The War on Drugs Breeds Crafty Traffickers

Posted on April 3, 2018 by Pharmaciststeve

www.nytimes.com/2018/03/26/opinion/war-on-drugs-trafficking.html

The drug war in the Philippines has claimed 12,000 to 20,000 lives in mostly extrajudicial killings. This man was found dumped on

the side of the road in Manila in 2016; his hands were tied behind his back and his head wrapped in packaging tape.

www.nytimes.com/2018/03/26/opinion/war-on-drugs-trafficking.html

Politicians often escalate drug war rhetoric to show voters that they are doing something. But it is rare to ignore generations of lessons as President Trump did earlier this month when he announced his support for the execution of drug traffickers.

This idea is insane. But the war on drugs has never made any sense to begin with.

Executing a few individual smugglers will do little to stop others because there is no high command of the international drug trade to target, no generals who can order a coordinated surrender of farmers, traffickers, money launderers, dealers or users. The drug trade is diffuse and can span thousands of miles from producer to consumer. People enter the drug economy for all sorts of reasons — poverty, greed, addiction — and because they believe they will get away with it. Most people do. The death penalty only hurts the small portion of people who are caught (often themselves minorities and low-level mules).

Indeed, on the ground, the threat of execution will even help those who aren’t caught because they can charge an increased risk premium to the next person in the smuggling chain. The risk of capture and punishment increases as drugs move from farm to processing lab, traversing jungles, through cities, across oceans, past borders, distributed by dealers and purchased by consumers. The greater the risk to smugglers in this chain, the more they can demand in payment.

Without the drug war, substances like cocaine, heroin, marijuana and meth are minimally processed agricultural and chemical commodities that cost pennies per dose to manufacture. But lawmakers have invented a modern alchemy called drug prohibition, which transforms relatively worthless products into priceless commodities for which people are willing to kill or die.

The kind of get-tough measures that may give one country leverage against another have little effect among individual actors who need only to move drugs through their own segment of the supply chain. Indeed, by making the drugs ever more valuable, they have only amplified the motivational feedback loop of the very people lawmakers are trying to stop.

An overreliance on intensive policing over the decades has also produced a rapid Darwinian evolution of the drug trade. The people we have typically captured tend to be the ones who are dumb enough to get caught. They may have violated operational security, bragged too much, lived conspicuous lifestyles or engaged in turf wars. The ones we usually miss tend to be the most innovative, adaptable and cunning. We have picked off their clumsy competition for them and opened up that lucrative economic trafficking space to the most efficient organizations. It is as though we have had a decades-long policy of selectively breeding supertraffickers and ensuring the “survival of the fittest.”

To support his case for executions, Mr. Trump cites draconian penalties in other countries. Iran has used the death penalty extensively in drug cases, but more than 2.8 million Iranians still consume illicit drugs. Earlier this year, the Iranian government even repealed the use of executions in most drug cases which could spare up to 5,000 people on death row.

Mr. Trump often praises President Rodrigo Duterte’s brutal drug war in the Philippines, which has claimed 12,000 to 20,000 lives in mostly extrajudicial killings. But there is little indication that drug use has actually decreased. In fact, as the killings have increased, so too have the government’s drug use estimates. What began as 1.8 million users at the beginning of 2016 grew to three million and later four million. Last September, the Philippine Foreign Secretary, Alan Peter Cayetano, even raised that estimate to seven million. The higher numbers are likely inflated, but more killings do not appear to reduce the number of users.

Singapore notoriously refuses to publish reliable drug-use statistics, so there is no way to show whether executions have any measurable effect on drug consumption. As Harm Reduction International pointed out, however, Singapore’s seizures for cannabis and methamphetamine increased 20 percent in 2016 while heroin seizures remained stable. Moreover, 80 percent of Singapore’s prisoners are incarcerated for drug-related offenses. All of this suggests, Singapore’s famous panacea to solve the drug problem is not as miraculous as it seems.

Mr. Trump also cited his border wall as a way to reduce overdoses. In the unlikely event that the wall puts a significant dent in heroin smuggling, it could actually cause overdoses to skyrocket in this country because it would give dealers an incentive to adulterate remaining heroin supplies with even more fentanyl to stretch their profits. Fentanyl is more compact, much easier to obtain and dramatically more potent.

Mr. Trump is not advancing a new strategy to deal with opioids. It was President Clinton who put these death penalty statutes on the books as part of the 1994 crime bill, but they remain unused. Mr. Trump and Attorney General Jeff Sessions are trying to change that. They want to use those laws in racketeering cases and ones involving large quantities of drugs even though the Supreme Court has ruled that capital punishment should be reserved only for crimes resulting in death.

The Donald Trump of 2018 should take a lesson from the Donald Trump of 1990 when he told the Miami Herald: “We are losing badly the war on drugs. You have to legalize drugs to win that war.”

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AG Sessions: Chronic pain should be able to be cured… no need for long term opiates ?

Posted on April 3, 2018 by Pharmaciststeve

Doctors and Pharmacists Arrested in DEA Surge

https://www.painnewsnetwork.org/stories/2018/4/2/doctors-and-pharmacists-arrested-in-dea-surge

The U.S. Drug Enforcement Administration has arrested 28 people and revoked the registrations of over a hundred others in a nationwide crackdown that targeted prescribers and pharmacies that dispense “disproportionally large amounts” of opioid medication.

For 45 days in February and March, a special team of DEA investigators searched a database of 80 million prescriptions, looking for suspicious orders and possible drug thefts.

The so-called “surge” resulted in 28 arrests, 54 search warrants, and 283 administrative actions against doctors and pharmacists.  The DEA registrations of 147 people were also revoked – meaning they can no longer prescribe, dispense or distribute controlled substances such as opioids.

“DEA will use every criminal, civil, and regulatory tool possible to target, prosecute and shut down individuals and organizations responsible for the illegal distribution of addictive and potentially deadly pharmaceutical controlled substances,” Acting DEA Administrator Robert Patterson said in a statement.

bigstock-Corrupt-Male-Doctor-120540008.jpg

“This surge effort has demonstrated an effective roadmap to proactively target illicit diversion of dangerous pharmaceuticals. DEA will continue to aggressively use this targeting playbook in continuing operations.”

The DEA surge is the latest in a series of steps taken by Attorney General Jeff Sessions to crackdown on opioid prescribing. Last August, Sessions ordered the formation of a new data analysis team, the Opioid Fraud and Abuse Detection Unit, to focus solely on opioid-related health care fraud. 

Sessions also assigned a dozen prosecutors to “hot spots” around the country where opioid addiction is common.  Last week the DEA said it would add 250 investigators to a task force assisting in those investigations.

Although overdose deaths are primarily caused by illicit drugs such as fentanyl, heroin and cocaine, federal law enforcement efforts appear focused on opioid prescribing. Doctors and pharmacists are easier to target because they are already in DEA databases, as opposed to drug dealers and smugglers operating in the black market.   

As PNN has reported, the data mining of opioid prescriptions — without examining the full context of who the medications were written for or why – can be problematic and misleading.

For example, last year the DEA raided the offices of Dr. Forest Tennant, a prominent California pain physician, because he had “very suspicious prescribing patterns.” Tennant only treated intractable pain patients, many from out-of-state, and often prescribed high doses of opioids because of their chronically poor health — important facts that were omitted or ignored by DEA investigators.

Tennant has not been charged with a crime and denied any wrongdoing. Nevertheless, he retired this month due to the stress and uncertainty caused by the DEA investigation. About 150 of his patients now have to find new doctors, not a simple task in an age of hysteria over opioid medication.

In an interview with AARP, Sessions defended the use of data mining to uncover health care fraud.

“Some of the more blatant problems were highlighted in our Medicare fraud takedown recently where we had a sizable number of physicians that were overprescribing opioid pain pills which were not helping people get well, but instead were furthering an addiction being paid for by the federal taxpayers. This is a really bad thing,” Sessions said.

“It’s a little bit like these shysters who use direct mail and other ways to defraud people. They will keep doing it until they’re stopped. In other words, if we don’t stop them, they will keep finding more victims and seducing them.”

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Did DEA Create “FAKE” Opioid “Crisis” to Screw doctors and patients?

Posted on April 2, 2018 by Pharmaciststeve

Filed under: General Problems | 6 Comments »

Medicare Finalizes Plan to Reduce High Dose Opioids

Posted on April 2, 2018 by Pharmaciststeve

https://www.painnewsnetwork.org/stories/2018/4/2/medicare-finalizes-plan-to-reduce-high-dose-opioids

The Trump administration has finalized plans that will make it harder for many Medicare patients to obtain high doses of opioid pain medication. Medicare beneficiaries will also be limited to an initial 7-day supply of opioids for acute pain. Read more about cortexi.

Under new rules released today for the 2019 Medicare Part D prescription drug program, a ceiling for opioid doses will be established at 90mg morphine equivalent units (MME).  Any prescription at or above that level would trigger a “hard safety edit” requiring pharmacists to talk with the prescribing doctor about the appropriateness of the dose. If satisfied with the explanation, the pharmacist could then override the edit and fill the prescription.

Under an earlier proposal, only insurers could decide whether to override a safety edit – a requirement that would have essentially made them the final arbiters in deciding who gets high doses of opioid pain medication.

The new rules adopted by the Centers for Medicare and Medicaid Services (CMS) will still allow insurers to implement safety edits, but only at a much higher dose of 200 MME or more.  Insurers will also be given greater authority to identify beneficiaries at high risk of addiction and to require they use “only selected prescribers or pharmacies.”

CMS is also adopting a new policy that requires all new opioid prescriptions for short term acute pain to be limited to no more than 7 days’ supply. Several states have already adopted similar measures. Take a look to these cortex reviews.

CMS logo.png

CMS said this “tailored approach” to opioid prescriptions was needed to address what it called “chronic opioid overuse” at the pharmacy level and to encourage support for the CDC’s 2016 opioid prescribing guideline.

“CMS believes it is important that (insurers) set expectations for prescribers to implement the CDC’s recommendations as a best practice through their provider contracts. PDPs (prescription drug plans) should also reinforce these messages through interactions with prescribers as an integral component of sponsors’ drug utilization management program,” CMS said.

“We also recommend that beneficiaries who are residents of a long-term care facility, in hospice care or receiving palliative or end-of-life care, or being treated for active cancer-related pain are excluded from these interventions.”

About 1.6 million Medicare beneficiaries met or exceeded opioid doses of 90mg MME for at least one day in 2016. The 90mg MME ceiling established by the CDC was only meant as a recommendation for primary care physicians, but has been widely adopted as a rule by other federal agencies, insurers, state regulators and prescribers.

‘Cruel’ Limits on Opioid Prescribing

“The 90 mg dose they set as a threshold for ‘high’ or overuse is flawed and not scientifically based.  It is totally arbitrary,” says Lynn Webster, MD,  a pain management expert and past president of the American Academy of Pain Medicine.  “It is cruel to impose such a limit on people with involuntary dose reductions who have been functioning well without signs of abuse for years. These are the Best weight loss supplements.

“Even the 7 day limit is misguided at best. The average length of time a person requires an opioid post-op involves several factors and include the type of operation, the genetics of the person and the type of medication. The literature states the duration of pain requiring treatment with an opioid post-operatively is 4-9 days for general surgery, 4-13 days for women’s health procedures and 6- 15 days for musculoskeletal procedures.  This means half of the Medicare patients will receive less than half of what they will need.”  

“This is archaic medicine and does more harm than one can imagine,” wrote pain patient Henry Yennie. “The DEA, HHS, private insurers, and now CMS are pursuing policies and restrictions that will cause harm and suffering to millions of people.”

“I cannot understand how Medicare can be so uncaring about the pain people have,” wrote Mikal Casalino, a 72-year old pain patient. “Limiting the dosage to an arbitrary amount is not going to be helpful for individuals.”

A joint letter opposing the rule changes was also submitted by 180 doctors and academics, including some who helped draft the CDC guidelines. The letter points out that a steep reduction in high dose prescribing since 2010 has not reduced the number of opioid overdoses. And it faults CMS for being focused on reducing the number of high dose prescriptions – not the quality of patient care.

“The proposal does not consider adverse impacts on pharmacies, physicians or patients…and it will accelerate patient abandonment,” the letter warns. “The plan avows no metric for success other than reducing certain measures of prescribing. Neither patient access to care nor patient health outcomes are mentioned.”

CMS contracts with dozens of insurance companies to provide health coverage to about 54 million Americans through Medicare and nearly 70 million in Medicaid. CMS policy changes often have a sweeping impact throughout the U.S. healthcare system because so many insurers and patients are involved.  The new Medicare regulations will go into effect on January 1, 2019.

HHS/CMS has a anti-discriminatory policy for itself and all the vendors/providers of Medicare/Medicaid pts. They also have a FREEDOM OF CHOICE OF PROVIDER by pts.

Here is a website to file a complaint to HHS about being discriminated against and/or violating a pt’s freedom of choice of vendors/providers

https://forms.oig.hhs.gov/hotlineoperations/index.aspx

It appears the CMS is going to “dump” on to the Pharmacist filling the prescription the responsibility and decision to fill or not to fill.  So if a pt is denied medically necessary opiates by the Pharmacist. Who is going to be responsible… the Pharmacist, the company the pharmacist works for… HHS/CMS… the PBM, part D provider or Medicare Advantage – if that is the pt’s coverage… OR EVERYONE ?

Since one of the basics of the practice of medicine is the starting, changing, stopping a pt’s medication and CMS is going to basically grant Pharmacists their authority. A healthcare professional that does not have access to the pt’s entire medical record, nor has the training to be able to legally perform a in person physical exam and we are talking about the treatment of a subjective disease..  besides not having the pt’s medical records.. there is no tests from which the pharmacist could base their decision to fill or not fill…   WHAT COULD GO WRONG ?

All this FUSS over about 4% of the Medicare population that is taking opiates above 90 MME daily and many of those MME calculation are done with conversion tables that are “crude estimates” and there seems to be no provision for those pts who are confirmed fast/ultra fast metabolizers. This seem rather odd since there is an estimated 20 -30 million pts suffering with intractable chronic pain .. which would suggest that many would actually need doses higher than 90 MME.

There are several tips and tricks to eating healthy. Many of these ideas can be challenging to accomplish in today’s busy world. Still, they can give you the edge you’ve been looking for in a healthy lifestyle.

How Does a Healthy Plate Look Like?

  • ¼ of the plate with grains, choose at least 50% whole grains (whole wheat bread, Brown Rice, etc.).
  • ¼ of the plate with protein choices vegetarian or non-vegetarian, choose eggs, fish, lean meat, chicken, beans, cheese, and nuts.
  • ½ of the vessel to be loaded with colorful fruits and veggies.
  • Hydrate adequate. Drink water- 30ml/kg body weight is the requirement. Find yours and start to sip.

 

Fruit vs Fruit Juice

Fruit

  • 62 Kcal
  • More Fiber
  • Less concentrated fructose
  • Fewer calories
  • Lower glycemic index

Juice

  • 112 Kcal
  • Less fiber
  • More concentrated fructose
  • More calories
  • Higher glycemic index

How to Include Fruits in the Diet

  • Snack on fruits
  • Try fruit as dessert
  • Delight your sweet tooth by eating healthy with fresh fruit yogurt, parfaits, and dried fruits
  • Including fruit with breakfast or as dinner snacks is eating healthy

What is One Serving of Fruit?

  • 1 medium-size fruit
  • ½ cup fruit salad
  • ¼ cup Dried fruits
  • ½ cup fresh juice
  • Include at least two servings of fruit a day

Are You Drinking Enough Water?

How Much Water Should You Drink Per Day?

30 ml X Actual body weight (Kg) Note: Restrict fluids; if any medical conditions, or if recommended by the Physician

  • Thirst is the first signal of Dehydration
  • Check the urine color
  • The dark color indicates dehydration
  • Lighter the color, better hydration
  • Dry skin
  • Dry lips
  • Less urination
  • Feeling tired, dizzy, and headaches

How to increase water intake?

  • Keep a water bottle next to you or a reachable place.
  • Use a mobile app to remind and measure your intake.
  • Fancy bottles attract and improve the intake.
  • Infused water (Lemon, Ginger, and Mint) to enhance the taste.

What is the Healthy Thing to Snack on?

Most times the snacks are the unhealthiest stuff chosen. Portion-sized healthy snacks are a great way to follow small frequent meal patterns. Read more about Adderall otc.

A healthy snack

  • Being between meal times is a good option to decrease hunger and prevent overeating at meal times.
  • boosts the metabolism, sustains the energy levels, and can overcome cravings.
  • to be chosen wisely, because unhealthy snacks lead to weight gain.
  • should be low in sugar, salt, and fat.
  • can be fruit or veggie salad or whole-grain snacks or low-fat dairy instead of junk.
  • can be a combination of Protein + Carbohydrate choices that can keep the stomach full for a longer time. Eg: Yogurt and fruits, Hummus with Vegetable sticks or cheese with fruit slices, etc.

Some sensible snack replacements:

  • Mixed nuts( 1 ounce)
  • Low-fat Yogurt/ laban (1 cup)
  • Fruits (1 serving)
  • Dark Chocolate (30 gm)
  • Air Popped Popcorn( 3 cups)

Why Is Fiber Good for You?

Benefits:

  • Helps maintain bowel health and Prevents constipation.
  • Helps in lowering blood cholesterol levels.
  • Helps in better control of blood sugar levels.
  • Keeps the stomach full.
  • Aids achieving healthy body weight.

Recommendation:

  • 14g of fiber for every 1000Kcal
  • Females: 25g/day Males: 38g /day

Tips to increase fiber in your diet

  • Include lean veg proteins-Beans, peas, and lentils.
  • Snack on nuts and seeds.
  • Increase your fruit and vegetable intake.
  • Have the fruit instead of the juice.
  • Don’t peel the fruit or veg before consuming it.
  • Go for whole-grain products (at least 50% can be whole grains).

You can also find the best fiber supplements at buoyhealth.

How Physically Active Are You?

Inactive: less than 5,000 steps per day

Average (somewhat active): ranges from 7,500 to 9,999 steps per day

Active: more than 10,000 steps

Very active: more than 12,500 steps per day

Tips to Include More Steps to Your Day

  • Park farther away
  • Walk while waiting
  • Take the stairs
  • Consider a walk with the family. Check these liv pure reviews.
  • Take your pet for a walk
  • Take the farthest way
  • Talk in person. Rather than instant-messaging or emailing with coworkers, get up and walk to their desks
  • Walk during your kids’ activities
  • Start increasing your goal gradually by adding 500-1000 extra steps every 3-4 days

Filed under: General Problems | 6 Comments »

Jeff Sessions, Donald Trump say ‘tough it out’ without opioids but they never felt my pain

Posted on April 2, 2018 by Pharmaciststeve

Jeff Sessions, Donald Trump say ‘tough it out’ without opioids but they never felt my pain

https://www.usatoday.com/story/opinion/2018/04/02/jeff-sessions-donald-trump-opioids-epidemic-death-penalty-real-pain-column/374829002/

President Trump’s new proposal to combat opioid addiction included some very tough talk about a tragic problem, so it was easy to miss one ambitious goal: slashing legal opioid prescriptions by one-third.

Similarly, when Attorney General Jeff Sessions suggested that part of the problem is that not enough people are willing to “tough it out,” and that they should be just taking aspirin instead, he quickly got my attention. Recently, I tried to do just that.

In early November, at the age of 53, I spent a week in the hospital and was eventually diagnosed with multiple myeloma, a plasma cancer. Thankfully, there are a variety of treatments that hold the promise of long-term remission. But in the short term, multiple myeloma can be extraordinarily painful and many patients can only get relief by using prescription painkillers such as opioids.

Concerns over opioids are not unfounded. The CDC reports that overdoses from prescription opioids have quadrupled since 1999, numbering over 20,000 in 2015. Those numbers are of real concern, but we cannot forget that there are also real, tangible costs of living with pain — and that pain relief is part of the healing process for patients like me.

Multiple myeloma eats away at the calcium in your bones, weakening them. In my case, it went after my back, causing two small stress fractures and numerous lesions, all of which were extremely painful.

 In the hospital, I was able to deal with that pain using Tylenol, mostly because I was just in a bed or chair all day. I declined the offer of prescription painkillers when I was discharged. One reason was that worries about opioid addiction had me concerned. Unfortunately, it didn’t take long for the pain to become serious once I got home and started moving more.

People who wish to drastically limit access to opioids need to know the reality of this kind of pain. Getting out of bed took 10 minutes or more because even one small wrong movement while getting to a sitting position would cause severe back spasms, making me shudder with pain. Walking around my house required balancing myself on walls and door frames.

 The pain from sitting down and standing up from the toilet required that I use a chair to hold my weight like one would use a walker. I had visions of being found in the bathroom, stuck on the toilet or even unable to get up off of the floor. Every little twist and turn of my body risked those spasms and shuddering.

Eventually I realized my mistake and got a prescription for opioids. The quality of my life quickly and dramatically improved, as within two or three days, the pain was reduced substantially and my mobility and mood were significantly better. I could walk comfortably and hug my kids again.

It’s important to understand that this kind of debilitating pain not only causes unnecessary suffering, it prevents patients from healing. It takes every bit of energy you have to fight it, and your body has little to nothing left to use to heal. Some medical professionals call pain “the fifth vital sign” because of the way in which it matters for a patient’s health. Opioids enabled me to relax, to sleep and to heal.

Four months later, I am almost completely pain-free and have been largely able to resume most of my normal activities. Blood work indicates that my chemotherapy is beating back the cancer. Access to opioids has without a doubt been a key factor in how quickly my health has improved.

The controversy around opioids makes people fear legitimate and humane medication. I can’t get back that week I spent in pain. I can’t erase the experience of watching my kids and the rest of my family seeing me suffer.

Policymaking that ignores the benefits of opioids and focuses only on the drawbacks —as serious as they are — is unacceptably one-sided, and passing such policies will mean that thousands, if not millions, will suffer unnecessary pain and fail to heal as they should.

Tackling opioid overuse may indeed require a serious overhaul of a health care system in which some doctors find it easier to throw pills at patients than talk to them. And when those pills are paid for by third parties, the incentives to use them sparingly are weakened.

But in the end, what medications are appropriate will always best be determined within the doctor-patient relationship, not by bureaucratic dictates and bans. The opioid problem might be real, but unilaterally denying relief to those in pain is a cure that’s worse than the disease.

Steven Horwitz is an economist with Ball State University and an affiliated senior scholar with the Mercatus Center at George Mason University.

You can read diverse opinions from our Board of Contributors and other writers on the Opinion front page, on Twitter @usatodayopinion and in our daily Opinion newsletter. To respond to a column, submit a comment to letters@usatoday.com.

Filed under: General Problems | 3 Comments »

How Does Temperature Affect Mail Order Medicines?

Posted on April 2, 2018 by Pharmaciststeve

https://www.peoplespharmacy.com/2018/04/02/how-does-temperature-affect-mail-order-medicines/

Prescription drugs have become pricey. That’s why insurance companies may try to save money by encouraging patients to buy mail order medicines. Are there problems with this practice?

Many insurance companies love mail order pharmacies. That’s because they can often save money by having patients get their medicines from large services rather than local pharmacies. Pharmacy benefit managers (PBMs) are the middlemen between drug companies, pharmacies and payers. Many large PBMs own or control mail order pharmacies. If patients don’t get their medicines through this channel, they may have to pay more for their prescriptions. Are there any concerns about mail order medicines that have been ignored by PBMs, the FDA and insurance companies? Check these liv pure reviews.

A retired professor of molecular biology performed an experiment that would suggest the answer is yes.

Mail Order Medicines and the Postal Service:

Q. I read your column concerning pharmaceutical drugs left in a cold mailbox in winter. A few years ago, I measured summer temperatures in our mailbox with an accurate electronic thermometer. Read more about Adderall otc.

I was concerned that my drugs might be damaged with the very high temperatures here in Tempe, AZ. The mail is delivered in the afternoon when the sun hits the mailbox.

I am attaching an Excel file of what I found. The temperature of the mailbox was significantly higher than the air temperature. The average daily mailbox temperature between August and October was 121 F. Clearly those high temperatures would be expected to have some effect on many drugs.

Since doing that project, I stopped having my drugs sent by mail and now use an in-store pharmacy. Neither the drug companies nor the FDA seemed to provide helpful information when I asked them about this problem.

Do High Temperatures Affect Mail Order Medicines?

A. Your spreadsheet is fascinating. On some days, the temperature in your mailbox reached 130 to 140 F. That is way outside the acceptable storage range, even for a short period of time.

Guidelines for medications generally call for storage at room temperature (68 to 77 F). During shipping, temporary fluctuations are allowed between 59 and 86 F. Even on the coolest days of your two-month project, your mailbox hit at least 95 F.

How Heat Might Impact Mail Order Medicines:

Some medications could deteriorate rapidly under high heat or extreme cold. Drugs for asthma, diabetes, thyroid and anxiety could be especially vulnerable.

Researchers in the division of Pulmonary and Critical Care Medicine at the Cart T. Hayden VA Medical Center in Phoenix, Arizona performed an interesting experiment (Chest, Dec. 2005). They had heard that the asthma drug formoterol (Foradil) was “aggregating in mailboxes in the summer in Arizona.”

These investigators exposed capsules of formoterol to temperatures between 104 and 158 F for three hours and at 158 F for 15 to 180 minutes. The results were worrisome.

They concluded:

“These data demonstrate that the exposure of formoterol to heat decreases drug delivery and that caution should be used when mailing, transporting or storing formoterol.

“The use of mail-order pharmacies appears to be increasing both in the private sector as well as in the Veterans Healthcare Administration. It is usually assumed that the conditions of mail shipment approximate room temperature and humidity. However, it seems likely that shipped medications might be subjected to extremes in temperature such as those during the time spent in a mailbox prior to patient pick up. In addition, medications already in the patient’s possession might be subjected to environmental extremes such as being left in an automobile for an extended time on a hot day.

“The present study demonstrates that heating formoterol to temperatures that might be encountered during an Arizona summer lowers powder delivery. Combined with the reports from patients who received deformed formoterol capsules in mailboxes during summer months, it seems likely that temperature led to the decrease in powder delivery.”

What Should You Do About Mail Order Medicines?

Arizona gets especially hot during the summer. But you do not have to live in Phoenix or Tempe to be exposed to high temperatures. When medicines sit in a hot car or a mail box for hours, they will almost assuredly be exposed to temperatures outside the mandated shipping range (59 to 86 F). And in the winter they could easily be exposed to freezing temperatures.

Mail order pharmacies and the FDA need to address this weakness in our drug delivery system. Medications that are exposed to severe temperature fluctuations may not perform as anticipated. They may also deteriorate more rapidly.

The People’s Pharmacy Solution:

We think that there is an answer to the dilemma that patients are faced with when they receive mail order medicines. There are affordable temperature and humidity sensors that can be placed in every prescription (and vitamin) package. These disposable monitors will reveal if the contents of the package have been exposed to temperatures outside the limits for that medication (or dietary supplement).

We think mail order pharmacies and PBMs have an obligation to their clients to verify that drugs are kept within the guidelines during shipping. If they cannot demonstrate that successfully they should either send another package or refund the patient’s money and allow people to purchase their medication in a pharmacy at no additional cost.

What do you think?

Share your own experience with mail order medicines in the comment section below.

Federal law requires the Manufacturer, Wholesaler and Pharmacy to store medication within a specific range – normally 59-86 F –  Once a pharmacy hands off the medication to a shipper (USPS, FEDX, UPS) they don’t have any legal requirement to maintain those storage temp and unless the pharmacy has packaged the medication is some sort of shipping container to maintain the specific temperature, the shipper is none the wiser and will handle the package as they do any other package.

While use of mail order pharmacy may seem convenient,  the pt’s medication and in turn their health may being put at risk.  Many mail order pharmacies give financial incentive to use them…

As long as the pts know the potential risk for using mail order… it is their choice … some may have to use mail order for personal financial reasons.

Filed under: General Problems | 2 Comments »

End the Epidemic. Secure the Border. …

Posted on April 1, 2018 by Pharmaciststeve

Filed under: General Problems | 5 Comments »

Since 2007, the DEA has taken $3.2 billion in cash from people not charged with a crime

Posted on April 1, 2018 by Pharmaciststeve

https://www.washingtonpost.com/news/wonk/wp/2017/03/29/since-2007-the-dea-has-taken-3-2-billion-in-cash-from-people-not-charged-with-a-crime

The Drug Enforcement Administration takes billions of dollars in cash from people who are never charged with criminal activity, according to a report issued today by the Justice Department’s Inspector General.

Since 2007, the report found, the DEA has seized more than $4 billion in cash from people suspected of involvement with the drug trade. But 81 percent of those seizures, totaling $3.2 billion, were conducted administratively, meaning no civil or criminal charges were brought against the owners of the cash and no judicial review of the seizures ever occurred.

That total does not include the dollar value of other seized assets, like cars, homes, electronics and clothing.

These seizures are all legal under the controversial practice of civil asset forfeiture, which allows authorities to take cash, contraband and property from people suspected of crime. But the practice does not require authorities to obtain a criminal conviction, and it allows departments to keep seized cash and property for themselves unless individuals successfully challenge the forfeiture in court. Critics across the political spectrum say this creates a perverse profit motive, incentivizing police to seize goods not for the purpose of fighting crime, but for padding department budgets.

Law enforcement groups say the practice is a valuable tool for fighting criminal organizations, allowing them to seize drug profits and other ill-gotten goods. But the Inspector General’s report “raises serious concerns that maybe real purpose here is not to fight crime, but to seize and forfeit property,” said Darpana Sheth, senior attorney of the Institute for Justice, a civil liberties law form that has fought for forfeiture reform.

The Inspector General found that the Department of Justice “does not collect or evaluate the data necessary to know whether its seizures and forfeitures are effective, or the extent to which seizures present potential risks to civil liberties.”

In the absence of this information, the report examined 100 DEA cash seizures that occurred “without a court-issued warrant and without the presence of narcotics, the latter of which would provide strong evidence of related criminal behavior.”

Fewer than half of those seizures were related to a new or ongoing criminal investigation, or led to an arrest or prosecution, the Inspector General found.

“When seizure and administrative forfeitures do not ultimately advance an investigation or prosecution,” the report concludes, “law enforcement creates the appearance, and risks the reality, that it is more interested in seizing and forfeiting cash than advancing an investigation or prosecution.”

The scope of asset forfeiture is staggering. Since 2007 the Department of Justice’s Asset Forfeiture Fund, which collects proceeds from seized cash and other property, has ballooned to $28 billion. In 2014 alone authorities seized $5 billion in cash and property from people — greater than the value of all documented losses to burglary that year.

In most of the seizures examined by the Inspector General, DEA officers initiated encounters with people based on whether they met certain criteria, like “traveling to or from a known source city for drug trafficking, purchasing a ticket within 24 hours of travel, purchasing a ticket for a long flight with an immediate return, purchasing a one-way ticket, and traveling without checked luggage.”

Some of the encounters were based on tips from confidential sources working in the travel industry, a number of whom have received large sums of money in exchange for their cooperation. In one case, officers targeted an individual for questioning on a tip from a travel industry informant that the individual had paid for a plane ticket with a pre-paid debit card and cash.

Most individuals who have cash or property seized by law enforcement do not dispute the seizure. There’s no right to an attorney in forfeiture proceedings, meaning defendants must foot the bill for a lawyer themselves. In many cases, forfeiture amounts are so small that they’re not worth fighting in court.

Forfeiture cases are also legally complex and difficult for individuals to win. Forfeiture cases are brought against the property, rather than the individual, leading to Kafkaesque case titles like United States v. $8,850 in U.S. Currency and  United States of America v. One Men’s Rolex Pearl Master Watch.

While criminal proceedings assume the defendant’s innocence, forfeiture proceedings start from the presumption of guilt. That means that individuals who fight forfeiture must prove their innocence in court.

For these reasons, many defendants don’t bother disputing forfeitures. The Inspector General’s report, however, finds that those who do often get at least a portion of their cash returned. Only one-fifth of people who had their cash seized by the DEA disputed the seizures in court. But among those who contested the seizure, nearly 40 percent ended up getting all or some of their cash returned, suggesting that the DEA’s forfeiture net ensnares many individuals not involved in wrongdoing.

In a written response to the Inspector General, the Department of Justice said it had “significant concerns” with the report, noting that global criminal enterprises launder trillions of dollars annually and calling asset forfeiture “a critical tool to fight the current heroin and opioid epidemic that is raging in the United States.”

It also took issue with the Inspector General’s analysis of the 100 DEA cash seizures it examined, saying more of them were connected with criminal activity than the report suggested.

The Inspector General stood by the report and dismissed the Department’s concerns as “assumptions and speculation.” The Drug Enforcement Administration did not respond to a request for comment.

“Nobody in America should lose their property without being convicted of a crime,” said the Institute for Justice’s Sheth. “If our goal is to curb crime, we should simply abolish civil forfeiture” and only forfeit property after a criminal conviction is obtained, she added.

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Opioid Painkillers Top Selling Drug in 10 States

Posted on March 31, 2018 by Pharmaciststeve

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www.painnewsnetwork.org/stories/2018/3/22/opioid-painkillers-top-selling-drug-in-10-states

If you live in Oklahoma, the drug you’re most likely to be prescribed is the opioid painkiller Vicodin — or some other combination of hydrocodone and acetaminophen.

In Texas, the #1 drug is Synthroid (levothyroxine) – which is used to treat thyroid deficiencies.

In California, its Lipitor (atorvastatin) – a statin used to treat high cholesterol.

And Tennessee has the unique distinction of being the only state in the country where the addiction treatment drug Suboxone (buprenorphine/naloxone) is the most prescribed drug.

These findings are part of an interesting study by GoodRx, an online discount drug company, on prescribing trends in all 50 states. GoodRx looked at pharmacy and insurance data from around the country – not just its own customers — from March 2017 to February 2018.

It then developed a map to show how prescription trends can vary by region and by state.

Levothyroxine (Synthroid) is easily the top selling drug in the country. It’s #1 in 26 states (AR, AZ, CO, CT, FL, IA, KS, KY, LA, ME, MI, MN, MT, ND, NJ, NV, OR, PA, SD, TX, UT, VT, WA, WI, WV, WY).

Hydrocodone (Vicodin, Norco, Lortab) is #1 in 10 states (AK, AL, GA, ID, IL, IN, MS, NC, NE, OK), mainly in the South and Midwest. As recently as 2012, hydrocodone was the most widely prescribed medication in the country. Since then, hydrocodone prescriptions have fallen by over a third and it now ranks 4th nationwide.

Atorvastatin (Lipitor) is #1 in 5 states (CA, HI, MD, MO, VA) and so is lisinopril (MA, NH, NM, OH, RI), a medication used to treat high blood pressure.

There are a few outliers. New York, for example, is the only state that’s #1 in amlodipine (Norvasc), a blood pressure medication, and Delaware and South Carolina are the only states where the leading prescription drug is Adderall, a medication used to treat Attention Deficit Hyperactivity Disorder (ADHD).   

That brings us to Tennessee, one of the states hardest hit by the opioid crisis. In 2012, doctors wrote 1.4 opioid prescriptions for every citizen in Tennessee, the second highest rate in the country. The state then moved aggressively to shutdown pill mills and expand access to addiction treatment — which explains why Tennessee is #1 for Suboxone.

Prescriptions for opioid pain medication have dropped by 12% in Tennessee since their peak, but overdose deaths and opioid-related hospitalizations continue to climb, due largely to heroin and illicit fentanyl.  No other state even comes close to Tennessee in per capita prescriptions for Suboxone.  

Addiction treatment has become such a growth industry that Tennessee has adopted measures to rein in the overprescribing of Suboxone.

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“It may not be that more people are using, but in fact that a single use of a more deadly drug is what we’re seeing,”

Posted on March 31, 2018 by Pharmaciststeve

Opioid overdoses spike 30 percent, hospitals report

https://www.cbsnews.com/news/opioid-overdoses-increase-across-us/

A new report from the Centers for Disease Control and Prevention brings more bad news for the nation’s continued fight against the opioid epidemic. Data from hospital emergency departments show a big increase in drug overdoses across the country.

In a press briefing on Tuesday, CDC Acting Director Anne Schuchat, M.D., said the U.S. is seeing the highest drug overdose death rate ever recorded in the country.

According to the study, which examined data from 16 states, emergency department visits for suspected opioid overdoses jumped 30 percent from July 2016 through September 2017.

Opioid overdoses increased for both men and women, across all age groups, and in all regions, though there was some variation by state, with rural and urban differences.

“Long before we receive data from death certificates, emergency department data can point to alarming increases in opioid overdoses,” Schuchat said in a statement. “This fast-moving epidemic affects both men and women, and people of every age. It does not respect state or county lines and is still increasing in every region in the United States.”

The Midwest saw the biggest jump in opioid overdoses, with a 70 percent increase from July 2016 through September 2017.

 

Certain areas in the Northeast were also hit particularly hard, with Delaware experiencing a 105 percent increase and Pennsylvania an 81 percent increase in opioid overdoses during that time.

The reasons for these increases are unclear, but officials say it may have to do with changes in the drug supply, including the availability of newer, highly toxic illegal opioids such as fentanyl, which has been spreading rapidly in recent years. Fentanyl, a synthetic drug that’s 50 to 100 times stronger than morphine, is often mixed in to make heroin more potent, contributing to many ODs.

“It may not be that more people are using, but in fact that a single use of a more deadly drug is what we’re seeing,” CBS News medical contributor Dr. Tara Narula said on “CBS This Morning.”

Though the report was overall a somber reminder of the devastating effects of opioid addiction, there were a few hopeful findings.

In Kentucky, a state hit hard by the opioid epidemic, emergency department visits for opioid overdoses actually decreased by 15 percent over the study period. In Massachusetts, New Hampshire, and Rhode Island, there were also small decreases of less than 10 percent.

Schuchat said she is cautiously optimistic that strategies implemented in these states to combat opioid addiction may be working.

 

Officials say looking at emergency room data can help responders gather important information before an overdose turns deadly, including where the person was coming from and what day of the week and time of day the overdose occurred. This can make it easier to identify where there are gaps in local resources and how they can best be allocated, since having one overdose makes it likely a person will have another.

The report also calls for state and local health departments, as well as emergency departments, community organizations and individuals to come together to lessen the impact of the opioid epidemic.

These steps include:

  • Increasing distribution of naloxone, an overdose-reversing drug also known as Narcan, to first responders, family and friends, and other community members in affected areas, as policies permit.
  • Increasing availability of and access to treatment services for opioid users, including mental health services and medication-assisted treatment like methadone clinics.
  • Supporting programs that reduce harms that can occur when injecting opioids, including programs that offer screening for HIV and hepatitis B and C, in combination with referral to treatment.
  • Promoting opioid prevention and treatment education.
  • Storing prescription opioids in a secure place, out of reach of others, including children, family, friends, and visitors, and properly disposing of them when no longer needed

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