James Gill: Putting a star lawman on trial

http://www.theadvocate.com/new_orleans/opinion/james_gill/article_6a621a34-be4c-11e7-9c7d-7b848a3b0d02.html

If prosecutors fail to convict Chad Scott, it will not be because his alleged misdeeds took them by surprise.

The feds received a tip that he was a crook thirteen years ago, although whether that panned out is unknown. What we do know is that Scott’s supervisors at the DEA were disciplining him for at least the fourth time when yanking his gun and badge in March after drugs and cash turned up missing. A whiff of corruption has attended pretty much his entire career, and his indictment has now been greeted in some circles with a shrug.

Scott has his fans too, however, and Matt Coman calls him “a fine upstanding public servant.” That endorsement might have carried more weight if Coman were still a federal prosecutor himself, but he quit that line of work for private practice a couple of years ago. He is gushing now in his capacity as Scott’s defense attorney.

Scott was long regarded as the star agent, making collars and seizing cash and drugs with such effect that he rated a line in a number composed by the Houston rapper Scarface. Scott’s “work has gone a long way toward continuing to eradicate the scourge of illegal drugs in this community. He’s a fantastic person, a fantastic agent — a credit to that agency,” according to Coman.

In his regard for Scott, Coman defers only to Scott himself, who evidently liked to assure suspects that he was the “baddest” law enforcer along the I-10 corridor and burnished his macho image by nicknaming himself, “the white devil.”

Scott, 49, is also a winner on the Big Dawg tour, a major event in the water ski world, and has been described in the public prints as “tall, athletic and handsome.” It would be unnatural if he hadn’t been wondering who would play him in the movie.

Perhaps he still is, but he is now more likely to be the villain than the hero in any scenario, for the grand jury does not share Coman’s high opinion.

According to the indictment, Scott has framed suspects, lied on the witness stand, falsified public records and embezzled cash seized from drug dealers. He denies it all and is scheduled for trial next month, when he could be sentenced to 17 years.

It is obvious that the Department of Justice has no doubt he is guilty. Prosecutors are not waiting to dismiss charges in cases handled by Scott, closed or open. Last year two drug dealers, facing 10 years, had their convictions overturned because Scott had suborned witnesses. And, such is the distrust of Scott that a few months ago, charges were dropped after a defendant had pleaded guilty in a double murder, although that prosecution will be revived in state court.

Scott is hardly the first law enforcer to be accused of breaking the rules. It is no doubt extremely rare for detectives and prosecutors to traduce defendants they know to be innocent, but dirty tricks have seem justified to prevent a guilty suspect getting away with it. They never are, of course; a zeal to convict does not excuse the perjuries of which Scott is accused.

But his alleged crimes go beyond such standard tricks as hiding exculpatory evidence. Scott, according to the indictment, wasn’t out just to win convictions, but, in cahoots with another member of a drug task force, to line his own pockets with cash lifted from the evidence room. A couple of other former agents have pleaded guilty and agreed to testify at Scott’s trial.

More charges in cases handled by Scott will no doubt be dismissed as the Justice Department goes back decades in search of further evidence that he perverted the course of justice. Guilty parties will presumably be let off the hook, while innocents will turn out to have been wrongly convicted.

This just goes to show that a single agent can bring the entire system into disrepute if he is given free rein long enough. Scott has attracted suspicion from time to time since at least 2004, when an informant accused him of “supplying narcotics,” but always skated away from trouble, perhaps because he racked up enough busts to be the blue-eyed boy. But that left his bosses with an even bigger tangle of dubious convictions to re-examine when his antics got so out of hand that they finally had to act.

Email James Gill at Gill1407@bellsouth.net

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https://www.nbcsandiego.com/news/local/Experts-Urge-Caution-With-Natural-Legal-Drug-Kratom–454685203.html

Users and health professionals are debating over the benefits and risks of Kratom, a natural substance, from the leaves of a tree that grows in Thailand.

The legal drug can be bought online and in stores. Users say Kratom is a stimulant that in small doses gives them energy and boosts their mood but if you take more of it, the drug has the opposite effect, working like a sedative or narcotic.

Jane Babin, a Kratom user said the natural drug is harmless, and helps with her joint pain.

“You know, my joints ache sometimes,” she said. “(I’m) probably getting arthritis, and you know, it works well, for me.”

Babin is a lawyer and biochemist. She said she buys Kratom legally on the internet, from sellers who import it from Southeast Asia.

“The euphoria or addiction potential is overstated,” she said. “It doesn’t really have that effect on me at all.”

NBC 7 Investigates found numerous overdoses associated with Kratom, causing sickness and death. According to the state Poison Control System, since 2015, there have been more than 100 calls for help to poison centers in California, 11 of those calls were reported in San Diego County.

In the last four years, according to the San Diego County Medical Examiner’s Office, 11 deaths have been linked to Kratom in the county with four of those deaths happening this year. According to the medical examiner reports, all but one of those fatalities involved other addictive drugs as well.

“People say it’s natural, so it has to be safe,” Dr. Clark Smith, a drug and addiction expert said. “You know what? Arsenic is natural.”

Smith said it’s foolish to assume Kratom is safe and no one should use it until clinical studies prove it’s not dangerous.

“Who knows, maybe somebody uses it casually for a couple of years, and they get kidney failure, or they go blind,” he said.

Last year, the DEA labeled Kratom as a dangerous substance, with no medical benefit. The agency planned to classify it as a schedule one controlled substance, making it illegal, everywhere. As news of those plans was made public, Babin and thousands of Kratom users flooded the agency with phone calls and petitions. They argued drug addicts use Kratom to help soothe withdrawal pains.

“It’s a better solution than prescription opioids for a lot of people,” Babin said.

In the end, 51 members of Congress and nine U.S. Senators supported that effort, and the DEA backed off.

“So, there’s really no control over it,” Smith said.

While not federally regulated, states and cities can, and have, passed laws related to Kratom, including the city of San Diego, which outlawed it last year.

Adults can legally buy Kratom in 17 of San Diego County’s 18 cities. Smoke shops sell bags and capsules of the natural substance.

Babin said responsible adults should have access to Kratom, but others disagree.

“The fact that there are deaths associated with it should give anyone a healthy fear of it,” Smith said.

“You know, when we have 91 people dying every day from opioid overdoses, the last thing we need is to have another opioid out there,” Amy Roderick with the DEA said. “Something else that somebody could really use for the first time, and become addicted to.”

In the city of San Diego, seven people have been charged with illegal possession for the sale of Kratom. If convicted, defendants face six months in jail and a $1,000 fine.

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Hello Steve I’m writing to ask for some clarification on a problem I had today. I went to fill a prescription for my wife who is afflicted with PTSD, rapid cycling bipolar, and BPD. despite being on the medication for a month and the risks of going without the medication the pharmacist refused to fill the medication due to a possible interaction between two drugs. Now one of these a had already been filled so we were unable to fill her mood stabilizes which had her so distraught that having been without it for a week, due to a mishap with her doctor not the pharmacy, that she was afraid she was going to need her 6th hospitalization in 5 years. I drove to the Dr’s office and had him call and force the prescription through, and I talked with the pharmacist about the issue. She informed me she had a right to refuse the medication and I subsequently informed her that the ADA provided her certain rights including getting her medication since the prescription was due to be refilled and was her not one but two conditions explicitly mentioned by the ADA. I spoke with two RNs as well as a LPN and they said they saw no reason for it not to be filled. I was hoping you might be able to offer some insight about the conflict between these two conflicting laws from your unique and experienced point of view. 

The typical pharmacy computer system throws out so many “potential interactions warnings” that most pharmacists come NUMB to all the warnings that require a override… that all to many get into the habit of not really paying attention to the warnings and just hitting the “OVER RIDE KEY” and keep going… after all the chain headquarters is always watching over your shoulder on how many prescriptions you are filling/verifying per hour – in the industry referred to as “METRICS “.

Here is a survey done in Chicago about one year ago where it was alleged that pharmacists missed about 50% of serious drug interactions when presented certain medication combination that was used in the test.  http://www.chicagotribune.com/news/watchdog/druginteractions/ct-drug-interactions-pharmacy-met-20161214-story.html

The most serious drug to drug interaction is classified as a LEVEL ONE… and those you really should pay attention to… those tend to be ones that you don’t just hit the “over ride key” and keep going… but  apparently this pharmacist claimed that there was a POTENTIAL INTERACTION, but since the pt had been taking these two medications for some time.. would suggest that the POTENTIAL is really not there. There is often a VERY WIDE GAP .. between a “potential text book interaction” and an “observed clinical interaction”

The job of a pharmacist is to talk to the prescriber and work out any concerns about the potential drug to drug interaction.. I can think of only a few times in my decades of practicing pharmacy do I remember just flat putting my foot down and saying NO..

IMO …What should have been done… is call the prescriber… if you can’t get the prescriber to change one of the meds to avoid the potential interaction… the pharmacist should document the conversation and  make the pt aware of what the potential interaction is and what to be on the lookout for and discontinue the medication and contact the prescriber if symptoms appear.

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Senators call for crackdown on pharmaceutical industry ‘revolving door’

https://www.washingtonpost.com/investigations/senators-call-for-crack-down-on-pharmaceutical-industry-revolving-door/2017/11/02/d0c3e6a2-bf34-11e7-959c-fe2b598d8c00_story.html

Seven Democratic U.S. senators today introduced legislation designed to slow the “revolving door” between federal agencies such as the Drug Enforcement Administration and the pharmaceutical companies they regulate.

“The pharmaceutical industry has a deep-rooted and strong influence in Washington, and a revolving door between drug companies and government cannot undermine the safety of our communities,” said Sen. Tammy Baldwin, (D-Wis.), who sponsored the bill.

The legislation would impose a two-year “cooling off” period on former officials from the DEA and the Food and Drug Administration, barring them from assisting pharmaceutical companies with lobbying efforts.

It is not unusual for corporations to hire federal employees directly from the government, nor for industry officials to join the government in high-ranking positions. Industry representatives say the pharmaceutical industry is highly specialized, and they rely upon the expertise of former government officials to help them comply with complex drug laws.

The current restrictions include a lifetime ban on participating “personally and substantially” on a “particular matter” that the official had handled while working for the federal government.

Government ethics experts say some of those laws are easily skirted.

“The bill could go further, but this is a nice step toward slowing the revolving door that is responsible for steering public policy in favor of the drug companies and distributors rather than in the favor of the public,” said Scott Amey, general counsel for the Project on Government Oversight, a Washington, D.C. watchdog group.

The proposed legislation follows a joint Washington Post/“60 Minutes” investigation into the opioid industry and its influence in Washington. Companies that manufacture or distribute highly addictive pain pills have hired dozens of high-ranking officials from the DEA during the past decade, many of them from a division that regulates some of the same companies.

A decade ago, DEA investigators began to crack down on large drug companies they suspected of failing to report unusually large orders of painkillers, many of which were winding up in the hands of street dealers and users. Since then, drug companies and the law firms that represent them have hired at least 46 DEA officials — 32 of them directly from the agency’s division that regulates the industry.

One of those DEA officials left the agency and formed a law practice to represent opioid companies. He later helped to write a law that undercut the agency’s enforcement efforts against large companies accused of violating federal drug laws, according to government documents and a legal analysis of the law by the DEA’s chief administrative judge.

In the wake of the Oct. 15 Post/“60 Minutes” investigation, Marino withdrew his nomination to be the nation’s drug czar under the Trump administration.

Several co-sponsors of the Marino bill have since come under fire from their constituents and political opponents for backing the measure at the height of the nation’s worst drug crisis. The prescription drug epidemic has claimed nearly 200,000 lives, more than three times the number of U.S. military deaths in the Vietnam War.

Baldwin said her proposed legislation would serve as a check on the power the pharmaceutical industry wields on Capitol Hill. She cited an investigation by the Associated Press and the Center for Public Integrity that found that the makers of prescription painkillers spent $880 million on campaign contributions and lobbying efforts between 2006 and 2015.

The bill is co-sponsored by Sens. Dianne Feinstein (D-Calif.), Kamala D. Harris (D-Calif.), Edward J. Markey (D-Mass.), Maggie Hassan (D-N.H.), Jeanne Shaheen (D-N.H.) and Tom Udall (D-N.M.) So far, no Republicans have signed onto the measure.

“Patients, families and the public need to have trust that the DEA and FDA are working for them, not powerful Washington interests,” Baldwin said.

Isn’t there a substantial REVOLVING DOOR between previous members of Congress and various industries… especially the LOBBYING INDUSTRY?

Don’t see any bills being put forth to shut down that revolving door ?

Filed under: General Problems | 1 Comment »

http://www.lasvegasnow.com/news/i-team-the-opioid-conundrum/803064908

LAS VEGAS – Nightly newscasts across the country are filled with stories about the opioid epidemic — the opioid crisis. Tens of thousands of Americans who die each year are found with opioids in their systems, and so government at every level has stepped in to put limits on otherwise legal medications, including here in Nevada.

For millions of chronic pain patients, the crackdown has been a nightmare. They are the forgotten victims in the opioid debate.

Approximately 50,000 people a year die with opioids of one kind or another in their systems. The number you don’t hear is this one — there are as many as 25 million Americans who suffer with chronic pain. For many of them, opioid medication means the difference between leading somewhat normal lives, or surviving in constant agony.

These are not the people who O.D. on heroin or mix drugs with booze. For the most part, they suffer and die in silence.

“It was like, for the first time in my life, I wasn’t in pain anymore. I felt great for a couple of years and then they started this total crackdown,” said Gary, a chronic pain patient, who asked that his real name not be used.

Gary’s life changed when his spine was shattered in a rollover accident. After several operations, his doctors prescribed opioids and he was able to lead a somewhat normal life, even as the discs in his back crumbled further. But then the opioid crisis blew up. His prescriptions were cut in half and it became tougher to find a pharmacy that would fill them.

“I’d have to drive to 10 to 12 pharmacies just to get four prescriptions filled. Just to fill them,” he said.

Reporter George Knapp: “And they look at you like…”
Gary: “Yeah, like you’re a criminal.”

“The only ones who understand chronic pain are the ones who have chronic pain. When you have chronic pain, it’s on your mind all the time,” said Jeremy, a chronic pain patient, who asked that his real name not be used.

Jeremy is a self-employed business professional whose work requires him to both drive and walk daily. A skiing accident and later a hip replacement led to sharp, constant pain over half his body. He tried various surgeries, therapies, and medications but nothing worked until a time-released pain med called oxycontin was developed.

“You can go to work and function and chronic pain patients don’t get high off of oxycontin. It just alleviates their pain and allows them to function,” he said.

The opioid crisis has meant significant reductions in the amounts that can legally be prescribed for Jeremy, Gary, and pretty much every other chronic pain patient. Contrary to what their doctors recommend, their medications have been reduced by half, sometimes more. And they’ve been told, more reductions are likely.

For millions of people, the consequences have been immediate and drastic. They can’t sleep, can’t work, lose their jobs. Some decide to put an end to the constant pain by taking their own lives.

“People are dying. People are committing suicide right now because their doctor tapered them down involuntarily off opioid medications,” said Rick Martin.

He has seen it from both sides. He spent decades working as a pharmacist, and even though he has chronic pain from a deteriorating spine and hip, with medication, he continued to work and could also pursue his passion — landscape photography.

“I used to be able to do stuff by myself, but I can’t do that anymore.”

Chronic pain patients like Rick follow their doctor’s instructions, undergo monthly drug screenings and urinalysis and have become collateral damage in the opioid crisis. Most of the publicity has focused on overdose deaths among people who obtain opioids illegally, mix them with booze or other drugs including heroin. 

The CDC, DEA, and various opioid task forces have responded to deaths caused by illicit drugs by cutting back on legally prescribed medications, the same drugs that make life bearable for millions with chronic pain.

Insurance companies have slashed coverage, and pharmacies now operate under strict quotas, to the point they won’t fill prescriptions for new patients, even those fresh out of surgery. Opioid prescriptions have actually declined significantly in each of the last three years, yet opioid deaths keep rising.

“The unintended victims are the senior citizens. If they can’t get their medications, they aren’t going to go buy heroin and shoot it and die of a heroin overdose. they’re going to suffer,” Jeremy said.

So, how do we explain that while legal prescriptions keep dropping, opioid deaths keep rising? It isn’t a simple issue, though politicians have seized on it as a winner. Cracking down on drugs is a tried and true political strategy, even though enforcement has never worked as a solution to drug abuse.

In the coming months, 8 News NOW will be looking beyond the obvious rhetoric about various opioid issues. As part of this project, we’d like your input. We’ve created a page where opioid patients, pain doctors, pharmacists, families of O.D. victims can share stories, either publicly or privately.

Filed under: General Problems | 6 Comments »

Troubling news from my doc about new FDA/DEA guidelines

https://upload.democraticunderground.com/10029780538

Sorry in advance for the length of this post…

The basics about my situation: Bad depression. Hospitalized once for it. Full-on panic attacks and many trips to the ER thinking I was dying. That was about 12 years ago. It took me a couple of years to get the right balance of Zoloft and Xanax that have made me live a fairly normal life, and I have been for a little over a decade now.

So today I go to my doc for the routine med check and new prescriptions for a few months.

She tells me I’m taking too much Xanax. (For the record it is a low dose: .25mg up to 3x daily as needed – I sometimes don’t even take that much – and 1mg when I go to bed.)

New FDA/DEA guidelines, she tells me, and gives me the form pictured below. She explains this is practice-wide and anyone taking opioids or benzodiazepines is getting this. (I later confirm this when a nurse tells me it’s been hard dealing with patients who are stressed about it, and then I hear another patient at checkout expressing concern.)

So after ten years of living a fairly normal life, the new plan is to get me off the Xanax. Right.

I wonder how the FDA and DEA are going to deal with the doctor shopping, pharmacy jumping, and illegal market they’re going to create with this?

The fill-in-the-blanks nature of the form is suspicious to me, as well as the blanket “should not be used for more than four weeks” statement.

I kind of wonder whether this practice is under some kind of scrutiny.

Anyone else getting this news, specifically about benzodiazepines? Has this already BEEN news and I just missed it?

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We Need to Consider Involuntary Treatment for Heroin Overdose

www.epmonthly.com/article/need-consider-involuntary-treatment-heroin-overdose/#comment-270064

For too long we have waiting for drug addicts to hit rock bottom before intervening. But the costs to individuals, and to society, are simply too high. We must take firm, compassionate action, and it starts in the emergency department.

How many times have we reversed a heroin overdose only to have the patient leave the ED to OD again? Maybe it’s time to change that cycle. Here in Maryland, I am spearheading a subtle yet radical new approach, and a growing coalition of medical professionals, social workers and politicians are beginning to show their support. I’d like to share it with you, my colleagues, because it’s an approach that often begins in the emergency department.   

Let’s consider a common scenario. A family brings in their grandfather who is depressed and suicidal. They found him sitting on the side of the bed with a shotgun in his mouth. With such evidence, you have the legal authority to commit the patient to a locked psychiatric ward – essentially incarcerate him – for up to three days or until such time that a judge can examine him to see if he is a “danger to himself.” If evidence of such is submitted to the judge, she can further commit/incarcerate him until such time that the “danger to self” has subsided.

Now let’s change the scenario slightly. Instead of a grandfather with a gun in the mouth, it’s a young adult with a needle in his arm. Both “weapons” are life threatening. The difference is that in the second scenario, the young adult is clearly not intending to commit intentional suicide. But it is reasonable, even obvious, to the rational person that the risk of death is so great that he is exhibiting a knowing and willful gross indifference to his own personal safety. And that is where we hope to change the law, to expand the definition of “danger to self” to include heroin addiction, to allow health care professionals, you and I, to involuntarily commit addicts to treatment. Before you start the push back let’s unpack this a little.

First and foremost, I’m not suggesting we mandate in-patient treatment. We don’t have enough psychiatric beds now. Patients can spend weeks in the ER waiting for such beds to open up. Furthermore, with people failing in-patient rehab multiple times, there simply will never be enough in the nations coffers to cover such a program. We could break the bank overnight.

But the cost of mandatory out-patient therapy is within reach, especially considering the savings over doing nothing. But how would mandatory out-patient therapy work? Maryland is already in the process of building its first “stabilization units” dedicated to substance abuse. After the catastrophes of the old drunk tanks, people picked up by ambulance and police with no other complaint but drunkeness could no longer be brought to jail, but had to go to the ER for clearance. Now we will have a place for such patients to be evaluated and stabilized before disposition. Such units could have an assigned judge that could hear emergency cases of “danger to self” resulting from drugs. A tracking ankle bracelet could be attached to the patient before being released to follow up the next day with an outpatient detox unit. If the patient failed to show up for medically assisted outpatient detox and therapy, a warrant for their arrest would be issued, and the standard punishment for this misdemeanor would be four days of incarceration. This just happens to be the standard time required for unassisted withdrawal. Cold turkey withdrawal is absolutely miserable, with its nausea, vomiting, muscle aches, and “goose flesh.” But it’s not life threatening. It’s a simple matter of “We can do this the easy way or the hard way.” After a few times of going through involuntary withdrawal, the patient will finally realize that outpatient therapy with medical assistance is not so bad.

For the patient with a tracking device and a mobile phone, telemedicine programs could help encourage follow up with therapy while letting them know when they are in dangerous areas of known drug dealing. Such tracking could also help alert law enforcement to areas where drugs are being sold.

I know what you’re thinking. Whoa, isn’t this a little over the top? A little big brother? Some civil libertarians might even argue in the abstract that “there is no law against stupid”. If there were, we might incarcerate smokers or extreme sport enthusiasts or even jaywalkers. But the heroin epidemic is a national disaster of historic proportions. It dwarfs the death toll of hurricanes, terrorist attacks, even recent wars. The Vietnam War cost America over 50,000 lives and untold injuries over the course of about 10 years. We will lose that many Americans to overdoses next year alone. And the body count continues to accelerate. Moreover, the secondary cost to society in health care, crime, cultural damage, and loss of productive lives in simply incalculable. A crisis of this proportion deserves a fundamental shift in culture and law. Our approach is to broaden the definition of “danger to self” with very narrow and specific language.  The courts will always be leary of infringements on personal rights and will fight hard to uphold the right to due process. But I believe laws can be drafted narrowly that rise to the danger without introducing more risk to our personal constitutional right to be left alone.

Some argue that you can’t really help the addict until they want help. They say that you can’t see improvement until the patient “hits rock bottom.” But there is a lot of physical and social carnage that occurs as the patient free falls to the “bottom.” Besides the obvious risk of death, there is the risk of disease, HIV, heart disease, trauma, and many other expensive disorders. And society ends up picking up the tab for most of it. Further, all of us have seen the secondary fall out of the addict’s behavior, family destruction, spousal and childhood abuse, and violent crime. Society has an interest in preventing such damage and cannot stand by as though we have no dog in this fight. We do. And we have the right and responsibility to act, for the benefit of the patient and ourselves.

Yes, such a law would require an expansion of the courts along with a loss in some aspect of personal freedom. But I think these problems are not insurmountable. The larger question is whether we currently have the infrastructure to handle the influx of patients, even in an outpatient setting. And the answer is a resounding NO. After retiring from emergency medicine I have taken a position as the Chief Medical Officer of the largest methadone treatment facility in the nation, treating over 3,000 patients daily. (I know, that’s jumping from the frying pan to the fire! More on that another time.) But it is estimated that there are over ten times that many heroin addicts in Baltimore alone. Can we build the capacity to serve that many patients? Not overnight, for sure. But this is a pathway that is both rationale and eventually doable. As they say, Rome wasn’t built in a day. We can start laying a foundation for a better future.

I’d love to hear your thoughts, your criticisms, and your suggestions. As ER docs we have been living with this problem for decades. I think it’s time that emergency physicians lead the charge in 50 states to do something to change it. You can reach me at mplaster@epmonthly.com.

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Trump opioid panel will recommend nationwide drug courts, tightened requirements for prescribers

www.statnews.com/2017/10/30/opiod-commission-draft-recommendations/

WASHINGTON — President Trump’s commission on combating the opioid epidemic plans to encourage the federal government to establish drug courts in every federal judicial district, adjust reimbursement rates for addiction treatment, and streamline federal funding used by state and local governments to implement drug treatment and prevention programs, according to a draft of the panel’s final report.

Those steps are among the 53 recommendations laid out in the draft, a copy of which was obtained by STAT. The final report is set to be released on Wednesday.

The highlights:

Drug courts in all federal judicial districts

As of 2015, according to the commission, less than one-third of federal judicial districts and 44 percent of U.S. counties operated drug courts, which serve as alternatives to the traditional court system and have been shown to increase engagement in addiction treatment and reduce recidivism rates. The commission will recommend the Department of Justice establish drug courts in every federal district, and that individuals with substance use disorder who violate probation terms be diverted to a drug court as opposed to prison.

Drug courts combine elements of criminal justice and addiction treatment to help those with substance use disorder avoid criminal sentencing, provided participants comply with a treatment course that can include counseling and medication-assisted treatment.

Staffers in nearly nearly every governor’s office, according to the report, expressed concern about opioid-related funding from the federal government being “fragmented.

The commission will recommend a system for distributing federal funding that expands and mirrors the process for obtaining block grants offered by the Substance Abuse and Mental Health Services Administration. That process should require only one application and result in states receiving at least equivalent funding while allowing them to redirect resources currently used for paperwork toward program implementation.

Changes to reimbursement rates set by federal addiction treatment providers

The commission will recommend that the Centers for Medicare and Medicaid Services review policies that incentivize the prescription of opioids over more expensive non-opioid treatments.

It will also urge the Department of Health and Human Services to review its rates to more adequately measure and cover the “true costs” of treating substance use disorder, including use of inpatient psychiatric facilities.

The report recommends lowering barriers to substance use disorder treatment, including those that impose limits on access to any of the three forms of medication-assisted treatment approved by the Food and Drug Administration. Separately, the report recommends increasing access to recovery coaches.

A best-practices guide issued by the National Highway Traffic Safety Administration — which oversees the federal Office of Emergency Medical Services — currently recommends that paramedics and advanced medical technicians be allowed by local communities to administer naloxone, the overdose-reversal drug. The report recommends the those guidelines be reviewed to allow emergency medical technicians to also administer the medication, and in higher doses.

Several states currently prohibit some classifications of emergency responders from administering naloxone.

Tighten requirements for prescribers

The report will recommend the Drug Enforcement Administration require prescribers seeking to renew licenses to prescribe opioids first demonstrate they have participated in an education program regarding the drugs’ prescription. The report also recommends that HHS develop a “national curriculum and standard of care for opioid prescribers,” and that pharmacists receive training “on best practices to evaluate the legitimacy of opioid prescriptions.”

Eliminating patient pain evaluations from surveys

The commission will recommend that CMS eliminate questions about pain levels from patient satisfaction surveys, thereby ensuring that providers are not incentivized to prescribe opioids in order to increase measured patient approval.

Steps to ensure parity

The draft report says federal and state regulators should have better ways of measuring health providers’ compliance with parity laws, which require providers to provide and fund services for mental health and addiction on an equal basis to other health conditions.

Media camaign

The White House, the commission will recommend, should fund and coordinate with private-sector and nonprofit groups to implement a “wide-reaching, national multi-platform media campaign addressing addiction stigma and the danger of opioids.” The report likens the effort to a similar initiative launched during the HIV/AIDS epidemic of the 1980s and 1990s.

In another prevention initiative, the report recommends a collaboration between states and the Department of Education to implement student assessment programs to identify at-risk youth in middle school, high school, and college in need of treatment.

The report will also recommend implementing policies that ensure patients are adequately educated about the “risks, benefits, and alternatives of taking opioids” before receiving an opioid prescription for chronic pain.

Expand compliance with the Prescription Drug Monitoring Act

The report will push the White House to endorse the Prescription Drug Monitoring Act, legislation currently before Congress that would require states receiving federal grant money to comply with regulations for prescription drug monitoring programs and share data with a national hub to be established by the Department of Justice.

Separately, the commission recommended integrating PDMP data with electronic health records systems, and that the DEA and the Office of National Drug Control Policy increase electronic prescribing to prevent forgery and drug diversion.

Better data on overdose deaths

“We do not have sufficiently accurate data from medical examiners around the country to determine overdose deaths,” the report reads. It directs the federal government to develop forensic and toxicology procedures for use while investigating drug-related deaths.

Leveraging Public Health Service personnel

The report recommends the White House deploy health care workers from the Public Health Service Commissioned Corps to administer treatment and care in areas with above-average opioid use.

Bolstering research money

The director of the National Institutes of Health, Francis Collins, has acknowledged already that while he hopes the agency will continue to play a major role in addressing the drug crisis, it will be unable to significantly do so by merely redirecting some of its current funding. The commission agrees, and cited three institutes within NIH it deems worthy of increased research funding: the National Institute on Drug Abuse, National Institute of Mental Health, and National Institute on Alcohol Abuse and Alcoholism. It did not specify recommended funding levels.

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Surgeons are worried overweight patients and smokers in England and Wales are being denied surgery to save money

http://www.bbc.com/news/health-36101302

A report by the Royal College of Surgeons found a third of local NHS health bosses in England put restrictions on access to surgery.

But it says this goes against official guidance and can prolong patient pain.

However, some local NHS groups criticised in the report say their polices are based on good evidence.

The Royal College of Surgeons has been increasingly alarmed about the rationing of surgery in the NHS in the tough financial climate.

Its report is based on freedom of information returns from nearly all of the 209 clinical commissioning groups in England and all seven health boards in Wales.

While some CCGs have voluntary policies in place, where patients are encouraged to stop smoking or lose weight, others have introduced mandatory policies, which means patients have to meet fixed criteria before surgery.

‘Soft targets’

The college says mandatory policies are “a cause for concern” and it fears patients with a high body mass index (BMI) or who smoke are becoming “soft targets” for NHS savings.

The report reveals 31% of CCGs and one health board in Wales have at least one policy requiring people to lose weight or stop smoking before they can be referred for routine surgery.

Local NHS groups which compel patients to meet fixed criteria before surgery include:

• Luton CCG – has a BMI cut-off of 30 for any planned surgical procedure
• East and North Hertfordshire CCG – requires a patient’s BMI to be under 30 or for them to lose 10% of their bodyweight before surgery
• North East Essex CCG – requires patients who smoke to stop and attend smoking cessation programmes before referral to surgery

• iWonder: Should the NHS always foot the bill?

Dr Hari Pathmanathan, who chairs East and North Hertfordshire Clinical Commissioning Group, said there were good reasons why they asked some patients to lose weight and stop smoking before being given an anaesthetic.

“These patients are much more likely to suffer serious breathing problems, get infections and have heart, kidney and lung complications,” he said.

“It also takes them longer to recover, and they have a higher risk of dying under anaesthetic.

“It is for these health reasons that patients who have a higher risk because of their weight are not be booked for routine surgery until they have lost enough weight to improve the outcomes of their surgery, although no-one would be asked to wait for more than nine months.”

Dr Pathmanathan added that every patient’s case was considered individually, based on their health needs, and the restrictions were for planned surgery only.

The report suggests one in five CCGs has mandatory policies on BMI levels before hip and knee replacement surgery, while 4% have mandatory policies on getting patients to stop smoking before hip and knee replacement surgery.

Of the CCGs that responded, 22% reported having at least one “voluntary” policy in place.

‘Case-by-case basis’

The Royal College of Surgeons said any blanket ban on surgery based on a patient’s weight or whether they smoked was wrong and not supported by national guidance.

Instead, president Clare Marx said, patients should be encouraged to sign up to programmes to help them stop smoking and manage their weight while awaiting surgery.

“NHS surgical treatment should be based on clinical guidance and patients should be dealt with on a case-by-case basis,” she said.

“In some instances, a patient might need surgery in order to help them to do exercise and lose weight.

“While it is difficult to categorically prove such policies are aimed at saving money, it is unlikely to be a coincidence that many financially challenged CCGs are restricting access to surgery.”

She added National Institute for Health and Care Excellence (NICE) guidance did not support these mandatory bans for routine surgery.

No justification

British Orthopaedic Association president Tim Wilton said there was no clinical or financial justification for refusing to fund hip or knee replacements.

“Good outcomes can be achieved for patients regardless of whether they smoke or are obese, even at BMIs of over 50, and these surgeries are highly cost effective, typically delivering sustained pain relief for a cost that equates to just £7.50 a week,” he said.

“Hard-and-fast rules also undermine the NHS’s ability to involve patients in decisions about their own care, and are a distraction from the task at hand: making sure patients receive the best possible advice and care, to enable them to make the best possible decisions for their health – including losing weight and stopping smoking where appropriate.”

However, Dr Anita Ray-Chowdhury, clinical director of system change at Luton CCG, defended their approach.

“We do everything we can to ensure that patients who need urgent or life saving surgery get the help they need quickly, irrespective of their weight or if they smoke.

“For less urgent surgery there is strong clinical evidence showing that being overweight and smoking can have an adverse effect to the outcome, so we advise that clinicians work with the patients to take a holistic approach by addressing lifestyle factors that may improve the outcome of surgery.”

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The Myth of an Opioid Prescription Crisis

https://www.cato.org/policy-report/septemberoctober-2017/myth-opioid-prescription-crisis

According to the New York Times, drug overdoses are now the leading cause of death for Americans under age 50. Opioid overdoses, in particular, have been on the rise in recent years, killing over 30,000 people in 2015. In response, many have called for stricter regulations on prescription opioids. But are doctor-prescribed drugs truly the cause of the increase in overdoses? At a Capitol Hill Briefing in June, Arizona surgeon and Cato senior fellow Jeffrey A. Singer argued that regulators, in their rush to interfere in the patient-doctor relationship, are actually causing more problems than they’re solving.

THE SCIENCE OF OPIOIDS
Many people in the policy world really don’t understand the science of opioids, so let’s begin by clearing up a few myths. First, it’s important to understand that the long-term use of opioids, unlike alcohol, really doesn’t have deleterious effects on the body. That’s why we place people on methadone maintenance, for example, sometimes for their whole lives.

And so far there’s no conclusive evidence that long-term use of opioids has any effect on cognitive faculties or on the brain itself. Second, I want to clear up misconceptions about heroin. Heroin is a brand name. The chemical name is diacetylmorphine. Its generic name is diamorphine. It was invented by Bayer in the late 1800s and given the brand name of heroin, which is a derivation of a German word that has to do with “strength.” It’s still on the formulary and used by doctors and pain patients in a lot of developed nations, including the United Kingdom, Canada, and others. It was banned in this country in 1924 because the head of the Narcotics Bureau at the time was convinced that it corrupted moral character. And despite appeals by the physicians at the time to leave it legal because there weren’t that many pain medications available, it was banned. So of course, as any economist will tell you, within a very short period of time heroin became the number one substance for opioid addicts — because what would you rather sell on the black market: something that’s totally banned, or something there are other ways to get?

Heroin is about three times more potent than morphine; and methadone, which we give people on methadone maintenance — we’ll get more into that later — is also two and a half to three times more potent than morphine. Dilaudid, which is legal and which we give to patients for whom morphine is not working, is three to four times more potent than heroin. And fentanyl, also legal, is 50 times more potent than morphine.

Another commonly held misconception is that if you take one hit of heroin, you’re hooked. That’s absolutely not true. If it is, then why isn’t that the case with morphine or Dilaudid or any other legal opioids we give people? In fact, as early as the 1960s, studies done in the New England Journal of Medicine and International Journal of Group Psychotherapy identified heroin users who were true recreational users. They used it on occasion, on weekends. They had productive lives and were not addicted, just occasional users.

And although we often hear the words “addiction” and “physical dependence” used interchangeably, there is a difference. A recent article in the New England Journal of Medicine by Nora D. Volkow points out that, on the molecular level, physical dependence is when you actually develop withdrawal symptoms when the drug is taken away, so you need to be tapered off — as opposed to addiction, which is a behavioral disorder, in which you actually seek the drug. You will make major sacrifices in your lifestyle that have negative consequences for you because it’s so important to you to take the drug.

That’s a lot different from physical dependence. I’m a surgeon, and most of our patients who come to the office dependent on opioids want to be off them, so we help them slowly taper off. An addict, on the other hand, doesn’twant to be off them, which is why you have a high recidivism rate when you’re treating drug addicts.

ARE OVERDOSES A PRESCRIPTION PROBLEM?
The National Survey on Drug Use in Health has found that the nonmedical use of prescription opioids such as oxycodone and hydrocodone actually peaked in 2012. Total opioid use was actually lower in 2014 than in 2012. Despite that, opioid overdose deaths have increased. There were 33,000 deaths in 2015.

An overwhelming majority of those deaths, however, are people who used mixtures of drugs. In 2013, New York City found that 94 percent of the people who died from heroin or other opioids had mixed drugs in their system. These were not necessarily chronic pain patients. And also, for the first time, this year more people died from heroin overdoses than from prescription opioid overdoses.

According to Chinazo Cunningham at Albert Einstein College of Medicine, who helped develop the 2016 Centers for Disease Control and Prevention (CDC) guidelines, the number of prescription opioid overdoses is actually stabilizing, but opioid overdose rates have not plateaued because heroin use is dramatically increasing. So that’s important to understand — that the big cause of overdose problems now is heroin. We’re also seeing heroin use become much more prevalent in people in upper socioeconomic groups, and among suburban and rural white individuals.

According to the National Survey on Drug Use and Health, only one-quarter of people who take opioids for nonmedical reasons get them by obtaining a prescription. So the sequence that everybody thinks exists, in which a patient gets narcotics for pain, gets hooked, and then eventually dies from an overdose, is not your typical story. In fact, a 2014 JAMA (Journal of the American Medical Association) study of 136,000 patients treated for opioid overdoses in emergency rooms found that just 13 percent of them were chronic pain patients. And the CDC cites a study showing that the opioid-related overdose rate for people who are on chronic pain medicine under the guidance of a doctor is 0.2 percent.

New addictions in people who take opioids for pain, in general, are uncommon. The most rigorous comprehensive review, from the Cochrane Library, found that the addiction rate of people put on prescription opioids was about 1 percent. It’s very rare that a doctor prescribes a painkiller for a patient in pain who then gets hooked and becomes a heroin addict.

THE TRUE CAUSE OF THE PROBLEM
Both the CDC and the Texas A&M College of Pharmacy report that what they areseeing, however, is that as pain patients who are physically dependent and are in pain are gradually cut off pain medicine by their doctors, who are getting pressured to stop prescribing, a lot of them go on to seek pain medicine through the illicit drug market. And of course when they go to the illicit drug market, they often buy counterfeit opioids, and they don’t know what they’re laced with. Oftentimes they’re laced with fentanyl. And many of them are buying heroin, because heroin is, according to the CDC, about one-fifth the price of streetobtainable prescription opioids.

Also driving the opioid problem is the promotion of tamper-resistant opioids. The Food and Drug Administration (FDA) is encouraging pharmaceutical companies to develop drugs that are tamper-resistant — in other words, you can’t use them for anything other than the medicinal use for which they were prescribed.

Mark Twain has been quoted as saying that history may not repeat itself, but it rhymes. Many people may be aware that back during the days of alcohol prohibition, ethanol was still allowed to be produced for industrial use. But the government required that the manufacturers put in what was called denatured alcohol — they put ingredients in it to make it unpalatable, so that bootleggers couldn’t steal vats of ethanol and sell it on the black market. But bootleggers are pretty resourceful people, and they soon found out how to distill those impurities out and still sell it. So in 1926, the government required industrial ethanol manufacturers to add methyl alcohol, or methanol, also called wood alcohol, which can make you blind when you drink it. (That’s where the expression “drinking himself blind” comes from.)

So they put methyl alcohol and benzene in the ethanol, and that, despite attempts, could not be distilled out. At least 10,000 deaths are documented since 1926 from people who were drinking bootlegged alcohol that contained methanol and benzene.

That was the alcohol prohibition years’ version of tamper-resistant alcohol, and it resulted in unintended consequences. I’m sure nobody wanted to see people die. But the same thing is happening today with tamperresistant drugs.

For example — in 2010, OxyContin was converted to a tamper-resistant package. And when people couldn’t crush it any more to snort it, they figured out how to boil it, turn it into an injectable form, and then inject it. A study published in the Canadian Medical Journal in 2015 found that “In Ontario and the US, overall rates of opioid-related deaths have continued to rise since the long-acting formulation of oxycodone (OxyContin) was replaced with a tamper-resistant formulation… . Rather, there is increasing evidence that individuals shift to other opioids, including uncontrolled formulations such as heroin.” In JAMA Psychiatry in 2015, Cicero and Ellis found that nonmedical users of OxyContin switched to other opioids, or to heroin, after the tamper resistant reformulation of OxyContin replaced regular OxyContin in 2010.

In June, the FDA asked the manufacturer of Opana ER to pull it off the market. Opana is the brand name for oxymorphone, stronger than oxycodone. It used to be very popular, when it was obtained in the black market, to crush it and snort it. The manufacturers then made it so that it was not crushable, so people figured out how to boil it and inject it. And then an outbreak of HIV was reported in the Indianapolis area from people sharing dirty needles to inject Opana ER. I understand what tamper-resistant measures are trying to do, but instead they’re actually creating a lot of these problems.

At the same time, all but one state (Missouri) have adopted PDMPs, or prescription drug monitoring programs. These programs give us doctors a report card — in the case of Arizona, it’s every quarter — of where you stand with respect to all of your colleagues in your specialty as to how many prescriptions you wrote for oxycodone, hydrocodone, and so forth. It is not broken down by how many patients you saw, just how many prescriptions you wrote. And it ranks you in ranges from normal to outlier, to extreme outlier.

That casts a chilling effect on doctors. Nobody wants to be seen as an outlier. It pressures doctors to cut back on prescribing, and then their legitimately suffering patients are driven to the illegal market where they get laced opioids, or they go to cheaper heroin and, of course, that is where the overdoses occur. A study just came out in May from the University of Pennsylvania that examined the effect of PDMPs from 1999 to 2014, and they found that PDMPs were not associated with reductions in drug overdose mortality rates, and may be related to increasedmortality from illicit and other unspecified drugs.

So what can we do from a policy standpoint? I’m an advocate of what’s known as harm reduction: if we can’t stop people from using these drugs, at least let’s do what we can to make sure they don’t harm themselves. An example of harm reduction is methadone maintenance, which has been around for decades. You basically replace an addiction to heroin with an addiction to methadone in the form of a pill, which prevents withdrawal but doesn’t give you the euphoria. It’s sort of like the opioid version of a nicotine patch.

Another policy being used in several countries is — and this may sound weird — heroin maintenance programs. Now remember, heroin is diamorphine, which is a pharmaceutical that is available and used in many developed countries. In 1994, Switzerland started a heroin maintenance program.

There are criteria to join it to make sure you’re not trying to game the system, but you declare yourself a heroin addict; you come into a clinic in the morning; you’re given pharmaceutical-grade diamorphine with a clean needle and syringe; a nurse is there watching you; you inject yourself; and then you leave. You sign in and sign out. They’ve found that many addicts, once they aren’t spending their whole day looking for their connection, get a job, some get married and have a family, and as they resume a more conventional lifestyle a significant number of them actually detox themselves off. A smaller program like this in the United Kingdom has been going on for about 10 years. In Vancouver, British Columbia, one just began in December 2016. Since heroin is a banned substance in this country, we would need to pass legislation to allow a few heroin maintenance pilot programs.

Another form of harm reduction, from the clinician’s standpoint: Instead of pressuring doctors through things like these prescription drug monitoring boards to decrease the amount of prescriptions we give to our patients, why don’t you just let us be doctors? That’s our job. When I have a patient who has recovered from major trauma surgery, and I know he’s physically dependent, and he’s asking me for another refill of oxycodone, and I think this has been going on a little longer than it should be — what I do ethically, as part of my profession, is have a discussion with my patient and see if I can get the patient to go along with my tapering him off. Sometimes patients are in denial. If they’re addicted, I can refer them to someone who has more expertise in treating addiction.

But if I’m faced with the decision between giving this guy another prescription under the condition that he’ll see me in two weeks so we can talk about this again, or cutting him off and risking that he’ll go get some counterfeit Percocet and maybe die of an overdose because it contained fentanyl or carfentanil — I think you should leave that judgment call to me, the doctor. If we can keep people on methadone maintenance, why can’t I decide, under close supervision, to keep a person on oxycodone maintenance? There’s no difference, chemically. My advice would be to stop interfering in the patient-doctor relationship — you’re actually making it worse.

In summary, our opioid overdose problem is not a product of the patient-doctor relationship. It’s a product of drug prohibition, because it’s the illegal market that has led to all these impurities and to people getting substances that kill them. We need to address drug prohibition, not the patient-doctor relationship.

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