Pharmacy school creates website to track overdose deaths

http://drugtopics.modernmedicine.com/drug-topics/news/pharmacy-school-creates-website-track-overdose-deaths#comment-5971

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My Life with Arachnoiditis

http://www.painnewsnetwork.org/stories/2015/3/23/my-life-with-arachnoiditis

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Last Week Tonight with John Oliver: Civil Forfeiture (HBO)

When facts are so far from the “circle of sanity” .. the comedians take it to task ?

 

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Amelia Watt: Complex Regional Pain Syndrome

http://danablog.org/2015/03/20/seeing-pain/

 

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HIV cases on the rise in Scott Co.

http://www.whas11.com/story/news/health/2015/03/10/hiv-scott-county-opana/24712561/

Scott County’s health department says all 42 people who’ve tested positive, admitted to injecting Opana into their system and sharing needles in the process. Opana is an opioid, often prescribed to cancer patients for extreme pain.

“Until now, everybody thought they could just do that at will and there was no consequence to it. Now we see so many people with HIV that never knew they had it,” Scott County Sheriff Dan McClain said

Sheriff McClain says the pain killer, often prescribed to cancer patients, us now the drug of choice, above heroin. He says 90 percent of his inmates are in jail due to drug-related crimes.

“Methamphetamine, heroin, marijuana, all those things are a lot easier for us to fight because they’re illegal drugs to start with. A prescription pill is only illegal if you don’t have a prescription,” McClain said.

So how are so many people getting the drug?

“The doctors of our county are doing a good job banding together and saying, we’re not going to prescribe these as much anymore. Our hospital has a whole policy with pain pills and not giving them out in the ER. So, that’s the question, where they’re getting them coming from,” Combs said.

With the I-65 corridor running through the county, Combs says the pills could come from anywhere.

“The only thing we can do right now is education. We need to educate. Don’t share needles,” Combs said.

For the first time, the Scott County Health Department is now hosting free HIV and STD screenings on Mondays and Thursday between 9 a.m. and 3 p.m. in Scottsburg. The tests are confidential and takes just minutes. Staff are also working to provide a screening office in Austin, where a majority of people infected with HIV live.

Combs says while HIV is on the rise, the number of people testing positive for Hepatitis C is “astronomical.” In many cases today, it’s possible those with HIV also have Hep. C and should learn how the diseases spread and how to prevent from giving them to others.

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Cytochrome P450 Testing In High-dose Opioid Patients

http://www.practicalpainmanagement.com/treatments/pharmacological/opioids/cytochrome-p450-testing-high-dose-opioid-patients

Severe, chronic pain patients who seek opioid dosages above normal standards should now be tested for genetic cytochrome P450 deficiencies.

While it is common knowledge that the cytochrome P450 (CYP450) enzyme system is critical for the metabolism of some opioids, genotype testing of pain patients for CYP450 polymorphism has not been generally recommended.^1,2 This situation, however, may change as pain specialists begin to recognize that patients who require high doses of opioids may have a genetic defect that may affect their ability to metabolize these agents.

In the past, genotyping for CYP450 polymorphisms was not cost effective or convenient. However, testing technology, commercial availability, third-party reimbursement, and most of all, clinical understanding, have recently coalesced to make CYP450 genetic testing an essential component of high-dose opioid therapy. It is my recommendation, therefore, that patients who require more than 150 mg per day of morphine equivalents be tested for three specific CYP defects—2D6, 2C9, and 2C19.

To study the validity of genotype testing, I prospectively studied 66 patients on high-dose opioids in my pain clinic. The study found that the vast majority of these patients had CYP450 defects.

What Is CYP450?
Although the name cytochrome P450 is somewhat unfortunate—perhaps a better name would have been “drug metabolizing enzyme system”—the enzyme derives its name from the heme pigment (deep red color), which absorbs light at a characteristic wavelength of 450 nanometers. CYP450 enzymes are primarily found in the liver, but can exist in the intestine, lungs, brain, and kidney. The CYP450 system consists of 481 separate genes that code for 74 unique families. A family name is denoted by an Arabic number, the subfamily by a Roman uppercase letter, and the individual enzymes by another Arabic number following the letter indicating the subfamily (ie, CYP-2D6).^3-5

Why Is CYP450 Important?
There are a number of opioids that are affected by CYP450 (Table 1).^6-20 Those that are metabolized via CYP enzymes include codeine, hydrocodone, oxycodone, tramadol (Ultram), fentanyl, and methadone. Some of these opioids are metabolized to metabolites for analgesic effectiveness and for elimination from the body to prevent a toxic build-up of opioids. Those opioids that are unaffected or mildly affected by CYP450 include morphine, hydromorphone, oxymorphone (Opana), and tapentadol (Nucynta).^6-19 Three opioids—hydromorphone, oxymorphone, and tapentadol—primarily use the alternate system, glucuronidation, for metabolism, so they may be used as therapeutic alternatives for clinical trials in patients who have defective CYP450 metabolism.^1,20

Patients vary in their CYP enzyme expression and function, which leads to distinct phenotypes. Genetic CYP testing has a terminology that may be unfamiliar to some medical practitioners.⁴ Laboratory results will list patient results as extensive metabolizer (EM; normal enzyme), rapid or ultrarapid metabolizer (UM; overactive enzyme), intermediate metabolizer (IM; underactive), or poor metabolizer (PM; inactive or minimally active). The latter two, IM and PM, mean the enzyme has decreased function (Table 2).²¹

It is also important to point out that most opioids will act without biotransformation at the opioid receptor, and provide pain relief without being metabolized by the CYP or glucuronidation system. However, some opioids are robustly metabolized in first-pass effect. This explains the increasing utilization of sublingual, buccal, patch, subcutaneous and intravenous injection, and intrathecal routes for opioid administration, since these non-oral routes allow either greater opioid effect or reach the central nervous system (CNS) prior to entering the liver.

Who Should Be Screened?
No published guidelines yet exist for generalized testing of the CYP system outside of certain populations (specific cancers, patients requiring anticoagulation, and human immunodeficiency virus patients). A major reason to perform CYP450 genetic testing is to identify pain patients who legitimately require a high-dose, or unusual, opioid regimen.^2,22 This includes patients who continually complain of inadequate pain relief despite standard opioid dosages, identify drugs that are more effective, or describe medicines that do not work well. Patients with a daily morphine equivalent dosage requirement of more than 150 mg per day should be tested to help validate that a high opioid dosage is needed. Caution must be exercised, however. All too often, these patients may be erroneously labeled as drug seekers or addicts. Before these labels are applied to a patient in pain, CYP450 testing should be considered.

Another reason to consider testing is the risk of drug–drug interactions (DDIs). A significant number of drugs may inhibit or enhance (induce) the activity of certain agents, thereby increasing or reducing clinical effects of drugs. Most DDIs involving opioid medications involve CYP450 inhibitors, which cause an increased level of opioids in the system—thus, placing a patient at risk of sedation, respiratory depression, and possible toxic effect.^1,10,13

CYP450 testing also may guide the practitioner in the selection of opioids that are compatible with a patient’s genetic status. For example, a patient with a CYP-2D6 defect may not respond well to codeine, which is considered a prodrug with the active metabolite morphine. Therefore, the efficacy and safety of codeine as an analgesic are governed by CYP-2D6 polymorphisms. Codeine has little therapeutic effect in patients who are CYP-2D6 PMs, whereas the risk of morphine toxicity following codeine administration is higher in UMs.²³

Since the CYP450 system is primarily liver-based, routes that avoid oral administration and first-pass liver metabolism may be an option in certain populations. This is particularly true in patients who demonstrate multiple CYP defects. Non-oral routes include sublingual, buccal, suppository, injection, topical (patches), and intrathecal.

Three CYPs to Test
Of all the enzymes in the CYP family, researchers have identified three that account for a significant amount of opioid metabolism and may currently be tested—2D6, 2C9, and 2C19 (Table 3).^1,3,12 These three enzymes have been intensively studied and there are now data detailing their interactions with numerous drugs.^1,4 Laboratory testing technology is reliable for these three enzymes, and third-party carriers, including Medicare, are now paying for these tests. Biologic samples for analysis can be taken from saliva, blood, or a buccal swab.

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Understanding the physiological effects of unrelieved pain

http://www.nursingtimes.net/nursing-practice/clinical-zones/pain-management/understanding-the-physiological-effects-of-unrelieved-pain/205262.article

A noxious stimulus or pain is a stressor that can threaten homeostasis (a steady physiological state). The adaptive response to such a stress involves physiological changes that, in the initial stages, are useful and are also potentially life-saving.

Peripheral adaptation involves moving energy substrates from storage sites to the bloodstream to overcome the stressor. It also includes an analgesic response, a reflex escape response and a variety of other physiological changes mediated by the sympathetic nervous system (Johnson et al, 1992). However, if the stress response is allowed to continue, a variety of harmful effects may ensue that involve multiple systems of the body and are potentially life-threatening.

Transmission of pain

The initial physiological changes that take place within the body after a painful episode are concerned with the transmission of pain. The four basic principles that are involved are:

– Transduction: this process involves changing a noxious stimulus in the sensory nerve endings into a nerve impulse. Nociceptors (primary afferent neurones) are nerve endings with the capacity to distinguish between noxious and innocuous stimuli. When they are exposed to noxious stimuli, a number of substances, including prostaglandins, bradykinin, serotonin, substance P and histamine, are released that facilitate the movement of the pain impulse from the periphery to the spinal cord;

– Transmission: the movement of impulses from the site of transduction to the brain. Transmission occurs in three stages: from the nociceptor fibres to the spinal cord, from the spinal cord to the brain stem and thalamus, and finally from the thalamus to the cortex. For the pain stimulus to be changed to an impulse and move from the periphery to the spinal cord, an action potential must be created; that is, the movement of sodium and potassium ions from the extracellular fluid to the intracellular fluid, and vice versa. Transmission occurs in C fibres and A delta fibres and neurotransmitters are needed at each synapse to continue the pain impulse across the synaptic cleft;

– Perception: the process involved in recognising, defining and responding to pain. It is a result of neural activity and is where pain becomes a conscious experience. Perception takes place predominantly in the cortex, but the limbic system and reticular systems are also involved;

– Modulation: this involves the activation of descending pathways that exert inhibitory effects on pain transmission. Descending fibres release substances such as endogenous opioids, serotonin, noradrenaline, gamma-aminobutyric acid, and neurotensin that have the capacity to inhibit the transmission of noxious stimuli and produce analgesia (McCaffery and Pasero, 1999).

Analgesic response

The stress response includes the production of naturally occurring endogenous opioids, which are also known as encephalins and endorphins. They are found throughout the central nervous system and bind to opioid receptor sites. These substances prevent the release of neurotransmitters such as substance P and, therefore, inhibit the transmission of pain impulses, bringing about an analgesic effect. Unfortunately endogenous opioids degrade too quickly to be considered as useful analgesics (McCaffery and Pasero, 1999).

Reflex escape response

Activation of the sympathetic nervous system during an episode of acute pain is known as the ‘fight or flight’ response. The physiological responses that take place via the sympathetic nervous system and the neuro-endocrine system are numerous and intrinsically linked.

Sympathetic nervous system

The sympathetic nervous system consists of a double chain of ganglia in front of the vertebral column in the cervical, thoracic and lumbar regions, giving rise to nerves supplying the internal organs. This system is involved in the immediate bodily response to emergencies, such as severe, acute pain.

Although the initial effects of the sympathetic nervous system allow survival of an individual, prolonged activation can be detrimental (Marieb, 2000).

The sympathetic nervous system is particularly concerned with the regulation of vascular tone, blood flow and blood pressure because sympathetic nerves have a stimulating effect on the heart to improve circulation. It also has a stimulating effect on the respiratory system by causing dilation of the bronchioles to increase oxygen intake (Ganong, 1995).

The sympathetic nervous system has an inhibiting effect on digestion by reducing or preventing the secretion of digestive enzymes throughout the alimentary canal and inhibiting peristaltic action in the gut wall. It achieves all of these physiological responses via the endocrine system and an increase in hormone production (Ganong, 1995).

Neuroendocrine system

The endocrine system comprises the pancreas; thalamus; hypothalamus; kidneys; pituitary, thyroid, parathyroid, pineal and adrenal glands; and the ovaries and testes. Its principal function is to maintain internal homeostasis despite changes in the environment.

The endocrine and nervous systems work in conjunction with each other to achieve this metabolic regulation (Vander et al, 1994). Multiple hormones cooperate to bring about appropriate biochemical and physiological responses to noxious stimuli such as pain.

These stimuli activate a coordinated neuroendocrine stress response by increasing levels of certain hormones, including adrenocorticotrophic hormone (ACTH), catcholamines, antidiuretic hormone (ADH), angiotensin and glucagon. The hormones are secreted directly from the endocrine organs into the bloodstream (Fig 1).

Corticotrophin-releasing hormone

Corticotrophin-releasing hormone (CRH) is released, as a result of stimulation by noradrenaline, and transported to the anterior pituitary gland where it activates the sympathetic nervous system and stimulates ACTH biosynthesis. CRH increases blood pressure and heart rate and also produces behavioural responses to stress. Cardiovascular responses are also controlled by CRH signals (Marieb, 2000).

ACTH

The release of CRH from the hypothalamus into the systemic circulatory system stimulates the secretion of ACTH in the anterior pituitary gland. Increased levels of ACTH activate the sympathetic nervous system. However, the main function of CRH is to regulate the endocrine activity of the cortex portion of the adrenal gland so as to stimulate cortisol production and increase the levels of circulating glucocorticoids (Johnson et al, 1992).

Cortisol

Cortisol is the principal glucocorticoid that promotes normal cell metabolism. It is produced and released by the adrenal cortex in response to rising blood levels of ACTH. An increased plasma concentration of adrenal corticosteroids is the major regulator of an adaptive response to stress that, in the short term, is beneficial.

However, in the long term it is disruptive and harmful. It has a widespread effect on most organs and is particularly involved in the coordination of the actions of catecholamines.

Cortisol also has the function of maintaining blood glucose levels and energy metabolism during periods of stress. It suppresses the inflammatory response by inhibiting prostaglandin activity and has an adverse effect on the immune system. Glucocorticoids are also thought to prevent other stress-induced changes from becoming excessive (Marieb, 2000).

Adrenaline and noradrenaline

These are both catecholamines released from the adrenal medulla when it is stimulated by the sympathetic nervous system during the stress response. The adrenal medulla is not essential for life but contributes to the stress situation by secreting catecholamines, which act directly on blood vessels, causing vasoconstriction. Blood pressure then rises to allow better perfusion of vital organs, and cardiac output also increases. In addition, adrenaline and noradrenaline dilate the small passageways of the lungs to increase oxygenation (Vander et al, 1994).

Adrenaline has an effect on metabolism and has a role in the inhibition of insulin release. It also causes an increased glycogenolysis in the liver (Thomas, 1998). Finally, heightened emotional awareness occurs with increased adrenaline levels.

Glucagon

Glucagon is a polypeptide produced by the pancreatic islets in the upper gastrointestinal tract. The stress response causes glucagon levels to increase, so elevating the metabolic rate and lowering insulin levels. The result is hyperglycaemia and impaired glucose tolerance, together with carbohydrate, protein and fat destruction (Park et al, 2002). An increase in glucagon and catecholamines stimulates glycogenolysis and the release of glucose from the liver into the circulation for immediate use by critical organs, such as the brain.

Vasopressin or ADH

This hormone is released from the posterior pituitary gland. Its function is to excrete water via the kidneys. During the stress response it causes sodium and water to be retained by the renal tubules and stored in the extracellular fluid (Thomas, 1998). It also has a role in controlling blood pressure.

Renin and angiotensin II

Renin is an acid protease enzyme secreted by the kidneys into the bloodstream. Its major function is the stimulation and release of aldosterone from the adrenal gland, promoting sodium re-absorption by the kidney. Renin secretion is increased by sympathetic activity and is mediated by increased circulating catecholamines (Fig 2). Renin is also involved in the conversion of enzymes to form angiotensin II, which causes generalised arteriole constriction resulting in hypertension.

Growth hormone

Growth hormone is secreted by the anterior pituitary gland and has a direct action on cellular activity and the metabolism of protein, carbohydrate and fat. Increased protein breakdown leads to a negative nitrogen balance, resulting in reduced wound healing (Marieb, 2000).

Interleukin 1

Following tissue damage, interleukin 1 (IL-1) is released from the hypothalamus and its effects are widespread, including activation of the inflammatory effects of the immune system. IL-1 interacts with the hypothalamic pituitary adrenal axis at two levels. First, it acts in the hypothalamus to induce the production of corticotrophin-releasing factor, which mediates ACTH release. Second, IL-1 acts directly with the adrenal cortex. Both of these events lead to the release of anti-inflammatory glucocorticoids such as cortisol (Vander et al, 1994).

Effects of physiological changes

The physiological changes described above have an impact on the cardiovascular, gastrointestinal, respiratory, genitourinary, musculoskeletal and immune systems. Increased heart and breathing rates facilitate the increasing demands of oxygen and other nutrients to vital organs (O’Hara, 1996). The physiological changes that take place can also induce vomiting and potentially can pre-empt chronic pain conditions. Psychological and cognitive adverse effects are also relatively common.

Cardiovascular system

The cardiovascular system responds to the stress of unrelieved pain by increasing sympathetic nervous system activity which, in turn, increases heart rate, blood pressure and peripheral vascular resistance. As the workload and stress of the heart increase, owing to hypertension and tachycardia, the oxygen consumption of the myocardium also increases. When oxygen consumption is greater than oxygen supply, myocardial ischaemia and, potentially, myocardial infarction, occur. The myocardial oxygen supply may be further compromised by the presence of any pre-existing cardiac or respiratory disease or by hypoxaemia due to impaired respiratory function (Macintyre and Ready, 2001).

Hypercoagulation occurs when there is a reduction in fibrinolysis together with an increased cardiac rate, workload and blood pressure. This activity increases the risk of deep vein thrombosis (DVT) and pulmonary embolism (Wood, 2003).

Gastrointestinal system

Increased sympathetic nervous system activity can lead to temporarily impaired gastrointestinal function. This can include delays in gastric emptying and reduced bowel motility with the potential for the development of paralytic ileus (Macintyre and Ready, 2001).

Respiratory system

Unrelieved pain can result in a patient limiting the movement of the thoracic and abdominal muscles in a bid to reduce pain. This may cause some degree of respiratory dysfunction with secretions and sputum being retained because of a reluctance to cough. Atelectasis and pneumonia may follow (Macintyre and Ready, 2001). This pulmonary dysfunction, caused by painful excursion of the diaphragmatic muscles of the chest wall, is also associated with a reduction in vital lung capacity, increased inspiratory and expiratory pressures and reduced alveolar ventilation. The resulting hypoxia can cause cardiac complications, disorientation and confusion and delayed wound healing (Wood, 2003).

Genitourinary system

Unrelieved pain can increase the release of hormones and enzymes, such as catecholamines, aldosterone, ADH, cortisol, angiotensin II and prostaglandins, which help to regulate urinary output, fluid and electrolyte balance as well as blood volume and pressure (McCaffery and Pasero, 1999). This causes retention of sodium and water, resulting in urinary retention. Increased excretion of potassium causes hypokalaemia (Park et al, 2002). A decrease in extracellular fluid occurs as fluid moves to intracellular compartments, causing fluid overload, increased cardiac workload and hypertension (McCaffery and Pasero, 1999).

Musculoskeletal system

Involuntary responses to noxious stimuli can cause reflex muscle spasm at the site of tissue damage (McCaffery and Pasero, 1999). Impaired muscle function and muscle fatigue can also lead to immobility, causing venous stasis, increased blood coagulability and, therefore, an increased risk of developing DVT (Park et al, 2002).

Pain can limit thoracic and abdominal muscle movement in an attempt to reduce muscle pain, a phenomenon known as ‘splinting’. The lack of respiratory muscle excursion can potentially lead to reduced respiratory function (McCaffery and Pasero, 1999).

Immune system

Depression of the immune system can be caused by unrelieved pain. This may predispose the patient to wound infection, chest infection, pneumonia and, ultimately, sepsis (Wood, 2003).

Psychological and cognitive effects

Anxiety and pain are positively correlated (Johnson et al, 1992). Individuals who express unusually high levels of anxiety also tend to have a higher than expected incidence of early noxious stress. The acute stress-induced hormonal changes that have been described in this article closely resemble the symptom complex of anxiety and depression and, finally, hypercortisolism, which is a consistent feature of anxiety physiology (Johnson et al, 1992). Therefore, the stressor effects of unrelieved pain have the potential to increase anxiety levels further and interfere with activities of daily living, such as diet, exercise, work or leisure activities and to interrupt normal sleep patterns causing varying degrees of insomnia (Macintyre and Ready, 2001).

Unrelieved pain can also result in an individual experiencing distressing cognitive impairment, such as disorientation, mental confusion and a reduced ability to concentrate (Wood, 2003).

Nausea and vomiting

When pain receptors in the central nervous system are stimulated, the true vomit centre in the brain is activated, causing vomiting to occur. Disturbance of the gastrointestinal tract can activate the release of the neurotransmitter 5-hydroxytryptamine (5-HT3), which can also initiate vomiting. Initially, 5HT3 travels via the circulatory system to the chemoreceptor trigger zone in the brainstem and on to the true vomit centre, again initiating vomiting (Jolley, 2001).

Chronic pain

Poorly controlled acute pain can lead to debilitating chronic pain syndromes. Appropriate aggressive acute pain management is essential to prevent this from occurring (McCaffery and Pasero, 1999).

Conclusion

Unrelieved pain has serious side-effects, therefore the containment of such a stressor is vital. The chronic activation of the catabolic process of the stress response can ultimately cause multiple system dysfunction (Johnson et al, 1992).

Good acute pain management, including an expert knowledge of analgesic drugs and an understanding of the physiological effects of pain, is an essential element of holistic nursing care.

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After Target wage hike, labor groups turn to drugstore chains

http://www.globalpost.com/dispatch/news/thomson-reuters/150320/after-target-wage-hike-labor-groups-turn-drugstore-chains

Major drug chains are already cutting staffing in the Rx dept… even with Rx volume is increasing… med errors are increasing dramatically… 90% + of the Rxs are billed to PBM’s  (Express Scripts..etc..etc..) who controls what reimbursements are.  Guess what is going to happen when they are forced to pay higher wages to technicians ? Most likely, they will cut man hours in the pharmacy even further and med errors will increase that much more.. 

CHICAGO (Reuters) – Some labor groups looking to broaden their push for minimum wage hikes after success at big U.S. retailers including Target Corp, are preparing to take on drugstore chains.

A source this week said Target will raise its minimum wage to $9 per hour in April, matching moves by rivals Wal-Mart Stores Inc and TJX Cos .

The retailers, which were targeted by labor advocates and their allies, are also facing tougher competition for employees as unemployment drops to its lowest level in more than six years.

Labor activists said the wage hikes by big retailers will give them greater leverage with drugstore operators, who make up one of the fastest-growing and most profitable areas in retail.

The United Food and Commercial Workers International (UFCW), a union which played a key role in pressuring Wal-Mart, said it will accelerate its efforts to organize Walgreens Boots Alliance Inc workers to demand better pay.

Walgreens is the top U.S. drug retailer, followed by CVS Health Corp and Rite Aid Corp .

“Given the current momentum, we expect a faster chance of success in hiking minimum wage within the retail space which includes drug chains, than say the fast food sector,” said Marc Goumbri, a spokesman for the UFCW.

Another labor group, The New York-New Jersey Joint Board of Workers United, an affiliate of the Service Employees International Union (SEIU), is planning to start wage negotiations this summer with the management of Duane Reade, a local subsidiary of Walgreens.

“What jumps out at me is that drugstores are not only reporting strong profits but expanding at a rapid pace and making multi-billion dollar acquisitions,” said the group’s President Julie Kelly.

“That puts them in a position to lead here and raise the wages they pay,” said Kelly. The recent moves by large retailers raises the chances of success, she added.

Kelly said her union has not decided on wage demands, although it broadly supports the $15 an hour “living wage” backed by labor groups nationwide.

Twelve percent of Walgreens employees earn less than $9 an hour, with a typical cashier earning about $8.60 per hour, compared to $8.70 per hour at CVS Health Corp, according to compensation analytics firm Payscale.com, which usually collects pay data from a sample of a company’s employees.

Walgreens spokesman Michael Polzin said the company meets or exceeds all wage ordinances and its pay scale varies as it seeks to remain competitive in local markets. He declined to comment on the prospect of wage hikes or the number of employees who earn less than $9.

Payscale data showed 10 percent of CVS employees’ hourly earnings and 16 percent of Rite Aid Corp workers’ are below $9.

CVS declined comment while Rite Aid did not respond to requests seeking comment.

A BETTER SHOT AT SUCCESS

Drugstores are a good target in part because of relatively high employee retention rates, which make organizing easier than in other sectors, including fast food, analysts say. Annual worker turnover at fast food chains is as high as 50-100 percent in some areas, they said. Some analysts last year put the turnover at drugstore chains as low as 11 percent.

With drugstores moving into 24 hour operations and employees demanding better benefits, the opportunity to organize the workforce has improved, said Burt Flickinger, managing director of retail consultancy Strategic Resource Group and a lecturer at Cornell University.

Flickinger said even regional drugstore operators like Fred’s Pharmacy, part of discount retailer Fred’s Inc , New York- and Vermont-based chain Kinney Drugs could see their workers organize and press for higher wages. Another target could be Florida-based Navarro Discount Pharmacies Inc, which was acquired by CVS last year, he said.

The companies did not respond to requests seeking comment.

“It will take 6-8 months for the results to start coming in,” he said. “But drugstores most certainly appear to be the ones next in line for a wage hike.”

(Reporting by Nandita Bose in Chicago, editing by Peter Henderson and Christian Plumb)

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March 20, 2015

Honorable Senator Jon Tester, DC Office
Honorable Senator Steve Daines, DC Office
Honorable Representative Ryan Zinke, DC Office
Honorable Governor Steve Bullock, Helena Capitol

Montana Board of Medical Examiners
301 South Park
Helena, MT 59602

Dear Honorable Senators Jon Tester, Steve Daines and Rep. Ryan Zinke, Honorable Governor Bullock; Respected Montana Board Members,
We are writing this letter on behalf of Dr. Mark Ibsen of Helena and patients suffering various acute and chronic pain conditions throughout Montana. We believe regulators are targeting the wrong physician (Ibsen). We want to bring you the harmed patient perspective as the model for treating chronic and intractable pain is FAILING THE CONSUMER and we desperately need your help.
We fear that you may not be aware of what is happening on the front lines. Unfortunately, the Montana State Medical Board is indirectly forcing consumers into the hands of interventional pain management, which we believe is a significant factor behind patient harm and need for opioid consumption. We will try to explain why.
First, back pain is a leading cause of disability and epidural steroid injections (ESIs) are pushed on back pain patients ESPECIALLY IN MONTANA. There is NO steroid approved by the FDA for epidural use and the most commonly used drug, Pfizer’s Depo-medrol, is now banned for epidural use in Australia and New Zealand: http://www.medsafe.govt.nz/profs/datasheet/d/Depomedrolinj.pdf
Kenalog, another commonly used drug, has a “Not For” (epidural use) on the datasheet.
There are 100 million Americans who suffer chronic pain, which meets the definition of a pandemic. Approximately 9 million injections are given annually in the U.S. (FDA Hearing, Nov. 24, 2014). At best, epidural steroid injections provide temporary relief. At worst, they cause a lifetime of pain and suffering and need for opioid therapy. Arachnoiditis is clearly listed on drug datasheets as a potential complication. Imagine what this costs insurance companies and federal /state disability retirement funds for temporary benefit (on the front end) plus permanent disabilities (on the back end).
We testified on the dangers of corticosteroids used to treat back pain at FDA headquarters in Silver Spring MD on Nov. 24, 2014. The Missoulian and Ravalli Republic reported our stories:
http://missoulian.com/lifestyles/hometowns/ravalli-county-residents-take-epidural-warning-to-fda/article_b45c9d85-c265-5f16-a6b2-31adeb21f053.html
The true risk of exposure is not thoroughly explained to patients. Terri presented a brief overview of risk, but it was difficult to present a comprehensive risk assessment at the FDA hearing as speakers were limited to 5 minutes: http://www.arachnoiditiscanada.com/fda-hearing-november-24.html
Rates of dural puncture vary depending on technique, experience, prior surgery, etc.
Gary testified about the abuse that he sustained as physicians in Missoula did not diagnose his intractable pain condition, arachnoiditis, caused by misplaced steroids in his spine. After he was harmed, his physician wanted to send him for MORE epidural steroid injections! Prior to medical injury, he was in excellent health and rarely took an aspirin for pain. Now he suffers intractable pain and cannot achieve adequate pain control in Montana because of the current attitudes towards prescribing.
Recent actions of federal agencies (DEA and FDA) are resulting in a shortage of opioids for legitimate pain patients; patients are denied access to pain control then coerced to undergo dangerous spinal procedures. Spinal surgeons in Missoula are pushing injections as a pre-requisite for spinal surgery. Epstein MD observed alarming rates of punctate CSF fistulas during lumbar surgery for stenosis/instability (18.2%) in her recent commentary on unnecessary ESIs (Surg Neurol Int. 2014).
Many other complications were discussed at the FDA hearing, including interarterial injection, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, and stroke. These serious complications are not being tracked: http://www.propublica.org/article/were-still-not-tracking-patient-harm
Second, patients are not informed about the true risk of many complications, and bodies are piling up in social media forums. One Arachnoiditis support group is now approaching 1000 members. Patients are typically given the run-around and labeled as drug addicts after they are harmed by physicians. Most arachnoiditis sufferers have to leave the State of Montana in order to achieve an accurate diagnosis. We are aware of other undiagnosed cases in Montana. Thanks to social media forums, patients are now training themselves to read their own MRIs (swollen or clumped nerve roots and scar tissue in the spinal cord on MRI axial images).
To add insult to injury, patients are misdiagnosed with Failed Back Surgery “Syndrome”, Post-Laminectomy “Syndrome”, and Fibromyalgia (to name a few) when in fact they suffer arachnoiditis.
We would be willing to assist with an educational awareness campaign as there is a serious problem with misdiagnosing in Montana. The most insidious problem associated with adhesive arachnoiditis is obstruction and alteration of cerebrospinal fluid flow because of SCAR TISSUE in the intrathecal space and the resulting “centralization” of pain, which most interventional pain doctors do not understand. It is critical that physicians learn how to differentiate central pain from peripheral extremity pain.
Dr. Forest Tennant provides guidance as uncontrolled pain can lead to serious health problems including cardiac arrest and stroke: http://www.thblack.com/links/RSD/Tennant-PainSigns-6p.pdf
Third, suicide is a problem for untreated chronic pain patients in Montana. Arachnoiditis survivors suffer suicide-level pain, and many take their lives to escape it. Our fellow arachnoiditis sufferer committed suicide after he could no longer endure the pain, following a brutal medical “assault” during which his pain physician injected several simultaneous steroid injections. His sister testified at the FDA hearing about the loss of her brother, and his tortuous life following the injections up until his death.
We lost yet another arachnoiditis friend to suicide as he suffered intractable pain, bowel and sexual dysfunction: http://www.thenationaltriallawyers.org/2014/03/2-88m-med-mal-man-suicide-pain/
We watch in horror as patients are coerced to undergo epidural steroid injections (over prescribing) because regulatory agencies are not addressing the underlying problems — driven by profit motives to do procedures, combined with the war on opioids. Unfortunately, the Montana Board’s attitudes towards opioids are now (indirectly) resulting in more patient harm. Patients are left with interventional pain practices, primarily ESIs and spinal implants. Patients are also coerced to undergo invasive “diagnostic” steroid injections prior to spinal surgery.
We suggest you take the time to watch videos produced by harmed patients as many rely on
high powered opiates to function. Their stories are all too familiar to us — denial of harm — then difficulty achieving an honest diagnosis:
https://www.youtube.com/watch?v=Of06usrj-tA
http://artforarachnoiditis.org/category/creative-non-fiction/survivors-stories/
http://www.cklaurence.com/epidurals.html
Some physicians in Missoula deny that Arachnoiditis even exists. We find this ironic now that the federal government (FDA) and Pfizer acknowledge it. It is grossly misdiagnosed in Montana. Patients who suffer are subjected to more abuse and denial of appropriate medications to treat pain. Clinical descriptions and case reports were presented in Practical Pain Management and Neurology Now:
http://www.practicalpainmanagement.com/pain/spine/arachnoiditis-part-1-clinical-description
http://www.practicalpainmanagement.com/pain/spine/arachnoiditis-part-2-case-reports
http://journals.lww.com/neurologynow/Fulltext/2014/10050/Agony_and_Arachnoiditis__Named_after_its.12.aspx
Montana is ground zero on this national debate. Many pain patients are misdiagnosed then accused of being addicts. The shortage of opioids – and the targeting of physicians who prescribe – is resulting in a national and state health care crisis, and Montana is in the midst of this national debate. Addicts will always find an available drug, but legitimate pain patients are thrown under the bus and left to suffer:
http://nationalpainreport.com/montana-becomes-ground-zero-in-the-opioid-debate-8825459.html
http://nationalpainreport.com/a-new-approach-to-prescribing-narcotics-8825780.html
Our request to the Montana Board of Medical Examiners
First, we ask that you dismiss any negative action(s) against Dr. Mark Ibsen because he is not the source of the problem in Montana. We think you need to be aware that Dr. Ibsen is not our physician, but it is a small world now, thanks to social media. Chronic pain patients are all in this together.
Second, we ask the Montana Board of Medical Examiners to investigate the alarming trend to coerce pain patients to undergo invasive procedures before physicians will prescribe medications. Interventional pain physicians are harming patients then abandoning them when they do not submit to more profitable invasive spinal procedures. We previously brought this to the attention of the Board as it is a serious public health issue.
Physicians must provide true informed consent to their patients. This includes sharing details regarding the April 2013 FDA warning: http://www.fda.gov/Drugs/DrugSafety/ucm394280.htm . It is also important that patients understand that all steroids are being used “off-label” when administered by the epidural route. After all, we have all been warned about the addictive nature of opioids.
It is critical that patients understand the potential risk of arachnoiditis (listed on Depo-medrol and Kenalog datasheets) before they submit to an ESI. If the Board had taken this action years ago, things would have turned out differently for us. Arachnoiditis is the suicide disease that often results in patients considering their exit as they lose everything to hellish pain; especially in the current climate as many no longer have access to appropriate doses of opioids necessary to control pain.
We are grateful to Dr. Ibsen for bringing this problem (access to pain control) from out behind the White Wall of Silence. We fear that if you sanction Dr. Ibsen, then more pain patients will either be abandoned or forced into harmful procedures. We have a front line perspective and hope you will listen to Montana patients as you address the source of the Big Pain problems in the Big Sky country.

Sincerely,
/s/ Terri Anderson
Terri Anderson
Injured Worker and Patient Advocate
Arachnoiditis Society for Awareness and Prevention A.S.A.P.
Hamilton, Montana

/s/Gary Snook
Gary Snook
Arachnoiditis Survivor and Patient Advocate
Arachnoiditis Society for Awareness and Prevention A.S.A.P.
Lolo, Montana

/s/ Terry Conyers
Terry Conyers
Arachnoiditis Survivor (Undiagnosed)
Hamilton, Montana

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Indiana has been using NPLEx for several years… and AG Zoeller implemented a website www.Bitterpill.IN.gov in Aug 2013.  Which is going to educate people on  how bad abusing drugs are… Apparently… not working all that well ?

Indiana Crowned Meth Capital of United States

http://www.tristatehomepage.com/story/d/story/indiana-crowned-meth-capital-of-united-states/31429/AU9QTgZ3UU6-SYJSwmx3-A

 Law enforcement has a mixed reaction to the numbers because Indiana seized more meth labs than any other state. Which means meth suppression tactics are working, but it could also mean the amount of meth labs are growing.
 
Here are the top five states for meth lab busts in 2013. Illinois with 673, Ohio with 1,010, Missouri, which held the crown last year, with 1,496, Tennessee with 1,616, and Indiana with the most meth lab busts in 2013 at 1,808.
   
Indiana State Police says the meth problem is growing across the state. “Last year was the first year that we had a meth lab seized in every county except one,” said Sgt. Niki Crawford with ISP Meth Suppression. The jewel in the meth crown, the county with the most meth lab busts is Vanderburgh County with 115 last year. “What that shows is the law enforcement efforts in Indiana particularly in Vanderburgh County and Evansville is ramped up. We’ve identified this is a problem in our community for over a decade now and as the years have gone by we have done more and more to address that problem,” said Sgt. Jason Cullum of the Evansville Police Department.

Law enforcement officers say there are several ways to counter the meth problem and it will take all hand on deck to overcome the widespread addiction. “It’s not always taking people the jail. That’s the easy part. The difficult part is getting buy-in from the community,” Sgt. Crawford.
In recent years state legislation has passed bills curbing the amount of the meth making drug pseudoephedrine can be purchased. Law enforcement is asking for tighter restrictions, but ultimately it’s up to the voters. “If the citizens aren’t communicating to their legislators what they want for their communities then the legislators don’t know what their constituents want,” said Sgt. Crawford. In the 2014 Indiana General Assembly several bills were introduced to further restrict the sale of pseudoephedrine, however none of them made it to the Governor Pence’s desk.

If you find a meth lab call 911 immediately. This enables an immediate response to a very dangerous situation. If you want to report suspicious activity in reference to methamphetamine production please call the Evansville Police Department Methamphetamine Suppression Unit at 812-436-7918

Here is a link to the ISP Meth Suppression page http://www.in.gov/meth/

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