Reporter looking for stories of collateral damage of the opiate crisis crackdown

Hi there,

I’m a reporter with the Washington Post, and I’m reaching out in the hopes you might be able to help me with a story. It’s about the increasingly complex geography of opioid proscriptions. As a growing number of states pass stricter legislation targeting over-prescription, and doctors become skittish, obtaining an opioid proscription in many states has become no easy matter. Unevenly-distributed policies has resulted in some longtime pain patients having to travel long distances to obtain proscriptions. I’ve heard this is much the case in Montana, and I was hoping to learn more and talk to a few people who have been forced into this situation. I’m interested in doing a story on what could be considered the collateral damage of America’s war on opioids.

Thanks a lot, and I’m looking forward to hearing from you.

Terry

_______
Terrence McCoy
Washington Post
Reporter
202-334-5215

UPDATE:

04/04/2018 this reporter just called me and he is interested in talking to people who are having to travel long distances to see a prescriber to get the pain management

 

The death of Kessee is currently under investigation by the Oklahoma State Bureau of Investigation.

https://youtu.be/MOz5zcePaEA

NPD Reviews Officer Interactions with Marconia Kessee

 
Date of Press Release: 
Tue, 01/23/2018
Press Release By: 
Sarah Jensen

The Norman Police Department responded to a report of a disturbance inside the waiting area of the Norman Regional
Hospital – Porter Campus, 901 N. Porter Avenue, at approximately 7:30 p.m. on January 16. Upon arrival, officers located a hospital security guard with the individual later identified as 34-year-old Marconia Kessee. Hospital security advised that Kessee had been seen by medical staff and released from the facility, but refused to leave. The officers assisted Kessee into a wheelchair and escorted him outside of the waiting area.

Once outside, two NPD officers attempt to persuade Kessee to seek shelter at the Salvation Army located nearby. Despite repeated attempts, Keesee refused to leave hospital property. Due to his refusal, hospital security cited Kessee for trespassing. Kessee was taken into custody by the two officers and transported to the Cleveland County Detention Center. Prior to transport, Kessee was determined to be fit for incarceration by a hospital physician. The body camera video provided shows the two officers’ contact with Keesee.

NPD was later notified that Kessee was found unresponsive in his cell approximately two hours after being booked into
the detention center. Detention center staff called 911, and a medical response by the Norman Fire Department and EMSSTAT was initiated. Kessee was transported by EMSSTAT back to Norman Regional Hospital – Porter Campus where he was pronounced deceased.

Protocol following an incident of this nature includes a review of the body camera footage of the department’s interactions with Kessee. Following the review of the video, it generally appears that the officers followed basic protocol. There is no indication at this time that the actions of the two officers contributed to the death of Kessee. However, the department has launched an administrative review of the actions and disparaging comments made by the two officers. By policy, the officers have been placed on administrative leave pending the outcome of the internal investigation. The officers involved are Master Police Officer Kyle Canaan who has been with NPD since October 9, 2009 and Officer Daniel Brown who has been with NPD since October 4, 2013. The internal investigation is ongoing.

The death of Kessee is currently under investigation by the Oklahoma State Bureau of Investigation. 

Watch the full body camera video of NPD’s interaction with Marconia Kessee:https://youtu.be/MOz5zcePaEA

AG Session: Feds will not fulfill its role as a leading protector of basic constitutional rights under his leadership

Sessions Says to Courts: Go Ahead, Jail People Because They’re Poor

https://mobile.nytimes.com/2017/12/28/opinion/sessions-says-to-courts-go-ahead-jail-people-because-theyre-poor.html

Last week, Attorney General Jeff Sessions retracted an Obama-era guidance to state courts that was meant to end debtors’ prisons, where people who are too poor to pay fines are sent. This practice is blatantly unconstitutional, and the guidance had helped jump-start reform around the country. Its withdrawal is the latest sign that the federal government is retreating from protecting civil rights for the most vulnerable among us.

The Justice Department helped shine a light on the harms of fine and fees when it investigated Ferguson, Mo., three years ago after the killing of the teenager Michael Brown by a police officer. As one of the lawyers on that case, I saw firsthand the damage that the city had wrought on its black community.

Ferguson used its criminal justice system as a for-profit enterprise, extracting millions from its poorest citizens. Internal emails revealed the head of finance directing policing strategy to maximize revenue rather than ensure public safety. Officers told us they were pressured to issue as many tickets as possible.

Even the local judge was in on it, imposing penalties of $302 for jaywalking and $531 for allowing weeds to grow in one’s yard. He issued arrest warrants for residents who fell behind on payments — including a 67-year-old woman who had been fined for a trash-removal violation — without inquiring whether they even had the ability to pay the exorbitant amounts. The arrests resulted in new charges, more fees and the suspension of driver’s licenses. These burdens fell disproportionately on African-Americans.

At the time of our investigation, over 16,000 people had outstanding arrest warrants from Ferguson, a city of 21,000. Untold numbers found themselves perpetually in debt to the city and periodically confined to its jail.

These problems were not unique to Ferguson. A Georgia woman served eight months in custody past her sentence because she couldn’t pay a $705 fine. A veteran battling homelessness in Michigan lost his job when a judge jailed him for bringing only $25 rather than the required $50 first payment to court. A judge in Alabama told people too poor to pay that they could either give blood or go to jail.

In 2015, the Justice Department convened judges, legislators, advocates and affected people to discuss this problem and devise solutions. Participants repeatedly asked the Justice Department to clarify the legal rules that govern the enforcement of financial penalties and to support widespread reform.

And so we did. Relying on Supreme Court precedent from over 30 years ago, the 2016 guidance set out basic constitutional requirements: Do not imprison a person for nonpayment without first asking whether he or she can pay. Consider alternatives like community service. Do not condition access to a court hearing on payment of all outstanding debt.

The Justice Department also provided financial resources to the field. It invested in the efforts of a national task force of judges and court administrators to develop best practices. And it created a $3 million grant program to support innovative, homegrown reforms in five states.

Along with private litigation and advocacy, these efforts have helped drive change around the country. Missouri limited the percent of city revenue that can come from fines and fees and announced court rules to guard against unlawful incarceration. California abolished fees for juveniles and stopped suspending the driver’s licenses of people with court debt. Louisiana passed a law requiring that judges consider a person’s financial circumstances before imposing fines and fees. Texas, where the court system’s administrative director said the guidance “was very helpful and very well received by the judges across the state,” issued new rules to prevent people from being jailed for their poverty. The American Bar Association endorsed the Justice Department’s guidance, and the Conference of State Court Administrators cited it in a policy paper on ending debtors’ prisons.

To justify reversing guidance that has had so much positive impact, Mr. Sessions asserts that such documents circumvent the executive branch’s rule-making process and impose novel legal obligations by fiat. Nonsense. The fines and fees guidance created no new legal rules. It discussed existing law and cited model approaches from local jurisdictions. The document also put state-level actors on notice that the department would take action to protect individual rights, whether by partnership or litigation.

Viewed in that light, the true intent of Mr. Sessions’s decision comes into focus. Sessions pulled 25 guidance documents last week. Sixteen of those involved civil rights protections — including 10 related to the Americans With Disabilities Act and one on the special harms that unlawful fine and fee practices can have for young people. Withdrawing these documents is consistent with the Trump administration’s hostility to civil rights in a host of other areas: abandoning oversight of police departments, reinterpreting anti-discrimination statutes to deny protection to L.G.B.T. individuals and switching sides in key voting rights cases.

The push to abolish debtors’ prisons will continue, as community advocates and local officials press on. It would be preferable, of course, for the federal government to fulfill its role as a leading protector of basic constitutional rights. Unfortunately, Mr. Sessions has made clear that under his leadership it will not.

Chiraag Bains (@chiraagbains) is a former senior counsel in the Justice Department’s Civil Rights Division. He is now a senior fellow at Harvard Law School’s Criminal Justice Policy Program and a fellow with the Open Society Foundations.

We care… just not that much…

 

I called expressscripts and BC/BS FEP mail order CVS caremark, I was told fentanyl patches required NO special cooling packs sending to central Fl. I questioned when my brand has a 6°F range 72°-78°? They insist that they are not required to be sent to keep the temperature. This is ridiculous as fentanyl is heat activated. My fear is these will be worthless when received. How can they get away with this knowing the range is so small and just barely manageable in a house never mind a mail truck or mailbox?

If you notice that most medications – even OTC’s – have a temp storage range requirement. Those storage requirements must be met by the manufacturer, wholesaler and pharmacy. Once a pharmacy hands off a prescription to a delivery service… they are not obligated to maintain those temperature storage requirements.  Here is a recent post that addressed how ambient temperature can cause a medication to deteriorate.

How Does Temperature Affect Mail Order Medicines?

Those temperature are required by at least the FDA…  I am not sure if the state board of pharmacy has the authority or the INTEREST in enforcing those requirements.

Where are the defenders of the under represented and those being discriminated against ?

AARP Member Card

ACLU sues Gov. Bevin for blocking and banning people on social media

These two organizations, in particular, openly profess to “protect” people from abuse, discrimination and the like.

I have heard about untold number of chronic pain pts reaching out to both of these organizations and either their effort to reach them was IGNORED or they were sent a letter/email stating that they did not have enough resources to handle the particular issue.

I have heard about one or more chronic pain pts sending the ACLU dozens of pages of documentation on the various federal regulations that are routinely being violated when it comes to chronic pain pts..  I have not seen any press releases from the ACLU about them taking any legal actions.

The above lawsuit by the ACLU involves a couple of activists in KY that Gov Bevin has blocked from posting on his Facebook and Twitter accounts..  REALLY… that is actionable and all the abuse/discrimination against the chronic pain community is beyond their ability to consider action ?  REALLY…

Our founding Fathers set our government up as having three distinct segments… but have they remained separate and distinct ?

Executive branch..  Pres Trump has surrounded himself with ATTORNEYS… many of whom are directly/indirectly  involved in the war on drugs and the theoretical opiate crisis

Judicial branch .. The Supreme Court and encompasses our entire judicial system

Legislative branch – Congress ( Senate & House of Representatives ) – with about 40% of the members of Congress are attorneys.

Maybe it is me… but.. all three branches seem to be highly infiltrated with ATTORNEYS

For those of us who have had to deal with attorneys at some point in time, it is quite obvious that they are well trained in generating billing hours – and revenue – not only for themselves but for other attorneys that may be involved in whatever issue there is.

The DEA is part of our judicial system..  they have been successful in turning a 43 million/yr budget in 1970 into a 81 billion/yr war on drugs and starting with 1200 employees now with abt 12,000 and just added another 250… Even though they have 20 odd regional offices.. they just opened a new one in Louisville KY, and this doesn’t count all those in the judicial system at the city, county, state level that are involved with the war on drugs.

Maybe we are all missing the point… maybe it is consider UNPROFESSIONAL CONDUCT for one attorney to sue another attorney or the judicial system itself?  After all … sharks don’t eat sharks – do they ?

 

The War on Drugs Breeds Crafty Traffickers

www.nytimes.com/2018/03/26/opinion/war-on-drugs-trafficking.html

The drug war in the Philippines has claimed 12,000 to 20,000 lives in mostly extrajudicial killings. This man was found dumped on

the side of the road in Manila in 2016; his hands were tied behind his back and his head wrapped in packaging tape.

www.nytimes.com/2018/03/26/opinion/war-on-drugs-trafficking.html

Politicians often escalate drug war rhetoric to show voters that they are doing something. But it is rare to ignore generations of lessons as President Trump did earlier this month when he announced his support for the execution of drug traffickers.

This idea is insane. But the war on drugs has never made any sense to begin with.

Executing a few individual smugglers will do little to stop others because there is no high command of the international drug trade to target, no generals who can order a coordinated surrender of farmers, traffickers, money launderers, dealers or users. The drug trade is diffuse and can span thousands of miles from producer to consumer. People enter the drug economy for all sorts of reasons — poverty, greed, addiction — and because they believe they will get away with it. Most people do. The death penalty only hurts the small portion of people who are caught (often themselves minorities and low-level mules).

Indeed, on the ground, the threat of execution will even help those who aren’t caught because they can charge an increased risk premium to the next person in the smuggling chain. The risk of capture and punishment increases as drugs move from farm to processing lab, traversing jungles, through cities, across oceans, past borders, distributed by dealers and purchased by consumers. The greater the risk to smugglers in this chain, the more they can demand in payment.

Without the drug war, substances like cocaine, heroin, marijuana and meth are minimally processed agricultural and chemical commodities that cost pennies per dose to manufacture. But lawmakers have invented a modern alchemy called drug prohibition, which transforms relatively worthless products into priceless commodities for which people are willing to kill or die.

The kind of get-tough measures that may give one country leverage against another have little effect among individual actors who need only to move drugs through their own segment of the supply chain. Indeed, by making the drugs ever more valuable, they have only amplified the motivational feedback loop of the very people lawmakers are trying to stop.

An overreliance on intensive policing over the decades has also produced a rapid Darwinian evolution of the drug trade. The people we have typically captured tend to be the ones who are dumb enough to get caught. They may have violated operational security, bragged too much, lived conspicuous lifestyles or engaged in turf wars. The ones we usually miss tend to be the most innovative, adaptable and cunning. We have picked off their clumsy competition for them and opened up that lucrative economic trafficking space to the most efficient organizations. It is as though we have had a decades-long policy of selectively breeding supertraffickers and ensuring the “survival of the fittest.”

To support his case for executions, Mr. Trump cites draconian penalties in other countries. Iran has used the death penalty extensively in drug cases, but more than 2.8 million Iranians still consume illicit drugs. Earlier this year, the Iranian government even repealed the use of executions in most drug cases which could spare up to 5,000 people on death row.

Mr. Trump often praises President Rodrigo Duterte’s brutal drug war in the Philippines, which has claimed 12,000 to 20,000 lives in mostly extrajudicial killings. But there is little indication that drug use has actually decreased. In fact, as the killings have increased, so too have the government’s drug use estimates. What began as 1.8 million users at the beginning of 2016 grew to three million and later four million. Last September, the Philippine Foreign Secretary, Alan Peter Cayetano, even raised that estimate to seven million. The higher numbers are likely inflated, but more killings do not appear to reduce the number of users.

Singapore notoriously refuses to publish reliable drug-use statistics, so there is no way to show whether executions have any measurable effect on drug consumption. As Harm Reduction International pointed out, however, Singapore’s seizures for cannabis and methamphetamine increased 20 percent in 2016 while heroin seizures remained stable. Moreover, 80 percent of Singapore’s prisoners are incarcerated for drug-related offenses. All of this suggests, Singapore’s famous panacea to solve the drug problem is not as miraculous as it seems.

Mr. Trump also cited his border wall as a way to reduce overdoses. In the unlikely event that the wall puts a significant dent in heroin smuggling, it could actually cause overdoses to skyrocket in this country because it would give dealers an incentive to adulterate remaining heroin supplies with even more fentanyl to stretch their profits. Fentanyl is more compact, much easier to obtain and dramatically more potent.

Mr. Trump is not advancing a new strategy to deal with opioids. It was President Clinton who put these death penalty statutes on the books as part of the 1994 crime bill, but they remain unused. Mr. Trump and Attorney General Jeff Sessions are trying to change that. They want to use those laws in racketeering cases and ones involving large quantities of drugs even though the Supreme Court has ruled that capital punishment should be reserved only for crimes resulting in death.

The Donald Trump of 2018 should take a lesson from the Donald Trump of 1990 when he told the Miami Herald: “We are losing badly the war on drugs. You have to legalize drugs to win that war.

AG Sessions: Chronic pain should be able to be cured… no need for long term opiates ?

Doctors and Pharmacists Arrested in DEA Surge

https://www.painnewsnetwork.org/stories/2018/4/2/doctors-and-pharmacists-arrested-in-dea-surge

The U.S. Drug Enforcement Administration has arrested 28 people and revoked the registrations of over a hundred others in a nationwide crackdown that targeted prescribers and pharmacies that dispense “disproportionally large amounts” of opioid medication.

For 45 days in February and March, a special team of DEA investigators searched a database of 80 million prescriptions, looking for suspicious orders and possible drug thefts.

The so-called “surge” resulted in 28 arrests, 54 search warrants, and 283 administrative actions against doctors and pharmacists.  The DEA registrations of 147 people were also revoked – meaning they can no longer prescribe, dispense or distribute controlled substances such as opioids.

“DEA will use every criminal, civil, and regulatory tool possible to target, prosecute and shut down individuals and organizations responsible for the illegal distribution of addictive and potentially deadly pharmaceutical controlled substances,” Acting DEA Administrator Robert Patterson said in a statement.

bigstock-Corrupt-Male-Doctor-120540008.jpg

“This surge effort has demonstrated an effective roadmap to proactively target illicit diversion of dangerous pharmaceuticals. DEA will continue to aggressively use this targeting playbook in continuing operations.”

The DEA surge is the latest in a series of steps taken by Attorney General Jeff Sessions to crackdown on opioid prescribing. Last August, Sessions ordered the formation of a new data analysis team, the Opioid Fraud and Abuse Detection Unit, to focus solely on opioid-related health care fraud. 

Sessions also assigned a dozen prosecutors to “hot spots” around the country where opioid addiction is common.  Last week the DEA said it would add 250 investigators to a task force assisting in those investigations.

Although overdose deaths are primarily caused by illicit drugs such as fentanyl, heroin and cocaine, federal law enforcement efforts appear focused on opioid prescribing. Doctors and pharmacists are easier to target because they are already in DEA databases, as opposed to drug dealers and smugglers operating in the black market.   

As PNN has reported, the data mining of opioid prescriptions — without examining the full context of who the medications were written for or why – can be problematic and misleading.

For example, last year the DEA raided the offices of Dr. Forest Tennant, a prominent California pain physician, because he had “very suspicious prescribing patterns.” Tennant only treated intractable pain patients, many from out-of-state, and often prescribed high doses of opioids because of their chronically poor health — important facts that were omitted or ignored by DEA investigators.

Tennant has not been charged with a crime and denied any wrongdoing. Nevertheless, he retired this month due to the stress and uncertainty caused by the DEA investigation. About 150 of his patients now have to find new doctors, not a simple task in an age of hysteria over opioid medication.

In an interview with AARP, Sessions defended the use of data mining to uncover health care fraud.

“Some of the more blatant problems were highlighted in our Medicare fraud takedown recently where we had a sizable number of physicians that were overprescribing opioid pain pills which were not helping people get well, but instead were furthering an addiction being paid for by the federal taxpayers. This is a really bad thing,” Sessions said.

“It’s a little bit like these shysters who use direct mail and other ways to defraud people. They will keep doing it until they’re stopped. In other words, if we don’t stop them, they will keep finding more victims and seducing them.”

Did DEA Create “FAKE” Opioid “Crisis” to Screw doctors and patients?

Medicare Finalizes Plan to Reduce High Dose Opioids

https://www.painnewsnetwork.org/stories/2018/4/2/medicare-finalizes-plan-to-reduce-high-dose-opioids

The Trump administration has finalized plans that will make it harder for many Medicare patients to obtain high doses of opioid pain medication. Medicare beneficiaries will also be limited to an initial 7-day supply of opioids for acute pain. Read more about cortexi.

Under new rules released today for the 2019 Medicare Part D prescription drug program, a ceiling for opioid doses will be established at 90mg morphine equivalent units (MME).  Any prescription at or above that level would trigger a “hard safety edit” requiring pharmacists to talk with the prescribing doctor about the appropriateness of the dose. If satisfied with the explanation, the pharmacist could then override the edit and fill the prescription.

Under an earlier proposal, only insurers could decide whether to override a safety edit – a requirement that would have essentially made them the final arbiters in deciding who gets high doses of opioid pain medication.

The new rules adopted by the Centers for Medicare and Medicaid Services (CMS) will still allow insurers to implement safety edits, but only at a much higher dose of 200 MME or more.  Insurers will also be given greater authority to identify beneficiaries at high risk of addiction and to require they use “only selected prescribers or pharmacies.”

CMS is also adopting a new policy that requires all new opioid prescriptions for short term acute pain to be limited to no more than 7 days’ supply. Several states have already adopted similar measures. Take a look to these cortex reviews.

CMS logo.png

CMS said this “tailored approach” to opioid prescriptions was needed to address what it called “chronic opioid overuse” at the pharmacy level and to encourage support for the CDC’s 2016 opioid prescribing guideline.

“CMS believes it is important that (insurers) set expectations for prescribers to implement the CDC’s recommendations as a best practice through their provider contracts. PDPs (prescription drug plans) should also reinforce these messages through interactions with prescribers as an integral component of sponsors’ drug utilization management program,” CMS said.

“We also recommend that beneficiaries who are residents of a long-term care facility, in hospice care or receiving palliative or end-of-life care, or being treated for active cancer-related pain are excluded from these interventions.”

About 1.6 million Medicare beneficiaries met or exceeded opioid doses of 90mg MME for at least one day in 2016. The 90mg MME ceiling established by the CDC was only meant as a recommendation for primary care physicians, but has been widely adopted as a rule by other federal agencies, insurers, state regulators and prescribers.

‘Cruel’ Limits on Opioid Prescribing

“The 90 mg dose they set as a threshold for ‘high’ or overuse is flawed and not scientifically based.  It is totally arbitrary,” says Lynn Webster, MD,  a pain management expert and past president of the American Academy of Pain Medicine.  “It is cruel to impose such a limit on people with involuntary dose reductions who have been functioning well without signs of abuse for years. These are the Best weight loss supplements.

“Even the 7 day limit is misguided at best. The average length of time a person requires an opioid post-op involves several factors and include the type of operation, the genetics of the person and the type of medication. The literature states the duration of pain requiring treatment with an opioid post-operatively is 4-9 days for general surgery, 4-13 days for women’s health procedures and 6- 15 days for musculoskeletal procedures.  This means half of the Medicare patients will receive less than half of what they will need.”  

“This is archaic medicine and does more harm than one can imagine,” wrote pain patient Henry Yennie. “The DEA, HHS, private insurers, and now CMS are pursuing policies and restrictions that will cause harm and suffering to millions of people.”

“I cannot understand how Medicare can be so uncaring about the pain people have,” wrote Mikal Casalino, a 72-year old pain patient. “Limiting the dosage to an arbitrary amount is not going to be helpful for individuals.”

A joint letter opposing the rule changes was also submitted by 180 doctors and academics, including some who helped draft the CDC guidelines. The letter points out that a steep reduction in high dose prescribing since 2010 has not reduced the number of opioid overdoses. And it faults CMS for being focused on reducing the number of high dose prescriptions – not the quality of patient care.

“The proposal does not consider adverse impacts on pharmacies, physicians or patients…and it will accelerate patient abandonment,” the letter warns. “The plan avows no metric for success other than reducing certain measures of prescribing. Neither patient access to care nor patient health outcomes are mentioned.”

CMS contracts with dozens of insurance companies to provide health coverage to about 54 million Americans through Medicare and nearly 70 million in Medicaid. CMS policy changes often have a sweeping impact throughout the U.S. healthcare system because so many insurers and patients are involved.  The new Medicare regulations will go into effect on January 1, 2019.

HHS/CMS has a anti-discriminatory policy for itself and all the vendors/providers of Medicare/Medicaid pts. They also have a FREEDOM OF CHOICE OF PROVIDER by pts.

Here is a website to file a complaint to HHS about being discriminated against and/or violating a pt’s freedom of choice of vendors/providers

https://forms.oig.hhs.gov/hotlineoperations/index.aspx

It appears the CMS is going to “dump” on to the Pharmacist filling the prescription the responsibility and decision to fill or not to fill.  So if a pt is denied medically necessary opiates by the Pharmacist. Who is going to be responsible… the Pharmacist, the company the pharmacist works for… HHS/CMS… the PBM, part D provider or Medicare Advantage – if that is the pt’s coverage… OR EVERYONE ?

Since one of the basics of the practice of medicine is the starting, changing, stopping a pt’s medication and CMS is going to basically grant Pharmacists their authority. A healthcare professional that does not have access to the pt’s entire medical record, nor has the training to be able to legally perform a in person physical exam and we are talking about the treatment of a subjective disease..  besides not having the pt’s medical records.. there is no tests from which the pharmacist could base their decision to fill or not fill…   WHAT COULD GO WRONG ?

All this FUSS over about 4% of the Medicare population that is taking opiates above 90 MME daily and many of those MME calculation are done with conversion tables that are “crude estimates” and there seems to be no provision for those pts who are confirmed fast/ultra fast metabolizers. This seem rather odd since there is an estimated 20 -30 million pts suffering with intractable chronic pain .. which would suggest that many would actually need doses higher than 90 MME.

There are several tips and tricks to eating healthy. Many of these ideas can be challenging to accomplish in today’s busy world. Still, they can give you the edge you’ve been looking for in a healthy lifestyle.

How Does a Healthy Plate Look Like?

  • ¼ of the plate with grains, choose at least 50% whole grains (whole wheat bread, Brown Rice, etc.).
  • ¼ of the plate with protein choices vegetarian or non-vegetarian, choose eggs, fish, lean meat, chicken, beans, cheese, and nuts.
  • ½ of the vessel to be loaded with colorful fruits and veggies.
  • Hydrate adequate. Drink water- 30ml/kg body weight is the requirement. Find yours and start to sip.

 

Fruit vs Fruit Juice

Fruit

  • 62 Kcal
  • More Fiber
  • Less concentrated fructose
  • Fewer calories
  • Lower glycemic index

Juice

  • 112 Kcal
  • Less fiber
  • More concentrated fructose
  • More calories
  • Higher glycemic index

How to Include Fruits in the Diet

  • Snack on fruits
  • Try fruit as dessert
  • Delight your sweet tooth by eating healthy with fresh fruit yogurt, parfaits, and dried fruits
  • Including fruit with breakfast or as dinner snacks is eating healthy

What is One Serving of Fruit?

  • 1 medium-size fruit
  • ½ cup fruit salad
  • ¼ cup Dried fruits
  • ½ cup fresh juice
  • Include at least two servings of fruit a day

Are You Drinking Enough Water?

How Much Water Should You Drink Per Day?

30 ml X Actual body weight (Kg) Note: Restrict fluids; if any medical conditions, or if recommended by the Physician

  • Thirst is the first signal of Dehydration
  • Check the urine color
  • The dark color indicates dehydration
  • Lighter the color, better hydration
  • Dry skin
  • Dry lips
  • Less urination
  • Feeling tired, dizzy, and headaches

How to increase water intake?

  • Keep a water bottle next to you or a reachable place.
  • Use a mobile app to remind and measure your intake.
  • Fancy bottles attract and improve the intake.
  • Infused water (Lemon, Ginger, and Mint) to enhance the taste.

What is the Healthy Thing to Snack on?

Most times the snacks are the unhealthiest stuff chosen. Portion-sized healthy snacks are a great way to follow small frequent meal patterns. Read more about Adderall otc.

A healthy snack

  • Being between meal times is a good option to decrease hunger and prevent overeating at meal times.
  • boosts the metabolism, sustains the energy levels, and can overcome cravings.
  • to be chosen wisely, because unhealthy snacks lead to weight gain.
  • should be low in sugar, salt, and fat.
  • can be fruit or veggie salad or whole-grain snacks or low-fat dairy instead of junk.
  • can be a combination of Protein + Carbohydrate choices that can keep the stomach full for a longer time. Eg: Yogurt and fruits, Hummus with Vegetable sticks or cheese with fruit slices, etc.

Some sensible snack replacements:

  • Mixed nuts( 1 ounce)
  • Low-fat Yogurt/ laban (1 cup)
  • Fruits (1 serving)
  • Dark Chocolate (30 gm)
  • Air Popped Popcorn( 3 cups)

Why Is Fiber Good for You?

Benefits:

  • Helps maintain bowel health and Prevents constipation.
  • Helps in lowering blood cholesterol levels.
  • Helps in better control of blood sugar levels.
  • Keeps the stomach full.
  • Aids achieving healthy body weight.

Recommendation:

  • 14g of fiber for every 1000Kcal
  • Females: 25g/day Males: 38g /day

Tips to increase fiber in your diet

  • Include lean veg proteins-Beans, peas, and lentils.
  • Snack on nuts and seeds.
  • Increase your fruit and vegetable intake.
  • Have the fruit instead of the juice.
  • Don’t peel the fruit or veg before consuming it.
  • Go for whole-grain products (at least 50% can be whole grains).

You can also find the best fiber supplements at buoyhealth.

How Physically Active Are You?

Inactive: less than 5,000 steps per day

Average (somewhat active): ranges from 7,500 to 9,999 steps per day

Active: more than 10,000 steps

Very active: more than 12,500 steps per day

Tips to Include More Steps to Your Day

  • Park farther away
  • Walk while waiting
  • Take the stairs
  • Consider a walk with the family. Check these liv pure reviews.
  • Take your pet for a walk
  • Take the farthest way
  • Talk in person. Rather than instant-messaging or emailing with coworkers, get up and walk to their desks
  • Walk during your kids’ activities
  • Start increasing your goal gradually by adding 500-1000 extra steps every 3-4 days

Jeff Sessions, Donald Trump say ‘tough it out’ without opioids but they never felt my pain

Jeff Sessions, Donald Trump say ‘tough it out’ without opioids but they never felt my pain

https://www.usatoday.com/story/opinion/2018/04/02/jeff-sessions-donald-trump-opioids-epidemic-death-penalty-real-pain-column/374829002/

President Trump’s new proposal to combat opioid addiction included some very tough talk about a tragic problem, so it was easy to miss one ambitious goal: slashing legal opioid prescriptions by one-third.

Similarly, when Attorney General Jeff Sessions suggested that part of the problem is that not enough people are willing to “tough it out,” and that they should be just taking aspirin instead, he quickly got my attention. Recently, I tried to do just that.

In early November, at the age of 53, I spent a week in the hospital and was eventually diagnosed with multiple myeloma, a plasma cancer. Thankfully, there are a variety of treatments that hold the promise of long-term remission. But in the short term, multiple myeloma can be extraordinarily painful and many patients can only get relief by using prescription painkillers such as opioids.

Concerns over opioids are not unfounded. The CDC reports that overdoses from prescription opioids have quadrupled since 1999, numbering over 20,000 in 2015. Those numbers are of real concern, but we cannot forget that there are also real, tangible costs of living with pain — and that pain relief is part of the healing process for patients like me.

Multiple myeloma eats away at the calcium in your bones, weakening them. In my case, it went after my back, causing two small stress fractures and numerous lesions, all of which were extremely painful.

 In the hospital, I was able to deal with that pain using Tylenol, mostly because I was just in a bed or chair all day. I declined the offer of prescription painkillers when I was discharged. One reason was that worries about opioid addiction had me concerned. Unfortunately, it didn’t take long for the pain to become serious once I got home and started moving more.

People who wish to drastically limit access to opioids need to know the reality of this kind of pain. Getting out of bed took 10 minutes or more because even one small wrong movement while getting to a sitting position would cause severe back spasms, making me shudder with pain. Walking around my house required balancing myself on walls and door frames.

 The pain from sitting down and standing up from the toilet required that I use a chair to hold my weight like one would use a walker. I had visions of being found in the bathroom, stuck on the toilet or even unable to get up off of the floor. Every little twist and turn of my body risked those spasms and shuddering.

Eventually I realized my mistake and got a prescription for opioids. The quality of my life quickly and dramatically improved, as within two or three days, the pain was reduced substantially and my mobility and mood were significantly better. I could walk comfortably and hug my kids again.

It’s important to understand that this kind of debilitating pain not only causes unnecessary suffering, it prevents patients from healing. It takes every bit of energy you have to fight it, and your body has little to nothing left to use to heal. Some medical professionals call pain “the fifth vital sign” because of the way in which it matters for a patient’s health. Opioids enabled me to relax, to sleep and to heal.

Four months later, I am almost completely pain-free and have been largely able to resume most of my normal activities. Blood work indicates that my chemotherapy is beating back the cancer. Access to opioids has without a doubt been a key factor in how quickly my health has improved.

The controversy around opioids makes people fear legitimate and humane medication. I can’t get back that week I spent in pain. I can’t erase the experience of watching my kids and the rest of my family seeing me suffer.

Policymaking that ignores the benefits of opioids and focuses only on the drawbacks —as serious as they are — is unacceptably one-sided, and passing such policies will mean that thousands, if not millions, will suffer unnecessary pain and fail to heal as they should.

Tackling opioid overuse may indeed require a serious overhaul of a health care system in which some doctors find it easier to throw pills at patients than talk to them. And when those pills are paid for by third parties, the incentives to use them sparingly are weakened.

But in the end, what medications are appropriate will always best be determined within the doctor-patient relationship, not by bureaucratic dictates and bans. The opioid problem might be real, but unilaterally denying relief to those in pain is a cure that’s worse than the disease.

Steven Horwitz is an economist with Ball State University and an affiliated senior scholar with the Mercatus Center at George Mason University.

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