Watch Claudia interview Bev Schechtman about her experience in the hospital when she was denied pain medication for kidney stones due to being a victim of sexual abuse.  

"Everything is looked at as drug-seeking.  No matter we do, they think we're drug-seeking." ~ Bev Schechtman

AMA (American Medical Association) has been vocal about their view of the 2016 CDC Opioid Prescribing Guidelines and the changes they feel are necessary. On September 21, 2021, AMA released a report showing that while there has been a 44.4% decrease in opioid prescribing, the drug overdose epidemic has never been worse. The press release for the new report can be found here. The report also discusses how as PDMP use has greatly increased, overdoses and deaths skyrocketed.  Does that mean the PDMP actually increases deaths?  It's possible. This issue is discussed further in this Reason article by policy analyst, Jacob James Rich. The DOJ has put hundreds of millions of dollars into funding the PDMP. Will they stop funding the PDMP since the results are definitely less than impressive? Doubtful, but we'll see. Contrary to what anti-opioid zealots like Andrew Kolodny from PROP and Gary Mendell from Shatterproof want people to believe, AMA President Gerald E. Harmon, M.D. said “The nation’s drug overdose and death epidemic has never just been about prescription opioids.” 

Chronic pain being discussed on Dr. Drew with Don't Punish Pain Founder Claudia Merandi Follow this link

Truth Out published an article on October, 1, 2021 regarding the DEA's recent public safety alert about the abundance of counterfeit prescription pills. Mike Ludwig's article is part of the series "The Policing of Pain: Inside the Deadly War on Opioids." This increase demand for prescription pills is largely due to a crackdown on prescribing of controlled substances. Mike explains that the link between "overprescribing" and the overdose crisisis greatly exaggerated, citing the fact that opioid prescribing has plummeted to the lowest it has been in a decade as overdoses have skyrocketed. Claudia Merandi, Founder and President of The Doctor Patient Forum, was interviewed for this article.

Where is the Abandoned Patient and Forced Opioid Taper Questionnaire?

How can I sign up to receive The Doctor Patient Forum's free newsletters?

How do I advocate for a loved one who is in the hospital?

How do I file a complaint about a civil rights (ADA) violation?

How do I request my Electronic Health Records and what do I do if there are errors in them?

What is NarxCare?

What do all of the abbreviations and acronyms mean?

What is the PDMP?

Is there a list of up-to-date statistics, research, and studies that I can use to show to media, my legislator, or my doctor?

Did the CDC know their Guidelines could potentially harm patients? Were they warned?

Do studies show that prescription opioids don't work for long-term chronic non cancer pain?

What is the SPACE Trial and does it prove that prescription opioids don't work for chronic long-term non cancer pain?

What is MME? Are the concepts of MME (Morphine Milligram Equivalent) and MME limits such as 90 MME, based on solid scientific evidence?

What are the 2016 CDC Guidelines? Will the updated CDC Guidelines make things better or worse?

Did The Doctor Patient Forum submit comments to the docket for the updated/expanded CDC Guidelines?

What is ORRP (Opioid Rapid Response Program) and do they actually help abandoned patients find doctors?

What is the FDA warning about Suboxone/Subutex/Belbuca and dental injuries? Is there a lawsuit about it?

What number do I call if I have had dental issues while on Suboxone/Bupe? 

What is the VALUE Study?

How can I sign up to receive The Doctor Patient Forum's free newsletters?

Click here to sign up!

Catch up on all of our past newsletters 

How do I advocate for a loved one who is in the hospital?

Some basic facts:

• If the patient is currently a chronic pain patient and takes daily prescription opioids, the patient is less likely to receive opioids while in the hospital.
• Chances are the hospitalist is already biased against the patient.

Step by step instructions: 

1. Have the patient ask for the charge nurse.
2. If you’re on the phone, ask the patient to put you on speaker so you can start a conversation with the charge nurse.
3. Introduce yourself saying:
   1. “Hello, my name is (insert your name here). I am a patient advocate based out of (insert your location). First, thank you for your hard work during the pandemic.  I know you’re terribly busy but I imagine we both have the same goal of controlling this patient’s pain.”
   2. “Can you please tell me whose care this patient is under? Is the hospitalist a resident? A fellow? Would you kindly provide me with their name, please?”
   3. Would you please contact the hospitalist, tell them the patient’s pain is unmanaged and he needs adequate pain relief?”
   4. “If the doctor is unwilling to put in an order for adequate pain medication, would you please tell me why?”
4. If the doctor still doesn’t put an order in, the next step is the have risk management, the charge nurse, the hospitalist and the surgeon all come to the patient’s room at the same time so you all can have a conversation together.
5. This is a time-consuming but necessary process.
6. Once discharged, if the patient’s health was made worse by the treatment received at the hospital, then the next step would be to contact a medical malpractice attorney.

Some more tips:

• Documentation is key. Write down the names of every person you speak with and exactly what they say to you. This will be very important if you choose to file a complaint with the medical board.
• Hospitals have protection from the feds, so there is no reason pain shouldn’t be treated while inpatient.
• Remember, hospitals do have patient advocates, but they work for the hospital, not for the patient.
• If the patient is under a pain management contract, the patient should not accept an opioid prescription upon discharge unless already agreed upon by the pain management doctor. Even accepting a prescription for 5 pills can cause a patient to be discharged from pain management if it hasn’t been discussed in advance.
• If the patient’s pain management doctor has agreed to allow the patient to accept a prescription from the hospitalist or surgeon, it’s always best to take it to the patient’s pharmacy instead of filling it at the hospital’s pharmacy.

PDF version of these instructions

What is NarxCare?

NarxCare, a product of a company called Bamboo Health, is a proprietary data analytics program. It uses up to 70 data points (that only Bamboo Health knows) and mixes them with your PDMP (prescription history) to assign four 3-digit scores letting your doctor or pharmacy know if you have a high risk of abuse or overdose. There is a Narcotic Score, a Stimulant Score, and a Sedative Score, and an Overdose Risk Score (ORS). According to Bamboo Health, "NarxCare aids care teams in clinical decision making, provides support to help prevent or manage substance use disorder, and empowers states with the comprehensive platform they need to take the next step in the battle against prescription drug addiction." Essentially, NarxCare pulls data from multiple state registries looking for red flags of drug seeking behavior. 

The three categories of prescription medication it looks at are narcotics (opioids), stimulants (ADHD meds) and sedatives (benzos, sleeping meds, etc.). "The NarxCare report identifies risk factors with interactive visualizations, as well as an Rx Graph, and a set of scores that numerically correspond to the patient’s PDMP data." Although Appriss states on their website that their product shouldn't be used by itself to make medical decisions, that's not what's actually happening. As shown in this NarxCare article, patients are being denied medication or even being dismissed from a medical practice based on a NarxCare score alone.

Some of the risk factors used in the proprietary algorithm are:

1. The number of prescribers a patient has had in a two-year period.
2. The number of pharmacies a patient used in a two-year period. 
3. The dosage (MME-Milligram Morphine Equivalent).
4. Amount of other medications that may increase potency of other medications.
5. Number of times prescriptions overlap with prescriptions from other providers
6. Any Mental Health Diagnosis
7. Distance from patient to doctor

Nobody knows (except Bamboo health) exactly what goes into the ORS (Overdose Risk Score).  Some of the factors we've found listed are criminal history, diagnoses in your EHR (Electronic Health Record) including mental health diagnosis (such as depression or PTSD), distance patient drives to the doctor, and diagnosis of sleep apnea.  

What are some of the problems with NarxCare?  Why isn't it a good thing?

1. There is no room for context. What does this mean? As mentioned above, if someone has more than one prescriber within a two-year period, that will increase the ORS.  But, there isn't a way to include an explanation such as if a patient moves, if a patient has multiple surgeries within that time period, or if a patient's doctor retires causing the need for a new physician.
2. A patient's pet's prescription history is included. This means if a patient has surgery and if her pet has surgery, it appears as though the patient is getting prescriptions from more than one doctor.  
3. The NarxCare algorithm has never been externally validated.  What does this mean? Essentially, it means the results of the study the algorithm is based on haven't been proven to apply to people outside of the study.  Yet, that's exactly what they are doing.  They are calling it evidence-based even though it is not.  
4. If someone is prescribed 90 MME (Morphine Milligram Equivalent) or more, the NarxCare score is automatically at the to 1% of all Overdose Risk Scores.  Why is this bad?  Well, the whole concept of MME and arbitrary thresholds such as 90 MME are flawed and not based in science.
5. The NarxCare algorithm has inherent gender and racial bias. How? Since they use criminal history, it is racially biased. Since more it women tend to have mental health diagnoses such as PTSD due to trauma, it automatically is biased against women. We have heard stories of women who have been denied prescription opioids due to having been a survivor of sexual abuse.

As summarized in this Wired article, the entire concept of NarxCare is flawed and is flagging patients who shouldn't be flagged.  "According to one study, 20 percent of the patients who are most likely to be flagged as doctor-shoppers actually have cancer, which often requires seeing multiple specialists. And many of the official red flags that increase a person's risk scores are simply attributes of the most vulnerable and medically complex patients, sometimes causing those groups to be denied opioid pain treatment."

Many people are fighting against the use of NarxCare. Almost every state uses Aprriss' PDMP platform and roughly 25 states in USA use NarxCare. Contact your local Department of Health to find out if your state uses it. For more information about Narxcare, we've included links to a few articles.

PDMP and NarxCare

Dosing discrimination 

What Every Patient Should Know About NarxCare

PDMP and NarxCare

The flawed study NarxCare is based on

What do all of the abbreviations and acronyms mean?

• BSC - Board of Scientific Counselors
• CDC - Center for Disease Control and Prevention
• CDC GL - CDC Guidelines (usually referring to the 2016 or 2022 guidelines for opioid prescribing).
• CNCP - Chronic non-cancer pain
• CPP - Chronic Pain Patient
• DPP - Don't Punish Pain
• EHR - Electronic Health Record
• HHS - Health and Human Services
• HR - Harm Reduction
• LTOT - Long-term opioid therapy
• MME - Morphine Milligram Equivalent
• OIH/OIHA - Opioid-induced hyperalgesia
• ORRP - Opioid Rapid Response Program
• ORT - Opioid Risk Tool
• PDMP/PMP - Prescription Drug Monitoring Program
• PROP - Health Professionals for Responsible Opioid Prescribing

What is the PDMP?

PDMP (Prescription Drug Monitoring Program) is a data base that records all controlled substance prescriptions including opioids, sleeping pills, ADHD medication, muscle relaxers, among some others. The first PDMP was developed in New York in 1918. It is now in all 50 states (as of 2021).  These data bases have been funded by the Department of Justice (to the tune of hundreds of millions of dollars).

We've seen several goals listed for the PDMP, but the most common is to give healthcare professionals real-time access to your prescription history so they can make sure you're not "doctor shopping," or otherwise abusing your medication.  Each state runs its own PDMP, usually by the HHS (Dept. of Health and Human Services). Thanks to a company called Appriss, PDMP's are now interconnected between states.

Some common questions answered:

1. Who enters your information into the PDMP?  The pharmacist/pharmacy technician.
2. Do you have real-time access to your PDMP report?  No.  Each state has different rules. Contact your HHS and ask how you can see your PDMP history and how to fix any errors.
3. Who has access to your PDMP? Pharmacies, doctors, hospitals, and in some states veterinarians and law enforcement.
4. What's a risk score in the PDMP?  This brings us to Narxcare.  PDMP pulls from many different data bases (criminal history, financial history, school grades, Electronic Health Records, etc.) and mixes it all with your prescription history to spit out a risk score as to whether your doctor should prescribe to you or not.  See the FAQ "What is Narxcare?" for a more detailed explanation. 

Still interested in reading more about PDMP? Here are a couple of articles we recommend:

Dosing Discrimination: Regulating PDMP Risk Scores

Is there a list of up-to-date statistics, research, and studies that I can use to show to media, my legislator, or my doctor?

Yes!  We have a printable document (both Word and PDF) listed here under Advocacy Tools

Did the CDC know their Guidelines could potentially harm patients? Were they warned?

Yes to both! They were warned by many organizations. They knew these Guidelines were dangerous. We gave all the details in our Debunking Lies section. It includes links to all the warnings and an explanation of what happened and how the CDC responded. Read our answer here.

Do studies show that prescription opioids don't work for long-term chronic non cancer pain?

No, they don't! But, that doesn't stop anti-opioid zealots from making this claim. Read all about it and how to counteract this false narrative here, in our Debunking Lies section.

What is the SPACE Trial and does it prove that prescription opioids don't work for long-term chronic non cancer pain?

It is a study funded by the VA and done by Dr. Erin Krebs. No, it doesn't prove that prescription opioids don't work for long-term chronic non cancer pain. Yet, it is cited as a reason to not prescribe opioids and to force taper. We broke down this study for you with all the links and information you need to counteract this false statement.

What is MME? Are the concepts of MME (Morphine Milligram Equivalent) and MME limits such as 90 MME, based on solid scientific evidence?

We answered this question in detail in our Debunking Lies section. Read all about it here.

What are the 2016 CDC Guidelines? Will the updated CDC Guidelines make things better or worse? How can I comment on them?

In March 2016, the CDC published opioid prescribing guidelines. There was a lot of controversy surrounding the lack of transparency and secrecy of the CDC Guidelines. 

As many of you know, the 2016 CDC Opioid Guidelines have caused harm to many. Whether the guidelines themselves are the problem or if they have just been misapplied has been widely discussed by experts. In July 2021, the CDC released their draft of the updated opioid guidelines. We explained it all in detail in our newsletter. If you haven't had a chance to read it, please do. It helps put all of this in context. The new draft of the guidelines was published last week. Here are two very important links:

Chart of the 2016 Guidelines vs 2022 Guidelines  

The 229 page document of updated guidelines

CDC is accepting comments here on the updated draft of the guidelines until April 11.  

We have some suggestions for commenting on the CDC Guidelines.

Many media outlets covered this story. Our favorite is from Josh Bloom "Panic in PROPville."

Here is the story from Pain News Network called "Why CDC Dropped One-Size-Fits-All Approach to Pain Care":

Did The Doctor Patient Forum Submit Comments on the Docket for the Updated/Expanded CDC Guidelines?

Yes, we did!  Feel free to use any of the information included in our comment.

Word  pdf

What is ORRP (Opioid Rapid Response Program) and Do They Actually Help Abandoned Patients Find Doctors?

We have all of the details here including e-mails we received from the director along with quotes from the intimidating phone call. They called us demanding we remove social media content that didn't exist.

What Number Do I call If I've Had Dental Issues While on Suboxone/Bupe?

410-442-6648

Listen to pain doctor and mal-practice attorney, Dr. Dan Laird discuss the false narrative and what the "opioid crisis" actually is. You won't want to miss him talking about the litigation narrative and how chronic pain patient advocates are helping to set the record straight. Click the following link:

Pain Med Prescriptions Did Not Cause the Opioid Epidemic 

• "Chronic pain patients are in a fight for their lives" ~Dr. Dan Laird

• "Prescribed opioids are approaching a 10-year low and opioid deaths are higher than they've ever been in the history of the world." ~Dr. Dan Laird

This article contains the following information:

• Why would CPP's want this information?
• What is illicit fentanyl?
• What are some myths about illicit fentanyl?
• What are illicit fentanyl testing strips?
• Are illicit fentanyl testing strips legal?
• Where can I get them?
• How do I use them?

Why Would CPP's Want This Information?

• I want to be clear that we at The Doctor Patient Forum do not encourage anyone to obtain pills on the street, from a friend, or from anywhere other than your pharmacy.
• We are aware that some chronic pain patients (CPP's) who have been medically abandoned have been so desperate for pain relief that they've either gone to the street or taken a pill from a friend.
• Since up to 42% of all pills on the street contain illicit fentanyl, we want to provide Harm Reduction information so if you are getting medication from somewhere other than your pharmacy, you know what to do to try to keep yourself safe.
• Please understand that when you take a pill that you obtained from someone other than your pharmacy, even if you use illicit fentanyl testing strips, there is no guarantee that the medication is safe for you to take. Even if you test your medication, we highly recommend you have Naloxone available (I will be adding content on this shortly, and I will link the information here) and that you don't ever take the medication when you're alone. In case you don't have anyone who can be there with you, there is a never use alone hotline 1-800-484-3731.  

What is Illicit Fentanyl?

Illicit Fentanyl is not the same as prescription fentanyl. It is often made in labs in China and then smuggled in the the USA through Mexico. Illicit fentanyl is the leading cause of all drug-related deaths in the USA. Many who end up taking illicit fentanyl don't even realize it's in the medication or drugs they ingest. Due to this fact, we prefer to call it a poisoning instead of an overdose. Those who sell it often use pill presses so it looks identical to prescription medication. It is made to look like hydrocodone, oxycodone, Xanax, and other prescription drugs. It has also been found in other illicit substances such as heroin, meth, or cocaine. One reason drug dealers are using illicit fentanyl is due to its potency. A tiny bit goes a long way, but that is also the reason it kills so many people. The last statistic I read was that 42% of all street pills tested has illicit fentanyl in them.

What Are Some Myths About Illict Fentanyl?

• A very common myth is that prescription grade fentanyl is what's killing so many people. This is absolutely false. Media and even addiction specialists often conflate prescription fentanyl with illicit fentanyl analogues. Illicit fentanyl, not prescription fentanyl, is what's killing so many people.
  • A recent toxicology study showed "Out of 18,393 deaths that were confirmed, probable, or suspected heroin deaths (including 2678 with morphine listed as cause of death on the DC) and 404 as probable pharmaceutical morphine deaths, among deaths with fentanyl detected, 89.3% were defined as probable or suspected IMF (illicitly manufactured) and 1.0% as probable pharmaceutical (prescription) fentanyl."
• There is a false narrative that's widely spread in media and repeated often that just touching illicit fentanyl or being in the same room as it can cause an overdose/poisoning. You see images of police in hazmat suits. This doesn't happen. It's important to understand this fact because if you by a pill off the street and test it for illicit fentanyl, and it turns out your pill contains illicit fentanyl, merely touching the substance will not cause an overdose/poisoning.

Ryan Marino MD often addresses the myths surrounding illicit fentanyl. He has shared the following image with permission to share it:

What Are Illicit Fentanyl Testing Strips?

Illicit fentanyl testing strips are part of Harm Reduction that assist in overdose prevention. They are actually FDA approved to detect fentanyl in urine, but are also increasingly being used as a Harm Reduction drug-checking strategy.

Are They Legal?

• Sadly, they are illegal in some states because they are considered drug paraphernalia. In the states they're illegal, Harm Reduction groups are fighting to change those laws. Josh Bloom wrote about this issue in an article called Fentanyl Test Strips Are Illegal. This Is Obscene

•  Please check hereTo find out if they're legal in your state.

Where Can I Get Them?

• For individual or small orders, you can get them at Dosetest. They cost about $1.00 each. 
• For larger orders (like if you want to order in bulk for yourself or to hand out) you can get them at BTNX. For more information about how to order them in bulk, please e-mail Michael@btnx.com.They sometimes offer a discount for new customers.

How Do I Use Them?

• Here is a Brochure from NYC Dept. of Health showing how to use illicit fentanyl testing strips. Here is a PDF of the Brochure.

• One important point to note is the results are opposite from other tests like pregnancy tests.
  • One tine = positive (+) result (meaning there is illicit fentanyl present).
  • Two Lines = negative (-) result (no illicit fentanyl detected).
  • The following graphic explains how to read results:

• Remember, a negative test result is not a guarantee that illicit fentanyl is not in your pill.

• Most how to videos and information are geared toward PWID (people who inject drugs). We know that most CPP's who go to the streets won't inject the medication. When testing a pill that you are not intending to inject you have two options -both are explained in the following video:

1. 1. Dissolve the entire pill in water and test it (this is the most reliable method). Once it tests negative for illicit fentanyl, you can still swallow the liquid, or you can put it in a capsule to avoid tasting the dissolved pill.
      • Here are two websites to purchase gel caps which are specifically made for liquid such as essential oils: 
        • Amazon
        • Azure Standard
      • How to fill a gel cap with liquid according to these websites:
        • Pull apart the capsule. One side is larger than the other, allowing the smaller end to fit inside the larger one
        • Draw your liquid supplements into a medicine dropper. Place the end of the dropper over the smaller side of the gel capsule.
        • Carefully squeeze the dropper to fill the capsule. Slide the larger end on to enclose the liquid inside the capsule.
        • Store in an airtight container in a cool, dry place. 
   2. You can scrape off part of the pill as Amanda shows in the following video. Just know there is no guarantee that the composition of a counterfeit pill is uniform throughout. So, it's possible that the small sample you test will be negative for illicit fentanyl, but other parts of the pill will be positive.

• If you bought more than one pill, testing one of the pills does not guarantee that the other pills will have the same composition.

Here is a how to video by an amazing Harm Reduction advocate, Amanda Mazur. Check out her Tik Tok videos for more information about Harm Reduction. In addition to teaching about Harm Reduction, Amanda also fights for the rights of CPP's to have access to prescription opioids.

As always, if you have any questions feel free to contact us through our contact page. 

This content was written by Bev Schechtman and Carrie Judy for The Doctor Patient Forum. Updated March 3, 2022

Introduction to fitness in chronic pain/illness

What does fitness mean in someone with chronic pain/illness?

Fitness in the world of chronic pain and illness seems impossible. Just hearing someone suggest it can be offensive and overwhelming. We know exactly what that feels like. Sometimes it can even feel like we are being blamed for our illness/pain. People have no idea how hard it is to be sick and in pain every minute of every day and night. We completely get it. This is why we added this category. There is a lot of information on the internet about fitness, wellness, health, and even how to manage an illness with diet and exercise. But, we haven't seen much out there that truly shows how a CPP (Chronic Pain Patient) can apply any of this to a life filled with sickness and pain. 

Fitness means different things to different people. To some, it can mean working out an hour a day at the gym. To others, it means making tiny changes in daily nutrition. It can even simply mean a change in mindset. 

Claudia and I (Bev) both have Crohn's Disease. We have spent years in and out of the hospital. We want to help you make tiny changes that can make a difference in your life. 

Is it really possible to achieve a fitness goal when stuck in bed or unable to leave the house?

Yes! It really is possible. We are going to give you tips about nutrition, exercises, and lifestyle changes that can all add up to make a difference for you. We know we can't ever cure our illnesses or painful conditions, but what we can do is make little changes that can help us live the best lives we can in the situations we are given.

Things you will hear us say...

• Small changes can make a big difference
• Be kind to yourself
• Listen to your body

Things you won't hear us say...

• It's your fault you're sick
• You did this to yourself
• If you could just (exercise, walk, go to the gym, get up earlier, etc.) you wouldn't be sick anymore

"Where's the Patient's Voice in Evidence-based Treatment & Research?"

Part 4 in the series "Pharmacist and Physician Opioid Collaborative"on Pharmacy Podcast Network.

Listen as Todd Eury, from Pharmacy Podcast Network, asks Bev a question that is long overdo..."What is the patient's perspective?"

"No one ever asks the patient what we think, we are kind of shoved out of it." ~Bev Schechtman

"But what they're missing, Bev, is they're missing the empathetic bedside manner to look you in the eye and give you a sincere little smile, showing they're there for me as a patient." ~Todd Eury

"We feel like everyone around us is going to treat us as though everything we say is a lie, that we're going to try to get out of whatever it is they think they're trying to catch us in, and we can't trust any of them." ~Bev Schechtman

"The way they set up the system patients can't be honest with our providers." ~Bev Schechtman 

"

A brand new article called:

Physician Liability for Suicide after Negligent Tapering of Opioids

by Mark A. Rothstein and Julia Irzyk

Are physicians liable if they abandon or force taper a patient who is on opioids and that patient takes his life? This is an excellent article to share.

"Abstract: The precipitous and medically contraindicated reduction or “tapering” of opioids for patients with chronic pain due to serious medical conditions has caused needless suffering and, increasingly, suicide. Physicians could be liable for wrongful death based on negligent tapering of opioids."

Some quotes from the article:

"Patients treated for chronic pain with opioids are highly vulnerable. They have medical conditions with severe pain that cannot be controlled by other treatment modalities or less potent analgesics. Their underlying medical condition, their pain level, and the opioids they take all may interfere with their cognitive or reasoning abilities. They are dependent on their physician’s renewal of their prescriptions; there are no safe and effective alternatives. Significantly, they bear the stigma of requiring drugs often associated with personal immorality or criminal activity. As a price for access to a substance that allows them to lead the semblance of a normal life, patients with chronic pain are often required to sign contracts pledging compliance with terms imposed on them, to submit to periodic or random urine testing, and to bear humiliation by a society that is frequently fearful, suspicious, and intolerant. Few other patients are subject to such indignities."

"Vulnerable patients should not be abandoned or have their treatment unreasonably delayed when they are at risk of accidental or intentional overdosing."

"A plaintiff must prove that the defendant-physician failed to meet the appropriate standard of care, which almost always requires expert testimony. An important issue is whether the standard may be established by the introduction of nonbinding professional guidelines or recommendations. In In re Jankowski, a state licensing agency brought disciplinary proceedings against a physician for, among other things, prescribing excessive levels of opioids without medical justification. The appellate court, in affirming sanctions against the physician, held that the 2016 CDC Guideline was the standard of care for a pain management physician, notwithstanding the statement in the Guideline that it applied only to primary care clinicians."

"America’s opioid crisis is well into its third decade. There are many causes of this problem and resolving them will take a variety of measures over an extended time. Unfortunately, some past efforts to reduce the morbidity and mortality associated with improper use of prescription opioids have been ineffective and led to
disastrous unintended consequences. One such attempt to limit the supply of prescription opioids involved the issuance of prescribing guidelines. Between 2012 and 2020, the number of opioid prescriptions declined dramatically from 255 million to 142 million, but the number of overdose deaths soared from 41,000 to 100,000. One of the most tragic consequences of curtailing the use of opioids for managing severe, chronic pain has been an increase in suicides, which now account for an estimated 30 percent of drug overdose fatalities. It is not known how many suicides result from a physician’s negligent, aggressive tapering of opioids."

"Many physicians are concerned that prescribing opioids could lead to criminal prosecution, license revocation, loss of employment or hospital privileges, or malpractice litigation. On the other hand, legal jeopardy for failing to continue prescribing opioids to existing patients, even when the standard of care requires it, does
not seem to be a widespread concern."

Season 1 Episode 5 - 9/5/22

Suicide due to untreated pain. CaSonya Richardson-Slone bravely speaks about her husband, Brent

Link to episode

Season 1 Episode 8 - 9/26/22

Link to episode

An extremely important article was just posted last week on September 17, 2021.  We at The Doctor Patient Forum/Don't Punish Pain have been researching the CDC Guidelines and how they were written.  We specifically have focused on one of the main authors, Dr. Roger Chou.  We had the privilege of collaborating with a palliative care doctor who is also on the AMA Opioid Task Force, Dr. Chad Kollas. Dr. Kollas along with a few other chronic pain patients and advocates worked together to put out this phenomenal article showing in detail the unacceptable conflicts of interests Roger Chou has, and explains in why we need a congressional investigation into how the guidelines were written.  How can you help?  Familiarize yourself with the content of this article, and forward it to your local legislators. your local representatives, your senators, etc.  The following goals are listed at the end of the article:

On March 1, 2022, the Supreme Court will hear a case that could make or break the future for pain doctors and their patients. Pat Anson, from Pain News Network, summed it up perfectly in this article "Supreme Court Case May Decide Future of Opioid Prescribing."

By Pat Anson, PNN Editor

December 29, 2021

"Over a dozen patient and physician advocacy groups have filed legal briefs with the U.S. Supreme Court in support of two doctors appealing their convictions for criminal violations of the Controlled Substances Act.

The nation’s high court has consolidated the cases of Dr. Xiulu Ruan of Alabama and Dr. Shakeel Kahn, who practiced in Wyoming and Arizona. Both doctors were sentenced to lengthy prison terms after being convicted on a variety of charges – including the prescribing of high doses of opioid pain medication to patients “outside the usual course of professional practice.”

Oral arguments will be heard by the Supreme Court on March 1, with a decision expected later in 2022. Monday was the deadline for interested parties to file “amicus curiae” briefs on the case, which could have a significant impact on opioid prescribing practices nationwide if the appeals are successful. Many doctors have stopped or reduced their prescribing of opioids because they fear being prosecuted under the Controlled Substances Act (CSA).

“It is no exaggeration to say that CSA prosecutions of physicians have already impaired the treatment of chronic pain,” Ruan’s attorneys said in their appeal. “In response to the opioid crisis, fear of prosecution has increasingly prompted pain management doctors to avoid or reduce opioid prescriptions, even when those decisions leave chronic pain patients without recourse.”

A successful appeal would mean Ruan and Kahn could ask for new trials, along with dozens of other doctors convicted of similar charges under the CSA.

“It will also avoid what I see as the chilling effect that it’s had on lots of doctors who are not doing anything even remotely suspicious, but are afraid that they are going to get caught because they prescribe a higher dose, and so they’re dropping people from care or tapering them,” said Kate Nicholson.

NPAC, along with other advocacy groups and the U.S. Chamber of Commerce, are asking the high court to clearly state how the practice of medicine should be regulated under the CSA. Some argued it is best left to state medical boards, not federal prosecutors or law enforcement.

“Patients with pain, addiction, or both desperately need appropriate care and treatment. If practitioners are held strictly liable under (the CSA), patient abandonment will become ever more common as practitioners act to avoid scrutiny,” Jennifer Oliva and Kelly Dineen, professors of health law and policy, said in their brief. “Progress in medical care in these areas can only recover if the regulation of medical practice is returned to the province of the states except in narrow circumstances.”

SCOTUS sides with the petitioner and Health Law Professors in Ruan v. United States 9-0! As explained by Jennifer Oliva:

The bottom line is that the DEA can no longer say "we think this exceeds the legitimate bounds of medical practice" and then put on their paid experts. INSTEAD, they must prove beyond a reasonable doubt that the doctor KNEW/INTENDED that the Rx was outside the legitimate bounds. What matters is the prescribers knowledge and intent.

Here is the ruling of the Supreme Court Ruan case. Here are some comments from the lawyers who worked so hard to 

Some comments about the case from Ron Chapman:

Many#cpp are wondering what this decision means for them. Simply put, it will be harder to prosecute physicians for medical judgment. We won’t see immediate effects but over time we will get there.

 Jennifer Oliva:

Once a doctor proves that they are authorized to prescribe a controlled substance (e.g., has state & federal registration), the government must PROVE BEYOND A REASONABLE DOUBT that doc KNEW or INTENDED that their prescribing conduct was unauthorized under the CSA This means that the doc must have known or intended to prescribe outside the legit bounds of medical practice. Not enough for DEA to say "we think this is outside the bounds." Must prove that doc knew it was outside the bounds. Huge win.

Kelly Dineen:

This is such a tremendous outcome. Honestly, even the conclusion in the concurrence (which would have required a subjective good faith defense) would have been a win in itself. Amazing news for so many patients. Now we need to get word out to the prescriber.

Kate Nicholson:

Today#SCOTUS ruled unanimously in Ruan v. United States, that doctors authorized to prescribe controlled substances can only be convicted for violating the Controlled Substances Act when they intend or know that they are prescribing in an unauthorized manner. The opinion tracks exactly what we argued in our amicus curiae brief and could not have been better for people living with pain. The Court specifically rejects the view that doctors are criminally liable if their prescribing is not in accord with current medical standards. The difference is important, and especially so for doctors treating patients in pain, who might otherwise be deterred from meeting the needs of their patients by the fear that disagreement with their medical judgment would subject them to serious criminal liability. Indeed, Justice Breyer, writing for the Court, specifically singles out the chilling effect of overdeterrence and the importance of distinguishing morally blameworthy from socially necessary and beneficial conduct (i.e., prescribing medication for her patients). Justice Breyer writes, “a strong scienter [or mens rea] requirement helps to diminish the risk of “overdeterrence,” i.e. punishing acceptable and beneficial conduct that lies close to, but on the permissible side of, the criminal line.” The opinion also addresses the “vague, highly general language of the regulation defining the bounds of appropriate prescribing,” and the importance that providers not be convicted criminally for what is essentially negligence: As Justice Breyer writes, “the Government’s standard would turn a defendant’s criminal liability on the mental state of a hypothetical “reasonable” doctor, not on the mental state of the defendant himself or herself.” It is also important thing to note is the concurring opinion by Justice Alito, in which Justice Thomas joins and Justice Barrett concurs in part, concurs fully with the Breyer opinion that the appropriate standard is the subjective state of mind of the prescriber. The government had argued for an objective state of mind standard which we considered to be an oxymoron, and which no Justice agrees with.

For an in depth explanation read the following:

March 1, 2022 at 10am EST, Dr. Ruan's case was heard before the Supreme Court.

We explained it all in detail here. 

Attorney Ron Chapman created this post after the case was heard:

Season 1 Episode 3 - 8/29/22

Link to this episode

"Interview with attorney Ron Chapman about the targeting of the doctors by the DEA"

US could loosen some restrictions on prescribing opioids

CDC considers rolling back limits on which doses can be prescribed and for how many days in cases of acute pain

The US could see loosened guidance around prescribing opioids, as the US Centers for Disease Control and Prevention (CDC) considers relaxing some of its guidelines in a move that could signal a new direction for managing chronic pain.

The CDC last Thursday released proposed changes to its guidance on prescribing opioids, rolling back limits on which doses can be prescribed and for how many days in cases of acute pain.

The agency created rules in 2016 to reduce prescriptions that were fueling the opioid overdose epidemic. But as rules like these were put in place, opioid overdose deaths rose instead of falling.

"Where's the Patient's Voice in Evidence-based Treatment & Research?"

Our VP, Bev Schechtman, was a guest on Pharmacy Podcast Network.

Part 4 in the series "Pharmacist and Physician Opioid Collaborative" on Pharmacy Podcast Network.

Listen as Todd Eury, from Pharmacy Podcast Network, asks Bev a question that is long overdo..."What is the patient's perspective?"

"No one ever asks the patient what we think, we are kind of shoved out of it." ~Bev Schechtman

"But what they're missing, Bev, is they're missing the empathetic bedside manner to look you in the eye and give you a sincere little smile, showing they're there for me as a patient." ~Todd Eury

"We feel like everyone around us is going to treat us as though everything we say is a lie, that we're going to try to get out of whatever it is they think they're trying to catch us in, and we can't trust any of them." ~Bev Schechtman

"The way they set up the system patients can't be honest with our providers." ~Bev Schechtman