Your suffering/pain management – or lack of pain management – during your hospitalization should not be a measurement of patient satisfaction about their care in the hospital ?

March 28, 2016
The Honorable Sylvia Mathews Burwell
Secretary, Department of Health & Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Dear Madam Secretary:
Prescription drug abuse has reached epidemic proportions with devastating
effects on families across America. In many states, it has also fostered a heroin
crisis, overwhelming our communities and families with often tragic
consequences. Recently, the Centers for Disease Control and Prevention (CDC)
announced that deaths from opioid pain relievers as a result of misuse and abuse
have soared over the last fifteen years.1 Moreover, the CDC reports that
healthcare providers wrote 259 million prescriptions for painkillers in 2012,
enough for every American adult to have a bottle of pills.2 It is alarming that
Americans consume opioids at a greater rate than any other nation, including
twice as many opioids per capita as Canada.3 The seemingly unending supply of
prescription opioids is subject to misuse and diversion, which has become one of
the foremost public health challenges facing our nation.
Of the over 136 million patient visits annually to the nation’s emergency
departments, 42% of these visits are related to painful conditions. While
emergency physicians write a considerable number of prescriptions for opioids,
we account for less than 5% of all opioid prescriptions in the US. In addition,
most are immediate release, the quantity in each prescription is generally
quite low, and refills are rare.
We also act as a bridge in the primary care system on nights, weekends, holidays,
and other times when a primary care provider is not available. We are often the
only access that patients have. Pain treatment centers regularly refer patients to
the emergency department if the patient has not followed the agreed upon
treatment plan and, as emergency physicians we must, by the EMTALA law,
evaluate every patient who presents to our departments.
1 CDC Newsroom Archives. “Drug overdose deaths hit record numbers in 2014,” December 18,
2015. Accessed from http://www.cdc.gov/media/releases/2015/p1218-drug-overdose.html.
2 “Opioid Painkiller Prescribing.” CDC Vital Signs. Accessed from
http://www.cdc.gov/vitalsigns/opioid-prescribing/.
3 Paulozzi, Leondard. “Vital Signs: Variation Among States in Prescribing of Opioid Pain
Relievers and Benzodiazepines – United States, 2012,” Morbidity and Mortality Weekly Report
2012. Accessed from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6326a2.htm.
In spite of the multiple efforts the Federal government (CDC’s revised guidelines, FDA’s Risk Evaluation and Mitigation Strategy, ONDCP educational sessions, CMS, etc.) has undertaken to tackle this crisis, we must point to a glaring issue that has worked at cross purposes not only for hospitals but soon for emergency physicians. Patient experience/satisfaction surveys are important, particularly regarding issues of treating patients with dignity and respect, but questions about pain have resulted in unintended consequences and the pursuit of high patient-satisfaction scores may actually lead health professionals and institutions to practice bad medicine by honoring patient requests for unnecessary and even harmful treatments.
On the hospital side, CMS operates the Hospital Value-Based Purchasing Program which includes a survey (HCAHPS) where discharged patients respond to questions including, “During this hospital stay, how often was your pain well-controlled?” and “During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?” Less than satisfactory patient perception scores will contribute to CMS reducing hospital DRG payments starting in 2016.
Similar questions are included in third draft version of the CMS’ Emergency Department Patient Experience of Care. (EDPEC Survey 3.0) which the pilot test administered between 2-42 days after patients were treated and released. After ACEP submitted written comments to the first two versions, providing CMS with specific wording to change the pain questions, the third version now asks “during this ED visit did you have any pain, did the doctors and nurses try to help reduce your pain, and did you get medicine for pain?”
Any questions which provide an opportunity for patients to express dissatisfaction because they didn’t get the drugs they sought, provide disincentives for physicians to prescribe non-opioid analgesics which will negatively affect their scores. This has been an issue for years with private surveys such as Press Ganey4. And, it is certainly not addressing important aspects of the opioid crisis that the government is expending tremendous resources to combat.
As DHHS continues to refine measures to reward quality care in the Medicare program, it is critical to correctly measure the quality being rewarded. Currently, there is no objective diagnostic method that can validate or quantify pain. Development of such a measure would surely be a worthwhile endeavor. In the meantime, we are concerned that the current evaluation system may inappropriately penalize hospitals and physicians who, in the exercise of medical judgment, opt to limit opioid pain relievers to certain patients and instead reward those who prescribe opioids more frequently.
4 Gunderman, Richard. “When Physicians’ Careers Suffer Because They Refuse to Prescribe Narcotics,” The Atlantic 2014, http://www.theatlantic.com/health/archive/2013/10/when-physicians-careers-suffer-because-they-refuse-to-prescribe-narcotics/280995/
We urge the Department to undertake a robust examination of whether there is a
connection between these measurements and potentially inappropriate prescribing patterns, and, until that is completed, we urge you to remove pain questions from the various CAHPS surveys. We appreciate your prompt consideration of this request, and will work with you at any time to address these serious public health challenges.
Sincerely,
Jay A. Kaplan, MD, FACEP
President

Filed under: General Problems | Leave a Comment »

Thousands of drug users are rescuing one another with antidote naloxone

https://www.washingtonpost.com/national/health-science/thousands-of-drug-users-are-saving-each-other-with-antidote-naloxone/2015/11/22/d1f2e408-87df-11e5-be39-0034bb576eee_story.html?tid=a_inl

BALTIMORE — Deep into a three-day heroin binge at a local hotel, Samantha told the newbie he was shooting too much. He wasn’t accustomed to heroin, she said, and hadn’t waited long enough since his last injection.

“But he didn’t listen,” she said. Sure enough, he emerged from a visit to the bathroom, eyes glazed, and collapsed from an overdose.

Samantha, who declined to give her last name to avoid trouble with her bosses at a nearby strip club, said she grabbed her naloxone, the fast-acting antidote to opioid overdoses. She was too panicked to place the atomizer on the end of the syringe, but her boyfriend wasn’t. He sprayed the mist into the nose of the unconscious drug user, who awoke minutes later.

“I always have it because I’m scared to death,” said Samantha, who said she has been shooting heroin for 22 years. “I don’t want to be helpless.”

As the opioid epidemic has exploded in small towns and suburbs in recent years, officials have scrambled to put naloxone in the hands of drug users’ families and friends, and to make it more widely available by equipping police officers with the drug.

At the same time, thousands of lives are being saved by giving the antidote to drug users. More than 80 percent of overdose victims revived by “laypeople” were rescued by other users, most of them in the past few years, according to one national survey published in June.

Baltimore has trained 12,000 people on the streets to use naloxone in the past 11 years, 2,150 of them this year alone. “If someone is using a drug that could kill them, they should also have the antidote available,” said Leana Wen, the city’s health commissioner. Chicago, New York and San Francisco also hand out thousands of doses to drug users at little or no cost.

But the rising number of rescues also highlights the shortcomings of what is, at best, a stopgap effort. With treatment for addiction available to a small portion of the people who need it, many people who survive overdoses return to drug use. Some first responders express frustration at reviving the same people again and again without hope of permanent change.

In Charleston, W.Va., where President Obama spoke about the opioid crisis last month and rescue personnel have carried naloxone for decades, Fire Capt. Mark Strickland said he has revived one 34-year-old man six times and other drug users three and four times each.

“I can’t just take everybody to the hospital,” Strickland said. “ . . . There has to be a ‘What next?’ ”

The drug’s cost also is beginning to influence anti-heroin strategy. The price of a nasally administered dose of naloxone — often known by its brand name, Narcan — has quadrupled in two years or less in many places, to nearly $50. Federal, state and local officials are pressing for discounts from Amphastar Pharmaceuticals, the only supplier of that form of the drug.

New York and Ohio have succeeded. In San Francisco, the major nonprofit distribution program for drug users has begun using cheaper injectable naloxone instead.

“No company should jeopardize the progress being made in tackling this emergency by overcharging for a critically important drug like naloxone,” Rep. Elijah E. Cummings (D-Md.) and Sen. Bernie Sanders (Vt.) said in a July letter to groups that represent U.S. mayors and counties.

Amphastar officials did not return e-mails and telephone calls seeking comment on the price increases.

[When life begins in rehab]

Deaths from heroin overdoses quadrupled to 8,260 between 2000 and 2013, according to the federal government, as did deaths from prescription opioids, which reached 16,235.

The number of people revived by naloxone is difficult to determine, but the Harm Reduction Coalition, a training and advocacy group, published a survey in June showing that 26,463 people had been revived by “laypersons” between 1996 and the first half of 2014. Nearly 83 percent of those rescues were made by other drug users.

More than 8,000 people were revived in 2013 alone, according to the coalition’s data, which covers only half of the organizations that distribute naloxone. Almost 38,000 kits were handed out to laypeople that year. These rescue efforts overwhelmingly involve people who have taken heroin, not prescription drugs.

“Drug users are the primary witnesses to drug overdoses,” said Eliza Wheeler, program manager for the coalition’s drug overdose prevention and education effort in San Francisco, who compiled the report. “This was about putting the effective tool into people’s hands.”

Baltimore started handing out naloxone in 2004, mostly through its needle-exchange program, eight years after the approach was pioneered in Chicago. Baltimore now makes it available to all residents via a prescription signed by Wen, the health commissioner, who is a former emergency room doctor. Drugstores sell it for a dollar to anyone on Medicaid. The city also trains soon-to-be-released jail inmates and others on the use of naloxone.

The only requirement for carrying it is a five-minute training course, like the one Samantha took recently in the back of the city’s needle-exchange van, parked by a seedy row of strip clubs, porn shops and food outlets known as “The Block.” A steady stream of drug users stepped into the small recreational vehicle to trade used needles for new ones, pick up condoms and register for a card that prevents police from arresting them for carrying drug paraphernalia.

Samantha was there for more naloxone. On this night, the city was handing out kits donated by the company Kaleo that sell for $575 apiece. About the size of a pack of cigarettes, the recently approved device contains two doses administered through an auto-injector, with audio instructions on how to use it.

Health educator Nathan Fields ran through the signs of an opioid overdose: slowed or nonexistent breathing; blue lips, skin and nails for whites or a grayish pallor for African Americans.

Anthony Williams was first in line that night, although he said he doesn’t use heroin. “I’m an alcoholic. I drink,” he said. But he lives in an abandoned building with several heroin users, he explained, including one who is going through a rough time.

“When you’re in a space, living with people [who] any moment they can go overdose and die, this is a very life-sustaining issue,” Williams said.

People revived by naloxone can flail or vomit when they awake, Fields warned Williams, and they will plunge immediately into the painful symptoms of withdrawal.

“That person will usually jump up, and the first thing he’ll say is what?” Fields asked.

“You f—ed up my high!” Williams responded, and they both smiled.

Naloxone hydrochloride, approved by the Food and Drug Administration in 1971, has long been carried by rescue personnel and used in emergency rooms. It works only on opioid overdoses, reversing them by blocking the receptors in the brain where opiates attach. Overdose victims usually resume breathing and awaken within minutes.

Baltimore officials long ago rejected the notion that widespread distribution of naloxone encourages drug use by prompting recklessness among drug abusers. And they are not troubled about helping “frequent fliers,” because research and experience show that relapses are common, even with treatment.

“You want to keep the person alive,” said Derrick Hunt, director of the city’s Community Risk Reduction program, “until they make better choices.”

Filed under: General Problems | 1 Comment »

Pain Patients Fed Up with Poor Treatment in Hospitals

http://www.painnewsnetwork.org/stories/2016/3/26/pain-patients-fed-up-with-hospital-treatment

“For a pain patient to go to a hospital for pain care and still have their pain unaddressed, under-treated, or misunderstood is clear evidence that we need better education for hospital staff.”

The lack of pain education in medical schools is not new. A 2012 study published in the Journal of Pain  called pain education “lackluster” in the U.S. and Canada. The study of 117 medical schools found that less than 4% required a course in pain education and many did not have any pain courses.

Filed under: General Problems | 1 Comment »

Nurses, other health providers not immune

http://www.bostonherald.com/news/local_coverage/2016/04/nurses_other_health_providers_not_immune

Have you every notice that everyone fighting the war on drugs … they always talk about educating people as to the dangers of using/abusing various substances including Alcohol, Tobacco, Opiates.  One one think that there would not be a group more educated about the dangers of using/abusing these substances that healthcare professional… Physicians, Pharmacists, Dentists, Nursing ..etc…etc…  yet, in this one state of Massachusetts there are dozens of healthcare professionals  every year admitted to a substance abuse recovery program.  Does this suggest that education cannot overcome a person with an addictive personality disorder ?

Filed under: General Problems | Leave a Comment »

How A Painkiller Designed To Deter Abuse Helped Spark An HIV Outbreak

http://www.npr.org/sections/health-shots/2016/04/01/472538272/how-a-painkiller-designed-to-deter-abuse-helped-spark-an-hiv-outbreak

When Kevin Polly first started abusing Opana ER, a potent prescription opioid painkiller, he took pills — or fractions of pills — and crushed them into a fine powder, then snorted it.

When Opana pills are swallowed, they release their painkilling ingredient over 12 hours. If the pills were crushed and snorted, though, the drug was released in a single dose.

“Just think about it,” Polly says, “12 hours of medicine, and, ‘BAM!’ you’re getting it all at once.”

But the drug’s manufacturer, Endo Pharmaceuticals, reformulated Opana in 2012. The new pills featured a coating that was intended to make them more difficult to abuse by crushing them into powder or dissolving them.

Polly discovered he could no longer snort the medicine in the pill, to which he had become addicted. But he and other Opana users soon found a way to remove the drug’s hard coating and receive Opana’s powerful dose all at once: injection.

Polly says he used to inject Opana as many as five times a day. He often shared needles with other people.

He says he never anticipated what would happen next. In early 2015, Polly tested positive for HIV. “It was devastating news,” he says.

Kevin Polly is among the 190 people in Indiana’s Scott County who have tested positive for HIV since early 2015, in the largest HIV outbreak in Indiana history.

The Change To Opana That Was Intended To Prevent Abuse

For its part, Endo has said that its decision to reformulate Opana was a well-intended attempt to prevent abuse. As the company told the Food and Drug Administration in 2012, Endo reformulated the drug “to provide a crush-resistant product, equally as effective as Opana ER, which would discourage abuse, misuse and diversion.” Endo declined repeated requests from NPR for an interview.

According to study data, as well as interviews with Indiana residents addicted to Opana, the reformulation effectively deterred many people from snorting the drug. But the change also led a significant number of people to abuse the drug by injection. When needles are shared, the injection route can transmit HIV, hepatitis C or other infections.

And interviews with experts, court filings, documents from the FDA, as well as Endo’s own statements, suggest the company’s decision to reformulate Opana was also motivated in large part by financial interests.

Public health experts say “abuse deterrent” drugs may serve a role in reducing what the Centers for Disease Control and Prevention calls a national epidemic of prescription opioid abuse. The FDA and members of Congress have also supported their development. But the experience with Opana’s reformulation may serve as a cautionary tale for the potential effects of “abuse deterrent” drugs.

Experiences In Austin, Ind.

While NPR’s Kelly McEvers and I were reporting in Austin, Ind., people who abused Opana and were familiar with changes to the drug’s formula told us similar stories.

“The pharmaceutical company, they changed it so you can’t crush them and snort them,” said Devin, a 26-year old. “Whenever they done that, that’s when everybody started shooting them.”

Jeff, a veteran of the Army National Guard, said he became addicted to Opana after being prescribed opioid painkillers for a back injury he sustained in Iraq.

At some point, Jeff said, he began crushing and snorting pills. Then, he said, the company “reformulated them, and the only way you could do them is to inject them.”

Joy, a former registered nurse who got addicted to opioids after a back injury, said that she initially stopped using Opana after the reformulation. But that didn’t last long. “Some genius figured out, ‘Hey we can cook this down and turn [it] into a liquid and shoot it up,’ ” Joy said. “And then it took off like wildfire after that.”

(NPR is withholding Devin’s, Jeff’s and Joy’s last names to protect their privacy.)

Because of the coating added to Opana, the process of preparing it for injection does take a little work. But in the end, it’s not that difficult.

My colleague Kelly watched people prepare Opana for injection, using just the bottom of a soda can, a small lighter, a cigarette filter and tap water.

Behind The Reformulation, Public Health And Business Considerations

So why did Endo Pharmaceuticals reformulate the drug in the first place?

Volunteers search for used needles near Rural Street in Austin, Ind. Scott County, in southeastern Indiana, experienced the worst outbreak of HIV in the state’s history after people began injecting the prescription painkiller Opana.

Seth Herald/NurPhoto/Corbis

The answer involves both public health concerns and business considerations.

Endo Pharmaceuticals released Opana in 2006. Taken orally, Opana is about twice as powerful as OxyContin, and the company says it is “indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment.”

Soon afterward, though, communities around the country began reporting abuse of Opana and even overdose deaths.

Endo said those concerns over public health and abuse were key motivations to reformulate the drug. Opana also was a major moneymaker for the company.

In 2011, for example, Opana generated $384 million in net sales for Endo, accounting for 14 percent of the company’s total revenue that year.

But the company also faced the threat of generic competition.

So Endo developed a strategy that would block its competitors and maintain Opana’s share of the market.

The company reformulated the drug, this time with features designed to prevent abuse, a move that could potentially protect Endo at a time it faced the loss of patent protection.

The FDA approved Endo’s reformulated Opana, and in 2012 the company began replacing the old versions of Opana on pharmacy shelves.

In August of that year, Endo took another step. The company filed a petition with the FDA, arguing that it had removed the old, crushable version of Opana from the market “for reasons of safety or effectiveness.” It also asked the agency to “refuse to approve” and “suspend and withdraw the approval” of generic, noncrush-resistant versions of Opana.

If the FDA agreed with Endo, the agency would effectively eliminate the company’s generic competition.

“We see this again and again in the pharmaceutical industry,” says Dr. Anna Lembke, an assistant professor of psychiatry at Stanford University Medical Center. “They come up with some new fancy formulation of basically the same old drug … and then that way they have a new drug that they can charge a lot of money for.”

Filed under: General Problems | 4 Comments »

Filed under: General Problems | Leave a Comment »

Woman’s Body Sat In Car Parked At Walmart For 3… by GeoBeats

Filed under: General Problems | 3 Comments »

After 7th Death, DEA Takes Over Search For Fentanyl Pills In Sacramento

http://sacramento.cbslocal.com/2016/03/31/after-7th-death-dea-takes-over-search-for-fentanyl-pills-in-sacramento/

SACRAMENTO (CBS13) — The Drug Enforcement Administration is taking over an investigation into how fentanyl ended up in drugs in the Sacramento area after a seventh person is believed to have been killed by the drug.

The family of Jerome Butler says he was taken off life support on Wednesday afternoon, just three days after his mother said he took a pill for chronic stomach pain he didn’t know had been laced with Fentanyl.

The drug is also believed to be responsible for 21 other hospitalizations.

CBS13 has learned recession budget cuts claimed narcotics teams in the Sacramento area who would track down drugs like Fentanyl.

Assemblyman Jim Cooper was once an undercover cop who busted drug dealers daily. He established Sacramento County’s first street narcotics team in 1988.

“It was turn and burn; you go out arrest someone, and get the next one,” he said.

His unit was dedicated to finding the guys dealing prescription pills like the ones now being blamed for multiple deaths in Sacramento County.
“It’s unfortunate, because those folks—the actual dealers selling out there right now—they’re out there unimpeded. They could do whatever they want,” he said.

The recession claimed the sheriff’s department’s team in 2008, while the Sacramento Police Department got rid of theirs in 2011. Neither has been restored.

Both agencies declined on-camera interviews, but defend their current operations. They say high-level drug task forces now pick up the slack.

“There’s lots of task forces in Sacramento, but they work on high-level drug dealers, but the street teams, they go out every night for that purpose, arresting drug dealers,” Cooper said.

He hopes the pill problem could be solved with a bill that would make locking pill bottles available to people with prescriptions, making it harder for addicts to steal the drugs.

For now, he hopes to see street teams back on the street deterring drug dealers and their deadly combinations.

“Otherwise you’re going to see more deaths with this,” he said

Filed under: General Problems | 4 Comments »

Extended-Release Naltrexone to Prevent Opioid Relapse in Criminal Justice Offenders

http://www.nejm.org/doi/full/10.1056/NEJMoa1505409#t=abstract

Read the Full Article…

Filed under: General Problems | 1 Comment »

‘Ahead of the curve’: Summit shows WV’s progress on drugs

http://www.herald-dispatch.com/news/ahead-of-the-curve-summit-shows-wv-s-progress-on/article_fc4301e0-89af-51dc-be12-9a1b173ff34e.html

Naloxone can be compared to finding someone starving to death.. you give them a meal/drink and hope that they stop starving.. Apparently WV… just revives people who overdose and puts them back into the environment from which they came and hope that they “get their act together”…  Is it that they just keep count of how many doses of Naloxone they have administered and that is really all that really matters.. the NUMBERS ?

Filed under: General Problems | 1 Comment »