As more U.S. states legalize the use of marijuana, Mexico’s violent drug cartels are turning to the basic law of supply and demand

Mexican cartels pushing more heroin after U.S. states relax marijuana laws

https://www.usatoday.com/story/news/world/2018/02/20/mexican-cartels-switch-gears-after-u-s-states-relax-u-s-states-legalize-marijuana-mexicos-cartels-sw/343389002/

CHIHUAHUA, Mexico — As more U.S. states legalize the use of marijuana, Mexico’s violent drug cartels are turning to the basic law of supply and demand.

That means small farmers, or campesinos, in this border state’s rugged Sierra Madre who long planted marijuana to be smuggled into the United States are switching to opium poppies, which bring a higher price. The opium gum harvested is processed into heroin to feed the ravaging U.S. opioid crisis.

“Marijuana isn’t as valuable, so they switched to a more profitable product,” said Javier Ávila, a Jesuit priest in this region rife with drug cartel activities.

Laws allowing marijuana in states like Colorado, Washington and California are causing shifts in the Mexican underworld that have also led to increased violence as the cartels move away from its cash cow of marijuana to traffic more heroin and methamphetamines.

Parker McMillan looks over products at MedMen in West

U.S. Customs and Border Protection statistics show that marijuana seizures fell by more than half since 2012, while heroin and methamphetamine seizures have held steady or markedly increased. 

The switch in illegal drugs coincides with Mexico hitting a record 29,168 murders in 2017, the most since the country started keeping homicide statistics in 1997. 

The jump in violence stems from several factors: cartels splintering into smaller factions, power struggles within the formidable Sinaloa Cartel after leader Joaquín “El Chapo” Guzmán was arrested and extradited to the U.S., plus the rise of the violent Jalisco New Generation Cartel, which expanded nationally and moved in on El Chapo’s turf. 

Few attribute Mexico’s rising violence just to legalized marijuana north of the border or the increasing opioid crisis, but those changes in the U.S. are causing problems here. 

 

The bodies of women lie on the sidewalk in the Rufo

In Chihuahua, state prosecutor César Peniche said criminal groups on Mexico’s Pacific Coast used to traffic marijuana to California. Now those groups are “looking for other routes to continue their trafficking” by usingborder crossings farther inland, he said.

“Criminal groups … enter the state of Chihuahua, and this causes confrontations,” Peniche explained. “It’s creating conflicts between criminal organizations to win control of the routes because some markets have closed, but others have stayed open. This sparks violence.”

In Mexico’s heroin-producing heartland of southern Guerrero state, the violence is so bad that the morgues are full and unable to handle all the bodies brought in for autopsies. 

 

The U.S. government recently toughened its travel warning to Americans against visiting Guerrero, which includes the tourist resorts of Acapulco and Ixtapa, in addition to remote villages that rely on planting opium poppies.

Growers in Guerrero, like those in northwest Mexico, also moved away from marijuana to focus on opium poppies. And they have no problem selling their harvests.

“In talking with middlemen and others (selling illegal drugs), the U.S. has an almost insatiable demand. … The cartels are never sitting on product,” said Myles Estey, producer of the Showtime series The Trade, which filmed in Guerrero.

He said the cartels “saw a lot more demand for heroin (in the United States) and responded.”

 

The cartels also freelance in non-drug crimes, such as kidnapping and extortion, to make quick money and “meet payroll” for their foot soldiers, said Guerrero state government spokesman Roberto Álvarez Heredia.

Álvarez also blames Mexico’s northern neighbor for Guerrero’s increased violence, saying it stems from lax U.S. gun laws and “a public health problem from the consumption of heroin.” 

“Guerrero’s problem is not a problem originating in the (Mexican) state. It’s a problem linked to what happens in the United States,” Álvarez  told USA TODAY.

But Catholic Bishop Salvador Rangel and others criticize the Mexican and local governments, pointing to corruption and accusing police of colluding with criminals. 

Rangel, in the state capital of Chilpancingo, claimed “all of Guerrero is in the hands of narcotics traffickers” and called for the army to stop eradicating poppy crops until the government offers campesinos another way to make a living.

“Kids don’t know how to read, but they know how to pick poppies,” said Abel Barrera, director of the Tlachinollan Mountain Human Rights Center in Guerrero.

“People speak of plant varieties, how one variety produces more than another. There’s a specialization,” Barrera said. “It’s all become a culture. And it’s become deeply rooted.”

 

Liberty Mutual WC Carrier : just cut my husbands pain medication from 120 a month to 30

Work Comp carrier’s “utilization management” team just cut my husbands pain medication from 120 a month to 30, they call it a “weaning” process. What a joke – in 10 days next stop hospital. He broke is back in 1977 and has been in Pain Management treatment since then. Do you really think that Liberty Mutual WC Carrier and whiz bang utilization management gives a shit – I can’t even talk to them on the phone – have to go through a process – and they could still deny the appeal. What a screwed up mess this is and I thought that the new drug rules were not to effect people that are in desperate need of pain meds for chronic pain – NO ONE CARES THE CRACK DOWN JUST LOOKS GOOD FOR THEIR BOTTOM LINE.

Opioid Crisis – Dr. Stephen Ziegler interview with George Knapp

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Sun says FDA again faults plant that is its key launch site for U.S. drugs

Halol manufacturing facility

https://www.fiercepharma.com/manufacturing/sun-says-fda-has-again-found-fault-plant-its-launch-site-for-u-s-drugs

After more than three years of effort and a couple of reinspections, India’s Sun Pharma has been unable to satisfy the the FDA’s expectations for its key plant.

 

Sun Pharma, India’s largest generic drugmaker, said that at today’s conclusion of it the FDA’s latest reinspection of its Halol plant in Gujarat, India, it was presented with a Form 483 with three observations.

“The company is committed to addressing these observations promptly,” Sun said in the announcement (PDF), adding that it continues to work closely with the agency “to enhance its GMP compliance on an ongoing basis.”

While it only received three observations this time, Sun has been been at this remediation and reconciliation effort since September 2014 when the the FDA first noted issues at the Halol facility.

While Sun has 40 manufacturing sites worldwide, Halol is the plant from which Sun launches most of its new products for the U.S., its largest market.

But new launches were cut off when the FDA in 2015 vilified the plant in a warning letter.

A reinspection in late 2016 was unable to lift the stigma. That visit resulted in 10 observations, some of which the FDA noted were repeats.

RELATED: Sun’s key plant in Halol again cited by FDA

The plant’s problems have also stymied Sun’s efforts to expand beyond the deteriorating U.S. generics market into novel drug products. Last year, Sun received a second complete response letter for novel epilepsy drug Elepsia XR (levetiracetam) that it licensed from its drug development arm SPARC. It said the application was denied after an inspection of the Halol facility.

 

On top of the deteriorating pricing situation for U.S. generics, this has roiled India’s top generics producer. In its latest earnings report this month, Sun reported that its U.S. finished dosage sales were down 35% to $328 million from the same quarter a year ago.

Total revenue from operations fell 16% to about $1 billion, while net profit fell to to about $57 million from about $227 million a year earlier.

House kicks off opioid legislative agenda, but appropriators will steer the money

http://www.modernhealthcare.com/article/20180222/NEWS/180229964

The U.S. House of Representatives is launching an intense legislative push to try to stem the opioid epidemic as the last big healthcare initiative before the election cycle, but the priorities for the new $6 billion allocated to address the crisis will fall to Congress’ appropriators.

The House Energy and Commerce Committee is kicking off the first of three hearings to consider a bundle of bills that focus on enforcing current law, none of which would set up additional funding streams, which means the $6 billion allocated in the 2017 budget deal is it for now. That money will be distributed over two fiscal years—$3 billion annually.

The specifics of where this money will go falls to appropriators. It could cover law enforcement and Justice Department efforts as well as treatment and prevention, and those decisions are all being worked out by leaders of both chambers and both parties as they approach the March 23 deadline for the spending omnibus.

President Donald Trump renewed his designation of the epidemic as a public health emergency last month. However, he has never called on Congress for new funding.

So far, Sens. Shelley Moore Capito (R-W.Va.), Joe Manchin (D-W.Va.), Jeanne Shaheen (D-N.H.) and Maggie Hassan (D-N.H.) have been the most vocal lawmakers requesting more money to combat the epidemic. They want to change the funding formula set in the 21st Century Cures Act, which set up $1 billion in grants to be administered by the Substance Abuse and Mental Health Services Administration. Their states have been hit with alarmingly high death rates, and they want the allocation to take into consideration mortality and scarcity of treatment centers and providers.

The Cures grants will run out next year and lawmakers are looking into where the money is going and whether the grants are effective.

Providers on the front lines have told Modern Healthcare the most important guarantee is knowing that money will continue. Missouri, for example, has started a pilot medication-assisted treatment and peer support program for 600 opioid-addicted patients in St. Louis. Missouri hospitals tout success so far—75% of these 600 people have stuck to treatment—but it doesn’t start to address the scale of the program.

Jennifer Sherman, a spokesperson for the House Energy and Commerce Committee, said the panel’s policymakers are working the appropriators “to ensure the $6 billion dedicated for new resources to combat the epidemic under the Bipartisan Budget Act of 2018 goes where it is needed most.”

Sherman also named the opioid crisis as House Energy and Commerce Chair Greg Walden’s “top priority.” In the hearings that are slated to start next week, legislative proposals will include mandating training for providers on best practices for prescribing opioids and detecting addiction; adding fentanyl to the controlled substance list; and expanding the use of telehealth in treating addicts.

We are already spending some 81 billion/yr in fighting the war on drugs… and adding another 3 billion/yr will make a dramatic impact ?

IASP Statement on Opioids

https://www.iasp-pain.org/Advocacy/OpioidPositionStatement

Opioids are indispensable for the treatment of severe short-lived pain during acute painful events and at the end of life (e.g., pain associated with cancer). Currently, no other oral medication offers immediate and effective relief of severe pain. Although opioids can be highly addictive, opioid addiction rarely emerges when opioids are used for short-term treatment of pain, except among a few highly susceptible individuals. For these reasons, IASP supports the use and availability of opioids at all ages for the relief of severe pain during short-lived painful events and at the end of life. IASP’s 2010 Declaration of Montreal states that access to pain management is a fundamental human right. In some cases, there is no substitute for opioids in achieving satisfactory pain relief.

Despite this stated value of opioids, the role of opioids in the treatment of chronic pain has come into question. Recent open-ended and indiscriminate long-term prescribing of opioids in the United States and Canada has led to high rates of prescription opioid abuse, unacceptable death rates, and an enormous burden to the affected societies. This burden has been a consequence largely of opioid prescribing for the treatment of chronic pain, where long-term effectiveness is uncertain and where harms, especially for high doses, are clear and strongly supported by cautionary data from the affected countries. Such harms include, but are not limited to, addiction and death. Increased prescribing for chronic pain is occurring in some other developed nations, while the developing world continues to struggle with lack of opioid availability for appropriate indications.

IASP strongly advocates for access to opioids for the humane treatment of severe short-lived pain, using reasonable precautions to avoid misuse, diversion, and other adverse outcomes. At the same time, IASP recommends caution when prescribing opioids for chronic pain. There may be a role for medium-term, low-dose opioid therapy in carefully selected patients with chronic pain who can be managed in a monitored setting. However, with continuous longer-term use, tolerance, dependence, and other neuroadaptations compromise both efficacy and safety. Chronic pain treatment strategies that focus on improving the quality of life, especially those integrating behavioral and physical treatments, are preferred. IASP also strongly advocates for continued research to identify ways to minimize opioid risk and find effective alternatives to opioids for the treatment of various pain problems.

Notes

  1. This statement is based on best available evidence and expert opinion. See References below.
  2. IASP recommends adherence to and promotion of local opioid prescribing guidelines, with special attention to assessing the supportive evidence with appropriate scientific rigor.
  3. IASP recognizes the importance of comprehensive educational efforts to teach safe and appropriate opioid use.

References

  1. Contextual evidence review for the CDC guideline for prescribing opioids for chronic pain – United States, 2016. CDC Stacks, Public Health Publications, March 18, 2016.
  2. Injury Prevention and Control: Opioid Overdose. Prescription opioid overdose data. Centers for Disease Control, Atlanta, GA, 2016.
  3. Attal N, Cruccu G, Baron R, Haanpaa M, Hansson P, Jensen TS, Nurmikko T. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur J Neurol 2010;17(9):113-e88.
  4. Baron MJ, McDonald PW. Significant pain reduction in chronic pain patients after detoxification from high-dose opioids. J Opioid Manag 2006;2(5):277-82.
  5. Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF, Ilgen MA, Blow FC. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 2011;305(13):1315-21.
  6. Boscarino JA, Rukstalis MR, Hoffman SN, Han JJ, Erlich PM, Ross S, Gerhard GS, Stewart WF. Prevalence of prescription opioid-use disorder among chronic pain patients: comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis 2011;30(3):185-94.
  7. Campbell G, Nielsen S, Bruno R, Lintzeris N, Cohen M, Hall W, Larance B, Mattick RP, Degenhardt L. The Pain and Opioids IN Treatment study: characteristics of a cohort using opioids to manage chronic non-cancer pain. Pain 2015; 156(2):231-42.
  8. Case A,Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci USA 2015; 112(49):15078-83.
  9. Cherkin DC, Anderson ML, Sherman KJ, Balderson BH, Cook AJ, Hansen KE, Turner JA. Two-Year Follow-up of a Randomized Clinical Trial of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care for Chronic Low Back Pain. JAMA 2017;317(6): 642-4.
  10. Cherkin DC, Sherman KJ, Balderson BH, Cook AJ, Anderson ML, Hawkes RJ, Hansen KE, Turner JA. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA 2016;315(12):1240-9.
  11. Chou R, Deyo R, Devine B, Hansen RL, Sullivan S, Jarvik JG, Blazina I, Dana T, Bougatsos C, Turner J. The effectiveness and risks of long-term opioid treatment of chronic pain. Rockville (MD): Agency for Healthcare Research and Quality (US); 2014 Sep. (Evidence Reports/Technology Assessments, No. 218). Report No.: 14-E005-EF.
  12. Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S, Brodt E. Noninvasive Treatments for Low Back Pain 2016, Comparative Effectiveness Reviews, No. 169. Rockville (MD): Agency for Healthcare Research and Quality (US): 2016 Feb. Report No.: 16-EHC004-EF
  13. Cunningham JL, Evans MM, King SM, Gehin JM, Loukianova LL. Opioid Tapering in Fibromyalgia Patients: Experience from an Interdisciplinary Pain Rehabilitation Program. Pain Med 2016;17(9):1676-85.
  14. Dillie KS, Fleming MF, Mundt MP, French MT. Quality of life associated with daily opioid therapy in a primary care chronic pain sample. J Am Board Fam Med 2008;21(2):108-17.
  15. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff M. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 2010;152(2): 85-92.
  16. Eriksen J, Sjogren P, Bruera E, Ekholm O, Rasmussen NK. Critical issues on opioids in chronic non-cancer pain. An epidemiological study. Pain 2006;125:172-9.
  17. Finlayson RE, Maruta T, Morse RM, Martin MA. Substance dependence and chronic pain: experience with treatment and follow-up results. Pain 1986;26(2):175-80.
  18. Frank JW, Lovejoy TI, Becker WC, Morasco BJ, Koenig CJ, Hoffecker L, Dischinger HR, Dobscha SK, Krebs EE. Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review. Ann Intern Med 2017;167(3):181-91.
  19. Goldenberg DL, Clauw DJ, Palmer RE, Clair AG. Opioid Use in Fibromyalgia: A Cautionary Tale. Mayo Clin Proc 2016;91(5):640-8.
  20. Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug- related mortality in patients with nonmalignant pain. Arch Intern Med 2011;171(7):686-91.
  21. Han B, Compton WM, Blanco C, Crane E, Lee J, Jones CM. Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health. Ann Intern Med 2017;167(5):293-201.
  22. Hooten WM, Townsend CO, Sletten CD, Bruce BK, Rome JD. Treatment outcomes after multidisciplinary pain rehabilitation with analgesic medication withdrawal for patients with fibromyalgia. Pain Med 2007;8(1): 8-16.
  23. Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, van Tulder MW. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev 2014(9):
  24. Noble M, Treadwell JR, Tregear SJ, Coates VH, Wiffen PJ, Akafomo C, Schoelles KM. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev 2010(1):
  25. Palmer RE, Carrell DS, Cronkite D, Saunders K, Gross DE, Masters E, Donevan S, Hylan TR, Von Kroff M. The prevalence of problem opioid use in patients receiving chronic opioid therapy: computer-assisted review of electronic health record clinical notes. Pain 2015;156(7):1208-14.
  26. Paulozzi LJ. CDC Grand Rounds: Prescription Drug Overdose, a U.S. Epidemic Morbidity and Mortality Weekly Report (MMWR), 2012; 61(01);10-13.
  27. Richmond H, Hall AM, Copsey B, Hansen Z, Williamson E, Hoxey-Thomas N, Cooper Z, Lamb SE. The Effectiveness of Cognitive Behavioural Treatment for Non-Specific Low Back Pain: A Systematic Review and Meta-Analysis. PLoS One 2015;10(8):e0134192.
  28. Schaafsma F, Schonstein E, Whelan KM, Ulvestad E, Kenny DT, Verbeek JH. Physical conditioning programs for improving work outcomes in workers with back pain. Cochrane Database Syst Rev 2010(1):Cd001822.
  29. Sjogren P. Epidemiology of chronic pain and critical issues on opioid use. Pain 2011;152(6): 1219-20.
  30. Toblin RL, Mack KA, Perveen G, Paulozzi LJ. A population-based survey of chronic pain and its treatment with prescription drugs. Pain 2011;152(6):249-55.
  31. Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain 2015;156(4): 569-76.

Benzodiazepine Harms Overlooked, Especially in Older Adults

https://www.medscape.com/viewarticle/892983

As attention remains focused on opioid abuse, another drug epidemic rages outside the spotlight: inappropriate prescription of benzodiazepines.

In an editorial published in the February 22 issue of the New England Journal of Medicine, Anna Lembke, MD, Jennifer Papac, MD, and Keith Humphreys, PhD, from Stanford University School of Medicine in California, point out that from 1996 to 2013, the number of adults who filled a benzodiazepine prescription rose from 8.1 million to 13.5 million, an increase of 67%. During roughly the same time (1999-2015), deaths from benzodiazepine overdose increased from 1135 to 8791.

“Despite this trend, the adverse effects of benzodiazepine overuse, misuse, and addiction continue to go largely unnoticed,” they write.

Concurrent opioid use figured in three quarters of the overdoses, “which may explain why, in the context of a widely recognized opioid problem, the harms associated with benzodiazepines have been overlooked,” the editorialists state. They cite data showing that coprescription rates nearly doubled between 2001 and 2013, going from 9% to 17%.

 

Of particular concern is benzodiazepine use among the elderly, who are especially vulnerable to adverse effects, including an increased risk for falls, fractures, motor vehicle accidents, impaired cognition, and dementia. Professional societies in several countries, including the American Geriatrics Society, have issued guidelines recommending against prescribing benzodiazepines to these patients, as has the Choosing Wisely International campaign, which aims to reduce inappropriate and low-value care.

Nevertheless, “[p]rescribing to older adults continues despite decades of evidence documenting safety concerns, effective alternative treatments, and effective methods for tapering even chronic users,” Donovan T. Maust, MD, MS, and coauthors wrote in the Journal of the American Geriatric Society in 2016. Other researchers have found that clinicians often are unaware of the dangers these drugs pose to seniors, or believe they have no other therapeutic options.

Now a new observational study of older adults in the United States, Canada, and Australia confirms that, despite a modest decline in benzodiazepine prescriptions in this population, “use remains inappropriately high — particularly in those aged 85 and older — which warrants further attention from clinicians and policy-makers,” the authors write.

Jonathan Brett, MBBS, from the Medicines Policy Research Unit at the University of New South Wales in Sydney, Australia, and colleagues published their findings online February 12 in the Journal of the American Geriatric Society.

The authors used prescription claims data from the US Department of Veterans Affairs (VA), the Ontario (Canada) Drug Benefit Program, and the Australian Pharmaceutical Benefits Scheme to analyze annual incident and prevalent benzodiazepine use among people 65 years of age or older between January 2010 and December 2016. The entire cohort included 8,270,000 people.

They observed a significant and linear decline in prevalent benzodiazepine use, defined as people with at least one prescription claim for a benzodiazepine during a given calendar year, in all three countries during the period studied. In the United States, it declined from 9.2% to 7.3%; in Ontario, Canada, it declined from 18.2% to 13.4%; and in Australia, it declined from 20.2% to 16.8%.

Incident use, defined as a new prescription in a given year for someone with no previous history of benzodiazepine use, also declined in the United States, going from 2.6% to 1.7%, and in Ontario, going from 6.0% to 4.4%. In Australia, incident use changed only slightly and nonsignificantly, going from 7.0% to 6.7%.

In all three countries, rates of incident and prevalent use were highest among women, Brett and colleagues write. In Australia and Ontario, prevalent use was highest among patients 85 years of age or older, but “decreased with advancing age in the U.S. VA population.”

 The observed decreases in prescriptions “are likely to be in response to safety concerns and lack of evidence of effectiveness,” the authors write.
 Still, despite these “modest changes,” and “in spite of consistent messaging about the hazards of using benzodiazepines in this population, the rates of benzodiazepine use in older adults remain high,” perhaps related to a tendency by clinicians and patients alike to minimize the risk these drugs pose.
 The finding of high use among the oldest patients in Canada and Australia was “particularly troubling,” the authors add, because of the greater potential for harm in this age group.
 They also express concern that clinicians may be prescribing “Z-drugs,” agents such as zopiclone and zolpidem, instead of benzodiazepines, in a mistaken belief that those products are safer.
 One way to begin reducing benzodiazepine prevalence might be to limit the conversion of new to chronic use by “explicitly limiting the duration of new prescriptions and not routinely providing repeat prescriptions,” the authors suggest. “For people who have been using benzodiazepines for a long time, a discussion about the risks and benefits of continued therapy and attempts to reduce the dose gradually might be the best strategy.”
 Lembke and colleagues also emphasize the need for discussions about tapering, and note numerous parallels between patterns of benzodiazepine and opioid use: “Despite the many parallels to the opioid epidemic, there has been little discussion in the media or among clinicians, policymakers, and educators about the problem of overprescribing and overuse of benzodiazepines and z-drugs, or about the harm attributable to these drugs and their illicit analogues,” they write.
 If measures designed to discourage people from using opioids divert them to benzodiazepines instead, “[i]t would be a tragedy,” Lembke and colleagues conclude in their editorial. “We believe that the growing infrastructure to address the opioid epidemic should be harnessed to respond to dangerous trends in benzodiazepine overuse, misuse, and addiction as well.”
 The authors have disclosed no relevant financial relationships.
 J Am Geriatr Soc. Published online February 12, 2018. Abstract
 N Engl J Med. 2018;378:693-695. Full text
Interesting the time frames they looked at  among people 65 years of age or older between January 2010 and December 2016 . In Jan 2011 the first baby boomer turned 65 and 10,000/day turn 65 since then and
use remains inappropriately high — particularly in those aged 85 and older this is the FASTEST growing segment of our population.. even if percentages remain the same… the raw numbers are going to increase..

Despite this trend, the adverse effects of benzodiazepine overuse, misuse, and addiction continue to go largely unnoticed,” they write. Concurrent opioid use figured in three quarters of the overdoses, “which may explain why, in the context of a widely recognized opioid problem

So there is little/few OD’s from benzo alone… so they have to put into the equation that opiates were involved… again … no suggestion that these OD could have been intentional as in SUICIDES ?  Is this another study that culled the data and the time frames to prove a preconceived conclusion ?

Lawmakers, Pharmacists Meet with CVS over Regulation of Pharmacy Benefit Managers

http://www.arkansasmatters.com/news/local-news/lawmakers-pharmacists-meet-with-cvs-over-regulation-of-pharmacy-benefit-managers/985681024

LITTLE ROCK, Ark. – Hundreds of pharmacists and patients from every corner of the state spilled out of the Old Supreme Court Room at the capitol Wednesday to fight for change. 

The nearly 750 pharmacies in Arkansas noticed cuts to their drug reimbursement rates at the beginning of the year. They have been working with lawmakers ever since to regulate who they say is to blame: pharmacy benefit managers (PBMs).

“This room is packed because this is an Arkansas issue,” Lt. Gov. Tim Griffin told the crowd. “This is every household in Arkansas. We don’t have a healthy market. We don’t have healthy competition. What we have is dysfunction because of oversized players who are basically helping themselves at your expense.”

The Arkansas Pharmacists Association obtained records of more than 270 popular drugs in the state and found CVS pays itself at least $60 per prescription more than it pays pharmacies.  

“This is an example of blatant self-dealing,” CEO Scott Pace told the crowd. 

Pace pointed to two cases in particular. While Arkansas pharmacies received about $28 for 30 tablets of Aripiprazole, a medication to treat depression, CVS received $512. The other showed the state’s pharmacists received about $909 for 20 tablets of Temozolomide, a cancer treatment. CVS received nearly $4,000. 

“When the fox guards the hen house, all sorts of games can be played and in Arkansas with the PBMs, they have been,” Pace said. “They operate behind a curtain of secrecy.”

The CEO has been working with lawmakers on the legislation to regulate these PBMs, giving the state insurance department oversight of them. 

Pace said they have trimmed the resolution from 14 to seven pages, which CVS saw for the first time Wednesday morning right before the press conference. He had another meeting scheduled with CVS representatives at 4 p.m. at the capitol. 

The Pharmaceutical Care Management Association, who represents PBMs across the country, released the following statement on the proposed Arkansas legislation: 

“This resolution would raise prescription drug costs for Arkansas’s patients, employers, state government, and taxpayers and do nothing to improve the quality of pharmacy benefits. The state should be encouraging market-based solutions to reduce drug costs, not giving special protections to the drugstore lobby.”

Arkansas pharmacists argue PBMs have forced them to cut hours and jobs, even consider closures in the near future. 

“They say it’s proprietary, but it’s affecting my business every day that I love,” said Mike Smith, the owner of Rose Drugstore in Russellville. “We are the boots on the ground. We are the ones with all the customers. We have been serving families for generation after generation that we need to take care of. We would like to have a reasonable, fair reimbursement on a level playing field.”

Gov. Asa Hutchinson plans to call a special session on this issue once lawmakers wrap up the fiscal session.

St. Rep. Michelle Gray, R- Melbourne, who is sponsoring the PBM legislation on the House side, is adamant about her colleagues addressing the issue immediately during the fiscal session. However, Gray said a meeting with Hutchinson Wednesday morning convinced her to back off.

“He assures me that this bill, which we are still working to finalize to make sure that there are no unintended consequences, will be on the special call,” Gray told the crowd. “He looked me in the eyes, and I have to trust that. If I can’t trust my governor to do what he says he’ll do, I might as well just pack up and go home.”

Rep. Gray and the legislation’s sponsor on the Senate side, St. Sen. Ron Caldwell, R-Wynne, said they would not have been able to act this fast without the help of their colleagues, pharmacists, patients and other community members across the state. 

 After CVS cuts reimbursement to independent pharmacies via their PBM ( Caremark )… then they send out solicitation letters to these same independents inquiring if they want to sell their stores to CVS Health.
For those of you who remember your history about Standard Oil.. where they would go into a area and sell gasoline below cost until all the competition had gone out of business and then Standard Oil would raise the price of the gasoline they sold above what it was before they entered the market.  That anti-competitive actions caused the Sherman Antitrust Act to be passed.
The PBM came into existence in 1969-1970 and they have never been transparent in how they operate financially. CVS Health/Caremark is just one of the many “bad actors”… here is a recent law suit where Anthem claims that Express Scripts – maybe the largest of the PBM’s… failed to share rebates on medications from the Pharmas  http://www.modernhealthcare.com/article/20160321/NEWS/160329992
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PETITION: Demand President Trump Stop the Criminalization of Kratom!

 

https://www.americankratom.org/copy-of-petitions

 

I need your help and so do 3-5 million people. In some cases this is the difference between life and death. Please help me keep Kratom Legal. I don’t want to be in agony again 24/7. We can’t fight three agencies, all at once, without your help. Chronic pain eventually will reach the majority of us. Please sign the petition to keep Kratom as an option for yourself. And please make sure you complete the form with too. Otherwise it won’t count.

Kratom has meant the all the difference in the world for my family. All of the things you see me post wouldnt be possible if it wasn’t for Kratom. I went from using a walker and wheelchair to biking or walking miles everyday. From being bedridden to tent camping road trips. I went from being prescribed fentanyl and dilaudid to taking zero opiates. I am truly afraid of what a future would look like for me without Kratom.

Looks like the government is giving each agency a turn at bat.

In 2016 the DEA took a swing at Kratom and Strrrrrrike. They tried to get to first base by trying to hit a home run by a 2-3 year emergency ban. But it was a fly ball. We caught it though so you’re OUT. Science prevailed.

Now the FDA has taken a strike at Kratom by having FDA scientists come up with a Model that predicts how Kratom may affect opioid receptors. But the scientific community at large has come out against the FDAs model. Can you imagine the fda accepting a computer model as scientific evidence that a drug is safe. No way. So Strrrrrrike.

So today the CDC came out with a warning that there were 28 salmonella cases ”associated” with Kratom. Notice how carefully they choose their words as not to be caught in an outright lie but make it sound bad. “Just last month a consumer advocacy group called on the FDA and CDC to do a better job of warning people about a romaine lettuce E. coli outbreak, which at last count had made 58 people sick in the U.S. and Canada. One person has died. However, when it came to the subject of infected vegetables that have actually resulted in a death, the CDC was hesitant to issue any serious warnings.

“Because we have not identified a source of the infections, CDC is unable to recommend whether U.S. residents should avoid a particular food.”

But when it comes to Kratom, which has caused zero deaths and has no proven correlation respective to the recent CDC Salmonella claims, it’s crystal clear what the CDC’s motives are in issuing this warning.” Washington Post and CNN just released stories on this. According to the CNN article “an estimated 1.4 million cases of salmonella occur in the US each year, according to the CDC. Of the 11 people who have been interviewed for this salmonella investigation, 8 reported consuming kratom in pills, powder or tea.” I could get my calculator but I am thinking that 8/1.4M= a pretty low %. Maybe there is some connection but this seems like a stretch.

So hopefully this is their last gov agency they will use to try to ban Kratom