruit the necessary medical capacity to support post-acute and long-term care for pain syndromes of every type. This has turned Montana into a pain care desert without trained, broadly experienced medical personnel or a continuum of care from onset of illness through end of life planning.”
In her obituary in the Helena Independent Record, pain activist Valorie Hawk wrote:
“The pain community mourns another unnecessary loss of a life – our souls are crushed as the numbers mount. Our hearts go out to Jennifer’s family and friends, we will keep fighting for those we have lost and those that can’t fight for themselves.”
One final note about Jennifer. She had a son, nicknamed “Tuff”, who is a middle school student in Helena. Like his mom, he is a remarkable athlete, well-liked by his peers and by all accounts a really “good kid”. When he returns to school this week he will be welcomed back by his classmates which we are sure and fervently hope will be of some comfort to the young man.
One final comment from this author: This stubborn fact remains: Chronic pain affects more American adults than heart disease, cancer and diabetes combined. And there’s no agreement on how to best treat it. We can do better. We will continue to expand our conversation about what can be done to better identify, educate and most importantly, treat chronic pain.
Request for Court Injunction Against ‘Opioid Safety Initiative’
[This is the actual paperwork filed by plaintiff, Robert D. Rose Jr., in Greeneville Federal Courthouse, 220 W Depot St # 200, Greeneville, TN 37743 (423) 639–3105 on May 7, 2018.]
Additionally the plaintiff makes the following requests of the Court and the Clerk of the Court:
a. This injunction request not be sealed. This case is the only hope thousands of veterans and civilians have that one day soon their healthcare needs will once again be met by medical professionals across the country.
b. The same as in the denied Ex Parte Injunction, the plaintiff respectfully requests an open hearing at the earliest possible convenience of the Court at which witness, veterans, loved ones and caregivers, can be provided detailing the harm the Department of Veteran Affairs’ opioid safety initiative is causing within the veteran community as well as in the civilian community. This request for testimony also includes civilians being affected by the Centers for Disease Control (CDC) copied and adopted a majority of the VA/DOD policy into the controversial CDC Opioid Guidelines targeting the elderly, cancer patients and the disabled.
c. Pursuant to advice from the clerk’s office, it is hereby requested in view that many witnesses are homebound and/or located in other states the court allow teleconferencing testimony from these witnesses either by Skype or other technology allowing their voices to be heard regarding this policy which is adversely effecting so many of our nations heroes.
Reasons for request for Preliminary Injunction:
In Doc 56, the court states “Plaintiff has managed to last a year and a half without “[p]roper pain management treatment,” he has failed to show that an immediate injury will occur…” The plaintiff’s response to this statement is as follows:
First, plaintiff has not died or committed suicide as have so many others since beginning the forced taper in November 2016 after being denied all pain medications on December 29. 2016. As a Christian, the plaintiff will never commit suicide and dishonor Jesus Christ our Lord and Savior or jeopardize being in His presence again.
The first incidence in which the plaintiff was in the presence of Jesus Christ was in 1991 when plaintiff incurred most of the injuries to his spine as he fell from a cliff into the Mediterranean Sea. As the plaintiff was drowning, plaintiff was surrounded by the most wonderful white light filled with unconditional love erasing all of plaintiff’s pain and worries. The plaintiff’s Savior embraced him in that moment and the plaintiff heard in his head “Not yet.” Although the plaintiff looks forward to being in His presence again, the plaintiff would prefer to remain around many more years to see his grandchildren.
As to the plaintiff’s being able to “manage[…]” the past one year, six months, two days, or 548 days with unrelenting pain speaks to plaintiff’s WILL to live; not to the plaintiff’s QUALITY of life. Since the beginning of the forced taper and ultimately the denial of all lifesaving medications AND ensuring a quality of life medications, the plaintiff’s quality of life has dropped to being less than the plaintiff’s worse day in Marine Corps boot camp during the summer of 1983 at Parris Island, sand fleas and all. Here are a few additional examples to supplement what was already included in the initial complaint and amended complaint.
a. Unable to attend son’s fiancé’s college graduation, December 2017 or after party because of pain and high blood pressure.
b. Summer 2017, mowing my yard required about two hours. Each time resulted in plaintiff being homebound for three or four days more if rainy. This did not include weed eating, blowing the driveway or trimming my trees or bushes. The plaintiff being unable to care for any of the many flowers in plaintiff’s gardens resulted in most dying. Spring 2018, Washington County city workers ruined trees and bushes shading plaintiff’s patio. Summer 2018, plaintiff is paying for minimal yard care.
c. A trip to the grocery store requires plaintiff to lie in bed for several hours before plaintiff is able to prepare minimal subsistence meals. Many days dinner consists of grilled cheese and bologna sandwiches.
d. Monday, April 23, 2018, it required approximately four (4) hours to travel to Greeneville Federal Courthouse, to file the Ex Parte Injunction (Doc. 53) and return to plaintiff’s in Gray, Tennessee. This one trip left plaintiff mostly homebound in bed for the following two and half days unable to complete basic hygiene or care for his 100% disabled wife, Pilar A. Rose.
e. Unable to decorate home with even a small Christmas tree or manger scene, December 2016 and December 2017.
f. Plaintiff is extremely frustrated at being unable to remember small things which were formerly committed to memory such as the Lord’s Prayer when pain levels explode.
g. Spring 2018, unable to go with wife to a special dinner prepared by son at his new apartment with his fiancé.
h. With much shame, the plaintiff has prayed multiple times to God to take him home as the pain has gotten too unbearable. Thankfully, God has ignored these pleas so that plaintiff might live to fight another day. Each morning and evening, regardless of suffering, plaintiff gives thanks to God for allowing plaintiff to remain for one more glorious day. “I can do all things through Jesus Christ which strengthens me.” Philippians 4:13
For each of the items listed, plaintiff can add additional items as to why plaintiff’s quality of life has diminished so dramatically. However, the plaintiff is a United States Marine. The plaintiff believes with all his heart he was spared in 1991 with these injuries so as to defend the right for quality healthcare for all his Brother and Sister WARRIORS in all branches of the Armed Forces. As long as their lives are in jeopardy by this policy and the Department of Veteran Affairs continue to deny veterans quality healthcare; the plaintiff refuses to die!
As to failing to show an “immediate injury will occur;” plaintiff has no answer. The complications associated to untreated pain were very clear and specific in the Ex Parte Injunction, (Doc 53) and other documents provided to the court. Plaintiff will testify that on multiple occasions he has taken Benadryl to lower pain induced high blood pressure and severe chest pains. Plaintiff can attest to being afraid to return to Mountain Home VAMC Emergency Room for fear of being arrested or discharged again without the benefit of proper medical care. Diagnosed years ago with Major Depressive Disorder, plaintiff assures the Court these conditions have worsened to the point of desperation most days: depressed mood, loss of interest or pleasure, significant change in appetite/weight, insomnia/hypersomnia, psychomotor agitation/slowing/loss of energy, feelings of worthlessness, inability to concentrate, recurrent thoughts of suicide.
Plaintiff can attest to not having sufficient funds to go to a civilian hospital for treatment of these conditions at the present time. Plaintiff has secured private insurance at significant cost which will go into effect July 1, 2018. It is the plaintiff’s desire with proper medical care,; this case will be better researched and presented in future correspondence and/or motions and especially at any hearings. The defendants will not stand a chance of anything less than GUILTY of all allegations by a jury of our peers.
In response to statement in Doc 56, in that plaintiff “fails to comply with the requirements of Rule 65(b)(1) in that “neither his original nor his amended complaint is verified,” the plaintiff is including the following summary of the original and amended complaints in hopes it is sufficient for the Court. Additionally, plaintiff makes the following declaration:
“As God is my witness and by the notary by and for the State of Tennessee located at the end of this Preliminary Injunction request, every statement and every document plaintiff, Robert D. Rose Jr., has made, is making or will make to the Eastern District Federal Court regarding Case #2:17-cv-204 Rose v Roe is truthful and factual to the best of the plaintiff’s ability, so help me God. May it be known now and forever.” “For there is nothing covered, that shall not be revealed; neither hid, that shall not be known.” Luke 12:2.
a. October 2016, defendant nurse practitioner Christina Craft, whom plaintiff had never met, called to inform per new VA policy to deny 90% of all veterans (elderly, cancer patients & disabled) all pain medications, she was going to put plaintiff on forced taper to zero. When objected, defendant stated the plaintiff had the normal spine of any other fifty year old male and that plaintiff had no choice. She refused for an in-person consult. She refused to provide this directive in writing.
b. October 15, 2016 after contacting the office of defendant David Hecht, an appointment with defendant Craft was granted. At this visit defendant repeated claims from the phone conversation. Defendant refused to look at years of medical records documenting injuries by Veterans Affairs medical personnel, civilian doctors and US Navy doctors (plaintiff has a copy of medical files from the United States Marines with inclusive records from 1983 to 1994) brought to the appointment by the plaintiff. Defendant again refused to provide a hard copy of guideline or directive she was using to force taper.
c. October 28, 2016, defendant James Crider, defendant’s Crafts supervising medical doctor, secretly entered into plaintiff’s VA medical records that plaintiff had broken “pain contract” for not complying with forced taper. Defendant Crider had never met or spoken to plaintiff. Beginning November 1, 2016 through December 29, 2016 plaintiff was forced to taper from 180mg Morphine Sulfate (three 60mg tabs daily) to zero. Plaintiff was advised of this entry in the plaintiff’s medical records by defendant Dale Whitson on October 24, 2017 in a secure message email notification of why he was refusing to treat veteran’s chronic pain disease: “Official violation of pain agreement was entered in chart on October 28, 2016 by Dr. James Crider. Apparently was taking morphine inappropriately, not according to his taper schedule.” This was the first time plaintiff was informed of this violation by any member of Mountain Home VAMC staff.
d. November 29, 2016 plaintiff went to Mountain Home VAMC Emergency Room for chest pains, difficulty breathing and excruciating pain (for full details, please see Amended Complaint Doc. 22 for full details). Defendant Suzanne Allen eventually discharged plaintiff apologizing for being unable to do more per opioid safety initiative. Defendant Allen refused to provide copy of policy or directive; a one page document stating to 1) continue with taper: 2) Moist heat to neck and back; 3) Use muscle relaxers as prescribed; 4) Call PCP for pain management referral; was all the discharge paperwork plaintiff was provided by discharge person. This occurred even though plaintiff was still experiencing same complaint as when first arrived and having an excessively high blood pressure reading (approximately 220/175 or 225/170) which was in the heart attack stroke range.
e. December 2019 defendant Craft called plaintiff to offer a return to a reduced 120mg Morphine Sulfate daily per excessively high blood pressure in Emergency Room and difficulty dealing with pain levels. Defendant Craft indicated it would only be temporary until plaintiff would be forced taper to zero. No exception. Plaintiff declined offer.
f. December 15, 2016 defendant John Hendricks met with plaintiff for the first time. In forty minutes or less defendant had determined the plaintiff suffered from “opioid use disorder,” “substance abuse disorder” and something else dealing with drug abuse. Plaintiff pointed out in clear terms, the plaintiff’s behaviors, actions and accomplishments in nearly twenty years or pain management did not meet the DSMV or DSMIV criteria for these diagnoses. Defendant Hendricks then strongly urged plaintiff to go through the detox program at Bay Pines Rehabilitation facility in Florida. Plaintiff declined per primary caregiver for 100% disabled wife, Pilar A. Rose. Defendant then urged plaintiff to accept Suboxone as an alternative to Morphine Sulfate as a pain management tool. Plaintiff declined for several reasons including the following:
a. Plaintiff is not an addict. b. Suboxone is illegal to be prescribed off-label in Tennessee; it is only for addicts addicted to ILLEGAL fentanyl, heroin and illegally acquired opioid analgesics. c. Research articles suggest Suboxone is specifically designed to be a more addictive synthetic opioid replacement drug with harsh withdrawal symptoms if attempting to end treatment. Additional research suggests Suboxone has a 66% (sixty-six percent) fail rate at helping addicts and/or chronic pain patients. d. Manufactures, Indivior, have a twenty plus page of dangers associated with this addiction treatment drug.
g. December 15, 2016 Dr. Lisa Paderna, plaintiff’s psychologist for many years, after observing her supervisor’s “interview” secretly entered in plaintiff’s medical records “opioid use disorder.” The accompanying note by Dr. Paderna suggests this diagnosis was ordered by her supervisor, defendant Hendricks. Plaintiff was unaware of this entry for many months until plaintiff accidently stumbled upon an “administrative note” entered in plaintiff’s medical record not meant for veteran’s eyes.
h. December 2016, defendant Craft doubled three separate blood pressure medications to control excessive high blood pressure readings (heart attack & stroke levels) due to the untreated chronic pain from injuries sustained in the United States Marines. As the court can ascertain by the dosages, these doses are now at highest recommended levels:
a. Hydrochlorothiazide 25 mg b. Benazepril HCL 40 mg tablet c. Amlodipine Besylate 10 mg tab
i. January 2017 at behest of defendant Dean Borsos, plaintiff met with defendant, defendants Mark Crider, Thomas Edwards (dismissed from case by court), David Hecht via telephone conferencing and a roomful of other staff members. The purpose of the meeting was to convince plaintiff to stop misbehaving and objecting to the force taper. Edwards promised he would do everything in his power to provide aid and quality medical care for injuries to spine. All present refused to look at military records or civilian records demonstrating the extent of damage to spine, hips, legs and ankles stating they understood the damage was extensive. All present refused to provide hard copy of policy/directive.
j. May 20, 2017 met with defendant Mark Vernon. Defendant stated plaintiff should never have been removed from established pain management protocols. Stated all medical staff was under new guidelines/directives preventing any prescribing of opioid medications. Stated plaintiff should continue to smoke to help with the stress of being in pain all the time. Although diabetic, plaintiff should continue drinking Mt Dew as the sugar molecules would attach to the pain receptors in the brain and block some of the pain signals. Although plaintiff had last dose of pain medications on December 29, 2016, defendant ordered a drug screen. This test was negative for ALL pain medications for spine, hip, leg and ankle issues; more importantly it was negative for all ILLEGAL substances.
k. May 23, 2017 met with Thomas Edwards and defendant Teresa Odom. During this encounter, defendant Odom offered wheelchair yoga class as a solution to the unrelenting pain but no medications to get plaintiff from home to the classes. Declined offer. Keep in mind, last dose of pain medications was on December 29, 2016 and drug screen on May 20, 2017 was negative for illicit drugs, Edwards offered the detox program at Bay Pines Rehabilitation facility in Florida. Plaintiff declined. Edwards then offered Suboxone for treatment of pain. Plaintiff declined for same reason explained above. Edwards then commented that plaintiff was out to destroy him and all doctors at Mountain Home VAMC. Plaintiff agreed to this statement by including statement “by all legal means available.” Plaintiff followed up this encounter with a Secure Message email re-stating “by all legal means available” and forwarded it to the leadership at the Department of Veterans Affairs and the Congressional VA Committees. Edwards and defendant Odom had plaintiff’s medical record “red-flagged” as being a threat to himself, others and the staff at the VA facility. The result of such a flag meant if plaintiff reported for any appointment at the VA facility the plaintiff would have been arrested and detained if not being properly escorted by VA facility law enforcement officers. Plaintiff was unaware of this flag until June when he received a letter ordering plaintiff to report to the Disruptive Behavior Clinic located in the VAMC police department.
l. June 6, 2017, plaintiff reported to Mountain Home VAMC police station as ordered met with defendant Jerry Shelton and four other individuals plaintiff had never seen before or since. The defendant Shelton had his badge, a sidearm and handcuffs prominently displayed for the plaintiff to see. The tone and atmosphere established defendant Shelton as an interrogator in an apparent effort of intimidation. Defendant Shelton did not provide or state his medical training which would have qualified defendant to determine mental health status of plaintiff. The entire meeting seemed to be targeted at getting plaintiff to accept the opioid safety initiative and to stop creating waves with medical personnel, the Department of Veterans Affairs leadership in Washington and numerous congressional leaders which had been contacted regarding the policy to deny 90% of all veterans, the elderly, cancer patients and the disabled, all pain medications. Plaintiff advised defendant he would continue to fight the policy using all legal means available. The flag was “cleared” meaning the plaintiff will not be arrested but remains as a warning to other providers’ plaintiff is seeking legal relief from these policies as they continually refuse to provide said policies in writing.
m. July 3, 2017 complete details of encounter with Mountain Home VAMC law enforcement acting on behalf of Defendant Roe and/or his staff was provided with Doc 31, at 01, 02 and 03 to the courts on March 22, 2018. Considering that information deals with criminal acts, plaintiff will not add to this request for a Preliminary Injunction against the Department of Veterans Affairs’ opioid safety initiative.
n. September & October 2017 plaintiff was informed defendant Vernon had been replaced by new primary care physician (PCP) defendant Whitson. Plaintiff made numerous attempts to contact defendant by phone, leaving messages each time to please return to call(s). Defendant never responded to these calls. October 11, 2017, Dr. Provence, Chief of Primary Care, whom the plaintiff had never met, called advising “my doctor” without naming the individual was out of town. Plaintiff sent secure message email on this date to Provence (Attachment 01) describing the difficulties contacting the new PCP, defendant Whitson. Then on October 24, 2017 defendant’s nurse advised via secure message defendant Whitson would not treat any pain conditions due to defendant Crider’s entry on October 28, 2016 stating the defendant had violated the patient pain contract.
o. October 9, 2017 plaintiff called and spoke with defendant Dean Borsos regarding the death of his sister Melissa Anne Rose on October 8, 2017. Plaintiff explained how at Sycamore Shoals Hospital, Elizabethton, Tennessee, plaintiff collapsed from the stress of pain, increased blood pressure and emotional loss simply from the forty minute drive to see his sister in the hospital (she was deceased by the time plaintiff arrived). Plaintiff begged the defendant for enough pain medication for one week to be with family and friends during this tragic period. He refused any medical treatment however throughout this week of grief; plaintiff received multiple calls from woman identifying herself as being in charge of hospice for Mountain Home VAMC, Dr. May. This person repeatedly insisted plaintiff should go to the Johnson City Medical Center or the Sycamore Shoals Hospital anytime there were chest pains, extremely high blood pressure or excruciating pain as the Department of Veterans Affairs would pay for the emergency room visit. Plaintiff advised Dr. May that defendant Borsos had stated the VA would not pay for such a hospital visit and defendant Lonnie Hatton had made similar statements on multiple occasions. Dr. May insisted the plaintiff could trust her and to just go to the emergency room. Plaintiff requested multiple times by phone and through secure messaging email (Attachment 02) for Dr. May to put these statements “the VA would pay for such medical treatment” in writing. After the secure message was sent, plaintiff never heard from Dr. May again.
p. January 5, 2018 the plaintiff was referred to East Tennessee Brain and Spine Center by Mountain Home VAMC for pain management treatment. On this date was plaintiff forced to provide drug screen; negative for thirteen (13) ILLICIT drug classes.
q. January 2018 plaintiff finally met with defendant Whitson. During this appointment the defendant made some extremely troubling statements.
a. Plaintiff should never have been removed from the pain management protocols established considering the dose had remained stable and effective with no violations of the pain contract as previously indicated by defendant Crider.
b. Medical staff, doctors and nurses were provided lists of five to ten [veterans’] names and told to discontinue all opioid related pain medications. Medical staff could request waivers from the administration but these were all denied. No exceptions.
c. Medical staff, doctors and nurses, was forced by intimidation of implied threats regarding continued employment with the Department of Veterans affairs if they did not comply with these directives. Defendant Whitson stated he only had a few years till retirement and was terrified of what he would do if terminated this close to the finish line.
d. Defendant Whitson stated he did not fear the lawsuit as he and everyone else working for the Department of Veterans Affairs were only following orders and not complicit in any wrongdoing.
e. Defendant Whitson refused to provide copies of any policies/directives or lists reminding plaintiff his retirement was too important to mess up by providing evidence.
r. April 2018, plaintiff was advised of being assigned a new PCP; no name provided in letter. Sent blind secure message email to Mountain Home VAMC to request medical assistance (Doc 53, at 01) from the new PCP. Nurse Sherry Pierce’s denial response (Doc 53, at 02) by the new primary care physician (PCP), Dr. Avonda, is the first time any member of Mountain Home VA Medical Center has put in writing the specific reason for denying 90% (ninety percent) of all veterans, the elderly, cancer patients, the disabled, all pain medications.
Plaintiff respectfully requests this Injunction endure until such time studies can be conducted to determine the number of deaths once a veteran has been forced tapered or denied all pain medications. The deaths should include those listed as natural causes (cancer, old age, heart attack, et cetera), illicit drug use and suicides AFTER the medical establishment abandoned all quality medical care/treatments, the Hippocratic Oath and scientifically proven lifesaving medications known as “opioids.”
Aren’t the lives of veterans worth the approximate $4 million dollars (advertising budget) it uses for media blackouts on the suicides, even on those VA properties and using it to proudly announce the statistical numbers of veterans denied these lifesaving medications without reporting the harm. Using the Department of Veteran Affairs’ own database, an external team should be able to quickly track these numbers from ALL fifty states, commonwealths and other VA/DOD medical system controlled facilities handling/submitting this information. It is imperative for an outside agency to conduct this research considering the level of misinformation put forth by the Department of Veterans Affairs and the Office of the Inspector General regarding the suicides since 2012 when the opioid safety initiative was first implemented in St Cloud, Fargo and Minneapolis Minnesota.
In reference to Courts Order (Doc 53), plaintiff “fails to certify any efforts made to give notice to defendants,” the plaintiff is providing certified mail certificates from the United States Postal Service as Attachment 03. Since these certificates are not possible prior to mailing, the defendants will not be receiving a copy of this specific attachment.
Again plaintiff makes the following declaration. As God is my witness, and by the notary by and for the State of Tennessee located at below of this Preliminary Injunction request, every statement and every document plaintiff, Robert D. Rose Jr., has made, is making or will make to the Eastern District Federal Court regarding Case #2:17-cv-204 Rose v Roe is truthful and factual to the best of the plaintiff’s ability, so help me God. May it be known now and forever: “And ye shall know the truth, and the truth shall make you free.” John 8:32
A new report says Michigan’s death rate from suicide, alcohol and drug use is poised to skyrocket over the next decade.
The report, Pain in the Nation, examines the effect of rising death rates related to drug use, alcohol abuse and suicide and the large need for users to seek alcohol detox center.
According to the report, Michigan’s death rate from these three preventable reasons is expected to soar 44% between now and 2025. That would lift Michigan’s death rate to 20th in the country.
The Trust for America’s Health and Well Being Trust released the report today.
The report’s authors say a more “robust” approach to the problem, encompassing the physical, mental, emotional and spiritual aspects of those at risk is needed.
“There is no fuzzy math here. It is very straightforward and Attorney General Jeff Sessions and his anti-pot crusade, are on the losing side of the argument.”
Kennedy criticized Attorney General Jeff Sessions for his stance on legalized pot as studies show that marijuana could help improve the opioid crisis
Walmart Inc said on Monday it would restrict initial acute opioid prescriptions to no more than a seven-day supply as the retailer aims to curb an opioid epidemic that has plagued the United States.
The Walmart logo is displayed on a screen on the floor of the New York Stock Exchange (NYSE) in New York, U.S., May 1, 2018. REUTERS/Brendan McDermid
The supply limit will begin within the next 60 days, the company said.
In January , Walmart said it would provide its customers filling prescriptions for opioids with a packet of powder that would help them dispose of leftover medication.
The U.S. Centers for Disease Control and Prevention (CDC) estimates that 115 Americans die on average every day from an opioid overdose.
The company also said on Monday that from Jan. 1, 2020 it would require e-prescriptions for controlled substances, noting that these prescriptions are proven to be less prone to errors and cannot be altered or copied.
The initiatives apply to all the pharmacies of Walmart and its Sam’s Club unit in the United States and Puerto Rico.
(This story has been corrected to add dropped words “initial acute” in first paragraph)
we all know that the opiate conversion tables are CRUDE ESTIMATES AT BEST… 
We all know that the majority of the studies that the CDC used to come to the opiate dosing guidelines were rated “3′ or “4”… where “1” = good/excellent, “4” = poor/crap.
