Today is 11/19/2017

2016 in review … what killed us

2600 Americans will die EVERY DAY – from various reasons


140 will be SUCCESSFUL – including 20 veterans

270 will die from hospital acquired antibiotic resistant “bug” because staff won’t properly wash hands and/or proper infection control.

350 will die from their use/abuse of the drug ALCOHOL

1200 will die from their use/abuse of the drug NICOTINE

1400 will contract C-DIF from Hospital or Nursing home because staff doesn’t properly wash their hands are adhere to infection control       80 WILL DIE mostly elderly.

850 will die from OBESITY

700 will die from medical errors

150 will die from Flu/Pneumonia

80 will die from Homicide

80 will die in car accidents


I am being completely weaned off my meds, & suspect I will kill myself with the amount of pain I am in, & will be by the time this is over (the wean that is). Already can’t function.

My husband committed suicide after being abandoned by his pain dr.

Please pray for me as I am on the brink of suicide! I don’t want to die but can’t handle the pain anymore! The doctor that I am currently seeing will not give me enough pills to last all month every month… I have to wait until Oct to get in with a pain management doctor whom I already know by others that I know sees this doctor that he will help me, need prayer to hold on until oct… I keep thinking of my family who needs me hear.

“We just lost another intractable member of our support group two nights ago. She committed suicide because her medications were taken away for interstitial cystitis (a horribly painful bladder condition) and pudendal neuralgia, both of which she had battled for years

D D., journalist and prescribed fentanyl patient for a dozen years joined me on air last weekend with her husband and spoke of her suicide plan should the only relief from constant agony be heavily reduced or taken away.

I was told last Friday that my Dr. will be tapering my meds again . When I told him I didn’t think my body could take another lowering he stated ” it wasn’t my
License on the line”, I stated ” no , but it’s my life on the line”!!!!! I can not continue to live this way . I can not continue to suffer in agony when my medications and dose where working just fine before and I was a productive member of society . I can no longer take this. I have a plan in place to end my life myself When I am forced to reduce my Medications again . I just can’t do it anymore .

On Friday at around 9 p.m. U.S. Navy veteran Kevin Keller parked his red pickup truck in the parking lot at the Wytheville Rite-Aid, walked across the grass and stood in front of the U.S. Veterans Community Based Outpatient Clinic next door.

Sick and tired of being in pain, he pulled out a gun, shot a hole in the office door, aimed the gun barrel at his head and ended his hurt once and for all.

As a longterm pain patient with a current unsupportive pain dr, I just thought I’d share the reality of the position I’m in right now…

I’m in very bad pain all the time for very legit and well documented reasons. My pain dr however never gives me enough meds to help me. He just keeps reducing them, which is causing me to be in even more pain and suffer so much more. My quality of life also continues to go downhill at the same time. I was just given a letter by him recently too about some study indicating an increase in deaths if you take opioids and benzos. It stated he’s no longer going to give pain meds to anyone who is taking a benzo. I take one, because I have to, for a seizure disorder, not because I want to. He told me to pick one or the other though, plus went ahead and reduced my pain meds some more. He doesn’t seem to care the least bit. I’ve looked hard and so far I can’t find another one to get in to see near me at this time, but I’m desperately still trying. Unfortunately, they’re few and far between here, in addition to the wait for an appointment being long. I’ve even called hospice for help. So far, they haven’t been of much help either, because I don’t have a dr who will say I have six months or less to live. I told them either choice my pain dr is giving me is very inhumane, so I’d rather just quit eating and drinking, to the point where I pass away from that, while I get some kind of comfort care from them. I don’t really want to though, although I do have a long list of some very bad health problems, including a high probability that I have cancer and it’s spread. Am I suicidal? No. Will I be if my pain and seizure meds are taken away. Highly likely. I never ever saw this coming either. I don’t have a clue what to do and the clock is ticking, but I’m still fighting for an answer. So far, I can’t find not even one dr to help me though. Not one. I know my life depends on it, but at what point will these drs let my suffering become so inhumane that I just can’t take it anymore. I just don’t know right now. It’s a very scary place to be in for sure. That I do know.

The patient was being denied the medicine that had been alleviating his pain and committed suicide because, “he couldn’t live with the pain anymore. He could not see a future. He had no hope. He had no life.”

I am a chronic pain patient who has been on fairly high doses of opiates for about nine years now. My dose has been forcibly reduced since the cdc guidelines. I moved to Oregon from Alaska and can’t find a doctor to prescribe my medication. I pray I have the strength not to take my own life!

Zach Williams of Minnesota  committed suicide at age 35. He was a veteran of Iraq and had experienced back pain and a brain injury from his time in service. He had treated his pain with narcotics until the VA began reducing prescriptions.

Ryan Trunzo committed suicide at the age of 26. He was an army veteran of Iraq. He had experienced fractures in his back for which he tried to get effective painkillers, but failed due to VA policy. His mother stated “I feel like the VA took my son’s life.”

Kevin Keller, a Navy veteran, committed suicide at age 52. He shot himself after breaking into the house of his friend, Marty Austin, to take his gun. Austin found a letter left by Keller saying “Marty sorry I broke into your house and took your gun to end the pain!” Keller had experienced a stroke 11 years earlier, and he had worsening pain in the last two years of his life because VA doctors would not give him pain medicine. On the subject of pain medication, Austin said that Keller “was not addicted. He needed it.”

Bob Mason, aged 67, of Montana committed suicide after not having access to drugs to treat his chronic pain for just one week. One doctor who had treated Mason was Mark Ibsen, who shut down his office after the Montana Board of Medical Examiners investigated him for excessive prescription of opioids. According to Mason’s daughter, Mason “didn’t like the drugs, but there were no other options.”

Donald Alan Beyer, living in Idaho, had experienced back pain for years. He suffered from  degenerative disc disease, as well as a job-related injury resulting in a broken back. After his doctor retired, Beyer struggled without pain medicine for months. He shot himself on his 47th birthday. His son, Garrett, said “I guess he felt suicide was his only chance for relief.”

Denny Peck of Washington state was 58 when he ended his life. In 1990, he experienced a severe injury to his vertebrae during a fishing accident. His mother, Lorraine Peck, said “[h]e has been in severe pain ever since,” and his daughter, Amanda Peck, “said she didn’t remember a time when her dad didn’t hurt.” During the last few years of his life, Peck had received opiates for his pain from a Seattle Pain Center, until these clinics closed. After suffering and being unable to find doctors who would help with his pain, Peck called 911. Two days later, Peck was found dead in his home with bullet wounds in his head. A note found near Peck read: “Can’t sleep, can’t eat, can’t do anything. And all the whitecoats don’t care at all.”

Doug Hale of Vermont killed himself at the age of 53. He had experienced pain from interstitial cystitis, and decided to end his life six weeks after his doctor suddenly cut off his opiate painkillers. He left a note reading “Can’t take the chronic pain anymore” before he shot himself in the head. His doctor said he “was no longer willing to risk my license by writing you another script for opioids”  (see attachment A for details of the problem as relyed by his wife Tammi who is now 10 months without a husband as a direct result of the CDC guidelines to prevent deaths)Bruce Graham committed suicide after living with severe pain for two years. At age 62, Graham fell from a ladder, suffering several severe injuries. He had surgery and fell into a coma. After surgery, he suffered from painful adhesions which could not be removed. He relied on opioid painkillers to tolerate his pain, but doctors eventually stopped prescribing the medicine he needed. Two years after his fall, Graham shot himself in the heart to end the pain.

Travis Patterson, a young combat veteran, died two days after a suicide attempt at the age of 26. After the attempt to take his own life, Patterson was brought to the VA emergency room. Doctors offered therapy as a solution, but did not offer any relief for his pain. Patterson died two days after his attempted suicide.

54-year-old Bryan Spece of Montana  killed himself about two weeks after he experienced a major reduction in his pain medication. The CDC recommends a slow reduction in pain medicine, such as a 10% decrease per week. Based on information from Spece’s relative, Spece’s dose could have been reduced by around 70% in the weeks before he died.

In Oregon, Sonja Mae Jonsson ended her life when her doctor stopped giving her pain medicine as a result of the CDC guidelines.

United States veterans have been committing suicide after being unable to receive medicine for pain. These veterans include Peter Kaisen,Daniel Somers, Kevin Keller, Ryan Trunzo, Zach Williams, and Travis Patterson

A 40-year-old woman with fibromyalgia, lupus, and back issues appeared to have committed suicide after not being prescribed enough pain medicine. She had talked about her suicidal thoughts with her friends several times before, saying “there is no quality of life in pain.” She had no husband or children to care for, so she ended her life.

Sherri Little was 53 when she committed suicide. She suffered pain from occipital neuralgia, IBS, and fibromyalgia. A friend described Little as having a “shining soul of activism” as she spent time advocating for other chronic pain sufferers. However, Little had other struggles in her life, such as her feeling that her pain kept her from forming meaningful relationships. In her final days, Little was unable to keep down solid food, and she tried to get medical help from a hospital. When she was unable to receive relief, Little ended her life.

Former NASCAR driver Dick Trickle of North Carolina shot himself at age 71. He suffered from long-term pain under his left breast. Although he went through several medical tests to determine the cause of his pain, the results could not provide relief. After Trickle’s suicide, his brother stated that Dick “must have just decided the pain was too high, because he would have never done it for any other reason.”

39-year-old Julia Kelly committed suicide after suffering ongoing pain resulting from two car accidents. Kelly’s pain caused her to quit her job and move in with her parents, unable to start a family of her own. Her family is certain that the physical and emotional effects of her pain are what drove her to end her life. Kelly had founded a charity to help other chronic pain sufferers, an organization now run by her father in order to help others avoid Julia’s fate.

Sarah Kershaw ended her life at age 49. She was a New York Times Reporter who suffered from occipital neuralgia.

Lynn Gates Jackson, speaking for her friend E.C. who committed suicide after her long term opiates were suddenly reduced by 50% against her will, for no reason.  Lynn reports she felt like the doctors were not treating her like a human being (Ed:  a common complaint) and she made the conscious decision to end her life.

E.C. committed suicide quietly one day in Visalia California.  She was 40.  Her friend reported her death.  “She did not leave a note but I know what she did”.  The doctor would only write a prescription for 10 vicodin and she was in so much pain she could not get to the clinic every few days.   We had talked many times about quitting life. Then she left.  She just left.

Jessica, a patient with RSD/CRPS committed suicide when the pain from her disease became too much for her to bear. A friend asserted that Jessica’s death was not the result of an overdose, and that “living with RSD isn’t living.”

Aliff, Charles

Beyer, Donald Alan

Brunner, Robert “Bruin”

Graham, Bruce

Hale, Doug

Hartsgrove, Daniel P

Ingram III, Charles Richard

Kaisen, Peter

Keller, Kevin

Kershaw, Sarah

Kimberly, Allison

Little, Sherri

Mason, Bob

Miles, Richard

Murphy, Thomas

Paddock, Karon

Patterson, Travis “Patt”

Peck, Denny

Peterson, Michael Jay

Reid, Marsha

Somers, Daniel

Son, Randall Lee

Spece, Brian

Tombs, John

Trickle, Richard “Dick”

Trunzo, Ryan

Williams, Zack

Karen Shettler Paddock  committed suicide on August 7, 2013 

Jessica Simpson took her life July 2017

Mercedes McGuire took her life on Friday, August 4th. She leaves behind her 4 yr old son. She could no longer endure the physical & emotional pain from Trigeminal Neuralgia.

Another Veteran Suicide In Front Of VA Emergency Department

 Depression and Pain makes me want to kill self. Too much physical and emotional pain to continue on. I seek the bliss fullness of Death. Peace. Live together die alone.

 Dr. Mansureh Irvani  suspected overdose victim

Katherine Goddard’s Suicide note: Due to the pain we are both in and can’t get help, this is the only way we can see getting out of it. Goodbye to everybody,”  

Steven Lichtenberg: the 32-year-old Dublin man shot himself  

Fred Sinclair  he was hurting very much and was, in effect, saying goodbye to the family.

Robert Markel, 56 – June 2016 – Denied Pain Meds/Heroin OD

 Lisa June 2016

Jay Lawrence  March 2017

Celisa Henning: killed herself and her twin daughters...

Karen Boje-58  CPP-Deming, NM

Katherine Goddard, 52 –  June 30, 2017 – Palm Coast, FL -Suicide/Denied Opioids List of Suicides, as of 9–10-17

Suicides: Associated with non-consented Opioid Pain Medication Reductions

Lacy Stewart 59,

Ryan Trunzo of Massachusetts committed suicide at the age of 26,-ryan-j  

Mercedes McGuire of Indiana ended her life August 4th, 2017 after struggling with agony originally suppressed with opioid pain medicine but reappearing after her pain medicine was cut back in a fashion after the CDC regulations. She was in such discomfort she went to the ER because she could not stand the intractable pain by “learning to live with it” as suggested by CDC consultants. The ER gave her a small prescription. She went to the pharmacy where they refused to fill it “because she had a pain contract”. She went home and killed herself. She was a young mother with a 4 year old son, Bentley. Bentley, will never get over the loss of his mom.


WWII veteran calls for help and dies as nurses laugh, video shows

A hidden video from 2014 showed nurses laughing as a World War II veteran repeatedly called for help and died while in their care.

The family of James Dempsey, 89, of Woodstock, Ga., hid a camera in the late veteran’s room in the Northeast Atlanta Health and Rehabilitation Center which captured the night he died.

The video showed the decorated WWII veteran repeatedly calling for help, saying he could not breathe. It also showed the nurses failing to take life-saving measures and laughing as they tried to start an oxygen machine.

Dempsey’s family sued the nursing home in 2014 following the veteran’s death. Dempsey’s family declined to comment on the video, citing a settlement with the nursing home, WXIA-TV reported.

The nursing home’s attorneys attempted to stop media news outlet WXIA-TV from getting the video but a DeKalb County Judge ruled to unseal the footage.

The nurses, including a nursing supervisor, Wanda Nuckles, told Dempsey’s family lawyers in the deposition that when she learned the veteran had stopped breathing, she rushed to his room and took over CPR, keeping it up until paramedics, WXIA-TV reported.

However, the secret video showed that nobody was doing CPR when she arrived, and she did not start immediately. After the attorneys showed Nuckles the video, she told them it was an honest mistake, based on her normal reactions.

When the attorney’s asked what Nuckles was laughing, she said she did not remember.

WXIA-TV reported the nursing home was told of the video in 2015 but did not terminate the nurses until 10 months later. Nuckles and another nurse did not surrender their licenses until this September when the Georgia Board of Nursing was sent a link to the video by the news station.


Two nurses surrendered their licenses in Sept. 2017.  (11 Alive)

Records showed the nursing home continued to have problems, including $813,000 in Medicare fines since 2015, WXIA-TV reported. It said the nursing home got a good inspection report in May, but still has Medicare’s lowest score, a one-star rating. The nursing home was currently still open.



Figures Lie and Liars Figure – Why the Demographics of the So-Called “Prescription Opioid Crisis” Don’t Work

Anybody who reads a newspaper or watches evening news has heard the screaming headlines:  “60,000 Drug Overdose Deaths” (or similar numbers).  When reporters seek maximum sensationalism, we hear deaths by overdose summed over 10 years or compared to casualties in the Vietnam War.  500,000 drug deaths is a much more impressive number — even though it’s mostly hype.

Unfortunately for all of us – and for US public policy makers — such numbers misrepresent more than they illuminate [Ref 1].  Public policy concerning opioid addiction which is based on such inflated numbers will inevitably fail spectacularly, just as the “War on Drugs” did in the 1980s.

When we boil off the hype, we find that the “real” numbers of yearly deaths where a pain killer prescribed to a pain patient might have been involved is much smaller — like maybe 7,000 instead of 60,000 in 2016. About half of drug-related deaths don’t involve opioids at all (thousands of deaths from heart failure or liver toxicity are attributed to Ibuprofen or Acetaminophen).  Among the remaining 33,000 deaths last year, most involved multiple street drugs and alcohol – something we rarely hear except as a footnote. The drugs most often detected by county medical examiners in 2016 were illicit fentanyl, heroin, morphine stolen from hospital dispensaries and methadone diverted from community drug treatment programs.  So-called “prescription” drugs come in fifth – but many of those drugs weren’t actually prescribed to patients. [Ref 2-4] They were diverted to the street by theft from pharmacies and home medicine closets. Under prevailing CDC rules for mortality data collection, any death where an opioid is detected among other factors is labeled “opioid related” [Ref 5].  When Massachusetts traced opioid related deaths into their State prescription tracking database, only 8% of OD victims had a recent prescription.  When a reporter breathlessly reports deaths by “opioid overdose” without clarifying sources or types of drugs, they’re essentially committing journalistic fraud.

Richard A. Lawhern, Ph.D

We also hear tragic stories about young adults who overdose and die following a sharp descent into addiction.  Many of them, we’re told, start down this path by being prescribed opioid pain killers for a few days or weeks after a sports injury or automobile accident.  Without doubt, such stories are tragic and the families are devastated. The problem is that such stories aren’t representative or typical [Ref 4].

90% of drug addicts first begin abusing drugs and alcohol in their teens or 20s.  According to the National Survey on Drug Use and Health, “…75% of all opioid misuse starts with people using medication that wasn’t prescribed for them—obtained from a friend, family member or dealer.”  The typical new addict is a young white male with a history of family trauma, sustained unemployment, and mental health issues.  [Ref 6]

So who is the typical chronic pain patient?  According to the National Academies of Medicine, over 100 million US citizens now suffer moderate to severe pain.  Of these, an estimated 18 million are prescribed opioids during any given year, and perhaps 2.7 to 3.3 million will be managed on opioids for longer than 90 days.  [Ref 7]

Causes of long-lasting severe pain are multiple and complex.  Some chronic pain seems to emerge “of itself” for no presently understood reason, while other cases follow from injury or diseases.  It might not be helpful to imagine a “typical” pain patient, due to the multiple overlapping conditions involved.  However, broad trends are well known [Ref 8-9].

–       Back pain is the leading cause of disability in Americans under 45 years old. More than 26 million Americans between the ages of 20-64 experience back pain. Many other chronic pain conditions also affect older adults [Ref 8].
–       Women are more likely to experience pain than men (~60% vs 40%) and to experience more intense pain.  Likelihood of pain increases with age, with new cases reaching a plateau or decreasing after Age 60. [Ref 9]
–       Non-white and poor people experience more — and more severe — pain than well educated white elites.[Ref 9]
–       For certain types of painful disorders such as facial neuropathic pain, Complex Regional Pain Disorder or Fibromyalgia, the typical patient is a woman in middle age or later. [Ref 10, 11]

When the known risk factors for addiction are compared with statistics on chronic pain, it becomes clear that attribution of the US “opioid crisis” to over-prescription of opioid pain relievers is unjustified.  The great majority of addicts begin as male adolescents from troubled or disadvantaged socio-economic backgrounds – a population that is medically under-served.  Few teens will see a physician for pain severe enough to justify prescription of an opioid for longer than a few days, and most such visits involve dental surgery.  By contrast, a significant majority of chronic pain patients are women of middle age who have a very low risk of opioid addiction.

The demographics simply do not work.    

The contrasts between addicts and chronic pain patients are strongly reinforced by the few available studies of the long-term effectiveness and risks of opioid treatment for common pain conditions.  Not many of these studies have been conducted.  But one which stands out is a 2010 Cochrane Review [Ref 13].  Key results of this review are worth repeating here: “We reviewed 26 studies with 27 treatment groups that enrolled a total of 4893 participants….” “Signs of opioid addiction were reported in 0.27% of participants in the studies that reported that outcome….”

“Many patients discontinue long-term opioid therapy (especially oral opioids) due to adverse events or insufficient pain relief; however, weak evidence suggests that patients who are able to continue opioids long-term experience clinically significant pain relief. Whether quality of life or functioning improves is inconclusive. Many minor adverse events (like nausea and headache) occurred, but serious adverse events, including iatrogenic opioid addiction, were rare.” As a parenthetical note, we do not know in detail, the reasons for “discontinuance of opioid therapy due to inadequate pain relief”.  But one of those reasons seems likely to be under-treatment of people who poorly metabolize opioids. [Ref 12]

The President’s Commission on Combating Addiction and the Opioid Crisis released its report in early November 2017.  Although some aspects of the report seem positive, it is deeply flawed overall by its clinging to the false narrative that medically managed prescriptions in some way provide a “gateway” to addiction. Some of the Commission’s recommendations will almost certainly drive more physicians out of pain management practice and more patients into agony through desertion or denial of adequate medication. [Ref 14] Perhaps the only saving grace for chronic pain patients in the Commission report, is a recommendation for expansion and clarification of the 2016 CDC Guidelines on prescription of opioids to chronic pain patients.  If this project is approached honestly and led by pain management specialists instead of addiction psychiatrists, almost the entirety of the CDC guidelines must be thrown out and done over.  There is wide agreement among medical professionals that the published Guidelines are biased against opioid pain relief, scientifically unsupported and seriously incomplete [Ref 12].

Whether the US Government will permit the correction of its sorry record of distortions and mistakes in the so-called “opioid epidemic” remains to be seen.  But it is now clear that the demographics of addiction and chronic pain only marginally overlap.  Effective public policy cannot be based on the fiction that doctor-prescribed pills are the problem. Pill counting is not a viable solution [Ref 15].  Americans deserve pain management practices based on facts rather than sensationalism.


Dr. Charles Szyman trial: Jury finds ex-Manitowoc doctor not guilty of drug trafficking

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

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

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

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

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

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

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

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


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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

Have you had enough bullying, torture, abuse yet by non-healthcare professionals dictating your care ?














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

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

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

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

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

Here is four quotes from the CDC opiates guidelines:

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

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

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

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

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

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

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

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

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




Minnesota Doctors Face Opioid Prescribing Limits: TARGET… Medicaid pts

Minnesota Doctors Face Opioid Prescribing Limits

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

MINNEAPOLIS (AP) — A Minnesota task force has set new limits on opioid prescriptions by doctors who participate in the state’s Medicaid program.

The rule was adopted by the state’s Opioid Prescribing Work Group on Thursday but won’t take effect until they’re approved by the state human services commissioner, the Star Tribune reported .

Nonsurgical physicians and dentists can have no more than half of their opioid prescriptions exceed 100 morphine milligram equivalents, which is equivalent to about 20 Vicodin or Percocet pills at the typical 5 milligram strength. Surgeons will have a limit of 200 morphine milligram equivalents per outpatient prescription.

Studies show that many patients can recover from acute pain from surgeries or injuries with small initial doses of opioids, said Dr. Chris Johnson, an Allina Health physician who heads the task force.

“You … don’t need near as much as you think you do,” he said. 

Doctors who exceed the new limits for more than half of their patients will receive warnings and undergo training. They could eventually face removal from the Medicaid program if they don’t reduce their dosage amounts.

Medicaid covers about 20 percent of the state’s population.

The limits will only apply to outpatient prescriptions meant to manage short-term or acute pain.

The task force was created in 2015 to deal with a spike in Minnesota residents dying from prescription painkillers. A newspaper review of state death records found that more than 400 deaths were linked to opioids in 2016, more than double the number of deaths in 2006.

Sudden, Unexpected Death in Chronic Pain Patients

Sudden, Unexpected Death in Chronic Pain Patients

Severe pain, independent of medical therapy, may cause sudden, unexpected death. Cardiac arrest is the cause, and practitioners need to know how to spot a high-risk patient.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

War on drugs shifting gears: Cocaine deaths surge in South Florida

Cocaine deaths surge with rise of drug smuggling into South Florida

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


number of drug over dose deaths are JUST ESTIMATED ?

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

Preliminary estimates of U.S. drug overdose deaths exceeded 60,000 in 2016 and were partially driven by a fivefold increase in overdose deaths involving synthetic opioids (excluding methadone), from 3,105 in 2013 to approximately 20,000 in 2016 (1,2). Illicitly manufactured fentanyl, a synthetic opioid 50–100 times more potent than morphine, is primarily responsible for this rapid increase (3,4). In addition, fentanyl analogs such as acetylfentanyl, furanylfentanyl, and carfentanil are being detected increasingly in overdose deaths (5,6) and the illicit opioid drug supply (7). Carfentanil is estimated to be 10,000 times more potent than morphine (8). Estimates of the potency of acetylfentanyl and furanylfentanyl vary but suggest that they are less potent than fentanyl (9). Estimates of relative potency have some uncertainty because illicit fentanyl analog potency has not been evaluated in humans. This report describes opioid overdose deaths during July–December 2016 that tested positive for fentanyl, fentanyl analogs, or U-47700, an illicit synthetic opioid, in 10 states participating in CDC’s Enhanced State Opioid Overdose Surveillance (ESOOS) program.* Fentanyl analogs are similar in chemical structure to fentanyl but not routinely detected because specialized toxicology testing is required. Fentanyl was detected in at least half of opioid overdose deaths in seven of 10 states, and 57% of fentanyl-involved deaths also tested positive for other illicit drugs, such as heroin. Fentanyl analogs were present in >10% of opioid overdose deaths in four states, with carfentanil, furanylfentanyl, and acetylfentanyl identified most frequently. Expanded surveillance for opioid overdoses, including testing for fentanyl and fentanyl analogs, assists in tracking the rapidly changing illicit opioid market and informing innovative interventions designed to reduce opioid overdose deaths.

The 10 states reporting data abstracted information from preliminary death certificates and medical examiner/coroner reports on unintentional and undetermined opioid overdose deaths using standard definitions for variables. Data were entered into the State Unintentional Drug Overdose Reporting System (SUDORS), the component of ESOOS designed for tracking fatal opioid overdoses.§ For each death, available data on demographic characteristics, circumstances of the overdose collected from death scene investigations (e.g., evidence of illicit drug use), and results of forensic toxicology testing were entered into SUDORS. Opioid overdose deaths occurring during July–December 2016 with positive test results for fentanyl, fentanyl analogs, and U-47700 in 10 states are described, and key demographic and overdose circumstance factors are stratified by substance. Full toxicology findings of decedents were reviewed, including the presence of heroin, cocaine, and methamphetamine. Because heroin involvement in overdose deaths is difficult to distinguish from prescription morphine, deaths in which heroin was confirmed by toxicologic findings were combined with deaths in which heroin was suspected because morphine was detected and death scene evidence suggested heroin use. The use of medical examiner/coroner reports, previously unavailable across states, provides unique insights into specific substances and circumstances associated with overdoses, which can inform interventions.

Fentanyl was detected in 56.3% of 5,152 opioid overdose deaths in the 10 states during July–December 2016 (Figure). Among these 2,903 fentanyl-positive deaths, fentanyl was determined to be a cause of death by the medical examiner or coroner in nearly all (97.1%) of the deaths. Northeastern states (Maine, Massachusetts, New Hampshire, and Rhode Island) and Missouri** reported the highest percentages of opioid overdose deaths involving fentanyl (approximately 60%–90%), followed by Midwestern and Southern states (Ohio, West Virginia, and Wisconsin), where approximately 30%–55% of decedents tested positive for fentanyl. New Mexico and Oklahoma reported the lowest percentage of fentanyl-involved deaths (approximately 15%–25%). In contrast, states detecting any fentanyl analogs in >10% of opioid overdose deaths were spread across the Northeast (Maine, 28.6%, New Hampshire, 12.2%), Midwest (Ohio, 26.0%), and South (West Virginia, 20.1%) (Figure) (Table 1).

Fentanyl analogs were present in 720 (14.0%) opioid overdose deaths, with the most common being carfentanil (389 deaths, 7.6%), furanylfentanyl (182, 3.5%), and acetylfentanyl (147, 2.9%) (Table 1). Fentanyl analogs contributed to death in 535 of the 573 (93.4%) decedents. Cause of death was not available for fentanyl analogs in 147 deaths.†† Five or more deaths involving carfentanil occurred in two states (Ohio and West Virginia), furanylfentanyl in five states (Maine, Massachusetts, Ohio, West Virginia, and Wisconsin), and acetylfentanyl in seven states (Maine, Massachusetts, New Hampshire, New Mexico, Ohio, West Virginia, and Wisconsin). U-47700 was present in 0.8% of deaths and found in five or more deaths only in Ohio, West Virginia, and Wisconsin (Table 1). Demographic characteristics of decedents were similar among overdose deaths involving fentanyl analogs and fentanyl (Table 2). Most were male (71.7% fentanyl and 72.2% fentanyl analogs), non-Hispanic white (81.3% fentanyl and 83.6% fentanyl analogs), and aged 25–44 years (58.4% fentanyl and 60.0% fentanyl analogs) (Table 2).

Other illicit drugs co-occurred in 57.0% and 51.3% of deaths involving fentanyl and fentanyl analogs, respectively, with cocaine and confirmed or suspected heroin detected in a substantial percentage of deaths (Table 2). Nearly half (45.8%) of deaths involving fentanyl analogs tested positive for two or more analogs or fentanyl, or both. Specifically, 30.9%, 51.1%, and 97.3% of deaths involving carfentanil, furanylfentanyl, and acetylfentanyl, respectively, tested positive for fentanyl or additional fentanyl analogs. Forensic investigations found evidence of injection drug use in 46.8% and 42.1% of overdose deaths involving fentanyl and fentanyl analogs, respectively. Approximately one in five deaths involving fentanyl and fentanyl analogs had no evidence of injection drug use but did have evidence of other routes of administration. Among these deaths, snorting (52.4% fentanyl and 68.8% fentanyl analogs) and ingestion (38.2% fentanyl and 29.7% fentanyl analogs) were most common. Although rare, transdermal administration was found among deaths involving fentanyl (1.2%), likely indicating pharmaceutical fentanyl (Table 2). More than one third of deaths had no evidence of route of administration.



This analysis of opioid overdose deaths in 10 states participating in the ESOOS program found that illicitly manufactured fentanyl is a key factor driving opioid overdose deaths and that fentanyl analogs are increasingly contributing to a complex illicit opioid market with significant public health implications. Previous reports have indicated that use of illicitly manufactured fentanyl mixed with heroin, with and without users’ knowledge, is driving many fentanyl overdoses, particularly east of the Mississippi River (3,4). Consistent with these findings, at least half of opioid overdose deaths in six of the seven participating states east of the Mississippi tested positive for fentanyl. Over half the overdose deaths involving fentanyl and fentanyl analogs tested positive for confirmed or suspected heroin (the most commonly detected illicit substance), cocaine, or methamphetamine. This supports findings from other reports indicating that fentanyl and fentanyl analogs are commonly used with or mixed with heroin or cocaine (3,4). Nearly half of overdose deaths involving fentanyl and fentanyl analogs, however, did not test positive for other illicit opioids, suggesting that fentanyl and fentanyl analogs might be emerging as unique illicit products.

Fentanyl and fentanyl analogs are highly potent and fast-acting synthetic compounds that can trigger rapid progression to loss of consciousness and death and thus might require immediate treatment and high doses of naloxone (5). Because of the potency of fentanyl and fentanyl analogs and the rapid onset of action, these drugs were determined by medical examiners and coroners to play a causal role in almost all fatal opioid overdoses in which they were detected. Injection, the most commonly reported route of administration in fatal overdoses, exacerbates these risks because of rapid absorption and high bioavailability. The high potency of fentanyl and fentanyl analogs, however, can result in overdose even when administered via other routes. Nearly one in five deaths involving fentanyl and fentanyl analogs had evidence of snorting, ingestion, or smoking, with no evidence of injection. Multiple overdose outbreaks and law enforcement drug product submissions across the country have reported counterfeit prescription pills laced with fentanyl and fentanyl analogs (10).

With few exceptions, fentanyl analogs are illicitly manufactured, because they do not have a legitimate medical use in humans.§§ The detection of fentanyl analogs in >10% of opioid overdoses in four states raises the concern that fentanyl analogs have become a part of illicit opioid markets in multiple states. The fentanyl analogs most commonly detected were carfentanil, furanylfentanyl, and acetylfentanyl. Carfentanil, which is intended for sedation of large animals, is much more potent than fentanyl, whereas furanylfentanyl and acetylfentanyl are less potent (9). Carfentanil contributed to approximately 350 overdose deaths in Ohio, but was detected in only one other state (West Virginia). Because of its extreme potency, even limited circulation of carfentanil could markedly increase the number of fatal overdoses. Recent data suggest that carfentanil deaths are occurring in multiple other states, including Kentucky, which reported 10 overdose deaths involving carfentanil in the second half of 2016 (Kentucky Department of Public Health, unpublished data, 2017) and New Hampshire, which reported 10 deaths in 2017.¶¶ Forty-six percent of SUDORS opioid overdose deaths involving fentanyl analogs tested positive for fentanyl or an additional fentanyl analog, ranging from 31% for carfentanil to 97% for acetylfentanyl. The increased mixing or co-use of fentanyl, heroin, cocaine, and varying fentanyl analogs might contribute to increased risk for overdose because persons misusing opioids and other drugs are exposed to drug products with substantially varied potency.

The findings in this report are subject to at least five limitations. First, results are limited to 10 states and therefore might not be generalizable. Second, the presence of fentanyl analogs is underestimated because commonly used toxicologic testing does not include fentanyl analogs, some fentanyl analogs are difficult to detect (9), and specialized testing for fentanyl analogs varied across states and over time. Third, the route of fentanyl and fentanyl analog administration must be interpreted cautiously because the data do not link specific drugs to routes of administration and thus the precise route of administration of fentanyl or fentanyl analogs cannot be determined in overdose deaths involving multiple substances (e.g., heroin and cocaine) and routes (e.g., injection and snorting). Fourth, the combination of deaths with toxicologic confirmation of heroin with those with detection of morphine and death scene evidence suggesting heroin use might have resulted in misclassification of some deaths. Finally, fentanyl source could not be definitively determined; however, only a small percentage of fentanyl deaths had evidence consistent with prescription fentanyl (e.g., transdermal use versus injection).

Illicitly manufactured fentanyl is now a major driver of opioid overdose deaths in multiple states, with a variety of fentanyl analogs increasingly involved, if not solely implicated, in these deaths. This finding raises concern that in the near future, fentanyl analog overdose deaths might mirror the rapidly rising trajectory of fentanyl overdose deaths that began in 2013 and become a major factor in opioid overdose deaths. In response to this concern, CDC expanded ESOOS to 32 states and the District of Columbia in 2017 and added funding for all 33 recipients to improve forensic toxicologic testing of opioid overdose deaths to include capacity to test for a wider range of fentanyl analogs.*** Increased implementation of evidence-based efforts targeting persons at high risk for illicit opioid use, including increased access to medication-assisted treatment, increased availability of naloxone in sufficient doses, and other innovative intervention programs targeting this group, is needed to address a large and growing percentage of opioid overdose deaths involving fentanyl and fentanyl analogs.


Next Epidemic: Diabetes .. Family and emergency medicine Dr. Janette Nesheiwat discusses the rise of diabetes among Americans

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

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

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

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

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

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

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

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

November is National Diabetes Awareness Month.

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