“The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped.” – Hubert Humphrey
passionate pachyderms
Pharmacist Steve steve@steveariens.com 502.938.2414
An update has been made to the PPM Opioid Calculator to remove conversions to and from buprenorphine. Here’s why.
While the original launch of the free PPM online opioid calculator in 2012 did not include any conversions to or from buprenorphine due to its complex pharmacology and pharmacokinetics (see below), these conversions were eventually added as several clinicians requested access to the calculation data in order to transition patients to a safer opioid alternative.
Unlike full agonist opioids, buprenorphine has a ceiling, or plateaued, effect on CO2 accumulation. It is important to note that the addition of buprenorphine, including transdermal patches and buccal films, to this calculator came with a preprogrammed conversion ceiling and a warning that conversions to or from buprenorphine could not be recommended. For example, if a user asked to convert morphine 80 mg orally to buprenorphine film (Belbuca), they would receive a warning “Result exceeds maximum daily dose. Patients on morphine 80 mg PO (or equivalent) or higher, must not receive Buprenorphine (BF) due to possible opioid withdrawal risk.”
Fast-forward to the contemporary opioid environment of 2018-2019, where ubiquitous state and federal policies and guidelines continue to push for safer alternatives. In addition to the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain, which cautions clinicians about morphine equivalent doses (MEDs), a new 2019 CMS rule will implement soft and hard edits at 90 MEDs and 200 MEDs, respectively.
Neither the CDC nor Medicare cites buprenorphine as having an MED.
Therefore, buprenorphine has been removed from the online calculator due to the following factors:
Buprenorphine is now more commonly considered a safer opioid alternative with efficacy often comparable to or superior to its full agonist cousins (its diminished risk for respiratory depression may also provide safety advantages compared to full agonists)
Prescribing clinicians are often evaluated or tracked based on their MED prescribing habits
Current clinical guidelines seem to align with the position that buprenorphine should not be assigned any MED.
With this change, it is hoped that clinicians may recognize the unique attributes of buprenorphine and see it as a valuable option that does not have a calculable MED by acceptable guidelines.
The complexities of buprenorphine
From a practical perspective, buprenorphine cannot have a linear conversion to/from morphine (or an equivalent) because of its complex pharmacology and pharmacokinetics, including:
Buprenorphine has a higher binding affinity to mu-receptors compared to every full-agonist opioid prescribed for in-home use as well as naloxone (Narcan)
The buprenorphine parent molecule is considered a partial mu-agonist, but will nevertheless overcome receptor binding by concomitant full agonist use
Because of #2, at 80 to 90 mg of morphine equivalent dose (MED), patients may experience withdrawal as the full agonists are displaced by buprenorphine mu-receptor occupation.
This is a pretty long dissertation of this study, appears to be done in/around Seattle WASH in the early 2000’s. So I am not going to post the entire text of the study buy the above link will take you to the entire posting
CVS Caremark, the in-house pharmacy benefit manager for CVS, has been accused of squeezing small pharmacies, driving some out of business.
Lawmakers in Arkansas and Ohio have been quick to pass laws designed to end this by demanding higher transparency or regulatory oversight.
CVS is also trying to buy up small pharmacies, which is much easier to do if they’re going out of business.
The short version of what happened to CVS in 2018 is this: The company got too greedy, and then it got caught.
In its greed, the company squeezed independent mom-and-pop pharmacies. The squeezing wasn’t being done by the part of CVS you buy dental floss from or visit to pick up a prescription, though it’s not unrelated. It’s a behind-the-scenes business known as a pharmacy benefit manager, which manages payments between insurers and pharmacies and drug companies.
The mom-and-pop pharmacies say CVS’ in-house pharmacy benefit manager, CVS Caremark, slashed reimbursements for medications sold to their patients on Medicaid. At the same time, they say, it was reimbursing CVS pharmacies at much better rates. With some of them on the verge of going out of business, these pharmacies have rallied lawmakers — both Democrats and Republicans — to put an end to this.
So now CVS faces a tide of resistance to the way it deals with smaller rivals. Already, Arkansas legislators have passed a law aimed at curbing this behavior. This is new regulation in a Republican-dominated state. That’s how bad things looked to the lawmakers.
Ohio is forcing PBMs to disclose more about the way their pricing and contracts work. Mom-and-pop pharmacists in states like Texas and Kentucky are realizing they have a CVS problem on their hands too. Caremark manages payment for Medicaid-managed care plans in more than 20 states.
This is important because CVS is trying to cut a $68 billion deal to buy a health insurer, Aetna — a deal that would make it even more powerful and more able to obscure the whys and hows of pricing all through the healthcare system.
What’s more, CVS isn’t the only healthcare company trying to turn into a leviathan. Over the past few years the largest healthcare companies — including insurers, PBMs, hospitals, and drug companies — have been combining in what is known as vertical integration, or mergers between companies in the same industry whose businesses don’t directly compete.
They say this is an effort to create efficiency in the healthcare system. What CVS has shown, though, is that this kind of integration can actually get companies drunk on pricing power, and create monopolistic monsters.
In Arkansas
To their credit, once legislators in Arkansas figured out what was happening to local pharmacies, they moved at blinding speed.
The state legislature nearly unanimously passed a bill designed to curb this behavior from PBMs on March 14.
The situation had gotten desperate, fast. The way mom-and-pop pharmacists tell it, CVS started bringing the pain at the beginning of 2018. Suddenly, reimbursement rates for Medicaid plummeted at the same time drug prices for Medicaid started rising. So in the beginning of February, Arkansas Attorney General Leslie Rutledge started investigating the matter.
“The amount paid to the pharmacy was less than half of what was being charged to the plans,” Scott Pace, of the Arkansas Pharmacists Association, told Business Insider.
Pharmacists in Arkansas, for example, say:
For a Fentanyl Patch 100, CVS pharmacies were reimbursed $400.65 while mom-and-pop pharmacies were reimbursed $75.74.
For Amoxicillin, CVS pharmacies were reimbursed $35.92 while mom-and-pop pharmacies were reimbursed $12.21.
For even something as simple as Ibuprofen, CVS pharmacies were reimbursed $5.86 while mom-and-pop pharmacies were reimbursed $1.39.
Sometimes, the pharmacists say, they weren’t reimbursed enough to cover the cost of filling the prescription. These aren’t the only ones, to be clear. Business Insider has seen a long list of alleged disparities like the ones above.
CVS, for its part, denies that it is squeezing the mom and pops. Business Insider sent the above examples to the company, and its spokeswoman Christine Cramer said they were patently wrong. However, she also said the pharmacists were “cherry-picking” reimbursements that look especially bad.
“The facts are that on an aggregate basis, we reimburse independent pharmacies at a higher rate than larger regional and national chains,” she said.
“CVS Caremark considers local, independently owned pharmacies to be important partners in creating our pharmacy networks, and in fact, independent pharmacies account for nearly 40% of our network,” she added. “Furthermore, we reimburse our participating network pharmacies, including the many independent pharmacies that are valued participants in our network, at competitive rates that balance the need to fairly compensate pharmacies while providing a cost-effective benefit for our clients.”
This response did not jibe with what legislators, patients, and pharmacists were seeing on the ground, though.
Out of a $50 drug, for example, say $22 was paid to the mom and pop, the rest went to CVS — to its PBM. At the same time, patients looking at how much a drug cost their health plan in their explanation-of-benefits portal would show a price of, say, $100.
“The numbers were stark,” Pace said.
Here’s the letter pharmacists are getting, urging them to sell their businesses to CVS.Business Insider
So until this was all figured out, people who bought medicines at their local pharmacies in Arkansas (and Ohio) didn’t know that their neighbors were getting screwed. They also didn’t know that, as their local pharmacists were getting squeezed, CVS was waiting in the wings, sending out letters offering to buy the very mom-and-pop shops it was forcing out of business.One pharmacist, Rick Pennington of Lonoke, Arkansas, said that if it weren’t for his business mailing a generic erectile-dysfunction pill to nine states, he’d be out of business.
“When you look at who’s controlling the money and who has the leverage, it’s the PBMs who have control,” Pace told Business Insider. “These folks are trying to get more integrated into the healthcare system, and so far we’ve seen that means patients lose. Next, they’ll buy a hospital and be an HMO. I think that’s bad for patient choice.”
He added: “It’s not a free market because there is no transparency on pricing.”
CVS, however, denies coordination between its PBM and its pharmacies.
“Our retail business has engaged in acquisition activity and outreach to other pharmacies since well before CVS and Caremark merged, and, in fact, the communications materials related to this activity has been relatively unchanged over the years,” Cramer said. “Any retail acquisition activity is completely unrelated to, separated from, and not coordinated in any way with the PBM business’ management of its pharmacy network.”
In Ohio
The story for pharmacists in Ohio is a bit different. There, some have viewed CVS as problematic for years, but instead of seeing reimbursement rates plunge, legislators and pharmacists said they’ve been moving up and down like crazy since around 2015. By October or November of last year, gross annual margins for Medicaid payments to mom and pops were going below zero, and pharmacists were losing money on most drugs sold.
“Because those rates are set arbitrarily you’re set up for a roller-coaster ride,” Antonio Ciaccia of the Ohio Pharmacists Association said in a phone interview with Business Insider. “No one expects to get rich off Medicaid … but if you sat down with a pharmacist that was willing to tell you, ‘Here’s what I was getting paid,’ you could match it up with state-utilization data and see the spread and how significant the loss was … That’s what kind of lit everything up in Ohio.”
And of course, CVS sent those letters soliciting acquisitions. One came on November 9 of last year, a particularly bad time for the state’s mom-and-pop pharmacists.
Suddenly, the number of people in Ohio government demanding answers, led by Ohio Speaker Cliff Rosenberger, started to multiply. They realized that the Ohio Department of Medicaid wasn’t even asking for the right pricing data, and CVS had never considered giving it to them. Now, as rules change within the department, it’ll have to.
Brad Miller, Rosenberger’s press secretary, said this was something his boss had been looking into for years.
“In order to be responsible stewards of taxpayer dollars, you must have access to reliable and accurate data,” he said. “Around the state, we are seeing the negative impact the current system is having on local, independent pharmacies, many of which have been forced to close in recent years. This, in turn, reduces patients’ treatment options and access to care. Having access to this data will go a long way toward lowering prescription-drug costs for patients and employers, as well as help reduce the burden on Ohio taxpayers.”
Ciaccia told Business Insider that during the three years CVS has been engaging in this behavior it has gained 68 pharmacies in the state. Its competitor Walgreens added only two locations over the same period.
“We are done messing around in Ohio,” he said. “This system is completely broken … It is layered and layered with conflicts of interest. I don’t care who the PBM is.”
What a tailor can do!
Health Strategies Group
PBMs have all sorts of tricks up their sleeves to make money not just from pharmacists but also from insurers and drug companies — basically anyone involved in getting medicine to you.Here are a few of their greatest hits:
They can make money (as we’ve seen here) off the spread between what they pay pharmacists and what they charge your insurance plan.
They have gag orders on pharmacists, so your pharmacist can’t tell you whether it’s actually cheaper for you to use plain old cash to buy a drug that isn’t part of your healthcare plan. (Note, the fact that there might even be a cheaper alternative challenges the PBMs’ claim that they save money for their clients in the first place.)
They get reimbursements from pharmaceutical companies. The fatter the rebate, the more likely they’ll include a company’s drug in a client’s (your) managed-care plan, but they don’t have to share that reimbursement with the client (you). They can keep some and negotiate rebates for themselves. They can collect all kinds of administrative fees and other types of fees from drug companies too.
We’ve been learning about this slowly. Three PBMs — CVS Caremark, Express Scripts, and UnitedHealth Group — control about 70% of the US market, and they guard their secrets zealously. Recently, though, the news site Axios published a contract template for Express Scripts. No two contracts are alike, and Express Scripts grumbled that the one Axios published (which was rife with loopholes to make Express Scripts money at every turn) was old and irrelevant.
Yet the company demanded that DocumentCloud, where the contract was posted, immediately take it down, citing copyright infringement.
This “Oh it doesn’t matter to our business — but DON’T TOUCH THAT!” response is trending in PBM world.
For example, earlier this month the US Senate introduced the Patient Right to Know Drug Prices Act, which would ban the so-called gag clauses mentioned above (as Arkansas lawmakers did in their bill).
The Pharmaceutical Care Management Association, the PBM lobby, responded to that by saying:
“We support the patient always paying the lowest cost at the pharmacy counter, whether it’s the cash price or the copay. This is standard industry practice in both Medicaid and the commercial sector. We would oppose contracting that prohibits drugstores from sharing with patients the cash price they charge for each drug. These rates are set entirely at the discretion of each pharmacy and can vary significantly from drugstore to drugstore.”
Sounds as if they’re for it, right? Wrong. Here’s the next sentence.
“Fortunately, to the degree this issue was ever rooted in more than anecdotal information, it has been addressed in the marketplace.”
Rep. Earl “Buddy” Carter of Georgia.C-Span, screenshot
So which is it, guys? Do you think transparency is important and support patient rights — or are you going to fight this bill?It’s a simple question. And it’s easy to see the answer.
Rep. Buddy Carter, a Georgia Republican, introduced the Prescription Transparency Act to the US House of Representatives this month. It does basically the same thing as the Senate bill, and, as the only pharmacist in Congress, he knows he’s facing a street fight from the PBM lobby.
“They spent $600,000 against me when I first ran for office three years ago to try to get me defeated, and over the past few years we’ve seen them ramp up their political activity,” Carter told Business Insider. He’s also noticed that legislators in Washington are finally waking up to the urgency of this situation. There have been hearings about drug pricing in both houses, and Scott Gottlieb, the commissioner of the Food and Drug Administration, has come out swinging especially hard, saying that the PBMs sit at the top of a “rigged system.”
“We’ve seen some companies that dropped the PBMs such as Caterpillar and they’ve been able to control drug prices,” Carter said in a phone interview. “Right now the focus is on prescription drug pricing, and the most impact we can have on pricing is to have control on transparency from the PBMs.”
If you believe that, you should also believe taking that control won’t be easy. Once we do, though, it may change the way you look at what our healthcare is trying to become.
Sadly, this is one of several transplant patients that I have heard of whose life will be at risk over this weekend because their transplant medications will not arrive on time. It’s not against the law for #PBMs to risk lives as they force to their mail-order pharmacy. That’s how they make profits. Sadly, these medications are most likely available at a local pharmacy, but the PBMs want to hoard the business for themselves. PBMs and their mail-order pharmacies will classify a drug a specialty drug, so they can force or steer us to their mail-order pharmacy by making patients pay 100% of the cost if they use their TRUSTED local pharmacy. #stopPBMabuse
How do insurance companies decide what medicines to pay for and when to pay for them?
Insurers and other payers look first at how well the drug works – not its cost – when they decide whether to cover the latest treatments, according to the nation‘s largest pharmacy benefits manager, Express Scripts.
The price patients eventually pay gets determined later, when an insurance company or pharmacy benefits manager decides where a drug fits on a list of covered treatments called a formulary.
The cost of prescription drugs has become a growing source of concern with doctors and patients, but it‘s not a factor considered by an independent committee used by Express Script to determine coverage of a new drug, Chief Medical Officer Dr. Steve Miller said.
That committee – 15 doctors and a pharmacist – reviews the information that federal regulators used to approve a drug and then decides whether it should be covered.
Some payer coverage decisions come with qualifications like a requirement that patients meet specific criteria or try other treatments first. That can limit patient access. Doctors say some patients have had trouble getting a new cholesterol-lowering drug, Repatha, that costs $14,000 a year, because of the restrictions.
Insurers largely use pharmacy benefits managers to set up the lists that determine how much a patient ends up paying. Some lists are divided into tiers, with drugs on the bottom generally being generic or least expensive. Those on the highest tier might include specialty medicines that could cost the patient hundreds of dollars even with coverage.
Whether a drug even gets on the list can depend on whether a similar medicine is already in the market and that can be found with options as a Canadian Pharmacy that offer medicines online. When the ground-breaking hepatitis C treatments Sovaldi and Harvoni from Gilead Sciences debuted a few years ago, Express Scripts had to include them. They cost more than $80,000 for a course of treatment, but the drugs essentially cure a debilitating disease and they had no competition.
But once the drugmaker AbbVie produced a third option, Viekira Pak, with a similar cure rate, Express Scripts was able to negotiate a price discount and switched to covering only Viekira Pak.
The nation‘s two largest pharmacy benefits managers, Express Scripts and CVS Health Corp., both say they cover Repatha.
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Editor’s Note: Terri Lewis, Ph.D. is a chronic pain advocate who, with the help of you, the readers of the National Pain Report, conducted one of the largest online surveys of chronic pain patients.
She sent us this report recently that speaks to the taper issue. It is a long read but we are going to publish much of it because she shared so many of the comments that survey respondents left.
Here was what she shared:
In a national survey of patient 4619 self-reports regarding interactions with pain management, 77.38% of respondents are female, and 21.35% are male. The bulk of respondents range in age from 40 – 70+ and the majority have at least some college or trade school education to report. Many hold post graduate professional degrees. The vast majority meet the definition of multiple chronic comorbidity or MCC – that is they have more than one progressive condition that requires treatment and that affects multiple body systems.
Responses from female respondents regarding their current experience with opioid prescribing as follows:
Abandonment – loss of a physician to provide appropriate medication management
Step therapy- replacement of existing routine with alternatives that may or may not provide an appropriate or satisfactory alternative to existing care routine
Involuntary taper-Rapid reduction or removal of opioids without patient choice making involved and as a contingency for continued care.
In many of these reports, patients provide ample evidence that opioids have been replaced by other drugs of concern, including anti-epileptics and anti-psychotics, or they have been forced to agree to invasive interventional procedures or unnecessary surgeries in order to continue under some kind of a care umbrella. Many report their physicians cite CDC regulations as law or DEA scrutiny as their reason for insisting on taper. Protesting the appropriateness of these alternatives seems to fall on deaf ears or result in discharge in many cases. Many feel strongly that physicians are dismissive of their concerns because of their gender. Thirty percent (30%) are enrolled in Advantage Plans. Respondents submitted reports from every state in the nation and two territories.
Within these responses are reports of suicide and plans for suicide when alternatives for care and relief are exhausted.
I have printed off some of the unedited commentary from female respondents, which align with the findings in Fenton JJ, Agnoli AL, Xing G, et al. Trends and Rapidity of Dose Tapering Among Patients Prescribed Long-term Opioid Therapy, 2008-2017. JAMA Netw Open. 2019;2(11):e1916271. doi:https://doi.org/10.1001/jamanetworkopen.2019.16271.
I am still deep into analytics. So this is not the final analysis, but it’s a credible snapshot.
Here are some of the comments left by those who took the survey.
I am currently as of February 2018 being FORCE TAPERED due to this hysteria My PM dr. Is force tapering me due to CDC Guidelines even though she said I was doing well on my high dose meds. She is afraid to lose her license.
Morphine forced tapered from 90mg to 15mg & dilaudid forced tapered from 4mg to 2mg.
Kaiser Permanente of Colorado says the 2016 CDC prescribing guidelines are actually law (even though I know the are not) so I was forced to taper from 135mme to 120mme last summer. Now that it is 2019 I must accelerate my taper to comply with the 90mme “law” from the CDC.
Terri A Lewis, PHD
I have a spinal stimulator that was placed to facilitate the original, willing, taper, and I have had to significantly increase the level of stimulation due to the loss of effective pain management. My doctor has replaced my gabapentin with Lyrica in an attempt to find better pain control as she refuses to return my pain medication to the level it was prior to the forcible taper by my previous doctor. She has referred me to a neurosurgeon to evaluate my back and to a physical therapist, at my request. The previous doctor claimed the reduction of my pain medication was due to FDA guidelines, despite the fact that I was already at a level of 90 mg morphine equivalent per the CDC’s recommended guideline of Oxycodone.
When I lost my pain doctor for that brief period, I was forced to take the following medications even though I had already tried them in the past (tried them one at a time): Lyrica – caused severe dizziness. Cymbalta – cause my liver enzymes to elevate, just like in the past. Flexeril instead of Soma – did nothing for my muscle spasms. Can’t remember the other medications but there was another one. My pain meds were cut by approx. 65% and my muscle relaxer was taken away. I was told that I had a choice of either getting a pain pump or a spinal cord stimulator or they would no longer prescribe my pain meds (had 2 SCS’s in the past). I was also required to redo all imaging, PT, drug screen every 2 weeks – otherwise, no pain meds and “if you don’t like it – go somewhere else”. I was supposed to go to biofeedback and other alternative treatments, and start ESI injections in order to continue getting my pain meds but I found my old pain doctor before I had to do any of the other treatments. I have had sympathetic blocks in the past with relief for only 24-48 hrs, and ESI won’t help my RSDS! I did have a spinal cord stimulator implanted (it was my 3rd one), by my old doctor, but that was just done recently and it was because he had to taper my meds, so I needed something because I was already having a lot of breakthrough pain even before he tapered me, but I was trying to tolerate it and work part-time. So I really had no choice. I’m in a w/c due to a complication with my first SCS and another “alternative treatment” 19 yrs ago. The doctor who put my most recent SCS in (my doctor’s partner), put the battery in the wrong place (instead of in a fat pocket in my hip or abdomen, he put it right over my largest back muscle next to my spine – low back, NOT hip where the fat is). So now I need another surgery to move it! It’s causing much more frequent and severe muscle spasms. My current doctor who I have been with for approx. 18 years with the exception of about 3 months, also required that I try various other medications but I expected that. Opioids was certainly not my first choice but it is what works!
Hawaii has no opioid limits but my pain management doctor is force tapering me saying “it’s coming ” and “your insurance will stop paying for it so you better get used to it “. He didn’t force taper me the month I agreed to bilateral epidural injections.
Methadone was initially prescribed as pain reliever, not as a bridge from one drug to another. I have decided to try and taper off methadone and try to use a less potent medication to fit in CDC recommendations of 90MME Max for my pain control. When I made this change or decision I was denied any help in the taper . Currently my regular doctor is trying to help but this may not last.
BotoxInvoluntary taper Reduced dose Dr #2 added botox injections which one time was HIGHLY effective but he has been unable to duplicate the exact injection site ever since. Also, he reduced my narcotics on day 1, no tapering ! He reduced oxycodone as follows old dosage 6 30mg/day=180mme and new dosage 4 10mg/day=40mme. Morphine old dosage 2 40mg/day=80mme new dosage 2 30mg/day=60mme. Bottom line? My old dosages totaled 260mg/day. My new dosages totaled 100mg/day. On less than half of my former dose, where I was stable and functioning, I am now reduced to living in pain that’s grown exponentially and reduced my functioning status to living on my heating pad in bed. Every. Single. Day.
Epidural injections (ESI)Involuntary taperSpinal cord stimulator When I was seeing a previous pain mngt dr, I was told I HAD to get the steroid spinal injections (which I later found that with my disease, the steroid injections only eat away at the collagen that my body is already low in since EDS is a collagen disorder). I was so desperate for help that I requested the spinal cord stimulator to help with low back pain but once I got it, it helped the CRPS in my feet some, the extreme pain in my knees some, but helped my lower back not at all. Very disappointing. Once he found that I was not getting relief from the spinal cord stimulator for my lower back he decided it was “time to taper back” on the oxycodone he was giving me, like my illness was suddenly improving, while I was only getting worse. It was horrible.
Involuntary taperOpioidsPain medications I have been forcibly tapered by SIGNIFICANT AMOUNTS from my successful dose of opioid pain medication against my will, leaving me in excruciating pain and virtually bedridden and homebound.
Anti-depressantsInvoluntary taperNeuroleptics (Gaba, etc)Opioids Yoga or Tai Chi When I was first told they’d be force tapering me they offered me antidepressants even though I am not depressed and recommended Tai Chi. These were the only alternatives offered as we had already tried Gabapentin, Savella, Amytriptaline, Lyrics, Abilify, Topomax, and a few others I’ve forgotten. I had severe reactions to several of them and no pain relief. I was encouraged to seek other physicians, though can’t find any willing to take a patient on opioids and some just won’t take Fibromyalgia patients.
ChiropracticInvoluntary taperPhysical therapy Step therapy New Physician is requiring me to taper opiates and eventually stop them as she doesn’t believe in using them. Wants me to see a chiropractor Am already getting Physical therapy, and using relaxation techniques.
BotoxInvoluntary taperMedical CannabisOpioidsPain medicationsSurgeryTENS Unit Before I was tapered I went to PT, warm water exercise, used tens, medical marijuana. I still use all of that. I failed methadone, neurontin, Botox, Marcane injections. Too painful and developed antibodies to Botox. My low platelets prevent spinal injections as well as surgery. Neurontin caused suicidal thoughts, psychotropics caused exacerbation of dystonia and tardive dyskinesia caused by misover prescribing of Reglan. Damage permanent. Only drugs that don’t exacerbate movement disorder and bleeding disorder are opioids
Involuntary taperOpioids I have been forced to taper by other physicians in the office even though they know my diagnoses because they don’t like opioids.
Again, with my move a year ago to a new state, it has been extremely difficult getting established with new doctors. And in most instances, near impossible. No one here wants to take on complicated cases, especially when it involves chronic pain. Several of my medications are being forceably tapered , and I am experiencing drastic loss of quality of life. No other alternatives for opiates exist for me. Yet I am being asked over and over again, to retry drugs such as Gabapentin, Lyrica, Topomax, etc that in the past have resulted in intolerable side effects, even hospitalization! Why would I want to retry a drug that I was not able to tolerate previously? Why are injections still being brought up to me, when I should NEVER have them again?
Before guidelines I was forced to taper and it cause major health issues so then doctor increased. Also after level 3neck fusion surgery Surgeon refused to treat severe pain that had kept me awake for 7 days I slept a total of 2 hours in 7 days family doctor seen I was in dire straights and gave me a fentanyl patch so I could recover he was gone on vacation after my surgery.everyday I begged Surgeons MA and RNs to give me stronger pain meds I was told to meditate,Pray listen to music I was ready to check out of life . ER refused to even see me .because the surgeon . so then went to family doctor office my doctor was on vacation and not in and then seen an RN and she would not even let me see a doctor that was my an associate of my family doctor as he was on vacation. Because of the severe pain RN’s were acting as doctors when my family doctor got back from vacation I had to lie to get into see my doctor .
Was told they would put me on suboxone for pain I was tapered for 9 months due to state laws, but I went to capital and fought for exemption trigger point injections were pushed on me even though I am allergic to steroids and I told him I did not want any more invasive treatments Living Life Well class was mandatory. He still makes me go to alumni meetings on Monday nights. I’d rather have a root canal
60 my of morphine sulfate per day and 2, 10 mg oxycodone per day. Every month they are tapering me down!!
I don’t understand above questions. Yes my Norco was tapered from 70 mg to 50 mg a day due to DEA recommendations. I use stimulation, epidurals, OTC Advil, lidocaine patch and compounded AIF cream for pain. Since lowering my norco mybpain is now unmanageable and nerve pain is miserable. All I want is relief to a level that is tolerable. I will never be pain free but a level of 5-6 is what I need and 60-70 mg a day of opiate worked fine for me. Now I’m couch ridden.
I had been using Fentanyl Transdermal patches, last month dosage was reduced—pain increased, oxycodone-same, Flexeril-stopped totally, Xanax—stopped totally-NO TAPER OFF, Duloxetine-same. Last month Dr. required me to fill prescription for NARCAN!!!! He said it was required— in case I overdosed!!!!! I am 69 years old!! He has known me to be a very compliant patient for 20 years!!!!! Now I had to spend $24.10 for something that I will have in my safe??? I don’t plan to O.D.—- but, if I did, who would deliver it to me??? We are pain patients, not Illicit drug addicts!!!
I have had a forced taper of the Morphine which has caused me to be put on Topamax (my version of Gabapentin/lyrica) to help with nerve pain, recieve various steroid injections, radio frequency ablation and I am now in the process of getting the spinal simulator implant to hopefully provide more relief. I currently can do very minimal activity & have little to no quality of life due to my pain levels.
No change in prescriber or physician, but i am now on a forced taper to comply with state rules.I take other medications in conjunction with opioid therapy but they only compliment it. Without opioids, they fail to reduce pain in any noticeable measure.
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Use the Medicare checklist to help you transition into Medicare. When signing up for Medicare, be sure that the diabetes treatments and other medicines you need are covered. Learn more about how Medicare works and some important considerations throughout this process.
Thomas McLellan, who worked in the drug czar’s office from 2009 to 2012, is accused of helping a fraudulent rehab center.
A former White House official high up in the drug czar’s office is named in a new federal lawsuit, accusing him of fraud in the drug rehabilitation industry and using his contacts to enrich his family.
Thomas McLellan served as deputy director of the Office of National Drug Control Policy from 2009 to 2012 in the Obama administration. The lawsuit is accusing McLellan and his son, Andrew, of holding on to millions of dollars from what it calls a “criminal, sham” addiction treatment center outside of Philadelphia.
The younger Andrew McLellan became a part owner and board manager of Liberation Way in 2015 after investing $300,000 that he was given by his father, according to the lawsuit. It also alleges that in 2016, Thomas McLellan offered to reach out “to his higher up contacts” that he used to work with to fend off an audit from an insurer that had developed “significant concerns” about Liberation’s activity. A year later in December 2017, McLellan’s son allegedly cashed out a nearly $5 million position in the company. And Newsy discovered county real estate records that show just one month later, he purchased this home in the Philadelphia suburbs for $2.9 million. On Zillow, the home is described as the “crown jewel” of its area, complete with a pool and seven bathrooms. By March of this year, state and federal officials charged Liberation’s remaining owners with an elaborate insurance fraud scheme — alleging the company and its officers were getting kickbacks related to blood and urine screenings, and billing for medically unnecessary treatments. The company collapsed following the criminal charges of the remaining owners.
“These individuals profited off of the pain of these individuals who were battling addiction,” Pennsylvania Attorney General Josh Shapiro said in his announcement of the charges.
Neither McLellan was criminally charged. But now the key lender in the purchase of Liberation Way — Oxford Finance — is suing in civil court to get its money back, saying it lent the money based on fraudulent information from the owners, and it would therefore be “unjust” if the McLellans got to keep their millions.
“They were defrauded into making the loan, so from an equitable standpoint, people shouldn’t make money off their fraud,” said Andrew Rothermel, who was appointed CEO of Liberation after investors learned about the alleged fraud.
Neither the McLellans nor their attorneys returned Newsy’s multiple requests for comment.
Advocates say the alleged actions of the former White House official and his son highlight larger concerns about what can happen when the little-regulated drug treatment industry doesn’t put patients before profits.
“What that does to the psyche of someone trying to work a program, work on his recovery, it’s shattering. It’s mentally and emotionally shattering them,” said Maureen Kielian of Southeast Florida Recovery Advocates.
Representatives Terri Sewell (AL) and David McKinley (WV) are trying to push through a new law ensuring that Medicare patients have equal access to “non-opioid” therapies after surgery. If they succeed then Medicare recipients will have earned the right to suffer along with the rest of us. Brilliant.
Despite a decade of indisputable evidence that we are not having an “opioid crisis.” but rather a “heroin/fentanyl crisis” you might think that people might start to figure this out and act accordingly.
No such luck. Legislators, policymakers, and other assorted ignorant and/or self-serving busybodies continue to play darts in a dark room with an Ikea bag over their heads. They cannot or will not see what is right in front of their collective faces – that 1) legitimate medical use of analgesics only rarely leads to addiction, and 2) more restrictions placed prescription analgesics has only resulted in more overdose deaths as well as ghoulish suffering of people in pain who need medications that they can no longer get. Yes, it is that obvious, but the false narrative that overprescription of painkilling drugs is responsible for today’s overdose deaths is like the Energizer Bunny – it just won’t quit.
No, I don’t have any idea why the Andrews Sisters are in there. They never sang the stupid song. Photo: The Growler
And the nonsense keeps coming, thanks to a mindless and misguided legislative effort that is making its way through the House of Representatives.
On the surface, a seriously awful bill that is being put forward by Rep. Terri Sewell (1), a four-term congresswoman in Alabama, would seem to be just more of the same – demonization of opioid analgesics to accomplish… whatever… and the usual blather about American deaths and addiction. But this one’s a bit different because of unintended irony.
Here’s a section of the November press release issued by Rep. Sewell’s office (emphasis mine):
Specifically, the bill would address payment disincentives for practitioners to prescribe non-opioid treatment alternatives in surgical settings by requiring CMS to place non-opioid treatments on par with other separately paid drugs and devices in Medicare Part B.
Rep. Sewell’s bill is an attempt to “level the playing field” by ensuring that Medicare patients will have “access to non-opioid treatments for pain.” In other words, Medicare patients will now have the same “right” to suffer as those who have private insurance by being forced to try the same unproven and ineffective “treatments”. Perhaps they can, as former Attorney General and permanent ignoramus Jeff Sessions said in 2018, “just take some aspirin sometimes and tough it out a little.” (See ‘Let Them Eat Aspirin’ – Jeff Sessions’ Painfully Ignorant Remarks)
And why? For a really stupid reason:
“Non-opioid treatments and therapies can be successful in replacing, delaying or reducing the use of opioids to treat post-surgical pain, and reduce the risk of opioid addiction.”
No, that’s just plain wrong. Let’s hear from some people who actually know what they’re talking about. Like ACSH advisor Dr. Dan Laird:
“Though we want to minimize opioid use when we can, the risk of opioid misuse, abuse, and addiction is low in post surgical patients. Unnecessary hysteria and anti-opioid zealotry harm patients; all medications have dangerous side effects but the overall benefit of opioids for post-surgical pain far outweighs the risk.”
Danial Laird, MD, JD 12/7/19
or ACSH advisor Dr. Jeff Singer:
“The likelihood of addiction, defined as compulsive use despite negative consequences, developing after taking just a few days worth of prescription opioids after leaving the hospital, is close to zero–as also the case with regard to physical dependence.”
Dr. Jeff Singer, 12/9/19
Or Dr. Thomas Kline, a specialist in geriatric medicine and long-time defender of pain patient rights:
“If the patient has had opiates before, the chance of addiction after surgery is zero. If not, that chance becomes 4 in 1,000 after age 12 and 2 in 1000 after age 20, largely due to genetic factors that control opioid addiction. In a recent study of 1,000 people given opioids following urological surgery two people became “street addicted.”
If Rep. Sewell really thinks that funding CMS to pay for non-opioid post-op treatments for the purpose of preventing addiction she is deluding herself.
Let’s take a look at some more of the bill (emphasis mine).
Congress finds the following:
(1) The United States is undergoing an epidemic of addiction and deaths caused by prescription drug overdoses. According to the [CDC], opioids are the main driver of drug overdose deaths accounting for 47,600 overdose deaths in 2017. Every day, over 130 people die in the United States from opioid overdoses.
I can’t believe that after all these years of refuting this crap I have to keep doing it. Yes, opioids are the main driver of overdose deaths, but not the legal prescriptions that Rep. Sewell is trying to restrict:
Let’s look at those 47,600 deaths (below). If you didn’t know any better this proposed legislation would lead you to believe that Vicodin is wiping out hoards of Americans. This is false. As I (and others) have written many times, the real killer is illicit fentanyl and its analogs (this is confusingly referred to as “synthetic opioids other than methadone” in Table 1 below). The fentanyls (illicit fentanyl and analogs) were involved in 28,466 deaths (60% of the total) in 2017 followed by heroin 15,482 (32%) of the overdose deaths. “Natural and semisynthetic opioids,” a confusing and ambiguous term for prescription analgesics were involved in 15,482 deaths (30%) (1,2).
Now let’s restate that portion of the bill so that it is factually correct: “Illegal opioids, mainly fentanyl and its analogs, and heroin are the main drivers of drug overdose deaths accounting for a huge majority of the 47,600 overdose deaths in 2017.
Table 1: Opioid overdose deaths (2014-2017) by opioid category. Note the massive increase in fentanyl-related deaths between 2014-2017. Source: CDC
If that’s not bad enough…
Research shows that patients receiving an opioid prescription after short-stay surgeries have a 44% increased risk of opioid use.
Please! Stop! This is making my hair hurt. People who get opioids after surgery are more likely to use them than people who don’t get opioids after surgery??? Seriously? Tell me that this isn’t conceptually identical to…
“People who lose their legs in auto accidents are less likely to subsequently develop athlete’s foot than those who do not.”
Rep. Sewell did not come up with this masterpiece on her own. She had help from Rep. David McKinley (West Virginia). Together they introduced the Non-Opioids Prevent Addiction in the Nation (NOPAIN) Act (H.R. 5172). McKinley’s incisive knowledge of medicine must certainly come from his former career… as an engineer:
“Our bill would ensure that CMS does not disincentivize the use of innovative non-opioid drugs and devices to treat and manage pain. While pain management for all patients should be handled individually, opioids should not be the first or only option given.”
Rep. David McKinley, B.S. Civil Engineering, 11/19/19
Sorry, Rep. McKinley. Whether opioids should or should not be given to post-surgical patients is something you know nothing about and is none of your business. Would you want Dr. Oz to redesign Hoover Dam?
Body Brokers Are Undermining Efforts To End The U.S. Addiction Crisis
