Obama vs Trump AG :Army vet faces trial for posting flags at VA site

Army vet faces trial for posting flags at VA site, Sessions asked to intervene

http://www.foxnews.com/politics/2017/02/24/army-vet-faces-trial-for-posting-flags-at-va-site-sessions-asked-to-intervene.html

A 74-year-old U.S. Army veteran is set to go on trial next month for the ‘crime’ of posting two American flags on the fence of a Los Angeles VA facility — and the Justice Department is facing calls to drop the case. 

The criminal prosecution of Robert Rosebrock dates back to charges filed under the Obama administration, but conservative group Judicial Watch is hoping new Attorney General Jeff Sessions will take a second look. 

“Frankly, President Trump should ask why the VA and his Justice Department are trying to jail this American patriot,” Judicial Watch President Tom Fitton said in a statement. His group is now representing Rosebrock. 

“The federal government’s pursuit of these vindictive charges against Mr. Rosebrock is mind-blowing,” he added. 

Judicial Watch Director of Litigation Paul Orfanedes confirmed to Fox News they have reached out to Sessions with a request to intervene before the scheduled March 7 trial.

Rosebrock is facing one criminal charge for displaying an American flag without permission on the fence outside the Greater Los Angeles Veterans Affairs (GLAVA) facility during a protest of the VA’s treatment of homeless veterans.

The charge is related to a 1973 VA regulation that prohibits individuals from posting materials or placards on VA property except when authorized by the head of the VA facility or a designee.

Rosebrock faces a criminal count of violating that policy during a protest last Memorial Day and on June 12, 2016. In the second incident, Rosebrock was not even the individual who posted the flag. Orfanedes told Fox News the reason why the police chose to enforce the policy on those days remains unclear.  

Rosebrock is facing an two additional counts for allegedly taking unauthorized photos of a VA police officer on Memorial Day and during the second protest when conservative activist Ted Hayes was handcuffed and detained. Hayes is not being prosecuted.

Rosebrock, who served in the Army from 1965 to 1967, pleaded not guilty but faces up to six months in prison if found guilty.

Neither the Justice Department nor the Department of Veterans Affairs returned calls seeking comment.

The roots of the unusual case date back almost a decade, when Rosebrock held his first protest. Every Sunday since March 2008, Rosebrock and other veterans have placed flags on the fence as a means of drawing attention to what they allege is VA mistreatment of homeless vets.

For almost 66 weeks, he and other veterans placed their flags on the fences without any interference from police. It was only after some of the protesters started hanging the flag upside-down that the police became involved.  

Starting in June 2009, they began issuing citations for “unauthorized demonstration or service in a national cemetery or on other VA property,” according to the ACLU of Los Angeles, which represented him in a 2010 First Amendment lawsuit.

In May 2011, U.S. District Judge S. James Otero found the VA had violated Rosebrock’s First Amendment rights, and the VA eventually dismissed the citations against him.

While it would not grant him any damages, the 9th Circuit Court determined that VA enforcement only began “when protestors hung the American flag union down on the fence.” Orfanedes said the protesters haven’t hung the flag upside-down since 2010. 

Although the VA may view Rosebrock and his fellow vets to be a nuisance, the attention on the VA’s management of the Los Angeles properties has led to change.

For example, the ACLU of Southern California also filed a lawsuit in 2011 alleging the VA had illegally leased land, including to UCLA for its baseball stadium and to a parking service. The VA eventually settled in 2015 and subsequently unveiled a plan to improve its management of the Los Angeles campus.

Will the Trump Admin take a different stance on the abuse of CPP by the CDC ?

CDC: Withdraw Guidelines for Prescribing Opioids for Chronic Pain

http://petitions.moveon.org/sign/cdc-withdraw-guideline.fb49?source=s.fb&r_by=18051621

The CDC’s Guidelines are inappropriate, short sighted, and are more harmful than helpful to pain patients. Developed in violation of the Federal Advisory Committee Act’s (FACA) regulations with little to no evidence used in support, the Guidelines are blatantly discriminatory to existing pain patients, licensed pain specialists, and responsible users of opioid medication, and should be withdrawn.
There are currently 5,105 signatures. NEW goal – We need 7,500 signatures!
 
 

Petition Background

This petition is on behalf of all chronic pain sufferers, as well as their families and loved ones. For myself and those like me, the responsible prescription and use of opioid pain medication is all that makes it possible for us to function as productive members of society. The CDC Guidelines have been developed irresponsibly and without the patient in mind, focusing instead only on the potential for abuse. The prescription of pain relief medication should not be dictated by government decree, but instead should be responsibly managed by a licensed physician and pain professional.

60 percent of all the caregivers made errors when doling medication into a pillbox

https://youtu.be/HVuSC67-ljI

Third of Home Care Staff Make Medication Errors – What You Can Do

http://www.123trump.com/49805.html

A Northwestern University study has shown that more than one-third of paid home care staff had difficulty reading and understanding health-related information and directions. Sixty percent made errors when sorting medications into pillboxes.

Nearly 100 paid, non-family caregivers were recruited in the Chicago area and their health literacy levels and the health-related responsibilities were assessed, said Lee Lindquist, MD, assistant professor of geriatrics at Northwestern University Feinberg School of Medicine and physician at Northwestern Memorial Hospital.

Nearly 86 percent of the caregivers performed health-related tasks. Most were women, about 50 years old, foreign born or with limited education. Many made under minimum wage.
Despite pay, country of birth, or education level, 60 percent of all the caregivers made errors when doling medication into a pillbox.

Lindquist said. “If you really want to know if the caregiver is doing a good job and is taking care of the health needs of your senior, start by going into the home, observing them doing the tasks, and asking more questions.”

When evaluating a care provider ask if:

* they provide training for staff at orientation on medication management.
* they provide ongoing training to staff as medications change, come and go.
* use a licensed pharmacist on a consulting basis.
* they equip staff with smart-phone apps that staff can download that can help with medication identification and management.

“Most physicians and family members do not realize that while the caregiver is nodding and saying ‘yes,’ she might not really understand what is being said,” he said.

 

Woman Sues Pharmacy Claiming She Was Given Wrong Pills

Woman Sues Pharmacy Claiming She Was Given Wrong Pills

Says She Hallucinated, Had ‘Terrible Nightmares’

http://www.newschannel5.com/news/local-news/woman-sues-pharmacy-claiming-she-was-given-wrong-pills

This woman’s adverse effects of getting the wrong medication is that much different than a opiate dependent pts being intentionally thrown into cold turkey withdrawal by a healthcare professional ?  And an attorney is willing to sue the “guilty party” … WHAT IS WRONG WITH THIS PICTURE ?

GALLATIN, Tenn. – A woman was written a prescription for sleeping pills, but she went home with an anti-psychotic drug and said she almost lost her mind.

Now Donna Duncan, a Mid-State woman, has sued in federal court, accusing the pharmacist of making a big mistake.

Her case might make people think twice before assuming they’re always getting the right medication.

Consider this: nearly five billion prescriptions have been filled every year in the U.S., and two percent have been mistakes.

It may not sound like much, but that means millions of patients get the wrong pills. For Duncan, that was a big problem.

“I was praying to God let it pass, and the other prayer was take me home. I just wanted it to end,” Duncan said.

She has suffered from restless leg syndrome and went for her usual prescription — Ropinirole — at a CVS pharmacy in Gallatin.

Duncan said she took it home, swallowed three pills, and her nightmare began.

“I didn’t know what was going on,” she said. “I was hallucinating. My body felt like the limbs were detached from me. I had terrible nightmares.”

Then Duncan woke up talking crazy to her husband and daughter, Molly.

“I started telling the story of being two years old out to sea, and I witnessed a murder,” said Duncan.

“I was like, okay, something is not right,” Molly observed.

Duncan’s daughter immediately noticed her rational, sensible mother was talking out of her head, so she checked her pill bottle for the Ropinirole.

“It says this is a pink round tablet with the ‘HH’ on the back,” said Molly.

But the pills she found inside were not pink, and they were marked with the letter “M.”

“Wrong pills in the right bottle with the right name with the right dosage with the right patient,” said Clint Kelly, Duncan’s attorney.

Kelly has sued Tennessee CVS Pharmacy in federal court alleging his client was given the wrong pills.

“Clearly some safety protocols were bypassed,” Kelly said.

He said Duncan was mistakenly given Risperdone, an anti-psychotic drug meant for schizophrenics.

“Serious mental patients in hospitals… everybody but Donna Duncan,” Kelly said.

“I didn’t know what was going on,” Duncan said.

She had to be hospitalized for taking the dose of Risperdone, which she did not need.

“They started pushing IV fluid to push it through me,” said Duncan.

She said the traumatic experience where she seemingly lost her mind has continued to haunt her.

Duncan added something like this could happen to anyone, so what does she do now if she needs a prescription?

“Every single time I fill a prescription, I see the pharmacist, we open the bag, and see the medication, and he must reassure me that it’s the medication it’s supposed to be,” said Duncan.

Attorneys for CVS have filed a response denying the allegations of negligence and recklessness.

They have been asking to have the lawsuit dismissed.

Light at the end of the tunnel – is not a TRAIN …

White House Opens Door To Crackdown On Recreational Marijuana

Trump pledged to respect states’ rights on marijuana during his campaign. This may signal a reversal on that promise.

http://www.huffingtonpost.com/entry/trump-recreational-marijuana-weed-states_us_58af3a8fe4b060480e05ef0e?

President Trump has stated that he was going to be a “law and order President”…  AG Sessions has also stated that he is going to enforce all laws.

As we have all noticed, President Obama was extremely discriminatory in enforcing some laws and likewise ignore or over looking the enforcement of many laws … particularly those involving people who have to deal with their subjective disease treatment.

How many times have we hear about Pharmacists discussing a pt’s health/medication issues in a load enough tone that many/all people around the Rx dept area could hear… can you say HIPAA VIOLATION ?

Likewise, how many times have we heard about Pharmacists “not being comfortable” about filling a pt’s prescription for some controlled medication. No reason given, just “not comfortable” and intentionally throwing dependent pts into cold turkey withdrawal.

Enforcement of the Americans with Disability Act was virtually non-existent…  under the Obama Administration … Let’s challenge the Trump Administration on its promise to be a “law and order administration”.

Obama/Holder told the DEA to not bother states where MJ had been legalized… they ignored them… Congress passed a law to tell the DEA to not bother states where MJ had been legalized.. they ignored Congress… a Federal judge told the DEA to not bother states where MJ had been legalized.. and they ignored him/her.

Here is the website to file a ADA complaint  https://www.ada.gov/filing_complaint.htm

If you are on Medicare/Medicaid/Medicare Advantage here is the website www.cms.gov  (800-MEDICARE) for denial of care or poor care by doctors, hospitals, pharmacies/pharmacists, insurance company, Part D provider.

Get your smart phone out and audio/video record denial of care by Rx dept staff.  The only way that you can guarantee that what was done/not done can’t be misrepresented by the Rx dept staff.

If you want proper treatment and want justice.. you have to STEP UP TO THE PLATE…

White House press secretary Sean Spicer suggested during a press conference Thursday that the federal government may crack down on states that have legalized recreational marijuana.

Spicer explained that President Donald Trump sees the legalization of medical and recreational marijuana as two distinct issues. When it comes to medical marijuana, Spicer indicated that the president understands the importance of the drug’s availability, especially to those facing terminal diseases. But when it comes to recreational use, Spicer had a very different take, connecting recreational marijuana use to the opioid crisis currently ravaging the nation.

“There’s a big difference between [medical marijuana] and recreational marijuana and I think that when you see something like the opioid addiction crisis blossoming in so many states around this country, the last thing we should be encouraging people ― there’s still a federal law that we need to abide by when it comes to recreational marijuana and other drugs of that nature,” Spicer said.

When asked if the federal government will take action around recreational marijuana, Spicer said, “That’s a question for the Department of Justice. I do believe that you’ll see greater enforcement of it. Recreational use … is something the Department of Justice will be looking into.”

Marijuana remains illegal under the federal Controlled Substances Act, despite statewide efforts to scale back on criminalizing the plant over the past few years. Legal recreational marijuana has been approved in eight states and Washington, D.C., which continues to ban sales, unlike the state programs. A total of 28 states have legalized marijuana for medical purposes. Former President Barack Obama’s Justice Department allowed states to forge their own way on marijuana policy with guidance urging federal prosecutors to refrain from targeting state-legal marijuana operations. But this guidance is not law and can be reversed by the Trump administration.

Spicer’s comments Thursday came moments after he addressed the White House’s controversial decision to rescind federal protections barring schools from discriminating against transgender students as a matter of “states’ rights” ― a philosophy that Trump appeared to support with regard to marijuana during his campaign, when he repeatedly said he would respect states’ positions on the issue. But following his election, Trump’s selection of Jeff Sessions as attorney general alarmed many drug policy reformers. 

That’s because Sessions has long held retrograde views on marijuana and the war on drugs. During a Senate hearing last year, Sessions spoke out against weed and urged the federal government to send the message to the public that “good people don’t smoke marijuana.” He went on to criticize Obama for not speaking out more forcefully against the drug, saying that “we need grown-ups in Washington to say marijuana is not the kind of thing that ought to be legalized.” In separate comments last year, Sessions also called the legalization of marijuana “a mistake.” 

Either the President is flip-flopping or his staff is, once again, speaking out of turn.” Rep. Jared Polis (D-Colo.)

Earlier this year, during Sessions’ confirmation hearings, the former Alabama senator offered only vague answers about how he might approach the drug. While he didn’t appear to suggest there would be any radical changes to federal enforcement, he left the door open for increased federal interference.

Drug policy reformers have raised concerns that Sessions could use the FBI to crack down on marijuana operations nationwide, or direct the Drug Enforcement Administration to enforce federal prohibition outside of the jurisdiction of the U.S. Court of Appeals for the 9th Circuit. The court ruled in August that a federal rider blocks federal officials from prosecuting state-legal marijuana operators and patients. But that rider must be re-approved annually, and if it’s allowed to expire, Sessions could then order the DEA to enforce federal law nationally. He could also sue the various state governments that have set up regulatory schemes.

Spicer’s comments Thursday are also in opposition to statements from Rep. Dana Rohrabacher (R-Calif.), a vocal proponent for reforming marijuana laws, who told The Huffington Post in November that Sessions would not interfere with states that have legalized marijuana, a position that he characterized as consistent with Trump’s.

Rep. Jared Polis (D-Colo.), a vocal proponent for reform of federal marijuana laws, said Spicer’s comments suggest that Trump may be “flip-flopping” on the issue. 

“The President has said time and again that the decision about marijuana needs to be left to the states,” Polis said in a statement to HuffPost. “Now either the President is flip-flopping or his staff is, once again, speaking out of turn, either way these comments leave doubt and uncertainty for the marijuana industry, stifling job growth in my state. The public has spoken on recreational marijuana, we’ve seen it work in Colorado, and now is the time to lift the federal prohibition.”

Rep. Earl Blumenauer (D-Ore.), who launched the congressional Cannabis Caucus earlier this month along with Polis and two other congressmen, said he was “deeply disappointed” by Spicer’s remarks.

“The national prohibition of cannabis has been a failure, and millions of voters across the country have demanded a more sensible approach,” Blumenauer said. The Cannabis Caucus is a group of lawmakers dedicated to protecting the burgeoning legal weed industry.

A federal crackdown on states that have legalized marijuana is in direct opposition with what American voters have said they want. A new survey from Quinnipiac University released Thursday found that a strong majority of American voters ― 71 percent ― want the federal government to respect state marijuana laws. Majorities of Republicans, Democrats, independents and every age group polled agreed: the feds should not enforce prohibition in states that have legalized medical or recreational marijuana. 

The trend of state-level legalization also reflects a broader cultural shift toward acceptance of marijuana, the most commonly used illicit substance in the United States. National support for the legalization of marijuana has risen dramatically in recent years, reaching historic highs in multiple polls just last month. States like Colorado have established regulated marijuana marketplaces, and successes there have debunked some lawmakers’ and law enforcers’ predictions that such polices would result in disaster

Recreational use … is something the Department of Justice will be looking into.” White House press secretary Sean Spicer

Drug policy reformers blasted Spicer’s Thursday remarks.

“If the administration is looking for ways to become less popular, cracking down on voter-approved marijuana laws would be a great way to do it,” said Tom Angell, chairman of Marijuana Majority. “On the campaign trail, President Trump clearly and repeatedly pledged that he would leave decisions on cannabis policy to the states. With a clear and growing majority of the country now supporting legalization, reneging on his promises would be a political disaster and huge distraction from the rest of the president’s agenda.”

National Cannabis Industry Association executive director Aaron Smith said it would be a “mistake” for DOJ to “overthrow the will of the voters and state governments” who have set up regulated adult-use programs.

“It would represent a rejection of the values of economic growth, limited government, and respect for federalism that Republicans claim to embrace,” Smith said.

Mason Tvert, director of communications for Marijuana Policy Project, said that while Spicer claims there’s a difference between medical and recreational marijuana, the “benefits and need for regulation” apply equally to both.

“This administration is claiming that it values states’ rights, so we hope they will respect the rights of states to determine their own marijuana policies,” Tvert added. “It is hard to imagine why anyone would want marijuana to be produced and sold by cartels and criminals rather than tightly regulated, taxpaying businesses.”

When asked for details on Spicer’s remarks, Department of Justice spokesman Peter Carr said that DOJ didn’t have “anything more to provide than what [Spicer] said at today’s briefing.”

Kevin Sabet, president of anti-legalization group Project SAM, said the current split between federal and state laws is “unsustainable” and that he was hopeful that the Trump administration’s enforcement priorities are pursued in a safe and healthy way.

“This isn’t an issue about states’ rights, it’s an issue of public health and safety for communities,” Sabet said.

A dose of reality

The upside of opiates: How drugs taken properly are saving lives

fox6now.com/2017/02/16/the-upside-of-opiates-how-drugs-taken-properly-are-saving-lives/

KENOSHA COUNTY — Michael Weirich, 51, rarely leaves his Kenosha County home.

Michael Weirich

Michael Weirich

When he does, he makes sure wherever he’s going has a bathroom and that he can get to it quickly.

Using the bathroom presents two major problems for the Air Force veteran.

 

 

 

Michael Weirich

Michael Weirich

The first is because of a condition called Autonomic Dysfunction, he is not in charge of his bowels which is why he wears a colostomy bag. The bigger problem is that every time he digests a meal, he’s in a great deal of pain. If you want an adjustable hernia belt, you can get it here, either online or offline. 

“It’s in my intestine. That’s where 90 percent of my pain is and it’s from multiple surgeries,” Weirich told Fox6 recently from his home. “From the time I get up to the time I go to bed, I’m in constant pain. I’ve been hospitalized 30 times in the last six years for that.”

Michael Weirich

Michael Weirich

Because of that, Weirich only eats enough to survive and each meal is topped off with a prescription opioid to help combat the intense pain that comes as his food is being digested.

 

 

 

prescription-painkillers3

Weirich is on disability and he watches a lot of television. He’s seen many of our Dose of Reality reports about the epidemic of opioid abuse and he’s worried that people abusing prescription pain killers are tainting the way the public looks at people using the drugs responsibly.

 

Michael Weirich

Michael Weirich

“I just want to let people know that not everyone who takes these drugs is a drug addict. There are actually people who take them who need them like I do. If I didn’t have them, I couldn’t eat at all,” said Weirich.

Doctor Scott Hardin of Aurora Health Care, is well aware that medications have been abused but too knows the quality of life they can add to patients when taken properly.

Dr. Scott Hardin

Dr. Scott Hardin

“There are very few to zero patients who died taking their prescriptions the way they are supposed to,” said Dr. Hardin.

Dr. Scott Hardin

Dr. Scott Hardin

Hardin says pain doctors and patients need to work together to make sure most patients are on them for a short time only.

“When we begin our patients on opioids we also have a plan to get them off — an exit strategy — so they’re on there for a short period of time compared to the past,” Hardin said.

The reason for the increase in opioid overdoses is that patients don’t realize how strong the drugs are and often take more than they should or physically alter the pills in an attempt to get a high. This is often a fatal mistake.prescription-painkillers2

As for Weirich, he wants people to know how careful most patients are.

“I hope they know there are people who take them like they’re supposed to and I go to the doctor every month like I’m supposed to and that there are people who take them and need them,” said Weirich.

Michael Weirich

Michael Weirich

Dr. Hardin says he can’t stress enough how important it is to follow directions, this is where you come in even if you’re not the patient. Keep tabs on how often, and how, a loved one is supposed to be taking painkillers. For example, if a 20-day supply is gone after ten days, there’s a problem and the prescribing doctor needs to know about it.

TV NEWS: Baby Dies Due To Medication Error at Seattle Children’s Hospital

TV NEWS: Baby Dies Due To Medication Error at Seattle Children’s Hospital

http://www.mensbroad.us/tv-news-baby-dies-due-to-medication-error-at-seattle-childrens-hospital

Q13 FOX – It was just last year that another patient at Children’s suffered a similar fate. Tammy Jarbo-Blakenship lost her son Michael on day after a routine visit for dental work. The family’s lawyer Chris Davis says the drug should have never been given to Michael.

“With respect to Michael who was given an overdose of a drug called Fentanyl pain patch that his dentist had prescribed for the first time in her career,” said Davis.

Davis says after Michael’s death Children’s Hospital promised the Blakenships it would establish new guidelines to prevent accidental overdoses.

“We were assured at the beginning of the lawsuit that they had taken changes, implemented changes to make sure this type of thing wouldn’t happen again. I’m absolutely shocked. It’s very tragic of course and absolutely unfortunate,” said Davis.

The nurse who caused this latest overdose death is on leave while the hospital investigates. The Blankenship’s lawyer Chris Davis says he doesn’t want to alarm the public, but after dealing with Michael’s death he’s learned getting to the truth in these types of cases may be difficult.

“The number of deaths and errors you see really hasn’t declined in my experience because the hospitals and medical profession goes to great lengths to keep it confidential,” said Davis.

The Blankenship Family just settled their lawsuit against Children’s as part of the deal; they’re not allowed to talk specifically about the settlement. As for changes the letter from the hospital says from now on only Pharmacists and Anesthesiologists can draw up doses of calcium chloride unless there’s a life-threatening emergency.

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VA & DOD: just avoid prescribing opiates ..There is no absolutely safe dose of opioids

Opioids for chronic pain: a new clinical guideline from the VA and Department of Defense

http://www.clinicaladvisor.com/pain-management-information-center/clinical-guideline-for-opioids-and-chronic-pain/article/639780/

A new clinical practice guideline regarding the use of opioids for chronic pain has been released by the Department of Veterans Affairs (VA) and Department of Defense (DoD).

The evidence-based recommendations are intended for practitioners throughout the DoD and VA Health Care systems and were developed by the Opioid Therapy for Chronic Pain Work Group. The revised guideline serves as an update to the 2010 guideline by the VA and DoD.

The guideline “is intended to assist healthcare providers in all aspects of patient care, including, but not limited to, diagnosis, treatment, and follow-up,” according to the work group. “The system-wide goal of this guideline is to improve the patient’s health and well-being by providing evidence-based guidance to providers who are taking care of patients on or being considered for long-term opioid therapy.”

The work group developed 18 recommendations and graded each as “strong for” or “strong against,” with the exception of the use of multimodal pain care in Recommendation 18, which was graded as “weak for.”

A summary of the work group’s recommendations is as follows:

Initiation and continuation of opioids

1. Avoid initiation of long-term opioid therapy for chronic pain. Use alternatives to opioid therapy such as self-management strategies and other nonpharmacologic treatments. When pharmacologic therapies are used, initiate nonopioids over opioids.
2. If prescribing opioid therapy for patients with chronic pain, a short duration is recommended. Note: Consideration of opioid therapy beyond 90 days requires reevaluation and discussion of risks and benefits with the patient.
3. For patients currently on long-term opioid therapy, the VA and DoD recommends ongoing risk mitigation strategies (see Recommendations 7-9), assessment for opioid use disorder, and consideration for tapering when risks exceed benefits (see Recommendation 14).
4. Avoid long-term opioid therapy for pain in patients with an untreated substance use disorder. For patients currently on long-term opioid therapy with evidence of an untreated substance use disorder, the VA and DoD suggest close monitoring, including engagement in substance use disorder treatment, and discontinuation of opioid therapy for pain with appropriate tapering (see Recommendations 14 and 17).
5. Avoid the concurrent use of benzodiazepines and opioids. Note: For patients currently on long-term opioid therapy and benzodiazepines, consider tapering one or both when risks exceed benefits and obtaining specialty consultation as appropriate (see Recommendation 14 and VA/DoD Substance Use Disorders CPG).
6. Avoid long-term opioid therapy for patients younger than 30 years of age secondary to higher risk of opioid use disorder and overdose. For patients younger than 30 years of age currently on long-term opioid therapy, we recommend close monitoring and consideration for tapering when risks exceed benefits (see Recommendations 14 and 17).

 

Risk mitigation

7. Implement risk mitigation strategies after initiation of long-term opioid therapy, starting with an informed consent conversation covering the risks and benefits of opioid therapy as well as alternative therapies. The strategies and their frequency should be commensurate with risk factors and include: Ongoing, random urine drug testing (including appropriate confirmatory testing), checking state prescription drug monitoring programs, monitoring for overdose potential and suicidality, providing overdose education, and prescribing of naloxone rescue and accompanying education.
8. Assess suicide risk when considering initiating or continuing long-term opioid therapy and intervening when necessary.
9. Evaluate benefits of continued opioid therapy and risk for opioid-related adverse events at least every 3 months.

 

Type, dose, follow-up, and taper of opioids

10. If prescribing opioids, prescribe the lowest dose of opioids as indicated by patient-specific risks and benefits. Note: There is no absolutely safe dose of opioids.
11. As opioid dosage and risk increase, the VA and DoD recommend more frequent monitoring for adverse events including opioid use disorder and overdose. Note: Risks for opioid use disorder start at any dose and increase in a dose-dependent manner. Risks for overdose and death significantly increase at a range of 20 to 50 mg morphine equivalent daily dose.
12. Avoid opioid doses greater than 90 mg morphine equivalent daily dose for treating chronic pain. Note: For patients who are currently prescribed doses greater than 90 mg morphine equivalent daily dose, evaluate for tapering to reduced dose or to discontinuation (see Recommendations 15 and 16).
13. Avoid prescribing long-acting opioids for acute pain, as an as-needed medication, or on initiation of long-term opioid therapy.
14. The VA and DoD recommend tapering to reduced dose or to discontinuation of long-term opioid therapy when risks of long-term opioid therapy outweigh benefits. Note: Abrupt discontinuation should be avoided unless required for immediate safety concerns.
15. Individualize opioid tapering based on risk assessment and patient needs and characteristics. Note: There is insufficient evidence to recommend for or against specific tapering strategies and schedules.
16. Use interdisciplinary care that addresses pain, substance use disorders, and/or mental health problems for patients presenting with high risk and/or aberrant behavior.
17. Offer medication-assisted treatment for opioid use disorder to patients with chronic pain and opioid use disorder. Note:See the VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders.

 

Opioid therapy for acute pain

18. Use alternatives to opioids for mild-to-moderate acute pain. The VA and DoD suggest use of multimodal pain care, including nonopioid medications as indicated when opioids are used for acute pain (weak strength). If take-home opioids are prescribed, the VA and DoD recommend that immediate-release opioids are used at the lowest effective dose with opioid therapy reassessment no later than 3 to 5 days to determine if adjustments or continuing opioid therapy is indicated. Note: Patient education about opioid risks and alternatives to opioid therapy should be offered.

 

“This guideline is not intended as a standard of care and should not be used as such,” stated the work group. “Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advances and patterns evolve. Today there is variation among state regulations, and this guideline does not cover the variety of ever-changing state regulations that may be pertinent. The ultimate judgment regarding a particular clinical procedure or treatment course must be made by the individual clinician, in light of the patient’s clinical presentation, patient preferences, and the available diagnostic and treatment options.”

Pharmacy loophole: Law allows pharmacists secrecy in prescription mistakes

Pharmacy loophole: Law allows pharmacists secrecy in prescription mistakes

http://www.fox19.com/story/34577659/pharmacy-loophole-law-allows-pharmacists-secrecy-in-prescription-mistakes

CINCINNATI, OH (FOX19) –

Randy Crews was just weeks away from retirement. He’d just finished up his final construction job, then planned to live out his retirement with his wife, Carmen.

Crews did have a medical problem. A problem many men his age have: high blood pressure.

It was an easy problem to control, Randy said, so long as he followed his doctor’s orders to take the 300mg of Labetalol he was prescribed.

Every eight hours.

But, it was a December 2013 trip to a Kroger pharmacy to refill that prescription that Randy and his wife said nearly cost him his life and left him needing a kidney transplant.

“I BELIEVE I SAVED HIS LIFE”

They still have the pill bottle. They still have the 76 Lamotrigine tablets Kroger’s pharmacist, Brittany Marino, admitted were given to the crews in that December 2013 prescription refill.

The Crews are storing the bottle and the pills they shouldn’t have at their attorney’s office for safekeeping while their lawsuit against Kroger and the Kenard Avenue Kroger Pharmacy makes its way through the Hamilton County court.

The Crews have lost their dining room to a dialysis machine and the $70,000 a month in supplies to keep Randy’s kidneys functioning. The boxes are stacked almost to the ceiling.

“These are his kidneys,” Carmen said as she showed us the dialysis setup in their dining room last week.

“This is seven days a week. He goes on the cycler at seven in the evening. He doesn’t get off until seven in the morning,” Carmen told FOX19 NOW.

“This is forever,” Carmen lamented.

Carmen’s the one Randy credits with saving his life in April 2014, four months after the Kenard Avenue Kroger Pharmacy filled his blood pressure prescription. Crews, who got his prescriptions in three-month refills, started taking the medication in early 2014.

By April 9, Randy Crews was lying in a Cincinnati hospital. Carmen told us that doctors told her had she waited two more days, her husband would be dead.

Carmen said she knew something was suspicious about the medication because her husband, whose blood pressure had always responded to the Labetalol, was seeing his blood pressure spike.

Carmen said she called her own pharmacist to find out what was going on with her husband’s prescription.

“I called the pharmacist and they identified it as Lamotrigine. It wasn’t Labetalol, it was Lamotrigine and they told me it was a psych/anti-seizure medication,” Carmen told FOX19 NOW investigative reporter Jody Barr.

After a five-day stint in the hospital, Randy Crews said he was sent home, carrying with him a lifetime sentence of daily dialysis treatment from Stage 5 kidney failure, commonly known as chronic renal failure.

His only other option of survival: a kidney transplant.

DEPOSITION EXPLAINS THE “HOW”

The Crews waited one year to the day of that December 2013 Kroger prescription fill to file a lawsuit against the grocery chain. The wait, as the Crews put it, was to “Give Kroger the chance to make this right,” Carmen said in our interview last week.

They didn’t even get an apology, the Crews told FOX19 NOW.

“Kroger was very standoffish,” Randy said, “They almost acted like they were unconcerned.”

“They, to me, wanted to treat this like he slipped and fell in the store. This is not a slip and fall case,” Carmen Crews said.

The Crews’ lawsuit accuses Kroger and its Kenard Avenue Pharmacy of negligence, product defect, failure to warn, improper labeling and loss of consortium. The Crews want a jury to decide the damages.

On April 28, 2016, the Crews’ legal team called Kroger Pharmacist Brittany Marino in for a deposition. Marino was the pharmacist on duty at the time of the Crews prescription filling on Dec. 31, 2013.

Marino admitted in the deposition that Kroger had multiple layers of checks in their dispensing protocol, but that the protections were overridden when the pharmacy put the wrong pills in the Crews bottle.

When filling a prescription, the pharmacy is supposed to scan the label on the patient’s bottle, then scan the stock bottle from where the pills are being dispensed. If the labels don’t match, the pharmacy computer alerts the pharmacy. The deposition shows Kroger calls this step the “accuracy scan.”

The next step would require the pharmacist to take one of the dispensed pills in hand, then compare the pill to an image displayed on the pharmacy’s computer screen. The final control would require the pharmacist to check the pill’s identifying information printed on the label to the imprint and description stamped onto the pill, itself.

Those three error-prevention moves failed to catch the mistake in this case. Marino admitted so in the deposition.

“We can tell if it was done and if it was – you can override that and it was overridden. So, the accuracy scan did not scan,” Marino told Randy Crews’ attorney, Chris Macke, in her sworn testimony in the April 2016 deposition.

“So the error was identified by EPRN and he – well, and it was overridden,” Macke asked Marino. “Yes,” Marino responded.

Marino told Macke the pharmacy technician, David Wang, overrode the accuracy scan alert, an action “Any technician can override,” Marino testified.

“Then he passes that to you for verification,” Macke asked. “Yes,” Marino answered, a step that required Marino to “physically examine” the pills.

“Was that done in this case,” Macke asked. “Yes,” Marino answered.

“Would part of your visual inspection have included comparing the numbers and letters that were printed on the pills, compared to what was on the image? Would that have been part of your verification,” Macke asked, “That—yes,” Marino answered.

“And your testimony is that you performed that verification then,” Macke asked. “Yes,” Marino answered.

The Crews pills were supposed to be stamped with NT 042, identifying the pill as a Labetalol tablet. The pills mistakenly placed in the Crews bottle were stamped NT on one side and 042 on the other, identifying the pill as a Lamotrigine tablet.

“You would have noticed that,” Macke asked Marino, “Right,” Marino answered. “I should have noticed that, yes,” Marino said her testimony.

“I didn’t notice or realize that it was the wrong imprint,” Marino admitted.

The deposition testimony also showed it’s common practice for Kroger pharmacists to ignore “accuracy scans” when filling prescriptions.

“Those accuracy overrides happen relatively frequently. So, yes, looking back at – would like to think that I would have noticed that. But that happens several times a day so it would –doesn’t necessarily mean it’s the wrong medication in there,” Marino said in the deposition.

With the Crews case, Kroger’s pharmacy inventory records would have shown 90 fewer Lamotrigine tablets and 90 more Labetalol tablets in the system. But, Marino’s deposition shows Kroger pharmacies don’t investigate discrepancies in pill counts when inventories are performed.

“Is there any comparison between what EPRN (EasyFill Pharmacy Retail Network, a system Kroger uses to process prescriptions and links all Kroger pharmacies) has in inventory and what is remaining on the shelf in inventory,” Macke asked.

“No,” Marino answered.

“So you would never notice this error if EPRN thought 90 tablets had been dispensed that hadn’t been dispensed, you wouldn’t notice an error like 90 tablets,” Macke asked. “Probably not, no,” the pharmacist answered.

The deposition also indicated Kroger pharmacists and pharmacy technicians did perform inventories of pills in stock. Those inventory audits were performed every three months, according to the Marino deposition.

Instead of investigating discrepancies in pill counts, the staff will “…change the on-hand EasyFill to match what’s on the shelf,” Marino admitted.

Marino admitted Kroger pharmacy staffers alter the inventory counts “dozens of times a day at—a given drug could be adjusted.”

The only time Kroger pharmacists would report a discrepancy, Marino admitted, would be “Only in the case of controlled substances.”

The pharmacy’s handling of inventory counts, Marino admitted, would have kept the pharmacy from ever knowing about the Crews prescription error, “If it was off by just 90, they more than likely wouldn’t have said anything,” Marino said.

“So there’s no attempts to explain or rationalize or, or try to understand these discrepancies, correct? There’s none, there’s no policies for resolving the discrepancies, correct,” Macke asked.

“Not that I’m aware of, no,” Marino answered.

Errors are reported internally to Kroger, Marino testified, but state law does not require pharmacists to report errors to the Ohio Board of Pharmacy.

We called and e-mailed Kroger early last week, requesting an interview for this report. Knowing the company wouldn’t comment on the Crews lawsuit, we asked the company to explain how it prevents errors and why those are not reported to the state.

“Thanks for reaching out. Unfortunately, we don’t have anyone available to appear on camera,” Kroger spokeswoman Patty Leesemann wrote in a Feb. 21 email to FOX19 NOW. Leesemann did provide this statement:

“At Kroger Pharmacy, nothing is more important to us than the safety of our patients. To ensure patient safety, we deploy rigorous pharmacy management systems and are vigilant about preventing errors when dispensing a prescription. We require every pharmacy associate to participate in patient safety training, as well as ongoing safety reviews. In addition, we regularly utilize patient and associate feedback to continually improve our processes. Our pharmacies fill more than 182 million prescriptions annually. We are committed to dispensing safe and accurate prescriptions.”

PHARMACY ERRORS: “COMMON PLACE”

A FOX19 NOW analysis of the 2016 meeting minutes of the Ohio Pharmacy Board shows 41 pharmacists paid $39,700 in fines in cases related to dispensing errors.

Board disciplinary records show nine separate dispensing errors against four different Kroger pharmacists in 2016.

Board disciplinary records do not show any disciplinary actions related to the Kroger pharmacist or staffers involved in the Crews case.

The Food and Drug Administration web site estimates “at least” one person each day in the United States dies as a result of “medication errors” and another 3,561 people are “injured” each day.

We could not pull any dispensing error statistics from Ohio, Indiana or Kentucky to include in this report because none of those states require pharmacists to report dispensing errors. The only way those states’ pharmacy boards will find out about an error is if a pharmacist, patient or doctor reports the error to state regulators.

“Under current law, there aren’t requirements,” Ohio Pharmacy Board Executive Director Steven Schierholt told FOX19 NOW.

We found Schierholt at the board’s Feb. 8 meeting in Columbus. The board declined multiple interview requests for this report in the weeks leading up to the publication of this news investigation.

Beginning in April 2017, Schierholt said, the Ohio Board of Pharmacy would have the authority to force Ohio pharmacists to report each dispensing error. But, that will not happen until the board votes to make reporting mandatory.

Schierholt noted during the interview that many pharmacies have procedures in place to prevent errors. In fact, Kroger pharmacies has controls in place in the Crews case, but the April 2016 deposition shows those controls are often “overridden.”

“If those are not followed, the state of Ohio would have no idea that something had happened unless they’re told that by the pharmacist or the patient,” FOX19 NOW Investigative Reporter Jody Barr asked Schierholt.

“Correct,” Schierholt answered.

“Do you think that’s good enough right now,” Barr asked. “Well, I think it certainly is something that ought to be looked at and we intend to do so,” Schierholt said.

“They’re kind of like a soccer goalie, they’re the last line of defense preventing errors, but just like a soccer goalie, they’re not going to stop every ball from going into the net,” Dr. Neil MacKinnon, dean of the University of Cincinnati’s pharmacy college.

MacKinnon, citing a Center for Disease Control, noted that medical errors are the third-leading cause of death in the U.S., trailing cancer and heart disease.

“In many ways, errors kind of is under the radar,” MacKinnon said, “really it should be more prominent in that it is a significant public health issue in this country.”

No state pharmacy board in the nation requires mandatory reporting of retail pharmacy dispensing errors, MacKinnon confirmed. To find one, you’d have to travel to Canada.

“It’s really a black box. We don’t know how bad this problem is, in fact, if you look at community pharmacies, there’s only one place on the planet that requires and tracks errors and that’s the province of Nova Scotia in Canada,” MacKinnon said.

Figures in Canada could indicate just how large of a problem dispensing errors could be in the U.S. MacKinnon said the mandatory reporting system went into effect in Nova Scotia six years ago. The program was in place in 300 pharmacies there.

In those six years, those pharmacies reported more than 120,000 dispensing errors and “near-misses,” MacKinnon said.

“We still have a lot of errors that are reaching patients that need to be caught,” MacKinnon said, noting that a mandatory reporting system should be implemented in Ohio.

“Certainly, the board will visit it in 2017, absolutely,” Schierholt told FOX19 NOW in that Feb. 8 interview.

Randy Crews was surprised to learn the state of Ohio doesn’t track dispensing errors, “It would be surprising. That seems immoral,” Crews said.

“It would seem like the normal, moral thing to do,” Crews told FOX19 NOW.

Schierholt did not have a detailed timeline for when the pharmacy board might take the mandatory reporting issue up, except to say it wouldn’t happen before April

States have “parity laws” .. all disease states must be treated equally ?

khn.org/news/facing-pressure-insurance-plans-loosen-rules-for-covering-addiction-treatment/

Could it be that states that are passing opiate dosing/limits laws, rules, guidelines.. if they have parity laws on the books…could they be unconstitutional ,in conflict of existing laws and/or discriminatory ?  Does this suggest that no matter what laws are on the books that it may take a law firm to intervene with a class action law suit  to get equal treatment under the existing laws ?

Both companies took the step after facing investigation with New York’s attorney general, whose office was probing whether their coverage practices unfairly barred patients from needed treatment. They made this adjustment as part of larger settlements.

They’re arguing based on a requirement that insurance plans, thanks to so-called “parity laws,” must cover addiction treatment, and cover it at the same level as they do other kinds of health care.