“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
My husband, Dr. Chris Christensen, is a Family Physician (MD) with 40+ years of broad spectrum primary care practice, most recently to the un(der)insured in rural Montana. He has been forced out of practice for several years, and now faces prosecution at a state level (the first case ever in Montana) for “overprescribing opioids” to chronic pain patients. This is ‘part and parcel’ of an overall effort to force physicians to give their first priority in health care decision making to the policies of the Federal bureaucracies and third party payors, rather than focusing their commitment on the care of the individual patient, who has entrusted their health and wellbeing to a physician of their choosing.
The case is scheduled in District Court of Ravalli County from Thursday, October 19 to November 17, 2017 with the exception of Wednesdays.
It is painful to witness him being tried in an extremely biased fashion in the media. Dr. Chris is a caring man and healer, and a loving husband and father. He treated patients, young and old, for a variety of ailments, not just chronic pain. He is an upstanding citizen, and in no way a criminal. I pray, with the assistance of an outstanding legal team, and God watching over us, that we can prove just that to a jury of his peers.
Overdoses from opioids have captured the national spotlight. And rightly so — they kill nearly 30,000 Americans a year and cause more than 1 million hospitalizations. Another overdose issue is playing outside their shadow: the misuse of over-the-counter pain medicines like acetaminophen, aspirin, ibuprofen, naproxen, and others.
These widely used “safe” medications can cause serious gastrointestinal bleeding; create stomach ulcers; damage the esophagus, intestine, and liver; and even kill. In the United States, misuse of these medications sends nearly 200,000 people to the hospital each year.
Roughly 8 in 10 Americans routinely reach for over-the-counter pain pills to relieve headaches, backaches, sore muscles, fevers, or colds. Most are unaware that these medications can be just as dangerous as prescription drugs if used incorrectly. As a gastroenterologist, I often see patients who have overdosed on over-the-counter pain medicines. I’m not alone: A national poll by the American Gastroenterological Association found that my colleagues and I see on average nearly two patients per week with complications from over-the-counter pain pills.
Many of those people were confident they could manage their pain or discomfort on their own with over-the-counter medication. Yet the same poll found that 39 percent of Americans knowingly took more than the recommended dosage. In most cases, they falsely believed that taking more medicine than what was indicated on the label would help them “feel better faster.”
Many Americans think about safety — we click our seat belts, strap on bike helmets, make sure the smoke detector has fresh batteries, and protect our computers from viruses. Yet many people are routinely endangering themselves by not carefully reading and following the instructions when taking acetaminophen, aspirin, ibuprofen, naproxen, and other over-the-counter pain medications.
This potentially harmful practice is relatively easy to fix. Consumers should take a minute to read the labels of their over-the-counter pain medicines. It will list the active ingredient and what to know about it, how much and how often to take the medication, what the side effects might be, and when to talk to a doctor. Few patients who overdose on over-the-counter pain medications connect their symptoms to these medications. Many wait too long to seek care; by then the damage is hard to undo.
Doctors, pharmacists, and other health care professionals can play their part, too, by asking their patients if they are taking any over-the-counter medicines and if these are the right medications for them.
To help improve the conversation on over-the-counter pain medications, the American Gastroenterological Association created Gut Check: Know Your Medicine, an educational campaign to encourage individuals to safely use over-the-counter pain medicines.
Patients and their doctors would benefit greatly by talking openly about the careful use of over-the-counter pain medications, to make sure these ubiquitous drugs bring needed relief instead of more pain.
Charles Melbern Wilcox, M.D., is professor of medicine in the division of gastroenterology and hepatology at the University of Alabama at Birmingham and a chair of Gut Check: Know Your Medicine. The campaign was developed by the American Gastroenterological Association with support provided by Johnson & Johnson Consumer Inc., McNeil Consumer Healthcare Division, which manufactures over-the-counter pain medicines. Johnson & Johnson Consumer Inc. had no input into the creation of this article.
Just a short question if I may.. I work at Walgreens as a tech we received a prescription for amoxicillin 500 bid but could not make out the directions.. the pharmacist refused to fill the script, but the store manager was pushing her to just fill it.. What would have been the consequences if she would if just filled it like he said. I get that it is amoxicillin bid. But the words and number in front of the bid were unreadable to all of us..
The script was given back to the patient in filled. There was no amount of caps on the script that we could make out only that it was bit but no amount of how many bid or an amount to dispense.. this was at 10.30 pm and the prescribed was not open we did try to contact
As Pharmacists want to be addressed as “Doctor” because they have a PharmD degree and yet some of them can’t even make a simple decision that is in the pt’s best interest… The recommended dose for Amoxicillin 500 is BID (twice daily) X 10 days.
The pharmacy profession wants Pharmacists to be granted “provider status” so that they can work at the “top of their license”and be able to charge for services.. just not depend on revenue from filling prescriptions to “pay the bills”.
If this is an example of a Pharmacists working at the “top of their license”… the pharmacy profession and the pharmacy educational system preparing these pharmacists – HAS A PROBLEM !
Behind the walls of the nation’s oldest veterans’ hospital, the reports were grim.
Medical experts from the Department of Veterans Affairs blamed one botched surgery after another on a lone podiatrist.
They said Thomas Franchini drilled the wrong screw into the bone of one veteran. He severed a critical tendon in another. He cut into patients who didn’t need surgeries at all. Twice, he failed to properly fuse the ankle of a woman, who chose to have her leg amputated rather than endure the pain.
In 88 cases, the VA concluded, Franchini made mistakes that harmed veterans at the Togus hospital in Maine. The findings reached the highest levels of the agency.
“We found that he was a dangerous surgeon,” former hospital surgery chief Robert Sampson said during a deposition in an ongoing federal lawsuit against the VA.
Agency officials didn’t fire Franchini or report him to a national database that tracks problem doctors.
They let him quietly resign and move on to private practice, then failed for years to disclose his past to his patients and state regulators who licensed him.
He now works as a podiatrist in New York City.
A USA TODAY investigation found the VA — the nation’s largest employer of health care workers — has for years concealed mistakes and misdeeds by staff members entrusted with the care of veterans.
In some cases, agency managers do not report troubled practitioners to the National Practitioner Data Bank, making it easier for them to keep working with patients elsewhere. The agency also failed to ensure VA hospitals reported disciplined providers to state licensing boards.
In other cases, veterans’ hospitals signed secret settlement deals with dozens of doctors, nurses and health care workers that included promises to conceal serious mistakes — from inappropriate relationships and breakdowns in supervision to dangerous medical errors – even after forcing them out of the VA.
USA TODAY reviewed hundreds of confidential VA records, including about 230 secret settlement deals never before seen by the public. The records from 2014 and 2015 offer a narrow window into a secretive, long-standing government practice that allows the VA to cut short employees’ challenges to discipline.
Some employees who received the settlements were whistle-blowers or appear to have been wronged by the agency. In other cases, it’s clear the employees were the problem.
In at least 126 cases, the VA initially found the workers’ mistakes or misdeeds were so serious that they should be fired. In nearly three-quarters of those settlements, the VA agreed to purge negative records from personnel files or give neutral or positive references to prospective employers.
In 70 of the settlements, the VA banned employees from working in its hospitals for years — or life — even as the agency promised in most cases to conceal the specific reasons why.
Michael Carome, a doctor and director of the health research group at Public Citizen in Washington, said removing records from personnel files and providing neutral references create potential danger beyond the VA.
“It’s unacceptable,” he said. “What they are saying is, ‘We don’t want you to work for us, but we’ll help you get a job elsewhere.’ That’s outrageous.”
The VA settled with a nurse who managers initially found had left a psychiatric patient bound in leather restraints for hours; a medical technician who made errors on critical bone imaging charts; and a hospital director accused of harassing female workers while his facility fell weeks behind in treating veterans.
The VA found radiologist Jorge Salcedo misread dozens of CT scans, images that detect tumors and blood clots, at a VA hospital in Spokane, Wash., according to Texas Medical Board records. Instead of firing him, the VA agreed to pay him up to $42,000 of unused sick and leave pay and let him resign with a clean reference in 2015. The Texas records show Salcedo told the medical board he resigned under investigation, but he didn’t admit or deny the VA’s findings.
The VA has been under fire in recent years for serious problems, including revelations of life-threatening delays in treating veterans in 2014 and efforts to cover up shortfalls by falsifying records. New VA leaders promised accountability, including increased transparency and a crackdown on bad employees.
In the years since, the VA has fired hundreds of employees involved in patient care. Details of each case — including the names of fired doctors — largely remain secret.
In denying requests for information, the agency cited federal privacy law and said protecting employees’ privacy outweighed the public’s right to know about problems involving veterans’ care.
Agency leaders who took over after President Trump’s inauguration declined to discuss how their predecessors handled cases uncovered by USA TODAY.
VA spokesman Curt Cashour said “we cannot explain or defend” settlements negotiated by past agency leaders.
In response to USA TODAY’s findings, VA Secretary David Shulkin ordered that all future settlement deals with employees involving payments of more than $5,000 be approved by top VA officials in Washington. In the past, decisions about most deals were left to local and regional officials. The settlements USA TODAY reviewed involved workers at more 100 facilities in 42 states.
In addition, the VA said it will review its policy of reporting only some medical professionals to the national data bank following USA TODAY’s questions about its investigation of Franchini, who did not get a settlement.
“We will review the specific elements of this situation, along with patient safety procedures and how and when we report to the National Practitioner Data Bank and state licensing boards,” Cashour said.
A forever reminder
April Wood lives with a permanent reminder of Franchini’s surgeries.
During Army boot camp in 2004, Wood sliced her hands on a rope during a training exercise and plunged 20 feet into a cargo net.
“I heard the bones break, and I felt it,” said Wood, 42. “And I know I let out a noise that’s ungodly.”
Her ankle did not heal properly, leaving her no choice but to accept a discharge months later. She moved to Maine and sought care for her foot at Togus VA hospital on the outskirts of the capital, Augusta. To Wood, Franchini seemed a savior.
“He said he could do all this wonderful stuff. So I was like, ‘Yay, finally somebody cares, somebody wants to help me.’ ”
She first went under Franchini’s knife in 2006. The result: years of excruciating pain.
Franchini said that she had “mushy bones” that were difficult to fuse, she said. She put up with the pain even while working long hours on her feet as a hairdresser and chasing three young children.
Franchini tried a second surgery in 2009, but Wood said her pain grew worse.
She started spending much of her life in a wheelchair, unable to work. By 2012, she said her path seemed clear.
“I had to believe that something else was better than that amount of pain,” Wood said.
On Aug. 28, doctors at the Togus VA amputated Wood’s leg below the knee.
Nearly five months later, the phone rang. The VA had concerns about Franchini’s surgeries, including hers. Franchini had resigned while under investigation two years earlier, and VA officials had been examining hundreds of his former patients’ cases.
Using previous X-rays and medical records, they concluded that Franchini had improperly fused her bones, leaving her heel permanently arched higher than the ball of her foot.
Franchini’s surgeries “more likely than not contributed significantly” to the chronic pain that led to her amputation, the VA report concluded.
Wood, living in rural Missouri, sued the VA.
In an interview with USA TODAY, Franchini denied making mistakes and said he never got to respond to all of the VA’s findings. When the VA placed Franchini on leave after finding problems with a small sample of his cases in 2010, his attorney submitted two outside reviews saying the VA’s findings were not backed up by the medical records.
The VA eventually reviewed nearly 600 of his surgeries from his six years at Togus. The 56-year-old podiatrist said several doctors were in the operating room with him, and no concerns were raised at the time.
Since leaving the VA, Franchini said, he has performed numerous surgeries without complications.
“If I was so bad, I would be bad all the time,” he said.
Dangerous policy
The VA’s investigation of Franchini did not end his career.
In 2010, after the agency stopped letting him see patients, Franchini resigned and took a job with a surgical center in the Bronx.
Despite leaving the agency under investigation — a serious event for practitioners — VA officials did not disclose his resignation to the National Practitioner Data Bank.
Under a nationwide VA policy in place for nearly three decades, the agency doesn’t report such events for podiatrists and other kinds of medical providers, including thousands of nurses and physician’s assistants working for the agency.
VA officials say the agency is only required under federal law to report medical doctors and dentists, and that all other providers are optional.
However, a review of the database shows other institutions go beyond the law and report podiatrists and other providers who may have harmed patients.
Podiatrists, foot doctors who attend colleges of podiatry rather than traditional medical schools, are trained to treat conditions of the feet and ankles. They perform surgeries and prescribe drugs, prompting experts to say they should be reported to the data bank.
Congress created the national clearinghouse in 1986 to prevent problem medical workers from crossing state lines to escape their pasts and keep practicing.
“It makes no sense to report only half the people who can cause harm,” said Michael Gonzalez, an Ohio health care lawyer who represents hospitals. “There are podiatrists who do a lot of foot and ankle surgeries.” The lack of reporting to the national database is not the only gap found by USA TODAY.
VA policy recommends officials notify another government authority — state medical licensing boards — within 100 days of launching an investigation into medical workers who may have harmed patients.
The VA provided USA TODAY with such reports for fewer than 50 employees in the past 10 years.
The VA said it has reported more employees to state boards than appear in those records, but the agency can’t provide a number because its hospitals fail to follow the agency’s policy to share all such reports with headquarters.
Even when the VA does report medical providers to states, records reviewed by USA TODAY show delays in making such reports can stretch for years.
It took VA officials two years to report their findings about Franchini’s surgeries to state medical boards. In that time, he was able to get jobs with no indication of his past problems on his licenses. What’s more, he was able to get licensed in two more states after leaving the VA — Massachusetts and Connecticut. State medical boards won’t discuss investigations, but Franchini remains licensed in New York, Rhode Island, Massachusetts and Connecticut and has practiced in three of the states in the past two years. Notices to state boards are confidential unless they result in disciplinary action, so there is no way to know if there have been complaints about him since he left the VA. Three of his recent employers declined to comment.
Experts said the VA’s reporting practices leave gaping holes that could endanger patients.
“The VA should do the right thing and report them,” Carome said. “It’s about protecting the public.”
Hundreds more secrets kept
The secret settlements obtained by USA TODAY represent a fraction of the problem doctors and other employees the VA has discovered over the past 10 years.
Each year, the agency fires hundreds of medical workers and pays out hundreds of malpractice claims.
The providers’ names remain secret.
USA TODAY asked to inspect the records for thousands of those cases, but the VA blacked out or would not release the identities of the providers or the details of what took place.
That’s what makes the small set of secret settlements obtained by USA TODAY so unique.
Though the records do not describe the wrongdoing, they provide the names, job descriptions, the amount of the settlement payments and other terms.
In the 230 deals, the agency spent $6.7 million to settle with employees, including doctors, nurses and other health-care workers.
One of the biggest payments went to Mario DeSanctis, the former director of the VA’s Tomah medical center in Wisconsin. The hospital became known as “Candy Land” because of the dangerous doses of powerful narcotics routinely dispensed to veterans. VA investigators warned DeSanctis in 2012 that the center was known to police as a supplier for drugs in the area and advised him to take action, according to testimony in a U.S. Senate investigation of the case.
Investigators blamed the hospital when a 35-year-old Marine veteran died two years later after he was prescribed a fatal cocktail of more than 13 drugs. His father had visited him hours earlier and said he was lying in the mental health ward, babbling and holding his head. The VA fired DeSanctis, but he fought it, and the agency struck a deal with him. It let him resign and paid him and his lawyer $163,000. It pledged neither side would divulge the details of the agreement. DeSanctis did not respond to interview requests. “It makes me sick,” the veteran’s widow, Heather Simcakoski, said of the secret payout. “He shouldn’t have anything. He should have been fired.”
Patients in the dark
The VA’s policy about medical mistakes is clear: Patients should be notified as soon as possible.
In 2012 — two years after the agency revoked Franchini’s clinical privileges — the VA’s top leaders had still not told the patients.
The findings reached VA headquarters in Washington, sparking a scramble to head off a crisis.
Chief Medical Officer Andrea Buck recommended that because there was an “absence of ongoing harm,” the agency should create a plan to notify Congress and a communication strategy before talking to his patients, according to records in a federal lawsuit against the VA.
It would be the next year — after Wood’s leg was amputated — when the VA told patients.
The notification surprised Kenneth “Jake” Myrick, 43, an Army combat veteran from Maine. It meant the VA would allow him to be re-examined for grueling pain he had endured for years. The result of his VA review: “substandard” care. Surgeons reviewing the case determined Franchini improperly used a technique that involves rerouting tendons to shore up failing ankles. Myrick said the operation failed, forcing him to walk with a cane. Not until doctors performed corrective surgery years later could Myrick properly walk again, he said.
By the time the agency informed Myrick about the surgical errors it had discovered, it was too late to sue. Maine’s three-year deadline to file suit for medical negligence had expired.
He’s one of at least six veterans suing the VA in a case that accuses the agency of fraudulently concealing Franchini’s mistakes. The VA has denied the claim, arguing in court that nothing prevented the veterans from suing earlier.
Brewster Rawls, a longtime Virginia malpractice lawyer and Army veteran who filed an unsuccessful claim for one veteran, called the delays “inexcusable.”
“How is the claimant supposed to know when (the VA) was sitting on this?” Rawls asked. “What they did was just wrong.”
Myrick said that if the VA followed its own guidelines, it could have helped the veterans the agency is supposed to serve and made sure other patients were not harmed.
“They were just trying to protect themselves,” Myrick said. “We are told to have honor, duty and sacrifice. The VA had no honor. They failed in their duties, and they were willing to sacrifice the people they were supposed to serve.”
Senator says soaring opioid epidemic calls for get-tough approach
(INDIANAPOLIS) – Legislators fighting the opioid epidemic may shift their focus next year to punishing drug dealers.
Indianapolis Senator Jim Merritt (R) says he’ll introduce several bills which would impose longer sentences for drug crimes. One would set an automatic 10-year minimum sentence for dealing the painkiller fentanyl. That would make it the only drug with a mandatory minimum in Indiana. Merritt says fentanyl or fentanyl mixed with other drugs is to blame for most of the soaring number of Indiana overdose deaths.
Merritt’s also calling for nonsuspendible prison terms for pharmacy robberies.
The emphasis on longer prison terms represents an about-face from a revision of Indiana’s sentencing laws three years ago, whose goals included seeking alternatives to prison for drug offenses. Merritt says that was “a different time.” With opioids becoming the main drug threat, Merritt says the stakes have grown, and says the state needs to send dealers a clear message.
Merritt says he’ll also introduce a bill to tear up Indiana’s laws attempting to outlaw synthetic drugs like Spice — laws Merritt authored. Merritt says the makers of those drugs continue altering their formulas faster than the state can outlaw them. He’s instead proposing an approach taken by Marion County Prosecutor Terry Curry to prosecute those drugs under a beefed-up version of Indiana’s “lookalike drug” law, imposing the same penalties for drugs which mimic marijuana or L-S-D as you’d get for the real thing.
September 18, 2017 Marilyn Tavenner President and CEO America’s Health Insurance Plans 601 Pennsylvania Avenue, NW Washington, DC 20004
Re: Prescription Opioid Epidemic
Dear Ms. Tavenner,
The undersigned State Attorneys General are sending you this letter to urge America’s Health Insurance Plans (AHIP) to take proactive steps to encourage your members to review their payment and coverage policies and revise them, as necessary and appropriate, to encourage healthcare providers to prioritize non-opioid pain management options over drug offences for opioid prescriptions for the treatment of chronic, non-cancer pain. We have witnessed firsthand the devastation that the opioid epidemic has wrought on our States in terms of lives lost and the costs it has imposed on our healthcare system and the broader economy. As the chief legal officers of our States, we are committed to using all tools at our disposal to combat this epidemic and to protect patients suffering from chronic pain or addiction, who are among the most vulnerable consumers in our society.
The opioid epidemic is the preeminent public health crisis of our time. Statistics from the Surgeon General of the United States indicate that as many as 2 million Americans are currently addicted to or otherwise dependent upon prescription opioids.1 Millions more are at risk of developing a dependency— in 2014, as many as 10 million people reported using opioids for nonmedical reasons.2 The economic toll of the epidemic is tremendous, costing the U.S. economy an estimated $78.5 billion annually.3 State and local governments alone spend nearly 8 billion dollars a year on criminal justice costs related to
1 Surgeon General of the United States, Opioids, https://www.surgeongeneral.gov/priorities/opioids/index.html (last updated June 1, 2017); Nora D. Volkow, M.D., America’s Addiction to Opioids: Heroin and Prescription Drug Abuse, National Institute on Drug Abuse (May 14, 2014), https://www.drugabuse.gov/about-nida/legislativeactivities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse. 2 See Surgeon General, supra fn. 1 (citing National Survey on Drug Use and Health, Substance Abuse and Mental Health Services Administration, 2014). 3 Healthday News, Opioid Epidemic Costs U.S. $78.5 Billion Annually: CDC (Sept. 21, 2016), http://www.health.com/healthday/opioid-epidemic-costs-us-785-billion-annually-cdc.
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opioid abuse.4 The human cost is even more staggering: Opioid overdoses kill 91 Americans every single day.5 More than half of those deaths involve prescription opioids.6
The unnecessary over-prescription of opioid painkillers is a significant factor contributing to the problem. Although the amount of pain reported by Americans has remained steady since 1999, prescriptions for opioid painkillers have nearly quadrupled over the same timeframe.7 This four-fold increase in prescriptions has contributed to a commensurate increase in the number of opioid overdose deaths.8 The dramatic increase in supply has also made it relatively easy to obtain prescription opioids without having to resort to the black market: Over 50% of people who misuse opioids report that they obtained them for free from a friend or relative, while another 22% misused drugs that they obtained directly from a doctor.9 While illegal opioids like heroin remain a serious problem that also must be addressed, the role played by prescription opioids cannot be ignored. While there is no panacea, any comprehensive effort to address and end the opioid epidemic must tackle the ever-increasing number of prescriptions for opioid painkillers. You could see page and see what needs to be done when it comes to the legalities.
Reducing the frequency with which opioids are prescribed will not leave patients without effective pain management options. While there are certainly situations where opioids represent the appropriate pain remedy, there are many other circumstances in which opioids are prescribed despite evidence suggesting they are ineffective and even dangerous. For example, the American Academy of Neurology has explained that while the use of opioid painkillers can provide “significant short-term pain relief,” there is “no substantial evidence for maintenance of pain relief or improved function over long periods of time.”10 Another recent study concluded that the use of opioids to treat chronic, non-cancer related pain lasting longer than three months is “ineffective and can be life-threatening.”11 When patients seek treatment for any of the myriad conditions that cause chronic pain, doctors should be encouraged to explore and prescribe effective non-opioid alternatives, ranging from non-opioid medications (such as NSAIDs) to physical therapy, acupuncture, massage, and chiropractic care.
4 Id. See also Costs of US Prescription Opioid Epidemic Estimated at $78.5 Billion, Wolters Kluwer (Sept. 14, 2016),http://wolterskluwer.com/company/newsroom/news/2016/09/costs-of-us-prescription-opioid-epidemicestimated-at-usd78.5-billion.html 5 Understanding the Epidemic: Drug overdose deaths in the United States continue to increase in 2015, Centers for Disease Control and Prevention, https://www.cdc.gov/drugoverdose/epidemic/ (last updated Dec. 16, 2016). 6Prescription Opioid Overdose Data, Centers for Disease Control and Prevention, https://www.cdc.gov/drugoverdose/data/overdose.html (last updated Dec. 16, 2016). 7 See Surgeon General, supra fn. 1; Opioid Addiction 2016 Facts and Figures, American Society of Addiction Medicine (2016), https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf. 8 Vivek Murthy, The Opioid Crisis: Our Solution, TIME (Oct. 13, 2016), http://time.com/4521562/2016-electionopioid-epidemic/ 9 Opioids, Substance Abuse and Mental Services Administration, https://www.samhsa.gov/atod/opioids (last updated Feb. 23, 2016). 10 Gary M. Franklin, MD, MPH, Opioids for chronic noncancer pain: A position paper of American Academy of Neurology, 83 Neurology 1277 (2014). 11 Eric Scicchitano, Geisinger doctors: Opioids ineffective for chronic pain put patients at risk, The Daily Item (Dec. 7, 2016), http://www.dailyitem.com/news/local_news/geisinger-doctors-opioids-ineffective-for-chronic-pain-putpatients-at/article_2d66014f-511e-554f-bed5-768886b48616.html (citing, generally, Mellar P. Davis & Zankhana Mehta, Opioids and Chronic Pain: Where is the Balance? 18 Current Oncology Reports 71 (2016), available at https://link.springer.com/epdf/10.1007/s11912-016-0558-1)
Insurance companies can play an important role in reducing opioid prescriptions and making it easier for patients to access other forms of pain management treatment. Indeed, simply asking providers to consider providing alternative treatments is impractical in the absence of a supporting incentive structure. All else being equal, providers will often favor those treatment options that are most likely to be compensated, either by the government, an insurance provider, or a patient paying out-of-pocket. Insurance companies thus are in a position to make a very positive impact in the way that providers treat patients with chronic pain.
Adopting an incentive structure that rewards the use of non-opioid pain management techniques for chronic, non-cancer pain will have many benefits. Given the correlation between increased supply and opioid abuse, the societal benefits speak for themselves. Beyond that, incentivizing opioid alternatives promotes evidence-based techniques that are more effective at mitigating this type of pain, and, over the long-run, more cost-efficient.12 Thus, adopting such policies benefit patients, society, and insurers alike. When it comes to accidents and injuries the truck accident attorneys from Thon Beck Vanni Callahan & Powell Company can provide the required legal assistance.
The undersigned Attorneys General serve an important role in combating the opioid epidemic. As the chief legal officers of our States, we are charged with protecting consumers, including patients suffering from chronic pain and opioid addiction. Among other things, we are committed to protecting patients from unfair or deceptive business practices and ensuring that insurers provide consumers with transparent information about their products and services.
We are thus committed to utilizing all the powers available to our individual offices to ameliorate the problems caused by the over-prescription of opioids and to promote policies and practices that result in reasonable, sustainable, and patient-focused pain management therapies. In the near future, working in conjunction with other institutional stakeholders (such as State Insurance Commissioners), we hope to initiate a dialogue concerning your members’ incentive structures in an effort to identify those practices that are conducive to these efforts and those that are not. We hope that this process will highlight problematic policies and spur increased use of non-opioid pain management techniques. In case of workplace related injuries workers comp law firm has lawyers that can help you get the compensation you deserve. The status quo, in which there may be financial incentives to prescribe opioids for pain which they are ill-suited to treat, is unacceptable. We ask that you quickly initiate additional efforts so that you can play an important role in stopping further deaths.
We look forward to having this discussion with you.
Sincerely,
Leslie Rutledge Pamela Jo Bondi Arkansas Attorney General Florida Attorney General
12 Harrison Jacobs, Pain doctors: Insurance companies won’t cover the alternatives to opioids, Business Insider (Aug. 10, 2016), http://www.businessinsider.com/doctors-insurance-companies-policies-opioid-use-2016-6 (“If you look at the long-term cost of [opioids], plus monitoring, office visits and drug screenings . . . it’s cheaper long-term to do the more advanced therapy,”) (quoting Dr. Timothy Deer, co-chair, West Virginia Expert Pain Management Panel).
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Wasn’t it 46 state attorney generals in the late 90’s that sued all the Tobacco Industry and got a settlement of a minimum of 206 BILLION dollars paid out over 25 yrs..
Isn’t some of the same members that signed this letter are lining up to sue the pharmaceutical industry over causing the opiate crisis ? How much do you think that settlement is going to total ?
Do you think that these same AG’s would hesitate to sue the health insurance industry for failing to conform to the AG’s wishes to reduce opiate prescriptions and/or limit opiates to only those who have cancer ?
They have already successfully sued a industry for the “damages” of producing and selling a LEGAL PRODUCT… and after that settlement that same industry went back to selling that same LEGAL PRODUCT.
After all it was our judicial system that in 1917 declared opiate addiction was a CRIME and NOT A DISEASE.. and they have operated under that judicial decision and in 1970 our Congress passed the Controlled Substance Act…that created the Federal Narcotic Bureau and its two million/yr budget with the BNDD (Bureau of Narcotics and Dangerous Drugs) with a 1200-1500 new agents and a 43 million/yr budget. Which has now entails abt 12,000 employees of the DEA and the war on drugs now costing 81 billion/yr AND GROWING.
It would appear that now our judicial system is trying to prove that they can stop opiate use/abuse/addiction by eliminating the prescribing of legal opiates for all pts except those suffering from cancer.
For over ONE HUNDRED YEARS our judicial system has attempted to “cure addiction” by using the only “treatment/cure” that they have available to them and that is jail/prison….. and we have seen how well that has worked over the past ONE HUNDRED YEARS
So now our judicial system has decided that abstinence will solve the opiate crisis.
House Bil No. 4405 was passed by the House in June of 2017 is up for discussion, but has yet to be voted on by the Senate Committee.
A pharmacists may refuse to dispense a prescription for a controlled substance if the pharmacist has reason to believe that the prescription was written for fraudulent reasons or being filled for a purpose that is not a medical purpose.
The amendment to the House Bill would protect the pharmacist from being liable for any damages that end in injury, death, or loss to a person or property because the pharmacist wouldn’t fill it.
“A pharmacists may refuse to dispense a prescription for a controlled substance if the pharmacist has reason to believe that the prescription was written for fraudulent reasons or being filled for a purpose that is not a medical purpose.”
Both of the above conditions means that the prescription is illegal/fraudulent prescription and the Pharmacist has a legal/professional responsibility to call the authorities. If the Pharmacist returns the prescription to the pt… then – IMO – the pharmacist is NOT CONFIDENT – does not have FACTS – that the prescription meets the above criteria. So they decline to fill the prescriptions because “they are not comfortable” So will “not comfortable” meet the above criteria for valid denial of filling a controlled substance ?
Also, the fact that this law is isolating a particular “type of pt”… does this make this proposed law in conflict with the Americans with Disability Act and/or Civil Rights Act and thus UNCONSTITUTIONAL… but… if signed into law… and no one challenges the CONSTITUTIONALITY of this proposed law.. it will be enforced as written
JUDY WOODRUFF: But, first, we continue with our America Addicted series, looking at the opioid epidemic.
Roughly 100 million Americans suffer from chronic pain. And most health officials agree that legal painkillers, prescribed by doctors and filled by pharmacies, triggered a tidal wave of addiction throughout the U.S.
Recent guidelines from the Centers for Disease Control and Prevention urge doctors to avoid or dramatically limit these prescriptions in most cases. But where does that leave the chronic pain sufferers?
Special correspondent Cat Wise has our report from Orange County.
AMY CRAIN, Kaiser Permanente Patient: Let’s go to the park.
CAT WISE: In many ways, Amy Crain’s story has followed the same path as hundreds of thousands of other chronic pain sufferers caught up in the opioid epidemic.
There was the accident, in her case, getting slammed in the family car… the hospitalization and surgeries that saved her from paralysis…
AMY CRAIN: Ready? One, two, three, jump.
CAT WISE: And a resulting dependency on prescription painkillers — OxyContin, methadone, and Norco, that had left her foggy and barely functional.
AMY CRAIN: I couldn’t lift my daughter, couldn’t care for her.
CAT WISE: But then Crain’s story took a dramatic turn that has led her on a very different path, thanks to this doctor and a new effort by one of the country’s largest health care providers to tackle this national emergency.
Dr. Anh Quan Nguyen is a Kaiser Permanente pain specialist who has been prescribing Crain and other patients alternative therapies, all covered by Kaiser’s insurance plan. The treatments include needles in the back, carefully placed by an acupuncturist; mindfulness at the clinic; yoga training, which she often practices in a local park.
And, perhaps most importantly, she’s been prescribed fewer and fewer pain pills. In fact, Crain is now taking just a small percentage of the meds she was once on … a result at first she didn’t think was possible.
AMY CRAIN: How am I going to do this? How am I going to, you know, get to clean my house? How am I going to, you know, get up in the mornings? And it was terrifying. But it wasn’t as hard as I thought it was, with the other tools.
CAT WISE: Crain knew the stakes were high; 33,000 people died in the United States in 2015 from opioid overdoses, and early estimates from last year indicate that the numbers are up significantly.
As communities and health care providers around the country seek solutions, some are turning here, to Southern California, where Kaiser Permanente’s program has led to a big drop-off in opioid prescriptions.
DR. ED ELLISON, Southern California Executive Medical Director, Kaiser Permanente: We have seen between 2010 and 2015 a reduction of more than 80 percent in the use of OxyContin, the long-acting opioid.
CAT WISE: Eighty percent?
DR. ED ELLISON: Eighty percent.
CAT WISE: Dr. Ed Ellison is the executive medical director for the Southern California Permanente Medical Group.
DR. ED ELLISON: Across the program, we have seen more than a 30 percent reduction in opioid prescribing. So, we’re seeing significant movements being made.
CAT WISE: Ellison says getting those reductions wasn’t easy — a sign that far too many of the drugs were being prescribed in the first place. In fact, in 2009, when a small group of Kaiser leaders gathered in Pasadena to look at recent prescription numbers, they were stunned. They expected to see diabetes and hypertension medications top the list.
DR. STEVEN STEINBERG, Southern California Family Medicine Chief, Kaiser Permanente: And instead, we saw hydrocodone, oxycodone, OxyContin, fentanyl, methadone.
CAT WISE: Dr. Steven Steinberg is the lead physician for the medical group’s controlled substance task force.
DR. STEVEN STEINBERG: And we saw these just massive numbers of prescriptions, massive numbers of refills. And not just that, huge numbers at one time. People were getting 800 or 1,000 pills at a time.
CAT WISE: Kaiser Permanente may have been among the first to spot the problem, but its numbers reflected a deep national trend.
Billions of pills have been prescribed over the past two decades. Addictions and overdoses have surged, both for prescription painkillers and a growing number of people turning to illegal opioids like heroin.
So, in 2010, Kaiser decided the new approach for patients like Crain, and their doctors, was needed. They called it the Safe and Appropriate Opioid Prescribing Program.
DR. ED ELLISON: Pain is very subjective. And I can’t sit here and tell you you’re not in pain. My job is to help alleviate that pain. The key is to understanding that all roads don’t lead to an opioid.
CAT WISE: It started with data assembled from the organization’s nearly 12 million members and 21,000 physicians. Doctors were given reports of their prescription habits and their patients’ histories with pain killers.
And Kaiser Permanente’s computer system was reprogrammed to make it harder for physicians to prescribe certain high-risk opioids or dangerous combinations.
DR. STEVEN STEINBERG: Type in OxyContin. You cannot proceed without answering various questions. Are there any other drugs that you tried first that are safer? Are you aware this is a dangerous drug?
And what we found is, people do change their behavior. It’s one thing when you know it, and one thing when you have to commit it to print.
CAT WISE: Pharmacists have been trained to spot high-risk activity, duplicate prescriptions, excessive quantities or early refills, and to contact the prescriber or a supervisor to discuss their concerns.
DR. ANU SINGH, ER Chief Physician, Kaiser Permanente: And on a scale of 10 to zero, where would you put your pain right now? It was eight?
CAT WISE: In emergency departments, where it was once the norm for patients to be handed scripts for 30 to 50 pain pills, patients have been put on notice that the rules have changed.
DR. ANU SINGH: We have posters in every room. We have handouts we give out to our patients where we don’t give out prescriptions for more than a three days’ supply. We don’t refill lost or stolen prescriptions. So, all those guidelines are made clear to every patient when they walk in.
CAT WISE: Dr. Nguyen and his colleagues have regular training sessions on opioids and meetings to discuss difficult cases. But they still worry about creating “opioid refugees,” pain patients who turn to street drugs like heroin when their medications are yanked away quickly.
That’s a sensitive subject for Crain and many other patients.
AMY CRAIN: I resent it when doctors treat us like we’re some kind of drug addicts, because I didn’t put myself in this situation.
CAT WISE: Dr. Nguyen says one of the first steps, with all his patients, is to build trust. And so he’s developed what he calls the difficult pain conversation.
DR. ANH QUAN NGUYEN, Pain specialist, Kaiser Permanente: The first thing I will tell patients is, ‘I know you have pain. I believe you. I’m going to examine you today, and figure out what I can do for you.’
After the examination, I say, ‘Look, I happen to notice that you’re on these medications, and I really want to have an open conversation with you about the dangers of these medications. Can we have this conversation?’
CAT WISE: George Teter has had that difficult pain conversation with Dr. Nguyen. Teter found himself on high levels of prescription fentanyl and other opioids after two surgeries on his elbow.
GEORGE TETER, Kaiser Permanente Patient: I would have to kind of schedule around, like, make sure I wasn’t doing any driving or anything like that.
CAT WISE: Dr. Nguyen’s slow and steady regimen of reducing his opioid intake made him feel more like his old self. Teter’s off fentanyl completely now and has cut his other opioid pain med by about 75 percent.
These days, when his pain surges at work, he finds relief by meditating at a fountain near his office. He says the process wasn’t always easy, but he credits Dr. Nguyen’s careful approach with saving his life.
GEORGE TETER: He told me one thing that really stuck in my head, that the pain will never kill you.
DR. ANH QUAN NGUYEN: But if you keep these medications up, it will kill you. These medications tell you to go to bed at night, ‘Stop breathing. Stop breathing.’ And eventually your brain listens to it, and then you don’t wake up in the morning.
So it’s not a painful way to die. It’s just very sad.
CAT WISE: But some doctors say the nationwide crackdown on pain pills has gone much too far.
In West Covina, California, just outside L.A., pain specialist Dr. Forest Tennant says patients are now flying in to see him from all over the country, like Gary Snook of Montana.
Tennant says a small fraction of pain patients, about 3 to 5 percent, have rare chronic conditions, like Snook, and need high doses of opioids to function, but can’t get them elsewhere.
DR. FOREST TENNANT, Pain Specialist: There’s no question about it. The pendulum has swung too far.
CAT WISE: After reviewing details on Kaiser Permanente’s program, Tennant had some praise for its depth and general approach. But he said there’s still a very good chance that the type of patients he sees most frequently would be left behind.
DR. FOREST TENNANT: It takes a lot of work to treat these people. It takes a special clinic, special time. And I hate to say it, but I’m afraid a lot of parties just don’t want to treat these folks.
CAT WISE: But, for chronic pain patient Amy Crain, Kaiser’s program, she says, was exactly what she needed, when others might have written her off. And it’s helped her learn to cope.
AMY CRAIN: You just kind of acknowledge the pain. You know, ‘OK, you’re there. I’m working with you today.’
CAT WISE: She now marks progress in the simple things, rides on the swing, trips down the slide, and in the laughter that makes her feel like she’s gotten her life back.
For the PBS NewsHour, I’m Cat Wise in Anaheim, California.
JUDY WOODRUFF: Online, you can find all of the stories in our America Addicted series. Just go to PBS.org/NewsHour.
Ohio has bragging rights as the top state for regulating prescription drugs. Via AP:
The American Medical Association has listed Ohio as the top state when it comes to monitoring prescription drugs.
The AMA says in a recent fact sheet that Ohio processed more than 24 million queries from doctors and other health professionals through the Board of Pharmacy’s Ohio Automated Rx Reporting System.
The state created the system to track the dispensing of controlled substances and monitor suspected abuse. OARRS has been a key tool in battling the state’s deadly addictions epidemic.
But is it working? Doesn’t look like it. According to the CDC, the state saw a 21.5 percent increase in overdose deaths from 2014-2015. Only six states had higher increases. The Buckeye State had a staggering 3,310 deaths in 2015, making it the second-worst state in the nation. Ohio’s 29.9 drug overdose deaths per 100,000 people earned the state a spot near the top of the national chart, behind only West Virginia and New Hampshire with 41.5 and 34.3 deaths per 100,000 respectively.
Gov. Kasich’s answer to these devastating statistics is to make it harder for people to get their hands on prescription opioids. He recently issued an executive edict limiting opioid prescriptions to seven days (five days for minors) for acute conditions.
“You are going to have to abide by these rules or else you’re in serious trouble, whether you’re a doctor, a dentist or a nurse,” he warned.
Warnings like this, while well-intentioned, hurt law-abiding citizens who now often suffer in pain because they can’t get the meds they genuinely need for legitimate health problems. Opioid pain medications can be safe and effective for treating pain when used appropriately, but increased regulations on these drugs as a result of the heroin epidemic have made it monstrously difficult for those with chronic pain to get the drugs they need. I’m always shocked to hear about the huge quantities of prescription opioids that addicts were able to obtain because for most people who follow the rules, quantities are strictly limited and they require regular follow-up visits with a physician. Doctors are being threatened to within an inch of their medical licenses if they get caught over-prescribing (which, again, makes me marvel that anyone is able to obtain enough opioids—legally—to abuse them).
A common narrative cited in discussions about the opioid crisis – that a medical patient is prescribed painkillers, gets addicted and dies of an overdose – is a myth, an expert on the topic argued Wednesday.
During a discussion at the Cato Institute, Phoenix-based general surgeon Jeffrey Singer cited studies from the Centers for Disease Control and Prevention, JAMA Psychiatry and various municipalities supporting his claim. According to the CDC, the opioid-related overdose death rate for patients prescribed pain medication by doctors is 0.2 percent. A 2014 JAMA study showed that out of 136,000 patients treated for opioid overdoses in emergency rooms around the country, 13 percent involved chronic pain patients.
And though the U.S. recorded 33,000 opioid-related overdose deaths (including heroin) in 2015, Singer said that the vast majority of those deaths can be attributed to people mixing narcotics with other substances. New York City reported in 2013 that 94 percent of its residents who died from heroin or opioid abuse had multiple drugs in their system.
“It’s not like doctors are prescribing a painkiller for a patient in pain, who then gets hooked and becomes a heroin addict. That’s not the usual way,” Singer said.
Dr. Lynn R. Webster, a physician who has treated chronic pain patients for more than 30 years, says that new rules issued by the Drug Enforcement Administration (DEA) limiting access to hydrocodone are inflicting harm on chronic pain patients. The new restrictions, which include a decision to relabel hydrocodone as a Schedule II drug, require that patients jump through burdensome hoops in order to receive the medication they need. Patients must see their physician every 90 days in order to receive refills and doctors can no longer call in prescriptions. “Pain advocates across the country were vocal when the DEA announced these changes,” Webster wrote. “They would have unintended consequences that would hurt, rather than help, legitimate pain patients in need.”
She cited a survey by the National Fibromyalgia and Chronic Pain Association (NFMCPA) that assessed the regulatory changes. The survey found that:
88 percent of patients felt that the changes denied their rights to access pain medication
71 percent report being switched to less effective medications by their doctors, who are fearful of legal issues
52 percent felt an increased sense of stigma as a patient receiving hydrocodone
27 percent of patients even reported suicidal thoughts when unable to access their prescription
“Controlling the abuse and overuse of pain killing drugs is necessary to keep patients safe, but the importance of decreasing drug abuse does not outweigh the needs of millions of people who suffer from chronic and depleting pain,” Webster explained. “When patients who suffer from these excruciating conditions are denied access to medication, they often turn to alternative forms of relief such as black market drugs, creating a larger issue of abuse.”
I suffer from chronic, often debilitating migraine headaches and have experienced first-hand the effects of the national war on opioids. I’ve been to doctors who refuse to prescribe any pain meds for migraine patients. The reason? Pain meds never help migraine pain, I was told, which is complete bull hockey. I’ve also been to practices that have a policy of not prescribing opioids to anyone for any condition. Unfortunately, it seems that for many doctors, it’s easier to just deny pain meds outright to all patients than to risk some becoming dependent. While opioids not may the most effective treatment for migraines, and they may be contraindicated in some (even many) cases, saying that they “never” help migraine pain is verifiably false.
In my case, I’ve found that while strong pain medications like Percocet won’t take a migraine away completely, they’ll sometimes buy me a few precious hours of respite from the blinding pain. That’s why I’m willing to drive an hour to a migraine clinic with doctors who recognize that opioids can and do play a vital role in managing this type of chronic debilitating pain.It wasn’t too many years ago that I was able to go to my family doctor’s office (or sometimes his home!) for a shot of Demerol to get me through an especially bad migraine episode, but now patients in pain are forced to go to the emergency room for relief (which again leaves me wondering where people are getting all these pills).
But going to the ER is one thing I won’t do when I have an excruciating, intractable migraine, even one that has gone on for a week with no end in sight, accompanied by constant vomiting. Migraine patients who show up at the ER are treated like drug addicts these days, thanks to the culture of fear that surrounds opioid abuse. Even if I tell them at the outset that I don’t want narcotics and say that I just need some (non-narcotic) DHE by IV, I’ll still be treated like a drug-seeking junkie. I’d rather suffer at home than under the bright lights at the ER with nurses searching my arms for needle marks and then leaving me languishing for hours on a stretcher, vomiting into the wastebasket, only to be sent home in worse shape than I arrived.
I’m no libertarian on drug policy, but I do support treating doctors like the trained professionals they are, which includes giving them a full arsenal of tools at their disposal to help patients who are suffering. (Yes, that includes medical marijuana.) It’s tragic that three thousand people a year die of drug overdoses in Ohio (and ten times that nationwide). But it’s also terrible that innocent chronic pain patients have to suffer and pay the price for the poor decisions of the minority of opioid users who go on to abuse drugs.
With eight states voting to legalize some form of cannabis, the pace of cannabis legalization picked up in 2016—but enforcement action by the DEA showed no sign of slowing down. New data from the federal agency indicates cannabis seizures increased by 20% last year.
DEA Head Chuck Rosenberg Resigns. Now Who Takes Over?
The 5,348,922 plants seized by the DEA was the most confiscated by the agency since 2011, when the agents confiscated over 6.7 million plants.
The value of seized property and cash also climbed last year. Asset forfeitures in cannabis eradication efforts totaled $51,937,207.01, almost doubling the amount seized in 2015 ($29,705,902.43).
Nearly all the seized plants were on outdoor grows—only 7% of seized plants came from indoor operations.
As NORML Deputy Director Paul Armanto notes, the DEA’s eradication efforts centered on California, with 71% of the seized plants coming from that state. The agency recorded more than 3.77 million cannabis plants seized in the Golden State last year, a fairly large increase over 2015’s total of 2.64 million seized plants.
Other states that saw a lot of cannabis seized included Kentucky, Texas, Florida, Tennessee, and West Virginia.
Kentucky saw over a half a million cannabis plants seized in 2016, along with 211 weapons also—one of the highest totals of any state. Texas, meanwhile had 333,000 plants seized in 2016, while Florida led the country in assets seized. In all, $23,905,180 in assets were seized in the state last year, nearly half the national total.
From Gayle Christensen
DEA Report: Cannabis Seizures Climbed By Nearly 20% Last Year
