CASE 22-6000: U.S. SUPREME COURT FAILURE TO GRANT CERT PETITION “CLEMENT vs. DEA,” INADVERTENTLY SANCTIONS DEA’s MIS-BEHAVIORS, ABUSES AND PAIN PATIENT’S DEATHS

http://https://youarewithinthenorms.com/2023/01/15/case-22-6000-u-s-supreme-court-failure-to-grant-cert-petition-clement-vs-dea-inadvertently-sanctions-deas-mis-behaviors-abuses-and-pain-patients-deaths/

PROVIDERS BY DOJ-DEA

Leo Beletsky of Northeastern calls the government crackdown on prescribers getting indicted low-hanging fruit. “The DEA measures success based on the number of arrests and prosecutions. Doctors are minor players. The DEA convicted two hundred sixty-three physicians on charges between 2003-2017, and over 3000 were forced to surrender their licenses.

a) They create their targets.

b) Who is the biggest prescriber in a region, state, and nationwide? They are investigated.

c) Who does the most procedures?

e) They use ‘flags’ like distance traveled, forgetting that by disincentivizing and terrorizing prescribers, there is no one left to prescribe, and patients must travel farther for the same services. 

The flags created during the pill mill era are now self-perpetuating. If you mine data enough, you might find something, and law enforcement can access data without individualized suspicion, probable cause, or any judicial review. 

“Numbers alone can’t determine whether a crime has been committed: The ‘normal’ amount of opioid prescribing for a physician treating pain or addiction will inevitably be much higher than the average for all doctors or the typical amount in most other specialties.” 

THEY CREATE THEIR TARGETS: POMPY PAIN AND PROSECUTION

WEST VIRGINIA vs. EPA

“The Supreme Court’s recent decision in West Virginia v. EPA reminds us that oftentimes an agency must point to “clear congressional authorization” for the authority it claims. No. 20-1530 (2022) (slip op. at 17-19).

In “extraordinary cases”, those in which “history and the breadth of the authority that [the agency] has asserted, and the economic and political significance of that assertion, provide a reason to hesitate before concluding that Congress meant to confer such authority”, prec- edent advises that an agency must point to “clear con- gressional authorization” for the authority it claims. Id. at 17 (quotations and citation omitted). The DEA’s interpretation of § 1306.04(a) is clearly an “extraordinary case” given the Court’s findings in Gonzales, 546 U.S. at 265-66.”

FROM THE PHARMACIST STREVE FILES

DOJ-DEA HELL BENT ON GETTING AROUND RUAN

“Jessica Fujimaki suffered from a rare disorder called arachnoiditis. A common cause of this very painful and irreversible health issues is a error or “sloppy technique” of a practitioner doing a ESI procedure ( Epidural Spinal Injection). Anything that is injected into the spinal fluid must not only be sterile but must be preservative free and only a SOLUTION  – NOT A SUSPENSION.  ESI involve the injecting of a corticosteroid in the EPIDURAL SPACE – NOT IN THE SPINAL FLUID. 

Jessica Fujimaki, 42, died in December, shortly after the DEA shut down her pain doctor. Image via GoFundMe campaign.

If the practitioner pushes the needle “a tad too far’ and accidentally injects the corticosteroid into the spinal fluid and the patients ends up with a VERY PAINFUL and IRREVERSIBLE MEDICAL ISSUE.   Outcomes – such as Jessica Fujimaki – is potentially what happens when these patients lose any/all pain management.  Likewise for Danny & Gretchen Elliott, 

As long as our law/judicial system is entitled to qualified immunity  https://leb.fbi.gov/articles/legal-digest/legal-digest-qualified-immunity-how-it-protects-law-enforcement-officers  it would seem that they will do as they damn please and they have no consequences.”

COURT IGNORING THE PHARMACY BENEFIT MANAGER SCRIPT SCAMS

The DEA ShutS Down a Pain Doctor. Now three People Are Dead

Dr. Bockoff has shown compassion beyond any doctor I have ever worked with, he is well versed in medicine and is cutting edge. my doctor for life, just try him once and you’ll never go back! the staff has become family to me.

“After a California doctor was labeled an “imminent danger” to the public, the consequences were devastating for his patients and their families.

First, there was the double suicide—a husband and wife from Georgia who took their lives one week after the Drug Enforcement Administration (DEA) suspended the license of their doctor, David Bockoff, a pain specialist in Beverly Hills. After Bockoff lost his ability to prescribe fentanyl and other powerful painkillers on Nov. 1, dozens of his patients became “opioid refugees” with nowhere to turn. The third death came barely a month later.

This Couple Died by Suicide After the DEA Shut Down Their Pain Doctor

Another ex-Bockoff patient, 42-year-old Jessica Fujimaki, died Dec. 10 at her home near Phoenix. Autopsy results are pending, but her husband told VICE News he believes the cause of death was complications related to opioid withdrawal and medical conditions that caused severe chronic pain. She left behind two daughters, ages 13 and 11.

The DEA alleges Bockoff prescribed “alarmingly high dosages” of opioids to multiple patients, posing an “imminent danger” to the public. The doctor—who does not currently face any criminal charges—is attempting to fight back in civil court, denying any misconduct and alleging that DEA agents are the ones responsible for harming the public by effectively shutting down his practice with no consideration for people who relied on medications he prescribed.

“Much like a diabetic is dependent on insulin,” Bockoff’s attorney wrote in one court filing, “taking away the controlled substances allowed only by prescription from a DEA registered physician can be life threatening.”

On Tuesday afternoon, a federal judge in Los Angeles denied Bockoff’s request to override the DEA and restore his authority to prescribe, citing “serious concerns about the improper dispensing of highly addictive and frequently abused substances that can have devastating consequences.”

But exclusive interviews with Bockoff patients and court documents reviewed by VICE News make it appear as though the devastation came only after the DEA intervened against Bockoff, sending his patients into desperate spirals to stave off withdrawals and manage their pain. 

Jessica Fujimaki’s husband Tad said his wife was a gymnast and ballroom dancer when she was younger, but she suffered from a rare disorder called arachnoiditis, which in recent years combined with other health problems to leave her unable to function without pain medications.

Jessica began seeing Bockoff in late 2021. After years of the DEA cracking down on “so called,” over-prescribing and billions of dollars worth of settlements against the pharmaceutical industry for helping to create an overdose crisis, finding a pain doctor was no easy feat. While illicit fentanyl smuggled across the border by Mexican cartels is fueling record overdoses, prescription medications have become more tightly controlled, with doctors, pharmacists, and insurers becoming highly restrictive with opioids under the threat of DEA raids and civil litigation.”

THE CLAW BACK: WHY IT’S BETTER TO PAY CASH AS THE US SUPREME COURT IGNORES GAG CLAUSES AND REBATES

The 80-year-old Bockoff had been a specialist in the field for over two decades and was one of the few physicians willing to treat Fujimaki and others with complex conditions and dependencies on high levels of opioids. In court filings, his lawyers called him “the last option for many patients with severe chronic pain.” Records show a medical expert consulted by the DEA raised concerns about five patients on unusually large doses of fentanyl and other drugs.

In a phone call with VICE News, Bockoff said of those five cases flagged by the DEA: “They typify my patients—I try to give absolutely the best quality of care possible.” Court records show those five patients disagree with the DEA expert’s assessment and are willing to testify on behalf of Bockoff in his efforts to get his DEA license renewed.

Bockoff said he fell into pain management as a speciality 30 years into his medical career, taking satisfaction in improving the quality of life for people with excruciating conditions. 

“There have been ups and downs through the decades with regard to the governmental view of opioids,” Bockoff said. “Hopefully we’re in a climate now where we’re a little more supportive of intractable pain patients, but I’m not sure.”

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DEA TAKES ISSUE WITH BOCKOFF, HOWEVER LACKS ANY AUTHORITY TO DICTATE THE PRACTICE OF MEDICINE

“The DEA has also taken issue with Bockoff’s record keeping and patient intake process, but Tad Fujimaki said Bockoff was always professional with his wife’s treatment, requiring a thorough screening and regular check-ups to get prescriptions renewed. Her last visit was Oct. 31, a day before the DEA visited Bockoff’s office and suspended his license. Their pharmacy declined to fill the prescription, leaving her with a limited supply.

“It’s not like my wife could see a primary care provider and have him prescribe Percocet or something,” Fujimaki said. “No, it doesn’t work that way. We tried so many pain management doctors and nobody would take her because she’s so complicated.”

The Fujimakis ultimately resorted to taking a trip across the border from Arizona into Mexico, where they purchased opioid pills at a pharmacy to help Jessica manage withdrawals. “But the day before Thanksgiving shit hit the fan, basically,” he said.

It seemed like she was having a heart attack and couldn’t move, he recalled. She went to the emergency room and received some opioids, but not her normal prescription. She died two weeks later.  Tad believes her death was caused by stress on her organs and high blood pressure linked to the withdrawals. She was stable until the upheaval caused by the DEA action against Bockoff.

“Whoever signed off on the decision to suspend Dr. Bockoff’s license must’ve had a healthy family to go back to,” Fujimaki said. “They just don’t understand why we need these medications. They don’t even think about it. But there are patients who need this medicine to have a decent quality of life.” 

In court filings, lawyers for the DEA said Bockoff’s patients needed treatment because of “his unsafe practices contributing to their opioid dependency and addiction,” adding that, “while it would be regrettable that Dr. Bockoff’s patients may face hardships,” there are other resources available, such as detox and rehab programs.

The patients who arrived at Bockoff’s office after the DEA suspension received a list of emergency rooms in the LA area where they could be treated—not for their pain issues, but for their severe withdrawal symptoms from losing their prescriptions.

For the patients and their advocates, the notion that they were addicts or victims is absurd. One wrote a letter to the court in Los Angeles saying the doctor’s care had given them a new lease on life.

“This pain medication allows me to practice law and serve as a prominent traumatic brain injury litigator for the largest personal injury firm in California,” wrote the patient, identified by the initials E.C., in a letter reviewed by VICE News. “Dr. Bockoff counsels me on how to manage my pain and prescribes medication for me that allows me to manage my pain so I can be a contributing member of society.” 

Another patient, identified by the initials D.L., wrote to the court that they and other Bockoff patients were “in unbearable pain and many contemplating suicide” since the DEA action.”

DEA STATED IN Scotus CASE 22-6000, “agency lacks authority to issue guidelines“

However, according to the DEA it lacks the authority to issue guidelines that constitute advice relating to the general practice of medicine. The DEA DEA has not promulgated new regulations regarding the treatment of pain. Federal law and DEA regulations do not impose a specific quantitative minimum or maximum limit on the amount of medication that may be prescribed on a single prescription on the duration of treatment intended with the prescribed controlled substance. 

The DEA has consistently emphasized and supported the prescriptive authority of an individual practitioner under the CSA to administer, dispense, and prescribe controlled substances for the legitimate treatment of pain within acceptable medical standards.

This is outlined in the DEA’s policy statement published in the Federal Register (FR) on September 6, 2006, titled, Dispensing Controlled Substances for the Treatment of Pain, 71 FR 52716. 

Thomas W. Prevoznik, DEA Deputy Assistant Administrator Diversion Control Division, LETTER To: Richard A. Lawhern, Ph.D. DATED FEBRUARY 12, 2021

1. (See exhibit 5-6F, Letter dated February 12, 2021, from Thomas W. Prevoznik, DEA Deputy Assistant Administrator Diversion Control Division, to Richard A. Lawhern, Ph.D. 3691 Nestling Lane Fort Mill, South Carolina 29708 lawhern@hotmail.com )

Thomas W. Prevoznik, DEA Deputy Assistant Administrator Diversion Control Division, LETTER To: KEVIN NICHOLSON, RPH. DATED NOVEMBER 04, 2019

2. (See exhibit 5-4D, letter dated November 04, 2019, from Thomas W. Prevoznik, Deputy Assistant Administrator Diversion Control Division, to Kevin N. Nicholson, R.Ph., J.D.Vice President, Public Policy and Regulatory Affairs National Association of Chain Drug Stores1776 Wilson Boulevard Suite 200 Arlington, Virginia 22209)

Thomas W. Prevoznik, DEA Deputy Assistant Administrator Diversion Control Division, LETTER To: Walter F. Wrenn MD DATED April 16, 2022

3. See letter dated April 16, 2022, from Thomas W. Prevoznik, Deputy Assistant Administrator Diversion Control Division, to Walter F. Wrenn, MD.

Further;

DEA’s Letter To Congresswoman Grace Meng, Member of Congress Sixty District of New York, DATED DECEMBER 18, 2021

“As a Law Enforcement agency, DEA is not in a position to authorize or dictate what a doctor prescribes to a patient. DEA cannot grant waivers of any kind when it comes to the practice of medicine because no such waiver exists as the United States’ component body charged with the management of controlled substances and chemicals for scientific, medical research, and industrial applications; the DEA regulates the flow of control substances, not the practice of medicine. The changing prescribing practices of practitioners are derived by a shift to prescribe medicine consistent with guidance issued by the Center for Disease Control and Prevention, along with guidance and recommendations of state boards of medicine.”

 _________________________

EXHIBIT 5-3C Norman Clement vs. DEA

3. (See exhibit 5-3c Congresswoman Grace Meng, Member of Congress Sixty District of New York, December 18, 2019). However, Pharmacists and pharmacies also get contradictory guidance from federal health agencies and even the DEA, which often disagrees with the plaintiffs’ theory that pharmacists should interfere with a doctor’s individualized medical judgment.(ibid 4)(5)

________________________________

4. https://corporate.walmart.com/newsroom/2022/09/06/correcting-the-record-on-opioid-lawsuits-against-walmart

5. https://open.spotify.com/episode/2XcLGf4PCN0wNVLjxyAze6? si=EpDSJrvYTlCuiWwYqXUgWw

An undated image of Danny and Gretchen Elliott. Provided photo.

ANALYSIS

Therefore, Congress did not even leave it to DEA to perform one of its core CSA functions—the scheduling of controlled substances— without health care agency oversight and evaluation. See id. § 811(b) (“The Attorney General shall, before initiating proceedings . . . [to schedule or reschedule a drug] . . . request from the [HHS] Secretary a scientific and medical evaluation, . . . The recommendations of the Secretary to the Attorney General shall be binding . . . as to such scientific and medical matters.”). 

Jessica Fujimaki, 42, with her husband Tad.

Rev. Dr. Martin Luther King 1968

“Yes the hour is dark, evil comes forth in the guise of good. It is a time of double talk when men in high places have a high blood pressure of deceptive rhetoric and an anemia of concrete performance.”

Then how is it that, DEA through comes forth in the guise of good and in this time of double talk when both men and women sitting in high places (Supreme Court of the United States) have a high blood pressure of deceptive rhetoric of “except as authorize, knowing and intentionally,” which they have failed to enforce within an anemia of concrete performance???

In which David Bockoff MD., faces life in prison, Norman Clement a Pharmacist/Dentist and are both classified along with countless other medical professionals whom have been authorized as a street drug dealers and their properties stolen without due process under forfeiture laws while Jessica Fujimaki, Danny & Gretchen Elliott along WITH thousands of other are needlessly dead through United States Drug Enforcement Administration Unauthorized Authority.

FOR NOW, YOU ARE WITHIN

THE NORMS

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Medicare Advantage Plans Take Top Spot in Shkreli Awards

— Lown president calls the list “a tragic comedy of grift and profiteering”

https://www.medpagetoday.com/special-reports/features/102564

Medicare Advantage plans took the top spot in this year’s Shkreli Awardsopens in a new tab or window, the annual list from the Lown Institute that calls attention to some of healthcare’s most greedy and unethical behavior.

The plans’ penchant for defrauding or overbilling Medicare by an estimated $25 billion in 2020 alone by saying beneficiaries were much sicker than they actually were earned them their top marks, according to the Lown Institute.

Others who made the 2022 list included Texas hospice leaders who tried to hasten patients’ deaths to avoid losing federal funds; a Wisconsin dentist who broke patients’ teeth so they would need crowns; and a Virginia hospital that diverted federal discounts from its poorer hospital to its wealthier ones.

The annual ranking is named after pharma executive Martin Shkreliopens in a new tab or window, who raised the price of a life-saving drug for AIDS patients from $13.50 to $750 per pill, and who was sentenced in 2018 to seven years in prison for securities fraud. Patient activists, health policy experts, and journalists were among the judges.

Lown Institute president Vikas Saini, MD, told MedPage Today that this year’s list reads like “a tragic comedy of grift and profiteering.”

If the actions of these companies and individuals seem to be worse than in past years, Saini said that’s because governmental agencies and media organizations appear to be “more vigilant in calling out bad actors.”

Medicare Advantage companies were selected as the worst offenders because the prevalence of fraud was so overwhelming, Saini said: “It struck a chord with our judges.”

“It was pretty prevalent in that nine of 10 insurers in terms of market share were among those named, so it’s not just one or two bad actors,” Saini said. “If anything, it is their business model. A pervasive and systemic problem with immense costs that in my view really represent foregone opportunities to make us all healthier.”

MedPage Today, in a series of stories on the downsides of Medicare Advantage plans, focused on enrollees’ problems getting access to specialistsopens in a new tab or window, deceptive and fraudulent MA plan marketingopens in a new tab or window, and federal attempts to approve all TV adsopens in a new tab or window before they can air. The series also pointed to a federally approved commission structure that results in brokers receiving two or three times as much in commission for selling MA plans than Medicare supplemental plans.

The winners are:

1. Most large Medicare Advantage insurers now face federal accusations that they have been defrauding the Medicare program by mining patients’ charts for diagnoses that have resolved or which they never had, or exaggerating their severity. The amount of overpayment is estimated at $25 billion in 2020 alone, according to a New York Timesopens in a new tab or window investigation and numerous other investigations by the Office of Inspector General, as reported by MedPage Todayopens in a new tab or window. The huge amount of overpayments has raised questions about continued federal payment policies to these companies and the health of the Medicare Trust Fund.

2. Private equity-backed startup Noble Healthopens in a new tab or window bought two rural Missouri hospitals, then left employees with drug and supply shortages that led to unsafe conditions for patients. Noble also stopped paying for employees’ health insurance, despite deducting premium funds from their paychecks. Then Noble closed the two hospitals after taking $20 million in COVID relief funds.

3. Safety net hospitals that have a disproportionate share of low-income patients benefit from the federal 340B program, which provides hefty discounts on medications. But Richmond Community Hospital, in the Bon Secours Health Systemopens in a new tab or window, profited from this program even though it lacks an ICU, maternity ward, or even a consistently working MRI machine. It diverted profits incurred by Richmond to its other hospitals in wealthier, whiter neighborhoods, “basically laundering money through this poor hospital to its wealthy outposts,” according to a former Richmond ER doctor.

4. Leaders of Novus Hospiceopens in a new tab or window in Frisco, Texas provided their employees with pre-signed prescription pads with directions to give patients morphine and hydrocodone without guidance or oversight from physicians. CEO Bradley Harris instructed employees to give higher doses of the painkillers to hasten patient death. The goal was to avoid longer lengths of stay that would result in a cap on government reimbursement to the hospice.

According to the Federal Bureau of Investigation, Harris sent an employee a text message saying, “You need to make this patient go bye-bye.” The Lown Institute said it was unclear whether any patients were actually overdosed or died because of Harris’ instructions.

5. Johnson & Johnsonopens in a new tab or window sold talc baby powder products for years knowing that they contained asbestos, a deadly carcinogen. Now faced with lawsuits from 40,000 cancer patients, many of them Black women to whom J&J marketed its powder products, the company created a subsidiary with all the baby powder-related liabilities. Then, it declared this company bankrupt. It ranked in the top 50 of Fortune’s largest companies last year.

6. Tobacco company Philip Morris has spent 175 years selling cigarettes known to cause heart disease, chronic obstructive pulmonary disease, and other health problems. According to STAT Newsopens in a new tab or window, it now is reaping profits by acquiring companies that make inhaled therapeutics that treat the conditions cigarettes cause. The Lown Institute said that experts have concerns the company could use research on these inhalation therapies “to hook even more people” on their products.

7. Rather than counsel low-income patients on financial assistance programs they might be entitled to, Washington state-based Providenceopens in a new tab or window healthcare system instead “hounded them to pay and sent debt collectors after them when they didn’t.” The “Rev-Up” campaign, developed with help from corporate consultant McKinsey, directed employees to inform patients about financial assistance programs only as a last resort.

More than 55,000 patients were pursued by debt collectors when they should have been offered a discount. Providence told New York Times reporters that they stopped the practice and will issue refunds to about 760 patients.

8. Three North Texas laboratoriesopens in a new tab or window got $300 million more from Medicare by bribing physicians to order unnecessary drug tests and blood work. The founders of the three labs pleaded guilty to fraud in April 2022.

9. Catholic Medical Centeropens in a new tab or window in Manchester, New Hampshire, continued to let cardiac surgeon Yvon Baribeau, MD, operate on patients despite knowing his high number of malpractice case settlements, including some involving 14 patient deaths. Yet the hospital system continued to support him and promote him in ads. His malpractice record was said to be among the worst in the country.

10. Wisconsin dentist Scott Charmoliopens in a new tab or window went from fixing 434 crowns a year to 1,000 by breaking patients teeth starting in 2015. He “intentionally broke their teeth with his drill in order to convince the insurance companies to pay for the crowns. In March 2022, a jury found him guilty of five counts of healthcare fraud and two counts of making false statements to insurance companies.” He was sentenced to 54 months in prison and ordered to pay more than $1 million in fines.

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Probably some definitions and explanations are needed here…. “Private Equity” is “businessmen”, for profit corporations that are acquiring office practices to MAKE MONEY out of owning there practices and often applying “common business practices” to lower overhead expenses and increasing profitability.

advanced practice providers (APPs) are also commonly known as mid-level practitioners ( NP, PA, ARNP, PharmD).  Generally speaking, services/care/procedures provided by a mid-level,  the entity they work for is reimbursed at abt 85% of what they would have been paid if it was provided by MD.

So, it would appear from this article, that these private equity firms that are buying these practice – in an effort to increase their bottom line – they are increasing the number of mid-levels to every MD on staff.

There’s More Clinician Replacement at Practices Acquired By Private Equity

These practices also saw increases in advanced practice providers versus those not acquired

https://www.medpagetoday.com/special-reports/features/102577

When it comes to workforce composition at physician practices, differences abound between those that had recently been acquired by private equity (PE) firms and those that had not, according to a study that used longitudinal clinician-level data linked to PE acquisitions.

Among dermatology, ophthalmology, and gastroenterology practice sites from 2014 to 2019, PE-acquired practices had higher clinician replacement ratios compared with their non-PE-acquired counterparts (1.75 vs 1.37), as well as significant annual increases in the number of advanced practice providers (APPs), reported Jane Zhu, MD, MPP, of Oregon Health & Science University in Portland, and colleagues in Health Affairsopens in a new tab or window.

This was also the case for each specialty on its own:

• Dermatology: 1.71 versus 1.28
• Gastroenterology: 2.18 versus 1.93
• Ophthalmology: 1.40 versus 0.98

Furthermore, entering physicians replaced exiting physicians at ratios of 1.50 and 1.14 in PE-acquired versus non-PE-acquired practices, respectively, and the replacement ratio for APPs was 2.51 in PE-acquired practices compared with 1.66 in non-PE-acquired practices, Zhu and team noted. This held true for both physicians and APPs across the specialties studied.

“Although these findings should be considered preliminary in nature, they raise important questions about the implications of PE ownership on the clinical workforce, particularly as PE investment accelerates across medical specialties,” the authors concluded.

Zhu told MedPage Today that “there may be both positives and negatives” when it comes to PE in the healthcare sector.

For instance, it is possible that hiring more APPs — such as physician assistants and nurse practitioners — might aid in expanding access to care to more patients, such as in cases when and where physicians are not readily available, she noted. But at the same time, it is possible that larger shifts in entrances and exits, and less longitudinal staffing may affect quality or continuity of care.

Overall, the topic “really does deserve further study,” Zhu said.

In addition, although the authors noted that they did not observe statistically significant changes for total physician counts, total counts of APPs per year increased at PE-acquired practices relative to non-PE-acquired practices (0.15, 95% CI 0.05-0.25, P=0.004).

At the individual clinician level, Zhu and colleagues found that the probability of both entering and exiting a practice was higher for physicians at PE-acquired practices compared with physicians at their non-PE-acquired counterparts. The estimated difference of entry for physicians was 15.74 percentage points (95% CI 10.79-20.69, P<0.001), and the estimated difference of exit was 6.0 percentage points (95% CI 1.91-10.07, P=0.004).

For APPs, the probability of entering was higher at PE-acquired practices compared with non-PE-acquired practices, but the difference was not statistically significant, the authors said. They further noted that they did not find evidence of differential probabilities of APPs exiting in PE-acquired practices compared with non-PE-acquired practices.

Replacement ratios were higher for younger physicians than for older physicians in both PE-acquired and non-PE-acquired practices: 1.70 vs 1.29 for physicians ages 40 to 60 and 0.50 vs 0.38 for those older than 60.

For this study, Zhu and colleagues examined a sample of 1,208 practice sites — including 691 in dermatology (1,735 clinicians), 166 in gastroenterology (741 clinicians), and 351 in ophthalmology (748 clinicians) — across the U.S. The PE sample included 422 dermatology clinicians at 112 practice sites, 259 gastroenterology clinicians at 45 practice sites, and 211 ophthalmology clinicians at 56 practice sites.

The authors combined several data sources to identify providers affiliated with PE-acquired versus non-PE-acquired practices, including Pitchbook (for mergers and acquisitions data), the IQVIA OneKey dataset (for individual provider-level and practice-level information), and the Medicare Physician and Other Practitioners dataset (to evaluate practice workforce turnover and composition over time.)

They then examined workforce change in three different ways. First they calculated clinician replacement ratios for PE-acquired versus non-PE-acquired practices. They also estimated whether practice-level entrants and exits differentially changed the total number of clinicians at PE-acquired practices versus non-PE-acquired practices. Finally they examined the probability of a clinician entering and exiting a PE-acquired practice versus a non-PE-acquired practice.

Zhu and colleagues noted that they may have missed some PE acquisitions, adding that it is also possible that there were some inaccuracies in how affiliations or clinicians were identified. Furthermore, the study did not estimate a causal effect of PE acquisition on workforce composition.

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‘Entire Body Is Shaking’: Why Americans With Chronic Pain Are Dying

https://dnyuz.com/2023/01/03/entire-body-is-shaking-why-americans-with-chronic-pain-are-dying/

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Physicians React: Are They Taking Right Path Now With Pain Management and Opioids?

https://www.medscape.com/viewarticle/986356

A Medscape report that explores how physicians prioritize substance abuse among leading American social issues also reveals their divergent views about a proper role in pain management through opioids.

The Centers for Disease Control and Prevention last month updated its guidelines for prescribing opioids to adults with acute and chronic pain. In part, the new guidelines 1) urge clinicians to maximize use of nonopioid therapies, 2) support lowest effective dosages and immediate-release drugs when physicians do turn to opioids, and 3) ask doctors to prescribe no greater quantity of opioids than needed for the expected duration of the patient’s pain.

Some survey respondents in the “Substance and Opioid Abuse Report 2022: Drugs and Alcohol Are Challenging Problems for Physicians and Their Patients” believe doctors still overfocus on pain management and 0-to-10 pain scales, even during the nation’s opioid crisis.

“It’s easy to become addicted to opioids when [physicians are] using a pain scale in the hospital and stating that post-op patients should be encouraged to use meds when they are at a 3,” an ob/gyn said. “If patients were told to expect significant post-op pain going into surgery, then they would have appropriate expectations post-op.”

“Our MIPS forms tell us that we need to present a plan if a patient complains of pain greater than zero,” a rheumatologist respondent added. “Primary care people feel compelled to treat pain. This has resulted in a far more cavalier use of opiates, because other medications have failed.”

And a toxicologist felt continuing “pressure on doctors for their overprescribing during the opioid crisis” would be a positive for society.

Beware Unintended Consequences

But some physicians in the Medscape survey felt the pendulum needs to swing back to more aggressive pain management, including prescribing opioids when appropriate. “Chronic pain and cancer pain patients are often undertreated by MDs, pharmacists, nurses, and support staff,” one internist argued. “These caregivers are not educated properly on pain control, and that is so unfortunate.”

A number of other doctors pointed to unintended consequences for which they said champions of stricter oversight of opioid prescribing cannot avoid responsibility.

“I think the government’s crackdown on physicians…has actually worsened” the opioid crisis, a gastroenterologist said. “Now, people are more often going to the streets and are getting fentanyl-laced drugs, resulting in accidental deaths. It’s a big problem.”

That viewpoint was backed by an orthopedic surgeon.

“Discouraging legal prescriptions doesn’t cure opioid use disorder,” he argued. “Other doctors and I are afraid to prescribe opioids, which is a boon to the illegal drug trade. Opioid prescriptions have been nearly cut in half in 10 years due to the new guidelines and rules, but overdoses and illegal opioids have nearly doubled.”

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Jessica Fujimaki suffered from a rare disorder called arachnoiditis. A common cause of this very painful and irreversible health issues is a error or “sloppy technique” of a practitioner doing a ESI procedure ( Epidural Spinal Injection). Anything that is injected into the spinal fluid must not only be sterile but must be preservative free and only a SOLUTION  – NOT A SUSPENSION.  ESI involve the injecting of a corticosteroid in the EPIDURAL SPACE – NOT IN THE SPINAL FLUID.  If the practitioner pushes the needle “a tad too far’ and accidentally injects the corticosteroid into the spinal fluid and the pt ends up with a VERY PAINFUL and IRREVERSIBLE MEDICAL ISSUE.   Outcomes – such as Jessica Fujimaki – is potentially what happens when these pts lose any/all pain management.  Likewise for Danny & Gretchen Elliott,  As long as our law/judicial system is entitled to qualified immunity  https://leb.fbi.gov/articles/legal-digest/legal-digest-qualified-immunity-how-it-protects-law-enforcement-officers  it would seem that they will do as they damn please and they have no consequences.

The DEA Shut Down a Pain Doctor. Now 3 People Are Dead

https://www.vice.com/en/article/dy7qqv/dea-beverly-hills-doctor-shut-down-opioids

After a California doctor was labeled an “imminent danger” to the public, the consequences were devastating for his patients and their families.

Filed under: General Problems | 6 Comments »

Could this mean that as the number of prescribers who have completed the new  obligatory requirement of taking the 8-hour training on managing patients with opioid and other substance use disorders that all pts that these practitioner who treat for chronic pain could be required to have at least a secondary diagnosis of “opiate use disorder” ?  Could the feds make the requirement to take this 8-hour training retroactive for all prescribers when they renew their DEA license –  which is every THREE YEARS.  In theory, every chronic pain pt could be diagnosed with opiate use disorder if the feds decided to go down this path.

The X Waiver Is Officially Dead

https://www.medpagetoday.com/special-reports/features/102520

But now, doctors will have to take substance use disorder training to get their DEA license

The Biden administration’s recent spending billopens in a new tab or window contained under-the-radar changes for addiction medicine, including eliminating the X waiver requirement for clinicians who treat opioid use disorder with medication-assisted treatment (MAT).

The X waiver, a special Drug Enforcement Administration (DEA) certification that allowed clinicians to prescribe buprenorphine (Suboxone), a partial opioid agonist that curbs opioid cravings, has long been considered a bureaucratic hurdle to improving treatment access for patients who struggle with opioid addiction.

While the administration has incrementally loosenedopens in a new tab or window the requirementsopens in a new tab or window for providers to obtain an X waiver in recent years, the provision included in December’s omnibus bill eliminates the certification entirely. The abolishment of the X waiver is included in the bipartisan Mainstreaming Addiction Treatment (MAT) Actopens in a new tab or window.

“Treatment for opioid use disorder is limited by there not being enough people that offer medications for opioid use disorder,” said Brian Hurley, MD, MBA, president-elect of the American Society of Addiction Medicine (ASAM). “Removal of the X waiver opens up the capability of prescribing to a much broader group of clinicians.”

Previously, obtaining an X waiver required 8 hours of training on prescribing MAT to patients with opioid use disorder. But in April 2021, the Biden administration nixed the training requirementopens in a new tab or window for doctors, nurse practitioners, and other providers who wanted to prescribe buprenorphine. Providers simply had to register for the waiver to prescribe.

But also included in the omnibus bill was another provision that bolsters training requirements for clinicians prescribing all controlled substances — not just MAT — called the Medication Access and Training Expansion (MATE) Actopens in a new tab or window.

This law requires all providers who apply for a DEA license to prescribe controlled substances to undergo a one-time, non-repetitive, 8-hour training on managing patients with opioid and other substance use disorders.

“That training is for you to get your DEA license, so that means, obviously, your controlled substance license,” said Rahul Gupta, MD, MPH, MBA, director of the Office of National Drug Control Policy, in an interview with MedPage Today. “That’s different from what used to be the X waiver training, which was primarily focused on prescribing of buprenorphine and opioid [abuse treatments].”

Hurley said ASAM is a “strong supporter of education for clinicians that have controlled substances prescribing authority, really to help preserve the safety of the patients that we treat.” As all controlled substances do carry a risk, it is critical for clinicians to understand how to prescribe them, and buprenorphine should not be singled out, he said.

Removing the X waiver does more than just make it easier to prescribe buprenorphine, Hurley said, adding that this action could pave the way for further de-stigmitization of MAT for opioid use disorder.

“When you put buprenorphine behind the X waiver, it creates the impression that the medication is complex or dangerous,” Hurley said. Clinicians routinely prescribe other medications that are more dangerous than buprenorphine — such as other opioids — which have not previously required additional training, Hurley said.

“So not only does the elimination of the X waiver create the regulatory pathway” for clinicians to prescribe buprenorphine without a separate certification, Hurley said. “It also removes the impression that the treatment of opioid use disorder with buprenorphine is a highly specialized, complex, or dangerous activity.”

While removing the X waiver is a positive change for addiction medicine, more action is needed to encourage providers to actually treat patients with addiction, said Allister Martin, MD, an emergency medicine doctor in Boston and CEO of the non-profit A Healthier Democracy.

“There are some parts of the population that could have been prescribing buprenorphine but simply because of the X waiver, they did not,” Martin said in an interview. “That’s the group that we now need to mobilize.”

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RE-HEARING CASE 22-6000: BEFORE THE UNITED STATES SUPREME COURT NORMAN CLEMENT vs. DEA AND THE DEATH OF TRAVIS REYES

https://youarewithinthenorms.com/2023/01/04/re-hearing-case-22-6000-before-the-united-states-supreme-court-norman-clement-vs-dea-and-the-death-of-travis-reyes/

The Case 22-6000 Norman Clement vs the DEA before the Supreme Court of the United States Petition for Rehearing involves life and death of millions of patients suffering pain and their healthcare providers treating the disease of pain. It ask questions:

1. Weather “red flags” are guidelines created by DEA in which the agency “lacks the authority to issue guidelines that constitute advice relating to the general practice of medicine and further lacks authority to promulgated new regulations regarding the treatment of pain?
2. We further ask this Court to determine whether a Pharmacists refusal to fill a  prescription for a “legitimate medical purpose” under the Pharmacists  “corresponding responsibility,” provision, constitute and violates the Eight Amendment prohibition against cruel and usual punishment?
3. Whether it was the intent Congress for DEA to regulate the field and practice of medicine and pharmacy auger deference awarded to administrative agencies ?

RETIRED DETROIT POLICE SARGENT SUFFERED UNDER TREATMENT OF PAIN FROM ALS

MOVING THE GOAL POST BACKWARD AND FORWARD

Those pharmacists who merely question these DEA policies risk loss of employment and/or administrative sanctions. The DEA can impose these errant actions because they possess unchecked authority and weapons the ability to intimidate by seizings property and assets.  Under this interpretation, a golf ball can become a football and baseball bat can enforced as a hockey stick. The DEA Administrator need not determine the underlying legitimacy of the prescriptions a pharmacy filled, but rather, may use “red flags” as a proxy to presume a prescription was illegitimate. 

GERALD KILEY FLORIDA UMBILICAL HERNIA 2019, TAMPA FL, HOWVER LISTED BY DEA AS DRUG SEEKER (SEE LINK)

The question we seek out as pharmacist here in is  when does a golf ball become a football, at what point in the game does a baseball bat become a hockey stick and at what point does the umpire call a strike across the plate third down? 

When does the referee call a prescription written for a “legitimate medical purpose” illegal so that a pharmacy violates its corresponding responsibility whether or not there is evidence of a prescription’s illegitimacy?  At what point on the mile marker does a prescription written by a licensed authorized provider to treat a medical disease of a disease state become illegal or can the Umpire convert the rules of the game into scienter as an financial incentive to issue more fines and expand his/her authority?

DEA’S CAMPAIGN OF DIS-INFORMATION

The DEA has been waging a campaign of disinformation to sway the public to a point prescribed narcotic analgesic medications are indeed drugs, dangerous drugs who dosages are red flags indicating abuse and trafficking contributing to the so-called Opioid crisis around America.  Notably, DEA’s evidences always realize upon execration on numbers of “pills” and street language such as “pill mills,” “Holy Grails,” and “Cocktails,” not on medical disease states or clinical conditions.

Prosecutors, have found these forms of distortion, redefinition of medical procedures effectively sells juries.  Further Judges often instruct the juries to ignore any clinical presentation or will not allow such testimony on the record. By 2006, federal regulatory agencies perceived what they called an “opioid crisis” and mistakenly attributed it to doctors “overprescribing” opioids and generating a growing population of opioid addicts. 

This formed the basis for an even more massive intrusion of federal and state power into the privacy of medical records, patient-doctor confidentiality, and the very way in which doctors are allowed to use scientific and professional knowledge to practice medicine. Medical decision making came increasingly under the purview of law enforcement, spark- ing a new wave of arrests and prosecutions.

Patients who had their pain controlled with long-term opioid treatment are being denied treatment or involuntarily tapered off their pain control, as doctors fear arrest and an end to their medical careers. A growing population of “pain refugees” has emerged, with some patients turning in desperation to the black market for opioids and some even turning to suicide.

As prescribing rates continue to plunge, overdoses from the non-medical use of opioids are skyrocket- ing, now largely caused by illicit fentanyl. These guidelines were disastrous for chronic pain patients. Many were driven to buy illegal drugs on the street, which were laced with poisonous fentanyl. In 2021 this led to 100,000 deaths in the United States. 

Unfortunately prosecutors and the DEA has learned when facts don’t support the charges one just fabricates the facts. Thus the phrase garbage in is garbage out or  the legal term false en uno false en omnibus is applicable.

It would have been expected a higher level of scientific accuracy and integrity from an agency such as the DEA entrusted to protect citizens’ health and welfare.

“…Without the discipline of good science, nontransparent implementation produces poor public outcomes. These outcomes are pressed into service in the field, offer no benefit, and harm physicians, pharmacies, patients, and public policy at large…” 

URGENT!!! HELP AND SUPPORT NORMAN CLEMENT vs. DEA IN US SUPREME COURT CASE NO: 22-6000

DONATE LEGAL DEFENSE

OR SEND

$100 $250, $500 DOLLARS SEND

TO ZELLE: 3135103378 OR CASH APP: $docnorm

THE NEEDLESS DEATH OF TRAVIS REYES

From Bob Sheerin pain care advocate:

“Let me add another friend to my list of folks who had a long life ahead of him and died because of chronic pain! Travis Reyes an athlete, a friend!

Travis and I had a-lot in common, we both were stand out athletes who were hurt in the hights of our glory! We were good at anything with a ball (big or small) running, jumping, lifting weights, and both of us cared for the pain community because we both knew what torture was caused by chronic pain.

Travis had his dad’s undying love and support! His dad  and I went to his defense and talked to his doctor and his dad then would drove way out of his way to find a damn pharmacy that would filled his prescription medication once we got the doctor to call it in elsewhere.

Today an Arizona doctor called me and said, he would take Travis! I was so excited I left him a message that said, hey Travis that doctor will see you… How are you brother! Only to find out my friend is now gone 12-11-2022 at such a young age!

This is such a common theme in this frigging community that I have grown personally tired of. It makes me wonder how the hell am I still here when Travis was so damn young and strong!

That kid was the age of my own son and his only mistake in life was being a chronic pain patient living in a country who hates chronic pain patients!

Another common theme I’m way to tired of is saying, Travis you will be missed my friend and thank you for the fight you gave to this community! Love ya Brother! RIP and maybe tell the big guy we could use some help down here! And to his beloved father I’m so damn sorry.”

CONCLUSION

Wherefore, For the foregoing reasons,  we respectfully request this Petition for rehearing in Case number 22-6000 submitted in a timely manner be granted and the revocation and the Court should further grant this Petitioner’s writ of certiorari as the decision in this case by this Court will have far-reaching effects on the professions of Medicine, and Pharmacy. The Petitioner is a Pharmacist Not a Street Drug Dealer.

Respectfully submitted:

Norman J Clement, pro se 

P.O. Box 280139

Tampa Fl. 33682

ywtn@umich.edu or prontopharmacy@aol.com  

DECEMBER 12, 2022

 

Help 

URGENT!!! HELP AND SUPPORT NORMAN CLEMENT vs. DEA IN US SUPREME COURT CASE NO: 22-6000

DONATE LEGAL DEFENSE

OR SEND

$100 $250, $500 DOLLARS SEND

TO ZELLE: 3135103378 OR CASH APP: $docnorm

FOR NOW, YOU ARE WITHIN

THE NORMS

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AUSA WAYNE F. PRATT, SMASHED TO THE GROUND BY RON CHAPMAN OF CHAPMAN LAW FIRM AND ATTY’S GEORGE DONNINI AND JOSEPH RICHOTTE: “POMPY FOUND NOT GUILTY !!” SO SAY WE ALL !!!

https://youarewithinthenorms.com/2023/01/04/ausa-wayne-f-pratt-smashed-to-the-ground-by-ron-chapman-of-chapman-law-firm-and-attys-george-donnini-and-joseph-richotte-pompy-found-not-guilty-so-say-we-all/

VICTORY FOR LESLY POMPY MD NOT GUILTY ON ALL COUNTS!!!

Since becoming fraud unit chief in 2010, the federal officials have successfully prosecuted more than 50 doctors and 30 pharmacists for felony violations involving fraud, controlled substances, and kickbacks.

In 33 years as an assistant United States Attorney, Wayne F. Pratt has prosecuted some of Michigan’s most “notorious narcotics traffickers and corrupt healthcare providers.” 

However Wayne F. Pratt messed with the “wrong Physician,” when he decided 8 years ago to taken on Lesly Pompy MD a Haitian born doctor, born out of the DNA of Jean-Jacques Dessalines, Toussaint Louverture , Marie Claire Heureuse Felcite Bonheur of the Haitian Revolution. Doctor Pompy, who chose to fight instead of running for the tall grass!!!

Wayne F. Pratt Chief of the Healthcare Fraud Unit Michigan

It is said that Wayne F. Pratt, Chief of the Health Care Fraud Unit for the U.S. Attorney’s Office for the Eastern District of Michigan, has saved Medicare nearly $1 billion and has done more to fight health care fraud than almost anyone else in the U.S. Department of Justice. 

However, a decade of Blue Cross Blue Shield’s influence has twisted Chief Prosecutor AUSA Pratt’s body and mind; he has indicted healthcare providers based on Blue Cross Blue Shield’s precious bidding.

The love and hate relationship with his “precious” Master, Blue Cross Blue Shield, has gradually corrupted him like Gollum by the ring’s power. And like Gollum, he has come to love and hate himself.

PROSECUTORIAL CORRUPTION

There has been massive government overreach of power by agencies of the United States Government, changing the rules to make arrests on healthcare providers, piling up more healthcare providers’ scalps while attempting to make heroes of what can best be identified as prosecutorial domestic terrorists. 

According to Richard Lawhern, Ph.D. :

“It is now apparent that doctors, nurses, and pharmacists are being persecuted (not merely sanctioned) in a US national witch hunt by the Drug Enforcement Agency, Department of Justice, State Attorney Generals, and State Medical Boards for the imagined “crime” of “over-prescribing” opioid pain relievers to patients in moderate to severe pain.  

This unjustifiable witch hunt is unsupported by science or ethics.  But it has resulted in the departure of thousands of physicians from pain management practice.  Millions of patients in agony have been denied access to community clinics or force-tapered from opioid therapy that has been the only effective means of controlling their pain.  This campaign’s death toll in medical collapse and suicide is rising.”

AUSA WAYNE F. PRATT

 

 

FOR NOW, YOU ARE WITHIN

 

 

THENORMS

LOW HANGING FRUIT

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50 states sign up for Walmart’s opioid settlement framework -3.1 billion

the settling of these lawsuits Walgreen & CVS agreed to a 10 BILLION settlement paid out over 10-15 yrs and Walmart agreed to a 3.1 BILLION settlement.

part of Walmart’s agreement: https://corporate.walmart.com/newsroom/2022/11/15/walmart-announces-nationwide-opioid-settlement-framework

Walmart has adopted many approaches to fighting the opioid crisis, such as:

• Educating and empowering pharmacists
• Reducing the amount of opioids dispensed
• Protecting against diversion and theft
• Increasing access to overdose reversal medication
• Educating our patients and our communities about opioid abuse
• Advocating for state and national policies aimed at curbing opioid abuse and misuse

There are more lawsuits forming against other chain pharmacies. The money from the TOBACCO SETTLEMENT from 1999 will soon drop dramatically or dry up entirely Many of the states did not use the money from that settlement- as they promised for anti-tobacco education, but … just dumped the money in their general fund.  All those states have become financially addicted to that “free money” and unless they find a new source of “free money” they may have to cut public services and/or raise taxes.

Depending how many lawsuit keep coming and the chains are forced to settle because 90%+ of entities taken to federal court are found guilty. I presume that the chains don’t want to waste money on a law firm when the odds are they are going to be found guilty and paying out money.

The chains may come to the conclusion that stocking/filling controlled meds is not a good financial business plan and just stop stocking and filling controlled meds Rx.

Many states’ Pharmacy practice act – unless they have changed it – are required to stock meds normally prescribed in the pharmacy’s market.

There is a lot of shifting in the pharmacy market place

UP TO 5% of TRICARE beneficiaries will have to make a 30+ MINUTE round trip to get their prescription filled because of DOD contract

Kroger: announced that we are terminating our Express Scripts agreement for commercial customers as of December 31

The GoodRx-Kroger Blowup: Spread Pricing, Pharmacy Margins, and the Future of Discount Cards

 

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