CDC Prescribing Guidelines: Federal Review is Biased and Inconsistent

https://www.painweek.org/news_posts/cdc-prescribing-guidelines-federal-review-is-biased-and-inconsistent.html

Study Finds Problems in Review Process Used to Justify Recommendations

The 2016 CDC guidelines on opioid prescribing have been faulted in some quarters for a lack of scientific basis, and an article earlier this week discusses a recent study of the federal review process used in their development. Led by past PAINWeek faculty member Daniel Carr, MD, MA, professor of public health and community medicine and program director of pain, research education and policy at Tufts University School of Medicine, the study concluded that the federal review used differing standards for studies of opioid efficacy compared to studies of other treatments including anticonvulsant, antidepressant, nonsteroidal anti-inflammatory drugs (NSAIDs) and behavioral therapies. This led to a biased assessment of the safety and efficacy of long-term opioid therapy compared to other treatment options, according to the authors.

Commenting on the study conclusions, PAINWeek faculty member Jeffrey Fudin, PharmD, co-editor of the Opioids, Substance Abuse and Addictions section of Pain Medicine agreed, saying, “There’s not good evidence for any long-term analgesic drugs, really, for extended periods of time… in 2015, we saw the same number of deaths from prescription NSAIDs that we saw from prescription opioids, and that’s just from gastrointestinal bleeds without consideration to iatrogenic kidney failure and heart disease. People are just selecting what they want to select and using sensationalizing opioid deaths.” There are also problems with the inclusion in the CDC guidelines of morphine equivalent daily dose (MEDD) cited by both Dr. Carr and Dr. Fudin. At the core is the need for more and better education for primary care, according to Dr. Fudin. “We really need to foster safer use of these drugs,” he said. “Somebody needs to require that physicians become highly educated in pain management. That’s the bottom line.”

At PAINWeek 2017, convening September 5-9 in Las Vegas, frontline practitioners can select from over 120 hours of accredited education in pain management. Great registration deals are still available, and can be accessed at www.painweek.org.

Read more about the study with commentary from opposing perspectives.

The journal abstract may be read here.

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I got awful news last night and I’ve had a pit in my stomach all day. Rumors abound now that Trump is not only seriously considering ending the DACA ( Deferred Action for Childhood Arrivals  https://en.wikipedia.org/wiki/Deferred_Action_for_Childhood_Arrivals  ) program, but that he might do it as soon as today.

This is beyond devastating. The human impact of 800,000 young people losing their legal status in this country is beyond heartbreaking; it is cruel. Every one of them, like the ones we work with every day, would lose their work authorization and be at risk for deportation.

But we’re not done fighting. Please join us.

Today we’re asking you to call your senators and ask them to co-sponsor the Dream Act.

The bipartisan Dream Act would protect DACA-recipients by providing qualified undocumented immigrants who came to the U.S. before the age of 18 a pathway to citizenship. To be eligible, individuals must graduate from high school or pass the GED and either attend college or enlist in the military.

For me, this is personal.

I was previously undocumented and my sister is a current DACA-recipient. She graduated from college last year and is pursuing her dreams in DC. I don’t know what will happen to her if she loses her status, but I’m going to fight for her and the nearly 800,000 young people just like her with all my means.

My sister and I came to this country as children. It is the only place we call home, and we’re fighting beside every ACLU supporter for the inclusive America we believe in.

I will keep you posted with new updates. Thank you for your support.

Lorella Praeli
Director of Immigration Policy and Campaigns, ACLU

I don’t know how many chronic pain pts I have read where they have contacted the ACLU about defending the discrimination against the chronic pain community – some 100 + million… and each request has got REBUFFED…

It would appear the it is CRUEL to deport illegal immigrants but is perfectly acceptable to cause chronic pain pts to be denied their medically necessary medications and cause them to be confined to house, chair, bed ?

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Top Massachusetts Court Rules Former Employee Can Sue Employer for Handicap Discrimination After Being Fired for Medical Marijuana Use

www.biggerlawfirm.com/top-massachusetts-court-rules-former-employee-can-sue-employer-for-handicap-discrimination-after-being-fired-for-medical-marijuana-use/

The Massachusetts Superior Court ruled that a woman who was fired for testing positive for marijuana usage can sue her employer for handicap discrimination. Christina Barbuto, who had a doctor’s prescription for medical marijuana, which is legal in Massachusetts, was fired on her first day of work for testing positive for the drug.

Barbuto alleged that she informed Advantage Sales and Marketing during interviews that she uses cannabis several nights a week to treat low appetite, a symptom of her Crohn’s disease. She explained that she followed her doctor’s orders to consume a low dosage before meals, but never consumed cannabis before or during work. She claims the hiring manager told her it would not be a problem. However, Barbuto was fired after failing the required pre-hire drug test.

In response, Barbuto filed a lawsuit against her employer, alleging handicap discrimination. The court ruled against the company, which alleged that she could not sue them for discrimination because marijuana possession remains illegal under federal law. However, Massachusetts Chief Justice Ralph Grant ruled that if a certified doctor determines that marijuana is the best treatment for an employee’s medical condition, an exception to the employer’s drug policy is a reasonable accommodation to make for that employee.

“Under federal law (and many state laws), an employer must provide a reasonable accommodation for any disabled employee as long as the accommodation does not present an undue hardship,” said San Francisco employment attorney Jason Erlich.

According to Justice Grant, the fact that marijuana possession is federally unlawful does not make this exception “per se an unreasonable accommodation.” Justice Grant said Massachusetts recognizes medical marijuana as the same as any other prescription drug, and anti-discrimination laws require companies to create acceptable accommodations for medical marijuana patients.

“By summarily terminating her employment after she tested positive for marijuana, the employer failed to engage in an interactive process with her and failed to discuss whether other equally effective medical alternatives might exist which did not conflict with the company’s drug policy,” Erlich said.

According to Barbuto’s attorneys, her win could set a precedent for employers and employees in Massachusetts, as well as other states where medical marijuana is legal.

Marijuana Use: Federal Law vs. State Law

One issue raised by this case is the relationship between state and federal law on marijuana policy. Marijuana remains illegal under federal law as a schedule one drug, but several states have their own laws regarding marijuana use and distribution.

California was the first state to legalize medical marijuana in 1996 after the California medical community acknowledged that cannabis contains medical benefits that can treat many types of symptoms. Now, 29 states participate in the medical marijuana program, and 8 states and Washington D.C. have legalized recreational marijuana.

However, the way employers implement marijuana policy faces challenges and confusion as the relationship between state and federal laws are often contradictory. “These challenges and confusions exist due to the fact that marijuana remains completely illegal under federal law because it is a schedule one substance (ironically defined as drugs with no commonly accepted medical use with addictive potential). This means, based on federal law, no employee may legally use, possess or sell marijuana. On the other hand, depending on the state, marijuana is either highly regulated but legal for recreational use, or highly regulated but legal for medical use,” said Michigan criminal defense attorney Patrick Barone.

“Marijuana use, distribution and sale has been illegal under the federal government since the early 1970s,” said New Jersey attorney Daniel T. McKillop, who leads a team of attorneys assisting clients operating in the legal cannabis industry. “However, in 2013 former Deputy Attorney General James M. Cole issued a memorandum indicating that in states with robust marijuana regulatory programs that do not interfere with federal enforcement priorities, the Department of Justice may decline to dedicate federal resources to enforcing the prohibition.”

According to McKillop, the Massachusetts ruling stands as a groundbreaking decision that could set a precedent for how similar cases involving employees using medical marijuana outside of work will be handled in court. However, cases like Barbuto’s will continue to arise as state and federal marijuana laws evolve.

As of March 31, 2017, 19 more states have bills pending that would legalize adult-use marijuana. Even on the federal level, lawmakers are trending toward opening up avenues for the decriminalization of the drug. On August 1, Sen. Cory Booker introduced legislation that would remove marijuana from the federal Controlled Substances Act, allowing states to set their own policies.

But until a marijuana rescheduling occurs at the federal level, private marijuana usage will continue to be a contentious and evolving issue for employers and private citizens alike. “This is still a very fluid area of employment law, and employers need to consult with a knowledgeable attorney to avoid litigation issues and stay abreast of state and federal law while implementing employment policies,” McKillop said.

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Study: Patients’ hearing loss may mean poorer medical care

https://www.upi.com/Health_News/2017/08/24/Study-Patients-hearing-loss-may-mean-poorer-medical-care/7971503593347/

THURSDAY, Aug. 24, 2017 — Many seniors may not hear everything their doctors tell them, new research suggests, and that could raise the risk of medical errors.

“In our study of 100 patients 60 and older, 43 reported mishearing a doctor or nurse in an inpatient or community health care setting, lending vulnerability to unintended error,” said researcher Simon Smith, from the University College Cork School of Medicine, in Ireland.

Earlier research has found that improved communication between doctors, nurses and families could prevent 36 percent of medical errors, Smith added.

The problem is not just a matter of doctors speaking louder. “The ability to separate speech from background noise is more intricate than volume alone,” he explained.

Often hearing tests don’t capture the complexity of how patients process medical information, and hearing aids may not be the answer, Smith said.

The process that leads to miscommunication that starts with hearing loss needs more study to help patients better understand what’s being told to them and to help find ways for doctors to better communicate, he said.

The report was published online Aug. 24 in the journal JAMA Otolaryngology–Head & Neck Surgery.

According to Dr. Darius Kohan, director of otology/neurotology at Lenox Hill Hospital in New York City, “This article brings into focus a major problem that patients and families and health care providers share in common: the flow of communication among the parties involved.”

After 60, a significant number of men and women start to have hearing problems, which can hamper communication, he said.

“This is even more of a problem in the medical field,” Kohan pointed out.

“Often in the medical care setting there is background noise impeding hearing, the content is often technical and unfamiliar to patients and families, and the setting is stressful on patients who may already be in distress due to their medical condition,” he explained.

In addition, doctors and other health care providers may also suffer from hearing loss and not always hear patients’ concerns.

Part of the solution could be quiet rooms in hospitals and clinics “where the flow of medical information between health care providers and patients and families can occur in private,” Kohan suggested.

“The hard-of-hearing must have means available to facilitate hearing and communication among clinicians and patients,” he said.

“Although this study is on a very small patient population, one can extrapolate their results to the rest of the medical community,” he added.

In the study, Smith and his colleagues found that 57 of the 100 seniors had some degree of hearing loss and 26 used a hearing aid. Moreover, 43 participants said they had misheard a doctor, nurse or both in a primary care office or hospital.

The main types of mishearing included misunderstanding what was said to them, not correctly hearing a doctor’s diagnosis or advice, and general breakdown in doctor-to-patient communication, Smith said.

One geriatric specialist said loss of hearing among older adults is a problem she encounters every day.

“It’s important that we assess hearing and treat hearing loss, because hearing loss also affects our memory and our brain stimulation. So when we lose that sensation of hearing we also lose information access and that can cause slowing of our mental function,” said Dr. Maria Torroella Carney. She is chief of the division of geriatric and palliative medicine at Northwell Health, in New Hyde Park, N.Y.

Many people have hearing loss, but don’t get a hearing aid. Hearing aids are often not covered by insurance, Carney noted.

“Hearing aids cost thousands of dollars, so patients don’t pursue it until absolutely necessary,” she said.

With some patients, Carney uses a hearing amplifier, which is a simple device that can help some patients hear better by increasing the volume of sound directly in their ear.

“That’s a tool we use regularly with our patients,” she said. “It’s remarkable when we bypass the hearing deficit. You don’t really appreciate how much they were missing until you use a device like that. It helps [you] communicate much better, especially when you have to communicate important information.”

For example, Carney recently used the amplifier with a patient who was then able to describe pain in detail, when before the patient did not understand the questions she was asking.

The device also helps patients understand medication instructions, she said. “If patients aren’t hearing everything, they don’t understand and they are not going to ask clarifying questions,” she said.

Carney added that hearing loss can make patients feel isolated and affect their quality of life.

It’s important to test older patients’ hearing and find the best ways to help, because restoring hearing can keep patients mentally alert, she said.

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Christie strikes tougher tone on opiod prosecutions. Will it get Trump to act on opioids?

http://www.nj.com/politics/index.ssf/2017/08/christie_sounds_a_lot_more_like_jeff_sessions_thes.html

NEWARK —  Gov. Chris Christie on Thursday evening again called for President Donald Trump to formally declare a national emergency in response to a plague of opioid overdoses that last year claimed more American lives than did the peak of the HIV/AIDS epidemic.

But as he did, the governor also publicly embraced the Justice’s Department’s new harder line on drug prosecutions to encourage a president whose administration has been inconsistent and hesitant in its response to the overdose crisis.

“I hope that when we get new leadership at the U.S. attorney’s office, that we’ll return to a time when we’re once again aggressive about drug enforcement as part of what needs to be done,” said Christie, who spent seven years as a U.S. attorney for New Jersey.

Laxness in interdiction, Christie argued Thursday, was helping fuel addiction.

“People who are profiting from spreading death throughout our neighborhoods and our communities need to held accountable and need to be put in jail for that.”

That jibes with U.S. Attorney General Jeff Sessions new policy of seeking drug convictions that “carry the most substantial guidelines sentence, including mandatory minimum sentences.”

But the governor made his remarks at a showcase of artwork from opioid addicts in recovery, and the crowd of 100 applauded cautiously at this new, harder-line rhetoric.

Christie has devoted his final year in office to addressing opioid addiction, and in March, Trump appointed him chair of presidential commission tasked with determining the federal response to the opioid crisis.

However, the president has vacillated on whether to accept the findings of the commission’s interim report.

Two weeks ago, Christie and his five member presidential commission unanimously argued for the declaration of a national emergency by the president, noting that 142 Americans die of drug overdoses daily, mostly from opioids.

What Christie said about Trump’s neo-Nazi comparisons

At first, Trump’s White House seemed to dismiss the national emergency declaration recommendation.

“We believe at this point that the resources that we need or focus that we need to bring to bear to the opioid crisis can be addressed without the declaration of emergency,” said Health and Human Services Secretary Tom Price on August 8.

But two days later, when Trump was asked by a reporter why the loss of as many American lives as were claimed by the 9/11 attacks every three weeks was not a national emergency, the president reversed himself.

“The opioid crisis is an emergency and I’m saying right now it’s an emergency. It’s a national emergency,” Trump said on August 10. “We’re going to draw it up and we’re going to make it a national emergency.”

Two weeks later, there’s been no formal emergency declaration by Trump.

On Thursday, a White House spokesman told CNN that the delay was because of “a legal review” and said that “we are declaring one but we are considering which option to use to declare one.”

A national emergency declaration made under the Stafford Act would provides access to resources and funding typically used by FEMA after natural disasters like Superstorm Sandy. Declaring one under the Public Health Services Act would give the Health and Human Services Department broader authority to act.

On Thursday, Christie again pressed his case for the president to make a formal declaration.

“I urged the president to declare a national emergency because this is a national emergency,” said Christie Thursday. “Let us have the kind of response that that loss of life that we had to the loss of life in the World Trade Center, and the Pentagon and Shanksville, Pennsylvania.”

But as he exited the DEA’s second annual opioid-themed art show at Newark’s Gateway Center, the governor declined to answer questions about if he knew why the president had not made a formal emergency declaration.

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Utah to Obey Order for DEA Drug Database Search

www.hightimes.com/news/utah-to-obey-order-for-dea-drug-database-search/

SALT LAKE CITY (AP) — Utah will obey a court order to let the U.S. Drug Enforcement Administration search a prescription-drug database without a warrant, despite a state law designed to protect patient privacy.

The state disagrees with the ruling that found people can’t expect privacy in the highly regulated prescription-drug industry, but state attorneys have decided not to appeal after reviewing similar cases, said Utah Attorney General’s Office spokesman Dan Burton in a statement Monday.

A federal appeals court also sided with the DEA in a case involving subpoenas of Oregon’s prescription-drug database.

All states maintain similar databases to help doctors and pharmacists prevent overprescribing amid a national opioid-drug epidemic. The databases hold records of medications like the anti-anxiety drug Xanax and sleep aid Ambien as well as opioid painkillers.

Utah is among a minority of states requiring police to get a warrant before they search the database. Utah state law enforcement will still have to follow the law, Burton said.

American Civil Liberties Union of Utah attorney John Mejia said he’s disappointed in Utah’s decision not to appeal the federal court judge’s ruling.

The DEA fought to be exempt from the law, saying the searches are an important tool in early investigations. The agency sued after agents asked to search the database to find out whether a medical provider was prescribing drugs to members of a criminal organization with ties overseas.

Officials refused to allow the search without a warrant, following a law that passed after two firefighters were wrongly charged with prescription-drug fraud following a wide-ranging search of the database in an ambulance drug theft investigation.

The firefighters were not linked to the thefts, but their relatively high number of prescriptions raised suspicion. The charges were later dropped after they showed all the drugs were properly prescribed, but still put their careers and personal lives at risk, they said.

The firefighters union joined the case to keep the DEA out of the database, as did an LGBT group. Equality Utah argued that the searches violate the privacy of transgender people whose hormone medications are recorded in the database.

But U.S. District Judge David Nuffer decided last month that database queries don’t violate laws against unreasonable search and seizure because the prescription drugs are already tightly controlled.

“Prescription drugs are a highly regulated industry in which patients and doctors do not have a reasonable expectation of privacy,” he wrote in the ruling handed down last month.

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No charges filed, despite ex-hospital employee’s admission he stole patients’ painkillers

http://www.desmoinesregister.com/story/news/health/2017/08/23/no-charges-filed-despite-ex-hospital-employees-admission-he-stole-patients-painkillers/594702001/

More than five months have passed since a former Des Moines hospital employee admitted to stealing painkillers that were be used to treat hundreds of patients, but no criminal charges have been filed. 

Victor Van Cleave was a pharmacy technician at Iowa Methodist Medical Center, who was accused in 2016 of stealing liquid fentanyl and hydromorphone. Many of the medications were meant to be used for patients undergoing surgery or giving birth. 

Van Cleave allegedly used a syringe to remove the medications from vials, then replaced them with sterile water. Other hospital staff members, unaware of the thefts, then tried to treat patients’ pain with the water. Patients have said the lack of medication left them in excruciating pain.

Van Cleave relinquished his state license in a March 7 settlement with the Iowa Board of Pharmacy. The settlement documents say he stole 252 vials of fentanyl and 18 vials of hydromorphone. He signed the documents, which say, “Respondent admits the allegations.”

Iowa Methodist faces lawsuits from several former patients who say they suffered needless pain because they were treated with water instead of medication.

Nancy Burton of Des Moines is one of those patients. She said she was affected during two visits to Iowa Methodist’s emergency department, where she was treated with water instead of medication for sharp pain from kidney stones. She said Wednesday she doesn’t understand why no criminal charges have been filed, given that the former pharmacy technician has admitted to the thefts. “It’s aggravating and depressing,” she said. “I wonder every day, ‘What’s what?'”  

Fentanyl and hydromorphone are opioids, which are effective painkillers but also are fueling the country’s drug-abuse epidemic. Illicit drug dealers reportedly have been adding forms of fentanyl to heroin to boost its potency. The practice is being blamed for a national wave of overdose deaths. Authorities have not said what allegedly became of the medications stolen from Iowa Methodist Medical Center. 

Courtney Rowley, a lawyer for Burton and several other former patients, said at a press conference in February that hospital administrators should have noticed the missing medications more quickly. “This was a systematic failure, an institutional failure, a failure to people who trusted this medical institution,” Rowley said.

Dusty Chapline, a Des Moines police officer who is a plaintiff in one of the lawsuits, said at the press conference that she gave birth to her first daughter at Iowa Methodist on Sept. 22, 2016. Chapline had to receive a second epidural during her 16 hours of labor after the first was ineffective, causing some of the “worst pain I’ve ever felt in my life,” she told reporters. “It was horrible,” she said. “I told my husband that I didn’t want to have another kid.”

Hospital leaders have defended their response to the situation, but they declined further comment Wednesday. Van Cleave could not be reached for comment.

After the thefts were discovered, the hospital urged as many as 731 patients who were affected to get tested for HIV and hepatitis C, because syringes were used in the thefts. The pharmacy technician agreed to be tested for infectious diseases and was negative, a hospital spokeswoman said in February.

But two of the former patients listed in a February lawsuit said that they tested positive for hepatitis C after receiving care at Iowa Methodist Medical Center while the thefts were going on. The virus, which can be spread through dirty needles, is a liver infection that develops into a lifelong ailment for most people who contract it and can ultimately lead to liver failure and cancer.

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Lawmakers Tell Sessions To Stop Blocking Marijuana Research

https://www.massroots.com/news/lawmakers-tell-sessions-to-stop-blocking-marijuana-research

A bipartisan group of members of Congress is asking U.S. Attorney General Jeff Sessions to stop standing in the way of increased research into marijuana’s medical potential.

“Over eighty percent of Americans believe that doctor-prescribed marijuana should be legal, according to recent polls,” two Republicans and two Democrats wrote in a letter to Sessions on Wednesday. “It is worrisome to think that the Department of Justice, the cornerstone of American civil society, would limit new and potentially groundbreaking research simply because it does not want to follow a rule.”

The letter references a story the Washington Post published last week reporting that the Justice Department has prevented the Drug Enforcement Administration (DEA) from even acting on applications from researchers who want to grow cannabis for scientific studies under a new program.

Last August, on the same day the DEA denied petitions to reschedule marijuana under the Controlled Substances Act, the agency also established a new procedure to license more facilities to cultivate marijuana for research.

The move was in response to concerns about the lack of quality marijuana available for trials. The only legal U.S. source of cannabis for science since 1968 has been a farm at the University of Mississippi, which is licensed by the National Institute on Drug Abuse (NIDA). Researchers have often argued that it is difficult to obtain product from the university and that even when their applications are approved, it is often of poor quality.

However, despite the fact that DEA has already received at least 25 applications to participate in the newly expanded licensing program, it has not acted on any of them. And that, according to the Post, is because top officials in the Department of Justice are impeding the proposals from advancing.

“They’re sitting on it,” an unnamed law enforcement official told the newspaper. “They just will not act on these things.”

A separate DEA insider said the Justice Department “has effectively shut down this program to increase research registrations.’”

In the new letter, Reps. Matt Gaetz (R-FL), Dana Rohrabacher (R-CA), Jared Polis (D-CO) and Earl Blumenauer (D-OR) told Sessions that they “encourage you to proceed with rapidity on the DEA’s permitting process, as we believe it is in keeping with President Trump’s campaign promises, and the best interests of the American people.”

The lawmakers cite marijuana’s potential to ease the symptoms of PTSD, “which has afflicted many of the heroic men and women of our armed forces,” they write, as well as other conditions.

“The cumbersome and lengthy permitting process, as well as the difficulty of obtaining different types and ‘strains’ of cannabis with which to perform research, have thwarted researchers’ ability to study the pharmacology and potential medical usage of cannabis,” the lawmakers said. “The DEA’s new permitting process of August 2016 does not attempt to change marijuana laws, except for the acquisition of research material. Such a change is small, but will greatly enhance scientists’ ability to perform research, and, as such, it should not be hindered unnecessarily.”

Ending with an appeal to Sessions’s affinity for law and order, they write, “Finally, because we know you to be a man with unwavering commitment to the rule of law, we ask with respect for the DEA’s rule to be followed, and for the permitting process to move forward with all possible expeditiousness.”

See the full text of the lawmakers’ letter to Sessions below:

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How we can fight back against Jeff Sessions’ new highway robbery policy

https://www.usatoday.com/story/opinion/2017/08/24/how-states-can-fight-back-against-jeff-sessions-new-forfeiture-order-herod-sibilla-column/586246001/

Under civil forfeiture, law enforcement can confiscate private property without ever filing criminal charges.

In a refreshing display of bipartisanship, the U.S. Commission on Civil Rights on Friday slammed a new expansion of civil forfeiture announced by Attorney General Jeff Sessions. Under civil forfeiture, law enforcement can confiscate private property without ever filing criminal charges. Notably, the Commission, which is usually divided along bitter, partisan lines, voted unanimously to rebuke the Justice Department and called to end civil forfeiture.

As the Commission recognized, “scaling up rather than scaling back on this practice means more innocent Americans will lose their property.” Worst of all, the Sessions order widens a loophole that allows agencies to circumvent state safeguards specifically designed to limit civil forfeiture.

Fortunately, states like Colorado are fighting back. Thanks to a landmark reform bill that took effect on Aug. 9, the Attorney General’s directive will barely be felt in Colorado.

The new Justice Department policy revitalizes part of a federal forfeiture program called “equitable sharing.” This program allows local and state agencies to collaborate with federal agencies and forfeit property under federal law. Litigating under federal law — one of the laxest in the nation — lets police and prosecutors bypass restrictions they otherwise would face. Across the country, the property owner was never indicted in 81% of all equitable-sharing cases.

More: Forget Russia. I’d fire Jeff Sessions over civil forfeiture.

More: How police steal from citizens

Consider Mark Brewer, an Air Force veteran who lost his life savings because of this loophole. While driving through Douglas County, Nebraska in 2011, a deputy pulled him over. Upon searching the car, no drugs were found. But the deputy did come across $63,530 in cash. Without ever charging Brewer with a crime (or issuing him a ticket), the deputy seized Brewer’s money.

Instead of turning the case over to Nebraska prosecutors, the Douglas County Sheriff’s Office relied on an equitable sharing program called “adoption.” The sheriff’s office referred the seizure to the Drug Enforcement Administration (DEA), which “adopted” the case less than a month later.

By transferring the case to the DEA, the Douglas County Sheriff’s Office could skirt state law, which required proving beyond a reasonable doubt that seized property had criminal ties. But under federal law, prosecutors can prevail under a much lower standard called “preponderance of the evidence” (i.e. more likely than not), which caused Brewer to lose his cash.

His case was not an isolated incident. Brewer was just one of nearly 62,000 people who had their cash seized through equitable sharing since 9/11. Spurred by this torrent of abuse, in January 2015, then Attorney General Eric Holder curtailed adoptive seizures, which accounted for one-fourth of all equitable sharing seizures nationwide.

Now Sessions has undone even that moderate progress. His order reverses the adoption limit and hurtles the nation in the wrong direction.

Moreover, the “safeguards” Sessions promised only apply to cash under $10,000 and can be bypassed with approval by a federal prosecutor. As for real estate forfeitures, including homes, the directive merely asks that Justice Department officials “proceed with particular caution.”

That guideline would have hardly helped property owners like Tony Jalali, who owned a $1.5 million office building in Anaheim. One of his tenants was a medical marijuana dispensary. Although medicinal marijuana was legal in California, an undercover officer bought $37 worth of cannabis from the dispensary. Based solely on that minor purchase from one tenant, Anaheim police wanted to confiscate the entire building.

Police first reached out to California prosecutors, but were rebuffed. Since California is one of 14 states that requires a conviction to forfeit property, Jalali — who was never even accused of a crime — should have been protected.

Federal law, however, has no such requirement. In other words, equitable sharing provided a loophole for the Anaheim Police Department to collaborate with the DEA in an attempt to take Jalali’s property. Fortunately, after the Institute for Justice became involved, the federal government dropped the case in 2013.

Disturbingly, there was also a pecuniary motivation for agencies to hand over Brewer and Jalali’s cases to the DEA. Once a property is forfeited under equitable sharing, agencies may collect up to 80% of the proceeds — a higher payout than what Nebraska and California both permit. Nationwide, the Justice Department funneled a staggering $6 billion to local and state agencies through equitable sharing since 2000.

As the U.S. Commission on Civil Rights correctly realized, allowing law enforcement to keep what they seize “creates an inherent conflict of interest,” which undermines “public trust in the police.”

POLICING THE USA: A look at race, justice, media

More: Know your rights when stopped by police

But in Colorado, the state’s new law largely ends this perverse incentive to partner and profit, by banning police from collecting bounties. Under the reform, agencies can still participate in equitable sharing, but can only receive federal forfeiture proceeds if the seized property relates to a criminal case and is worth more than $50,000. Data analysis by The Institure for Justice found that 92% of all equitable-sharing forfeitures in Colorado were under that threshold. Together, these safeguards should protect hundreds of innocent people from federal confiscations.

Previously, circumvention ran rampant. Colorado agencies managed to collect nearly $50 million through equitable sharing — roughly four times the amount taken through state forfeiture laws. Now Colorado is one of just eight states where Sessions’ directive should have little impact.

For the remaining states, the Attorney General’s announcement gives a new urgency to close the equitable-sharing loophole and resist federal interference. Our constitutional rights are too important to forfeit.

State Rep. Leslie Herod is a Democrat from Denver and the author of House Bill 17-1313, concerning civil forfeiture reform. Nick Sibilla works at the Institute for Justice.

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

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14 Situations Where Physicians Should Lawyer Up

http://www.diagnosticimaging.com/blog/14-situations-where-physicians-should-lawyer

Physician practices handle a wide variety of business and administrative issues on a daily basis, often with the help of experienced practice managers who bring knowledge and expertise to the job.  However, there are time when I recommend that a practice and its manager recognize when there may be issues on which they have limited knowledge and where legal advice may be appropriate.  Often my clients call me too late after trying to handle something on their own.

The following are some circumstances where I think it’s worth it to call your lawyer, especially the ones like Attorney Stephen Phillips, to be sure you handle the situation for the best possible outcome:

1. The practice receives a letter from an attorney making a demand (for money, cease and desist, etc.). 

2. The DEA, FBI or other state or federal agent calls or comes to the practice or home of one of the owners/employees to ask questions about anything.

3. Any documents are received affecting a physician’s license, Board status, medical staff privileges at a hospital, etc. This is an area where mistakes cannot be easily remedied and talking to legal counsel immediately is very important! In no event should a resignation be submitted before legal counsel is consulted.

4. The practice is served with a complaint by the EEOC, State Department of Human Rights, Department of Labor, OSHA or any other state or federal agency regarding an employment or practice matter.

5. The practice receives a non-routine billing audit, desires to self-report or enter into negotiation with the government, or any payer, on a repayment or integrity agreement.

6. The practice is named in a lawsuit or its employees/owners are required to testify related to a lawsuit, or otherwise participate in any government or agency interview or investigation.

7. The practice discovers, or is accused, of a breach of HIPAA.

8. The practice discovers theft of prescription drugs or prescription pads, the false ordering of drugs by an employee, or that prescription drugs have been ordered from a non-permitted supplier.

9. There is a complaint of criminal or sexual misconduct, harassment or discrimination, by an employee or partner of the practice.

10.  The practice discovers theft of funds or property by an employee or partner, or an illegal scheme of any kind.

While the above may seem like obvious reasons to call a lawyer, too often practices try to handle these matters on their own.  Additionally, some healthcare/transactional issues that should also lead to a call to counsel include:

1. Employing a new physician.  Practices often rely on outdated contracts that contain errors or are not updated to reflect current law (i.e. non-compete requirements, fee-splitting, supervision of mid-levels). This also applies to legal enforcement of contracts and making legal threats.

2. Introducing new ancillary services to a practice which are “designated health services” under the federal “Stark” law.  Practices must be aware that a legal analysis of the practice structure and modifications to corporate documents may be required.

3. Entering into agreements with new vendors related to items or goods billable to federal payers or commercial insurance (DME, lab, PT) or developing marketing arrangements. All of these potential arrangements can implicate state and federal self-referral and anti-kickback statutes.

4. Entering into arrangements with other healthcare providers or entities for space, equipment, personnel or similar arrangement, especially when there may be direct or indirect referrals of patients between the parties.

I am sure there are many more examples to add to this list. The key is to really understand your practice’s own limitations and to appreciate that sometimes even the best practice manager does not know what they do not know! A practice should develop a relationship with healthcare counsel who can be available, even for a quick question. There is no doubt that sometimes the cost of not getting advice may be more than a practice can afford.

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