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When Will Forced Tapering of Opioids End?
Lynn Webster, M.D.
6-8 minutes
When Will Forced Tapering of Opioids End?

20th April, 2019

By Lynn Webster, M.D.

This article, in a slightly edited form, first appeared on Pain News Network on April 17, 2019.

“Larry” recently wrote to me asking for advice. He describes himself as “virtually crippled totally” after having his opioid medication cutback.

“I am being forced tapered and the PA I now have will not budge one inch on the weaning, as he calls it. I hate him. I have never had a more callous doctor in my life,” Larry wrote.

“What does one do in my situation? Blow my brains out? A[n] intentional overdose? I have two beautiful dogs that depend on me and a son who needs me. I have to stay here on planet Earth although I want out of here so bad I beg God to kill me every morning noon and night. It is my daily prayer.”

Unfortunately, Larry is only one of many patients who are struggling to be heard by their providers. Physicians are under government pressure to adhere to the CDC’s 2016 opioid prescribing guideline.

Although the CDC designed its guideline as voluntary, government agencies interpreted it as a mandate instead. The Drug Enforcement Administration has pursued doctors who prescribe a level of opioids that exceeds the guideline’s recommended daily limit of 90 MME (morphine milligram equivalent), even when no patients have been harmed.

According to Maia Szalavitz, writing for Tonic, Dr. Forest Tennant was one of the few physicians who still were willing to prescribe high-dose opioids for the sickest pain patients. The DEA raided his California office and home, allegedly because the agency had reason to believe some of his patients were selling their medication.

There simply was no evidence of that. But as a result of the raid, Dr. Tennant retired from clinical practice.

Szalavitz wrote that the raid “terrifies pain patients and their physicians, who fear that it could lead to de facto prohibition of opioid prescribing for chronic pain and even hamper end-of-life care.”

Dr. Mark Ibsen in Montana had his license suspended by the state medical board for allegedly overprescribing opioids. According to Dr. Ibsen, the DEA warned him “he was risking his livelihood and could end up in jail if he kept prescribing.” A judge later overturned the board’s decision.

As Dr. James Patrick Murphy, a Kentucky-based pain and addiction specialist, told the Courier-Journal, “many well-intended doctors are unfairly arrested ‘all the time’ in the hunt for those who recklessly contribute to patients’ addictions and fatal overdoses.”

As of this writing, The American University Law Journal plans to publish an alarming article by Michael Barnes, JD, about the raids on America’s top physicians.

Although few physicians are incarcerated for prescribing high dosages of opioids, many of them are threatened with losing their licenses to practice medicine. Doctors and pharmacists told a POLITICO survey that they felt enormous pressure to limit their prescriptions for painkillers. Their fear of the consequences of noncompliance with the CDC guideline exceeded their responsibility to treat patients with severe pain.
Second Thoughts About CDC Guideline

On April 1, the attorneys general of 39 states and territories wrote a letter on behalf of the National Association of Attorneys General to Dr. Vanila Singh of the U.S. Department of Health and Human Services. The letter expressed concern with the draft report of the Pain Management Best Practices Inter-Agency Task Force, which recommends changes in the CDC guideline to end the forced tapering of patients.

The attorneys general said “it is incomprehensible that officials would consider moving away from key components of the CDC guideline.” Additionally, they expressed their hope that the report would be revised “to clearly state that there is no completely safe opioid dose.”

Yet on April 9, the Food and Drug Administration issued a medical alert warning doctors not to abruptly discontinue or rapidly taper patients on opioid medication, because it was causing “serious harm” to patients, including uncontrolled pain, psychological distress and suicides.

Now it seems the CDC may be moving in the same direction.

Dr. Daniel Alford, a Professor of Medicine at Boston University, wrote a letter to the CDC asking it to address the misapplication of its guideline with a “public clarification.” He was writing on behalf of Health Professionals for Patients in Pain, and 300 healthcare professionals signed his letter.

The CDC’s response, published on April 10, echoed the FDA’s statement. CDC Director Dr. Robert Redfield observed that the CDC guideline “offered no support for mandatory opioid dose reductions in patients with long-term pain.” He reinforced the fact that the guideline was voluntary and that doctors should use their knowledge of their patients to determine which dosages were appropriate for them.

Dr. Redfield wrote that “CDC is working diligently to evaluate the impact of the Guideline and clarify its recommendations to help reduce unintended harms.” And he agreed that “patients suffering from chronic pain deserve safe and effective pain management.”

STAT News points out that the overzealous enforcement of the CDC guideline was indeed causing patients harm. “Denying opioids to patients who have relied on them — sometimes for years — may cause some to turn to street drugs, thereby increasing their risk of overdose,” STAT warned.

According to The Washington Post, “Many patients have claimed that long-term use of the drugs is all that stands between them and unrelenting pain, and that they can take the medication without becoming dependent or addicted.”

The CDC and the FDA now admit the guideline has been misapplied and mainstream media outlets are beginning to pick up the story. The question is: Will the DEA stop pursuing doctors who treat pain patients with levels of opioids that exceed the guideline’s recommendations?

For Larry and other pain patients who have been forcibly tapered, the answer may be a matter of life and death.

http://www.lynnwebstermd.com/forced-tapering/

Here is four quotes from the CDC opiates guidelines:

https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

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

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

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

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

The entire CDC guidelines are some 90 odd pages.   What “key components” of the CDC guidelines are they focused on 90 MME ? – out of 90+ pages.  I particularly like this quote from these 39 “medical experts”  to clearly state that there is no completely safe opioid dose… there is no really “safe dose” of ANY MEDICATION… they are trying to force our body to do something that it naturally wants to do.

The CDC guidelines completely ignores the fact that we have a test .. CYP-450 opiate metabolism test – a simple cheek swab – that will determine if a pt is slow, normal, fast, ultra fast metabolizer and the pt’s dose may have to be increased and/or frequency of the dose increased and/or BOTH !

These same guidelines IGNORE that all of the opiate conversion programs have a footnote stating – the same or similar – that the results of using these conversion programs – ARE CRUDE ESTIMATES AT BEST and should not be used as black/white pt dosing .. only as a starting point.

Some of us believe that the CDC did not have the statutory authority to even generate and publish these guidelines.  Maybe that is why the then head of the CDC Tom Frieden shortly after they were released made a public statement that these guidelines were just RECOMMENDATION and DID NOT HAVE THE AUTHORITY/WEIGHT OF LAW.  Could that have been a “back door” admission that the CDC did not have the legal authority to publish these guidelines ?  After all the CDC’s primary charge is dealing with contagious diseases.

But then when you assembly a committee to develop these guidelines that each has a personal interest in treating substance abusers, what would one expect but a final product that primarily deals with .  It also seems suspicious that this committee met behind closed doors and the CDC tried to keep the committee members anonymous .

So in the end we have 39 state AG’s who wish to continue honoring “guidelines” as LAW that were created by a Fed agency that may not have had the statutory authority to generate them in the first place and they may well be unconstitutional. 

Also it seems to be a quote from these AG’s “it is incomprehensible that officials would consider moving away from key components of the CDC guideline”.. so it would appear that these AG’s prefer to only chose a favorite sentence, paragraph or page out of the 90+ page document to be the “key components” that they wish to have adhered to.

It would not be the first time that a legislative body will have passed a bill that gets signed into law and remains on the books and is enforced until someone challenges the constitutionality of the law in the courts.  In our legislative system, there is no process to validate the constitutionality of a bill before it gets signed into law.

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Pain Patients Get Relief from War on Opioids

https://www.scientificamerican.com/article/pain-patients-get-relief-from-war-on-opioids/

U.S. agencies warn doctors not to abruptly cut off the medications for long-time users

Ever since U.S. health authorities began cracking down on opioid prescriptions about five years ago, one vulnerable group has suffered serious collateral damage: the approximately 18 million Americans who have been taking opioids to manage their chronic pain. Pain specialists report that desperate patients are showing up in their offices, after being told by their regular physician, pharmacy or insurer that they can no longer receive the drugs or must shift to lower doses, no matter how severe their condition.

Abrupt changes in dosage can destabilize patients who have relied for many years on opioids, and the consequences can be dire, says Stefan Kertesz, an expert on opioids and addiction at the University of Alabama at Birmingham School of Medicine. “I’ve seen deaths from suicide and medical deterioration after opioids are cut.”

Last week, after roughly three years of intensive lobbying and alarming reports from the chronic pain community, the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) took separate actions to tell clinicians that it is dangerous to abruptly curtail opioids for patients who have taken them longterm for pain. The FDA did so by requiring changes to opioid labels specifically warning about the risks of sudden and involuntary dose tapering. The agency cited reports of “serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide” among patients who have been inappropriately cut off from the painkillers.

One day later, CDC director Robert Redfield issued a clarification of the center’s 2016 “Guideline for Prescribing Opioids for Chronic Pain,” which includes cautions about prescribing doses above specific thresholds. Redfield’s letter emphasized that these thresholds were not intended for patients already taking high doses for chronic pain but were meant to guide first-time opioid prescriptions. The letter follows another recent clarification sent by the CDC to oncology and hematology groups, emphasizing that cancer patients and sickle cell patients were largely exempt from the guideline.

Taken together, these actions represent a significant victory for the chronic pain community. “The combination of the FDA and CDC speaking out reconfigures the conversation going forward in a very, very helpful way,”  says Kertesz, who was one of five doctors associated with the advocacy group Health Professionals for Patients in Pain (HP3) who received Redfield’s letter.

Tougher rules on opioid prescriptions from federal and state authorities, health insurance companies and pharmacies, were an understandable response to the nation’s “opioid crisis,” an epidemic of abuse and overdose that led to a 345 percent spike in U.S. deaths related to legal and illicit opioids between 2001 and 2016. Since 2016, most fatal overdoses have involved illegally produced fentanyl sold on the street, according to CDC data, but past research has shown that many victims got started with a prescription opioid such as oxycodone.

The CDC’s 2016 guideline was aimed at reining in irresponsible prescribing practices. (The agency’s own analysis showed that prescriptions for opioids had quadrupled between 1999 and 2010.) The guideline stressed that the first-line treatments for chronic pain are non-opioid medications and non-drug approaches such as physical therapy. When resorting to opioids, the guideline urged doctors to prescribe “the lowest effective dosage,” to carefully size up risks versus benefits when raising doses above 50 morphine milligram equivalents (MME) a day, and to “carefully justify a decision” to go to 90 MME or above.

That advice on dosage was widely misinterpreted as a hard limit for all patients. Kertesz has collected multiple examples of letters from pharmacies, medical practices and insurers that incorrectly cite the guideline as a reason to cut off long-term opioid patients.

Frank Gawin, a retired psychiatrist in Hawaii, is one of many chronic pain sufferers ensnared by that kind of mistake. For 20 years he took high-dose opioids (about 400 MME daily) to manage extreme pain from complications of Lyme Disease. Gawin, an expert on addiction himself, was well aware of the risks but notes that he stayed on the same dose throughout those 20 years. “It helped me profoundly and probably extended my career by 10 to 15 years,” he says. About five months ago, his doctor, a pain specialist he prefers not to name, informed Gawin and other patients that she would be tapering everyone below 80 MMEs because she was concerned about running afoul of medical authorities. Gawin has not yet reached that goal, but his symptoms have already returned with a vengeance. “As I am talking to you, I am in pain,” he said in a phone interview. “I’m having trouble concentrating. I’m depleted. I’m not myself.”

Last week’s federal actions could go a long way in informing physicians not to cut off patients like Gawin. Of particular value, say patient advocates and experts, is the emphasis on working together with patients on any plan to taper the drugs. “It’s finally about patient consent,” says Andrea Anderson, former executive director of the Alliance for the Treatment of Intractable Pain, an advocacy group. She notes that the FDA urged doctors to create an individualized plan for patients who do wish to taper and that the agency stated that “No standard opioid tapering schedule exists that is suitable for all patients.”

The CDC is relying on pain advocacy groups to get the word out about its clarification. Any formal update to the guideline will await the results of a systematic review of chronic pain research currently underway, said Debbie Dowell, chief medical officer of the CDC’s Injury Center, in an email; Dowell is the lead author of the 2016 guideline.

Gawin hopes the federal actions will persuade his doctor that forced tapering is wrong for him. “The only way I can see getting back to normal,” he says, “is to get back to the medication that worked for me.”

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Washington state lawmaker riles nurses by saying that some spend ‘considerable’ time playing cards

https://www.foxnews.com/politics/washington-state-lawmaker-riles-nurses-by-saying-that-some-spend-considerable-time-playing-cards

A Washington state lawmaker has provoked the ire of nursing professionals after saying that some nurses “play cards” for a “considerable” portion of their shifts.

State Sen. Maureen Walsh, R-Walla Walla, was debating a bill on Tuesday that would require uninterrupted meal and rest breaks for nurses and would also provide mandatory overtime protections for them.

Walsh pushed for an amendment that would exclude hospitals with fewer than 25 beds from the provision, arguing that such small facilities struggle to provide 24-hour care as it is.

“I would submit to you that those (small hospital) nurses probably do get breaks,” Walsh said, according to The Olympian. “They probably play cards for a considerable amount of the day.”

Walsh’s remarks were posted to a blog by the Washington State Nurses Association, receiving so many hits that the site crashed.

The ill-received comments also inspired plenty of social media mockery; the hashtags #maureenwalsh and #nursesplaycards went viral.

Walsh’s comments even drew backlash from comedian Kathy Griffin who said her mother worked in a hospital for decades.

The bill specifically requires that nurses and some other staff, such as surgical and diagnostic radiologic technologists, be given uninterrupted meal and rest periods, except when there is an unforeseeable circumstance.

If a rest break is interrupted before 10 complete minutes, an additional 10-minute break is required. The measure would also prohibit health care facilities from using what the nurses’ association considers a legal loophole to require overtime.

Ultimately the bill was passed with Walsh’s amendment. It previously passed the House without it but both bills will have to be reconciled before it can be signed into law.

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Commentary: Suicide Signals a Broken Health Care System

www.nationalpainreport.com/commentary-suicide-signals-a-broken-health-care-system-8839600.html

I read this article recently about a veteran killing himself in a VA waiting room and it brought me back to a recent conversation that we’ve been having on the National Pain Report about suicide.

And so, I spent some looking at the comments sections on the stories and was struck—again—by the increasing feelings of hopelessness and isolation that are permeating many people who have chronic pain.

The system is failing them.

When I was talking with Terri Lewis, Ph.D. recently about the topic, she said something that has stuck with me.

“Every person has a plan for exiting the planet when they’ve had enough. Remarkably, communities and health systems don’t have a plan.”

Hard to argue.

Reader Dave Brooks wrote about the importance of loved ones.

“The thought (of taking his life) has crossed my mind more than once. I keep going knowing my children always tell me they love me when I have a chance to talk to them… Always!!!

Elizabeth R. spoke about the fear that many are feeling in a place where they shouldn’t be fearful—their doctors’ offices.

“If We patients tell our doctors the truth about our pain and how it really affects us despite our efforts to manage it, we will be punished.”

A reader named Lindsey is at her wit’s end.

I have my suicide plan and materials ready. It gives me peace of mind. I have cancer also and am six months overdue on my surgery. I have so much pain that I KNOW I would never survive recovery on 2 or 3 days off extra pain relief

David Hickle expressed the fear that the government not only hasn’t been listening, it won’t.

“Our government isn’t going to listen all they are doing is buying their time covering their ass until they betray the American citizens, I don’t trust anyone anymore in the USA or humanity because whatever anyone says is a load of crap.”

When you consider that 22 veterans—at least some of them with chronic pain– are taking their lives EACH DAY and that many people who have chronic pain are telling us they are considering suicide, it tells you—or at least tells me—that this health care system is failing people.

It’s long past time to do something.

Don’t you agree?

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US Attorney expects more opioid take downs of medical providers in the future

https://whnt.com/2019/04/19/us-attorney-expects-more-opioid-take-downs-of-medical-providers-in-the-future/

MADISON COUNTY, Ala. – We’re learning more about the largest opioid takedown of medical providers in the nation. It resulted in charges against 60 individuals from seven states including Alabama. Three of the four arrests in Alabama are doctors from Madison County. US attorney for the Northern District, Jay Town, says investigations into doctors can take years. The task force completed theirs in just a few months.

To help combat the opioid crisis, the U.S. Department of Justice formed a strike force for the Appalachian region designed to investigate illegal opioid prescriptions and distribution.

“We ended up doing investigations that would normally take two years, took about 4 months,” Town said.

Town credits that to the use of resources. “We have hyper-accurate data at the DEA and other agencies in the federal government where we are able to that data and we can sort of pinpoint where these pills are being over-prescribed just by the population center in which they’re being prescribed.”

The takedown itself was coordinated in 18 hours. Town says 60 people were arrested, 31 were doctors who allegedly prescribed 32 million pills.

“That’s more pills than people in these states in which these cases are being prosecuted,” he said.

That sounds like a lot, but Town says it only scratches the surface of this issue.

“There are more doctors out there, there are more people working in clinics, and physicians offices, or pharmacies, or in compounding pharmacies, that we still have ongoing investigations or beginning investigations,” Town said.

And he is confident there will be more takedowns like this in the future.

“If you’re a doctor and you want to act like a drug dealer, we’re going to treat you like one. And sometimes the only difference between a doctor and a drug dealer is a white coat,” he said.

Often times, takedowns can leave patients without a doctor. This task force took measures to help patients. Town says they were able to get access to their file and agents directed them to clinics that are operating legally in the community.

Isn’t that NICE…these members of LAW ENFORCEMENT was able to get to the pt’s medical records and apparently made the “medical decision” which pts were LEGIT PTS and they DIRECTED them to clinics that are operating legally in the community.  However, did they know if these clinics had the capacity to accept these pts into the practice  and/or if the clinics would accept those pts in the first place.  Typically, when a prescriber’s practice is raided… the pts of those practices are treated like leopards by the other local clinics and few if any will be accepted by those practices as a pt.

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These Virginia counties are ignoring the real problem in the opioid crisis: Treatment

https://www.washingtonpost.com/opinions/local-opinions/these-virginia-counties-are-ignoring-the-real-problem-in-the-opioid-crisis-treatment/2019/04/19/b90e0788-57bb-11e9-9136-f8e636f1f6df_story.html

Roanoke, Roanoke County and Salem are joining a legal battle over the opioid addiction crisis by filing civil suits against drugmakers, distributors and pharmacy benefit managers. These lawsuits are part of a national push to hold companies accountable for irresponsible practices in the sale, marketing and distribution of opioid-based medications.

While these lawsuits might help somewhat, the real debate raging in the world of addiction is how best to treat it and the incorporation of medications into other long-standing treatment methodologies.

As a licensed professional counselor in Virginia, I have worked with people from all walks of life over the past 34 years. I have had the privilege of being a part of the recovery process for several thousand people dealing with what we now call “substance-use disorders.” The public hears about “addiction,” “substance abuse,” overdose deaths and the opioid crisis, but what we are facing is a human problem.

While counseling, talk therapy and self-help groups are valuable, they cannot be the only answers for everyone. We now have effective, safe medications that, when combined with traditional approaches, can give individuals with opioid and other addictions a fighting chance in the desperate battle to overcome the life-threatening consequences that often ensue.

Traditionalists continue to advocate an abstinence-based approach and often seek to blame pharmaceutical companies as in these lawsuits. Traditionalists see true recovery as consisting only of complete abstinence from mood-altering substances. Though this approach is consistent with that of many self-help groups and has certainly been helpful for millions of people, it has many holes.

People clearly benefit from prescription medications for physical or psychiatric conditions, and others are given a pass from the abstinence mentality for their use of more societally accepted substances, such as nicotine and caffeine. Effective medications, which allow people with an opioid addiction to replace high-risk opioid use with safer, “medication-assisted” therapy or treatment, are frequently frowned upon by traditionalists who insist on an outdated, one-size-fits-all model that is inconsistent with research and developing approaches.

On the other side of the debate is the medical community, supporting the use of new and promising medications that can be both lifesaving and humane. Places such as Phoenix House Mid-Atlantic, based in Arlington, are successfully incorporating approaches such as office-based opioid treatment into their treatment strategies, with much success.

Medications such as suboxone and methadone allow people with an opioid-use disorder (addiction) to replace high-risk opioid use with safer, medication-assisted therapy or treatment, while naltrexone blocks the effects of opioids and can be administered either orally or via a monthly injection known as Vivitrol. Naloxone (or the brand name Narcan), which is better-known, provides a lifesaving response in the case of an overdose, reversing the opioid’s effects and saving countless lives. These approaches, however, are too frequently criticized by the abstinence community and some segments of the general public for not being a permanent solution or simply replacing one addiction with another.

We even limit the number of patients that physicians approved to prescribe suboxone may have on their caseloads, an unprecedented and even unfathomable reality when one considers the scope of the opioid crisis.

Of course, simply throwing medication alone at a problem of this magnitude will have only a minimal impact at best. People with the complex set of problems associated with substance-use disorders need effective, trained counselors and access to a wide variety of services to enable them to return to full health and functioning.

The question, then, is when will we embrace an approach that designs and provides specific care to meet the needs of the particular individual in question. Drawing from both arenas is the only way to meet the crisis, which is claiming more than 70,000 lives annually across the United States, including more than 1,100 in Virginia. A frank, no-holds-barred dialogue is needed and immediate action required to address this public-health emergency.

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https://bkbooks.com/blogs/something-to-think-about/8-things-to-consider-regarding-end-of-life-pain-management-1#

There is so much confusion and fear regarding end of life pain medicines, morphine in particular, that I am addressing what I consider major issues. I have made the list simple, short, and to the point so that you can use this as a guideline when your loved one is receiving a narcotic.

* To be effective, pain medicine needs to be given on a regular, around the clock, schedule.

* Over time the original dosage may have to be increased.

* Everyone’s pain is different so everyone’s pain medicine and amount will be different.

* There is no standardized medicine dosage for pain. It takes time to find the correct pain medicine and the correct amount.

* The biggest fears about taking narcotics for pain management is fear of addiction and overdosing.

* Most medicines given by mouth can be given rectally. Some pain medicines can be made into creams and rubbed on the skin.

* Generally there isn’t a need for needles in end of life pain management.

* Pain doesn’t stop when a person is non-responsive. Continue the pain management schedule until death.

I am adding an additional caveat to the above knowledge: Dying is not painful. Disease causes pain. If pain has not been an issue during the disease process then just because a person is actively dying does not mean they are in pain. If pain has been an issue during the disease process that pain is present to the last breath.

Often dying looks painful to the people watching. Dying is a struggle to get out of the body. There are sounds that ordinarily would indicate discomfort but, when a person is actively dying, are part of the struggle. Just as the little chick works to get out of its shell, a person works to get out of their body. It takes effort to release from our body. That includes rattling and gasping sounds, twitching, random hand and leg movements, picking the air, facial grimaces, and talking that doesn’t make sense. All of this is part of the natural struggle to get out of the body. Nothing bad is happening, nothing pathological. This is how people and other animals die.

What I have described in the paragraph above is generally interpreted as an expression of pain unless someone tells the watchers differently. That is where knowledge of end of life and the dying process comes in, that is where health care professionals can give important guidance IF they, themselves, understand the normal natural way people die. Sadly to say, all too often, even health care professionals do not know.

Something More about… 8 Things to Consider Regarding End of Life Pain Management

To educate families who have a loved one in the dying process, I encourage the palliative care team and the hospice team to give them Gone From My Sight (the hospice Blue Book) and show them the 25 minute film NEW RULES for End of Life Care.  To educate the palliative care and hospice team (social workers, chaplains, nurses and volunteers) I encourage agencies to watch THIS IS HOW PEOPLE DIE.  Both films check the boxes for continuous care of families and agencies with medicare and raise CAHPS scores.

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Colorado’s new U.S. attorney wants law enforcement to treat overdose deaths as homicides as he focuses on opioids

www.coloradosun.com/2019/04/15/jason-dunn-us-attorney-colorado-opioids/

Jason Dunn, appointed by President Trump, laid out some of his office’s redoubled tactics in an interview with The Colorado Sun — his most extensive remarks to the news media since taking office

Jason Dunn. (Provided by Brownstein Hyatt Farber Schreck)

Jason Dunn, Colorado’s new U.S. attorney, has made stemming the state’s opioid epidemic a top focus of his office, encouraging law enforcement in the state to investigate deaths as homicides. He is also digging into data on doctors and nurses who prescribe unusually large quantities of opioid painkillers, with an eye toward prosecuting those who are illegally diverting the drugs and, he feels, adding to the scourge of heroin.

“You have dealers who either know they are selling fentanyl instead of heroin or know that it has already caused death and continue to sell it,” Dunn said in an interview with The Colorado Sun Friday in his downtown Denver office, where he offered his most detailed remarks since taking office in October. “We think they’ve met the required element that they can be charged.”

The tactics mark a redoubling of efforts that began in Colorado’s U.S. Attorney’s Office under Dunn’s predecessors and amid growing efforts statewide to tackle an epidemic that killed 560 Coloradans in 2017. They also come after Dunn warned Denver against a proposal to allow a supervised drug consumption site where people could inject heroin under the watch of a medical professional in an effort to reduce overdose deaths.

“We created a task force within our office that’s both criminal and civil,” Dunn said. “The civil side is really interesting because it’s focused on the diversion of opioids — from doctors, pharmacies, nurse practitioners. Clearly, if we can get people to stop abusing prescription opioids, then we can have a huge impact on the heroin problem.”

Federal prosecutors in Colorado have been combing through Medicare and Medicaid databases, as well as the records of Tricare, the military health insurance program, to find out which medical professionals are prescribing the most opioids, including OxyContin, in the state. They are also looking to see if they have patients who are traveling long distances, an indication that a person might be seeking out drugs for illicit reasons.

“You can see, when you start charting it, where the top people are,” he said. “… There’s a three-drug cocktail of opioids that apparently enhances the opioid high. We look at, OK, which doctors are prescribing that three-drug cocktail the most. Because there’s really no reason you would do it other than for illegitimate purposes. So we’re using that data and we’re starting to see some success with that.”

In terms of what those successes are, Dunn said, “most of it, I can’t go into detail because they’re ongoing investigations.”

“While there are a lot of U.S. attorneys around the country that are doing that data mining, we’ve taken it to kind of another level,” Dunn said.

Dunn said his attorneys have been working to get access to Colorado’s state-level opioid prescribing database, which has far more information. But the information is only available via subpoena, which the federal prosecutor called a “hindrance.”

“There’s a state statute that says law enforcement can’t get access to that database without a subpoena and only in a specific investigation. So we’ve served subpoenas and gotten it on a specific case-by-case basis,” he said. “But we really would love to have that data, even if it’s anonymized initially to mine it and see where the statistical outliers are. We’ve had conversations with the state about that.”

State Sen. Brittany Pettersen, a Lakewood Democrat who is heavily vested in ending the opioid crisis, said she would like to see enforcement action focused on pharmaceutical companies and not on doctors and nurses. She said charging those medical professionals could lead to more problems.

MORE: The opioid maker being sued by Colorado for fanning the overdose epidemic says everything it did was FDA-approved

“More people will die because they will be cut off from their prescriptions,” she said. “They will go to heroin to deal with their withdrawal.”

Dunn calls his plan to approach overdose deaths as homicides a “street-level” approach.

There’s currently a national debate about charging drug dealers in overdose deaths. Opponents worry that doing so would prevent people from seeking help in an overdose situation and question if it really serves as a deterrent.

Pettersen, whose mother has struggled with heroin addiction, cautioned against criminalizing the issue. She says she has nothing but hatred for the man who introduced her mom to heroin and would give the drug to her, even while she was in the hospital. But Pettersen said she recognizes that he, too, had a problem.

“It’s incredibly complicated,” she said. “A lot of people who are dealing drugs are also addicted and trying to feed their habit. They are doing desperate things to feed their disease. Throwing these people in jail is not going to solve the opioid crisis.”

Many states, Colorado not among them, either have specific laws on the books to use in those situations or are considering them. The federal government also has a distribution of heroin resulting in death charge.

Fifth Judicial District Attorney Bruce Brown, a Democrat whose territory covers Summit and Eagle counties and surrounding areas, has been using this tactic for years. His office has successfully pursued a number of cases against people who provided the heroin used in fatal overdoses, charging defendants with criminally negligent homicide, manslaughter or drug distribution offenses.

“Generally speaking, the law enforcement community customarily treated people who overdosed not so much as victims of crime, but maybe victims of their own criminality,” Brown said. “I have tried and worked very hard with our local law enforcement to convince them that they are homicides and the people who overdose have a health issue.”

Brown said Colorado’s safe-harbor law should prevent people who call 911 in an overdose situation from facing charges. But, he said, whether the tactic serves as a deterrent is a difficult question to answer, though he’s hopeful.

“Our goal is that the dealers think twice,” Brown said. “I do think that in some way there’s a likelihood that we’re saving lives. Can we definitely say that? No.”

Dunn said his office has set up a training program to encourage local law enforcement in Colorado to treat overdose deaths not as accidents, but as potential homicides with crime scenes.

He is urging law enforcement officers to check fatal overdose scenes for pill bottles or cellphones with information that might point investigators toward the drug supplier.

“We’re trying to encourage local law enforcement to actually contact us,” Dunn said. “We’re actually giving them the name of one of our attorneys here that, even in the moment at the scene, to call him and he can say, ‘Look, do this, this, this and this at the scene and treat it like a homicide.’”

Dunn’s office already has successfully prosecuted one Denver-area heroin dealer in a case involving an overdose and in which a woman’s body was dumped in an alley. A second person also has been charged in that case.

During the interview, Dunn re-emphasized his opposition to a supervised drug-consumption site in Colorado. That idea, an attempt to bring a first-in-the-nation program to Denver following a similar effort in Vancouver, Canada, has been shelved.

“I think a safe-injection site is a bad idea,” he said. “Again, we don’t weigh in on specific legislation or city ordinances, but I felt like it was important to let people know that we take that very seriously and that the Department of Justice takes it very seriously. I felt like the right thing to do was, working with the Drug Enforcement Administration, to let the city and the state and the public know that we will treat that seriously and that federal law enforcement will engage if such a facility were opened.”

Dunn said that if such a site were to open, there are a range of options he could take to push back. “It ranges from everything from asset seizure — seize the facility — to civil under the Controlled Substance Act all the way to criminal (charges) for individuals.”

Whatever happened to our FOURTH AMENDMENT – probably cause and unreasonable search and seizure ?

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Patient Privacy in the Pharmacy

https://www.managedhealthcareconnect.com/content/patient-privacy-pharmacy

April 18, 2019

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The Real Headline From The CDC Report On Kratom Being Detected In Medical Examiner And Coroner Reports

https://www.ptcommunity.com/wire/real-headline-cdc-report-kratom-being-detected-medical-examiner-and-coroner-reports

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