“The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped.” – Hubert Humphrey
passionate pachyderms
Pharmacist Steve steve@steveariens.com 502.938.2414
Two months ago, Gary Rager’s girlfriend asked him to do the unthinkable.
The 44-year-old woman, who has suffered disabling pain for the past three years, asked Rager if he would help her end her life.
“I don’t want to kill her, and I don’t want to go to prison. But I don’t want to see her suffer anymore either,” said Rager, a 59-year-old Sanford sculptor whose work appears at area theme parks and public spaces throughout Orlando.
Such are the desperate measures that many afflicted with chronic disabling conditions — and those who love them — contemplate.
Some do more than think about it.
Like many patients in chronic pain, Karen Brooks has seen dozens of doctors over the past few years.
All take tests and discuss her physical health, but few have inquired about her mental health, said her sister, Michelle Brooks, of Maitland, who takes her sister to her doctors’ appointments.
Given the high correlation between chronic illness or pain and depression — even suicide — more providers need to bring up the dark subject, health experts say.
Large-scale studies show that at least 10 percent of suicides — and possibly as many as 70 percent — are linked to chronic illness or unrelenting pain.
Authors of a 2011 British study that looked at the link concluded that patients with such conditions “should be considered a high-risk group for suicide … and much greater attention should be given to providing better … psychological support.”
But doctors are often too busy focusing on physical problems to deal with the mental ones that go with them, say those specializing in chronic illness.
Fading away
Brooks has been diagnosed with several medical conditions in an attempt to explain and treat the severe pain that consumes the left half of her face. Her most recent diagnosis, which she got last week, is rheumatoid arthritis.
A progressive, chronic disease that causes painful inflammation in joints throughout the body, rheumatoid arthritis is often misdiagnosed, said Dr. Shazia Bég, assistant professor of rheumatology at University of Central Florida College of Medicine.
Though she is not Brooks’ doctor, Bég said the recent diagnosis could very well explain Brooks’ chronic facial pain as well as her overall stiffness, wasting and suicidal thoughts.
Today, at 5-foot-five, Brooks weighs just 90 pounds — 40 pounds less than in better days. She can’t chew, or eat solid food, or get up or walk by herself. She needs someone with her 24 hours a day.
“I can’t imagine living 20 more years like this,” said Brooks, sitting in her mother’s compact Winter Park home.
“It’s hard to watch someone you love be in pain and fade away,” said Rager, who met Brooks in 2007. “But the way the medical system is set up, there’s nothing we can do. She has to suffer every day from now until she dies.”
Brooks traces the pain in her jaw back to 1999. She went to several dentists and cranio-facial experts. She tried acupuncture, pain medications, laser pain treatment and even brain surgery, during which a neurosurgeon moved some blood vessels pressing on a facial nerve.
Nothing has brought relief.
“They euthanize a poor animal that’s suffering, and call that humane,” said Rager. “But they will let a person rot away over years. That’s just wrong.”
“It’s so sick that these prisoners on death row who have killed 20 people get to lay there with a needle and just fall asleep,” said Brooks. “That’s the best way to die, and they’re the ones who get to die that way.”
More need to listen
“It’s well-known that people with rheumatoid arthritis have a high risk of depression and anxiety,” said Bég. About one-third suffer from these mental-health problems.
Many believe the number is probably higher, but many patients and doctors don’t talk about it.
Depressed patients do worse with pain relief, which puts them at an increased risk of death from suicide, studies show. That’s the case not only for patients who suffer from autoimmune diseases such as rheumatoid arthritis and lupus, but also for those with heart disease and cancer, experts say.
“We know that chronically ill patients who are also depressed have lower rates of compliance with their health plans, and poorer outcomes,” said Dr. Julie Demetree, a psychiatrist at South Seminole Hospital, in Longwood.
Although doctors are paying more attention to the relationship between chronic pain and illness and suicide, “there’s still room for improvement,” she said.
Part of the solution is for doctors to listen more. “You can get a lot from a patient in a 20-minute visit without having to order tests,” said Bég.
“Not every specialist is trained to treat depression, but all are trained to ask about it, and that’s not done,” she said.
Because Brooks is on Medicaid, the list of doctors she can see is short, and the wait for an appointment often long.
Last April a primary-care doctor referred Brooks to a rheumatologist, a doctor who specializes in arthritis. She finally got in to see him last week. He diagnosed her as having rheumatoid arthritis, but never asked about her mental health, said Michelle Brooks, who sat in on the visit.
Though Brooks still feels her situation is hopeless, Rager and her sister are hopeful that the new diagnosis and new treatment regimen, which includes steroids, will turn her around.
“If the diagnosis is correct — and today’s blood tests are very accurate — and she gets proper treatment, I would expect her to get better,” said Bég.
“I can’t believe it’s taken us so long to get here,” said Rager. “If this really is the solution, think of all the suffering that could have been prevented.”
A 58-year-old former patient of Seattle Pain Centers committed suicide last month, leaving notes claiming he could find no help for his chronic pain after the chain of clinics closed in July following state sanctions.
JoNel AlecciaBy JoNel Aleccia
Seattle Times health reporter
Two days before he shot himself in the head, Denny Peck called 911 and said he couldn’t stand the pain.
Peck, 58, told the fire-department dispatcher that he had been a patient of Seattle Pain Centers, a chain of Washington clinics, until it closed abruptly in July amid allegations of improper oversight and patient deaths.
“They’ve been shut down by the government,” Peck said in the Sept. 15 call, which was punctuated by sharp cries and grunts. Find help
Seattle Pain Centers’ former patients should seek advice from their primary-care providers and insurance plans about finding a new source of pain management, officials said.
Call the Washington Recovery Helpline at 1-866-789-1511, or visit www. warecoveryhelpline.org
Or call the Washington Suicide Prevention Life Line at 1-800-273-8255.
Washington State Department of Health
“And, anyways, I got severe back pain and everything. I took the last of my pills and I’m going through some serious withdrawal symptoms. I got the crawling skin and everything else. Can you guys help or not?”
But the woman on the phone said she couldn’t give Peck any drugs, only a trip to the hospital, which he declined. In the weeks before he called 911, Peck’s family said he contacted primary-care doctors and went to emergency rooms. The family doesn’t know all the details, but Peck said he couldn’t get the pain pills he needed.
On Sept. 17, just after 10 a.m., Thurston County sheriff’s deputies were summoned by the worried manager of Peck’s mobile-home park outside Yelm. They found Peck in bed, two guns in his lap and bullet wounds on both sides of his head, according to the deputy’s report.
“Can’t sleep, can’t eat, can’t do anything,” said a handwritten note left nearby, “And all the whitecoats don’t care at all.” Denny Peck, 58, of Yelm, killed himself on Sept. 17, two months after the abrupt closure of Seattle Pain Centers cut off his supply of pain medications. (Courtesy of Lorraine Peck) Part of this note was read by Lorraine Peck at the memorial service for her son, Denny Peck, who killed himself Sept. (Ken Lambert/The Seattle Times)
1 of 2 Denny Peck, 58, of Yelm, killed himself on Sept. 17, two months after the abrupt closure of Seattle Pain Centers cut off his supply of pain medications. (Courtesy of Lorraine Peck)
The death of Peck — an easygoing Seattle native who was injured 26 years ago in a commercial-fishing accident — is the only fatality reported among former Seattle Pain Centers patients since the clinics closed, state health and Medicaid officials said. Many factors can contribute to suicide, but the case provides a window into the desperation some pain patients feel.
“Every time someone takes their life, it’s a tragic loss for their family and the community,” Dr. Kathy Lofy, the Washington state health officer, said in an email.
“We know that many people struggle with pain, both physical and emotional. We want people to know that it can get better and that there are people and resources that can help. If anyone feels helpless or desperate, we hope they will reach out for help and that people surrounding them will take action.”
About 8,000 patients were prescribed opiates by Seattle Pain Centers this year, part of an estimated 25,000 seen at eight clinic sites since 2008. The sites closed days after state regulators suspended the medical license of former director Dr. Frank Li, saying he failed to properly monitor Medicaid patients, possibly contributing to at least 18 deaths since 2010.
Li, who has denied the allegations, has not been charged with a crime.
A hearing before members of the state Medical Commission is set for April. “Left in a lurch”
Government documents showed that state officials were warned in 2015 about overdose deaths among Seattle Pain Centers patients. And they were told three years ago that Li had been blocked from prescribing for the state workers’ compensation program.
Some critics complained that state health officials took too long to act. Others said that when they did, there was no plan in place to absorb a huge number of pain patients, including many, like Peck, who were taking very high doses of dangerous opiates or who had complicated medical conditions.
“This was such a huge surprise to the entire system,” said Dr. Ray Hsiao, president of the Washington State Medical Association. “This is unprecedented.”
State health-department officials said legal constraints prevented them from warning people about the charges that were coming against Li. Once they were public, Lofy and others reached out immediately to providers and patients.
People are falling through the cracks. It’s just terrible. It’s just tragic.” – Jennifer Hanscom, executive director of the medical association
“When Dr. Li closed his clinics, we developed information and strategies to help patients know how to find help,” health-department spokeswoman Julie Graham said in an email. “We’ve also been working to make sure that health care providers understand how to take on the care of patients with chronic pain issues within the guidelines of the state’s pain rules.”
Still, thousands of former Seattle Pain Centers patients flooded emergency rooms and others reported desperate efforts to find new care. Officials at the state’s largest pain programs scrambled to absorb hundreds of clients.
Officials at the medical association urged their primary-care members to help. In a recent blog post, Hsiao was blunt.
“No matter your opinion on the state’s handling of this situation, one thing is clear: thousands of patients in our communities have been left in a lurch, suddenly and unexpectedly cut off from appropriate treatment for their pain, or opioid medication management.”
But Hsiao said that while some doctors have agreed to help, others have balked.
“They’re saying, I just don’t have the capacity for it,” Hsiao said in an interview. “I’m seeing patients every 15 minutes. How can I give these patients the time?”
Some doctors said they’re skeptical of stepping up after being told to send chronic pain patients to specialists, as recommended in guidelines pioneered by Washington state in 2007 and finalized in 2012.
“For years, primary care physicians have been pushed away from treating chronic pain, threatened with lawsuits and licensure action,” Dr. Russell W. Faria of Auburn said in an email. “I can fairly guarantee that primary care physicians will not be very receptive to this call, to put it mildly.”
The result? “People are falling through the cracks,” said Jennifer Hanscom, executive director of the medical association. “It’s just terrible. It’s just tragic.” Decades of pain
For Peck, the trouble began in 1990, when he was injured while working on a fishing boat in Juneau, Alaska, crushing several vertebrae.
“He has been in pain ever since,” said Peck’s mother, Lorraine Peck, 86, of Seattle.
The pain haunted Peck, who was raised in Ballard and is remembered by his family as a kind, smart, friendly guy who played the drums, worked as a cook and a welder and ran a limestone plant before signing on to the trawler. He lived on a boat at Seattle’s Fishermen’s Terminal for a time, and always wanted to be near the water.
Peck had two children, a son, Jasen Peck, 35, and a daughter, Amanda Peck, 32.
Amanda Peck said she didn’t remember a time when her dad didn’t hurt.
Denny Peck moved to Yelm five years ago and kept his pain under control with visits every three months to a local Seattle Pain Centers site, according to a clinic bill. At the time of his death, he still owed $131.82 for care, it showed.
Peck was taking high daily doses of opiates, including morphine and oxycodone/acetaminophen, plus powerful muscle relaxants, prescription records showed.
When the clinics closed in July, Peck tried to find a new primary-care provider, as state health officials advised patients to do.
“No doctor would chance losing his license due to new laws, and Denny saw no help from the medical people although he tried and tried,” said Peck’s obituary on the funeral-home website.
Peck’s family said he sought help at the Washington Center for Pain Management, another provider, but his family contends he wasn’t given enough medication. Officials at that center said privacy laws prevented them from confirming whether he had been treated there.
Peck rationed his final pills, his mother said. But then he ran out.
“He was in so much misery,” she said.
When Lorraine Peck talked to her son in the days before he died, she urged him to talk to a pastor with a local church.
“I think he found peace,” she said. “I could not fault him at all. He could see no other way out.”
About three dozen people gathered for a memorial service for Denny Peck on Oct. 15 — the day Seattle was threatened with a big windstorm — to say goodbye.
Stories were shared, as was the letter he left behind.
“I feel sorry 4 all of the people that got kicked out and R still in pain,” Peck wrote. “Find them and help them!! Help them, please, they hurt still.”
Editor’s Note: John Sandherr is a 58-year old man who lives near Pittsburgh, Pa. He has suffered from chronic pain for thirty years and has undergone 10 surgeries. . He is an arachnoiditis survivor and is an outspoken chronic pain advocate. He credits his wife Deb for helping him survive the past thirty years. We’re glad he has added his voice to the National Pain Report.
On August 8th just over 2 months ago I went to my monthly visit to see my Pain doctor. It was like any other appointment that I’ve had for over 15 years. Every 28 days I would go in to get my pain medication and get a short but thorough exam from the Dr. or by his Physician Assistant. Each month was routine for me because of all the documentation that supports the severe pain I suffer with.
There was nothing routine about my visit on that day – as soon as I walked in I was told by the receptionist, “Today is your last visit, I need you to sign this paper and you will be given your medical records. As of August 12th Dr. Frank will no longer treat pain patients, you need to find a doctor and fast.” I must have looked like I was hit by a truck and then a train because the girl said, “are you OK?” and I said, “NO, will you be giving me the name of a doctor that I can follow up with?” “NO” was all she said.
I took a seat and completed the forms I was given and returned them to the girl, she then handed me a large yellow envelope that had 186 pages of office notes that went back 6 years. I didn’t ask but I assumed that 6 years is the required amount of time to conform to the guidelines.
After I went back to my chair I was lost and broken and as I sit and write this all of those feelings come rushing back, my mind is blank but racing, my breathing is slow and then fast, my heart is pounding so fast I can actually hear it. I remember – three cleansing breaths – i can quiet my racing heart but for just a few minutes.
After a 10 to 15 minute wait Dr. Shani called my name, she could hardly look me in the eyes. I sat across from her in the same chair I always have but there must have been a look of desperation mixed with fear etched into my face as Dr. Shani said to me, “John you look terrible” and I came right back with, “I can’t believe this is happening.” She didn’t know what to say while I sat there with tears that started rolling off my lower jaw. “I’m scared to death” I said, “and I don’t know what I’m going to do, no doctor is going to prescribe what I’ve been taking for the last 10 years. I’m done.” She couldn’t disagree and I knew it.
Dr. Shani spent the next 10 minutes giving me a pep talk – I gave her credit for trying and for caring. I had regained what composure I had left and asked Dr. Shani “why is Dr. Frank closing the pain clinic”? The answer came with no hesitation as Dr. Shani looked me right in the eye and uttered “he wants to spend more time in the Operating Room and more time at the Addiction Clinic he opened last year”. That statement left me thinking, I know Dr. Frank is a workaholic, he has fewer pain patients but that was due to those that got booted for failing a drug test or requesting more medication much too early. I was Dr. Frank’s oldest or longest patient, no one else had 15 years of treatment at the clinic, just me.
Glued to the chair, I knew getting up meant never coming back. This wasn’t easy, just 6 months prior I had asked Dr. Shani if the anti-opiate campaign was something I should worry about, was Dr. Frank going to close his doors someday soon. Shani told me not to worry and that Dr. Frank was a well established Dr. in the field of pain management and the patients had nothing to worry about, I needed to hear that. It seems that no one could foresee all that would happen over those next 6 months and I felt like I should have been ready for it, I read about this situation while on The National Pain Report and I never thought it would happen to me.
With nothing left to do and thinking about what was next, I had but one last thing to ask Shani, “can you please give me the name of a Dr. I can call, a Dr. that might be able to prescribe anywhere near the dose I’m on and have been on for over 10 years,” Shani said, “I can’t do that John” so I said, ”Okay, how about off the record?” She wrote down three names on a small piece of paper she had ripped off her calendar and slid it across the table to me. I asked if these Dr’s would be comfortable keeping me on my current dose and I already knew the answer to that question (I’m on over 350 mg of OxyContin & OxyCodone, daily) – “No, you will need to wean yourself down over the next 60 to 70 days, as much as you can – you can do it John”, that was her reply.
Shani slid the prescriptions across the table and said – Good luck. I looked over the medication, everything was there. Fifteen years of what I believed to be good successful years had come down to 12 sheets of paper and little hope.
Medication, I now had enough to get me through the rest of the year, if I cut back starting the next day, plus it gave me more time to look for and find a Dr. to treat me.
I just couldn’t walk out of that office without making some kind of a statement. I walked over to Shani and first gave her a big hug for taking such good care of me for so many years and then with my hands on her shoulders I looked at her and said “I can reduce the medication and I will do my best, but no matter what, I’m still going to end up in the Hospital and it won’t be for a short stay. It’s not the reduction of the medicine that worries me, it’s all that pain that will only get worse and that’s what worries me the most, I’m afraid I won’t be able to take the pain.” Shani, a short thin woman from India looked up at me with sad eyes and said, “I know John and I’m sure you will.” That reply left me feeling extremely helpless and fearful but it’s that kind of attitude that won’t do me a lick of good.
Out the door I went and as I got into my car I kept thinking – my pain is real, I’m not a drug addict, there is little hope of finding a Dr. to treat me, my condition is progressive, I’ve tried nearly every pain modality medicine has to offer and the one thing that allows me to be a productive member of society and ease my suffering is Opiate Pain Medication. Every day I read a news article that says a vast number of Americans believe that there is no place for opiates to treat any kind of pain. Now I hear that many are calling for a complete ban on opiates and I wonder if those people have ever had the need for a pain medication. If opiates are banned, what will people use in their place? I’m not sure if they have given that any thought and they won’t until they are in severe pain.
Fifteen years is a long time, so, Dr. Frank became very familiar with my medical issues and my personal issues, he once asked me, “how can you even walk when according to these test results you should be in unbearable pain and I can see that on your face and when you squirm in that chair yet you always seem to have a smile on your face.” I would say, well I can smile or I can cry but I know I’m better off than the patient I just saw in the waiting room, sitting in a wheel chair with no feeling from the waist down and still in pain. There will always be a person that is worse off than me and that keeps me going.
Less than a week later I was at my surgeon’s office for a follow up visit with Dr. K an Orthopedic specialist I’ve been seeing for over 12 years. I’d developed drop foot in my right foot; the left foot went about 4 year prior. After only a few minutes Dr. K came walking through the door. He said, “John Sandherr, man are you screwed.” He said, “I spoke to Dr. Frank the other day and he told me he was closing his pain clinic.” He told me the DEA was making it almost impossible to treat pain patients with Opiates so he’s going to stick with his addiction clinic. “What are you going to do,” he asked me. “I know what you’re taking and it’s a big dose, but you need it John.” He said, “I could operate on you and you might feel better for a few months, but after that you will be worse off because of all that scar tissue you have from the other 10 operations you’ve had…or is it eleven. I feel for you brother, If ever there was a patient that needs to use pain medicine it’s you.” Dr. K went on to tell me about a good friend of his that had a run in with the DEA over a single prescription he had written for a patient, the standard 7 day supply of Percocet following knee surgery. He was told that some of the pills wound up in the hands of someone other than the patient and for that reason he is now under investigation.
I hold no grudge against Dr. Frank for closing the Pain Clinic and I know it was not a choice he made purely for money. What angers me is we now have a government telling Dr’s what they can or cannot prescribe for a patient that has not demonstrated any sign of drug addiction. People that are in pain and depend on opiates for relief deserve to be treated with what helps them the most. Just a week after my last visit the Governor of Pennsylvania signed a new bill that will almost force Dr’s to comply with when prescribing opiates. With that and the new “Monitoring System” the state just put in place, Dr’s now have a difficult and time consuming job and what they really want to do is help those in pain.
When I found out that – Bain Capital a Hedge Fund company – are investing in substance abuse for profit it all made sense. I was working with Northpoint Mortgage Loans when the housing market collapsed; there were Hedge Funds for investing in housing failure. Many became multi-millionaires overnight.
It was Dr. Isben that said “follow the money” and I’ve started to do that. The money is invested heavily on addiction, not helping people in pain. Can we convince enough of the right people that the real facts have not been revealed?
John Sandherr is a 58-year old man who lives near Pittsburgh, Pa. He has suffered from chronic pain for thirty years and has undergone 10 surgeries. He is an arachnoiditis survivor and is an outspoken chronic pain advocate. He credits his wife Deb for helping him survive the past thirty years. We’re glad he has added his voice to the National Pain Report.
GREENWOOD, Ind. – Greenwood police arrested a pharmacy worker this week for stealing more than a thousand pills from her employer over the course of several months.
It happened at the CVS pharmacy on State Road 135. Police said Samantha Beaver confessed to skimming 1,281 pills from customers; 256 of those pills were Hydrocodone.
Police said customers tipped of managers at the pharmacy when they noticed they weren’t getting all their medication. When staff investigated and reviewed surveillance video, they saw Beaver taking the pills and stuffing them in her socks.
“When she would fill someone’s prescription, before she would give it to them, she was hiding behind the counter or behind shelves there in the pharmacy, taking pills off the top and apparently stuffing them in her socks,” explained Assistant Police Chief Matt Fillenwarth.
Police reported Beaver told them she was stealing the drugs for personal use. Fillenwarth said this is just the latest story telling the terrible tale of Indiana’s opioid epidemic.
“It is such a terrible addiction. It’s such a strong addiction. And unfortunately right now it is just rampant,” he said. “Nothing else matters in life. Not their kids, not their family, not their job. Not maybe thinking somebody’s not getting the medicine they need.”
Beaver bonded out of jail. The prosecutor’s office has not filed any official charges against her yet.
Some days Cindy Laux feels like her skin is on fire. The scorching pain shoots down her legs like she just spilled hot coffee on her lap. Other days it feels like insects are crawling all over her. Laux has adhesive arachnoiditis, a rare, incurable condition often brought on as a result of multiple medical procedures. She’s had four back surgeries since a work-related injury in the 1990s forced her into early retirement from her nursing career. Now the nerves in her lower spinal cord are clumped together, causing severe pain, urinary problems, and weakness in her legs. At only 53, she carries a cane at all times because she never knows when she’s going to need it.
“My pain is out of control,” Laux said recently from her home in Orange County, California. “I mean, I can stay alive, but my quality of life has dramatically decreased.”
Laux has lived with debilitating chronic pain for more than 20 years, but for 15 of those years, she says, it was well managed with opioid painkillers. She took oxycodone and used a fentanyl patch. She could go hiking, travel to see her parents in Florida. That all changed beginning in 2011, when her doctor unexpectedly began prescribing her less and less with each visit. He gave no explanation aside from a vague reference to a rise in opioid-related overdoses. “Apparently, people are dying,” she remembers him saying.
People were dying, and at an alarming rate. That year, the Centers for Disease Control and Prevention first used the term “epidemic” to describe the opioid crisis. Overdose deaths involving opioid painkillers had quadrupled over a span of 12 years, from 4,030 deaths in 1999 to 16,917 deaths in 2011. Emergency rooms were overwhelmed: Nationwide, they were treating as many as a thousand patients a day for prescription opioid misuse. As pill addiction — and, never far behind, heroin addiction — tore through communities and wrecked families, rehabs were taking in more patients than they could properly handle. One study of private insurance claims showed that diagnoses for opioid dependence shot up a staggering 3,203 percent between 2007 and 2014.
All of this paralleled a fourfold increase in the number of opioid painkillers being sold each year in the United States. While the drugs were once reserved mostly for short-term treatment of serious pain, like after an operation or a car accident, zealous marketing by pharmaceutical companies starting in the 1990s convinced more doctors to prescribe opioids for chronic conditions like arthritis and lower-back pain, ushering in an unprecedented era of overprescribing.
Efforts to curb the problem have unleashed an intensifying tide of regulatory and policy restrictions at the local, state, national, and institutional level: limits on doses, drug testing for patients, crackdowns on pain clinics, prescription drug monitoring. In 2014, the Drug Enforcement Administration reclassified hydrocodone from a Schedule III drug to the more restrictive Schedule II category, and last month the Justice Department announced a far-reaching strategy to fight the opioid crisis with stepped-up enforcement measures, including prosecuting doctors who improperly prescribe painkillers. Meanwhile, President Obama is urging Congress to approve $1.1 billion in new funding to tackle the epidemic, largely by expanding access to addiction treatment.
In the five-plus years since the CDC issued that first warning, the opioid conversation has changed, a culture shift that culminated in March when the agency released sweeping new prescribing guidelines urging primary care doctors not to prescribe opioids for pain lasting longer than three months.
But for Cindy Laux and many chronic pain patients like her, the change has not been for the better. They feel like casualties in the opioid war, labeled as drug addicts and denied medication that they had relied on for years and sometimes decades. Today, Laux is still treated with opioids, but her dose has been so significantly reduced that she says she has lost her ability to function. She lives in a constant state of anxiety, terrified that further restrictions could prompt her doctor to cut her off completely.
“It’s a fear I live with every day,” Laux said.
The CDC insists it isn’t trying to create barriers to legitimate treatment. The new guidelines, the agency says, are the result of extensive input from experts and a thorough review of the available evidence. They don’t explicitly rule out opioids for chronic pain, but they do send a clear message that opioids should not be considered a first-line treatment. Debbie Dowell, a CDC senior medical advisor and the lead author of the guidelines, said the goal is to educate doctors and patients. “The guideline supports informed clinical decision-making in the context of the provider-patient relationship,” she said.
Still, the agency faced resistance from pain specialists, patients, and patient advocates who say the guidelines were based on scant data (studies examining the long-term effects of opioids are limited) and would only further stigmatize pain sufferers. The draft proposal attracted more than 4,300 comments from the public, many from people in pain, or their loved ones, who begged and pleaded with the CDC not to make it harder for people to get the medication they rely on.
Alternatives do exist. For instance, the CDC says exercise therapy has been shown to improve physical function in some patients. Non-opioid medications, such as acetaminophen or ibuprofen, can be useful for conditions like arthritis and lower back pain, and some antidepressants and anticonvulsants are also effective.
But many patients say they have already tried every non-opioid option without success, or that they suffer from rare conditions that do not fit neatly into a one-size-fits-all treatment strategy. Over the years, Laux has tried every alternative treatment imaginable, from steroid injections to anti-inflammatories to biofeedback therapy. She even drank holy water from Lourdes, France. Her concern is that the CDC’s guidelines, while not legally binding, will encourage a top-down approach to pain care that ignores the complex realities of individual patients.
Jacqueline Melzer, a 48-year-old chronic-pain patient, says she was told by her doctor in Reno, Nevada, earlier this year that he would no longer prescribe hydrocodone to treat her fibromyalgia and migraine pain. When she asked why, he said it was because there was no clinical evidence the medication she was taking for almost 20 years was helping her.
“I just looked at him and said, ‘What am I supposed to do?” Melzer said.
It’s a question many of the 25 million Americans who suffer with daily pain lasting longer than three months may be asking themselves. And for many of them, no one seems to have a good answer.
Two decades ago, it was pain — not pill addiction — that was being called an epidemic, with millions said to be suffering needlessly due to undertreatment by physicians. At least, that was the idea proffered by some physicians and pharma-backed nonprofit groups. In 1996, the American Pain Society launched its influential “fifth vital sign” campaign, giving pain equal billing with blood pressure, pulse, temperature, and rate of breathing.
That same year, Purdue Pharma released OxyContin, a powerful painkiller sold as a slow-release pill, which the company aggressively marketed as a godsend for pain patients, often to doctors with little knowledge of abuse-disorder warning signs. OxyContin was a blockbuster, reaching sales of over $1 billion by the end of the decade. But it turned out the drug was also pretty easy to crush, snort, and inject for a high — and Purdue downplayed the risk of patients becoming addicted. In 2007, the company and its executives agreed to pay fines of $635 million for misleading the public.
That didn’t stop big pharma from pushing opioids: A recent investigation by the Associated Press and the Center for Public Integrity found that drugmakers and opioid-friendly lobbyists spent $880 million from 2006 to 2015, often to fight state-level restrictions on the drugs. And sales of OxyContin and other opioids have continued to soar, with doctors writing some 259 million prescriptions for opioid pain medication in 2012, four times what they were in 1999. According to the CDC, those liberal prescribing habits played a key role in the dramatic rise in opioid painkiller-related deaths, which hit a record high of 18,893 in 2014.
Against this backdrop the agency released its prescribing guidelines, saying the risks associated with the drugs had to be weighed against their benefits. Those risks are much clearer now than they were in the 1990s. One study the CDC looked at showed that dependence among patients on opioid therapy was as high as 26 percent. Researchers also point to conditions like hyperalgesia, an increase in pain sensitivity, which can be brought on by long-term opioid use.
As for the benefits of long-term opioid therapy, the evidence is scarce. The CDC says few studies have rigorously assessed the benefits of the drugs for pain lasting longer than three months. Most randomized clinical trials the CDC reviewed lasted less than 12 weeks. Clearly more research is needed; in the meantime, the CDC says the urgency of the crisis required action.
But if the evidence doesn’t support opioid treatment for long-term pain, why are so many chronic pain patients convinced they need the drugs to function? Andrew Kolodny, an influential substance-abuse expert and one of the country’s most vocal critics of opioid overprescribing, thinks he has a pretty good answer. Those patients, he says, are probably dependent on the drugs and may be addicted.
“The language that they’ll use to describe how they think opioids are helping them is the exact same language my heroin-using patients use,” Kolodny told me. “I’ve been treating opioid addiction for about 15 years. They use the same exact language: ‘Doc, imagine what it feels like every morning — feeling like you’ve been hit in the chest with a baseball bat until you take your first dose.’”
In Kolodny’s view, these patients are feeling better from opioids not because the medication is treating an underlying pain problem but because it’s treating their withdrawal pain. And his view holds a lot of sway. He is the co-founder of an advocacy group called PROP, or Physicians for Responsible Opioid Prescribing, and a committee member of the Fed Up! coalition, which wants the federal government to commit more money to addiction treatment. He was also a member of the stakeholder review group that offered input to the CDC as it was crafting its guidelines.
Some pain patients I spoke with see Kolodny as Public Enemy No. 1 in a propaganda war, fueling an anti-opioid hysteria that favors hyperbole over nuance and glosses over the complexities of treating many painful conditions. One of those patients is Richard Oberg, a retired pathologist in Jackson, Tennessee, who says the current media narrative surrounding the opioid crisis is the most alarmist he’s witnessed in 30 years of practicing medicine.
“I have never in my life seen an issue where the patient doesn’t come first,” Oberg told me. “They’re confusing legitimate pain management with addiction. Those are completely separate venues.”
Personable and charming with an affinity for colorful metaphors, Oberg speaks with a disarming Southern drawl that makes almost anything he says sound reasonable. But he’s no neutral participant in the opioid debate. He suffers from psoriatic arthritis, a painful inflammatory condition that began to affect his ability to function when he was 39. He’s now 62. For 18 years, he treated his pain with hydrocodone. (He also took biologics, which he said eventually stopped being effective.) As the condition worsened, he added low-dose methadone in 2011. It all ended three years later when the Medical Clinic of Jackson, where he received care, sent him a letter saying it would no longer prescribe long-term opioids, citing changes in Tennessee state guidelines. Oberg suffered through a three-week process of methadone withdrawal. He has since given up his practice.
“When they ceased it, it knocked the props out from under me, and that was it,” Oberg said. “My time had come.”
Eventually, he was able to find a local doctor who would prescribe hydrocodone, 50 milligrams a day, which he says is not enough to provide even a decent night’s sleep.
Oberg’s wife, Holly Clowers, suffers from Ehlers-Danlos syndrome, a painful connective tissue disorder, which she treats with buprenorphine. She says the bureaucratic and regulatory barriers to pain treatment have made receiving adequate care a demoralizing and physically taxing experience. In one case, she signed a treatment contract that required her to provide a urine sample whenever the clinic requested one, an experience she likened to being a prisoner.
In the current backlash to opioids, Clowers sees a callous prejudice against pain patients and a lack of compassion from physicians who see the sick as drug-seekers. “When you’re sick, people assume you brought it on yourself, like it’s your fault,” she said. “We’re not suggesting that there isn’t a problem with addiction, but it shouldn’t be causing chronic pain patients to be dumped across the nation.”
Oberg and Clowers say the treatment roadblocks they’ve encountered are symptoms of a broken health care system. Their conditions are difficult, requiring time, effort, and careful management on the part of practitioners. Outpatient clinics have no place for them and primary care physicians, no time. Family doctors, as most of us know, tend to prefer an eight-minute visit — blood pressure, vitals, and maybe a few questions. Just as the “fifth vital sign” campaign encouraged physicians to prescribe opioids indiscriminately, the current crackdown on the drugs has provided a convenient excuse to abandon “complicated” patients, Oberg says, because the administrative burden is too high.
“We end up being the baby that gets thrown out with the bathwater,” Oberg said. “It’s just fine with them, because they don’t want to see us anyway.”
Kolodny doesn’t waver when I mention the desperation I’ve heard from sufferers. “You’ve found a group of very vocal patients who are convinced that everyone is trying to take their opiates away from them,” he said. “They believe that the CDC guidelines — that advocacy groups like mine — that what we’re really after is stopping drug abusers, and that they’re being made to pay the price. That’s totally not what’s going on. What’s motivating us is an understanding that opioids are lousy drugs for chronic pain.”
For consensus, Kolodny says to look to the country’s leading pain clinics. The Cleveland Clinic, the Mayo Clinic, and the Washington University School of Medicine are a few of the institutions whose experts now say long-term opioid treatments are ineffective and risky.
But there are still pain specialists who disagree. One of them is Howard Fields, director of the Wheeler Center for the Neurobiology of Addiction at the University of California, San Francisco. Fields’s interest in pain research dates back to his tour of duty in the Vietnam War, when he worked with a neurosurgeon who saw soldiers with painful nerve injuries. He worries that the current anti-opioid climate is being fueled not by evidence that opioids don’t work for chronic pain but by a lack of evidence that they do. What’s being lost in the debate, Fields says, is the old-fashioned practice of listening to patients, including those who say opioids are helping them. To simply write them off as addicts isn’t fair.
“Why wouldn’t you believe what the patient says?” he asked. “My attitude is, the patients pay you to make them feel better.”
Meanwhile, there are signs that the era of overprescribing has peaked. A recent report from IMS Health, a health-data firm, found that 17 million fewer narcotic painkiller prescriptions were written in 2015 than the year before. But reducing prescriptions presents new quandaries: First, how do providers discern which pain patients could still benefit from long-term opioid therapy, even if it’s only a small percentage? And second, what do we do with the estimated 9 million to 12 million American adults who are already taking opioids long-term?
Even Kolodny concedes that some patients have been on opioids so long that they may never be able to function without them. Long-term use can cause physical changes in the brain that are potentially irreversible. “What we don’t want is for primary care doctors to just start firing these patients,” he said. “That would be really bad. It’s a problem that we need good solutions for.”
Asked about that problem, the CDC’s Debbie Dowell pointed out that the prescribing guidelines recommend tapering opioids slowly enough to minimize symptoms of withdrawal, a process that can take weeks or months. She agrees that simply whipping medications away from patients is inhumane. In fact, it’s the only thing everyone seems to agree with. “It is almost never appropriate to abruptly stop prescribing opioid pain medication,” Dowell said.
But as health care facilities change their policies and doctors grow more reluctant to prescribe, patients all over the country are reporting similar experiences of having their medication denied or reduced. In Tennessee, the Tennova Pain Management Center sent a letter to patients earlier this year, warning that it would no longer prescribe long-term opioids. It gave 30 days’ notice. In Florida, pharmacies have been caught by local media refusing to fill legitimate opioid prescriptions after a statewide crackdown on “pill mills.” In Oregon, Providence Health, a chain of 34 hospitals and more than 400 clinics, told the CDC that its pain specialists were seeing primary care doctors entirely discontinue prescribing opioids.
These instances may be rooted in good intentions, but they are riddled with side effects for patients who are slipping through the cracks. Some may turn to heroin or an illegal black-market for pills, a concern voiced by medical professionals and backed up by studies. Others may consider suicide. As the medical community grapples with how to reduce prescriptions without neglecting the needs of patients, disagreements about how to do that compassionately will continue to come up.
For Cindy Laux and patients like her, a sensible solution means the difference between agony and relief. Their pain is immediate, and whether you see them as patients or addicts, they are suffering in the same flawed system. If you’re lucky enough not to live with chronic pain, and you don’t know someone lost to addiction, this may feel distant and hypothetical. But that’s only until it’s not.
“Pain is everyone’s problem,” Laux said, “because everyone is eventually touched by pain.”
Christopher Zara is a journalist based in New York City who covers culture, media, and technology.
November is national CRPS/RSD awareness month, and what better way to raise awareness than by participating in the Color The World Orange annual event on November 7th.
Color The World Orange, is an annual event held the first Monday in November to spread awareness of Complex Regional Pain Syndrome (CRPS), also known as Reflex Sympathetic Dystrophy (RSD), and is less than two weeks away, but there is still time to get involved!
Raising awareness is easy and FREE – The easiest way to participate is to wear orange and post a picture to social media with the hashtag: #CRPSORANGEDAY.
However, the team at Color The World Orange has also put together suggestions and a collection of materials to help you raise awareness – all offered for free on their website (and below).
Founded in 2014 to bring global attention to CRPS/RSD, Color The World Orange does not receive any money from its fundraisers, and in the last two years has helped supporters raise more than $11,650 for the national non-profit RSDSA, to be used for research.
More information directly from the Color The World Orange Team:
Encourage friends and family to get involved and to wear orange as well – it can be something as small as an orange bracelet or an orange t-shirt, or as elaborate as one supporter who in 2014 wore orange head to toe, literally!
Download Color The World Orange pamphlets (http://bit.ly/2draCTZ) to hand out to family and friends so they can learn more about the event as well as CRPS/RSD.
Speak with local businesses and ask if you can display pamphlets and orange ribbons, or ask to hang up Color The World Orange signs (http://bit.ly/2e0E7w6).
Another easy way to get involved is to change your social media backgrounds to display the Color The World Orange logos – you can download them from our Facebook page https://www.facebook.com/ColorTheWorldOrange
If you are feeling a bit more adventurous, have an orange dinner on Nov. 7 – encourage your family to wear orange and fill the table with orange food and decorations.
There is also still time to reach out to local media to pitch a story about Color The World Orange and CRPS/RSD. A number of supporters were interviewed for last year’s event, which helps to build awareness of the condition. Use our ‘Build Your Own Press Release’ to reach out to your local news station and paper. A copy can be found on our Facebook page: http://bit.ly/2esV1H7
The most important thing is to be creative and have fun! Color The World Orange aims to bring everyone together to spread awareness of CRPS/RSD and your participation is a key aspect of the day.
To help light the night orange, more than 30 buildings and landmarks around the world have agreed to turn orange for Color The World Orange including Niagara Falls and Trafalgar Square in London.
In the US, the following buildings will be lit orange in support of Color The World Orange:
Retirement Systems of Alabama buildings in Mobile and Montgomery, Alabama
Coca-Cola Orlando Eye in Orlando, Florida
SunTrust Bank Building in Tampa, Florida
Skyview Atlanta in Atlanta, Georgia
IPL Building in Indianapolis, Indiana
Boston Harbor Hotel in Boston, Massachusetts
lights on France Avenue in Edina, Minnesota
35W Bridge in Minneapolis, Minnesota
Con Edison Clock Tower, New York
dome of the Nassau County, New York
Theodore Roosevelt Executive and Legislative Building, New York
FDR Mid Hudson Bridge lights, New York
Peace Bridge, which spans the Niagara River between Fort Erie, Ontario Canada and Buffalo, New York
Wells Fargo’s Duke Energy Center in Charlotte, North Carolina
Terminal Tower in Cleveland, Ohio
Myriad Botanical Gardens in Oklahoma City, Oklahoma
Emery Towers in Bradford, Pennsylvania
South Street Bridge in Saegertown, Pennsylvania
PPL Tower in Allentown, Pennsylvania
dome of the Westmoreland County Courthouse in Westmoreland County, Pennsylvania
Bank of America Plaza in Dallas, Texas
Houston City Hall in Houston, Texas
Cedar Rapids Bank & Trust in Cedar Rapids, Iowa
Kansas City Power and Light Building in Kansas City, Missouri
Crazy Horse Memorial, South Dakota
In Canada, the following buildings will also be lit orange in support:
BC Place in Vancouver
Calgary Tower in Calgary
High Level Bridge in Edmonton
Port Coquitlam City Hall in British Columbia
In the United Kingdom:
Central Library in Swindon Town Centre
Blackpool Tower in Blackpool
For more ideas on how to get involved, visit the Color The World Orange website: www.colortheworldorange.com
Color The World Orange was founded in 2014 to bring global attention to CRPS/RSD.
EpiPendamonium. EpiPendemic. EpiPanic. The popular press has had a field day with the public outcry over the growing gap between the price of EpiPen (epinephrine auto-injectors, Mylan) and the ability of patients, even insured patients, to pay
. The furor over EpiPen pricing is simply the best publicized of many similar price hikes that have left patients unable to pay.
Jeremy Counts, PharmD“Raising the EpiPen price to more than $600 is ridiculous,” said Jeremy Counts, PharmD, owner of Main Street Pharmacy in Blackburg, VA. “Like every other pharmacist in the country, I’m having patients come in every day asking ‘what can I do? I don’t have $600.”
Pharmacist in the Middle
“What gets missed in all the media frenzy is the pharmacists who are caught in the middle,” said Dorinda Martin, PharmD, who owns three Martins Compounding and Wellness Pharmacy locations in Austin, TX. “Parents aren’t just buying one box of EpiPens, they’re buying two or three or four boxes for each child who needs it. Depending on your health plan, you may be paying $10 or you may be paying full price. So
mebody is making a good profit on EpiPens, but it isn’t the pharmacy. We just get to take patients’ totally justified anger and frustration over prices that nobody understands.”
Patients are particularly frustrated because there is no single answer for price increases.
Options, Not Solutions
Whatever the reason for a particular drug price hike, pharmacists have few good choices. PUTT, Pharmacists United for Truth and Transparency, has published a poster that details EpiPen pricing. Pharmacies can use the poster to help patients understand who is profiting, said Arizona pharmacy owner and PUTT president Teresa Stickler, PharmD. But understanding pricing doesn’t help patients afford it. Or believe it.
“There is no good way to explain the price increases because they often defy logic even to us,” said Bradley Arthur, PharmD, president of the National Community Pharmacy Association. “To try to explain it to a layperson just leaves them more befuddled.”
Dr. Arthur noted that about 98 percent of his claims are paid by third parties, so patients may not even be aware of price increases. The problem is the remaining two percent that may no prescription drug coverage or have high deductible coverage that exposes patients to a significant portion of the retail price. If deductibles are high enough, patients may be responsible for the entire cost.
“Any major price increase will make it harder for patients to access their drugs,” SAID Mohamed Jalloh, PharmD, Assistant Professor of Clinical Sciences at Touro University California College of Pharmacy and Ambulatory Care Pharmacist at OLE Health in Napa, CA. “A recent is the price increase for EpiPen. Due to the drastic price increase, many patients have told me they can no longer afford it.”
Just as the reason for price increases depends on the specific product, pharmacists’ ability to help patients work around drug costs depends on the specific patient, drug and drug coverage. Pharmacists may be able to help patients navigate the Byzantine labyrinth of drug prices and copays, but they cannot solve the problem.
Patients with type 1 diabetes, for example, need insulin. They may have no choice but to pay the price or go without.
Patients with type 2 diabetes may have a little more flexibility.
“If insulin injections become too expensive for managing your type 2 diabetes,” Dr. Jalloh noted, there are so many other agents that are available and affordable. Encourage patients to sit down with you and with their physician to identify alternative agents.”
Manufacturers may have patient assistance programs that can cover all or part of the retail cost. Depending on income level and other requirements, some patients without coverage may be able to get financial help. Patient assistance programs are most common for biologics and other high-cost products, but it never hurts to check.
For patients who have some sort of third party coverage, coupons or copay cards may help. Coupons generally work to keep drug prices high and inflate spending on brand name products, explained Steven Schondelmeyer, PharmD, PhD, Professor and Head of the Department of Pharmaceutical Care and Health System and Director of the PRIME Institute at the University of Minnesota College of Pharmacy. But for individual patients, coupons can be the difference between being able to afford a drug and having to go without.
Mylan, for example, has a $300 copay card that can effectively cover half of the current retail EpiPen price.
Patients can sign up for the program online. Enrollment can even be done at the point of sale and the coupon applied immediately. But it may not be enough.
“We have patients displaced at $300 for EpiPens and many more at $600,” said Amber Korn, University of North Carolina pharmacy resident at Sona Pharmacy and Clinic in Asheville, NC. PharmD. “A lot of patients are just not getting prescriptions filled because of the cost.”
Sona’s alternative is to create an epinephrine kit with drug and syringes. But a kit does not meet school requirements for an auto-injector device. Other pharmacies around the country sell similar epinephrine injector kits to patients and emergency response systems that cannot afford EpiPens.
King County (Seattle, WA) Emergency Medical Services saved more than $150,000 a year using kits instead of EpiPens. The agency sells kits, minus epinephrine, to health agencies across the region.
If generics for a high-priced product are available, it may be possible to dispense the cheaper product. Depending on the product category, therapeutic substitution may be a practical alternative.
“For dermatological products, we have had success suggesting alternatives,” Dr. Arthur said. “Unfortunately, this is not often an option with products like digoxin or those with tight therapeutic windows such as the anti-seizure meds.”
And just because a therapeutic alternative is available doesn’t mean it is practical. It may be possible to substitute Adrenaclick (epinephrine injection, Amedra) for EpiPen, suggested Norman Tomaka, PharmD, a hospital pharmacy consultant in Melbourne, FL. That could bring the price down to around $400, but availability and insurance coverage are spotty.
“Worst case, you can dispense an injection kit,” said Dawn Butterfield, RPh, owner of West Cocoa Pharmacy and Compounding in Cocoa, FL. “A kit isn’t as convenient as an EpiPen, but it is just as effective once injected.”
Jeremy Counts took the kit concept a step farther. He dispensed prefilled epinephrine syringes. Prefilled syringes have been standard in wilderness medicine and other price or space and weight sensitive applications for years. But shelf life is limited. And the state Board of Pharmacy soon put a stop to prefilled syringe sales.
“I cautioned my patients the FDA does not recommend prefilled syringes for more than 30 hours,” he said. “I also told them the literature says prefilled epinephrine syringes are good for three months when protected from heat and light. I absolutely encourage everyone to get an EpiPen if they can. It has better shelf life, it’s reliable, it’s easy, it’s the best solution you can get on the market today. But if you can’t afford EpiPen, a prefilled syringe or a syringe and an ampule of epinephrine can still save your life.”
Mylan has raised the price of EpiPens from about $60 before it acquired the product in 2007 to just over $600 in 2016, just in time for the back to school rush.
“EpiPen is a very seasonal product,” said industry analyst Ronny Gal, PhD, Sanford C. Bernstein & Co. “More than half of sales are in the two months ahead of the school year as parents refresh their kids’ backpacks. The recipe for this outcry is a seasonal product, purchased largely by young families that have moved to high deductible health plans and aggressive price increases by the manufacturer.”
Mylan’s aggressive pricing is hardly unique in the industry. Turing Pharmaceutical made headlines in 2015 by boosting the price of Daraprim (pyrimethamine), a single-source generic used primarily to treat parasitic infections, by 5,000 percent.
An article published in the Journal of the American Medical Association in August noted that noted that the price of insulin jumped 300 percent between 2002 and 2013. Isoproterenol prices jumped 2,500 percent and digoxin 637 percent. Despite the widespread assumption that generic drug prices generally fall, the price of some 400 generics increased more than 1,000 percent between 2008 and 2015.
The problem
According to industry insiders, there is no single cause for price increases. Some price skyrocket just because the manufacturer can do it.
Manufacturers with patent protection for a product have free rein to set pricing. As long as the company has market exclusivity, it can set any price as long as it is willing to bear the blowback from public, providers and payers. Highly effective hepatitis C medications such as Harvoni (ledipasvir 90 mg/sofosbuvir 400 mg, Chiron) were introduced at more than $1,000 a tablet simply because the manufacturer could.
Market exclusivity give manufacturers a legal monopoly. In some cases, drug makers with products that have lost patent protection can still enjoy a functional monopoly.
“This is exclusivity that comes from being the only manufacturer of a product in the marketplace,” explained Dr. Schondelmeyer. “For a new generic to enter the market takes two, four, maybe five years to develop and get FDA marketing approval. That sole manufacturer has a functional monopoly. Some raise prices extremely aggressively, some are a little less aggressive and raise the price by ‘only’ 50 to 100 percent.”
Turing Pharmaceuticals became the poster child for aggressive price hikes after purchasing the rights to Daraprim from Impax Laboratories in 2015. Although the patent on pyrimethamine expired decades ago, Turing was the sole manufacturer. Turing chief Martin Shkreli drew fire from Wall Street to Main Street and Capitol Hill when he hiked the price of Daraprim from $13.50 to $750 per tablet.
EpiPen has a similar functional monopoly. The biggest difference is that Mylan has spread its price increases over several years, although most of the increase has come in the past three years.
EpiPen was originally approved by the Food and Drug Administration in 1988 and was eventually acquired by Merck KGaA. In early 2007, the list price for EpiPens was $68. Rising generic maker Mylan acquired the product as part of a larger purchase.
Since 2007, Mylan has had little competition. Marketing and lobbying campaigns have boosted awareness of anaphylactic shock, the utility of epinephrine and the safety of its auto-injector. EpiPens are available at Disney parks, on airliners and schools nationwide. Other companies have tried, and largely failed, to enter the epinephrine auto-injector market.
By July, 2013, the price was up to $265, then jumped to $461 in 2015. This year the price jumped to $608. Mylan has announced a generic version of EpiPen that could be available later this year for $300.
Products that are about to lose patent protection often see steep price increases toward the end of market exclusivity. Manufacturers want to extract the maximum profit possible before generic competition and new entrants force prices lower. Analysts speculate that the potential for generic competition and competing formulations could be one reason behind the rising rate of EpiPen price increases over the last three years.
Impending competition has been responsible for much of the pricing increase in insulin products. Lantus (insulin glargine injection, Sanofi-Aventis) has seen significant price increases as its biosimilar Basaglar ((insulin glargine injection, Lilly, Boehringer Ingelheim) moved toward approval.
And sometimes price increases are the result of genuine shortages. The FDA tightened quality requirements after 81 patients in the U.S. died from contaminated heparin traced to counterfeit raw materials in China. The price of heparin skyrocketed as supplies of approved product dwindled.
Rassan M. Tarabein, MD is the next good doctor illegally attacked by the US government. Dr. Tarabein is a neurologist who also does pain management at his independent clinic, Eastern Shore Neurology and Pain Center in Daphne, Alabama. His office and home were raided by the FBI and DEA yesterday. As a prior US Attorney once said, “They go to where the money is and the guns aren’t.”
As shown on my list of doctors being attacked, Dr. Tarabein fits the profile:
Minority, of foreign background: Dr. Tarabein’s medical training was at the University of Damascus in Syria.
Independent clinic: Dr. Tarabein is the self-employed owner of his clinic in Daphne.
Dr. Tarabein’s record as a physician is noteworthy.
He is a lecturer and publisher of research with advanced medical and neurological training in Neurovascular Doppler/Ultrasound, Electromyography, VNG and invasive pain management.
He was awarded the “National Leadership Award” and the “Businessman of the Year” in Alabama for 2001 and 2002 by the US congress.
In 2007 he was featured on the cover page and was honored with an eight-page story in MD News, a state-wide physician magazine.
In 2012, Dr Tarabein was awarded the “World Leading Physician”
So why is he being attacked? Money, promotions and government overreach into the medical profession “because they can”.
The first news article I read about Dr. Tarabein was from WKRG5. I won’t even go into that here. Their article was so propagandizing it was pitiful. Basically, if members of the jury saw their news or read their article Dr. Tarabein’s goose is cooked. But that’s the basic plan. It is my belief and theory that CBS is in cahoots with the US government in every affiliate station in the country to spread their propaganda. He should sue them for defamation of character and slander/libel because most of what they wrote is wrong, or at least misleading.
My response to them was:
Your news about Dr. Rassan Tarabein is misleading. I’ll bet you are a CBS affiliate. To correct your negative, propagandizing statements, consent orders with Boards of Medicine are not admissions to wrongdoing. They state that the physician neither admits nor denies the allegations. Usually the physician would deny them, as is the case with Dr. Tarabein, but legal expenses and having to go through a board review is not in the physician’s best interest at the time. We are told that we aren’t admitting to the allegations when we sign a consent order, but the Justice Department then treats them in court like they are admissions. That is wrong. But it is even more wrong for you, the media, to extend that wrong-doing into the realm of publicity. You should retract your comments about admission of those charges. You should also inform people that these attacks are simply DOJ and government agency job security tactics. Note also, that most of the attacks are on self-employed minorities, and are discrimination at its highest. In fact, why don’t you interview me for your next news cast? My guess is you won’t do any of the above, because you are part of the government propaganda machine. But this note will appear on my next post about Dr. Tarabein.
After writing that post, I checked. WKRG IS the CBS affiliate. Surprise, surprise. NOT!!
I did immediately receive a reply from Brad Gunther in which he referred me to the ALBME consent order. But he did not mention any interview to expose the truth behind these attacks. He basically stuck to their propagandizing story.
Alexa Knowles, reporter for FOX10 News, was less propagandizing. She reported on Fox’s 2006 interview with Dr. Tarabein after he was put on probation by the Alabama Board of Medical Examiners in 2004 following his consent order. This interview showed that Dr. Tarabein did NOT admit to the charges the Board made. He said, “There is a real mania among all medical boards in every single state. They are all in a real race, trying to show the public that they are the toughest boards in the whole nation.” “Physicians who are disciplined should be disciplined for legitimate reasons and not because of some personal conflict with the board.”
As a warning to other well-intentioned physicians, Dr. Tarabein was also a suboxone-certified clinic. This is the next hole the government has dug to attack physicians. They are extending the Suboxone prescribing practice by law, enticing more doctors to jump in. But then the DEA and US Attorneys will be waiting to charge you with criminal intent. WATCH OUT!!
PEOPLE, we have to stop this government overreach and illegal attacks on good doctors. Please read this and pass it on to all of your contacts. In every part of the country doctors are simply being indiscriminately targeted because they can’t fight back. We, the physicians and also the chronic pain patients now being discriminated against by new government laws, must take a stand. Understand that opiates are NOT the cause of drug abuse or addiction. You can learn what the real cause of abuse is by coming to my webinars or purchasing my DVDs. Then this information needs to be shared. We can’t let another innocent physician spend one day behind bars.
Rules being considered by the Minnesota Board of Pharmacy reflect a quandary facing pharmacists across the United States: How many hours should pharmacists be required to work?
The MBP has proposed that pharmacists not work more than 12 continuous hours a day—and and be provided a 30-minute break if they work more than six hours straight.
Courtesy/Shutterstock“Basically, there have been studies done in related professions that have showed the likelihood of errors goes up in high-pressure intense working conditions of healthcare, and we think that’s exactly what’s happening in pharmacies these days,” said Cody Wiberg, executive director of the Minnesota Board of Pharmacy, told the Mankato Free Press.
A spokesperson for the National Association of Community Pharmacists (NCPA) said the decision on how many hours a pharmacist should work should be left up to owners. “For example, what is required in a pharmacy that just opened and has limited staff, might be entirely different than what would be the case in a pharmacy that has been around for decades,” John Norton, NCPA’s director of public relations told Drug Topics.
The issue of how many hours pharmacists and pharmacy techs are required to work has long been a contentious issue in the profession. Even the most competent pharmacists can make script errors due to severe understaffing, inadequate number of competent techs, 12-hour shifts, and no meal breaks, Dennis Miller, RPh, wrote in this Drug Topics article.
CVS paid $7.4 million last year to more than 1,600 pharmacists throughout California who claimed the retail giant forced employees to work seven days in a row without paying overtime. A California pharmacist also filed a class-action lawsuit against Walmart last year, accusing the retailer of cheating pharmacists out of work breaks and overtime pay.
In Minnesota, CVS Health said it “strongly believes that a pharmacist should continue to manage their own work schedule and not rely on a Board rule to dictate work conditions,” a representative from the chain wrote. Other chains submitted similar statements opposing the Board setting a limit on the number of hours worked.
Small, independent pharmacists are also worried about the proposed rules, saying they could lose business. Typically, there is only on pharmacist on staff at small locations and the pharmacy would have to close when a pharmacist is not there, according to state rules.
However, a Hy-Vee Pharmacy Manager, Brian Cornelius, said he partially supports the proposal for his fellow pharmacists, even though he typically works a nine-hour day that includes a break. However, “I could also see it could be an inconvenience for patients if the pharmacy has to close,” he told Mankato Free Press.
Vikki Patterson worked for CVS for 17 years, starting off when it was still Longs Drugs.
She had been a dedicated and faithful employee, working whenever needed without complaint. Vikki loved her employees, many of them were known as her “work kids” and went to her for all kinds of help. She loved her customers, became invested in their lives over the years and they in hers.
She worked in that store on Placer St in Redding, CA since that shopping center was built.
On Thursday October 13 2016 there were two suspicious customers in the store, one woman had filled her purse up with nearly 300 dollars worth of merchandise (and hundreds more in the cart that she didn’t have time to shove in her purse). She was swearing at Vikki and the other employee working and as the employee went to lock the door to call the police the shoplifter rushed the employee. Vikki ran to protect her “work kid” with her keys in one hand and cell phone in the other. She was forced outside with the suspect and her keys got caught in the woman’s hair. The suspect ended up punching Vikki multiple times, splitting her lip open and scratching her all over. She tried to steal her phone in the tussle while Vikki was calling 911.
Once Vikki was able to free her keys from the woman’s hair, she ran off and got into a car with the other woman she was with in the store.
Redding police spotted their vehicle while responding to CVS and pulled them over. They recovered all the merchandise as well as merchandise from other stores. The suspect was arrested for theft and battery.
CVS was notified of the situation and asked Vikki to write up her statement. The morning they received it, she was suspended without pay. Today, they terminated her employment.
Vikki has been the caregiver for her husband Rob for years. Using all her vacation time to take him to/from doctors appointments and surgeries. This job was their main income, and her insurance was what saved Rob multiple times. Through a heart attack, triple bypass, seizures, strokes, dialysis, kidney and pancreas transplant, and countless other medical emergencies over the last 5 years. Vikki and Rob are friends of many, they are caring people and involved in the community.
This whole situation sends the wrong message, it tells thieves that it’s ok to steal hundreds of dollars worth of merchandise and assault innocent people because it’s not them who will be punished.
Chronic-pain patients at high risk of suicide
Raising awareness is easy and FREE – The easiest way to participate is to wear orange and post a picture to social media with the hashtag: #CRPSORANGEDAY.
Rassan M. Tarabein, MD
He is a lecturer and publisher of research with advanced medical and neurological training in Neurovascular Doppler/Ultrasound, Electromyography, VNG and invasive pain management.
Reinstate Vikki Patterson