http://www.htrnews.com/story/news/2017/11/17/dr-charles-szyman-trial-jury-finds-ex-manitowoc-doctor-not-guilty-drug-trafficking-overdose-deaths/872710001/

GREEN BAY – Dr. Charles Szyman, a Manitowoc doctor accused of over-prescribing narcotic medications, was found not guilty of all charges by a jury Friday afternoon.

“I think what this verdict ultimately proves is that the United States government’s attempt to scapegoat and paper over the opioid crisis by blaming doctors who are just trying to do their job for people who are suffering from pain, that’s not going to work,” said Beau Brindley, lead counsel for Szyman’s defense.

During a five-day trial in the United States District Court of Eastern Wisconsin, prosecutors tried to prove Szyman, through his pain clinic with Holy Family Memorial, prescribed narcotics outside the scope of normal medical practices.

RELATED: Dr. Charles Szyman trial day 4: Ex-Manitowoc doctor says work was ’emotionally draining’

RELATED: Dr. Charles Szyman trial day 3: Former Manitowoc doctor’s dosages called ‘egregious’

RELATED: Dr. Charles Szyman trial day 2: Ex-patient’s husband says she was ‘a walking zombie’

RELATED: Dr. Charles Szyman trial: Day one marked by opening statements, witness testimony

“We do not go after doctors and blame them for a bigger problem, as opposed to actually deal with and treat that problem,” Brindley said. “Dr. Szyman worked hard to take care of his patients for years and years and years, and this jury validated that.”

Both sides gave their closing arguments for the case Friday morning before the jury started its deliberations.

Assistant U.S. Attorney Matthew Jacobs began his statement with a list of quotes heard from Szyman during a recording of Drug Enforcement Administration Agent Greg Connor’s appointments with Szyman.

“Don’t tell me what you don’t want, tell me what you want,” Szyman said during the February 2014 appointment.

Jacobs said that quote, and similar ones, showed Szyman’s attitude toward prescribing narcotics was flippant, at best.

“He (Szyman) is the gatekeeper between the patients and narcotics,” Jacobs said.

According to Jacobs, Szyman failed his duty to protect his patients when he prescribed them ever-increasing doses of narcotics without understanding the source of the patients’ pain and properly monitoring their use.

Jacobs went through the records of each of Szyman’s patients brought to the stand during the course of the trial. He pointed out that all of them were prescribed high doses of narcotics despite many of them showing signs of overuse, addiction and diversion.

Brindley began his defense of Szyman by pointing out that the case is not about medical malpractice, not about negligence, but was a criminal case.

“They are not calling Charles Szyman a doctor, they are calling him a criminal,” Brindley said.

According to Brindley, Szyman acted in good faith and truly believed he was prescribing appropriate amounts of medication to address the debilitating pain many of the patients complained of.

“What was Dr. Charles Szyman’s terrible crime?” Brindley asked. “It comes down to one thing: he trusted his patients too much. Trusting too much is not a crime.”

He also said there was no reason for Szyman to knowingly give patients more narcotics than they needed. He said Szyman did not profit from giving out prescriptions for narcotics and he didn’t receive any kickbacks from pharmaceutical companies for pushing drugs patients didn’t need.

“Where is the bad faith?” Brindley asked. “I’m not talking about if he should have been more skeptical. I’m talking about bad faith, bad intention.”

Szyman’s trial began Nov. 13 in the United States District Court of Eastern Wisconsin. He was indicted for 19 counts of drug trafficking for allegedly over-prescribing narcotic medications June 2016 and pleaded “not guilty” to each of the charges later that month.

The indictment, dated June 21, 2016, stated Szyman “knowingly and intentionally distributed unlawfully, and attempted to distribute and dispense unlawfully, a controlled substance outside of his professional practice and not for a legitimate reason.”

Szyman is also facing a wrongful deaths lawsuit with Holy Family Memorial in Manitowoc County Circuit Court. The lawsuit, filed Oct. 4, 2016, alleges Szyman caused the deaths of Heidi Buretta, Monica Debot, Mark Gagnon and Alan Eggert through his practice and prescription of narcotics.

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It has become apparent that there is no SAFE SPACE for chronic pain pts… NO ONE can keep their head low enough not to be noticed. Chronic pain pts… even when they get adequate pain management therapy have DOUBLE THE SUICIDE RATE of the rest of the population. With relatively stable pain pts having their pain management meds reduced again and again with the apparent goal to eliminate the pt getting anything other that OTC pain meds… We are seeing the suicide rate of chronic pain pts increasing and we don’t know how many are committing suicide that never get anyone’s notice – other than the immediate family.  We don’t know how many are dying from health complications of having to deal with unrelenting – torturous – pain levels.. like hypertensive crisis, strokes and subsequent death that is classified intentionally or unintentionally as a cardiovascular event to avoid stating the real reason for the death.

The Medical Licensing Boards and Pharmacy Licensing Boards are turning a blind eye/deft ear to the fact that many different non-medical entities are over writing or rescinding their respective licensees’ authority that is granted by the state’s practice act.  The practitioners on these various boards do not seem to have the back bone or the balls to tell these various entities to BACK THE HELL OFF…

I know for a fact that the DEA is FORCING pharmacists to do things that they are neither trained to do … nor does the state’s practice act gives them the legal authority to do and the various Boards of Pharmacy – who’s primary charge is to protect the public’s health & safety… are DOING NOTHING.

We have seen what has happened to pts that have complained about their pain meds being reduced… often… the prescriber fabricates some “lame reason” for discharging the pt.  It is no wonder that most/many/all chronic pain pts want change but don’t want to have their name or fingerprints on what it takes to make change happen.

HOWEVER, this is where the spouse of the chronic pain pt can possibly get the attention of those who are dictating the chronic pain pt’s proper care. Most claim that they are just following the CDC guidelines… but.. in reality they are just following the MOST STRICT portions of the guidelines.  Here is a link and quote the the published CDC guidelines for primary care prescribers… they do not apply to chronic pain specialists:

Here is four quotes from the CDC opiates guidelines:

https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

“The guideline is intended to ensure that clinicians and patients consider safer and more effective treatment, improve patient outcomes such as reduced pain and improved function.”

“Clinicians should consider the circumstances and unique needs of each patient when providing care.”

“Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient’s clinical situation, functioning, and life context.”

“This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.”

When a otherwise stable chronic pain pt is facing their pain medications being reduced, which has/will cause the pt to be in increased level of pain and becomes house, bed, chair confined.  This is the point where a spouse can send a certified letter – or hire an attorney to do it – put the prescriber, and the legal dept of the prescriber’s employer (hospital), insurance company, pharmacy on notice that the spouse is concerned about the chronic pain pt’s health/safety… remind them of increased chance of suicide and that other documented health issue could deteriorate… and any that could lead to the pt’s premature death.

If the prescriber ignores the letter, then the spouse would have the ability to file a complaint with the appropriate licensing board for unprofessional conduct for failing to follow “best practices and standard of care ” of the CDC published guidelines. Also unprofessional conduct for failing to follow their Hippocratic Oath of “doing no harm”.

If this causes the various entities to discharge the pt… then there is the potential for justification for a lawsuit for retaliation, pt abandonment, pt/senior abuse, and other issues…

If the pt ends up committing suicide or dies from complications… then there is the potential for assisting/contributing to the suicide and/or premature death… and lawsuit by the spouse and children on loss of companionship and other issues associate with the loss of a spouse or parent.

Right now, most/all healthcare professionals have no fear of pts… they can discharge for fabricated issues, reduce their pain medication without concern… it is something like the “school yard bully” that goes about doing as he pleases without any fear of retaliation or consequences.  Maybe it is time for that to change ?

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Minnesota Doctors Face Opioid Prescribing Limits

https://www.usnews.com/news/best-states/minnesota/articles/2017-11-17/minnesota-doctors-face-opioid-prescribing-limits

A Minnesota task force has set new limits on opioid prescriptions by doctors who participate in the state’s Medicaid program

Filed under: General Problems | 3 Comments »

Sudden, Unexpected Death in Chronic Pain Patients

https://www.practicalpainmanagement.com/sudden-unexpected-death-chronic-pain-patients

Sudden, unexpected death may occur in a severe, chronic pain patient, and the terminal event may be unrelated to medical therapeutics. Fortunately, sudden death is not as commonly observed in pain patients as in past years most likely due to better access to at least some treatment. Sudden death still occurs, however, and practitioners need to know how to spot an “at-risk” patient.

Unexpected, sudden death due to severe pain is poorly appreciated, since many observers still view severe pain as a harmless nuisance rather than a potential physiologic calamity. In many cases, just prior to death, the patient informs their family that they feel more ill than usual and seek relief in their bed or on their couch. Unfortunately, some of these patients don’t awaken. Other patients die, without warning, in their sleep or are found collapsed on the floor. Modern medicine’s aggressive toxicology and forensic procedures after death have contributed to the poor understanding of pain’s death threat. In some cases, a pain patient that was being treated appropriately with an opioid or other agent with overdose or abuse potential has suddenly and unexpectedly died. Drugs were found in body fluids after death, and in my opinion a coroner wrongly declared the death to be an “accidental overdose” or “toxic reaction” to drugs rather than implicate the real culprit, which may have been an “out-of-control” pain flare.

This article is partially intended to call attention to the fact that the mere finding of abusable drugs at autopsy doesn’t necessarily mean that the drugs caused the death. In fact, the drugs may have postponed death. Some physicians have been falsely accused of causing deaths due to drug overtreatment when, in fact, undertreatment of pain may have caused the death. Additionally, opioid blood levels assessed at autopsy of a patient who died suddenly are all too often wrongfully considered accidental overdoses because the pathologist is unaware that chronic pain patients on a stable dose of opioids can be fully functional with serum levels of their prescribed opioids that far exceed lethal levels in opioid-naïve patients.¹

Given here are the mechanisms of sudden, unexpected death in pain patients and some protective measures that practitioners must take to keep from being falsely accused of causing a sudden, unexpected death. More importantly, given here are some clinical tips to help identify the chronic pain patient who is at high risk of sudden, unexpected death so that more aggressive pain treatment can be rendered.

A Brief Anecdotal History
As a senior medical student at Kansas University in the early 1960s, I was required to take a rural preceptorship with a country doctor. In making our rounds one day to the county’s nursing home, I heard a farmer’s wife declare, “pain killed my mother last night.” Since then, I’ve repeatedly heard that pain killed a loved one. Folklore frequently mentions that people die “from,” as well as “in” pain. There is, however, little written detail of these events.

In the early years of my pain practice, which I began in 1975, I had several patients die suddenly and unexpectedly. This rarely happens to me today as I’ve learned to “expect the unexpected” and to identify which patients are at high risk of sudden death. In recent years, I’ve reviewed a number of litigation and malpractice cases of sudden, unexpected death in chronic pain patients. In some of these cases, physicians were accused of over- or misprescribing and causing a sudden, unexpected death, even though the patient had taken stabilized dosages of opioids and other drugs for extended periods. Also, the autopsy showed no evidence of pulmonary edema (a defining sign for overdose and respiratory depression). In cases where the physician was falsely accused, the post-death finding of abusable drugs in body fluids caused a family member, regulatory agency, or public attorney to falsely bring charges against a physician.

Setting and Cause
Unexpected deaths in chronic pain patients usually occur at home. Sometimes the death is in a hospital or detoxification center. The history of these patients is rather typical. Most are too ill to leave home and spend a lot of time in bed or on a couch. Death often occurs during sleep or when the patient gets up to go to the toilet. In some cases, the family reports the patient spent an extraordinary amount of time on the toilet just prior to collapse and death. Sudden and unexpected death, however, can occur anywhere at any time, as pain patients who have died unexpectedly and suddenly have been found at work or in a car.

Coronary spasm and/or cardiac arrhythmia leading to cardiac arrest or asystole is the apparent cause of death in the majority of these cases, since no consistent gross pathology has been found at autopsy.^2-5 Instant cardiac arrest appears to account for sudden collapse or death during sleep. Perhaps constipation and straining to pass stool may be cardiac strain factors as some pain patients die during defecation. Acute sepsis due to adrenal failure and immune suppression may account for some sudden deaths.

Two Mechanisms of Cardiac Death
Severe pain is a horrific stress.^6,7 Severe pain flares, acute or chronic, cause the hypothalamic-pituitary-adrenal axis to produce glucocorticoids (cortisol, pregnenolone) and catecholamines (adrenalin and noradrenalin) in an effort to biologically contain the stress.^8,9 Catecholamines have a direct, potent stimulation effect on the cardiovascular system and severe tachycardia and hypertension result.¹⁰ Pulse rates may commonly rise to more than 100 beats per minute and even rise to more than 130 beats per minute. Blood pressure may reach more than 200 mmHg systolic and more than 120 mmHg diastolic. In addition to adrenal catecholamine release, pain flares cause overactivity of the autonomic, sympathetic nervous system, which add additional stimulation to catecholamine-induced tachycardia and hypertension. Physical signs of autonomic, sympathetic overactivity, in addition to tachycardia and hypertension, may include mydriasis (dilated pupil), sweating, vasoconstriction with cold extremities, hyperreflexia, hyperthermia, nausea, diarrhea, and vomiting.

The combined physiologic effects of excessive catecholamine release and autonomic, sympathetic discharge may put such strain on the heart to cause coronary spasm, cardiac arrhythmia, and sudden death.¹¹ Pain patients who have underlying arteriosclerosis or other cardiac disease are at higher risk of sudden death. For example, a patient with angina or generalized arteriosclerosis is at high risk, and should be aggressively treated. Anecdotal reports have been made in which a patient whose pain was well controlled on opioids died unexpectedly with an underlying cardiac disease. In one report, a 40-year-old pain patient on opioids was found dead and the autopsy revealed previously unrecognized coronary artery disease, which was determined to be the cause of death. Some patient deaths may be due to other comorbid conditions, whether known or not known, and may not be related to the pain problem.

Case Example #1
A 60-year-old male with severe pain due to Lyme’s disease–related arthritis has generalized arteriosclerosis. When his pain flares, he has hypertension, tachycardia more than 100 beats per minute, and angina. On numerous occasions, he had been hospitalized for chest pain and he regularly requires nitrates for emergency coronary relief. He was treated with a long-acting opioid for baseline pain and a short-acting opioid for breakthrough pain. This regimen has controlled his angina and has prevented hospitalizations for more than 2 years.

The second mechanism, which may produce sudden death, is adrenal insufficiency. The hypothalamic-pituitary-adrenal axis may acutely and suddenly deplete during episodes of severe pain resulting in a life-threatening drop in cortisol, aldosterone, and possibly other adrenal hormones (Figure 1).¹² With a precipitous drop in adrenal hormone production, there can be a severe electrolyte imbalance (eg, low sodium, high potassium), which may produce cardiac arrhythmia and death. Although undocumented, some sudden deaths may likely be a simultaneous result of excess sympathetic stimulation and electrolyte imbalance.

Identification of the At-risk Patient
An active, ambulatory pain patient who has mild to moderate, intermittent pain is not at high risk for sudden death. The patient at high risk for sudden death is a severe pain patient who is functionally impaired and has to take a variety of treatment agents, including opioids and neuropathic drugs, to control pain. In all likelihood, the patient who has centralized pain and who has central nervous system inflammation due to glial cell activation is the patient who will likely have flares severe enough to affect the endocrine and cardiovascular systems. Acute pain severe enough to cause cardiac overstimulation and death is usually only seen with severe trauma. Pain as a result of modern-day surgery is well controlled by analgesics, so perioperative sudden death due to surgically induced pain, per se, is essentially a thing of the past. Accidents, trauma, and war wounds are exceptions. In these situations, a patient in excruciating pain who shows signs of excess sympathetic discharge needs progressive emergency pain treatment to control excess sympathetic discharge.^13,14 Excess sympathetic discharge signs that can be discerned at the bedside, emergency room, or accident site include mydriasis, diaphoresis, hyperthermia, tachycardia, hypertension, and hyperreflexia.^15,16

The chronic pain patient who is at high risk for sudden death can usually be spotted at a clinical visit (Table 1). Patient and family will give a history of functional impairment. The most typical history will be one in which the patient will have constant, daily pain intermixed with severe flares, which cause a bed or couch-bound state. Even though medication dosages may be high, they may not be effective enough to prevent pain flares and sudden death. The patient will likely demonstrate excess sympathetic discharge. By history, this includes waves or episodes of allodynia, hot and cold flashes, hyperalgesia, and severe insomnia. Physical exam may reveal excess sympathetic discharge by any or all of the following signs: tachycardia, hypertension, vasoconstriction (cold hands/feet), mydriasis (dilated pupil), and hyperreflexia.

Cortisol, pregnenolone, or corticotropin (adrenocorticotropic hormone) serum levels may be subnormal indicating that the immune and healing systems are impaired, leaving the patient subject to infections and interference with opioid effectiveness.

When high-risk indicators are found, therapeutic adjustments in type, quantity, and quality of pain treatment must be implemented to minimize or eliminate risk factors. In particular, there should be attempts to normalize hypertension, tachycardia, and hormone levels.

Methadone Administration And Sudden Death
Other than overdose and respiratory depression, the opioid methadone has been associated with a cardiac conduction defect (prolonged QT interval) called “torsades de pointes,” which may cause an unexpected, sudden death.^17,18This defect may cause sudden death by cardiac arrests. No other opioid has been credibly associated with cardiac conduction defects. In addition to the problem of QT prolongation, many methadone-related deaths occur during the first few days of use, making the deaths in these instances more likely due to the prescriber’s unawareness of methadone’s long half-life and, therefore, accumulation in the bloodstream because the dose was titrated too quickly.

However, the recognition of QT prolongation has caused considerable controversy and many experts believe that an electrocardiogram should be done to screen for a prolonged QT interval before and/or during methadone administration.¹⁷ The occurrence of “torsades de pointes” with methadone is usually dose related and associated with concomitant use of antidepressants or benzodiazepines. If a patient who takes methadone suddenly dies due to cardiac arrhythmia, there will be no gross pathology at autopsy, which is typical of sudden death in a pain patient. The prescribing physician may, however, be accused of overprescribing methadone. Due to this risk, many physicians have made a choice to shun methadone and avoid the risk of being falsely accused for overprescribing. From a clinical perspective, the use of antidepressants and benzodiazepines should be restricted if methadone is prescribed, since these ancillary agents appear to facilitate methadone deaths.

Risk of Sepsis
Although not well documented, acute sepsis and sudden death probably occur in some severe, chronic pain patients. The mechanism is probably initiated by subnormal serum levels of cortisol or other hormones due to adrenal depletion. Chronic subnormal adrenal hormone levels severely compromise the protective immune system in the body, rendering the patient susceptible to virulent bacteria and other pathogens.^19,20 The author has frequently found extremely low levels of cortisol (fewer than 1.0 mg/dL) in undertreated intractable pain patients. One can only wonder as to how many pain patients have suddenly died from acute sepsis. Although documentation of this pathologic event is scant, practitioners should be aware that extremely low serum levels of adrenal hormones are known to be associated with a compromised immune system and sepsis.

Death Following Sudden Opioid Cessation
There is the misguided notion among some addiction and mental health practitioners that withdrawal from opioids is an innocuous procedure that is risk free. This school of thought says that only withdrawal from alcohol and benzodiazepines is risky. This is generally true unless the patient who is dependent upon opioids has severe underlying pain and is taking opioids solely for pain control. In some patients, opioids may mask underlying pain so well that a practitioner may not even believe that pain recrudescence is a possibility once opioids are stopped.

Patients who have severe pain that is well controlled by opioids may be sudden-death candidates if their opioids are precipitously stopped. If opioids in a severe pain patient are precipitously stopped, the masked pain may flare causing severe autonomic, sympathetic discharge and overstimulation of the adrenals to produce excess catecholamines with subsequent cardiac arrhythmia and arrest. Malpractice suits have occurred when opioids have been precipitously stopped in a pain patient. Here are two examples known to the author.

Case Example #1
A 45-year-old woman with fibromyalgia and severe pain was well controlled with extended release morphine for baseline pain and short-acting hydrocodone for breakthrough pain. She entered an in-patient detoxification program where she was told that fibromyalgia only required psychotherapy and no opioids. The detoxification program precipitously stopped all her opioids and placed her in isolation for punishment because she was using opioids as a “crutch” rather than “facing her problems.” She died suddenly about 36 hours after all opioids were stopped.

Case Example #2
A 42-year-old male had a work injury and subsequently suffered reflex sympathetic dystrophy (RSD) or complex regional pain syndrome (CRPS). His pain was reasonably well controlled with fentanyl transdermal patches (Duragesic) for baseline pain and short-acting oxycodone (OxyContin) for breakthrough pain. His workers’ compensation carrier had him evaluated by “experts” who claimed that pain couldn’t possibly exist for more than about 6 months after injury, and RSD and CRPS were not “legitimate diagnoses.” His workers’ compensation carrier, based on their “experts’” opinions, precipitously stopped all his opioids by refusing to pay for them. The man died suddenly 4 days after abrupt cessation of his opioids.

Value of Opioid Serum Levels
Patients who have severe chronic pain, take opioids, and demonstrate some high-risk signs and symptoms for sudden death as described above should have opioid blood levels done. Why? Legal protection. If a severe chronic pain patient who takes opioids suddenly dies, the practitioner may be accused of overprescribing and causing an overdose death unless he/she has pre-death opioid blood levels on the patient’s chart. Keep in mind that there will be no gross cardiac pathology at autopsy if the patient suddenly dies of a cardiac arrhythmia or arrest. And, the coroner will likely call the death a drug overdose and blame the prescribing physician. Here are two illustrative cases.

Case Example #1
A 28-year-old male, former football player had severe spine and knee degeneration. He died in his sleep and his death was brought under investigation by the coroner. At autopsy he had a methadone blood level of 400 ng/mL. The prescribing physician was about to be charged with negligence by the local district attorney, until the physician showed that, in life, the patient’s methadone blood levels ran between 500 to 650 ng/mL.

Case Example #2
A 58-year-old female with genetic porphyria had suffered from severe generalized pain for more than 20 years. She collapsed in her living room in sudden death. At autopsy she was found to be wearing three fentanyl dermal patches (100 mcg/hour). At autopsy she demonstrated a fentanyl blood level of 10 ng/mL and a morphine blood level of 150 ng/mL. Her prescribing physician was able to show the sheriff’s investigators that in pre-death treatment, she had fentanyl and morphine blood levels considerably above these found at autopsy. No charges were ever brought against the physician.

Summary
Although sudden, unexpected death in chronic pain patients appears to be declining in incidence due to greater access to treatment, practitioners need to be aware that sudden, unexpected death may occur independent of opioid administration. The precise mechanism of death is cardiac arrest or asystole due to coronary spasm, arrhythmia, and/or electrolyte imbalance. Severe chronic pain produces excess sympathetic discharge through the autonomic nervous system and overstimulation of the hypothalamic-pituitary-adrenal axis, which causes great output of adrenal catecholamines. The chronic pain patient who is at highest risk for sudden death is the patient whose uncontrolled pain and pain flares are so great as to cause a high degree of functional disability. Those pain patients who are ambulatory and active are not at high risk for sudden death. The attainment of opioid blood levels during treatment of patients who are at high risk for sudden death are advised as a medical-legal protection should opioids be present in blood after death. Patients who are identified as high risk should be monitored by regular clinic visits, and efforts should be done to control excess sympathetic discharge and adrenal deficiencies.

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Cocaine deaths surge with rise of drug smuggling into South Florida

http://www.sun-sentinel.com/local/palm-beach/fl-reg-cocaine-deaths-surge-20171116-story.html

Cocaine killed more people in Florida last year than any other drug, and authorities expect it will only get worse as traffickers push more of the narcotic through the Sunshine State.

Cocaine-related fatalities rose for the fourth year in a row in 2016, contributing to the deaths of 2,882 people, according to the latest data from the Florida Medical Examiner’s Commission.

The Drug Enforcement Administration says the deaths statewide coincide in part with an increase in Colombian cocaine moving through the Caribbean and entering South Florida. Much of the cocaine is being smuggled on planes and boats.

“What you’re seeing in the medical examiner data is a direct result of the increasing supply of cocaine,” said Justin Miller, intelligence chief for the DEA’s Miami field division. “Unfortunately, we are seeing the consequences of having that much cocaine coming into our region.”

Cocaine production in Colombia has hit a record high. That’s partly because the government ended the practice of aerial spraying of herbicides over coca fields, which curbed cultivation of the crop. The Colombian government ended the decadeslong program over health concerns.

Palm Beach, Broward and Miami-Dade counties last year saw some of the highest rates of cocaine-related deaths among Florida’s 67 counties, medical examiner data shows.

— Palm Beach County had more than 25 deaths per 100,000 people and was among the top four counties with the highest rates of cocaine-related deaths, at 405.

— Broward and Miami-Dade counties had 15 to 20 deaths per 100,000 people. Broward County had 328 cocaine-related deaths, while Miami-Dade had 439.

With the supply increasing, the price is going down. One kilo — about 2.2 pounds — of pure cocaine was worth between $28,000 and $35,000 two to three years ago, he said. Today, the same amount is worth $26,000 to $28,000.

On the streets of Miami, a gram sells for between $50 and $80 these days, Miller said.

Florida’s Customs and Border Protection says it seized 4,500 pounds of cocaine during its most recent budget year, a slight increase over the 4,200 pounds seized the year prior.

Trafficking organizations have begun dropping drugs into the ocean in waterproof packaging for retrieval using GPS coordinates, according to the DEA.

About 50 miles off the coast of Key West last year, recreational divers found more than 10 pounds of cocaine anchored to the ocean floor.

Colombian trafficking organizations ship cocaine and heroin directly to Florida, specifically Miami and Orlando, through private and commercial flights, air cargo, shipping containers and small boats, DEA records show.

An increased supply of cocaine isn’t the only reason for the rise in deaths.

Jim Hall, an epidemiologist for Nova Southeastern University, said many of the cocaine-related deaths are instances where people are using more than one drug at the same time, or one right after the other.

“Many of these people are dying because of cocaine with an opioid,” he said. “Or, they are taking contaminated cocaine.”

Miller, too, said much of today’s cocaine supply is “tainted” by other drugs. “In our lab submissions, we are seeing cocaine, heroin and fentanyl all being sold as the same substance,” Miller said.

With even more cocaine arriving on U.S. shores this year, the entire country — including Florida — can expect more deaths to come, DEA records show.

“Right now, from an enforcement standpoint, we are hitting them very hard. We have some tremendous operations going on right now,” Miller said. But still, “the outlook doesn’t look good right now.”

I wonder what/who the DEA is going to blame was the “gateway drug” for all of these people using/abusing Cocaine.  Since prescribers don’t issue prescriptions for COCAINE… AND  …Cocaine killed more people in Florida last year than any other drug…  cocaine related deaths INCREASING FOUR YEARS IN A ROW… and where are all the DEA/law enforcement seizures ?

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Deaths Involving Fentanyl, Fentanyl Analogs, and U-47700 — 10 States, July–December 2016

https://www.cdc.gov/mmwr/volumes/66/wr/mm6643e1.htm

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Diabetes rises to more than 100 million in the US, costing $850 billion per year globally

http://www.foxbusiness.com/features/2017/11/17/diabetes-rises-to-more-than-100-million-in-us-costing-850-billion-per-year-globally.html

The U.S. is dealing with a potential health epidemic as more than 114 million Americans are now living with diabetes or pre-diabetes, according to a report released by the Centers for Disease Control and Prevention (CDC).

Diabetes is the seventh-leading cause of death in the U.S. with nearly one in four adults living with diabetes, and 7.2 million Americans may not be aware they have the condition.

In an interview with FOX Business’ Trish Regan, Family & Emergency Medicine’s Dr. Janette Nesheiwat said sedentary lifestyles and unhealthy diets are contributing to the rapid increase in the number of people with diabetes in the U.S.

“Unhealthy foods is usually the contributing factor to diabetes and that’s because unhealthy living, unhealthy foods are cheap, fast and easy to get and it tastes good,” Dr. Nesheiwat said. “It tastes good because it’s loaded with chemicals and preservatives.”

The International Diabetes Federation reports that the number of people living with diabetes worldwide has tripled since 2000, costing $850 billion annually.

According to the CDC, Type 2 diabetes accounts for 90% to 95% of all diabetes cases and is linked to obesity and an inactive lifestyle.

“It is a little bit more difficult to eat healthier because you have to plan in advance, but that’s just a lifestyle change … that you have to make in order to live longer because our health habits now, our lifestyle now plays a role in how long we live,” Dr. Nesheiwat said.

November is National Diabetes Awareness Month.

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Former FDA Commissioner Testifies in Pennsylvania Xarelto Lawsuit, Says Safety Warnings Were Inadequate

https://www.rxinjuryhelp.com/news/2017/11/17/former-fda-commissioner-testifies-in-pennsylvania-xarelto-lawsuit-says-safety-warnings-were-inadequate/

A Indiana woman who allegedly suffered a serious gastrointestinal bleed due to Xarelto continued to present her case this week in the Philadelphia Court of Common Pleas, where Pennsylvania’s first trial involving the blooding thinner is currently underway.

On Tuesday, a former U.S. Food & Drug Administration (FDA) commissioner testifying on her behalf told the assembled jury that Xarelto’s warning labels were inadequate, asserting that they downplayed the potential for internal bleeding that had been observed in the drug’s clinical trials.

Dr. David Kessler: Xarelto Label Downplayed Bleeding Risk

Most of  Dr. David’s Kessler’s’ testimony focused on the ROCKET-AF study, which was key to Xarelto’s FDA approval in October 2011. Though the results from the trial showed a 3.6% rate of a bleeding event among Xarelto users globally, patients in the U.S. experienced bleeding side effects at a rate exceeding 8%.

Kessler, who served as FDA commissioner during both the George H.W. Bush and Bill Clinton administrations, criticized Bayer and Janssen Pharmaceuticals for failing to inform U.S. doctors of the findings.

“It’s important information to me,” he said. “I would want to know about it. It’s a clinically significant adverse event, it’s a demographic characteristic, and it should be in the label.”

Xarelto Lawsuit Plaintiff Underwent Transfusions for Gastrointestinal Bleed

More than 1,800 Xarelto lawsuits have been consolidated in a mass tort program now underway in the Philadelphia Court of Common Pleas. The case currently at trial was filed on behalf of an Indiana woman who took Xarelto for just over a year before she experienced a gastrointestinal hemorrhage. According to her complaint, the plaintiff spent four days in the hospital and underwent two blood transfusions while her doctors tried to find the source of her bleeding.

Nationwide, Bayer and Janssen are named defendants in more than 21,000 Xarelto lawsuits, all of which accuse the companies of downplaying the risk of internal bleeding and wrongly promoting it as a superior alternative to a much older blood thinner called warfarin.

While both warfarin and Xarelto can cause dangerous episodes of internal bleeding, warfarin-related hemorrhaging can be stopped via the administration of vitamin K. However, there currently exists no FDA- approved antidote to stop bleeding events linked to Xarelto.

The majority of U.S. Xarelto lawsuits are pending in the U.S. District Court, Eastern District of Louisiana, where all federally-filed product liability claims involving the blood thinner have been centralized for coordinated pretrial proceedings. So far, that litigation has convened three trials, all of which were decided for the defense.

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The Pain Pendulum

http://abc7chicago.com/health/the-pain-pendulum/2654223/

Imagine being in excruciating pain and not being able to get the relief you need, or any relief at all. Patients suffering from chronic pain say while the country is taking steps to battle the opioid epidemic, they are being victimized.

Sufferers of chronic pain told the I-Team the national crackdown on opioids is affecting their ability to get the narcotic medication they have been using effectively and responsibly for years, and they are scared.

Maria Pollock suffers from a connective tissue disorder called Ehlers-Danlos Syndrome. She said she’s been diagnosed with a genetic polymorphism, a condition that makes her resistant to many pain medications.

Pollock said the opioid drug that worked for her has been taken off the market due to abuse concerns. Now she’s having trouble finding a pain specialist willing to take her on as a patient.

Annette Delgado battles crippling pain attacks brought on by sickle cell disease. She sees a team of sickle cell experts at the University of Illinois Hospital in Chicago. Delgado said doctors there are doing their best to keep her pain in check, but said the long-acting morphine that keeps her functioning is now being denied by insurance.

Jenni Grover, an ambassador for the U.S. Pain Foundation and a chronic pain advocate, said the stories of desperation she hears are heartbreaking. She said patients tell her they’re being treated as if they are criminal drug addicts, and doctors are abandoning them because of new regulations and possible scrutiny by the medical community and federal regulators.

Grover, who also runs the website ChronicBabe.com, said many in the pain community are reporting their doctors are either refusing to prescribe opioids or notifying them that they will no longer be patients in their practice. She said this is a challenging and complicated issue for millions of people in the United States.

State and federal leaders, as well as medical practitioners and other providers, are using multiple strategies to address the opioid crisis; curtailing the opioid supply is one of them. Drug abuse experts say between 2001 and 2011 there was a huge increase in prescriptions for drugs such as morphine, codeine and hydrocodone. They say these pills flowed too freely to the wrong kind of patient, causing unnecessary and deadly addictions and helping fuel the drug epidemic.

Government data shows the number of prescriptions written for opioids has been falling since 2012.

The Centers for Disease Control and Prevention produced guidelines in 2016 recommending shorter durations for opioid prescriptions and the use of non-drug treatment for pain.

CLICK HERE for the CDC’s 2016 opioid guidelines

Some physicians insist opioids are not the best choice for chronic pain even if they seem to work. They said prescribing practices need to be re-balanced, but even as they try to address the problem they are also facing a troubling backlash.

Police said this past July in Mishawaka, Ind., Michael Jarvis became enraged when Dr. Todd Graham, a Northwestern Medicine graduate and physical medicine and rehabilitation specialist, refused to prescribe opioids to Jarvis’s wife for back pain relief. Police said Jarvis gunned down Dr. Graham before taking his own life.

Now federal agencies, lawmakers, even corner drug stores are putting opioid guidelines and restrictions in place.

New analysis from the National Conference of State Legislatures shows 24 state governments taking action.

CLICK HERE for the NCSL analysis

Most of the legislation limits first-time prescriptions to seven days. Some states are also setting dosage limits. As of right now, Illinois has no mandated restrictions.

The president of the Illinois State Medical Society said the group will continue to lobby against regulation.

But, Dr. Kern Singh, a spinal surgeon with Midwest Orthopaedics at Rush University Medical Center, said the reality is it’s very difficult to get insurance coverage for the non-narcotic, safer alternative treatments because they are so expensive.

Working with other pain specialists at Rush, he said they have created an effective approach to surgical pain that uses fewer opioids, but is frustrated because most insurance companies refuse to cover the safer, more expensive medication.

In the meantime desperate chronic pain patients can only wonder what they will have to resort to if they’re left with no options.

In a statement America’s Health Insurance Plans, an association representing the health insurance community, said, “Health insurance providers will continue to work with doctors, hospitals and state and local leaders to provide people with better pathways to healing – without putting their lives in danger because of opioids.”

Last week the Illinois Legislature passed a measure that would require medical providers to check the state’s Prescription Monitoring Program before writing an opioid prescription. Supporters said it’s designed to make it harder for patients to obtain prescriptions from multiple doctors, a practice known as doctor shopping.

FULL STATEMENT FROM THE AHIP

I think we can all agree that we’re dealing with a very serious, very pervasive epidemic in this country. Every 2.5 weeks we lose as many lives as we did during the attacks on September 11th as a result of the opioid crisis. America’s health insurance providers have been on the front lines of this emergency for some time and have seen firsthand the harm and disruption it has caused to their customers, their families and their communities.

We have several resources on this issue, including our work with the President’s Commission on Combatting Drug Addiction and the Opioid Crisis: https://www.ahip.org/issues/opioids/

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17-MJ-02867 (Application For SW) (1)

click on above link for all 78 pages

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