“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
Some in the pharmacy community are pushing for Pharmacist to be considered a “practitioners” , which basically means that there is hopes of being able to charge pts and insurance companies for services/advice that has nothing to do with the dispensing of medication. This article adequately describes the paradox that today’s corporate employee has to deal with. When I was in school, the legal advice I was given that no matter what you did “in the pt’s best interest”.. as long as you did not charge for whatever you did… there was no “monetary motive” for your actions and you were in a very safe position. In today’s corporate environment, apparently any piece of inventory that is used without being paid for – regardless of the reason – it is considered THEFT. In this – or similar example – LOSS PREVENTION would come down on the Pharmacist and probably get fired for saving the pt’s life. IMO.. this ethical Dilemma is going to play itself out over and over in the coming year(s)… with now that bureaucrats are moving Narcan/Naloxone to a OTC status. The answer is… will Pharmacists be thrown under the bus ..by the corporation wanting to prevent NEGATIVE PR for not “giving away” Naloxone for someone in front of them dying of a overdose or will they be “fired” because the Pharmacist took care of a person in front of them dying from a OD without getting paid.
I remember staring out the window of my pharmacy school on a sunny day longer ago than I care to admit, suffering from a full-scale attack of senioritits. Graduation was just around the corner, and the professor was doing her best to keep the roomful of restless future pharmacists engaged in something productive. I was tuning in and out of the conversation until I heard the professor say something like the following.
“Say a person was walking past your pharmacy counter and suddenly started having serious chest pain. They’d never been in your store before, so they’d have no prescriptions on file with you. Would you give them a nitroglycerin tablet?”
I ignored what I thought a silly question (of course you would!) and went back to my daydreaming, until I realized to my amazement that a lively discussion was going on, with many soon-to-be professional pharmacists asserting that it would be the best decision not to offer relief to a person in serious distress.
When I took my first pharmacist job I asked my boss, who was then serving on the Ohio Board of Pharmacy, about this, and he chuckled.
“No matter what you do,” he assured me, “if you can frame it as ‘It was what was best for the patient,’ then you’ll be fine.”
Sound, commonsense advice for professionals who uses their judgment and expertise to make decisions, I thought.
Best, yes — but for whom?
Fast forward a couple decades, and as it turns out, that classroom discussion wasn’t so hypothetical after all. Consider this:
Katherine O’Connor was having an asthma attack while walking home in New Jersey with her boyfriend. Luckily, there was a drug store right there. But she only had $20, and the inhaler cost $21. And the pharmacist wouldn’t give it to her.
“I said, ‘Can you just give her the pump? She’s on the floor wheezing … I didn’t know if an ambulance would get there on time. He said there was nothing he could do for me.”
The above came from a story reported by New York’s Fox5 TV that made its way around the internet a few years ago.
By the time I saw it, I wasn’t nearly so surprised as I was in the classroom that day long ago. It was an extreme case, but after 20 years spent working for chain drugstores, I can understand how the corporate environment could intimidate someone into making the wrong decision.
Don’t get me wrong. I’m sure that if you were to ask any of the corporate bigwigs directly, they would tell you not to leave an asthmatic wheezing on the floor of their store. But those same bigwigs are also constantly sending out memos that say you must do this and we have zero tolerance for that, while the company’s liability lawyers have done everything they can to come up with a policy for every situation, which employees violate at their peril.
So when a snap decision is called for, “What is our corporate loss-prevention policy?” can compete in an employee’s brain with “What is the best thing for the patient?”
This means we have too many pharmacists who want all the credit for being professional without ever taking the responsibility for making a decision, such as ones who won’t dispense syringes to a patient with insulin in their medication profile, or who tell a tourist with no refills on a blood pressure medication that they’re just out of luck over the weekend.
We’ve all worked with one of “those” pharmacists, and from what I’ve seen, correcting “those” pharmacists doesn’t seem to be a priority among the big chains.
Am I wrong?
I might be wrong. Maybe there are now state board regulators who would discipline a pharmacist for giving nitroglycerin to a heart attack victim. If so, I’m dying to hear from one.
But not so literally as the patient who might be affected.
The war on drugs has made criminals of otherwise law-abiding citizens. Minority communities have been devastated, and our prisons are filled to a level never seen before.
Things are not going well. Falcon Heights, Minnesota. Baton Rouge, Louisiana. Dallas, Texas. All are locations of our most recent senseless deaths, leaving families and friends devastated beyond comprehension.
This national nightmare, when studied, always brings us back to the same conclusion. This country’s war on drugs bears direct responsibility for the militarization of the police, and it has caused a decades-long degradation of inner-city minority communities.
Just one glaring example of what the drug war has done to our judicial system involves the Fourth Amendment to the Bill of Rights, which states citizens are protected against unreasonable searches and seizures. This requires police under oath to convince an impartial judge an arrest or search should be made. Otherwise, evidence illegally obtained was inadmissible to prove guilt. This is called the exclusionary rule.
This radical restraint on the police is unique to all the other countries of the world. For 200 years it stood. Then came the drug war.
Keep in mind most illegal drug transactions are between consenting adults. Judges, out of some misguided sense of civic duty, began finding exception after exception for the exclusionary rule. The Fourth Amendment is now so shot full of holes that it more accurately resembles the flag that flew over Fort Sumter. Remember the words of Supreme Court Justice Louis Brandeis in this 1928 dissenting opinion from Olmstead v. United States: “The right to be left alone — the most comprehensive of rights and the right most valued by civilized man.”
All races of Americans use drugs at roughly the same rates, but the drug war is waged disproportionately against black and Latin-Americans. Tactics used in drug law enforcement in inner cities would not be tolerated for a single week in white suburbia. The drug war reduces police resources for investigating and prosecuting homicides. Homicide clearance rates in all major cities have fallen dramatically over the drug war years.
The war on drugs has made criminals of otherwise law-abiding citizens. Minority communities have been devastated, and our prisons are filled to a level never seen before. Millions of young persons have had their life chances dashed by the drug war.
The police are victims of the drug war, too. The police are duty-bound to enforce laws, no matter how foolish. Police frustration boils over into ever-increasing violent, invasive tactics. This has been going on for so long that the police’s role in our society has become almost irreversibly distorted.
If we want to have a peaceful, prosperous and just society, we must end prohibition. Narcotics control belongs in the public health arena, not in the criminal justice system.
Ever wonder why marijuana is scheduled by the U.S. Drug Enforcement Agency as “highly addictive and having no medicinal value?” It is because the Department of Health, Education and Welfare in 1970 determined that marijuana was similar to alcohol and should be similarly regulated.
When President Nixon learned of this, he transferred authority for scheduling drugs from the doctors and scientists at that department and to law enforcement at DEA. In spite of half of the states’ legalizing medical marijuana, the DEA clings stubbornly to keeping marijuana as a schedule I drug, i.e., having no medicinal value. A cynical person might suspect the DEA is really trying to stay in business.
Can we as a people pull ourselves together during these times? We cannot continue to wage a war on ourselves. The war on drugs must end.
This is the opinion of Robert E. Pottratz, an attorney from Melrose.
Conflicts of interest have become more the rule than the occasional exception. Even the trusted US Centers for Disease Control and Prevention (CDC) receives heavy funding from industry.
How this conflict of interest may have affected the organization’s decisions is the topic of an article1 in the British Medical Journal (BMJ), penned by the journal’s associate editor, Jeanne Lenzer, who notes:
“The Centers for Disease Control and Prevention (CDC) includes the following disclaimer with its recommendations:
“CDC, our planners, and our content experts wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products… CDC does not accept commercial support.”
The CDC’s image as an independent watchdog over the public health has given it enormous prestige, and its recommendations are occasionally enforced by law.
Despite the agency’s disclaimer, the CDC does receive millions of dollars in industry gifts and funding, both directly and indirectly, and several recent CDC actions and recommendations have raised questions about the science it cites, the clinical guidelines it promotes, and the money it is taking.”
Is the CDC Protecting the Private Good Rather Than the Public?
When confronted about the discrepancy between the CDC’s public disclaimer and the reality that corporate funding is flowing into the organization, Tom Frieden, director of the CDC, responded, saying:
“Public-private partnerships allow CDC to do more, faster. The agency’s core values of accountability, respect, and integrity guide the way CDC spends the funds entrusted to it.
When possible conflicts of interests arise, we take a hard, close look to ensure that proper policies and guidelines are followed before accepting outside donations.”
In other words, the CDC believes, and “assures” you, it has the moral backbone to do the right thing, despite the fact that studies have revealed moral fiber tends to significantly deteriorate as soon as a funding source with an agenda starts doling out money.
Moreover, a 2009 investigation by the Office of the Inspector General concluded the CDC has “a systemic lack of oversight of the ethics program,” noting 97 percent of disclosure forms filed by the organization’s advisors were incomplete, and 13 percent of advisors didn’t file one.
Did Industry ‘Buy’ CDC Recommendation for Expanded Hepatitis C Screening?
External funding to the CDC in the form of industry “gifts” was authorized in 1983—nearly 40 years after the organization’s inception in 1946. After the passing of legislation in 1992 that encouraged relationships between the CDC and industry, the non-profit CDC Foundation was formed in 1995.
Last year, this Foundation received $12 million from private corporations, and the CDC itself received another $16 million in funding earmarked for special projects from companies, manufacturers, and various philanthropists.
“For example, in 2012, Genentech earmarked $600 000 in donations to the CDC Foundation for CDC’s efforts to promote expanded testing and treatment of viral hepatitis. Genentech and its parent company, Roche, manufacture test kits and treatments for hepatitis C,” Lenzer writes.
Since 2010, when the CDC and the CDC Foundation formed the Viral Hepatitis Action Coalition, manufacturers of hepatitis C tests and treatments have donated more than $26 million to the coalition.
In addition to Genentech, donors include: Abbott Laboratories, AbbVie, Gilead, Janssen, Merck, OraSure Technologies, Quest Diagnostics, and Siemens.
Two years later, in 2012, the CDC issued guidelines recommending expanded screening for hepatitis C for everyone born between 1945 and 1965, saying newer antiviral drugs can effectively halt disease progression.
However, “the science behind cohort screening has been challenged and is said to be ‘the subject of major debate.’ The scientific debate along with the price tags of the newer drugs (over $84 000 per treatment course for the new drug sofosbuvir), raise questions about CDC’s industry funding,” Lenzer writes.
CDC Recommendations Increasingly Skewed
The CDC and the CDC Foundation also received monies from Roche for the creation of the CDC’s “Take 3” flu campaign, again raising questions about the influence of funding on its drug recommendations.
Step 3 in the CDC’s flu campaign advises you to “take antiviral medicine if your doctor prescribes it.” In an article titled, “Why CDC Recommends Influenza Antiviral Drugs,” the agency cites a number of studies supporting its recommendation, including a recent meta-analysis published in The Lancet.2
The problem with that, Lenzer points out, is that the CDC describes this study as “independent,” when in fact it was sponsored by Roche. Moreover, all of the four authors have financial ties to Roche, Genentech (both of which sell Tamiflu), or Gilead (which holds the patent).
In addition to that, the CDC did not include last year’s systematic review3 of 83 trials conducted by the Cochrane Collaboration, which is the “gold standard” for independent research analysis.
Was this analysis ignored because it concluded Tamiflu alleviates symptoms of the flu by less than 17 hours, has limited effect on your risk of pneumonia, no effect on adult hospital admissions, and causes nausea, vomiting, headaches, renal problems and psychiatric syndromes?
According to the Cochrane group: “The trade-off between benefits and harms should be borne in mind when making decisions to use oseltamivir [brand name Tamiflu] for treatment, prophylaxis, or stockpiling.”
Another issue is this: CDC director Tom Frieden has stated that taking Tamiflu might save your life, yet the US Food and Drug Administration (FDA) has warned Roche it cannot claim the drug reduces pneumonia or deaths as they’ve never produced any evidence for that claim.
But who needs scientific evidence when the CDC is making off-label claims for you? “Shannon Brownlee, senior vice president of the Lown Institute and former journalist covering the CDC, told
The BMJ, “This looks like classic stealth marketing, in which industry puts their message in the mouths of a trusted third party, such as an academic or a professional organization,” Lenzer writes.
FDA: The Poster Child for Industry Bias
The Food and Drug Administration (FDA) has also become notorious for its conflicts of interest and close ties to various industries, and there are many examples of this.
Last year, emails and letters between the FDA and Pfizer suggest the drug giant was given an inappropriate amount of leverage to decide when and how to tell the public about the hazards associated with its veterinary drug roxarsone.4,5
FDA researchers found low levels of inorganic arsenic in the livers of chicken who consumed the drug. Correspondence between Heidi Chen, then attorney in Pfizer’s animal health division, and William Flynn, the FDA’s deputy director for science policy at the Center for Veterinary Medicine, reveal the agency allowed Pfizer to edit the wording of a press release about the roxarsone data, and more.
Government Must Act to Protect Scientific Integrity
Getting back to the CDC, it was created and has been relied upon as an independent agency without industry ties that might muddy the water in terms of the health and safety recommendations it issues. Now, it’s become apparent that not even the CDC can be counted on for unbiased science-based advice. So what, if anything, can be done to rectify the situation?
Considering the fact that CDC funding from industry was approved by the government, the answer, as noted by Jerome R Hoffman,6 methodologist and emeritus professor of medicine at UCLA, is to “get the government to reject this devil’s bargain, by changing the rules so this can no longer happen.” It’s simply unreasonable to believe that any organization will ignore its cash cows, and it’s equally naïve to believe that industry will continue donating money if the agency decides to do anything that even hints at cutting into industry profits.
For example, the NRA promptly withdrew its CDC funding when the agency began investigating gun violence.7 In summary, conflicts of interest endanger lives. People’s well-being become secondary to the corporate bottom line, and no organization or corporation is immune to the effects of conflicts of interest—not even the CDC. Even well-respected research universities like the University of Minnesota have fallen prey, relaxing research ethics to the point that research subjects die.8
Head of CDC Now Head of Merck Vaccines
The infamous revolving door between the government and the drug industry is another factor that has done an awful lot to destroy scientific integrity and government accountability. One classic example is Dr. Julie Gerberding, who headed up the CDC—which among other things is charged with overseeing vaccines—from 2002 to 2009 before becoming the president of Merck’s vaccine division, a position she currently holds today.
The influence her former high-level ties to the CDC wields is enormous, considering the fact that Merck makes 14 of the 17 pediatric vaccines recommended by the CDC, and 9 of the 10 recommended for adults. And while vaccine safety advocates are trying to rein in the number of vaccines given to babies, safety concerns keep falling on deaf ears. The vaccine industry is booming, and it’s become quite clear that profit potential is the driving factor behind it. It is this type of reprehensible and inexcusable behavior that makes it an enormous challenge to change this seriously flawed paradigm.
Half of Published Research Likely to Be Completely False, Warns Editor-in-Chief of Major Medical Journal
Just as the CDC insists it has the ability to maintain its integrity awash in industry cash, corporations insist they have the integrity to stay on solid scientific ground when researching its own products. But, just as studies show the source of funding alters scientific conclusions, so research reveals that industry-funded research is riddled with flaws, shortcomings, and outright fraud. As reported by the Progressive Review:9,10
“… Dr. Richard Horton, the current editor-in-chief of the Lancet…recently published a statement11 declaring that a lot of published research is in fact unreliable at best, if not completely false. ‘The case against science is straightforward: much of the scientific literature, perhaps half, may simply be untrue. Afflicted by studies with small sample sizes, tiny effects, invalid exploratory analyses, and flagrant conflicts of interest, together with an obsession for pursuing fashionable trends of dubious importance, science has taken a turn towards darkness…’
Dr. Marcia Angell…makes her view of the subject quite plain: ‘It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of the New England Journal of Medicine’” [Emphasis mine]
Omission of Data Often Protects Corporate Profits
Omission of data is another common tactic employed to skew the scientific consensus, and this is just as dangerous as publishing complete fabrications. For example, according to Dr. Lucija Tomljenovic,12,13 a post-doctoral fellow at the University of British Columbia (UBC) where she works in neurosciences and the Department of Medicine, many vaccine manufacturers and health authorities are actually well aware of dangers associated with vaccines, but have chosen to withhold this information from the public. She writes, in part:
“Deliberately concealing information from the parents for the sole purpose of getting them to comply with an ‘official’ vaccination schedule could thus be considered as a form of ethical violation or misconduct. Official documents obtained from the UK Department of Health (DH) and
the Joint Committee on Vaccination and Immunization (JCVI) reveal that the British health authorities have been engaging in such practice for the last 30 years, apparently for the sole purpose of protecting the national vaccination program.”
Many industry-funded studies with negative findings simply never see the light of day, as suggested by a recent NEJM review14 looking at compliance rates with results reporting at ClinicalTrials.gov. The Food and Drug Administration Amendments Act (FDAAA) mandates timely reporting of results of applicable clinical trials to ClinicalTrials.gov, but only 13.4 percent of trials reported summary results within 12 months of completing the trial, and 45 percent of industry-funded trials were not required to report results. For comparison, only six percent of trials funded by the National Institutes of Health (NIH) and nine percent of studies funded by other government or academic institutions were excluded from result reporting.
Doctors Also Share the Blame…
Bias is another major problem that has increasingly sullied the scientific community, and no one is immune—not even doctors, especially not when they’re receiving large sums of money from a drug company. According to “the most comprehensive accounting so far of the financial ties that some critics say have compromised medical care,” published last year, American doctors and teaching hospitals received a whopping $3.5 billion from drug and medical-device companies in the last five months of 2013 alone.15
A recent article16 in NEJM titled “Understanding Bias — The Case for Careful Study,” offers a discourse on bias, at the core of which you find financial conflicts of interest. But there are also a number of other hidden, largely subconscious conflicts within any given individual that can color his or her decision-making, such as how easy one treatment is versus another—one might require hours of work, while the other would allow the doctor some well-needed sleep.
Either way, conflicts of interest do have an impact on the patient, and when the motive is selfish—be it to gain more money or sleep—that impact is likely to be detrimental. As noted in the NEJM article:
“Some 94 percent of physicians have relationships with industry, though these interactions most often involve activities such as receiving drug samples or food in the workplace… Physicians who attend symposia funded by pharmaceutical companies subsequently prescribe the featured drugs at a higher rate… Are any of these interactions, or efforts to curtail them, beneficial or harmful to patients? It depends on how you define harm. Consider pharmaceutical ‘gifting,’ a practice that smacks of bribery — which may be sufficient reason to prohibit it. But does it actually hurt patients? According to one influential commentary, it does…”
Doctors Urged to Stop Overtreating Patients
Yet another BMJ article17 urges doctors to stop overmedicating and overtreating patients, warning they’re doing more harm than good. As reported by BBC News18:
“Launching the Choosing Wisely campaign, experts are calling on medical organizations to identify five procedures each that should not be offered routinely or in some cases not at all. These might include: Pills for mild depression; Too many routine and unnecessary blood tests; Medicines for mildly raised blood pressure… [E]xperts say individuals should be encouraged to check whether procedures are definitely right for them. For example, patients are advised to ask: Do I really need this test or procedure?; Are there simpler options?; What happens if I do nothing?”
Overmedicating and overtreating is one result of excessive industry influence, although it’s certainly not the sole reason. From my perspective, it seems clear that more drugs, tests, and surgeries do not equate to better health. On the contrary, it raises the risks of side effects that may be as bad or worse than the original problem. It also raises the risk of fatal medical errors—a fate that befalls 440,000 Americans each year! As reported by Forbes19 in 2013:
“These people are not dying from the illnesses that caused them to seek hospital care in the first place. They are dying from mishaps that hospitals could have prevented. What do these errors look like? The sponge left inside the surgical patient, prompting weeks of mysterious, agonizing abdominal pain before the infection overcomes bodily functions. The medication injected into a baby’s IV at a dose calculated for a 200 pound man. The excruciating infection from contaminated equipment used at the bedside. Sadly, over a thousand people a day are dying from these kinds of mistakes.”
Drug Ads May Lose Fine Print Details About Side Effects
Have you ever asked your doctor if a certain drug was right for you—as instructed by virtually every drug ad you see on TV? Clearly, this ploy works, or the drug industry wouldn’t spend $4.53 billion a year on direct-to-consumer (DTC) advertising.20 In the midst of all the faux science backing up recommendations to use drugs of all kinds, the Food and Drug Administration (FDA) is considering simplifying DTC print ads by making the manufacturers summarize potential side effects in layman’s terms—and omitting certain drug details altogether. Cutting the laundry list of side effects from radio and TV ads is also under consideration, ostensibly to improve your understanding of the drug’s risks.
“‘In general, FDA believes that exhaustive lists that include even minor risks detract from, and make it difficult for, consumers to comprehend and retain information about the more important risks,’ the FDA says in its draft guidance on the proposed changes to print ads.The agency cites research showing that people can only process a limited amount of information offered in DTC drug ads. Furthermore, the FDA found, virtually no one reads even half of the fine print in drug ads, and of those who do, 55 percent say it’s hard to understand. The agency also cites several studies showing that when drug risks are described in laymen’s terms instead of medical jargon comprehension skyrockets.”
It’s difficult to discern whether a change like this might actually change how consumers “hear” or “see” the benefit versus risk potential of any given drug. In my view, the most reasonable approach would be to dramatically reduce or ban DTC drug ads altogether, as they do absolutely nothing to improve public health. On the contrary, luring people into thinking they might benefit from a drug is a recipe for disaster, as it reinforces the fallacy that there’s a magic pill for every ill, when in fact most ailments can be effectively prevented or addressed with inexpensive lifestyle changes that have no detrimental side effects whatsoever.
History is replete with examples of drugs causing far more harm than good. Vioxx is one classic example. It killed about 60,000 people before being withdrawn from the market. Most recently, Takeda Pharmaceutical has agreed to pay $2.4 billion to settle some 9,000 lawsuits from patients who developed bladder cancer from the drug22–a side effect the company concealed, according to plaintiff attorneys. Despite such risks, Actos is still sold in the US and other countries.
Hopefully, you will resolve to take control of your health and avoid becoming a statistic of a conflict-of-interest-driven system that places greater value on share holders than patients. Addressing your diet is an obvious place to start, along with a regular exercise program.
If your boss gave you an TASK/JOB to accomplish… would you come back and generate a report that clearly demonstrates that you were failing miserably… do you think that you would keep your job if you just produced a warning video telling everyone that you were failing your appointed task/job and putting many in the public at risk. Do you think that you should keep your job or should you be given more money and staff to continue doing what you have been doing – badly – for the last 46 years ?
Hundreds of thousands of counterfeit prescription pills, many containing deadly amounts of fentanyl and fentanyl-related compounds, have made their way into the U.S. drug market, according to a DEA intelligence report released today. Law enforcement nationwide report higher fentanyl availability, seizures, and known overdose deaths than at any other time since the drug’s creation in 1959.
Fentanyl is a synthetically produced opioid that, when produced and administered legitimately, is used to treat severe pain. Overseas labs in China are mass-producing fentanyl and fentanyl-related compounds and marketing them to drug trafficking groups in Mexico, Canada and the United States.
In addition to being deadly to users, fentanyl poses a grave threat to law enforcement officials and first responders, as a lethal dose of fentanyl can be accidentally inhaled or absorbed through the skin.
DEA recently released the Police Roll Call video below, nationwide to warn law enforcement about this danger.
(‘FENTANYL – A Real Threat to Law Enforcement’, courtesy of the DEA)
Fentanyl and fentanyl-related compounds are traditionally mixed into or sold as heroin, or on its own, oftentimes without the customer’s knowledge. Since 2014, U.S. law enforcement agencies have been seizing a new form of fentanyl—counterfeit prescription opioid pills containing fentanyl or fentanyl-related compounds. The counterfeit pills often closely resemble the authentic medications they were designed to mimic, and the presence of fentanyl is only detected upon laboratory analysis.
Fentanyl traffickers have been successful at expanding the fentanyl market and introducing new fentanyl-laced drug products to the U.S. drug market. The DEA National Forensic Laboratory Information System (NFLIS) reported that there were 13,002 fentanyl exhibits tested by forensic laboratories across the country in 2015 (the latest year for which data is available), which is a 65 percent increase from the 7,864 fentanyl exhibits in 2014. There were approximately eight times as many fentanyl exhibits in 2015 as there were during the 2006 fentanyl crisis, clearly demonstrating the unprecedented threat and expansion of the fentanyl market.
The rise of counterfeit pills that contain fentanyl in the illicit drug market will likely result in more opioid-dependent individuals, overdoses, and deaths. There were over 700 fentanyl-related deaths reported in the United States between late 2013 and 2014. During 2013-2014, the Centers for Disease Control (CDC) reported that deaths from synthetic opioids increased 79 percent, from 3,097 to 5,544. Although the synthetic opioid category does contain other opioids, this sharp increase coincides with a sharp increase in fentanyl availability, and the CDC reports that a substantial portion of the increase appears to be related to illicit fentanyl.
In March 2016, law enforcement officers in Lorain County, Ohio, seized 500 pills that visually appeared to be oxycodone. The pills were blue and had “A 215” markings, consistent with 30 milligram oxycodone pills. Laboratory analysis indicated that the pills did not contain oxycodone, but were instead the research chemical U-47700. U-47700 is an unscheduled synthetic opioid not studied for human use that has caused at least 17 overdoses and several deaths in the United States.
Many Chinese laboratories illicitly manufacturing synthetic drugs, such as fentanyl and their precursors, also manufacture legitimate chemicals for purchase by U.S. companies. This means that laboratories responsible for supplying fentanyl in counterfeit pills can also run legitimate businesses. Although Chinese clandestine laboratories may be contributing to the fentanyl supply, legitimate laboratories may also be sources of supply.
Traffickers can typically purchase a kilogram of fentanyl powder for a few thousand dollars from a Chinese supplier, transform it into hundreds of thousands of pills, and sell the counterfeit pills for millions of dollars in profit. If a particular batch has 1.5 milligrams of fentanyl per pill, approximately 666,666 counterfeit pills can be manufactured from 1 kilogram of pure fentanyl.
To access the full report “Counterfeit Prescription Pills Containing Fentanyls: A Global Threat”, click here.
#10. I vote Democrat because I love the fact that I can now marry whatever I want. I’ve decided to marry my German Shepherd.
# 9. I vote Democrat because I believe oil companies profits of 4% on a gallon of gas are obscene, but the government taxing the same gallon at 15% isn’t.
# 8. I vote Democrat because I believe the government will do a better job of spending the money I earn than I would.
# 7. I vote Democrat because Freedom of Speech is fine as long as nobody is offended by it.
# 6. I vote Democrat because I’m way too irresponsible to own a gun, and I know that my local police are all I need to protect me from murderers and thieves. I am also thankful that we have a 911 service that gets police to your home in order to identify your body after a home invasion.
# 5. I vote Democrat because I’m not concerned about millions of babies being aborted so long as we keep all death row inmates alive and comfy.
# 4. I vote Democrat because I think illegal aliens have a right to free health care, education, and Social Security benefits, and we should take away Social Security from those who paid into it.
# 3. I vote Democrat because I believe that businesses should not be allowed to make profits for themselves. They need to break even and give the rest away to the government for redistribution as the Democrat Party sees fit.
# 2. I vote Democrat because I believe liberal judges need to rewrite the Constitution every few days to suit fringe kooks who would never get their agendas past the voters.
…And, the #1 reason I vote Democrat is because I think it’s better to pay $billions$ for oil to people who hate us, but not drill our own because it might upset some endangered beetle, gopher, or fish here in America. We don’t care about the beetles, gophers, or fish in those other countries.
A recent study suggests that medical mistakes are the third leading cause of death in this country.
That means – surgical mistakes, prescription medicine mistakes, misdiagnosis and more.
And medical error is not an “official” cause of death on death certificates so it can be hard tally the total.
But some doctors and hospitals are working to change that — and are putting patient safety, front and center.
You may remember the headlines: Pennsylvania Congressmen John Murtha went into Walter Reed Medical Center for gall bladder surgery.
He died a month later at Virginia hospital reportedly due to complications from a mistake during the operation.
“If medical-care-gone-wrong were a disease, it would rank as the third-leading cause of death in the United States,” said surgeon Dr. Marty Makary.
Dr. Makary, at Johns Hopkins, spearheaded a recent study which analyzed death rate data from the past eight years.
The results, published in the journal BMI, put death from medical errors just behind heart disease and cancer.
“Unnecessary treatments, fragmented care, people falling through the cracks, overdoses, complications which are totally preventable, these are the collective causes that comprise the problem of people dying when they should not, people dying under our care,” Dr. Makary said.
He underscores that most of the mistakes are not due to inherently bad doctors.
“We shouldn’t look to doctors to blame the problem on individuals, we are human, but we can talk about how can we design the system to capture mistakes, provide safety nets,” Makary said.
Early on a Monday morning, in downtown Washington dozens of new medical interns are attending a safety seminar given by Medstar Health.
“Our job is to give you these tools to train so that you can provide the safest, highest quality care possible,” said Dr. David Mayer, with Medstar Health. “We need to break down those barriers we need to do huddles with everyone involved with a person’s care so anyone can chime in with a concern.”
He cites miscommunication and diagnostic error as significant causes of medical mistakes.
And he believes educating and supporting young doctors is critical.
“We have to make sure that it’s safe for them to go up the chain of command, to call a senior resident, to call and attending, when they’re uncertain, and they’re trying to make a critical thought process in a patient’s care,” Mayer said.
But Dr. Makary hopes more funds will be directed towards combating medical error for the long term.
“We spend a lot of time and money on heart disease and a lot of time and money on cancer but we have yet to recognize that our complex medical system can harm people just as any diagnosis or medical treatment can go wrong,” she said.
Right now, pharmacists are able to deny valid prescriptions for any reason they see fit. This negatively impacts many citizens, including, but not limited to, women seeking birth control or emergency contraception, women seeking fertility medication, and transgender people seeking hormones. This needs to change. I think it imperative to restrict their power of refusal to true medical reasons. Denying a person treatment based on your own beliefs and opinions is abhorrent, and should not be allowed. Therefore, I suggest a system of communication in which a pharmacist must submit a document outlining the reason for refusal to both the prescribing doctor and their employer. The reason for refusal MUST be a true medical reason, lest they be subject to fines and stripping of their license.
First it was those in the chronic pain community being denied their legit/on time/medically necessary… Then CVS told smokers that they would need to take their business elsewhere – at least the purchase of their tobacco products… now, it would seem that – at least in this one Ohio store – members of the LGBT community are not welcome and being refused their legal prescriptions. While the number of people that identify themselves as part of the LGBT community is kind of “fuzzy”… apparently the number could be upward to 25 million or about 7%-8% of the USA population.
I was discriminated against today by your pharmacist Cindy (not sure about the spelling tbh) at the Bedford, OH location at the corner of Northfield and Solon Rd. I am a transman taking testosterone from a testosterone replacement therapy center, and I entered a refill into your system last night for pickup today. When I called and asked what the holdup was (about two hours after the intended pick up time entered the night before), she said she would not fill my prescription, putting intentional and unnecessary emphasis on both my legal first name and the word “miss.” When I pressured her as to why, she just said “Because I refuse,” and wouldn’t say more. As a customer, I expect the same treatment as others would receive, not discrimination and refusal to fill a doctor’s prescription because I am transgender. It’s not a pharmacist’s place to insert their own personal beliefs into their work.
Your customer service line is fantastic though. When I called to report this incident, the two people I spoke to were incredibly courteous in addressing me as Mr. Graver and “sir.”
Do you not have an anti-discrimination policy for your employees or is it just who you feel like making follow such policies? One of your pharmacists in Bedford, Ohio refused to fill a testosterone prescription for a transgender friend of mine and referred to HIM as “miss.” I do not care what her personal beliefs are, she has NO right to refuse filling a prescription for anyone and should be fired! What’s next? Are you going to allow your pharmacists to refuse to fill birth control or allow your clerks to refuse the sale of condoms? If they can’t work with the public and provide the public with services WITHOUT prejudice, maybe they shouldn’t be working, thankfully I found this testosterone replacement therapy center.
I am disgusted at the discriminatory actions of your pharmacist, Cindy at your Bedford, Ohio location. Bigotry is to be abhorred and that person should be reprimanded at the very least. It would be better that she were fired if she is going to apply her bigotry to her job.
I would like to start by saying thaty Uncle works for CVS, and would be rather disappointed to hear about what occurred at your Bedford, Ohio location. A close friend of mine, who I consider family, was discriminated against vehemently by a pharmacist named Cindy there, and she blatantly refuse to fill his prescription, which is exceptionally dangerous as you don’t just STOP taking your medicine (and I am certain we can all agree as to why).
I would very much like to see action and a response from your company or Cindy herself – whether that be retraining, reprimand, or a simple, heartfelt apology – and my brother’s prescription filled.
I am disgusted and horrified by the discriminatory and disrespectful attitude and practice of your pharmacist, Cindy, at the Bedford, Ohio location on Solon Road. I thought CVS was better than that. How can you allow this? Please look into this matter and take action.
CVS, you should be ashamed. This is the 21st century, and there are other pharmacies where we can do business instead. I hope you as a corporation plan to take action against Cindy at the Bedford, OH location. If she doesn’t want to help patients, then she should not have become a pharmacist. Unbelievable!
I hope you make it right for the gentleman in Bedford. I will no longer shop at CVS and will transfer my scripts if not. I’m absolutely disgusted by this Cindy’s behavior. Unacceptable.
Have you ever tried to round up a bunch of feral cats ?
In efforts to get those in the chronic pain community to organize and commit to a common action.. I am not sure that rounding up feral cats wouldn’t be a lot easier.
The last Presidential election there was 126 million votes cast and five million separated the winner from the loser.. it is also stated that there was 106 million eligible voters.. that did not vote… strangely the number in the same range as the number of estimated chronic pain pts.
For over 100 years Congress has been laying the ground work for starting and escalating the war on drugs… the war on drugs has escalated to the point where it is more a war on docs and pts than the original drug cartels targets.
You can blame or exonerate the Obama administration for the acceleration of the war on docs and pts, but the facts are is that it was dramatically ramp up during the 2009-2011 time frame.
There is no reason for all chronic painers failing to vote… you can register by mail… you can vote by mail.. unless you are totally immobilized to the point that you can’t make it to the mail box.
Historically, 99% of those in Congress who runs for re-election .. get re-elected… and we have seen during this primary season just how entitled the upper level seniority members of Congress believe they are. Every time an incumbent gets re-elected.. it is a mandate that what they have been doing is what they believe they should continue doing… how is that concept working for you personally ?
How many of you have signed petition, wrote letters, emails,faxes and phone calls…and all the form letters you have received promising nothing more than to take your opinion into consideration if a vote comes up ? How is that concept working for you personally ?
First the chronic pain community needs to organize and “VOTE THE BUMS OUT”
Once they are voted out… then we start a communication campaign using the above graphics… Make it a email, a fax, a postcard, a letter.. use your own words on it… but.. basically state .. you wouldn’t listen to our needs.. so we have kicked your ass out of office..
Then once their replacement gets into office… we start a communication campaign… Get the DEA out of practicing medicine… DEFUND the DEA… ENFORCE the ADA.. we put you in office.. and in two years… if you ignore us as your predecessor did… don’t even both running a re-election campaign..
If the chronic pain community cannot accomplish this… then either there are not 106 million chronic painers or they are more like feral cats than people are tired of being treated like addicts/junkies/criminals.
For far too many years, pain researchers and clinicians have relied on the concept of the morphine equivalent daily dosage (MEDD), or some variant of it, as a means of comparing the “relative corresponding quantity” of the numerous opioid molecules that are important tools in the treatment of chronic pain. This concept dates back to the mid-1980s, first appearing in the cancer pain treatment guidelines by Portenoy and colleagues,[1] and has subsequently been used empirically and clinically for a variety of purposes.
For example, researchers have relied on non-empirically derived “equivalent dosages” as a means to facilitate research in which opioid consumption serves as a dependent variable. Clinically, opioid “conversion” tables have been routinely used when switching a patient from one opioid to another. And, most unfortunately, opioid prescribing guideline committees have relied on this concept as a means of placing (usually arbitrary) limits on the levels of opioids that a physician or other clinician should be allowed to prescribe. Although these guidelines typically bill themselves as “voluntary,” their chilling effect on prescribers and adaptation into state laws[2] makes calling them “voluntary” disingenuous.
Although some scientists and clinicians have been questioning the conceptual validity of MEDD for several years, a recent study[3] has indicated that the concept is unequivocally flawed—thereby invalidating its use empirically and as a tool in prescribing guideline development. This analysis determined that a fundamental inadequacy of the MEDD concept is the lack of a universally accepted opioid-conversion method. The authors used survey data from pharmacists, physicians, nurse practitioners, and physician assistants to estimate daily morphine equivalents and found great inconsistency in their conversions of hydrocodone, fentanyl transdermal patches, methadone, oxycodone, and hydromorphone—illustrating the potential for dramatic underdosing or, in other cases, fatal overdosing.
Regarding the use of MEDD in research, our suspicion is that many pain investigators have known about the problems with this prodigiously flawed concept for many years. For example, in a 1991 Australian review of the polymorphic metabolism of opioids,[4] the authors concluded that “Pharmacogenetics may play an important role in explaining the wide variability of the clinical response to many opioid drugs.” Yet, a quarter of a century later, MEDD remains routinely used in pain research worldwide. Given that invalid dependent variables in research result in invalid findings, our hope is that investigators will begin to conduct studies comparing morphine with morphine, hydrocodone with hydrocodone, and so on—as opposed to relying on the standard (and far more convenient) approach of MEDD
Clinically, prescribers need to use this information regarding the flawed MEDD concept to begin practicing dosage-switching and opioid rotation in a more thoughtful and scientific manner. Thus, even if the charts suggest that 1 mg of oxycodone is the “equivalent” of 1.5 mg of morphine, the practice of opioid rotation based on the concept of pharmacogentic homogeneity needs to be seriously reconsidered.
Furthermore, the evidence supporting pharmacogenomic differences among patients is mounting[5,6] and needs to be carefully weighed before labeling a patient who requires 30 mg of morphine rather than the prescriber’s “standard” of 10 mg in order to achieve adequate analgesia as an “addict.” Patients with chronic pain (particularly that of noncancer origin) who are reliant on opioid analgesia are already sufficiently stigmatized and marginalized[7] to allow this type of practice to continue to be the norm.
Although the use of MEDD in research and, to a greater extent, in practice, is probably due to unawareness of its inaccuracy, we posit that the use of MEDD by recent opioid guideline committees (eg, the Washington State Opioid Guideline Committee[8] and the Centers for Disease Control and Prevention Guideline Committee[9]) in the drafting of their guidelines is based more heavily on disregarding available evidence rather than ignorance. Furthermore, their misconduct in doing so has been more pernicious than the use of MEDD by researchers and individual clinicians, because these guidelines widely affect society as a whole as well as individual patients with persistent pain syndromes. We opine that these committees are strongly dominated by the antiopioid community, whose agenda is to essentially restrict opioid access—irrespective of the lack of data indicating that opioids cannot be a useful tool in the comprehensive treatment of carefully selected and closely monitored patients with chronic pain.
Although we emphatically agree that opioid analgesia should not be the first-line treatment for chronic noncancer pain, when other nonopioid treatments have either failed, are contraindicated medically or owing to behavioral and emotional factors, or are inaccessible because of the health insurance industry’s refusal to cover them (irrespective of their established evidence-bases), opioids should be considered. Guidelines that contain language suggesting that alternative treatments are regularly available when this is not the case are shortsighted and troubling.
Recently, we published an article in the Journal of Pain Research titled “The MEDD Myth: The Impact of Pseudoscience on Pain Research and Prescribing-Guideline Development,”[10] with Dr Jacqueline Pratt Cleary as our coauthor. This article goes into considerably more detail regarding the clinical and ethical imbroglio that we address in the current brief article, and as an open-access publication, the Journal of Pain Research encourages readers to access the full text at no cost here. We feel that the healthcare community must learn more about the need to work toward a paradigmatic revision in the consideration of opioids in research, clinical practice, and prescribing guideline development.
