Avoid opioid use in surgery to reduce postop pain


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Science for years has confirmed that opioids trigger inflammation and that creates pain. Trauma and surgery also create inflammation that leads to pain. How logical is it then to continue use of sufentanil for anesthesia when it is the most highly potent opioid 500 to 1,000 times stronger than morphine. Where is the logic in creating pain by using sufentanil as the anesthetic? A new one on the market will be 10,000 times stronger than morphine. Inflammation is not always easy to reset after you strafe the innate immune system with an opioid.

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Why is ketamine not used more often for surgical anesthesia when we know ketamine profoundly lowers the inflammatory response thus reducing pain more than ever. Studies for years have shown that even a small dose of ketamine reduces postop pain. This is not new.

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A study needs to be done comparing patients who receive no opioids. At least this study showed that when fewer opioids are used, pain scores are 37% lower than if more had been given. Patients given higher doses of opioid, had higher analgesic requirements postop. That increases the risk of persistent chronic pain and the tragic risk of addiction.

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Opioids inflict known lasting harm, pain and suffering, perhaps disability and addiction.

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Reduced opioid use in surgery linked to improved pain scores
Written by Brian Zimmerman

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After anesthesiologists at the University of Virginia Health System in Charlottesville began administering fewer opioids to patients during surgeries, patients’ self-reported pain levels dropped, according to a study led by three UVA anesthesiologists.
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For the study, the team examined 101,484 surgeries that took place in the UVA Health System from March 2011 to November 2015. During this time period, the amount of opioids administered via general anesthesia at the system was reduced by 37 percent.
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For the same time period, self-assessed patient pain scores recorded in post-op recovery units dropped from an average of 5.5 on a 10-point scale to an average of 3.8, marking a 31 percent improvement.

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One of the study’s leaders, UVA anesthesiologist Marcel Durieux, MD, PhD, said the impetus behind the pain score improvements is likely attributable to several factors. One, previous research has indicated opioids can ultimately make people more sensitive to pain. And two, the increased use of non-opioid painkillers like lidocaine and acetaminophen during surgeries at UVA was likely effective.

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….”There is very clear evidence that people can become opioid-dependent because of the drugs they get during and after surgery,” said Dr. Durieux. “I think that by substantially limiting opioids during surgery, we’ve made an important step in addressing that problem.”

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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.

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It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

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Opioids: a think tank to expose the deep-rooted failures and injustices in our health care system


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STAT is “a new national publication focused on finding and telling compelling stories about health, medicine, and scientific discovery” in partnership with the Lown Institute.

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“The Lown Institute is a think tank dedicated to research and public communication to expose the deep-rooted failures and injustices in our health care system, and to helping clinicians, patients, and communities develop a shared vision for a better health system.”

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.“Since 2012, the Lown Institute has been a leading voice in the movement to recognize the harms of overuse of medical care, and in pointing out the clear connection between wasteful medical treatment and our system’s failure to deliver needed care.”

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This article from STAT, excerpted below, beautifully and painfully describes the opposing sides of the deep divide in our country about treatment with opioid analgesics for chronic pain. It is a divide deeper than the growing upheaval of politics in America, and it is unique to us. The United States, with 5% of the world’s population, consumes 80% of the global opioid supply, and an estimated 99% of hydrocodone. “Pain drugs are the second-largest pharmaceutical class globally, after cancer medicines.”

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I have seen both sides, those who cannot live or function without opioids and those whose pain improves radically once they taper off. The war on patients plays out many times daily, while patients and doctors alike are deeply concerned at the lack of research in this volatile unpredictable field, where patients are subjected to whack-a-dose prescriptions since the March 2016 CDC fiat that dictated slashed opioid dosages, a dictate that now entitles insurers to deny all medication overnight —saving them tremendous costs. All denied, no matter how small the dose, nor how intense the diagnoses and pain.

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This irrational, inhumane, and unpredictable disease of change has become a constant, destroying lives of patients and caregivers while addicts continue to overdose evermore and prisons are filled with low level street corner dealers —never the rich who buy their way out of prison. Cheating is a way of life for corporations, condoned by congress.

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A ‘civil war’ over painkillers rips apart the medical community — and leaves patients in fear

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PALO ALTO, Calif. — For Thomas P. Yacoe, the word is “terrifying.”

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Leah Hemberry describes it as “constant fear.”

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For Michael Tausig Jr., the terror is “beyond description.”

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All three are patients struggling with chronic pain, but what they are describing is not physical agony but a war inside the medical community that is threatening their access to painkillers — and, by extension, their work, their relationships, and their sanity.

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Two years after the United States saw a record 27,000 deaths involving prescription opioid medications and heroin, doctors and regulators are sharply restricting access to drugs like Oxycontin and Vicodin. But as the pendulum swings in the other direction, many patients who genuinely need drugs to manage their pain say they are being left behind.

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Doctors can’t agree on how to help them.

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There’s a civil war in the pain community [my emphasis],” said Dr. Daniel B. Carr, president of the American Academy of Pain Medicine. “One group believes the primary goal of pain treatment is curtailing opioid prescribing. The other group looks at the disability, the human suffering, the expense of chronic pain.”

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Pain specialists say there is little civil about this war.

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“There’s almost a McCarthyism on this, that’s silencing so many people who are simply scared,” said Dr. Sean Mackey, who oversees Stanford University’s pain management program.

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“The thing is, we all want black and white. We don’t do well with nuance. And this is an incredibly nuanced issue.”

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Stanford’s Mackey said those risks are important to recognize. But, he said, nearly 15,000 people die a year from anti-inflammatory medications like ibuprofen. “People aren’t talking about that,” he said….

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…Dr. Anna Lembke, who practices alongside Mackey at Stanford’s pain clinic and is chief of the Stanford Addiction Medicine Dual Diagnosis Clinic, published a book about the opioid crisis last year. It was titled: “Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop.

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Lembke believes that long-term opioid use can cause patients to perceive pain even after the original cause of pain has cleared. Some patients, she said, find themselves free of pain only once they have endured the often agonizing effects of opioid withdrawal.

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“That’s what we’re seeing again and again,” she said.

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…. a single father of two teens, said that every month he needs to fill a prescription, he’s fearful it will be denied.

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Mackey says doctors being trained at Stanford’s pain center have grown increasingly fearful about prescribing opioids...

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[Dr. Mackey describes a practicing 81 year old physician who cycled to work until recent back surgery. His life is now complicated by severe back pain and he requires opioids to continue to function.]

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“If you’re 81 and you stop getting out of bed, it’s a slippery slope,” he said.

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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.

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It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

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If you wish an appointment, please telephone the office to schedule.

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Heroin Addiction absent or rare in UK prescribing


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Diamorphine (heroin) is prescribed for pain in the UK . Yesterday’s LA Times Op-Ed

What’s really causing the prescription drug crisis?

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Studies show addiction to opioids of any kind, even heroin, is rare in the UK. Not what we see in the US. They have more socialized care for housing, medical care, medications including for the jobless. They do not have the hopelessness that leads to desperation and addiction. Desperation is why all patients with chronic pain must work with a psychologist. Pain is not in your head, but desperation is, and a psychologist can help you learn tools to deal with desperation. If you don’t, pain will go up, up, up and that’s what’s in your head. Unless you use those tools, I promise you will suffer because it will get worse and worse and worse.

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“Doctors in many parts of the world — including Canada and some European countries — prescribe more powerful opiates than their peers in the United States. In England, if, say, you get hit by a car, you may be given diamorphine (the medical name for heroin) to manage your pain. Some people take it for long periods. If what we’ve been told is right, they should become addicted in huge numbers.

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But this doesn’t occur. The Canadian physician Gabor Maté argues in his book “In the Realm of Hungry Ghosts” that studies examining the medicinal use of narcotics for pain relief find no significant risk of addiction. I’ve talked with doctors in Canada and Europe about this very issue. They say it’s vanishingly rare for a patient given diamorphine or a comparably strong painkiller in a hospital setting to develop an addiction.

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Given that really powerful opiates do not appear to systematically cause addiction when administered by doctors, we should doubt that milder ones do. In fact only 1 in 130 prescriptions for an opiate such as Oxycontin or Percocet in the United States results in addiction, according to the National Survey on Drug Use and Heath.

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So what’s really happening? The second, clashing story goes, again, crudely, like this: Opiate use is climbing because people feel more distressed and disconnected, and are turning to anesthetics to cope with their psychological pain.

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Addiction rates are not spread evenly across the United States, as you would expect if chemical hooks were the primary cause. On the contrary, addiction is soaring in areas such as the Rust Belt, the South Bronx and the forgotten towns of New England, where people there say they are lonelier and more insecure than they have been in living memory.”

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Healthcare costs in the US are a very serious problem. Opioids require monthly visits. Patients on opioids are forced to see a pain specialist, many for decades when pain is chronic. That’s bad enough, but the cost of opioid medications are outrageous. I know some whose opioids cost $17,000 per month or more. And some doctors in my area have mandated urine drug tests every single month, $750 per test, to prove you are not taking street drugs. High risk patients and nonaddicts alike, every month, just to pee in a cup and get your prescription opioid. 

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Now congress is getting rid of the ACA, to make it better. I can only imagine how helpful they have been. Privatize social security, privatize medicare, privatize everything. Of course that will be better for them. Will it help anyone else? 

 

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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.

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It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

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This site is not for email and not for appointments.

If you wish an appointment, please telephone the office to schedule.

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Opioid Production in US Cut 25% by DEA in 2017


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The DEA regulates how much opioid is allowed to be made each year. Production will be cut by 25% in 2017. Some will be cut by more than 25%, for example hydrocodone will be cut 34%.

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The reasons given are that demand is falling and the opioid epidemic is not. Congress of course could think about funding addiction treatment and offering clean injection sites for addicts such as Vancouver’s.

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The order will be published tomorrow in the Federal Register.

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In June 2016, Senator Richard Durbin interrogated Chuck Rosenberg, acting administrator of the Drug Enforcement Administration (DEA), during a Senate Judiciary Hearing.

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Durbin has introduced legislation to fight opioid abuse. One section of the bill would require DEA to consider opioid addiction when setting production quotas. If annual quotas increase, DEA would be required to justify that in writing, explaining why the bump outweighs the risk of having more addictive drugs available.

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Opioid death stats demonstrate the ravages of the epidemic.
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About 47,000 people died from overdoses in 2014, Rosenberg said. That’s 129 every day. About 61 percent were due to prescription opioid and heroin.

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The material on this site is for informational purposes only, and is not a substitute for medical advice,

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Opioid Overdoses ~130 every day, the capacity of a Boeing 737 – naloxone $4,500, up from $690 in 2014. You pay


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LA Times reports

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As need grows for painkiller overdose treatment, companies raise prices

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$4,500

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$4,500.

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$4,500 for naloxone manufactured by Kaleo, Richmond Virginia. Naloxone reverses opioid overdose.

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That seems to be their Evzio two-pack, two single-use injectors of naloxone in a hard case handy to carry in a pocket for someone who has an opioid overdose.

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Each has a 0.4 mg injection that last 2 or 3 minutes each, just long enough to call an ambulance.

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A drug that costs pennies, sold as a 2-pack for $690 in 2014, then $900, now $4,500 as of Feb. 1.

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“…Columbus, Ohio, said the city’s firefighters last year used 2,250 naloxone doses, or about 6 doses a day — at a cost of $147,000. Recently, Columbus also stocked the drug in 115 police cruisers….”

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FDA approved Evzio in April 2014 after granting fast-track status. Fast track now means gold mine status. 

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Naloxone was first approved in 1971.

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“In July 2005 its average wholesale price for a vial of the injectible drug was $1.10, according to Truven Health Analytics.

By 2014, the price was almost $19 a vial.” 

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Medical costs are astronomical, insurance premiums are up, insurance deductibles are $5,000 to $10,000 for many. Police, fire department and EMT’s are using naltrexone to save lives and lower ER visits.

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Taxes are high. Where is the initiative and innovation among EMT’s, police, fire? How many hours per day do they get paid full salary to work out at the gym and stay fit while they sit and wait for the next call to rescue an addict who overdosed. Then retire on double pensions if they hold two city jobs. While they wait for next calls, could they not fill syringes from a vial of naloxone? How much do taxpayers pay for these overpriced robotic filled syringes at factories.

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Pharma is raking it in. Pharma’s blood sucking 1% are overdosing on costs. Many of my patients with intractable pain who are on opioids were not able to afford $690. They are not addicts but any dose of opioid can kill. Your tax dollar pays for naloxone for addicts found dead, unresponsive.

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We are all paying a fortune for inexcusable pharma costs. Costs for millions of drug addicts all over the country. Costs for prescription medications. Congress unwilling to address anything that would cut the flow of donations to their coffers from pharma.

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Just remember, in Israel, it is illegal for corporate lobbyists to contact any politician.

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“Late last year, Adapt introduced a naloxone nasal spray named Narcan for a average wholesale price of $150 for two units, according to Truven.”

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That is a BD syringe fitted with a flared BD adapter at the tip to fit the nostril. It requires the user be capable of pushing the 1 mL syringe so the liquid is sprayed into nostril.

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For Pete’s sake. I’ve been prescribing medicine in these BD syringes with nasal adapter for years. Is there no EMT smart enough to make and stock their own supply to use for emergencies?

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“…as the demand for naloxone has risen — overdose deaths now total 130 every day, or roughly the capacity of a Boeing 737 — the drug’s price has soared.
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…Increased access to naloxone is among the measures included in federal legislation that Congress passed last week in response to the painkiller deaths. The White House has said that President Obama plans to sign the bill.
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Last month, U.S. Sens. Susan Collins (R-Maine.) and Claire McCaskill (D-Mo.) wrote to Kaleo, Rancho Cucamonga’s Amphastar Pharmaceuticals and three other drug makers, asking why they had hiked prices for naloxone during a public health crisis.
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“At the same time this epidemic is killing tens of thousands of Americans a year,” said McCaskill, “we’re seeing the price of naloxone go up by 1,000% or more.

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 …Mylan, which sells a vial [how many doses per vial?] for an average wholesale price of $23.70, according to Truven and Adapt Pharma of Dublin, Ireland.”

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Oxycontin Investigation – A Pulitzer for LA Times?


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A TIMES INVESTIGATION

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Inside an L.A. OxyContin ring that pushed more than 1 million pills. What the drugmaker knew

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By HARRIET RYAN, LISA GIRION AND SCOTT GLOVER

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JULY 10, 2016

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This LA Times investigative report by Ryan, Girion and Glover is now a contender for Pulitzer Award. They expose years of passively tracking extreme volume sales by leaders at the top of Purdue Pharma, the maker of OxyContin. While they racked up billions in sales, they tracked the surge in prescriptions from pill clinics in LA to gangs trafficking in Washington State for sale on the street. 80 mg tablets, deaths, crime, gangs, heroin – waves of heroin related crime and overdoses in cities all over the world.

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Purdue could track suspicious high volume sales of their pill:

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Until a decade ago, Purdue, like most drug manufacturers, didn’t monitor pharmacies for criminal activity. The DEA has held wholesalers, not drugmakers, responsible for identifying and reporting suspicious orders from their customer pharmacies.

In 2007, the DEA pressured drug manufacturers to do more to stem the prescription drug crisis and warned that it would be looking at every step in the supply chain. In response, Purdue decided to gather detailed information about pharmacies, Crowley said.

The company approached wholesalers and struck agreements allowing the company access to their sales reports. With the new data, the security team in Stamford could see all wholesalers’ OxyContin sales to individual pharmacies, down to the pill.

“I can look at something and say, ‘Geez, that stinks’ without me even visiting the place,” Crowley recalled.

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……What Purdue knew

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More than 194,000 people have died since 1999 from overdoses involving opioid painkillers, including OxyContin. Nearly 4,000 people start abusing those drugs every day, according to government statistics. The prescription drug epidemic is fueling a heroin crisis, shattering communities and taxing law enforcement officers who say they would benefit from having information such as that collected by Purdue.

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A private, family-owned corporation, Purdue has earned more than $31 billion from OxyContin, the nation’s bestselling painkiller.

 

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In 2015, the Week published:

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How the American opiate epidemic was started by one pharmaceutical company

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From Pacific Standard

Mike Mariani

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OxyContin’s ball-of-lightning emergence in the health care marketplace was close to unprecedented for a new painkiller in an age where synthetic opiates like Vicodin, Percocet, and Fentanyl had already been competing for decades in doctors’ offices and pharmacies for their piece of the market share of pain-relieving drugs.

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These reports must demand a Congressional investigation into Oxycontin (before and after the 2010 abuse deterrent version) and all potentially addicting drugs currently on the market, not just pain killers.

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Congress needs to address pharma’s drug trafficking, data collection, and,duty to report.

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Pharma needs to be tracking distribution not just for sales and profit, but for common sense to interrupt drug trafficking. Obviously there is no law.  Profit always wins.

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Business ethics is not good enough to justify the explosion of opioid abuse that stems from years of Oxycontin pills. Profiteering at the cost of deaths and drug abuse. Vote with your stock holdings.

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Cannabis for pain and symptom relief

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Congress has lost the average person’s respect for scheduling cannabis as Schedule 1. It is an essential medication that has been used medically, safely for thousands of years. Patients are arriving in office with the discovery that CBD, simply CBD, works for their intractable pain. That’s not exactly correct, but there is a topical cannabis mixture that can relieve malignant pain – I mean disabling, not cancer.

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Reschedule cannabis as Schedule 3 immediately. It needs to be legalized, studied and taught. When MD’s are not taught about the cardiovascular potential with THC and when patients arrive in the ER without knowing what was in the marijuana they used, our hands are tied.

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Congress owes a release to the millions jailed simply for felony cannabis possession.

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Cannabis  “to date has been responsible for the arrest of about 20 million US citizens,” written in 2010 by Emeritus Professor of Psychiatry Lester Grinspoon.

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Opioids: Will We Let Politicians Treat Pain? Need Presidential Debates on Precedent


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Pain kills

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Cutting back my patient’s opioids when they were helping, when there is no better alternative, none better –  it is the most painful thing I’ve ever been asked to do as a doctor. Withdraw necessary medicine. On orders from the federal government forcing me to harm my patient.

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Harm my patient. The thought sickens. Forced by government orders to harm my patient.

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Orders. Cold as a steel gun held by DEA Swat team bursting into my office if I don’t act on government orders. Certain dictatorships treat citizens that way.

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Congress is pushing this opioid bust very hard.

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That is demagoguery

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I am pained and suspicious in several ways.

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Legal nationwide precedent.

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A precedent in government, deciding for each individual person, without good faith history and examination of each, now orders each person’s medical treatment.

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It overrides judgement. I feel my judgement specializing for decades in pain management, with or without use of opioids, using comprehensive multi-specialty approaches has always chosen excellence in the field of pain management, in accord with State and Federal guidelines until this new one, and within the best practices of the American Pain Society.

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Best practices are irrelevant. Choke on that one. The lack of options is impossible to swallow. It is life-changing for the most severely disabled patients across the country.

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It has nothing to do with the subject: pain control.

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Nothing to do with helping to relieve pain.

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It causes grave harm to my patients and their families and sets an astonishing precedent among healthcare insurers to never allow more than the guidelines; the federal CDC-invented, arbitrary, pseudoscience, one-size-fits-all guideline for opioids because:

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the government can’t deal appropriately with the heroin epidemic and the war on drugs. They ignore results from countries that have done more enlightened research to point the way.

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Demogogues order doctors how to treat everyone. This country is has done what China and Russia have done to their citizens. I am in shock. My patients are in shock. Aghast. Feeling forced to bend over and swallow an undemocratic, unscientific piece of

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This used to be a free country with certain rational sets of behavior and one that recognized a need for pain specialists. Only recently did it create specialists in pain management. Specialists who get ignored. Does this happen in every other field? Shouldn’t we all care no matter our expertise because we may all have bad pain if we live long enough? Chronic noncancer pain. What if some federal agency starts ordering you that dialysis will be allowed less often?

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None of us gets away from the grip of the irreligious opioid guidelines. Will we have intractable pain at some time in our lives? Will we allow government to dictate that you or your spouse or gram cannot be given the dose that has safely helped for years? The guidelines were forced on us.

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Insurance will not pay for more.

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This needs to be discussed as a presidential election debate issue.

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Demagogues appear at times of unrest across the country. Politicians may feel forced to bow to the anti-opioid groups, angry because of the heroin epidemic and at how badly addiction treatment is neglected in this country.

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But for pain patients not addicts, to be subjected to directives from federal agencies, CDC and DEA, how do we object to this unscientific, irrational precedent? At least debate it on a presidential level.

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Drug abuse, addiction, pain management and healthcare insurance as it pertains to these new federal opioid guidelines presume to treat pain but force us all into a cage of irrational pseudoscientific dictates. And we are forced to mangle the finely adjusted treatment of your pain, your spouse or your granny’s pain. We’ve slogged through so much to get there. It’s tough to find the right balance with chronic daily pain.

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Those running for president:

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What is the candidate’s position on this unprecedented fiat that dictates your maximum morphine equivalent daily dose (MEDD) you can receive?  It is a dose that is far less than you’ve been on for years that had been helping.

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Is this creating unprecedented pain among 50 million Americans with chronic pain?

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Are we going to let politicians treat our patients with pain?

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This site is not email. Not intended for medical advice.

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This is the start of all sorts of federal dictates

into your medical care.

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