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  • Why Can't I Get Help Managing My Pain? Patient Denied Opioids Due To Being a Sexual Abuse Victim!

    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

  • Advocacy Tools

    Step-by-step instructions on how to advocate for a loved one who is in the hospital (pdf)

    Sample letter to Congress or legislators regarding the CDC Guidelines and the conflicts of interest of the co-author, Roger Chou.

    How to start the process of getting legislation passed in your state

    A list of important studies, articles, interviews, podcasts, etc.

    Table of recent studies, research, and statistics showing overdoses, rate of addiction, PDMP use, etc. (useful when speaking to legislators, media, doctors, etc.)

    How do I file a complaint for a civil rights violation (according to the ADA-American With Disabilities Act)

    Steps to request copies of your Electronic Health Records (EHR) and steps to correct errors in them


    Sample letter to Congress or legislators regarding the CDC Guidelines and the conflicts of interest of the co-author, Roger Chou

        (pdf)  or (Word)


    How to start the process of getting legislation passed in your state

    NH CPP advocate, Bill Murphy, walks you through the steps to get legislation in your state:


    A list of important studies, articles, interviews, podcasts, etc.

    Here are links to important helpful studies, articles, podcasts, interviews to help you when talking to legislators, media, doctors, etc. These are about the false narrative, the litigation narrative, PDMP, NarxCare, CDC Guidelines, PROP, Conflicts Of Interest, etc.

    We will add new links as they come out.

    Overdose, opioid treatment admissions and prescription opioid pain reliever relationships: United States, 2010-2019 

    New Data on Opioid Dose Reduction - Implications for Patient Safety - Jama -Dr. Stefan Kertesz

    The Opioid Crackdown Leaves Chronic Pain Patients In Limbo - The Hill

    Greg Gutfeld: We Should Legalize Drugs And Here's Why - Fox News

    Pain Med Prescriptions Did Not Cause The Opioid Epidemic, Courts Rule - Las Vegas news, George Knapp interviews Dr. Dan Laird

    Against The Pain: The Opioid Crisis and Medication Access - NPR, radio show

    PROP's Disproportionate Influence On U.S. Opioid Policy: The Harms Of Intended Consequences - Pallimed

    Roger Chou's Undisclosed Conflicts Of Interest: How The CDC's 2016 Guideline For Prescribing Opioids Lost It's Clinical And Professional Integrity - Pallimed

    The Pain Was Unbearable So Why Did Doctors Turn Her Away? - Wired

    Prescription Drug Monitoring Programs: Effects On Opioid Prescribing And Drug overdose Mortality - Reason

    Dosing Discrimination: Regulating PDMP Risk Scores -  Law Journal

    How Fear, Misinformation, Stigma Have Devastated US Pain Patients - Filter 

    Physician Convicted Of Illegally Prescribing Opioids Says The DEA  Has Turned Doctoring Into 'Another Aspect Of The War On Drugs.' - Chicago Tribune

    How Drug Warriors Made The 'Opioid Epidemic' Deadlier- Reason

    If Lawmakers Really Want To "Follow The Science" They Will Repeal Codified Opioid Guidelines - Cato Institute

    A New Study Finds No Relationship Between Opioid Prescriptions And Unintentional Injury Deaths - Reason

    ASA Urges Changes To Draft Updated CDC Guideline For Prescribing Opioids - ASA

    Time To Revamp CDC's Problematic 2016 Opioid Rx Guideline  - AMA

    A New Study Finds That Reducing Pain Medication is Associated With An Increased Risk Of Overdose And Suicide - Reason

    CDC's Crackdown on Opioid Pain Medications is Abysmal Failure - Didn't Fix the Crisis and Americans are Suffering with Severe Pain - Gateway Pundit from Fox News story

    Evaluating the Stability of Opioid Efficacy over 12 months in patients with chronic noncancer pain (shows opioids work)


    Table of recent studies, research, and statistics showing overdoses, rate of addiction, PDMP use, etc. (useful when speaking to legislators, media, doctors, etc.)

    Document in Word

    Document in PDF


  • Do Doctors Get Paid More Money to NOT Prescribe Opioids?

    Many of you have heard Kolodny or other anti-opioid zealots make comments like "pharma pays doctors to prescribe opioids." So first, let's address that. It is illegal for a pharmaceutical company to pay doctors specifically to prescribe their medication. What they can do, though, is pay them as "consultants" or for "speaking engagements." Do I think it's ethical? Probably not, but that's how it works. Medical device companies do the same thing. Well, actually, they often pay more than pharma, as seen in this article called "Medtechs top pharma in cash to doctors for consulting, travel.."  If you ever want to look up a company and see how much they pay doctors, or look up doctors to see how much they've accepted, you can look up these two websites. Open Payments and Dollars For Docs. So, do opioid makers specifically "pay doctors to prescribe"?  I would say no more than any other company does. For anyone to specifically state that companies that make opioids pay doctors to prescribe is incredibly misleading. But, that doesn't stop doctors from making that statement or from media repeating it. Why would people want to mislead the general public about opioids? It helps vilify these companies for the litigation narrative we're always talking about. This whole narrative was done in preparation for opioid litigation, which we see taking place across the country now. There are around 3,000 lawsuits that the Attorneys General have brought against pharma, pharmacies, and manufacturers. 

    What they don't mention is that doctors are now getting paid more money to NOT prescribe opioids? Yes, you read that correctly. BCBS of Michigan actually incentivizes doctors by paying them 35% more money if they don't prescribe opioids after certain procedures. Read all about it in this article called Fewer Opioids, More Pay: New Tack on How Doctors Prescribe Them . So, if you live in Michigan and have BCBS, this might be the reason why your surgeon isn't treating your post-op pain with opioids. I'll include the rest of the article below.

  • Illicit Fentanyl Testing Strips

    This article contains the following information:

    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:

    Image

    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?

    •  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?

    • 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:

    Screenshot 31

    • 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. 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: 
        • 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

  • Supreme Court ruled in our favor 9-0!

    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:


    "ORAL ARGUMENT IN RUAN V. UNITED STATES

    The Supreme Court heard oral argument today in the most important healthcare case since 1975, Ruan v. United States . While we were hoping for a glimmer of justice, what we got was a dizzying lesson on grammar, parsing of words, and speed limit analogies. But Justice Gorsuch in his gentle, fatherly cross examination style attempted to bring the argument for petitioners back on track by showing the nonsensical and circular nature of the Government’s argument.

    This issue before the Supreme Court is thoroughly addressed here and if you aren’t familiar go back and read that article first.

    Before we get into the oral argument its important to understand the changes in the case prior to the parties taking the podium. The issue before the 11th Circuit was the failure to give a “good faith” instruction which essentially permitted the Government to convict Ruan under a strict liability standard. The 11th Circuit believed that if his conduct failed to comport with the objective requirements of the practice of medicine then he should be convicted. Petitioners argued that if he subjectively believed he was following objective standards then he should be acquitted. The Government, straying from the 11th Circuit’s opinion pivoted in their opening brief and said that the physician must make an “honest effort to comply” with the objective standard of practice. This is where the train left the tracks. As Ruan’s counsel pointedly argued - the Government’s argument is a malpractice standard gussied up as an objective standard. The Government pivoted so hard that their argument appeared to turn in the direction of the petitioner, arguing that a subjective “honest effort” is enough. But instead of seizing on that juicy opportunity the justices questions sped past the issues at the heart of the case and turned into a confusing digression into the statutory elements of the offense.

    I’ll explain.

    THE INTENT COMPONENT

    21 U.S.C. 841(a) is a drug trafficking statute. It basically says that its unlawful to knowingly and intentionally distribute controlled substances. But an exception exists in the statute for licensed practitioners. Doctors, pharmacists, and other prescribers and dispensers are exempt from the statute as long as their conduct is “for a legitimate medical purpose in the course of professional practice”. In order to address whether the “good faith” of a physician is relevant the court needed to answer a threshold question and that is whether the intent requirement of the statute applies to the distribution or the exception. Thus, the question is: Does the government need to prove that the doctor knowingly and intentionally distributed drugs or does the government have to prove that the doctor knowingly and intentionally prescribed “outside the course of professional practice and for other than a legitimate medical purpose”. If the government needs to prove only that a physician intended to prescribe drugs then the only doctor who escapes this element is one who prescribes in a coma - as Ruan’s counsel pointed out.

    And so the court debated, for some time, whether the intent of the statute was to incorporate the prescriber’s exception as an element of the offense or an affirmative defense to the crime. If its an element, the the intent component must apply to the exception if its not then the intent component only applies to the distribution. Justice Alito seemed to think that the intent element is only related to the distribution and Gorsuch seemed to think that its related to the prescriber’s exception. The other justices didn’t offer much of a position but it seems that Breyer and Alito favor applying it to the distribution because failure to do so creates a statute with two separate intent requirements - one for prescribers and a separate for the general public. Breyer and Alito likely believe that such a reading frustrates the intent of congress in creating the statute.

    ONE GLARING OMISSION

    But in all of the heated debate surrounding the statutory text of the Controlled Substances Act, the Court and the parties missed the most important issue in the case, and all physician prosecutions. Both the Government and Petitioners conceded in their briefs that the standard applied in such cases is an objective standard of practice- which is incorrect. Both United States v. Moore and Gonzalez v. Oregon clearly state that the Federal Government lacks authority to regulate the practice of medicine. The Government only has authority to punish physicians who act so flagrantly that their conduct can be seen as “drug pushing”. And so, the Government’s proof that a physician’s conduct departed from some sort of “objective standard of care” amounts to mere malpractice and something for State Boards to consider - an issue hinted at in Justice Thomas’s final question. Petitioners should have taken the position that the standard of care is relevant in physician prosecutions only to show the jury the reasonableness of the physician’s conduct but in order for the government to fully satisfy the elements of 841(a) they must prove that a physician’s conduct departed so far from the practice of medicine that they ceased practicing medicine at all.

    For more on that point read my article “7 Dirty Words”.

    Instead of arguing this federalist argument, the parties were landlocked by the fact that the court granted Cert on the “good faith” issue which necessarily requires an argument regarding the intent elements instead of elevating above this crucial digression and discussing the authority of the Controlled Substance Act to regulate the practice of medicine generally.

    Tying an objective standard of care to the elements of an 841(a) violation is dangerous because (1) there is no consensus on what that standard actually is in the medical community, (2) it requires juries to grapple with complex and ever changing medical topics, (3) it allows the government and DEA to drive the standards of practice through CDC guidelines, “red flags”, DEA administrative decisions, and other unpromulgated guidance documents. This is dangerous because either subjectively or objectively the parties have permitted the government to take the position that violation of an invisible and ad hoc standard is sufficient for conviction in the first place.

    PREDICTION OF THE COURT’S DECISION IN RUAN V. UNITED STATES

    Predicting the outcome of a pending supreme court case is a bit like predicting the weather 30 days out - it ignores the dynamic interplay of the politics of the court. But I’ll take a stab. The Government abandoned the 11th Circuit’s rationale and the Court has no choice but to reverse the 11th Circuit and permit a good faith instruction or at the very minimum a proper instruction on the intent component of an 841(a) violation. It seems that at least five justices agreed with the fact that the intent requirement relates to the prescribers exception: Barrett, Gorsuch, Kavanaugh, Thomas, and Roberts. I think there are enough votes for reversal. But the tougher question is what relief, if any, can be afforded to doctors in the future given that both sides seemed to agree that an objective standard of practice is the standard in interpreting the phrase “legitimate medical purpose”. Kavanaugh seems to take the position that the statute is vague in the first place and may offer a concurring opinion and discuss vagueness unless he can pull the other four in his direction. But I don’t think he will be successful because of the politics of the Court. Determining that 841(a) is vague as applied to physicians will disrupt the balance of justice and require reversal of a lot, actually a ton, of convictions. And one thing we know about the Supreme Court is that it doesn’t favor such sweeping changes. Now this problem was set up by the Court in the first place in failing to address the statutory text since it was first enacted. Since 1975 we have been left without the voice of the court on this statute allowing the circuits to take differing interpretations and circuit splits as they grapple with the statutory text that was most likely written by a congressional staffer in 1970. But I do expect at least some comment on vagueness.

    In sum, I expect Ruan and Khan to get some sort of relief from this decision because the jury instructions in their case mis-applied the intent requirement of the statute and made drug trafficking a strict liability offense (like speeding) as applied to physicians. But I don’t expect a sweeping change here, I expect a tailored attack on the 11th Circuit’s reasoning and I expect that the Circuit Courts will pigeonhole the Supreme Court’s decision to prevent its broad application to all physicians convicted under the statute.

    There is some good news, potentially, on the horizon though. The Court has held the case of Naum v. United States pending the outcome in Ruan. This is a case where the federalism argument is very much alive. Its a case I have personally handled and if Cert is granted I will be arguing before the Supreme Court. We don’t know why Naum was held by the court but its likely because the Court didn’t want to address the federalism argument until it first decided the more minor issue of good faith and its application to the statutory text."

     

The Doctor Patient Forum

Claudia A. Merandi 5 Chedell Avenue / East Providence, RI 02914 / USA 1.401.523.0426

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