Attorneys general in Appalachia pressure, sue health insurers over opioids

http://www.cnhinews.com/cnhi/article_73975d9e-9d4f-11e7-b68b-f3d8febecaf0.html

HUNTINGTON, W. Va. — The nation’s advancing opioid epidemic has officials and lawmakers in the most impacted states taking on the entities they deem responsible for skyrocketing drug addiction and overdose numbers.

Kentucky Attorney General Andy Beshear and West Virginia Attorney General Patrick Morrisey announced at Marshall University Monday they will press the health insurance companies that have made billions off the sales of opioids to help curtail the nation’s largest drug problem to date.

They joined 37 other attorneys general in writing a letter to insurers requesting they adopt a “financial incentive structure” for the use of non-opioid pain management techniques when viable for chronic, non-cancer patients.

They argued insurance companies have the power to reduce opioid prescriptions and simplify patient access to other forms of pain management treatment.

“We’re not physicians, and we’re not going to be writing these policies,” Morrisey said. “What we’re doing today is asking these insurance companies to look closely at their coverage and payment policies so those unintentional payment incentives don’t exist.”

As opioid addiction and resulting fatalities have swept the country, both Kentucky and West Virginia have been especially hard hit by the epidemic. Last year, Kentucky had more than 1,400 opioid-related overdose deaths reported, according to a state report.

Last week, an additional Kentucky county joined nearly 20 others to file suit against the nation’s top 3 opioid producers in hopes of fighting to curb the rampant prescription drug problem in the Bluegrass State.

Beshear announced in June that his office intends to file multiple lawsuits against drug manufacturers, distributors and retailers where there is evidence that they contributed to the opioid epidemic by illegally marketing and selling opioids to Kentucky residents.

Beshear issued a request for proposal (RFP) for legal services to assist the Commonwealth in multiple lawsuits and to ensure that Kentucky tax dollars are not used for the costs of the litigation.

Beshear, a Democrat, and Morrisey, a Republican, said the deadliest overdose epidemic in U.S. history is a bipartisan issue.

Suppliers of prescription opioids are partly to blame for the rise in heroin use in the Tri-State region, Beshear said.

“Nearly 80 percent of heroin users first become addicted through prescription pills,” Beshear said. “If we can reduce opioid prescriptions and use other forms of pain management treatment, we will slow or even reverse the rate of addiction.”

Beshear suggested insurers could cover costs for physical therapy treatments rather than simply provide pain pills, for instance. “Every one knows some patients will need prescription pills,” he said. “But a lot of people should have access to other forms of treatment.”

“There are steps that should be taken before subjecting a young mind to the power of these addictive pills,” Beshear said.

Morrisey said he’s optimistic every insurance company will “respond positively” to the letter from the attorneys general.

“I think 37 attorneys general provides a tremendous amount of pressure. We start how you’re supposed to start — asking nicely,” Beshear said. “But ultimately, when you don’t work with attorneys general and you end up working against them, you can ask the tobacco companies how that works out.”

Beshear told the Ashland, Kentucky Daily Independent the attorneys general don’t “want to go in with threats” but instead open a dialogue with the insurers, and it would be a “long way down the road” before any type of litigation is considered.

In addition to Kentucky and West Virginia, attorneys general from Illinois, Indiana, Missouri, Virginia joined in sending the letter to health insurers.

Our previous Surgeon General stated publicly that addiction is a mental health issue and not a moral failing http://www.huffingtonpost.com/entry/vivek-murthy-report-on-drugs-and-alcohol_us_582dce19e4b099512f812e9c

Since it is highly unlikely that taking a opiate can cause a MENTAL HEALTH ISSUE.. who with “three brain cells hold hands” could come to the conclusion that addiction is nothing more than a symptom or manifestation of a person with undiagnosed/under/untreated mental health issues.

Keep in mind that our judicial system in 1917 declared that opiate addiction was NOT A DISEASE BUT A CRIME… and apparently out judicial system is still functioning under that century old edict.

Here is a picture of a Ford automobile from that era… how many of us would want to use such a vehicle as our primary mode of transportation TODAY ?

In 1917 women still did not have the right to vote, alcohol prohibition was still yet to come, it was just abt ONE DECADE after the Wright Brothers first took to flight.

There is a simple 24 questions – 5 minute – test http://nationalpaincentre.mcmaster.ca/documents/soapp_r_sample_watermark.pdf 

Imagine if it was a required test before the first refill of a opiate for anyone treated with a opiate for acute pain.

Imagine if PMP’s were indexed by digital finger or palm print, digital eye scan, or facial recognition.

Delta to roll out facial recognition technology at airport bag check   

Delta is using facial recognition to self-check baggage at airports and many software systems already use digit finger print recognition to login to pharmacy and point of sale equipment. Why the “push back” from implementing this for PMP and opiate prescribing and dispensing ?  If the bureaucrats are really interested in trying to deal with opiate addiction… shouldn’t they be interested in pulling out all the “digital stops”

Maybe the same bureaucrats that are failing to implement these “state of the art” tools are the same ones that are now attempting to extract untold millions of dollars from the same businesses that are part of the opiate manufacturing and distribution system ?

Remember the Tobacco settlement money will be running out in a few years… are they just looking for another “golden goose” that they can “milk” to replace that Tobacco money for another 10-20 yrs.

Maybe this fabricated OD crisis is more of a “smoke screen” for another agenda

Filed under: General Problems | 3 Comments »

6 Stages of Fibromyalgia

https://www.life-enthusiast.com/articles/6-stages-of-fibromyalgia

Stage 1

You started experiencing pain and fatigue more than before, you’re not sure what is going on but you hurt and you are tired. You can hold a job, you can make it through your day, but you know something isn’t right… so it’s something you’re going to start researching.

Stage 2

You are in pain a lot, sometimes taking an anti-inflammatory drug or what have you. You do not get much relief, and you have accepted the fact this is something you are going to have for a while. you feel a lot of pain and you are exhausted almost every day, but for the most part you keep going and hold down a job, can still go to events, spend time with your friends and loved ones, and have some good time here and there.

Stage 3

You are in constant pain, you are constantly tired, you wonder whether you will be ever able to function normally again. You are considering not working, because you no longer have the energy you once had, you come home from work and all you can do is rest. You have to turn down invitations, you have no energy left and you have to rest up just to go back tomorrow. In this stage you start to feel more alone, and more and more people are beginning to think you whine too much. This stage can last a long time, perhaps years.

Stage 4

You are in unrelenting pain all the time, good days are few and far between. You are calling into work sick more than you even make it in. You are in bed a good portion of your day. When you do have a good day you take advantage of it, and do as much as you can, all the things you have left in the past weeks you cram into your day, knowing well that tomorrow you will be paying for it. Your flares last for days. By this time your friends make plans without you, they already know your excuses and are nearly certain you will not be able to join in. Your family begins to think you are using fibromyalgia as an excuse to not do things, because stages 1-3 you were able to do much of what you just can’t do now. They think you are using your illness as an excuse, you feel alone, isolated, worried, emotional, sad. This stage can last years.

Stage 5

You have already been let go or have quit your job, you are asking questions about permanent disability and how long it takes to get it. You have heard horror stories about people being denied and the process taking years. You are struggling to make ends meet. Maybe have a person who takes care of you. You spend a lot of your day in bed, although you still take advantage of that one good day once in awhile. You are sore, very sore, you cry a lot, you feel like a prisoner in your own body. By this time you have already explained to your friends that it still feels good to be invited even if you don’t go. You have found that the only people that can relate to you are in a similar predicament. You wish your friends and family could understand.

Stage 6 (The Final Stage)

You may or may not still be waiting for disability pension. You cannot hold down a job. Fibromyalgia is now your lifestyle, most of your friends are living with fibromyalgia themselves, everything you do takes all your precious energy, simple daily tasks you took for granted in earlier stages, going to the bathroom, washing your hair, taking a shower, getting dressed, tying your shoes, take all you can give. You get irritated by your hair or clothes touching your skin, you have no energy or desire to put on “your face” before going out, no energy to keep a neat home. With all the medication you are on now or have tried, you are dealing with side effects and constant pain.

You are a human and still enjoy some things, like watching TV. You try to stay current on any news regarding fibromyalgia, in hopes they are closer to finding a cure. Most of your old friends are not around anymore, they have things to do. You need to rest a lot. It’s easy to feel overwhelmed in this stage, because things are piling up around you: bills, laundry, dishes. You do a little everyday, you push yourself so you don’t feel like your day was wasted in bed, you feel guilty that you no longer pull your own weight in the house. Your kids, spouse or family do things for you more than ever. They try to do it in a nice manner but you still feel like a burden, you can’t remember anything, cannot recall names or dates and you lose your train of thought mid-sentence. Also you know more about fibromyalgia in this stage then your own doctor and basically laugh when trying a new medication. You are without hope, same drill as before, same results, nothing helps much.

Filed under: General Problems | Leave a Comment »

States ask insurers to prioritize non-opioid pain treatment

http://abcnews.go.com/Health/wireStory/states-insurers-prioritize-opioid-pain-treatment-49937810

Attorneys general representing the majority of states asked health insurers Monday to encourage pain treatment through means other than prescriptions for opioid painkillers, which are responsible for tens of thousands of deaths a year in the U.S.

The top government lawyers in 35 states signed a letter to the trade group America’s Health Insurance Plans. The group, which also includes attorneys general for Puerto Rico and the District of Columbia, asked insurers to make coverage of non-opioid treatments such as physical therapy and massage a priority.

“The status quo, in which there may be financial incentives to prescribe opioids for pain which they are ill-suited to treat, is unacceptable,” the attorneys general wrote.

The letter targets prescribing powerful drugs for chronic pain, a practice several studies have found is not effective.

The insurers group did not immediately respond to requests for comment.

Opioid-related overdoses have hit especially hard in the Appalachian states. On Monday, the attorney generals from two of them, Kentucky and West Virginia, held a joint news conference to highlight the pressure on the health insurance industry.

“If we can get the best practices changed with insurance companies and the payment incentives are just a bit different than what they are today, I think that’s going to continue to see the number of pills prescribed and dispensed drop dramatically,” said West Virginia Attorney General Patrick Morrisey, a Republican. “This is an important new front to open up.”

Kentucky’s Andy Beshear, a Democrat, said the number of overdoses might not fall quickly if companies follow the requests, but said it could help prevent more people from becoming addicted in the future.

The nation is in the thick of an opioid epidemic. In 2015, more than 52,000 people across the country died from drug overdoses — more than from car crashes or shootings.

Nearly two-thirds of those overdoses were from opioids, including prescription drugs such as OxyContin and Vicodin and illicit drugs including heroin and fentanyl. Often, abusers switch between prescription and illegal drugs.

A few years ago, governments were reacting mostly through measures such as creating databases of prescriptions to identify abusers or by increasing the availability of a drug that counteracts overdoses.

Lately, they’ve been getting more aggressive.

More than 60 local and state governments have filed, announced or publicly considered lawsuits against drug makers or distributors. In June, several attorneys general announced a multi-state investigation of the industry.

Since last year, states have been adopting laws limiting initial prescriptions to opioids in the hopes of cutting down on misuse.

Filed under: General Problems | Leave a Comment »

Tylenol Isn’t So Safe, But At Least It Works, Right?

https://www.acsh.org/news/2017/09/18/tylenol-isnt-so-safe-least-it-works-right-11827

I’m not a big fan of Tylenol, which becomes rather obvious if you read the first part of this two-part series. For a drug that is so widely used, it is quite easy to consume enough, accidentally or otherwise, to take enough to suffer a toxic overdose due to irreversible liver damage.

But drugs cannot be judged by safety alone. Both the good and the bad – benefits and risks – must be taken into account to get the true measure of the quality of a drug. So if Tylenol isn’t all that safe, you might expect that, at the very least, it should work well. Otherwise, why would so many people be taking it?

That’s the $64,000 question, and here’s the answer. In reality, Tylenol doesn’t work very well at all, and there is plenty of evidence to back this up, especially in systematic Cochrane Reviews – highly regarded, evidence-based reviews that carefully evaluate the quality of data in multiple studies. Here are some representative analyses.

Osteoarthritis of the Knee and Hip

A group of five pain specialists and pharmacologists in Denmark examined seven studies of patients with hip- or knee osteoarthritis. All seven included a comparison between acetaminophen (used continuously for more than two weeks) with placebo. The review, entitled “Acetaminophen for Chronic Pain: A Systematic Review on Efficacy” was published in the journal  Basic & Clinical Pharmacology & Toxicology. The conclusion:

“All included studies showed no or little efficacy with dubious clinical relevance. In conclusion, there is little evidence to support the efficacy of acetaminophen treatment in patients with chronic pain conditions. Assessment of continuous efficacy in the many patients using acetaminophen worldwide is recommended.”

Z. Ennis, et. al., Basic & Clinical Pharmacology & Toxicology, 2016, 118, 184–189

Well, that doesn’t sound so marvelous. Perhaps it’s just a single bad paper. Or not.

Acute and Chronic Lower Back Pain

A 2016 Cochrane Review entitled “Paracetamol for low back pain” (1) examined the utility of Tylenol in treating lower back pain. The review included three trials with a total of 1825 participants, mostly middle-aged, who had acute back pain, and another trial in which the participants had lower back pain for more than six weeks. All of the trials also had a placebo arm. The drug was administered either orally or by IV in doses that ranged from one gram to four grams. How did that work? Ouch.

“We found high-quality evidence that paracetamol (4 g per day) is no better than placebo for relieving acute LBP in either the short or longer term. It also worked no better than placebo on the other aspects studied, such as quality of life and sleep quality.”

B.Saragiotto et. al., Cochrane Review, June 2016

Back Pain, and Hip and Knee Osteoarthritis

The hits keep coming. A 2015 review in the British Medical Journal entitled “Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo-controlled trials” examined reports of 13 randomized trials. The review examined several measures of pain relief: pain intensity, disability, and quality of life in people with low back pain, and hip or knee osteoarthritis. and concluded:

“Paracetamol is ineffective in the treatment of low back pain and provides minimal short term benefit for people with osteoarthritis. These results support the reconsideration of recommendations to use paracetamol for patients with low back pain and osteoarthritis of the hip or knee in clinical practice guidelines.”

M. Ferreira, et. al, BMJ 2015; 350

Headaches

OK, so it doesn’t work for back pain or arthritis, but that’s OK because most people use it for headaches. Well, it works. Sort of. A Cochrane Review entitled “Oral paracetamol for treatment of acute episodic tension-type headache in adults” looks at just that. This may surprise you. 

Things look OK at the beginning of the results sections: “The International Headache Society recommends the outcome of being pain free two hours after taking a medicine. The outcome of being pain free or having only mild pain at two hours was reported by 59 in 100 people taking paracetamol 1000 mg…”

It may not be perfect, but a 59% response isn’t all that terrible. Until you read the rest of the sentence: “…and in 49 out of 100 people taking placebo. This means that only 10 in 100 or 10% of people benefited because of paracetamol 1000 mg.

Now, *that’s* pretty bad. Of the 59 of you who are getting headache relief from the stuff either believed that their headache went away, or it went away within two hours on its own, not from the drug. So, the real efficacy of Tylenol is 10%. That’s enough to give you a headache. 

Colds

Tylenol is often used to treat symptoms of a common cold. For a cold, the data are not as conclusive as in the studies about, but there is little evidence that acetaminophen is effective.

“Acetaminophen may help relieve nasal obstruction and rhinorrhoea [runny nose] but does not appear to improve some other cold symptoms (including sore throat, malaise, sneezing, and cough). However, two of the four included studies in this review were small and allocation concealment was unclear in all four studies. The data in this review do not provide sufficient evidence to inform practice regarding the use of acetaminophen for the common cold in adults.”

S . Li, et. al, “Acetaminophen (also called paracetamol) for the common cold in adults.” Cochrane Review, June 2013

Tooth Pain

For a pain following wisdom tooth extraction, Tylenol is inferior when compared with ibuprofen (Advil), but when two are combined there seems to be a synergistic effect.

“There is high quality evidence that ibuprofen is superior to paracetamol at doses of 200 mg to 512 mg and 600 mg to 1000 mg respectively based on pain relief and use of rescue medication data collected at six hours postoperatively. The majority of this evidence (five out of six trials) compared ibuprofen 400 mg with paracetamol 1000 mg, these are the most frequently prescribed doses in clinical practice. The novel combination drug is showing encouraging results based on the outcomes from two trials when compared to the single drugs.”

E. Bailey et. al, “Ibuprofen versus paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth  Cochrane Review, December 2013

Fever

Tylenol is given to children to lower fever, and it does so successfully. So do NSAIDs, such as aspirin and ibuprofen. There is some indication that giving the two together or alternating the drugs may be more effective, but the evidence is weak. 

“Paracetamol (also known as acetaminophen) and ibuprofen lower the child’s temperature and relieve their discomfort…. There is some evidence that both alternating and combined antipyretic therapy may be more effective at reducing temperatures than monotherapy alone. However, the evidence for improvements in measures of child discomfort remains inconclusive.”

T. Wong, et.al., “Alternating and combined antipyretics for treatment of fever in children.” Cochrane Review, October 2013

This article is not intended to be a comprehensive examination of every review about the efficacy of acetaminophen. There are undoubtedly studies that demonstrate efficacy, however, I chose to include (mainly) information from Cochrane, since it is widely considered to be a high-quality source for evidence-based medicine. 

To wrap this up: acetaminophen largely ineffective. And I have already demonstrated why it is only marginally. This makes it one lousy drug.

Note:

(1) Paracetamol is another name for acetaminophen, the generic name of Tylenol. It is commonly used in Britain.

Filed under: General Problems | 1 Comment »

Hippocratic Oath: Classical Version

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art—if they desire to learn it—without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.

If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

“Thank you so much for accepting my friend request. I have no idea what prompted me to contact you but I sit here tonight preparing to check into a psychiatric hospital to detox off the opiates that I was prescribed for almost 15 years and now I can not find a single soul to prescribe them to me. Mine is a textbook case of the hysteria that has overcome our nation. In 2013, after ten years with the same prescribing physician, I was informed that he would no longer be giving any of his patients opiates any longer due to a patient’s death. Obviously, not mine nor did I ever breach the contract, fail a drug screen or ask for early refills. I was on a stable dose for three years, yes it was above the 90mme that is being “suggested” but, it worked for me. I was given a three month supply and sent on my way to pain management where no sooner did the door close behind the PA/NP was I informed that if I didn’t have terminal cancer I would be titrated off all opiates. My thoughts on the matter were irrelevant. I signed myself out of that clinic and then spent the next three years trying to find another pain clinic that would keep me on my prior dose that I was stable and content on. I found no one. My PCP had agreed to “bridge” the gap until I was able to find a provider but that day never came. I was on a medication that didn’t alleviate my pain whatsoever but since he was my primary care doctor he said his hands were tied and that he was out of his comfort zone even prescribing them to me and therefore he wouldn’t adjust the medication the first pain clinic had reduced me to.

I have medical records inches think that document me need for opiates yet each time I would visit a pain doctor I was told that my condition didn’t cause pain or that I was addicted and needed “Suboxone”…blah, blah, blah. My orthopaedic surgeon has written letters that confirm I have a connective tissue disorder and that my bones are the age of a 75-85 year old woman when I am only 46. They don’t want to operate until I am older as the replacement surgery has a high failure risk due to my disorder. I have yet to have one pain doctor even take the time to read my MRI results let alone give me an examination. I can not go to the ER to receive pain relief as they all say they won’t treat chronic pain. The guidelines say this and that. Sorry, see ya’!

So now, my PCP is leaving his clinic and I have no other option but to check into a detox facility. What’s even worse, is that I can not use marijuana as I have a rather strange reaction to it. I’ve tried Kratom as well, nada. Neurontin and gabapentin (spell) both make me feel drunk and stupid. Also, I have been tested and have a confirmed diagnoses of being a poor metaboliser involving the CYP-450 enzyme (I have one allele working at 50%) group with being a rapid metaboliser of methadone enzyme. (C19 I think??) The doctors don’t care. Even with the proof right in front of them. CBD oil is about the only thing I haven’t tried and I have little hope that it will be successful. This is very disappointing and discouraging and if I have to go through withdrawal after 15 years I will too be suicidal which is why I’m checking in. Now, I will definitely be labeled an addict and most likely end up never being prescribed opiates again. I’m supposed to have right foot reconstruction on December 12th and I desperately tried to find a doctor to prescribe to me before because if I have to go through detox I will most likely cancel the surgery so I don’t have to go through this all over again! So, basically I am going to be worse off instead of better after I go through “treatment” for opiate dependence. 

Thank you again, I just wanted to share my story because I honestly do not know what to do at this point, other than wave my white flag and surrender. I love what you’re doing and I sure hope things go back to normal for you soon!! Thanks for reading.

Please forgive any errors as I wasn’t able to go back and proofread! Lol. ☺️”

Law Enforcement Oath of Honor

On my honor, I will never betray my badge, my integrity, my character or the public trust.

I will always have the courage to hold myself and others accountable for our actions.

I will always uphold the constitution, my community, and the agency I serve.
Everyone – especially professionals – take a oath to uphold certain standards of their profession. Over the last decade or so… certain professionals seems to regard those oaths as JUST WORDS, and their day to day actions seem to have become more focused on SELF-SERVING.

Filed under: General Problems | Leave a Comment »

As pharmacists we are in a tough spot. I had a DEA agent stand in my pharmacy and watch as a lady handed over a stack of narcotics rxs to the technician. He said no one should be taking those unless they have cancer. ( his words, not mine). This same DEA agent told me I shouldn’t be dispensing diet pills to someone if I judge them to be thin. ( now, my definition of thin bight be different than his). My point is I don’t think it’s my place to be the judge. Also, I don’t see the patient in an office to get all the facts. I don’t always know why someone is taking those pills. According to him, it IS my job to be the judge. I trust the doctor to make that decision, but we aren’t supposed to do that either!

sadly when they are standing there with a gun, you just end up doing what they say when they threaten you…..
No doubt this guy is a total jerk. I did ask him if he was a pharmacist or doctor, as an indication that I thought he had no expertise. He’s not either and didn’t care.

Filed under: General Problems | 3 Comments »

Filed under: General Problems | 1 Comment »

Op-ed: Chronic pain sufferers need access to opioids

https://www.deseretnews.com/article/865688783/Op-ed-Chronic-pain-sufferers-need-access-to-opioids.html

My 26-year-old daughter, Madison, is an extremely intelligent, articulate, creative and beautiful young woman. Anyone blessed with these attributes should be well on their way to a wonderful and fulfilling life. But Madison is suffering in ways that most people could never imagine. Diagnosed at 13 years old with Complex Regional Pain Syndrome, formerly known as Reflex Sympathetic Dystrophy (CRPS/RSD), an incurable and progressive chronic pain disease of the sympathetic nervous system, she lives every day in severe pain.

CRPS/RSD is ranked as the most painful form of chronic pain that exists today by the McGill Pain Index. With the advice of numerous physicians over the last 13 years, we have tried every possible remedy and every possible treatment. None of them worked. So many days, I can only hold her in my arms as she cries in agony. The only thing that eases her suffering slightly is her prescription of opioid medication. Yet the government, in a short-sighted effort to combat widespread opioid abuse, wants to take Madison’s lifeline away. She, along with many others in her situation, are apparently considered collateral damage.

Collateral damage is not acceptable. Our military does the best it can to minimize collateral damage on the innocent and unintended targets even if it means sparing the intended targets. This is supported by not only by our government, but by the international community as well. And it should be that way. It’s compassionate.

Why, then, is our government inflicting cruel and unusual punishment for innocent victims here at home? They are putting extreme pressure upon physicians, under the threat of being removed from their practice, to reduce and/or eliminate the levels of prescribed opioids to all patients. But there will be collateral damage to this. Tens of thousands of people who have chronic pain will suffer. For them, there is no relief without opioid medication, and for whom the reduction or the elimination of their medication will cause unspeakable pain and even death.

The United Nations Universal Declaration of Human Rights states in Article 5, “No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment.” Medical doctors in the United States take the Hippocratic Oath that states, “I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.”

How can we be in direct conflict to both the Declaration of Human Rights and the Hippocratic Oath, and cause immense suffering to those of us who are in chronic, incurable pain? How can we reconcile the fact that, as a country, we can show compassion and lend assistance to refugees, and send food and medical aid to Third World countries, yet allow our family and friends to be denied the medication they need to survive?

It is because we are only being shown one side of this story. What we are not shown are the millions of patients in the USA alone who, but for their opioid medication, would be left in constant and excruciating pain. Taking away their right to be treated for their pain is the real opioid crisis.

Sadly, there are thousands of people who die from the over-the-counter drug ibuprofen every year. There are tens of thousands of people dying from their antidepressants and benzodiazepines. There are hundreds of thousands of people who die from complications associated with anticoagulants. Although these numbers are tragic, we would not want to see the physicians associated with these prescriptions threatened. This, however, is exactly what is happening in the case of the opioid crisis.

This is not acceptable.

Filed under: General Problems | 5 Comments »

Physicians Get Too Much Blame for Opioid Crisis, Some Say

http://www.medscape.com/viewarticle/885760

SAN ANTONIO, Texas — People looking to place blame for the nation’s opioid crisis too often point the finger at physicians, some speakers said at a reference committee for the American Academy of Family Physicians (AAFP) 2017 Congress of Delegates.

As communities across the country deal with the escalating opioid crisis, clinicians, public health officials, and the public are increasingly looking for answers, solutions, and — sometimes — where to place blame.

Several resolution clauses presented in a committee hearing Monday addressed shared responsibility and the need for education of physicians, officials, and the public on evidence-based prescribing. But the clause that caught the most attention directed the AAFP to mount a nationwide public relations effort to “dispel the myth that places blame on physicians.”

Some delegates who spoke against the resolution pointed to the large cost estimated for the proposal (more than $550,000 for a 12-month campaign). Others noted that changing minds would take time. And some simply said it was not a road AAFP should take.

However, the resolution passed the committee and was referred to the AAFP board on Wednesday.

Timothy Alford, MD, a delegate from Mississippi, which sponsored the resolution, said, “I can tell you we’ve got good physicians in rural America, right in the wheelhouse of what we do, where this problem is very pervasive, and they’re getting thrown under the bus by the press, and everybody else.”

David Hoelting, MD, a delegate from Nebraska, told Medscape Medical News, “Physicians, especially family physicians and orthopedists, are receiving the most pressure for prescriptions of opiates. A lot of this started as a result of the “fifth vital sign” program started around year 2000. First there was pressure to relieve all pain, then when addiction levels soared, we got the blame. The most serious problem now is that physicians are stopping narcotics to many of the patients abruptly, forcing them to resort to illegal street drugs, and risking overdoses.”

Jim Taylor, MD, an alternate delegate from Louisiana, said the issue has become a political football.

“The perception battle is one we’re losing. I think a half-million dollars is a very reasonable amount to spend on a national campaign to push back against those who actually push us into this.”

Other clauses in the resolution included asking that the AAFP to support appropriate and individualized pain treatment by physicians, educate family physicians in evidence-based pain management and prescribing, and educate government and law officials that a balanced approach is needed.

Clauses also promoted prescription monitoring and cognitive-behavioral therapy.

Domenic Casablanca, MD, a delegate from Connecticut, said those parts of the resolution are already being covered by current AAFP policy and launching the public relations campaign would take the academy in the wrong direction.

“Our delegation felt strongly there’s nothing to be gained in terms of making us look better by the PR campaign. It’s a multifactorial problem and we don’t want to lower ourselves to that level,” he said.

Dennis Dmitri, MD, a delegate from Massachusetts, said 2 years ago political will had turned against physicians, and physicians in the state were getting blamed for the opiate crisis.

It wasn’t until physicians sat down with government officials and legislators to work cooperatively with them, rather than defensively, on the issue that the tide turned, he said. That had a positive effect on the kind of legislation that was subsequently passed.

Dr Dimitri said the Massachusetts Medical Society launched a public relations campaign, but “not one aimed at buffing the reputation of physicians.” Instead it was aimed at educating the public about why there is an opioid crisis, how it could be addressed, how members of the public could be more careful about their own use of opiates, and how they could better interact with their physicians.

“That really changed the perception of physicians and the role they might play,” he said, “other than simply trying to say it’s not our fault.”

Filed under: General Problems | 1 Comment »

Five myths about heroin

https://www.washingtonpost.com/opinions/five-myths-about-heroin/2016/03/04/c5609b0e-d500-11e5-b195-2e29a4e13425_story.html?utm_term=.616c93a6ee4d

1. Most heroin addiction starts with a legitimate pain prescription.

People who misuse prescription pain relievers are 40 times more likely to become addicted to heroin than those who don’t, according to the Centers for Disease Control and Prevention. Research also shows that 75 percent of patients in heroin treatment started their opioid use with prescription medications, not heroin. That sounds like pain treatment is at the root of the problem, and the CDC is targeting doctors with new guidelines aimed at reining in prescriptions.

But overwhelmingly, prescription-drug misusers are not pain patients. According to the National Survey on Drug Use and Health, more than 75 percent of recreational opioid users in 2013-14 got pills from sources other than doctors, mainly friends and relatives. Even among this group, moving on to heroin is quite rare: Only 4 percent do so within five years; just 0.2 percent of U.S. adults are current heroin users.

The proportion of patients who become newly addicted to opioid medications during pain treatment is also low. A 2010 Cochrane review — considered the gold standard for basing medical practice on evidence — found an addiction rate of less than 1 percent. A study of more than 135,000 emergency-room visits for opioid overdose found that just 13 percent of patients had a chronic pain diagnosis.

Further, a 2015 study showed that only 6 percent of those who received an initial prescription for opioids took the drugs for more than four months; the authors didn’t determine how many of those ongoing prescriptions were medically appropriate and what proportion were linked to addiction.

The real risk factor for opioid addiction is youth. Like 90 percent of all addictions, the vast majority of prescription-drug problems start with experimentation in adolescence or early adulthood, typically after or alongside binge drinking, marijuana smoking and cocaine use. Having a prior or current addiction to another drug is the best predictor of developing problems with prescription drugs — not pain care.

2. The best treatment for heroin addiction is inpatient rehab.

When the media covers addiction among the rich and famous, they almost always include an inpatient stay at a plush rehab center. Dr. Drew Pinsky’s “Celebrity Rehab” is typical of such programs. Like many who run inpatient programs, Pinsky rejects the ongoing use of anti-addiction medication (though Hazelden, the original model for the 28-day rehab center, began offering it to some patients in 2012 after experiencing record high death rates). Similarly, most drug courts and many state Medicaid programs also deny continuing access to the two best-studied maintenance medications, methadone and buprenorphine (Suboxone).

The position that residential treatment centers and their abstinence-only philosophies are superior to medication ignores overwhelming data and keeps families from seeking the best care. Let’s start with Dr. Drew’s patients: Nearly 13 percent who appeared on “Celebrity Rehab” died not long afterward; most had been addicted to opioids. While that may be an especially poor showing, research on more than 150,000 patients receiving treatment for opioid addiction in Britain found that people in abstinence-only care had double the death rate of those who received ongoing maintenance treatment. And other studies find that maintenance medication cuts death rates by 70 percent or more. Since untreated heroin addiction carries a mortality rate of 2 to 3 percent per year, the benefit is substantial.

This is why the World Health Organization, the National Institute on Drug Abuse, the Institute of Medicine and the White House drug czar’s office all agree that maintenance treatment — indefinite, possibly lifelong medication use — is superior to abstinence rehab for opioid addiction. While some argue that total abstinence is a moral imperative, dead people can’t recover. Sadly, only a small proportion of people with opioid addiction are currently in medication-assisted treatment — largely because of limits placed on it by misguided ideology, government policies and insurers.

The prognosis for heroin addiction seems grim because of the high mortality rate and because rehabs typically report relapse rates of 60 percent or greater. However, the odds of recovery are better than they appear.

Early evidence for this idea came from studies of Vietnam veterans, who, as young men, should have had particularly high addiction and relapse risk. Heroin and opium were cheap and easily available to American servicemen overseas; nearly half tried these drugs, and half of these soldiers became addicted. But upon returning home, just 12 percent of those who had been addicted relapsed within three years, and only 2 percent were still addicted at the end of the study — nowhere near 60 percent. Fewer than half got any treatment, and it didn’t make a difference in terms of who recovered.

This phenomenon, known as “natural recovery” or “maturing out” of addiction, is common with other drugs, too. Large population surveys show that most people who are addicted to alcohol or cocaine quit without treatment. The same type of study shows that around 60 percent of people who met the criteria for prescription opioid addiction at one time no longer do so — and one third of them never received any treatment. This research also finds that the average prescription opioid addiction lasts eight years; for heroin, the average is a decade. For alcohol, the average addiction lasts 15 years.

So why do heroin addicts appear so hopeless in the public imagination? Because people who quit on their own don’t show up for treatment — and so, while they are included in large epidemiological studies, they aren’t included in treatment research. This means that rehabs see only the worst cases, leading to an unduly pessimistic picture of recovery. Although opioid addiction certainly can be deadly, it doesn’t have to be — and those who struggle with it should absolutely seek help. Still, more research is needed to understand what people who recover without help can teach those who need it.

4. Tough love is the only thing that works.

The idea that people with addiction must “hit bottom” — or experience the worst possible consequences — before they can get better is prevalent among parents and policymakers. One drug court official told a researcher that “force is the best medicine” for treating addiction, and the 12-step program Al-Anon warns against “enabling” addiction by doing things like helping people avoid jail.

But research shows that the opposite is true. Like any other human beings, people with addiction respond best to being treated with dignity and respect. Programs that nonjudgmentally distribute clean needles, provide overdose-reversal drugs or offer safe spaces for injection do not prolong addiction; a Canadian study found that 57 percent of people who came to a safe injection facility to shoot up ultimately entered treatment . An approach for helping addicted family members that uses kindness, rather than confrontation or detachment, was found in another study to be twice as effective as a traditional confrontational “intervention” — and no studies show that harsh treatment or incarceration is superior to empathetic care.

Similarly, there’s no evidence that naloxone programs, which provide users and their families with the overdose-reversal drug, prolong addiction. But they do prolong life: The overdose death rate was cut by nearly 50 percent in communities that fully implemented these programs.

5. Whites have recently become the majority of people with heroin addiction.

In an article headlined “In Heroin Crisis, White Families Seek Gentler War on Drugs,” the New York Times recently claimed that “today’s heroin crisis is different,” because it is not “based in poor, predominantly black urban areas” and because use “has skyrocketed among whites.” NPR, the Atlantic and other major media outlets have run similar stories, often citing a study, published in JAMA Psychiatry, which found that 90 percent of new heroin users in the past decade were white.

What most of them omit is that the same study showed that whites have made up more than half of all heroin addicts since the early 1970s and hit 80 percent before 2000. In 1981, Newsweek panicked about a new wave of “middle-class junkies,” and in 2003, a Times headline read “Heroin’s New Generation: Young, White and Middle Class.” White heroin users are nothing new.

The reason for the misperception is political: Politicians from the first “drug czar,” Harry Anslinger, in the 1930s to Ronald Reagan in the 1980s have portrayed heroin and other illegal drugs as a black or “foreign” problem in order to justify tough policies. In the early 1900s, when heroin was sold over the counter without warning labels, the typical user was a white middle-class woman, and she was seen as a victim of unscrupulous manufacturers, not a criminal. After heroin became illegal and was framed as a problem of the poor and minorities, law enforcement began to predominate. Only now are policymakers beginning to recognize the failure of criminalization.

Filed under: General Problems | Leave a Comment »