A ophiophobic’s opinion why people dealing with acute or chronic pain should NOT BE GIVEN A OPIOID

Posted on April 14, 2025 by Pharmaciststeve

Short-sighted: Why the administration’s opioid plan won’t work

https://thehill.com/opinion/5247116-opioid-crisis-prevention/

by Chris Fox, opinion contributor  chris@nonopioidchoices.org  https://nonopioidchoices.org/

Last week, the Trump administration released a five-step plan to address the country’s opioid addiction crisis. The administration’s new drug czar’s plan focuses largely on attempts to prevent opioid-related overdose deaths.

It won’t work. Here’s why: The plan continues a years-old downstream focus on overdose death prevention and neglects the opportunity to prevent addiction in the first place.

In 2023, the last year for which we have full-year overdose data, 81,000 Americans died from an opioid-related overdose — an average of more than 220 deaths per day. Despite these staggering numbers, the administration’s plan primarily focuses on stopping the flow of illicit fentanyl into the U.S., relying on border control and punitive measures against drug cartels.

While addressing fentanyl trafficking is important, this approach tackles only one part of a far more complex problem. The reality is that overdose deaths remain high not only because of illegal fentanyl but also because millions of Americans continue to receive prescription opioids to manage postsurgical pain, whether they need them or not. In fact, as many as 90 percent of all surgical patients in the U.S. today receive an opioid prescription for post-operative pain.

The administration’s approach also touts increasing access to naloxone and medication-assisted treatment for opioid-use disorder, which are essential components of addiction treatment and overdose prevention. However, these measures are reactive, not proactive. They miss an important opportunity to prevent addiction before it starts by expanding non-opioid pain management options.

Current pain treatment protocols incentivize the use of generic prescription opioids. They do so because such medicines are cheap and well-known to health care professionals, and most patients will tolerate these medicines without incident.

However, some —  estimates show between 6 percent and 20 percent —  will misuse these medicines. Some may become addicted and move on to other illicit forms of opioids. Some will overdose. Some will die.

This overreliance on prescription opioids strips patients of real choices and unnecessarily increases the risk of long-term dependency. We have the tools to change the status quo.

We must change how we treat pain in this country and ensure that patients and health care providers have options when it comes to treating acute pain. The passage of the Non-Opioids Prevent Addiction in the Nation Act in 2022 was a major step forward, ensuring that non-opioid alternatives are available in outpatient surgical settings.

But there is more work to do.

We must ensure that all patients in all settings can easily access non-addictive pain treatment options. This is especially true for patients covered by Medicare Part D plans.

Earlier this year, legislation was introduced in Congress called the Alternatives to Prevent Addiction in the Nation Act. This critical legislation would make sure that patients can easily access non-opioid medications at the pharmacy counter.

The opioid addiction epidemic is far from over. Hundreds of Americans still die every day, and the crisis is evolving in ways that demand urgent action. Focusing solely on border control and fentanyl supply reduction ignores the deeper issue: how we manage pain in our health care system.

If we are serious about preventing addiction and saving lives, we must prioritize non-opioid choices — before it’s too late.

Every day we delay action, more patients are denied access to a non-opioid pain management tool. Recently, a major insurance company announced that it was making it more difficult for Americans to access non-opioids. We cannot stand idly by and let this happen.

This proposal would ensure that all patients can access non-opioid treatments in all settings. It can prevent addiction before it starts.

Congress has a chance to get ahead of this crisis — but only if they act now. Passing the act is a concrete step toward ensuring that patients have real choices in pain management. If we are serious about preventing addiction and saving lives, we must prioritize non-opioid choices.

We cannot afford to fight the opioid crisis with half measures.

Chris Fox is executive director of Voices for Non-Opioid Choices.

https://nonopioidchoices.org/about/members/

This article was appropriately noted as provided by: by Chris Fox, opinion contributor. I find the adjective OPINION very true, unfortunately, his opinion has very little to do with reality.

Generally, addiction is not caused by Opioids or some other substances that the person with pre-existing mental health issues. They have unknown- to them- “monkeys” on their back and/or “demons” in their head, and their interaction with some substance or activity will silence those “monkeys” or “demons”. They experience a “mental peace” they had no idea was possible. Depending on what statistic one wishes to believe, 0.6% to 3% of the people prescribed an opioid for acute or chronic pain will become addicted. It appears that this organization, Voices for Non-Opioid Choices believes that >97% of anyone dealing with acute or chronic pain should be denied effective, FDA-approved medications.

 

Recently, I asked www.perplexity.ai the following question: What comorbidities issues are generally involved with addiction?

Comorbidities associated with addiction, also known as substance use disorders (SUDs), are common and can significantly complicate treatment and recovery. These comorbidities span mental health disorders, medical conditions, and behavioral issues. Below is an overview of the most prevalent comorbidities:

Mental Health Disorders

  1. Depression and Anxiety Disorders: These are among the most frequent comorbid conditions. Many individuals use substances to self-medicate, which can create a vicious cycle of dependency12.

  2. Bipolar Disorder: Substance abuse often exacerbates mood instability in individuals with bipolar disorder13.

  3. Post-Traumatic Stress Disorder (PTSD): Trauma survivors may turn to substances to cope with distressing memories and emotions12.

  4. Personality Disorders:

    • Borderline Personality Disorder (BPD): Impulsivity and emotional dysregulation in BPD increase vulnerability to substance use.

    • Antisocial Personality Disorder (ASPD): Individuals with ASPD are more likely to engage in substance abuse due to impulsivity and disregard for societal norms13.

  5. Psychotic Disorders: Schizophrenia frequently co-occurs with SUDs, complicating treatment adherence and symptom management13.

Medical Conditions

  1. Infectious Diseases: Injection drug use is linked to a higher risk of HIV/AIDS and hepatitis.

  2. Cardiovascular Issues: Stimulant use can lead to hypertension, arrhythmias, and heart attacks.

  3. Liver and Gastrointestinal Problems: Chronic alcohol or drug use can cause liver damage and gastrointestinal disorders.

  4. Diabetes and Cancer: Addiction may exacerbate these systemic conditions by hindering proper management46.

Behavioral Disorders

  1. Eating Disorders: Conditions like anorexia, bulimia, and binge eating disorder often co-occur with SUDs due to shared risk factors such as low self-esteem13.

  2. Gambling Disorder: Both behaviors share underlying vulnerabilities in brain reward systems1.

Challenges in Diagnosis and Treatment

Diagnosing comorbidities is challenging due to overlapping symptoms, stigma, and limited integration between mental health and addiction treatment services. Untreated comorbidities often worsen outcomes by increasing relapse risks and reducing treatment effectiveness26.

Integrated Care Approach

Effective management requires a multidisciplinary approach that simultaneously addresses addiction and comorbid conditions through personalized treatment plans. This includes pharmacological interventions, psychotherapy, and social support systems tailored to individual needs12.

Addressing these comorbidities holistically improves recovery outcomes and enhances quality of life for individuals struggling with addiction.

Citations:

  1. https://www.serenityspringsrecovery.com/blog/common-comorbidities-with-substance-use-disorders/
  2. https://www.euda.europa.eu/spotlights/comorbid-substance-use-and-mental-health-problems_en
  3. https://www.unodc.org/documents/drug-prevention-and-treatment/UNODC_Comorbidities_in_drug_use_disorders.pdf
  4. https://footprintstorecovery.com/comorbid-medical-conditions-addiction/
  5. https://www.youtube.com/watch?v=5RbEotf0jqI
  6. https://thephoenixrc.com/blog/addiction-recovery/handling-comorbidities-with-substance-use-disorder/
  7. https://www.ncbi.nlm.nih.gov/books/NBK571451/
  8. https://nida.nih.gov/research-topics/co-occurring-disorders-health-conditions
  9. https://altacenters.com/addiction-resources/comorbidity/
  10. https://www.helpguide.org/mental-health/addiction/substance-abuse-and-mental-health

Answer from Perplexity: pplx.ai/share

 

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Private Equity’s Growing Role in Disability Care Demands Urgent Oversight

Posted on April 13, 2025 by Pharmaciststeve

Just imagine when a private equity company buys a company whose primary function is to provide medical care to mostly pts who are high acuity, complex, and most likely disabled. However, the primary function of private equity companies is to generate profits. One can only imagine what happens to the healthcare companies that they buy.

Private Equity’s Growing Role in Disability Care Demands Urgent Oversight

Patients are not lines on a balance sheet

https://www.medpagetoday.com/opinion/prescriptionsforabrokensystem/115074

Private equity (PE) has become a powerful and often invisible force reshaping how care is delivered across the country. A recent report from the Private Equity Stakeholder Projectopens in a new tab or window shines a light on one of the latest, and most concerningopens in a new tab or window, developments: the growing role of PE in services for people with intellectual and developmental disabilities (IDD).

This trend is alarming not just because of the populations involved, but because of what it reveals about how healthcare is increasingly being treated — not as a social good, but as a business opportunity ripe for financial exploitation.

The Lifeline of Medicaid-Funded IDD Services

Many of the services supporting individuals with IDD — residential facilities, home care, adult day programs, physical and occupational therapy, and more — are funded primarily through Medicaidopens in a new tab or window. For nearly 10 million Americans with IDD, these programs represent far more than care: they are the foundation of daily life, independence, and survival. Historically, these services have been provided primarily by non-profits and religious organizations.

And yet, as PE firms continue to acquire companies that provide these services, we must ask a difficult question: What happens when profitability becomes harder to maintain, especially when Medicaid dollars are cut or restrictedopens in a new tab or window? The answer, based on past precedent in other areas of healthcare, is not promising.

The PE Playbook: High Returns, Low Transparency

PE firms generally operate on a 4-to-7-year investment horizon. Their goal is generally to double or triple returns during that short window. In order to get results quickly, PE firms often resort to significant cost-cutting, rapid scaling, and creating “operational efficiency.” In sectors with strong commercial margins, this approach might be sustainable. But in IDD care — an underfunded, labor-intensive space that relies heavily on government reimbursement — this model could result in real harm.

According to the Private Equity Stakeholder Project’s report, PE firms are already applying their traditional cost-saving strategies in IDD. They are reducing staffing levels, relying on lower-paid and less-trained workers, eliminating oversight roles, and prioritizing rapid expansion. The result? Allegations of substandard care, including abuse and neglect, abound and are being investigated by federal and state lawmakers.

The changes put in place by PE firms might boost margins in the short term, but they undermine quality, safety, and continuity — the very pillars of care for individuals with IDD.

And let’s not forget: these significant policy changes will affect vulnerable individuals with lifelong needs, who are often unable to advocate for themselves and are reliant on stable, skilled, and compassionate care teams. Additionally, people with IDD already experience significant health and social inequities. They face shorter life expectancies, higher rates of chronic illness, increased mental health challenges, and greater risk of pregnancy complications. These disparities are rooted in structural barriers, including difficulty accessing care, lack of provider training, and social marginalization.

Now layer on top a business model that prioritizes efficiency over empathy and returns over relationships, and the risks become unacceptable. Indeed, the shift from mission-driven nonprofits and religiously affiliated organizations to profit-maximizing investors represents a fundamental change in how care is conceptualized and delivered — and it is a terrible shift.

We Have Seen This Before

As I have written in MedPage Todayopens in a new tab or window, private equity is not inherently bad. When firms are responsible and transparent, they can fuel innovation, expand access, and help modernize outdated systems. But when left unchecked, firms’ incentives are often misaligned with the core mission of healthcare: to care for people.

This argument is not speculative.

In fact, we have seen the negative effects of PE in emergency medicineopens in a new tab or window, where PE-backed staffing firms have contributed to burnout and dissatisfaction among clinicians. We have seen it too in nursing homesopens in a new tab or window, where aggressive cost-cutting has coincided with drops in quality and oversight. And we are seeing PE expand into behavioral healthopens in a new tab or window, where providers under financial strain are already stretched too thin to meet patient needs. Health policy researchers, patient advocacy groups, and providers worry that similar quality declines will be seen in mental health care with PE acquisitions.

What is unfolding in the IDD space has all the same warning signs, but with even higher stakes.

If we are serious about protecting people with IDD and about ensuring our healthcare system upholds the dignity of those who need it most, we must act now. We must:

  • Require PE firms to disclose ownership structures and report quality outcomes in IDD settings
  • Strengthen federal and state oversight to ensure that care quality, not just financial returns, is being measured
  • Mandate regulatory review before PE firms can purchase entities serving vulnerable populations
  • Set minimum staffing ratios and require specialized training for caregivers in IDD services
  • Encourage financial firms to invest with integrity, prioritizing people over profits in high-impact areas like disability care

Healthcare is not a commodity, and people with disabilities are not lines on a balance sheet. When profit is prioritized over people, we do not just lose efficiency, we lose trust, compassion, and the fundamental integrity of care. If we are not vigilant, the most vulnerable will pay the highest price for someone else’s financial gain.

 

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Who will the new chronic pain pts be tomorrow?

Posted on April 13, 2025 by Pharmaciststeve


It is claimed that there are some 50,000 new chronic pain pts every year – that is about 140/day… that is about SIX EVERY HOUR – 24/7/365!

How many of your family, friends, or neighbors will become a chronic pain pt in the next day?  Could you become a chronic pain pt in the next 24 hrs?  All it takes is one serious accident that may or may not be your fault. What is even worse is that most of those 50,000 people will discover that our healthcare system doesn’t want to be the intensity of the pt’s pain nor will be willing to treat their pain for more than MAYBE just a few days.

Today, many chronic pain pts have been basically put under HOUSE ARREST because they receive inadequate pain management that most of their days, they spend laying in bed or a couch and/or sitting in a chair. 

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The Era of Compounded GLP-1 Drugs Is Over. What Now?

Posted on April 12, 2025 by Pharmaciststeve

The Era of Compounded GLP-1 Drugs Is Over. What Now?

https://www.medscape.com/viewarticle/era-compounded-glp-1-drugs-over-what-now-2025a10008kq

Now that the US Food and Drug Administration has removed both tirzepatide and semaglutide from its Drug Shortages List, the widespread compounding of these drugs is ending. Tirzepatide’s deadline has already passed, while physicians and pharmacies have until April 22 for semaglutide. An estimated 2 million Americans have been using these more affordable copycats every month.

Even with direct-to-consumer discounts, monthly doses of brand-name versions cost hundreds more than compounded ones, putting them beyond the reach of many people. This means a significant number of compounded glucagon-like peptide 1 (GLP-1) users will be forced to go cold turkey — but studies consistently show weight regain when patients stop taking them abruptly. So how can you help your patients?

Forced Off GLP-1s

While published research into best practices for discontinuing the use of GLP-1s is scant, accessibility and price issues have already forced physicians and patients to devise workarounds. Not everyone was willing to rely on the compounded versions, after all. And some who succeeded on a brand name were reluctant to spend that much money every month for the rest of their lives.

As a result, anecdotal information already exists about tactics like stretching out the time between injections, tapering the dosage, and adding strength training to patients’ exercise routines.

photo of Jennifer Manne Goehler
Jennifer Manne-Goehler, MD

“Anecdotally, some doctors and patients are being forced into this,” said Jennifer Manne-Goehler, MD, a researcher at Harvard Medical School, Boston, and the lead author of a paper in JAMA Internal Medicine that looked at what we know about off-ramping these drugs.

“I get messages from people saying, ‘Do you think microdosing is okay?’ or, ‘I had a patient who ran out, or they couldn’t get more tirzepatide, so they started taking it every other week,’” she said.

So far, success seems to be dependent on the individual patient’s level of motivation and their ability to commit to lifestyle changes. Regular communication with the patient goes a long way toward determining what might work.

“Subjectively, patients know when things are working for them or not,” said Jeremy Korman, MD, medical director of the Cedars Sinai Marina Weight Management Center in Marina del Rey, California. “That’s a way, without any concrete algorithm, that I work with my patients who’ve reached a target weight. We start using those subjective measures of hunger and cravings and tapering in that way, whether it’s tapering on time interval or tapering on dose.”

Slow Tapering May Work

Last year, researchers presented findings on a slow tapering method at the European Congress on Obesity. When participants reached their goal weight, their dosage was gradually reduced over an average of 9 weeks while they continued with coaching on diet and exercise. Data was available for 85 participants — 6 months after tapering to zero, and their weight remained stable.

“Because they’ve engaged in some of the lifestyle changes, when they eventually taper off, they keep the weight off without semaglutide,” lead researcher Henrik Gudbergsen, MD, told Medscape Medical News at the time. “I think there’s a strong linkage between the initial phase of using this medication with lifestyle changes and actually being capable of keeping the kilos off once they’ve stopped.”

Given the small number of participants, more research is necessary. But those initial results are promising, Korman said.

“The European study, tapering over 9 weeks, is very interesting,” Korman said. “The original studies just stopped the medication, and all the weight came back. We still have to be a little skeptical, even if we taper properly, that it’s going to be as durable as we hope. It could be, but it’s very early on.”

Of course, the end of mass-produced compounded GLP-1s is less than 9 weeks away. But in Reddit discussions among compounded tirzepatide users, many said they have stockpiled a supply, enough to last for months. A slow taper could work for them. For those without a ready supply, a short-term prescription for a brand-name GLP-1 might do the trick.

Turn to Older Generation Weight-Loss Drugs

Another option that shows potential is simply migrating from a GLP-1 to an older generation, generic version of an anti-obesity medication. A study in the December issue of Obesity followed patients on this protocol. Out of an initial group of 105 participants, 40 used a GLP-1 medication for 12 months to reach a body mass index of less than 30, then transitioned to generic phentermine, phentermine/topiramate, topiramate, metformin, bupropion, and/or naltrexone. They maintained their initial weight loss for up to 2 years when the study ended.

photo of Gitanjali Srivastava
Gitanjali Srivastava, MD

Gitanjali Srivastava, MD, medical director at Vanderbilt Obesity Medicine in Nashville, Tennessee, co-authored the study. She compared this approach to cancer treatment: If a patient comes in with an aggressive tumor, the oncologist might use expensive therapies to decrease the size of the tumor burden. Once that’s achieved, the oncologist can move the patient to less intense, less costly therapies.

“In the same way, when we think about obesity as a disease process, patients with severe obesity have a very high disease burden,” she said. “With GLP-1 medications, you’re shrinking the size of that disease burden, then exposing them to the older generation armoire.”

She’s been using this approach in her practice for several years.

“Even though the GLP-1 drug classes have created hype, I don’t think we should forget some of these older-generation medications that are less expensive, that patients still do really well on and respond very favorably to, if there are no contraindications,” she said. “For instance, metformin is free at Publix. Topiramate is just a few dollars. A combination of phentermine and topiramate, which is sold under the brand name Qsymia, you can get for less than $20 a month.”

Discoveries Still to Come

With so many patients being forced off compounded GLP-1s at once, we’re likely to learn a lot about what helps — and what does not — to maintain a substantial weight loss. One thing will almost certainly be a crucial factor: Guiding patients toward a healthier lifestyle in general.

“Regardless of what treatment we give a patient, even with surgery, our weight loss outcomes and the durability of them depend on lifestyle modification,” Korman said. “That has to be the foundational concept. If we’re just going to rely on the meds, and we’re not going to commit to that, nothing is going to work.”

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The enforcement of all our laws seems to depend who is in charge of enforcing them.

Posted on April 12, 2025 by Pharmaciststeve

I shared this article on April 7, 2025, referencing our Fed AG Jan 31, 2019 decision. This was during President Trump’s administration. It is typical for these things to take some time to reach a conclusion. But preceding this date, several people held the office of AG or acting AG, which led up to this conclusion.   Jeff Sessions, Rod Rosenstein, Matthew Whitaker   Below that link to the article, I am sharing the information provided by perplexity.ai when I asked it: what comorbidities issues are generally involved with addiction.

I asked perplexity.ai what the DOJ has done regarding discrimination of pts with SUD/OUD since Jan 2019, and it came up with NADA. With our new Fed AG Pam Bondi, I doubt if she will pursue anything as well. I guess we have another law that is enforced at the discretion of  “who is in power.”

DOJ Considers Opioid Use Disorder an ADA Covered Disability and Pursues Claims Against a Provider for Refusing Medical Services to Opioid Users

what comorbidities issues are generally involved with addiction

Comorbidities associated with addiction, also known as substance use disorders (SUDs), are common and can significantly complicate treatment and recovery. These comorbidities span mental health disorders, medical conditions, and behavioral issues. Below is an overview of the most prevalent comorbidities:

### **Mental Health Disorders**
1. **Depression and Anxiety Disorders**: These are among the most frequent comorbid conditions. Many individuals use substances to self-medicate, which can create a vicious cycle of dependency[1][2].
2. **Bipolar Disorder**: Substance abuse often exacerbates mood instability in individuals with bipolar disorder[1][3].
3. **Post-Traumatic Stress Disorder (PTSD)**: Trauma survivors may turn to substances to cope with distressing memories and emotions[1][2].
4. **Personality Disorders**:
– **Borderline Personality Disorder (BPD)**: Impulsivity and emotional dysregulation in BPD increase vulnerability to substance use.
– **Antisocial Personality Disorder (ASPD)**: Individuals with ASPD are more likely to engage in substance abuse due to impulsivity and disregard for societal norms[1][3].
5. **Psychotic Disorders**: Schizophrenia frequently co-occurs with SUDs, complicating treatment adherence and symptom management[1][3].

### **Medical Conditions**
1. **Infectious Diseases**: Injection drug use is linked to a higher risk of HIV/AIDS and hepatitis.
2. **Cardiovascular Issues**: Stimulant use can lead to hypertension, arrhythmias, and heart attacks.
3. **Liver and Gastrointestinal Problems**: Chronic alcohol or drug use can cause liver damage and gastrointestinal disorders.
4. **Diabetes and Cancer**: Addiction may exacerbate these systemic conditions by hindering proper management[4][6].

### **Behavioral Disorders**
1. **Eating Disorders**: Conditions like anorexia, bulimia, and binge eating disorder often co-occur with SUDs due to shared risk factors such as low self-esteem[1][3].
2. **Gambling Disorder**: Both behaviors share underlying vulnerabilities in brain reward systems[1].

### **Challenges in Diagnosis and Treatment**
Diagnosing comorbidities is challenging due to overlapping symptoms, stigma, and limited integration between mental health and addiction treatment services. Untreated comorbidities often worsen outcomes by increasing relapse risks and reducing treatment effectiveness[2][6].

### **Integrated Care Approach**
Effective management requires a multidisciplinary approach that simultaneously addresses addiction and comorbid conditions through personalized treatment plans. This includes pharmacological interventions, psychotherapy, and social support systems tailored to individual needs[1][2].

Addressing these comorbidities holistically improves recovery outcomes and enhances quality of life for individuals struggling with addiction.

Citations:
[1] https://www.serenityspringsrecovery.com/blog/common-comorbidities-with-substance-use-disorders/
[2] https://www.euda.europa.eu/spotlights/comorbid-substance-use-and-mental-health-problems_en
[3] https://www.unodc.org/documents/drug-prevention-and-treatment/UNODC_Comorbidities_in_drug_use_disorders.pdf
[4] https://footprintstorecovery.com/comorbid-medical-conditions-addiction/
[5] https://www.youtube.com/watch?v=5RbEotf0jqI
[6] https://thephoenixrc.com/blog/addiction-recovery/handling-comorbidities-with-substance-use-disorder/
[7] https://www.ncbi.nlm.nih.gov/books/NBK571451/
[8] https://nida.nih.gov/research-topics/co-occurring-disorders-health-conditions
[9] https://altacenters.com/addiction-resources/comorbidity/
[10] https://www.helpguide.org/mental-health/addiction/substance-abuse-and-mental-health

—
Answer from Perplexity: pplx.ai/share

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FULL HEARING: Facebook Whistleblower Testifies Before Senate Judiciary Committee

Posted on April 11, 2025 by Pharmaciststeve

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Beyond Medical Paternalism: Restoring Control to the Individual

Posted on April 7, 2025 by Pharmaciststeve

Beyond Medical Paternalism: Restoring Control to the Individual

https://www.cato.org/free-society/spring-2025/beyond-medical-paternalism-restoring-control-individual

Heavy-handed government policies often undermine patient autonomy, restricting the medicines they can take, the doctors they can see, and the information they can access.

rom the earliest days of their training, health professionals are taught the critical ethical principle of respecting their patients’ autonomy. But in the broader realm of public policy, that principle often gets trampled under the weight of bureaucracy.

Government agencies frequently dictate which doctors a patient can see, restrict access to new medications, and even regulate the information pharmaceutical companies can share with consumers.

Autonomy in health care is not just an academic ideal. It’s about empowering individuals to make decisions about their lives, their bodies, and their well-being. But while doctors are bound by the principle of informed consent, government policies often assume that individuals are incapable of making informed choices about their own health.

A Shift in Medical Ethics: From Paternalism to Informed Consent

The doctrine of informed consent—the right to accept or refuse medical treatment even at personal risk—is a relatively modern concept. Barely a century ago, it was commonly accepted that doctors could do whatever they thought was in the best interests of their patients, regardless of a patient’s wishes or priorities.

Dr. Jeff Singer in Scrubs

Dr. Jeffrey Singer, who has worked in private practice as a general surgeon for over 35 years, at his medical office in Phoenix. (Photo by Duane Furlong Studios)

This model of care sometimes had tragic results. From 1932 to 1972, the Tuskegee Syphilis Study saw government health agencies withhold treatment from nearly 400 black men to observe the progression of the disease while intentionally not informing participants that a cure for the disease existed. Even as late as the 1970s, some doctors routinely withheld diagnoses from cancer patients, fearing the emotional impact would derail treatment.

“Today, informed consent is a cornerstone of the patient-doctor relationship. But outside the exam room, government policies often ignore this principle, restricting individual autonomy in profound ways.”

Today, informed consent is a cornerstone of the patient-doctor relationship. But outside the exam room, government policies often ignore this principle, restricting individual autonomy in profound ways.

Barriers to Choice: Licensing Laws and Monopolies

State licensing laws, originally framed as a means of protecting public health, now often serve as barriers to patient choice. In the 19th century, the American Medical Association lobbied aggressively for laws that restricted entry into the medical profession. Over time, similar restrictions spread to other health professions, creating a complex web of regulations that limits competition and stifles innovation.

This dynamic is evident in the turf battles that play out in state legislatures, where professional groups vie to protect their monopoly over specific practices. Patients are left with fewer options, and the assumption persists that the government knows better than individuals who should provide their care.

But as economist Milton Friedman noted, licensing laws rarely ensure quality care. Instead, they raise costs and limit access. Private accrediting organizations could fill this role, providing certifications that help patients make informed choices while opening the door to greater competition and innovation.

“Without [medical licensing], they would have no power to do harm,” Friedman told a group of medical professionals at the Mayo Clinic in 1978. “Why is that the case? Because the key to the control of medicine starts with who is admitted to practice.”

The Freedom to Access Information

Health and Human Services Secretary Robert F. Kennedy Jr., who was nominated by President Trump with a mandate to “Make America Healthy Again,” has argued passionately against the “priesthood” of the medical establishment, calling for greater transparency and personal responsibility in health care. Yet he supports banning direct-to-consumer advertising by pharmaceutical companies—a move that would restrict patients’ ability to access vital information about treatment options.

The US Supreme Court has repeatedly affirmed that the First Amendment protects the free exchange of scientific information. Prohibiting pharmaceutical ads would make clinicians the sole gatekeepers of knowledge, further disempowering patients. Policymakers should reject such bans and embrace policies that enhance transparency and trust.

Ending the Prescription Monopoly

Since 1938, the federal government has controlled which medications Americans can legally purchase. In 1951, Congress expanded that authority, requiring prescriptions for certain drugs—a decision previously made by pharmaceutical companies. While intended to protect public health, this policy has driven up costs, delayed access to life-saving treatments, and forced patients to navigate unnecessary bureaucratic hurdles.

Patients in other countries often access medications over the counter that require a prescription in the United States. Reforming this system—whether through small changes or sweeping overhauls—could help restore patient autonomy and reduce health care costs without compromising safety.

The Right to Choose Substances

Prohibition didn’t work for alcohol, and it hasn’t worked for drugs. Yet for over a century, government policies have criminalized substances for medical and recreational use, creating black markets and fueling violence.

In many cases, driving these drugs underground makes them far more dangerous and deadly. For example, opioids, when used responsibly, are less harmful to organ systems than alcohol or tobacco. But prohibition has pushed these drugs into the black market, where adulteration and unknown potency make them far more dangerous.

More recently, lawmakers have set their sights on food additives. Proposals like the Do or Dye Act and the Stop Spoonfuls of Fake Sugar Act aim to ban certain dyes and sweeteners. Instead of letting consumers make their own choices, these measures would increase costs and limit freedom—all while ignoring policies that drive the use of cheaper additives, such as agricultural subsidies and import tariffs on sugar that incentivize the use of high-fructose corn syrup.

Embracing Harm Reduction

Harm reduction is a pragmatic approach to health care that seeks to minimize the risks associated with certain behaviors without endorsing them. It’s why doctors prescribe medications for smoking cessation or manage chronic conditions linked to lifestyle choices.

But federal and state laws often block harm-reduction strategies for drug users. In five states, distributing fentanyl test strips—tools that can detect lethal contaminants—is illegal. A federal law known as the “crack house statute” prohibits overdose prevention centers, where drug users are monitored and opioid antidotes and oxygen administered. Such centers have saved lives in 16 countries since 1986.

These policies not only infringe on personal autonomy but also exacerbate the problems they claim to address. By embracing harm reduction, policymakers could save lives and empower individuals to make safer choices.

Toward a Healthier, Freer Future

In my forthcoming book, Your Body, Your Health Care (Cato Institute, April 2025), I explore the many ways government paternalism has eroded personal autonomy, often with devastating consequences. Restoring this autonomy isn’t just a matter of principle—it’s a path to better health outcomes and a freer society.

If the Trump administration is serious about “making America healthy again,” its first priority should be to return control to the individual.

Filed under: General Problems | 1 Comment »

DOJ Considers Opioid Use Disorder an ADA Covered Disability and Pursues Claims Against a Provider for Refusing Medical Services to Opioid Users

Posted on April 7, 2025 by Pharmaciststeve

According to this article, Selma Medical had a policy to not prescribe narcotic controlled substances to any pts. This was SIX YEARS ago, why has there not been a lot of lawsuits against practitioners that refuse/decline to treat pts whose health issues require the use of  opioids?

DOJ Considers Opioid Use Disorder an ADA Covered Disability and Pursues Claims Against a Provider for Refusing Medical Services to Opioid Users

https://www.healthlawadvisor.com/doj-considers-opioid-use-disorder-an-ada-covered-disability-and-pursues-claims-against-a-provider-for-refusing-medical-services-to-opioid-users

The U.S. Department of Justice reached a January 31, 2019 settlement of an American with Disabilities Act (“ADA”) Title III complaint against health care provider Selma Medical Associates relating to provision of medical services to an individual with opioid use disorder (“OUD”).  The settlement is notable for health care providers and employers as it makes clear that DOJ considers OUD as a disability under the ADA thereby triggering the full panoply of ADA rights for those with OUD.

The DOJ complaint was premised on the alleged refusal of Selma Medical to schedule a new patient family practice appointment after the patient disclosed he takes Suboxone.  Suboxone is a prescription medication approved by the Food and Drug Administration for treating OUD.  The complaint further alleged that Selma refused to treat patients with narcotic controlled substances, including Suboxone, thus imposing “eligibility criteria that screen out or tend to screen out individuals with OUD.”  The compliant also alleged a failure to make reasonable accommodations to policies, practices or procedures when necessary “to afford such goods, services, facilities, privileges, advantages, or accommodations to individuals with disabilities.”

Under the settlement, Selma agreed to:

  1. Not discriminate or deny services on the basis of disability, including OUD;
  2. Not use eligibility standards, criteria or methods of administration that tend to deny benefits on the basis of disability including OUD;
  3. To modify its policies as necessary;
  4. To draft and submit within 30 days for DOJ approval a non-discrimination policy and to remove any inappropriate existing policies;
  5. After DOJ approval, to adopt and disseminate to all employees the new non-discrimination policy;
  6. To train all management and employees within 60 days and annually for three years as to the new policy and ADA compliance with the initial training conducted live, with a Q&A opportunity, and by a trainer to be approved by DOJ;
  7. Submit compliance reports to DOJ for three years; and
  8. To pay compliant $30,000 in damages and a civil penalty to the U.S. of $10,000.

The DOJ-Selma Medical settlement is highly significant in an environment where in 2015, OUD affected 2 million people aged 12 and over (Drug and Alcohol Dependence, Vol. 169, Dec. 2016, pp. 117-127) and .6 million persons aged 12 or over had heroin use disorder (id.) and the lifetime percentage of individuals with Diagnostic and Statistical Manual-IV prescription OUD among adults 18 and over had more than doubled from 1.4% in 2001-2002 to 2.9% in 2012-2013 (id.), and likely higher today.  And, of course, this does not include those who are OUD for reasons other than prescriptions.  This means that health care providers are highly likely to encounter significant numbers of potentially challenging OUD patients.  DOJ has now made clear that providing the full range of care and services to such patients is required under the ADA – and that any failure to do so can lead to litigation, costly settlements and adverse publicity.

All employers, not just health care providers, should take note of this settlement as it clearly means that employers will also need to reasonably accommodate employees who seek time off for treatment or other accommodations unless the employer cannot show the requested accommodations would be an undue hardship.

The Selma Medical settlement is also a reminder that health care providers should make sure they have appropriate non-discrimination policies in place as required pursuant to Health and Human Services regulations for compliance under Title III of the ADA, the Rehabilitation Act of 1973, and the non-discrimination requirements of Section 1557 of the Affordable Care Act.  We can assist with any questions regarding the required policies and other issues as to compliance with the ADA, the Rehab Act and Section 1557.

Filed under: General Problems | 6 Comments »

Don’t let the facts get in the way and interfere with your agenda

Posted on April 6, 2025 by Pharmaciststeve

I asked www.perplexity.ai the following fairly (IMO) complex question. It looked at 58 different sources to come up with this answer/explanation.  It has been several years since the DEA has published what they were spending to fight the war on drugs. Recent estimates are that it is 120 – 140 million/yr. I have read recently that the 1970 CSA directed the DEA to deal with the diversion of pharma opioids. That might explain why we don’t see the DEA involved with all the illegal opioids and various illegal substances showing up on our streets. Our DEA is part of our FED DOJ, and they have an array of laws they are in charge of enforcing, and sometimes their interpretation(s) of the laws. Which our SCOTUS declared a year ago that Fed agencies do not have the statutory authority to make new interpretations of the laws they are in charge of enforcing. SCOTUS has no authority to enforce our laws. That is the duty of the DOJ. Unfortunately, many bureaucrats and politicians seem to work under the premise that “no one is above the law… except those who are in charge of enforcing our laws”. So, those entities that choose to enforce or ignore our laws can pretty much establish their own agenda. Their agenda prevails, and the FACTS are just ignored, and “experts” come forward to contradict and deny the facts are untrue and/or meaningless.

Most of your footnotes reference the use of opioids and treating SUD. Little/no deal with treating chronic pain. A couple of years ago the DEA stated that < 1% of pharma opioids were being diverted, but followed up by reducing pharma production quota. The National agreement was a mediated agreement – no court case. It would seem that there was no consideration of those agreements causing chronic pain patients to have access to their prescribed, medically necessary medications. Who determines what adequate pain therapy is? The vast majority of OD/poisoning is with opioids. The illegal opioids are known to be coming primarily from China & Mexican cartels. Over the last decade, pharma opioid production quotas have been reduced > 50%, and yet OD/poisoning is up 6-7 times. Are politicians & bureaucrats ignoring the real source of OD/poisoning – illegal opioids?

The opioid overdose crisis has shifted dramatically toward illicit synthetic opioids like fentanyl, yet policy and regulatory responses often lag behind this reality. Here’s an analysis of the disconnect between the current overdose drivers and policy focus:

—

### **1. Overdose Trends vs. Policy Focus**
– **Illicit opioids dominate deaths**: Over 80% of opioid-related deaths now involve illicitly manufactured fentanyl, with China supplying precursors and Mexican cartels producing/distributing the drug ([4][5][8]). Meanwhile, pharmaceutical opioid prescriptions have declined by over 50% since 2012 ([9]).
– **Policy emphasis persists on prescription opioids**: Recent settlements (e.g., 2022 distributor agreement) and 2025 DEA regulations ([3]) continue targeting pharmaceutical supply chains, despite <1% diversion rates for prescription opioids ([8]). These policies risk restricting access for chronic pain patients without addressing the primary overdose driver: illicit fentanyl.

—

### **2. Chronic Pain Patient Challenges**
– **Stricter quotas and oversight**: The DEA’s 2025 opioid production quotas and CMS care coordination edits (90 MME/day threshold) prioritize reducing prescription volumes ([3]). However, guidelines still emphasize **individualized care**, noting opioids may be appropriate for some chronic pain patients when benefits outweigh risks ([1][2]).
– **Documentation burdens**: Physicians face increased administrative requirements to justify opioid therapy, which can delay or deter treatment for legitimate patients ([1]).

—

### **3. Political and Regulatory Blind Spots**
– **Partisan divides**:
– **Democrats** increasingly focus on pharmaceutical accountability and treatment access ([10]), which risks overemphasizing prescription opioids’ role.
– **Republicans** prioritize border security and illicit drug interdiction ([10]), but underfund harm reduction strategies (e.g., naloxone distribution, overdose prevention centers) proven to save lives ([6][7]).
– **International policy gaps**: While China and Mexico are central to fentanyl production, U.S. efforts to disrupt supply chains remain inconsistent. China’s 2019 fentanyl ban reduced direct exports but not precursor flows, and Mexican enforcement varies by administration ([4][5][8]).

—

### **4. Data vs. Action**
– **Overdose deaths vs. prescription trends**: Between 2012 and 2025:
– Pharmaceutical opioid prescriptions dropped by ~60% ([3][9]).
– Overdose deaths increased 6-7x, driven by illicit fentanyl ([7][8]).
– **Misaligned solutions**: Funding from opioid settlements often supports law enforcement rather than addiction treatment or pain management programs ([7][10]). For example, only 12% of settlement funds in 2023–2024 were allocated to harm reduction or patient care ([7]).

—

### **5. Who Decides “Adequate Pain Therapy”?**
– **Guidelines vs. reality**: The CDC’s 2022 guidelines ([2]) and state policies ([1]) delegate decisions to clinicians but impose structural barriers (e.g., dosage caps, prior authorization). This creates a “chilling effect,” where physicians avoid opioids even for appropriate cases due to liability concerns.
– **Patient exclusion**: Chronic pain advocacy groups report being sidelined in policy discussions, with settlement negotiations ([3][8]) and legislation ([10]) prioritizing public health agencies and law enforcement over patient representatives.

—

### **Conclusion**
Politicians and regulators are disproportionately focused on legacy issues tied to prescription opioids, despite overwhelming evidence that illicit fentanyl drives the overdose crisis. Chronic pain patients face collateral damage from restrictive policies, while harm reduction and international supply-chain interventions remain underprioritized. Effective solutions require:
– Reallocating settlement funds to **patient access programs** and **illicit drug interdiction**.
– Pressure on China and Mexico to disrupt precursor networks ([4][8]).
– Revisiting CDC/DEA guidelines to prevent nonmedical opioid use without penalizing legitimate patients ([1][2][3]).

Until policymakers confront the synthetic opioid pipeline and balance supply-side enforcement with patient-centered care, overdose rates will likely remain elevated.

Citations:
[1] https://www.mbc.ca.gov/Download/Publications/pain-guidelines.pdf
[2] https://www.cdc.gov/overdose-prevention/hcp/clinical-guidance/recommendations-and-principles.html
[3] https://titangroupdea.com/blog/new-opioid-regulations-pain-management-specialists-need-to-know-about-2025?hsLang=en
[4] https://www.brookings.edu/articles/the-fentanyl-pipeline-and-chinas-role-in-the-us-opioid-crisis/
[5] https://www.npr.org/2025/02/02/nx-s1-5283957/fentanyl-trump-tariffs-china-canada-mexico
[6] https://www.thinkglobalhealth.org/article/how-overdose-prevention-centers-became-political-scapegoats
[7] https://www.npr.org/2023/12/28/1220881380/overdose-fentanyl-drugs-addiction
[8] https://www.cfr.org/backgrounder/fentanyl-and-us-opioid-epidemic
[9] https://pmc.ncbi.nlm.nih.gov/articles/PMC5565130/
[10] https://ldi.upenn.edu/our-work/research-updates/partisan-politics-and-the-opioid-epidemic-a-social-media-analysis/
[11] https://www.humhealth.com/blog/chronic-pain-management-cpt-codes-and-billing-guide-2025/
[12] https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
[13] https://www.aafp.org/family-physician/patient-care/care-resources/pain-management/aafp-chronic-pain-management-toolkit.html
[14] https://docrx.com/2025-billing-updates-for-non-opioid-pain-treatments-key-takeaways-for-healthcare-providers/
[15] https://www.ncbi.nlm.nih.gov/books/NBK92054/
[16] https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/opioid-prescribing.html
[17] https://nacns.org/wp-content/uploads/2025/02/Pain-Management_2025_02_04_FINAL-.pdf
[18] https://www.azdhs.gov/documents/prevention/womens-childrens-health/injury-prevention/opioid-prevention/appendix-b-state-by-state-summary.pdf
[19] https://end-overdose-epidemic.org/wp-content/uploads/2020/07/Principles-of-Evidence-Informed-Pain-Care-FINAL_template-1.pdf
[20] https://painmed.org/clinical-guidelines/
[21] https://www.ncbi.nlm.nih.gov/books/NBK572085/
[22] https://www.ncbi.nlm.nih.gov/books/NBK553030/
[23] https://www.ncbi.nlm.nih.gov/search/research-news/19707
[24] https://www.congress.gov/event/118th-congress/house-event/115371/text
[25] https://www.dea.gov/sites/default/files/2020-03/DEA_GOV_DIR-008-20%20Fentanyl%20Flow%20in%20the%20United%20States_0.pdf
[26] https://www.wilsoncenter.org/article/lab-overdose-synthetic-opioid-crisis-shaping-us-mexico-agenda
[27] https://www.dea.gov/sites/default/files/2024-05/NDTA_2024.pdf
[28] https://www.pa.gov/agencies/ddap/overdose/opioid-overdose.html
[29] https://www.cbp.gov/border-security/frontline-against-fentanyl
[30] https://www.samhsa.gov/find-help/helplines/national-helpline
[31] https://www.whitehouse.gov/presidential-actions/2025/02/imposing-duties-to-address-the-flow-of-illicit-drugs-across-our-national-border/
[32] https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates
[33] https://fsi.stanford.edu/sipr/fentanyl-blame-game
[34] https://www.dea.gov/resources/facts-about-fentanyl
[35] https://pmc.ncbi.nlm.nih.gov/articles/PMC9838196/
[36] https://www.azag.gov/issues/opioids
[37] https://www.cdc.gov/overdose-prevention/about/understanding-the-opioid-overdose-epidemic.html
[38] https://www.naccho.org/programs/community-health/injury-and-violence/overdose/health-equity-drug-overdose-response
[39] https://www.hhs.gov/overdose-prevention/
[40] https://www.cbo.gov/publication/58532
[41] https://siepr.stanford.edu/publications/policy-brief/opioid-crisis-tragedy-treatments-and-trade-offs
[42] https://calmatters.org/explainers/california-opioid-crisis/
[43] https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2022/01/07/an-equitable-response-to-the-ongoing-opioid-crisis
[44] https://journalofethics.ama-assn.org/article/how-fda-failures-contributed-opioid-crisis/2020-08
[45] https://publichealth.jhu.edu/2024/nearly-one-third-of-us-adults-know-someone-whos-died-of-drug-overdose
[46] https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm
[47] https://www.asahq.org/~/media/sites/asahq/files/public/resources/standards-guidelines/practice-guidelines-for-chronic-pain-management.pdf
[48] https://www.dir.ca.gov/dwc/DWCPropRegs/2025/MTUS-Evidence-Based-Update/Chronic-Pain-Guideline.pdf
[49] https://www.va.gov/painmanagement/docs/cpg_opioidtherapy_summary.pdf
[50] https://www.healthquality.va.gov/guidelines/pain/cot/
[51] https://nida.nih.gov/research-topics/opioids
[52] https://www.bbc.com/news/articles/cvg93nn1e6go
[53] https://www.canada.ca/en/health-canada/services/opioids/overdose.html
[54] https://medlineplus.gov/opioidoverdose.html
[55] https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0236815
[56] https://pmc.ncbi.nlm.nih.gov/articles/PMC9261968/
[57] https://www.ama-assn.org/system/files/ama-overdose-epidemic-report.pdf
[58] https://pmc.ncbi.nlm.nih.gov/articles/PMC5846593/

—
Answer from Perplexity: pplx.ai/share

Filed under: General Problems | 3 Comments »

Once Again, NO ONE is above the law – except those who are in charge of enforcing such laws

Posted on April 5, 2025 by Pharmaciststeve

Please read Mark’s letter below.. Mark reached out to me some 8-9 yrs ago as the MT medical board was starting to “go after him.”

As I understand it, one or more large practices in Maine have decided that all pain pts will be treated with Buprenorphine for pain management.

In Reading the Maine’s Pain Management Policies. It would seem that -collectively – Maine’s legal and healthcare professionals are violating their own law in regards to at least Brandy.

Opioid Prescribing Limits**: Maine’s 2017 law restricts opioid prescriptions to ≤100 morphine milligram equivalents (MME)/day for chronic pain, with exceptions for palliative care, cancer, and substance use disorder treatment

Here is:  Maine’s Pain Management Policies

Maine’s approach to pain management does not mandate the universal use of buprenorphine for all pain patients, but its regulations encourage cautious opioid prescribing while allowing flexibility for evidence-based treatments. The literature supports buprenorphine’s efficacy in managing chronic pain, particularly in high-intensity cases, with studies showing sustained pain relief and reduced tolerance development. For patients with high CYP-450 metabolism, pharmacokinetic interactions are manageable and rarely clinically significant.

### Maine’s Pain Management Policies
– **Opioid Prescribing Limits**: Maine’s 2017 law restricts opioid prescriptions to ≤100 morphine milligram equivalents (MME)/day for chronic pain, with exceptions for palliative care, cancer, and substance use disorder treatment[1].
– **Non-Opioid First Approach**: Clinicians must prioritize non-opioid therapies and use “Universal Precautions” (risk assessment, monitoring) when prescribing controlled substances[2][3].
– **Buprenorphine in Practice**: While not explicitly mandated, buprenorphine is permitted under exceptions for medication-assisted treatment (MAT) and chronic pain[1][3].

### Buprenorphine’s Efficacy in Pain Management
– **Chronic Pain**:
– A 36-month study of transdermal buprenorphine patches demonstrated sustained pain reduction (NRS scores decreased by 4.2–5.1 points) and high patient satisfaction (PGIC scores improved by 76%)[5].
– Systematic reviews found buprenorphine rotation from full opioids maintained or improved analgesia in 53–83% of patients, with fewer adverse effects than traditional opioids[10].
– **High-Intensity Pain**:
– Perioperative protocols recommend continuing buprenorphine and supplementing with short-acting opioids for acute pain, as abrupt discontinuation risks withdrawal[4].
– Partial agonism at µ-opioid receptors provides a “ceiling effect,” reducing respiratory depression risk while maintaining analgesia[11].

### CYP-450 Metabolism Considerations
– **Pharmacokinetics**: Buprenorphine is metabolized primarily by CYP3A4 and CYP2D6, with inhibitory effects on both enzymes[6][7][13].
– **Drug Interactions**:
– **Inhibitors (e.g., ciprofloxacin)**: Increase buprenorphine exposure by 33–44% but are unlikely to require dose adjustments[8][12].
– **Inducers (e.g., rifampin)**: Reduce exposure by 28%, which may necessitate monitoring[8].
– **High/Ultra-High Metabolizers**: Limited data suggest therapeutic doses remain effective, as buprenorphine’s high receptor affinity offsets rapid metabolism[6][8].

### Key Recommendations
1. **Chronic Pain**: Consider transdermal buprenorphine for long-term management due to its stable efficacy and low tolerance risk[5][10].
2. **CYP-450 Interactions**: Monitor patients on concurrent CYP3A4 inhibitors/inducers, though dose adjustments are rarely needed[8][12].
3. **Acute Pain**: Maintain buprenorphine and add short-acting opioids rather than discontinuing therapy[4].

Buprenorphine’s pharmacological profile and clinical evidence position it as a safer alternative to full opioids, aligning with Maine’s emphasis on risk mitigation without compromising pain control.

Citations:
[1] https://academic.oup.com/ajhp/article/73/12/854/5101528
[2] https://regulations.justia.com/states/maine/02/380/chapter-21/section-380-21-4/
[3] https://www.maine.gov/boardofnursing/laws-rules/Chapter%2021%2005.27.20.pdf
[4] https://www.painphysicianjournal.com/current/pdf?article=NTAwMQ%3D%3D&journal=109
[5] https://www.frontiersin.org/journals/pharmacology/articles/10.3389/fphar.2024.1454601/full
[6] https://pubmed.ncbi.nlm.nih.gov/12756210/
[7] https://www.jstage.jst.go.jp/article/bpb/25/5/25_5_682/_pdf
[8] https://pubmed.ncbi.nlm.nih.gov/33750027/
[9] https://www.themainewire.com/2025/02/mainecare-spending-on-suboxone-has-surged-since-2019/
[10] https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2784021
[11] https://en.wikipedia.org/wiki/Buprenorphine
[12] https://www.drugs.com/drug-interactions/buprenorphine-with-ciprofloxacin-438-0-672-0.html?professional=1
[13] https://go.drugbank.com/drugs/DB00921
[14] https://www.maine.gov/sos/cec/rules/10/144/ch101/c2s089.docx
[15] https://library.samhsa.gov/sites/default/files/pep21-06-01-002.pdf
[16] https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/me-sud-care-initiative-midpoint-assessment-03282024.pdf
[17] https://mesudlearningcommunity.org/wp-content/uploads/2023/02/Prior-Authorization-Processes-Buprenorphine-FAQ-July2021.pdf
[18] https://lawatlas.org/sites/default/files/2025-03/VS%20Buprenorphine%20Policy%20Brief_March2025_final_3.26.25.pdf
[19] https://www.azdhs.gov/documents/prevention/womens-childrens-health/injury-prevention/opioid-prevention/appendix-b-state-by-state-summary.pdf
[20] https://www.maine.gov/boardofnursing/news.html?id=10822550
[21] https://www.mainehealth.org/care-services/behavioral-health-care/substance-use-disorder-care-addiction/opioid-use-disorder-care-mainehealth-behavioral-health/opioid-provider-resources-mainehealth-behavioral-health
[22] https://www.samhsa.gov/substance-use/treatment/find-treatment/buprenorphine-practitioner-locator
[23] https://www.federalregister.gov/documents/2025/01/17/2025-01049/expansion-of-buprenorphine-treatment-via-telemedicine-encounter
[24] https://www.mainehealth.org/health-care-professionals/clinical-guidelines-protocols/substance-use-disorder-clinical-guidelines
[25] https://pmc.ncbi.nlm.nih.gov/articles/PMC8163969/
[26] https://pmc.ncbi.nlm.nih.gov/articles/PMC8567798/
[27] https://pcssnow.org/wp-content/uploads/2022/03/PCSS-GuidanceTreatmentOfAcutePainInPatientsReceivingBup.Fiellin-SrivastavaUpdate_03_24_22.pdf
[28] https://www.ncbi.nlm.nih.gov/books/NBK459126/
[29] https://www.dovepress.com/frontline-perspectives-on-buprenorphine-for-the-management-of-chronic–peer-reviewed-fulltext-article-JMDH
[30] https://accpjournals.onlinelibrary.wiley.com/doi/10.1002/phar.2676
[31] https://academic.oup.com/painmedicine/article-abstract/25/12/691/7716541
[32] https://academic.oup.com/painmedicine/article/21/4/714/5699282
[33] https://www.va.gov/formularyadvisor/DOC_PDF/CRE_Buprenorphine_for_Chronic_Pain_MAR_2024.pdf
[34] https://www.tandfonline.com/doi/full/10.2217/pmt-2020-0013
[35] https://pmc.ncbi.nlm.nih.gov/articles/PMC4675640/
[36] https://pmc.ncbi.nlm.nih.gov/articles/PMC4283787/
[37] https://www.recoveryanswers.org/research-post/tried-true-methadone-shows-superiority-buprenorphine/
[38] https://www.tandfonline.com/doi/full/10.1080/00325481.2016.1128307
[39] https://www.oaepublish.com/articles/jtgg.2020.35
[40] https://www.bccsu.ca/wp-content/uploads/2022/06/Buprenorphine-Naloxone-Drug-Drug-Interactions.pdf
[41] https://www.jstage.jst.go.jp/article/bpb/25/5/25_5_682/_article/-char/en
[42] https://academic.oup.com/cid/article/43/Supplement_4/S216/282268
[43] https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1002/prp2.271
[44] https://legislature.maine.gov/legis/statutes/22/title22sec3174-UU.pdf
[45] https://micismaine.org/wp-content/uploads/2019-MICIS-Opioid-Law-Presentation-11.2019.pdf
[46] https://www.samhsa.gov/substance-use/treatment/statutes-regulations-guidelines/mat-act
[47] https://mainedrugdata.org/focus-area-2023-2025-treatment/
[48] https://pubmed.ncbi.nlm.nih.gov/38340973/
[49] https://pmc.ncbi.nlm.nih.gov/articles/PMC7709797/

—
Answer from Perplexity: pplx.ai/share

 

To whom it may concern:

Brandy Stokes reached out to me by referral through Steve Ariens.
At the time she was in the middle of a forced taper instituted by Eva Quirion, Np, DNP.
This was reported to be a “compassionate taper“, and indeed it was slow. But it was not compassionate. Brandy metabolizes  opiates and super rapid ultra metabolism.
Prior to the forced taper, she had been stable on 30 mg oxycodone 30 tablets a day. She was started on this regimen by all the smart doctors in Boston that took care of her after her ankle fracture osteomyelitis pick line sepsis, endocarditis valve replacement and diffuse complex regional pain syndrome.
Dr. Loeffler took care of her for over eight years and she was stable. Disabled but stable. She formally taught eighth grade. She raised three boys as a single mother, and I’ve never met anyone with the persistence and tenacity that this patient demonstrates.
At any rate, she was down to 22 tablets of 30 mg oxycodone a day and she was in active withdrawal:
She had blood pressure levels over 220/180.
Chest pain at a level above nine out of 10, and was forced to go to bed, unable to care for herself.
Naturally, she was suicidal at this time.
She’s a very religious person and would not or could not complete suicide without violating her most core values.
In considering taking her on as a Pain refugee,
I spoke to Dr. Loeffler, Dr. Adams , and nurse practitioner Matthews.
I spoke to her pharmacy, Hannaford pharmacy, and the pharmacist there was quite compassionate and eager to restore Brandy’s previous level of pain, relief and functionality.
I believe her name is Grace.
I queried Grace about the prescription drug registry and Grace! told me that Brandi had used one pharmacy and a stable dose of these pain pills for years. There were no early refills, etc.
She was highly trusted and highly responsible according to Grace the Hannaford pharmacist.
I asked Grace if she was willing to fill the prescription if I sent one in and she said yes.
I was then of course, disturbed saddened, and upset when the prescription was canceled by Dr Quirion. I did not think she had the authority to override a prescription from another physician. I suspected a HIPAA violation had occurred, and I immediately reported it to the board of pharmacy in Maine.
Hannaford then pharmacy refused to fill any prescription from me for Brandy.
At this point, she was having trouble keeping her blood pressure under control and she couldn’t get anyone to fill her blood pressure medication’s either.
We were able to find a Walgreens pharmacy to Phil one weeks worth of her medication’s to keep her alive.
Brandi had already notified Dr. query on that she was seeking help from someone who would treat her palliative care, under MAINe palliative care program B. ( due to Brandy’s advocacy. The palliative care program was already in place.)
I made it clear to the Hannaford pharmacy people and their supervisors up the line that I was considering that she was abandoned by this pharmacy, arbitrarily and capriciously.
At any rate for the next year, Brandi was able to beg and plead for one or two weeks of her life-saving medication from numerous compassionate pharmacies in Maine. That would only treat her for that one week or two.
Ultimately, she was able to find for herself a pharmacy in New Hampshire that would fill three weeks worth of her medication’s prescribed by me.
Brandi now travels four hours each way to New Hampshire to fill her prescriptions every three weeks.
Because of the severity of her pain and hypertension and flare of her complex, regional pain syndrome, Brandy developed swelling, blisters, and weeping lesions on her lower extremities, which were very difficult to manage and disqualify her from WATER physical therapy.
Once her pain management regimen was restored, she was able to heal these circumstances.
It took months for her legs to heal.
I attribute this difficult. To the interruption of her stable pain regimen. I suspect it also relates to the hypertension that was secondary to her pain. This hypertension was unfortunately unresponsive to the limited amount of blood pressure medicine. She was still able to use from her stash.
I SAY THIS IN NO UNCERTAIN TERMS: BECAUSE SHE WAS FIRED FROM THE ST. JOHN’S MEDICAL GROUP BY Eva, she was unable to get any of her standard medication‘s
In other words, she was completely abandoned for all her medical needs, would you curse to me as retribution.
She was given the diagnosis of chronic persistent, opioid dependence, CPOD.
There is no DSM code for this diagnosis and it is not been accepted by DSM five in the psychiatric diagnostic and statistical manual.( BY THIS I MEAN IT’S A NEW MADE UP DIAGNOSIS.)
It’s an unnecessarily redundant term given that her pain is chronic and persistent and her opioid dependence is obvious. She is dependent, but not addicted to the pain medication’s. That keep her alive.
In the time that I’ve been taking care of her, she has shown remarkable resilience and determination to stay alive.
She has been sorted by not having enough medication’s to travel to South Carolina to visit her two grandchildren, born 18 months and two weeks ago.
She’s dependent in many other ways also.:
She dependent on the generosity of random pharmacist throughout the state of Maine.
She depending on her son to drive her to New Hampshire every three weeks.
She’s depended on the compassion of her pharmacist in New Hampshire. Who sees many other Payne refugees from Maine who are not getting what they need.
And, of course, she’s dependent on my tenuous medical license.
The state of Maine sent me a cease and desist letter to get me to abandon Brandy.
We responded to the cease-and-desist letter by making sure that she and I meet in New Hampshire on video every time she gets her prescriptions filled in New Hampshire.
Brandy and I appeared on a panel discussing Pain Refugees with The Cato Institute, led by Dr Jeffrey Singer.
There are 
No more Pain  refugees in my practice that I can count.
Brandy is too strapped financially to pay for more than one or two of my visits over the last almost 2 years.
I have committed to standby Brandi as long as I possibly can. Because she’s lost three different providers, I’m aware that the same fate could land on me.
She has not been able to find anyone to assume her care within the state of Maine.
She’s not an addict.
An addict’s life falls apart when they take their substance.
A pain patient’s life comes back together when they get their relief.
Since her pain treatment has been restored, she’s become one of our leading advocates in the movement to protect patients in pain.
IF SHE LOSES HER PAIN CARE, HER RISK OF DEATH IS GREATER THAN 50%. HER BLOOD PRESSURE WAS OUT OF CONTROL AND SHE WAS NEAR DEATH WHEN I MET HER.
We have plenty of evidence of the harm caused to her by her forced  taper, which is categorically and undeniably counter to the flawed CDC guidelines of 2016 and 2022
I remain at Brandi’s service, and I remain in awe of her tenacity and commitment to not only help herself but the likely 400,000 people suffering in Maine from the same fate.
I am eager to speak with anyone who reads this.
I’m also eager to rebut any accusations made by the Attorney General of the state of Maine, who asked me to break main law by abandoning Brandy.
By the way, I am now fully compliant with the seasoned assist order. I’m no longer treating Brandy in the state of Maine. Her prescriptions are filled in New Hampshire and she stands on the ground in New Hampshire when I visit with her.
She and I have also met in person within the last month.
Be advised that I’ve been operating under the Covid emergency guidelines extended by the dea through 2025. This allows for telemedicine for scheduled prescriptions, which began during Covid. These guidelines have been extended annually for the last five years.
Here’s the science behind Genetic pleomorphism:
It’s settled science. Anyone ignoring the fact that some patients metabolize opiates in an ultra rapid fashion is in denial or lying.
According to multisystem reviews, the chance of addiction for pain medication’s is less than one percent.
Those claiming that pain pills lead to risk of overdose death ignore the risk of untreated pain.
Ask yourself this question:
If there’s over prescribing, then statistically there has to be under prescribing as well.
This is a term that’s never been defined by dea skateboards of Medicine or any critic of pain management
Feel free to see below my book and movie about these topics.
I stand by Brandi and I stand ready to assist anyone who reads this and understanding the cruel ignorant and evil campaign against her and her doctors.
MarkIbsenMD 
406–4 39–0752

 

Bestselling Author: Dr Bison’s Fables, An Allegory of The American Pain Refugee Crisis.
 CDC: “24-126 million Americans in chronic pain”
Pain Warriors 2020 documentary, international Award-Winner,  featuring Mark Ibsen MD

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