“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
In our neighbor to the north, the cannabis industry is budding at an incredible pace. Canada legalized medicinal marijuana all the way back in 2001, and Health Canada, its version of the U.S. Department of Health and Human Services, has been overseeing licensing and production ever since.
Today, Canada stands on the verge of legalizing recreational cannabis. A bill introduced in April 2017 has made its rounds in the federal government and is set for a June 7 Senate vote that should lead to legalization shortly thereafter, assuming passage in the Senate. According to regulators, adults over 18 in Canada should be able to legally purchase cannabis beginning in August or September, leading to $5 billion or more in annual sales, if approved.
The U.S. cannabis industry is stuck in neutral
Comparably, the United States is stuck in the marijuana “Stone Age.” Not only is there little hope of recreational legalization on the horizon, but there’s virtually no chance that the federal government with alter its Schedule I classification on pot, which makes it entirely illegal and categorizes it as highly prone to abuse and having no recognized medical benefits.
This Schedule I classification makes life very difficult for medical patients, investors Opens a New Window. , and marijuana businesses alike. For example, businesses have limited or no access to basic banking services, including lines of credit or something as simple as a checking account. Since U.S. financial institutions report to the Federal Deposit Insurance Corporation, a federally created entity, and pot is illegal at the federal level, any assistance provided by banks to marijuana companies could be construed as money laundering, under a strict interpretation of the Controlled Substances Act (CSA).
Similarly, pot-based businesses are forced to pay a ridiculously high effective tax rate that can approach 70% to 90% as a result of tax code 280E. Put simply, since cannabis is illegal, businesses that primarily generate their sales and income from an illegal substance under the CSA are unable to take normal corporate income-tax deductions.
As for patients, they’re left out in the cold because of bureaucratic red tape. With only one legal growing facility in the U.S. at the University of Mississippi, researchers’ hands are tied in validating the scientific risks and benefits of medical cannabis.
Jeff Sessions declares war on the U.S. pot industry
And at the heart of this opposition is Attorney General Jeff Sessions, who has made clear on a number of occasions how he feels about weed. He’s suggested that “good people don’t smoke marijuana,” as well as intimated in speeches that marijuana is one of the drugs to have caused the opioid epidemic, rather than being a solution for it.
Last May, Sessions sent a letter to a handful of his congressional colleagues requesting that they repeal the Rohrabacher-Farr Amendment, also known as Rohrabacher-Blumenauer. This amendment is attached to federal spending bills, and ii’s what currently disallows the Department of Justice from using federal dollars to go after medical marijuana businesses in legal states. Sessions hasn’t been successful in getting this amendment tossed out.
But Sessions was able to successfully rescind the Cole memo Opens a New Window. on Jan. 4. The Cole memo, written by former Deputy Attorney General James Cole under the Obama administration, outlined a set of guidelines that states would have to follow if they wanted to keep the federal government from interfering with their weed industry. Among these guidelines were provisions to keep marijuana away from adolescents, as well as ensuring that pot grown within a state stayed in that state. The rescinding of this memo by Sessions, who claimed it overstepped its bounds when implemented, now allows state prosecutors to use their discretion in bringing charges against businesses and individuals that violate the CSA — even in states that have legalized.
Congress strikes back
However, Sessions’ views aren’t in the majority. A Gallup poll released in October showed that an all-time high 64% of respondents favors the idea of legalizing marijuana nationally. What’s more, four other national polls Opens a New Window. since April 2017 have shown similar support for legalization.
Therefore, it should come as no surprise that a federal spending bill designed to fund the government through Sept. 30, the end of the current fiscal year, contains a rider designed to protect medical marijuana businesses from the Justice Department and Jeff Sessions. Under Section 538 of the new law, the Justice Department won’t be allowed to use federal dollars to go after medical marijuana businesses. It also continues existing protections for industrial hemp research. The law will limit the scope of what Sessions can do to slow the expansion of cannabis at the state level.
Of course, that’s not all. Last week, a group of nearly five dozen bipartisan lawmakers wrote a letter to the House Appropriations Committee requesting that new, broader provisions be included in the 2019 federal budget that protect all marijuana businesses, not just medical ones, from federal prosecution as long as they’re complying with state-passed cannabis laws. As noted in the letter:
Thirty states have legalized medical cannabis in the U.S. — Virginia became the 30th very recently — and nine others have OK’d recreational weed. The stakes are high, and Congress appears to finally be siding with the majority view of the public, at least in this rare instance.
Don’t expect marijuana’s scheduling to change anytime soon
But it’s also pretty clear that as long as Jeff Sessions is the attorney general, and President Trump remains in the Oval Office, there’s virtually no chance marijuana’s scheduling will be altered.
Back in 2016, the U.S. Drug Enforcement Agency (DEA) had an opportunity to reschedule or de-schedule pot following two petitions to do so, but following the recommendation of the Food and Drug Administration it decided to let things be Opens a New Window. . In particular, the DEA found a lack of medical benefit evidence, as well as a high probability for misuse, as reasoning to leave its Schedule I classification in place. Considering how long petitions can take to work their way up the chain of command at the DEA, it’s unlikely marijuana will get another look from the regulatory agency anytime soon.
Meanwhile, Trump, who was supposedly “100 percent” behind the idea of medical marijuana during his campaign, has seemingly cooled on the topic of legalization Opens a New Window. . For example, Israel recently shuttered plans to export dried cannabis for medical purposes to the United States to satisfy Trump, according to reports.
There simply isn’t a pathway to legalization at the federal level right now, which leaves what could be the most lucrative marijuana market in the world stuck in limbo. That’s bad news for patients who might benefit from medical cannabis, as well as for investors.
Before Cynthia Bly used up the last of her prescription of pain pills in January, she was able to do the dishes, cook meals and take short walks with her husband outside their rural Springfield home.
Now that the 64-year-old former office worker no longer has access to hydrocodone, an opioid pain reliever, the pain from her chronic back problems and other medical conditions is too overwhelming for her to enjoy those simple activities. She spends most of her days in a recliner or wheelchair and uses a portable commode to avoid the pain and risk of falling on the way to the bathroom.
“It’s been terrible for me because they took away everything that helped me walk,” she said. “My God, I can’t do anything anymore.”
Bly, who lost access to prescription painkillers late last year when her longtime doctor stopped practicing full time, is one of perhaps millions of chronic-pain patients nationwide who have been affected by a nationwide opioid epidemic fueled in part by overprescribing, but largely driven by abuse of heroin and fentanyl.
Patients who aren’t abusing opioids are the “silent majority,” said Dr. Andrew Bland, president of the Sangamon County Medical Society.
But doctors are involuntarily weaning many of the nation’s 10 million to 12 million chronic-pain patients off opioid medications, suddenly ending prescriptions or declining to treat such patients altogether, experts say.
The actions, according to critics of the trend, have taken place because of government recommendations in 2016 to encourage more conservative prescribing of narcotic pain relievers, along with ongoing concern stemming from the punishment of alleged opioid over-prescribers by state regulators and the U.S. Drug Enforcement Administration.
“These cases are a reality,” said Dr. Nestor Ramirez, a Champaign physician who is president of the Illinois State Medical Society.
Advocates for patients and health-care providers say patients are being treated like heroin addicts and suffering needlessly without being offered effective alternatives.
The patients tend not to complain because they are too sick or too scared of being abandoned by their doctors, according to those advocates, some of whom have been accused of being in league with pharmaceutical manufacturers for accepting contributions from them.
In extreme cases, patients are becoming even more debilitated, buying prescription opioids and illegal opioids such as heroin and fentanyl on the street, sometimes overdosing on those drugs, critics of the crackdown charge. Critics say some pain patients are dying by suicide, though such deaths are rare.
Chronic pain, opioids and overdoses, by the numbers
* One-third of Americans have chronic pain, and 3 percent to 4 percent of the total U.S. adult population receives prescription opioid painkillers for longer than three weeks, according to medical studies.
* Almost two-thirds of the 63,600 drug-overdose deaths in the United States in 2016 were caused by opioids ranging from heroin to prescription opioids such as methadone and oxycodone or fentanyl, according to the U.S. Centers for Disease Control and Prevention.
* Commonly prescribed opioids such as hydrocodone, oxycodone and morphine are associated with a significant number of fatal opioid overdoses — 40 percent — according to federal statistics that indicate more than 200,000 Americans died from 1999 to 2016 from overdoses of such prescription drugs. But federal officials say heroin and fentanyl are driving the increases in opioid-related death. Deaths related to fentanyl, a drug 30 to 50 times more powerful than heroin and which can be obtained through prescriptions or made illegally, are rising at some of the highest rates. Fentanyl often is mixed with heroin by dealers and users to produce a more intense “high.”
* More than 60 percent of people who died from an opioid overdose had been diagnosed with a chronic-pain condition, and many had been diagnosed with a psychiatric disorder, a study of more than 13,000 overdose deaths found.
* There were more than 30 nonfatal overdoses for every opioid-related overdose death in 2016.
* Of Sangamon County’s 42 opioid-related deaths in 2017 — the highest number of such deaths since detailed statistics began being collected locally — all but nine primarily involved heroin or fentanyl, according to the county coroner’s office. And fentanyl was the primary component in 20 of the deaths.
* Statewide, 1,502 of the 2,022 opioid-related deaths in 2017, or about three-quarters, involved opioids classified as prescription drugs. But according to the most recent statistics, fentanyl-related drugs played a role in more than 70 percent of those deaths.
The use of opioid painkillers has dropped in recent years, and that trend needs to continue, Ramirez said. But he said he believes there has been “misinformation and misinterpretation” of the U.S. Centers for Disease Control and Prevention’s 2016 guidelines on opioid prescribing.
Those guidelines discourage opioids as routine therapy for pain lasting longer than three months except for cancer patients, palliative care and end-of-life care.
Ramirez said there needs to be more education of doctors and patients on treating chronic pain and more willingness by health insurance plans to pay for medication-assisted treatment for opioid addiction and alternative pain treatments such as physical therapy, massage and acupuncture.
Bland said he is working with others in Sangamon County’s medical community on a “rational approach” to prevent patients from becoming dependent on opioids in the future and to prevent overprescribing so fewer unused pills are stolen or otherwise “diverted” for street sales.
That approach, he said, can reduce local doctors’ fears of punishment and give them more confidence and knowledge to help patients dependent on opioids reduce use of the drugs and decide who can safely continue on long-term opioids.
But until there’s a more nuanced understanding of how patients can be best served, pressure being put on doctors across the country by their peers, professional organizations and the government means “the people in pain are forgotten,” according to Dr. Lynn Webster, a pain researcher in Salt Lake City and former president of the American Academy of Pain Medicine.
“What we’ve done is say, ‘Opioids are bad and everybody who’s on opioids long term is at risk of overdosing,’ and that’s wrong,” Webster said. “The legitimate pain patient is paying the price.”
A more cautious prescribing approach
It’s undisputed that the use of prescription painkillers for legitimate medical problems can lead to addiction and overdoses, but such a path is uncommon in the general population of patients.
One study says 3 percent to 10 percent of patients receiving painkillers after surgery become chronic users of those drugs, and 1 percent of surgical patients abuse the drugs — using them beyond their intended medical purpose.
Research suggests that two-thirds of overdoses related to prescription drugs involve drugs that have been diverted, meaning they have been stolen or sold and not used by the patient for whom they were prescribed, Webster said.
That’s a big reason experts say it’s important for doctors not to overprescribe.
Illinois’ Prescription Drug Monitoring Program, which provides a database of patients that doctors can check before issuing opioid prescriptions, helps reduce “doctor shopping” among patients and overprescribing by health professionals, according to Maria Bruni, acting director of the state’s Division of Alcoholism and Substance Abuse.
The program has seen use of the database skyrocket since the enactment of a state law in January requiring prescribers to register in the program and document certain new opioid prescriptions, Bruni said.
The program, she said, “is meant to change that interaction between the prescriber and their patients” without denying needed medicine for chronic-pain patients.
Eventual heroin use is rare among legitimate prescription drug users, according to the National Institute on Drug Abuse. The institute says an estimated 4 percent of people who abuse prescription opioids, after obtaining them for medical or nonmedical purposes, become heroin users.
Prescription opioid users do face higher risks, though.
A study indicated that frequent prescription opioid users and those diagnosed with dependence or abuse of prescription painkillers are 40 times more likely to end up using heroin. And almost 80 percent of heroin users report using prescription opioids, for either medical or nonmedical purposes, before turning to heroin, the institute said.
Institute officials said the use of multiple mind-altering drugs, not just prescription opioids, during a person’s life can be the most common path to heroin.
“It’s about the progression of a disease,” Webster said. Prescription opioids, he said, are not “gateway” drugs.
Austin Wells, 31, a recovering heroin addict living in Springfield who has been clean about nine months, said he previously used cocaine, marijuana, alcohol and LSD before he became addicted to opioids, and eventually heroin, after he was prescribed opioid painkillers for a back injury in his early 20s.
He agrees with experts who say doctors considering prescribing opioids should first determine a patient’s substance-abuse history to gauge long-term risk of abuse.
“My mind acts differently than most people,” Wells said. He was never dependent on the other drugs, but once he began using opioids, he said, “I was hooked.”
But many doctors are refusing to treat pain patients or weaning their existing patients off opioids against their will rather than considering non-opioid alternatives or weighing appropriate opioid doses, said Bob Twillman, executive director of the Academy of Integrative Pain Management in Lenexa, Kansas.
Doctors often don’t want to deal with patients’ mental-health issues, or battle with insurance companies that often refuse payment for alternative treatments, he said.
Dr. Andrew Kolodny, an opioid researcher at Brandeis University in Massachusetts and director of Physicians for Responsible Opioid Prescribing, advocates for more-cautious prescribing of opioid pain medicine. He said he has criticized pain industry-funded professional organizations that “promote aggressive use of long-term opioids.”
“The evidence suggests that for the vast majority of people with chronic pain, the risks of taking opioids around the clock, for weeks and years, outweigh the benefits,” Kolodny said.
However, he added that many doctors don’t under understand how hard it is for patients to be weaned off of opioids, and some patients need treatment for addiction rather than scorn.
Some chronic-pain patients think they’re being treated like addicts, but “nobody is calling them addicts,” Kolodny said.
An “important proportion” of pain patients are being “unilaterally withdrawn” from their medicine, said Dr. Kurt Kroenke, a researcher and practicing physician at the Indiana University School of Medicine in Indianapolis.
Kroenke said he isn’t an advocate of opioids and opposes high doses for patients in most cases, but “it doesn’t make sense to take them off if it’s working for them.”
The national push to “get everybody off” opiates has created a stigma for patients and doctors alike, resulting in chronic-pain patients being classified as “drug seekers,” he said.
“This is somewhat of a polarizing issue right now,” Kroenke said.
In fact, Kroenke discourages excessive use of the term “opioid epidemic” because it increases stigma.
“An epidemic generally suggests a disease that is widespread and usually highly contagious rather than limited to a minority of those exposed,” he wrote in 2017 in the Journal of the American Medical Association. “An unintended consequence of excessive concerns raised about opioids could be an increasing reluctance among clinicians to prescribe even small amounts of opioids for a limited time for acute pain, including for patients discharged from the emergency department.”
Kroenke told The State Journal-Register that the CDC guidelines are “not unreasonable” but “they’re being over-interpreted.”
Doctors see need for chronic pain programs
Dr. Loren Hughes, president of Springfield-based HSHS Medical Group, said doctors are using the guidelines appropriately. But he said chronic-pain patients are a lot of work for doctors who have limited time for visits and face stagnant or declining reimbursements from Medicaid, Medicare and private insurers.
There aren’t enough multi-disciplinary programs locally or nationwide to treat chronic-pain patients, including those well-served with long-term opioid medicine, and take the burden off primary care doctors, Hughes said.
Chronic-pain patients whose needs require that attention are among the opioid epidemic’s collateral damage, he said.
It can be especially difficult for patients when their longtime doctors retire, he said. These patients may find it difficult or impossible to find another doctor willing to manage their care and potentially face scrutiny for long-term opioid prescriptions, he said.
Bly, the Springfield pain patient, said she was functioning adequately with the help of hydrocodone for more than a decade before she said she was told by a nurse that her doctor, Memorial Physician Services internist Mary Saunders, would be retiring in December.
Bly said she was told by Saunders’ nurse that she needed to find a new doctor. So Bly made an appointment with another MPS doctor, Avinash Viswanathan, whom she said subsequently told her that he couldn’t take on her care because he wasn’t prescribing opioids for new patients. He told her that he would inform Saunders they had spoken, Bly said.
Even before Bly left Saunders’ care, Saunders earlier in 2017 reduced the number of hydrocodone pills that she was willing to prescribe.
Saunders said she was “afraid of getting in trouble with the DEA and the CDC,” according to Bly.
After meeting with Viswanathan, Bly said she received a puzzling letter from Saunders mentioning that Bly had visited another doctor and dismissing Bly as a patient.
“She made it sound like I was doctor-shopping to get more opioids,” Bly said. “We got along really well. I don’t know what happened.”
Bly eventually learned that Saunders continued to practice on a limited basis instead of retiring. But Bly said she didn’t want to ask whether she could resume care from Saunders after the apparent insult.
Bly hasn’t been able to find another doctor willing to continue her hydrocodone prescription. Her current doctor, from HSHS Medical Group, has agreed to care for her but isn’t treating chronic pain with opioids, Bly said.
“Now I’m in a wheelchair instead of walking,” she said.
Bly even tried illegal marijuana because she heard it might ease her pain, but it didn’t work for her.
“All it does is make me want to eat and sleep,” she said.
Memorial Physician Services officials wouldn’t comment on Bly’s interactions with Saunders and Saunders’ office. Officials also wouldn’t say whether MPS doctors have been involuntarily weaning patients off of opioids or deciding to no longer prescribe opioids.
The medical group “does not mandate care plans for how physicians treat individual patients, including the management of opioid medications,” said Michael Leathers, spokesman for Memorial Health System. The system operates the medical group.
“Each physician partners with their patients to make the most medically appropriate decisions for their care and well-being, including changing medications that are not effective or where the risks outweigh the benefits of use,” Leathers said.
Dr. Virginia Dolan, medical director of population health for Memorial Health System, said the medical group convened an internal task force last year to produce a chart with non-binding recommendations to give its doctors, nurse practitioners and physician assistants more comfort when prescribing opioids.
The chart, expected to be in use by April, is designed to ensure that prescribing habits are “conservative,” in line with “best practices” and give patients “the least amount of medicine to get the job done,” she said.
Dolan said the chart also could help to avoid situations in which patients may be cut off or weaned off of opioids unnecessarily.
Hughes said the HSHS medical group doesn’t have any overall policy requiring doctors not to accept new pain patients. He said he doesn’t know whether any HSHS doctors may have altered their practices in this way or decided as new members of the group not to treat pain patients.
Officials from Springfield Clinic and SIU Medicine — the physician group associated with Southern Illinois University School of Medicine — either didn’t respond to requests for comment for this story or declined comment.
‘I wonder how I survived’
Earl Hill, 46, of Springfield said he didn’t dispute his doctor’s decision nine months ago to reduce the prescriptions for hydrocodone and methadone the former construction and convenience store worker used for more than 10 years to deal with a variety of back and nerve problems that eventually disabled him.
Hill said he didn’t want to upset his doctor for fear the doctor would drop him as a patient.
“I didn’t say anything to him because doctors do what they pretty much want to do,” Hill said. “They have control over you.”
Hill’s life took even more of a turn for the worse about six weeks ago, when the doctor’s office told him the Medicaid program wasn’t approving any more payment for his hydrocodone. Hill went through withdrawal from the drug on his own and said the pain made his arms shake so badly that he slipped and broke his left hand about a month ago when he tried to get out of the bathtub.
Now Hill, who is single, said he no longer is able to endure the pain of pushing his wheelchair outside to his porch to watch people walk by. He worries that his doctor eventually will cut him off from all methadone pills.
“It’s making my depression worse because I can do less than before,” he said. “I don’t want to live all crippled. It’s like life isn’t worth living anymore.”
Hill gave permission for a reporter to get information from the state about his case, and a spokesman for the Illinois Department of Healthcare and Family Services, the agency in charge of Medicaid, said payment for the hydrocodone prescription renewal wasn’t approved because the doctor didn’t submit the required additional documentation.
“HFS staff has also been working closely with the doctor to find a tapering plan that would best suit the patient, including non-narcotic alternatives,” HFS spokesman John Hoffman said.
Jennifer Bertoni of Rochester said it’s unfair how pain patients are being affected, but she said she benefited from doctors eventually turning her down for prescription opioids.
Nerve damage and other medical problems caused by an indirect lightning strike in 1992 eventually led to Bertoni, 45, becoming addicted to hydrocodone, she said.
“It made me feel like I had no worries about anything,” said Bertoni, a paramedical examiner and former emergency medical technician and phlebotomist who didn’t use other drugs recreationally and never was tempted to use heroin.
When one doctor dropped her, she went to another, then another, she said. She said she was hospitalized a few times for overdoses.
Bertoni, a divorced mother of three, said she eventually resorted to buying hydrocodone through social connections, spending $6 to $8 per pill, or $300 to $400 for 60 to 80 pills that would last her a few days.
She said she continued to work, sometimes alongside health professionals who also were abusing opioids after starting on the drugs to deal with pain.
When her parents stopped helping her pay her bills and stopped talking with her, she went through treatment at Gateway Foundation and has been clean 10 months.
Her chronic pain remains, she said, but it’s being relieved somewhat by the drug Suboxone, which helps reduce opioid cravings.
Bertoni said she realized that she never needed as much pain medicine as she was taking in the past. Dependency to the medicine, she said, led to pain associated with withdrawal.
“People who are in addiction isolate themselves,” she said. “I wonder how I survived.”
Contact Dean Olsen: dean.olsen@sj-r.com, 788-1543, twitter.com/DeanOlsenSJR.
*****
Chronic pain, opioids and overdoses
* One-third of Americans have chronic pain, and 3 percent to 4 percent of the total U.S. adult population receives prescription opioid painkillers for longer than three weeks, according to medical studies.
* Almost two-thirds of the 63,600 drug-overdose deaths in the United States in 2016 were caused by opioids ranging from heroin to prescription opioids such as methadone and oxycodone or fentanyl, according to the U.S. Centers for Disease Control and Prevention.
* Commonly prescribed opioids such as hydrocodone, oxycodone and morphine are associated with a significant number of fatal opioid overdoses — 40 percent — according to federal statistics that indicate more than 200,000 Americans died from 1999 to 2016 from overdoses of such prescription drugs. But federal officials say heroin and fentanyl are driving the increases in opioid-related death. Deaths related to fentanyl, a drug 30 to 50 times more powerful than heroin and which can be obtained through prescriptions or made illegally, are rising at some of the highest rates. Fentanyl often is mixed with heroin by dealers and users to produce a more intense “high.”
* More than 60 percent of people who died from an opioid overdose had been diagnosed with a chronic-pain condition, and many had been diagnosed with a psychiatric disorder, a study of more than 13,000 overdose deaths found.
* There were more than 30 nonfatal overdoses for every opioid-related overdose death in 2016.
* Of Sangamon County’s 42 opioid-related deaths in 2017 — the highest number of such deaths since detailed statistics began being collected locally — all but nine primarily involved heroin or fentanyl, according to the county coroner’s office. And fentanyl was the primary component in 20 of the deaths.
* Statewide, 1,502 of the 2,022 opioid-related deaths in 2017, or about three-quarters, involved opioids classified as prescription drugs. But according to the most recent statistics, fentanyl-related drugs played a role in more than 70 percent of those deaths.
U.S. Attorney General Jeff Sessions was in Tallahassee Thursday afternoon where he announced a new initiative that he says will take drug traffickers off the street and put them in prison cells, and suggested the death penalty be handed down “in drug trafficking cases where it is appropriate to do so.”
“Today, I am announcing with Acting DEA Administrator Rob Patterson that the DEA will surge 250 task force officers—and dozens more analysts—to places across America where the opioid crisis is at its worst,” Sessions said in a speech given at the U.S. District Courthouse in Florida’s capital. “These new resources will help us catch and convict more of the drug traffickers and corrupt medical professionals who are fueling the opioid crisis. And when we do, we will pursue the tough sentences they deserve.”
Sessions said an estimated 64,000 Americans died as the result of drug overdoses in 2016, 42,000 of them from opioids.
“That’s the equivalent of the entire city of Daytona Beach dying from drug overdoses in a single year,” Sessions added.
He says for Americans who are under the age of 50, drug overdoses are now the leading cause of death. He says the crisis is being driven by the abuse of opioids, such as prescription painkillers, heroin, or even synthetic drugs like fentanyl.
“Let’s be clear about this: drug dealers take lives every day in America. As President Trump has said, career drug traffickers can take more lives than a mass murderer,” Sessions sa“That’s why the President has ordered us to seek the death penalty in drug trafficking cases where it is appropriate to do so. And just yesterday we began implementing this order at the Department.”
Speaking to a room of local and federal law enforcement officers and prosecutors, the attorney general pointed out the death penalty can also be given to drug dealers under Florida law. The car accident injury cases lawyers in San Antonio helps with injury cases.
“The people’s representatives have voted for these laws because they intend for us to use them,” Sessions said.
Sessions’ visit to Tallahassee comes just days after Gov. Rick Scott signed legislation into law that imposes tougher restrictions on prescription drugs and reinforces treatment programs in an effort to combat the opioid epidemic in Florida. The Law Offices Of Michael H. Pham welcomes the decision made by the government which would control the drug flow inside the country eventually reducing the number of users gradually.
Florida’s opioid law places a three-day limit on prescriptions issued to help patients deal with acute pain. That limit could be extended to a seven-day supply of painkillers if a doctor determines a longer supply is medically needed for a patient.
Those with severe medical conditions, including cancer patients, people who are terminally ill, palliative patients, and those who suffer from major trauma, would be exempt from the restrictions.
The new law would mandate that doctors check with the state’s prescription drug database, known as the prescription drug monitoring program, before they prescribe or administer drugs. Before now, doctors were not required to check with the database. The requirement is designed to prevent people from going to multiple doctors to get prescriptions for painkillers.
The law aims to reduce the number of people who abuse street drugs, like heroin and fentanyl, after becoming addicted to prescription painkillers.
It’s estimated the state’s opioid epidemic claims the lives of at least 16 people in Florida every day.
“And as we all know, these are not just numbers – these are moms, dads, daughters, spouses, friends, and neighbors,” Sessions said in his speech. “Sadly, even newborn babies are suffering because of this epidemic. By the time this speech is over, another baby will be born in the United States who is physically dependent on opioids.”
Sessions vowed that the Trump administration will not sit back as the opioid epidemic shatters lives, families and communities. He says various programs have been initiated by the U.S. Justice Department in recent months to help fight the opioid crisis.
There is only one word for IDIOT …but.. there is so many ways to demonstrate who it should apply to.
President Trump has surrounded himself with numerous attorneys – many/most of them who know someone who has OD’d on some substance(s). One of his advisors is an admitted alcoholic/drug addict in recovery. How many within the administration are current or former alcohol/drug addicts is unknown.
Congress has abt 40% attorneys, part of the same judicial system that contains the DEA… and the war on drugs that is currently a 81 billion/yr industrial complex that employs some 500,000 to ONE MILLION people. Which started out 48 yrs ago with 1200-1500 employees and a 42 million/yr budget.
Death Penalty – REALLY – here is a member of management being charged with involuntary manslaughter because of a fatal accident on a water ride. This park is park of a 5 park family owned park and operations director at the water park was Tyler Miles who is being charged with involuntary manslaughter. Maybe because the 10 yr old was the son of a Kansas representative.. https://www.thesun.co.uk/news/5890053/caleb-schwab-verruckt-water-slide-schlitterbahn-water-park-kansas/
There are more people killed in vehicle accidents than illegal opiates… but don’t see anyone charging any part of the auto industry being charged with manslaughter because the sold someone a car.
Do we really know the number of deaths caused by cell phone use while driving ?.. but we don’t see anyone charging any part of the cell phone industry with manslaughter because someone misused a cell phone.
There is nearly 7000 people in the USA that die every day.. from some reason… how many because someone is using or misusing some product. Are we moving toward a point where … when a relative/friend of a bureaucrat/politicians/attorney that we have another fabricated crisis because to those “important people” it should not have happened to someone they knew or a family member and don’t want it to happen to anyone ever again… and we find a need to punish someone – even maybe the DEATH PENALTY.
We eliminated the vast majority of illegal liquor stills that existed during the 12-14 yr of alcohol prohibition, perhaps it is time to consider the decriminalization and legalize all substances. Just let individuals be responsible for their own choices and quit trying to legislate personal responsibility and morality ?
We have had #ATT&T for most of the last 25-30 yrs… even back when they called it #Cingular. People use to make comments about #MA-BELL and her “it my way or the highway”.. which was probably behind the government causing her to be broken up into “Baby Bells”.
It would seem that #MA-BELL is back with her old attitude.
Recently, I tried to login to my #ATT&T online account and couldn’t get in.. after a phone call I was told that if I hadn’t logged into my on line account in the last 30 days they would have DELETED my on-line account.. So I had to create a new account.. and once I got into the account, I found out that last month.. something happened with the processing our our charge card and the account was a month pass due.. So I arranged for both the past due and current amounts to be taken care of.. This also paid off our two Iphone 6S.
Both phone paid off, account current, no contract… maybe it is time to look elsewhere. After paying off the phones our monthly bill would be $80 + fees/taxes
I keep hearing the Consumer Cellular… and with a little investigation.. it would seem that they use #AT&T and T-Mobile’s towers.. they are nothing but bulk reseller of cell service…
Come to find out that for the same service.. Consumer Cellular would charge us $52.50 + fees & taxes.
I call Consumer Cellular to start the process and a few days later I get two new SIMS cards for our phones… then the FUN BEGINS…
They start “porting” the numbers over and my phone will not update… it is DOA.. according to Consumer Cellular website if you have a AT&T or T-Mobile phone and/or your phone is “unlocked”… the transfer should be “a piece of cake”…
Come to find out, Consumer Cellular send me a T-Mobile SIMS card.. and not a AT&T SIMS card … which means that my AT&T phone has to be UNLOCKED… call AT&T and they give me a website to request it to be UNLOCKED… filled out the online form and I am informed that it takes TWO BUSINESS DAYS for them to process my request.. since the request was done on Thursday.. it would not be finished processing until MONDAY – still have TWO DOA cell phones.
I go to the Consumer Cellular website… and I find a address to send a email… after filling out the email … and got a response – we will respond to your email WITHIN 5 DAYS…
I did a web search “how to make a phone call with laptop over internet”… found GOOGLE VOICE 🙂
Call Consumer Cellular again.. I can go to the nearest Target and get the correct phone calls… drive 8 miles to Target – don’t have any AT&T SIMS cards in stock.
So back home and back on the phone with AT&T… they ported my numbers and left our phones LOCKED ??? Spent a hour on the phone with AT&T … including talking to a supervisor… mentioned that I had a disabled wife and having only GOOGLE VOICE was not the best situation… “sorry… we have a processes… it will be MONDAY “
Called back to Consumer Cellular.. and the person I spoke with offered to send out the AT&T Sims cards… and when would I get those – THREE TO FIVE DAYS !!!
So it would appear that with AT&T cellular… even after you have satisfied your contract, paid all outstanding bills… they maintain a “tight hold” on the equipment that you have paid for.
Once we get on Consumer Cellular service… I will update…
President Trump held a meeting earlier this summer with the Secretary of Health and Human Services (HHS), the Director of the Office of National Drug Control Policy (ONDCP), and other advisers to take a deep dive into solving the nation’s worsening opioid overdose problem.
The Trump administration is clearly shifting into high gear on this issue. HHS Secretary Price, for example, agreed with a reporter during the press briefing that followed, when the reporter called it a “national emergency.” Even more disturbing, however, were recent assertions made by New Jersey Governor Chris Christie in a recent interview. Christie, who heads a White House Drug Addiction Task Force, claims that in 2015 doctors prescribed enough opioid painkillers to medicate every American adult for 3 weeks.
If these numbers appear implausible or like they are missing some context, it’s because they are. And the Administration’s resorting to hyperbole creates an atmosphere of panic that is likely to lead to policies that will only make matters worse.
Let’s start with the context-dropping. What does the governor mean by “medicated?” To a practitioner “medicated” means being treated with a medicine in order to achieve a desired result. Does that mean one 5mg oxycodone tablet every 4 hours (6 per day) for 21 days? Some patients are prescribed two 5mg tablets every 6 hours. Or is he talking about 7.5 or 10 mg oxycodone tablets? Maybe he means hydrocodone. That also comes in 5mg, 7.5mg, and 10mg doses and is sometimes prescribed every 4 hours but sometimes every 6 hours. Then there’s hydromorphone (dilaudid), oxycontin, and let’s not forget codeine.
The point is, millions of Americans have genuine, medically necessary reasons to be taking opioids. They make up the vast majority of opioid users and it doesn’t make sense to lump them into the opioid crisis.
And opioid use itself, for medical purposes or otherwise, is indeed decreasing. In July the Centers for Disease Control (CDC) reported that prescriptions for opioids by health care providers have been coming down. And the National Survey on Drug Use and Health (NSDUH) has reported that nonmedical use of prescription opioids peaked in 2012 and has been steadily dropping.
That’s not to say the problem is resolving itself. Unfortunately deaths from opioid overdose have been steadily increasing, reaching a new peak of 33,000 in 2015. For the first time the majority of those deaths were from heroin overdose, and the death rate from fentanyl overdose comprised over 4,000 of those deaths. Meanwhile, overdose deaths from prescription opioids have stabilized.
With the crisis already this severe, it’s crucial we get the facts right. Frightening and imprecise rhetoric leads to hastily designed policies with unintended consequences, often making matters worse.
Not all solutions are created equal. States have made the opioid antidote naloxone more available to chronic pain patients and to first responders. And more money is being spent on rehab programs. But so far most proposals for dealing with the overdose problem focus on increased surveillance on patients and providers, inducing doctors to prescribe fewer opioids, and making manufacturers cut back on the amount of opioids produced.
No matter how much regulators clamp down on the medical use of opioids the overdose rate grows. Yet the overwhelming majority of overdose victims are not patients receiving opioids for pain. Less than 1% of well-screened patients become addicted to opioids, according to a 2010 Cochrane analysis. A less comprehensive 2015 review from researchers at the University of New Mexico found the addiction rate ranged from 8-12%. And the CDC has cited a recent study showing the risk of overdose in non-cancer patients chronically receiving opioids for pain at less than 0.2 percent.
In fact, it’s fair to say that many of the deaths from opioid overdoses are the result of drug prohibition. Opioids obtained on the black market are often counterfeit and frequently laced with dangerous additives, such as fentanyl and carfentanil. The dosages are unknown or unreliable. Prohibition also increases profits to drug dealers peddling cheaper and more powerful narcotics.
If policy makers in the Trump administration want to effectively address the problem, there are other ways to do it. They should promote “harm reduction” programs, including pilot “heroin maintenance” programs, such as those that have worked successfully in Switzerland, the UK, Germany, the Netherlands, and Canada. They should also take note of recent evidence from Johns Hopkins University, the University of Michigan, and the RAND Corporation that have shown a dramatic decrease in opioid use and overdose rates in states that have legalized marijuana for medicinal use.
The opioid overdose problem requires a calm and reasoned approach, and a willingness to admit to previous policy mistakes. Rhetoric aimed at frightening the public does not foretell a propitious start.
A contract template used by Express Scripts, the largest pharmacy benefit manager in the U.S., provides a window into how pharmacy benefit managers — middlemen that manage drug coverage for businesses throughout the country — steer negotiations with drug companies to benefit their own financial interests.
Why it matters: These benefit managers have a lot of power over the prescription drug coverage people get through their employers, and they’re supposed to negotiate discounts so coverage is cheaper for insurers and employers. If they’re not making it cheaper, there’s less chance people will get relief from high drug prices.
The details: Axios obtained a 36-page Express Scripts contract template from a source who works in the health care industry. Express Scripts and employers use the document as a starting point to determine how medications are paid for and how pharmacy networks work, but the contract usually is not in the public’s view. Since it’s a template, there are no hard numbers or terms of any specific agreements.
The big takeaway: There’s nothing illegal about these contracts. But the language is clearly written with the PBM’s financial interests in mind, and critics say those kinds of provisions can result in lost savings for everyone, especially for small companies and their employees.
“This whole contract is about the undisclosed spreads that they take.”
Even some of the largest companies think they are protected because they have in-house and outside attorneys vetting contracts, yet that’s not necessarily the case.
“That’s a little bit like going to Las Vegas and consistently thinking you can beat the house at their own game,” said one source who has worked in the industry for many years. “These PBMs have entire departments of lawyers where this is their game.”
The other side: Express Scripts, which is in the process of being acquired by Cigna in a $67 billion deal, didn’t dispute the contract template was its own. But spokeswoman Jennifer Luddy said in an email the document was “several years old,” although some sources said it appeared to be current.
Luddy added that employers are “savvy purchasers of pharmacy benefits” and that these contracts are common: “It is industry standard terminology used by all PBMs, and is well-understood by clients and consultants.”
In a follow-up email, Luddy said: “It is clear to us that there are several vocal PBM critics who are eager to provide their biased interpretations of this template contract to serve their own agenda.”
The details: These are some of the major provisions. The contract was explained in interviews with several people who work in or are familiar with the pharmacy benefit industry, most of whom asked not to be named given the sensitivity of the issue and to speak candidly.
Rebates
A primary function of a PBM is to negotiate rebates from drug companies. Most of those rebate dollars flow back to employers (not workers).
But Express Scripts collects other rebate-like fees from drug companies that it doesn’t have to pass along to employers.
The Express Scripts contract explicitly says “rebates do not include things” like “administration fees” from drug manufacturers, “inflation payments” and numerous types of “other pharma revenue.”
“There are so many carve-outs of what they consider a rebate that it’s very murky of what’s being kept and what’s being passed through (to clients),” an industry source said.
The contract also says Express Scripts negotiates rebates “on its own behalf and for its own benefit, and not on behalf of sponsor.”
The brand/generic algorithm
Multiple people said the “proprietary” algorithm is one of the most important definitions, as it gives Express Scripts full authority to determine whether a drug is brand or generic without being transparent.
The algorithm allows Express Scripts to pocket the difference between a brand-drug discount and a generic-drug discount — a major tactic to maximize profits.
“This is why they don’t miss earnings,” said one person familiar with the industry.
Payment schedules
The “MAC list” and “maximum reimbursement amount” also permit Express Scripts to pay for drugs in a way that is “most advantageous to them,” according to a source.
For example, using these different lists of drug costs, Express Scripts can charge its employer clients $15 for a particular medication but pay the pharmacy just $1 for the same medication — and keep the extra money for itself.
Financial disclosures and auditing
The last two pages rehash some of the initial definitions, but also reiterate how Express Scripts can collect almost any type of revenue it wants and “may realize positive margin” — code for reaping big profits and not having to share with employers.
Employers can choose to have their agreements audited, but they have to get Express Scripts’ approval on what auditor is used.
And sometimes they don’t get it. Hayes, a pharmacy benefit consultant who agreed to review the document and speak on the record, said Express Scripts has not allowed her firm to conduct audits.
Update: DocumentCloud removed the contract after receiving a Digital Millennium Copyright Act complaint from Express Script. We’re working on an alternative way to post the full document.
Religious liberty is not a license to discriminate and harm. Yet Trump’s Department of Health and Human Services wants to let health care providers use their religious beliefs to justify turning away patients in need. This is a betrayal of the department’s own mission, and it could have disastrous consequences – particularly for women and LGBT patients.
The department is taking public comments on this proposed rule – which means they must consider and respond to our opinions. We have a short window to mount overwhelming opposition to this rule and stop it from taking effect.
This proposed rule, if it were adopted, could have serious repercussions for patients seeking treatment like abortions, HIV treatment, or gender-confirming surgery to which some people – like extremist Vice President Mike Pence – might object. Here are just some of the ways the proposed rule could hurt patients:
Pregnant women experiencing miscarriages or other serious pregnancy complications could be refused abortion care even when the woman’s life is at risk, and even when the fetus has no chance of survival.
Health providers could discriminate against transgender patients seeking medically necessary care.
Hospital staff could refuse to sign in patients seeking abortions, to assist patients in any way before getting sterilizations, or even provide any information about medical conditions and treatment options.
The Department of Health and Human Services should be protecting our health, not proposing rules that could hurt the health and lives of women, trans people, LGB people, people living with HIV, and others seeking critical care.
We’ve already taken legal action for patients hurt by similar discriminatory policies – and if this rule goes into effect, then we’ll see the Trump administration in court. But let’s get to work now to stop this license to discriminate in its tracks.
On March 6, 2018, the Journal of the American Medical Association published a 12-month randomized clinical trial [authors Erin E Krebs, Amy Gravely, Beth DeRonne, Elizabeth Goldsmith, and others] which compared opioids to non-opioid medications for treatment of moderate to severe osteoarthritis and back pain among 240 Veterans Administration patients. In the days since publication, the study has been picked up by popular online magazines and blogs under blaring, but incorrect, headlines. The trial supposedly “proves” that opioid pain relievers work no better than acetaminophen (Tylenol) or non-steroidal anti-inflammatory drugs (NSAIDs), and that the risks of opioids make them unacceptable in the treatment of these types of pain.
In reality, the trial proves no such thing. To an informed reader, the study is profoundly flawed on several grounds, despite the considerable effort that seems to have gone into study design and execution:
The study addresses types of pain for which opioids have never been a preferred treatment of choice. The first line treatment is anti-inflammatory drugs (NSAIDs).
The study protocols were flawed; the group set up two cohorts of patients in a “practical” trial that offered several medications in sequence until something was found that worked. About 11% of the patients in the “non-opioid” leg of the trial eventually tried tramadol (brand name Ultram) – an atypical opioid pain medication that was not identified as such in the study.
Patients on “non-opioids” were switched between medications an average of four to five times during the year of the study before a medication was found that worked. Patients on opioids either had successful therapy on the first medication tried or were switched only once. This difference was not detailed in the study results.
As noted by senior editor Jacob Sullum in a Reason Magazine blog,“… the researchers excluded patients who were on long-term opioid therapy, which means they ignored people who had already found they did not get adequate relief from other treatments. It seems reasonable to assume that people who are currently using opioids to treat chronic pain are doing so because they think these drugs work better for them than Advil or Tylenol, and they may even be right to think that. If you exclude those patients from a study of pain treatment, you are excluding precisely the people who are most likely to get more relief from opioids.”
Observations of Stephen Nadeau, MD (a specialist in the treatment of chronic pain) in a private email to the author are also meaningful:“The mean dose of opioid was 21 mg morphine equivalent (MEQ)/day and only 12.6% of patients randomized to the opioid group were on > 50mg MEQ/day. The operational clinical range for opioids used in the [the] treatment of chronic non-malignant pain is roughly 50-1000 mg MEQ/day [and yes 1000 is not a typo]. There are excellent scientific data on this, even as the CDC and others have avidly promoted a “one size fits all” concept and advocated for daily dosage of <90 mg MEQ (resulting in untold suffering and many deaths in the 1.6 million people with chronic pain and on doses of >90 mg MEQ/day).
“Variability in opioid dosing requirement is related to genetic variations in the mu-1 opioid receptor gene and to variability in opioid metabolism. Thus, the doses used in the Krebs trial were unlikely to be effective, even for the — on average — moderate pain that characterized this population. Bottom line conclusion: insufficiently titrated doses of opioids are not superior to non-opioid alternatives in the treatment of chronic nonmalignant pain. We have known this for decades.”
“Three different antidepressants were specifically noted as alternatives for pain treatment in the non-opioid group. Just over 25% of the patients in this trial were at least moderately depressed. However, the authors do not provide data on antidepressant use in the two groups — a key omission. Antidepressants are highly effective in treatment of pain and can reduce the dose of opioids needed. Differences in outcome between the two groups relating to opioid use could have been masked by the use of antidepressants in the non-opioid group.
The bottom line is that the study seems to have set up to give a predetermined result: to discredit opioids in favor of NSAIDs and Tylenol. It was a bit like staging a race between some contestants in leg-irons versus others who ran after taking steroids for months.
Any of these biases alone should have disqualified the study from publication in JAMA, but the fact that three of them are found in the same paper raises suspicions, and rightly so. The fact that JAMA editors let this piece see the light of day should have us all questioning the integrity and/or standards of the journal.
The CDC guidelines were published about two years ago and we are seeing a growing list of evidence that the CDC was being deceitful in coming to the conclusion that were included in their guidelines.
At first the members of the “special CDC committee” that were to compile the guidelines were to be kept “confidential”, but they didn’t last long. At least one of the committee members was known as a Medical College Professor that was well known as not being a proponent of treating chronic pain with opiates.
Another committee member was reportedly had financial interest in rehab centers.
It has been reported that some/most of the studies that the committee used to come to their conclusion were rated on a “creditable scale” of 3’s & 4’s.. where “1” is excellent and “4” being rated as unreliable “crap”
The final guidelines were released referencing opiate conversion tables that all have the same or similar “fine print cautions”:Published equianalgesic ratios are considered crude estimates at best and therefore it is imperative that careful consideration is given to individualizing the dose of the selected opioid. Dosage titration of the new opioid should be completed slowly and with frequent monitoring.
There is no reference in the guidelines to make exceptions – dosage adjustments – in regards to the pt’s CYP-450 opiate metabolism status.
One has to ask… how many more studies are going to be released/published … that are created with manipulated data to arrive at a predetermined conclusion, and these same studies will be accepted by many as “gold standard results” and in turn base their decisions, policies and other things that will have good/bad impacts on those pts dealing with chronic pain ?
His pain has eased now, but two weeks ago, “It was excruciating. I’d say it was about an 8 [out of 10 ], when they were asking me at the hospital.”
Several North Texas hospitals are acknowledging a shortage in powerful pain medications.
It is a nationwide shortage, believed to be caused in large part by a move the Drug Enforcement Administration made to combat opioid abuse.
According to W. Stephen Love, President and CEO of the Dallas-Fort Worth Hospital Council, in 2017 the DEA lowered the limits regulating how much of these drugs pharmaceutical manufacturers can produce.
“They were doing that to be part of a solution,” Love explained. “The DEA recognized that all of us have to be working on this opioid crisis.”
The result is a change in the way patients like Gilbert Cavello are treated.
His pain has eased now, but two weeks ago, “It was excruciating. I’d say it was about an 8 [out of 10], when they were asking me at the hospital.”
Cavello is paralyzed from the chest down and is prone to bladder infections. He says the last infection was terrible, and his treatment was different.
“Usually, they automatically start me on antibiotic and then, to ease pain, they put me on Dilaudid, but this time they put me on morphine and it wouldn’t help, it wouldn’t last,” he said.
Gilbert was a patient at UT Southwestern Medical Center, one of the North Texas hospitals experiencing the shortage. Particularly drugs such as Dilaudid, fentanyl and morphine are in short supply.
Love says doctors he’s spoken with are working closely with pharmacists, clinical staff and nurses to coordinate pain management. Parkland Hospital, UT Southwestern and Methodist Health System say staff are transitioning patients to oral medication when appropriate, as pills are more readily available than those that are intravenously delivered.
Love said he believes hospitals are also being more candid with patients.
“Probably, in some ways, the pendulum may have swung too far as far as trying to keep the patient experience extremely pain free,” Love said. “We want it to be pain-free but in the same token we want it to be done in a very responsible way.”
Love says the shortage could potentially ease if the DEA adjusts the production limits.
But, changing patients’ expectations could take time.
“People need it, especially those in severe pain like me,” Cavello said.
