FSAM NEWS

Deep Cuts for Mental Health and Substance Abuse Treatment Programs

2012-02-15T19:49:00.001-08:00

Attached a link State Senate proposes $87 million cut in mental health, substance-abuse programs to an article titled " State Senate proposes $87 million cut in mental health, substance-abuse programs" reporting that a Florida Senate proposal would make deep cuts in funding for adult mental health and substance-abuse programs, and entirely eliminate support for some of them.The proposal would slash overall state spending on adult mental health and substance-abuse treatment by about 40 percent, or $87 million.The cuts would include eliminating state support for some programs — including, potentially, the Miami Behavioral Health Center and the Northside Mental Health Center in Tampa.Sen. Joe Negron, the Stuart Republican in charge of the Senate’s healthcare budget, stated that “When it comes to funding, an 85-year-old woman in a nursing home matters more to me than a 45-year-old guy with a substance-abuse problem,” he said. “It’s all about priorities.”Unfortunately, his statement reveals that most politicians have yet to understand that mental health and substance abuse treatment represents cost-effective care! The benefits of treatment far outweigh the costs. Even beyond the enormous physical and psychological costs, treatment can save money by diminishing the huge financial consequences imposed on employers and taxpayers. Comparing the direct cost of treatment to monetary benefits to society determined that on average, costs were $1,583 compared to a benefit of $11,487 (a benefit-cost ratio of 7:1)! In comparing cost offsets in Washington State of people in treatment to non-treated, the authors noted lower medical costs ($311/month); lower state hospital expenses ($48/month);lower community psychiatric hospital costs ($16/month); reduced likelihood of arrest by 16%; and reduced likelihood of felony convictions by 34%!It is a penny wise and pound foolish approach to CUT finding for mental health and substance abuse treatment because in the long run we as tax payers have to pay the higher price for short term political decisions.For more information see Cost Offset Substance Abuse.I urge you to e-mail, call or write Senator Negron!YoursBernd

Ban on Bath Salts

2012-02-15T19:26:00.001-08:00

Attached a link http://www.miamiherald.com/2012/02/14/2641748/lawmakers-seek-to-expand-bath.html to an interesting article titled "Lawmakers seek to expand bath-salt ban" reporting that Florida lawmakers want to make it a third-degree felony to manufacture or sell new synthetic drugs which have returned to convenience-store shelves.The drugs – which are marketed as herbal smokes, incense, bath salts, plant food and cleaning products – have been problematic throughout the state. Last year, the Florida Legislature banned several forms of synthetic cathinones, or bath salts, that had become popular among teenagers. Lawmakers also banned synthetic cannabinoids, known informally as K2. The drugs have been known to cause violent hallucinations, paranoia, muscle damage and kidney failure.In Charlotte County, three high-school students were recently hospitalized after overdosing – and a fourth had to be restrained after chasing his father around the house with a machete while hallucinating, Sheriff Bill Cameron said.I wholeheartedly support the measure but we certainly have to play catchup during the next legislative session to respond to new synthetic drugs which are going to be developed by clever chemists.We should brainstorm to develop ideas on how to respond to the synthetic drug challenge. Please feel free to share your suggestions on our blog at http://fsamnews.blogspot.comYoursBernd

We Are Making Progress

2012-02-10T20:26:00.001-08:00

Attached a link http://www.sun-sentinel.com/news/opinion/editorials/os-pain-pills-editorial-0209-20120209,0,3698549.story to an interesting article published in the Sun Sentinel titled "Pill mill law sends 'pillbillies' packing."Indeed, we are making great progress: "In a state that had garnered the humiliating national reputation as the go-to state for Oxycontin, the number of oxycodone pills purchased last year by Florida doctors plunged an astonishing 97 percent. Overall oxycodone sales dropped 20 percent, according to figures from the Drug Enforcement Administration. Didn't hurt that the roster of the top 100 oxycodone-buying doctors shed its overwhelmingly Florida vibe. Two years ago, 90 of the top 100 doctors hailed from Florida; last year, only 13 made the list."But more work needs to be done!! We need to create awareness among our fellow colleagues to sign up for and to use the PDMP in their daily practice of medicine; we need to close loopholes that exempt doctors from using the PDMP which includes ALL physicians employed by the Veteran Administration resulting in a sharp increase of opioid use by VA patients. I also suspect that those patients represent a source for illegal prescription opioid street sales.Furthermore, we must identify those doctors in the community which still prescribe prescription opioids in large amounts contributing to overdose deaths of patients. Even though I believe in educating them about safe prescription practices I also advocate for swift revocation of their licenses to protect the public from their actions.Looking forward to your comments.YoursBernd

Addiction and Brain Changes

2012-02-05T21:22:00.000-08:00

Attached a link Abnormal Brain Structure Implicated in Stimulant Drug Addiction to an interesting article published in a recent edition of Science. The authors report that they discovered abnormalities in fronto-striatal brain systems implicated in self-control in both stimulant-dependent individuals and their biological siblings who have no history of chronic drug abuse; these findings support the idea of an underlying neurocognitive endophenotype for stimulant drug addiction.
Drug dependence is increasingly recognized as a “relapsing brain disorder”and, in support of this view, marked structural changes in striatal and prefrontal brain regions have been reported in people dependent on stimulant drugs . These reports, however, raise the question of whether these brain abnormalities may have predated drug-taking, rendering individuals vulnerable for the development of dependence.
Individuals at risk for drug dependence typically have deficits in self-control, which may reflect a diminished ability to recruit prefrontal networks for regulating behavior. Stimulant drugs are highly reinforcing, because they directly affect brain systems implicated in motivated behavior, such as the basal ganglia and the limbic system, and they modulate control systems in the prefrontal cortex. Malfunction of these circuitries may increase the susceptibility for stimulant-induced neuroadaptive changes and facilitate the development of drug dependence.
In the study they compared brain structure and the ability to regulate behavior in 50 biological sibling pairs; within each pair, one sibling satisfied the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for dependence on stimulant drugs and the other had no history of chronic drug or alcohol abuse. The sib-pairs were also compared with 50 unrelated healthy volunteers matched for age and intelligence quotient.
The findings indicate that gray matter changes in the dorsal striatum, together with abnormal inferior prefrontal cortical connectivity, underlie an increased risk for developing stimulant drug dependence. However, the almost equivalent impairments in SSRT (Stop-Signal Reaction Time) in both the stimulant-dependent individuals and their unaffected siblings need careful interpretation, as they do not reflect the classic pattern for endophenotypes, i.e., that the first-degree relatives have trait values intermediate between the patients and the unrelated healthy volunteers. Presumably, the siblings must have some other resilience factors that counteract the familial vulnerability to drug dependence. The identification of these brain and behavioral biomarkers for familial risk of drug dependence demonstrates that an individual’s predisposition to become addicted to stimulant drugs may be mediated by brain abnormalities linked to impaired self-control.

Stratify Patients for Opioid Misuse and Abuse Risk : Internal Medicine News

2012-02-05T20:09:00.000-08:00

Attached a link Stratify Patients for Opioid Misuse and Abuse Risk : Internal Medicine News to an interesting article titled " Stratify Patients for Opioid Misuse and Abuse Risk" to assess which of your patients is likely to misuse or abuse opioid medications.
The risk stratification tool utilized in the article is based on quantitative opioid misuse assessment such as the Opioid Risk Tool (ORT) http://www.opioidrisk.com/node/887
Looking forward to your comments.
Yours
Bernd

Binge Drinking

2012-01-16T18:38:00.001-08:00

PostAccording to a recent study by the Centers for Disease Control and Prevention about one out of six adults in the United States is a binge drinker.Results http://www.cdc.gov/media/releases/2012/t0110_binge_drinking.html from a 2010 telephone survey show that more than 38 million U.S. adults are binge drinkers, defined as consuming five or more alcoholic drinks in a short period of time for men and four of more for women. The average frequency of binge drinking was four times a month, the study found.Key findings include: Overall, about 1 in 6 U.S. adults surveyed said they had binged on alcohol at least once in the previous month, though it was more than 1 in 4 for those ages 18 to 34. Excessive alcohol consumption, including binge drinking, accounts for an average of 80,000 deaths and 2.3 million years of life lost in the united states each year and costs the U.S. an estimated $223 billion dollars in 2006 or about $1.90 per drink. Binge drinking is responsible for over half of deaths, two-thirds of the years of potential life lost and three-quarters of the economic costs that are due to excessive drinking. Binge drinking was most common among those in the 18 to 34 age group but the frequency was higher among those over age 65. It was most common in the Midwest, New England, Washington, D.C., Alaska and Hawaii, the survey found said. Men were twice as likely as women to binge drink, according to the study Binge drinking is more common among Americans with household incomes of $75,000 or more per year. The study also found that Americans with household incomes of less than $25,000 per year consume more drinks when they binge drink, averaging eight or nine drinks per binge.YoursBernd

Marijuana Legislation

2012-01-12T20:50:00.001-08:00

Attached a link http://blogs.miaminewtimes.com/riptide/2012/01/medical_marijuana_bills_introd.php to an article titled "Medical Marijuana Bills Introduced In Florida Senate and House" reporting that State Sen. Larcenia Bullard (D-Miami) has " fired up a big ol' blunt of legislative reform..", , as her proposal to give Florida voters a chance to legalize medical marijuana was introduced in the Senate. Bullard's bill joins a similar proposal by Rep. Jeff Clemens (D-Lake Worth) in the House -- the first time in decades that both Florida chambers have had marijuana reform bills at the same time. Both the House and the Senate resolution would put the legalization of medical pot into the hands of voters, adding a statewide referendum later this year that would need 60 percent approval to pass.Sixteen other states around the country have already legalized some uses of marijuana; Miami Beach advocates recently collected enough signatures to force a vote on whether to decriminalize small amounts of weed, although the city attorney is still contesting that referendum.Sen. Larcenia Bullard, D-Miami, who is sponsoring the bill in the Senate, said that what started as a courtesy filing has become a cause for her, after she started looking into it. Her belief that it should pass stems from 1) wanting to de-glamorize it for young people who are looking to do something illegal, and 2) the medical relief it offers to those who need it. And it’s good for the state budget, too, she said.“The state spends $288 million of effort due to the prohibition of marijuana,” she said, adding that it could also be a source of tax revenue.For more information and the original text of both resolutions see HJR 353 at http://www.myfloridahouse.gov/Sections/Documents/loaddoc.aspx?FileName=_h0353__.docx&DocumentType=Bill&BillNumber=0353&Session=2012 and SJR 1028 at http://www.myfloridahouse.gov/Sections/Documents/loaddoc.aspx?FileName=_s1028__.DOCX&DocumentType=Bill&BillNumber=1028&Session=2012.I strongly urge all of you to OPPOSE such initiatives to legalize and promote the medical use of marijuana!!!There is currently no conclusive evidence that marijuana, in the smoked form, has accepted medical use for treatment. Furthermore, marijuana has a high potential for abuse and lacks the safety of medical supervision. The science, though still evolving, is clear: marijuana use is harmful. Marijuana smoke contains more than 400 chemicals, including most of the harmful substances found in tobacco smoke. While marijuana may provide relief from pain, it is also associated with dependence, respiratory and mental illness, poor motor performance, and cognitive impairment, among other negative effects. According to recent surveys marijuana use among youth is on the rise. Nearly two thirds (63 percent in 2009) of the first time users of marijuana are below the age of 18. Research shows that people who used marijuana before age 15 are six times more likely to develop a substance use disorder later in life than those who did not start using until they were 18 or older. Making marijuana more available through legalization efforts will lead to greater use and increased dependence. We already know that about 10 percent of marijuana users develop marijuana dependence which costs our communities monetarily and socially. Prolonged marijuana use is associated with lower test scores and lower educational attainment. This drug affects the user’s ability to learn and process information, thus influencing attention, concentration, and short-term memory. I ask for the active support of the Florida Society of Addiction Medicine to lobby against these two House and Senate resolutions.I look forward to your comments.YoursBernd

Florida PDMP Update

2012-01-11T19:45:00.001-08:00

Attached you find the link https://docs.google.com/viewer?url=http%3A%2F%2Fwww.eforcse.com%2Fdocs%2FPDMP_Annual_Report_2011_FINAL.pdf to the 2010-2011 Prescription Drug Monitoring Program Annual Report.The information collected in the database is available to registered health carepractitioners to help guide their decisions in prescribing and dispensing certain highly abused prescription drugs. It may also assist health care practitioners in identifying patients who are “doctor shopping” or trying to obtain multiple prescriptions for the same controlled substance from multiple health care practitioners, which is a felony in the State of Florida. The PDMP became operational on September 1, 2011, when it began receiving controlled substance dispensing data from pharmacies and dispensing practitioners. Health care practitioners began accessing the data reported to the PDMP on October 17, 2011, and Law Enforcement Agencies began requesting PDMP reports during the course of active investigations on November 14, 2011Here are some highlights: As of November 15, 2011.Number of Pharmacies/Dispensers who have reported to the PDMP 5,502. Number of prescription records reported to the PDMP 21,248,872 For this reporting period, 873,814 INDIVIDUALS filled prescriptions for Schedule II drugs and 2,567,209 for Schedule II and III drugs. The report also identified that 2,710 of the individuals died with at least one prescription drug in their system that was identified as the cause of death. Among the licensed professionals, pharmacists have the highest registration rate, with over 9.7% registering. Roughly 3.7% of all medical doctors and osteopathic physicians and 2% dentists have registered as of November 15, 2011. BUT 56,218 licensed PRESCRIBERS in Florida issued one or more controlled substance prescriptions and most probably do NOT check the PDMP. Number of PDMP Queries by Registered Users: October 2011 34,486 November 2011 71,928 TOTAL 106,414 Number of Data Request by Law Enforcement 36 !!This demonstrates that we have a wealth of data available on which we can base our prescription decisions BUT only 3.7% of all medical doctors in Florida choose to use the system!! Furthermore, the available data indicates that law enforcement is far less "trigger happy" to access the data than previously claimed.What problem(s) remain? More physicians should be encouraged to use the PDMP. Otherwise, we have to consider mandating its use prior to the issuance of a controlled substance prescription. I personally use the program each time I issue a Schedule II,III or IV prescription and have discovered quite a few surprises!! In 2009, 223,700 controlled substance prescriptions were dispensed by out-of state pharmacists in Alabama, Louisiana, North Carolina, Arizona, and Vermont for prescriptions written by Florida prescribers. Currently health care practitioners licensed outside the state of Florida are not allowed access to Florida’s PDMP prior to dispensing. Therefore, we need to allow for exchange of Florida PDMP data with other state PDMP programs which will enable health care practitioners and law enforcement officers to determine if their patient/subject has received controlled substance prescription drugs in the State of Florida.YoursBernd

US Healthcare Costs

2012-01-08T19:51:00.001-08:00

According to the latest edition of "Health at a Glance" http://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2011_health_glance-2011-en published by the Organization for Economic Co-operation and Development (OECD) The United States stands out as performing very well in the area of cancer care, achieving higher rates of screening and survival from different types of cancer than most other developed countries. The United States does not do well in preventing costly hospital admissions for chronic conditions, such as asthma orchronic obstructive pulmonary disease, which should normally be managed through proper primary care. Avoidable hospital admissions for asthma complications and chronic obstructive pulmonary disease (COPD) are much greater in the United States than the OECD average. For asthmaadmissions, the rate in the United States was 121 per 100 000 adults in 2009, more than two times greater than the OECD average of 52. For COPD, hospital admission in the United States was 230 per 100 000 adults, compared with an OECD average of 198. Regarding healthcare expenditures the United States spent 17.4% of GDP on health in 2009, much more than the OECD average of 9.6%. Spending per person is two-and-a-half times higher than the OECD average. Following the United States were the Netherlands, France and Germany, which allocated respectively 12.0%, 11.8% and 11.6% of their GDP to health.Is US health spending higher due to higher prices or higher service provision? (or both?)Facts:1) US prices for a set of hospital services is over 60% higher than the average of 12 OECD countries,2) US prices for certain procedures (including appendectomy,coronary angioplasty, coronary artery bypass graft, hip & knee replacement) are much higher than in other OECD countries,3) Almost DOUBLE the spending on Insurance administration expressed in terms of purchasing power parity.Its also of interest to note that in most countries, health spending is largely financed out of taxes or social security contributions, withprivate insurance or ‘out-of-pocket’ payments playing a significant but secondary role. This is not the case in the United States which, together with Mexico and Chile, is the only OECD country where the government plays the smallest role in financing health spending. The public share of health expenditure in the United States was 47.7% in 2009, much lower than the OECD average of 71.7%. However, the level of health spending in the United States is so high that public (i.e. government) spending on health per capita is greater than in all other OECD countries, except Norway and theNetherlands. For this amount of public expenditure in the United States, government provided in 2009 insurance coverage only for the elderly and disabled people (through Medicare) and some of the poor (through Medicaid and the State Children’s Health Insurance Program, SCHIP), whereas in most otherOECD countries this was enough for government to provide universal health insurance. Public spending on health in the United States has been growing more rapidly than private spending since 1990, largely due to expansions in coverage.Private insurance accounted for 33% of total health spending in the United States in 2009, by far the largest share among OECD countries. Beside the United States, Canada and France are the only two other OECD countries where private insurance represents more than 10% of total health spending.Conclusions: we are spending more for healthcare per person than in any other country in the world utilizing an inefficient private insurance model. But also public (i.e. government) spending on health per capita is greater than in all other OECD countries but fails to provide universal coverage.We must achieve a broad based consensus on how to efficiently allocate our healthcare resource to achieve high quality healthcare for all Americans.Tinkering on the edge will not provide us with a meaningful and sustainable solution. If we do not engage in such a dialogue now we will face rationing and further economic slowdown.YoursBernd

Pharmacies and Pill Mills

2012-01-02T19:54:00.001-08:00

Attached a link http://www.miamiherald.com/2011/12/24/2560690/painkiller-peddlers-pharmacies.html to an important article you might have missed titled "Painkiller peddlers: Pharmacies targeted in pill-mill crackdown" published in the Miami herald on December 24th, 2011.The article reports that according to a federal indictment an ordinary mom-and-pop pharmacy, conveniently located on the first floor of the Stephen P. Clark Government Center, the 28-story heart of Miami-Dade County government, steps from a heavily used Metromover stop, was actually operating as a pill mill illegally trafficking in painkillers, part of a wave of rogue pharmacies that have become the new front line in the continuing war on prescription drug abuse in Florida.In the emergency order suspending the owner's pharmacy permit based on the U.S. Drug Enforcement Administration investigation, the Florida Department of Health said he posed a serious danger to the public health and showed reckless disregard for pharmacy laws and rules by dispensing excessive or inappropriate dosages of oxycodone and oxymorphone. The four Robert’s Drug stores purchased a total of 1,692,700 tablets of oxycodone between Jan. 1 and June 1 this year, according to the DEA. A state expert said in state documents that an 80-mg. daily dose of oxycodone “is potentially lethal” for some people but that Aryan’s customers routinely received far more.But there aslo good news to report: After a three-year investigation, federal authorities dismantled four of the nation’s largest pain clinics in August along with two pharmacies and one pharmaceutical supplier. Thirty-two people from across South Florida were indicted. Over the years, the enterprise doled out 20 million pills and profited $40 million from illegal sales of controlled substances. In July, federal authorities arrested a family of five charged as part of a drug and money laundering enterprise based at a Plantation pharmacy. From April, 2009 to May, 2010, the pharmacy ordered 1,038,560 tablets of oxycodone, more than 28 times the national average for dispensing pharmacies, according to federal documents. The profits: nearly $2 million.Last month, CVS — with more than 700 stores in the state — notified a small number of Florida physicians that it will no longer fill their prescriptions written for Schedule II narcotics, including oxycodone, a measure to “prevent drug abuse and keep controlled substances out of the wrong hands,’’ according to a statement.Looking forward to your comments.Happy New YearYoursBernd

Oxycontin in the News

2012-01-02T19:42:00.000-08:00

Attached a link http://www.pressdisplay.com/pressdisplay/viewer.aspx to an interesting article titled "Stronger form of Oxycodone means more pain for the US" published in the Sun Sentinel on December 29th, 2011.In this commentary the author points out that "several drug companies are completing FDA trials to introduce a new, much stronger form of Oxycodone to the $10 billion opiate prescription drug market in 2013. Unlike the more than 400 opiate pain killers already on the market that blend the powerful narcotic with other medications, the new drug is solely composed of pure Oxycodone. It will be very potent, delivering up to 10 times more pain relief than present prescriptions."Whereas all of us are struggling to contain the prescription drug epidemic, pharmaceutical companies, driven by the profit motive, seem to have found a business opportunity to sell more powerful narcotics to the ever growing number of opioid dependent addicts.Therefore, I agree with the authors conclusion: "If tobacco companies are forced to contribute a portion of each sale of a cigarette pack to pay for the effort to curb tobacco use and the financial and medical consequences cause by American smoking cigarettes, why not the manufacturers of the most abused addictive prescriptive drug in the United States? It is time to make politically powerful drug companies responsible and accountable for their destructive products. They, not U.S. taxpayers, should have to bear the brunt of the financial and social burdens from rampant illegal misuse of Oxycodone."Looking forward to your comments.Happy New YearYoursBernd

Among Teenagers Marijuana Use on the Rise

2011-12-17T19:52:00.000-08:00

More teens are turning to pot and see it as less of a risk at the same time alcohol use among the same age group has dipped to historic lows, according to an annual national survey of drug use released Wednesday. The findings were based on a survey of 47,000 eighth-, 10th- and 12th-graders conducted by the University of Michigan for the National Institute on Drug Abuse ( see http://www.ns.umich.edu/new/multimedia/9-videos/20124-marijuana-use-continues-to-rise-among-us-teens-while-alcohol-use-hits-historic-lows).Among the more important findings from this year's Monitoring the Future survey of U.S. secondary school students are the following:Marijuana use among teens rose in 2011 for the fourth straight year—a sharp contrast to the considerable decline that had occurred in the preceding decade. Daily marijuana use is now at a 30-year peak level among high school seniors.Synthetic marijuana," which until earlier this year was legally sold and goes by such names as "K2" and "spice," was added to the study's coverage in 2011; one in every nine high school seniors (11.4%) reported using that drug in the prior 12 months.Alcohol use—and, importantly, occasions of heavy drinking—continued a long-term gradual decline among teens, reaching historically low levels in 2011.Energy drinks are being consumed by about one third of teens, with use highest among younger teens.SUMMARY:The proportion of young people using any illicit drug has been rising gradually over the past four years, due largely to increased use of marijuana—the most widely used of all the illicit drugs.The proportion of students reporting using any illicit drug other than marijuana has been following a gradual decline for some years, but has remained fairly stable over the most recent three years, with 2011 levels being similar to the 2008 levels. YoursBernd

Florida Medicaid Pilot

2011-12-16T21:33:00.001-08:00

On Thursday the federal officials agreed to extend Florida's five-county Medicaid managed-care experiment to 2014 but required the state to make significant improvements to the program. They include the denial of the medical-loss-ratio waiver requiring the participating private health plans to spend 85 percent of funds on patient care and the denial to cap benefit levels for Medicaid beneficiaries preventing the termination of Medicaid services because recipients had already met their $500,000 maximum for the year. These requirements will protect patients from arbitrary insurance service denials and will force private health insurance plans to manage taxpayers dollars efficiently and responsibly. Meanwhile, we should continue to oppose any expansion of the pilot project UNLESS the State of Florida can provide solid and indisputable data that the pilot project improves access and enhances the quality of care for all Medicaid enrollees. So far I have not found any evidence to substantiate Governor Scott's claim that "we've seen higher quality in administration of care, produced cost savings and consumers in the pilot have found improved access for Medicaid recipients."Looking forward to your feedback.YoursBernd For more information see:http://htpolitics.com/2011/12/15/feds-make-key-decisions-on-medicaid-and-health-insurance-for-floridianshttp://blogs.orlandosentinel.com/news_politics/2011/12/what-is-changing-in-florida-medicaid-maybe.html

Prescription Drug Abuse Update

2011-12-14T18:41:00.000-08:00

Attached you find facts and information regarding the prescription abuse epidemic in the US and Florida: In October 2011 the Drug Enforcement Administration on Friday announced the formation of a new squad created to solely investigate the illegal use and distribution of prescription drugs in Central Florida. That squad is investigating rogue doctors and pharmacies, and details of their first probe — involving a Winter Park pharmacy — was one of several cases statewide announced by the nation's top law-enforcers. In this context it is of concern in June 2011, DEA received 263 applications for new pharmacy licenses nationwide. Of those, 139 were from Florida. That means that the drug dealers in white coat referring their "patients" to "friendly" pharmacies to fill their prescriptions for controlled substances. Most of these clinics are probably owned by the same business people who run pain clinics.About 170,000 Medicare patients sought prescriptions for frequently abused drugs from five or more physicians and other health professionals in 2008, a Government Accountability Office analysis of claims data found.The Oct. 4 report accused 1.8% of the Part D beneficiary population of doctor shopping for one or more of 14 abused drugs, such as painkillers hydrocodone and oxycodone. Spending on the drugs cost the program $148 million, representing 5% of the total spent on these drugs in 2008. Some examples quoted in the report include: One Georgia patient obtained prescriptions for a 1,679-day supply of oxycodone pills from 58 prescribers, the GAO said. A physician treating the patient recalled her asking for early refills of the painkiller repeatedly; A patient in California received prescriptions for fentanyl from 21 prescribers in 2008. The patient's physician later received a letter from the state prescription drug-monitoring program informing her that within a four-month period the patient had 33 prescriptions from 10 prescribers. The physician then notified the patient that she would no longer treat the patient. The best way to prevent doctor shopping is through state prescription drug-monitoring programs. Each of us by now should have access to E-FORCSE, Florida's Prescription Drug Monitoring Program, and use it to look up each and every patient who is being prescribed a controlled substance. The House of Representatives voted on 12.08. 2011 to ban synthetic drugs nicknamed "bath salts" and other compounds that mimic marijuana, cocaine and methamphetamines (http://www.miamiherald.com/2011/12/08/2537445/house-votes-to-ban-synthetic-drugs.html#ixzz1gZAWX7YG).Rep. Charlie Dent, R-Pa., said his legislation identifies chemical compounds that affect the brain in ways similar to THC, the active ingredient in marijuana. They would be added to the highly restrictive Schedule I of the Controlled Substances Act.The bill also bans chemical compounds in synthetic drugs marketed as "bath salts" or "plant food" and under brand names such as K2 and Spice that have been used as substitutes for cocaine and other narcotics. They are now sold legally in some states.The vote was 317-98, with some Democrats saying the bill went too far in restricting chemicals that could be valuable to researchers looking for cures to diseases such as Parkinson's disease. When a drug is placed on Schedule I, said California Democrat Zoe Lofgren, "It becomes difficult to obtain not only for illegal purposes but for researchers who wish to study its pharmaceutical and medical potential.A Miami Herald editorial titled "Dangerous prescription" the Miami Herald called for a federal law banning the online sale of narcotics. Such a legislation must be enforced through a strong, combined effort. Authorities along with domain registering websites, social media networks and credit card companies need to be alert to spot online pill mills and report suspicious activity involving illegal, counterfeit and dangerous products. We should strongly support such efforts because questionable online pharmacies skillfully abuse loopholes to provide anyone with controlled substance of their choice provided they can pay. Read more: http://www.miamiherald.com/2011/12/09/2539336/dangerous-prescription.html#ixzz1gZByFnoW

Personhood Amendment

2011-11-02T21:22:00.001-07:00

On November 8th Mississippi voters will be asked to decide on a proposed amendment to the state constitution, which would define as a person “every human being from the moment of fertilization, cloning, or the functional equivalent thereof.” For most voters it sounds like a good idea and it will most probably pass. Therefore, several other states, including Florida http://personhoodfl.com/, are preparing similar constitutional amendments. Florida Senate Majority Leader and former US Senate Candidate Mike Haridopolos recently signed the FL Personhood Amendment!! The ambiguous language in the Florida and Mississippi 'personhood' amendment are intentionally not being represented properly by the proponents of this ballot initiative.A recent New York Times article http://www.nytimes.com/2011/10/31/opinion/mississippis-ambiguous-personhood-amendment.html correctly points out the following problems: "First, what does “fertilization” mean? As embryologists recognize, fertilization is a process, a continuum, rather than a fixed point. The term “fertilization” — which is sometimes considered synonymous with “conception” — could mean at least four different things: penetration of the egg by a sperm, assembly of the new embryonic genome, successful activation of that genome, and implantation of the embryo in the uterus. The first occurs immediately; the last occurs approximately two weeks after insemination (or, in the case of embryos created through in vitro fertilization that do not get implanted, never). Thus, on some reasonable readings of the amendment, certain forms of birth control, stem cell derivation and the destruction of embryos created through in vitro fertilization would seem impermissible, while on other equally reasonable readings they are not." Following the "logic" of the "personhood" advocates doctors can be charged with manslaughter or even murder by prescribing morning after pills, because it can irritate the lining of the uterus (endometrium) so as to inhibit implantation of a fertilized egg, i.e. "killing a person."A doctor could also be criminally charged by inserting an IUD because it adversely affects a new embryo as it enters the uterus, thus preventing it from implanting in the uterine lining . Again, according to the "personhood" advocates this constitutes the "killing of a person."Even though, abortions are still being protected by federal law women may still face criminal charges according to state law.Other unintended consequences include the question if the treatment of an ectopic or a molar pregnancy requires first a court order to overrule a "personhood" amendment in the respective state constitution. Needless to mention that any delay of these time-sensitive treatment decisions may harm the mother and even jeopardize the life and well-being of a women.I urge all of you to speak up against any such ballot initiatives, to protect the physician-patient relationship and to guard against further state intrusion into our lives.YoursBernd

Drug Treatment Instead of Prison

2011-10-30T20:04:00.001-07:00

Attached a link http://www.sun-sentinel.com/news/opinion/editorials/fl-prison-bill-editorial-dl-20111030,0,3676874.story to an interesting editorial published in today's Sun Sentinel titled " State prisons need drug treatment alternative."The Sun Sentinel Editorial Board supports legislation — CS/HB 177 and SB 448 — which intends to establish a re-entry program for nonviolent offenders that offers intensive substance abuse treatment, adult education courses and vocational training as alternatives to long prison sentences. The idea is to reduce recidivism, which is essential if state officials want to get a handle on the costs of incarceration.The bills are sponsored by State Sen. Ellyn Bogdanoff, R-Fort Lauderdale, and State Rep. Ari Porth, D-Coral Springs. The two lawmakers are trying to pass needed, positive legislation to help the state of Florida reduce the costs of operating its prisons.In my opinion we should support this legislation and begin lobbying members of the Florida House and Senate. E-mail, twitter, mail or call your representative because " Unlike prison privatization and the more controversial ideas to cut state prison costs, the re-entry program is a simple solution that promises both savings and a much-needed reduction in the state's ongoing recidivism problem."YoursBernd

Substance Abuse Counseling and Preventive Health Care

2011-10-30T19:50:00.000-07:00

Attached a link http://www.ama-assn.org/amednews/2011/10/17/bica1017.htm to an interesting article titled "Counseling on alcohol helps patients and is billable" published in AMA News and posted on October 17th, 2011. Several highlights:

* Since early 2011, many commercially insured patients have been able to receive alcohol counseling paid at 100% with no co-pay or deductible, and the same is expected to be true for Medicare beneficiaries as of Jan. 1, 2012.
* Just asking about alcohol abuse will not necessarily lead to reimbursable payment, but treating those who screen positive most probably will. In addition to the usual fee-for-service, other incentives on the table should further make dealing with the issue more financially feasible for practices and make it more likely that patients will enter treatment.
* Tracking the percentage of adolescents and adults with new episodes of alcohol or other drug dependence who initiate treatment is on the list of eligible professional measure specifications from the Centers for Medicare & Medicaid Services.
* Information should be noted in the patient's chart, along with the time spent on this task. Counseling sessions longer than 15 minutes are billable, but shorter ones are not.
* On July 19, CMS issued a proposed decision memo stating that, as of Jan. 1, 2012, Medicare will cover annual alcohol misuse screening. (A final decision has not yet been made.) Under the proposal, Medicare would pay for four brief, face-to-face behavioral counseling interventions a year. The American Medical Association and other medical societies support his move.
* In addition, alcohol misuse screening and counseling is on the list of preventive services that non-grandfathered health plans must cover at 100% with no deductible or co-pay, according to the Patient Protection and Affordable Care Act. Grandfathered health insurance plans are those that have not changed since the health system reform law was enacted. Non-grandfathered ones are new policies issued after Sept. 23, 2010, and must cover a recommended list of preventive services with no cost-sharing with patients.
* When billing private insurers, the CPT codes are 99408 for an intervention lasting 15 to 30 minutes. An intervention longer than 30 minutes should be coded 99409. H0049 is the code for alcohol and drug screening of Medicaid beneficiaries. H0050 can be used for every 15 minutes of intervention. The services can be provided by a nurse practitioner or physician assistant as well as a physician.

Yours
Bernd

Drug Testing Halted

2011-10-26T19:14:00.001-07:00

Attached a link http://www.miamiherald.com/2011/10/24/2470519/florida-welfare-drug-testing-halted.html to another article titled "Florida's welfare drug testing halted by federal judge" reporting that A federal judge in Orlando on Monday temporarily blocked Florida’s controversial law requiring welfare applicants be drug tested in order to receive benefits. Judge Mary Scriven issued a temporary injunction against the state, writing in a 37-page order that the law could violate the Constitution’s Fourth Amendment ban on illegal search and seizure.Gov. Rick Scott, who signed the measure into law on May 31, touted it as a way to ensure taxpayer money isn’t “wasted” on those who use drugs. “Hopefully more people will focus on not using illegal drugs,” he said then.
But, in her order, Scriven issued a scathing assessment of the state’s argument in favor of the drug tests, saying the state failed to prove “special needs” as to why it should conduct such searches without probable cause or reasonable suspicion, as the law requires. “If invoking an interest in preventing public funds from potentially being used to fund drug use were the only requirement to establish a special need,” Scriven wrote, “the state could impose drug testing as an eligibility requirement for every beneficiary of every government program. Such blanket intrusions cannot be countenanced under the Fourth Amendment.”
Fortunately, our legal system still provides protection against the growing government intrusion in our lives spearheaded by a conservative majority in our legislature. We need to continue to push back the growing number of bills threatening not only the practice of medicine but also the freedoms each and every citizen is entitled to.
Yours
Bernd

Florida Prescription Drug Monitoring Program

2011-10-26T18:59:00.000-07:00

Attached a link http://www.usatoday.com/news/nation/story/2011-10-13/pill-mill-drug-trafficking/50896242/1?loc=interstitialskip to an interesting article in USA Today titled "States target prescriptions by 'pill mills'" highlighting the Florida painmill problem, the actions taken to combat this issue which include the Prescription Drug Monitoring Program ( PDMP) . We should be ware that the death rate from oxycodone in Florida increased 265% from 2003 to 2009, the CDC found. By 2009, the number of deaths involving prescription drugs was four times the deaths involving street drugs, the CDC said in a July report. Hopefully, the number will decrease but this requires our active participation and support INCLUDING our use of the just recently launched PDMP, or E-FORCSE.
I am using this program now for the last week and am pleased to report that it truly works! For example, I have implemented a protocol which requires that the prescription record of each and every patient who receives a controlled substances has to be crosschecked with the medication listed on E-FORCSE.
I have already discovered that several of my patients did not inform me that they visit different physicians to receive controlled substances. One patient who is currently being treated with Suboxone received prescriptions for a total of 360 Hydrocodone pills from another MD "specializing" in pain management. I called her and she was very surprised to find out that I knew what she was prescribed. She tried to convince me that she only fills these scripts for "psychological reasons" but is not taking but hoarding them at home. I asked her to come to my office for a follow-up visit including drug testing but she never showed up. I suspect that she may sell, or share this medications with others.
I urge you to obtain your username and password and to incorporate this valuable tool into your practice.
Yours
Bernd

Medicaid and Suboxone

2011-09-05T18:17:00.001-07:00

"The evidence does not support rationing buprenorphine to save money or ensure safety."

Attached you find a link http://content.healthaffairs.org/content/30/8/1425.abstract to a very interesting article from the recent edition of "Health Affairs" titled "The Evidence Doesn’t Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine" arguing that the evidence does not support rationing buprenorphine to save money or ensure safety.

ABSTRACT:

Many state Medicaid programs restrict access to buprenorphine, a prescription medication that relieves withdrawal symptoms for people addicted to heroin or other opiates. The reason is that officials fear that the drug is costlier or less safe than other therapies such as methadone. To find out if this is true, we compared spending, the use of services related to drug-use relapses, and mortality for 33,923 Massachusetts Medicaid beneficiaries receiving either buprenorphine, methadone, drug-free treatment, or no treatment during the period 2003–07. Buprenorphine appears to have significantly expanded access to treatment because the drug can be prescribed by a physician and taken at home compared with methadone, which by law must be administered at an approved clinic. Buprenorphine was associated with more relapse-related services but $1,330 lower mean annual spending than methadone when used for maintenance treatment. Mortality rates were similar for buprenorphine and methadone. By contrast, mortality rates were 75 percent higher among those receiving drug-free treatment, and more than twice as high among those receiving no treatment, compared to those receiving buprenorphine. The evidence does not support rationing buprenorphine to save money or ensure safety.

PDMP goes online!

2011-09-03T17:41:00.001-07:00

Attached a link http://www.miamiherald.com/2011/09/01/2385732/fla-prescription-data-base-goes.html to an article from today's Miami Herald titled " Fla. prescription database goes into operation" highlighting the fact that as of September 1st Florida's prescription drug tracking system finally was up and running. That means that dispensers and pharmacies must upload their prescription data for Schedule II to IV to the database. Rebecca Poston, the system's program director in the Department of Health said that "Everything is working wonderful, I have not heard of any glitches related to the dispensers registering or uploading information in the system."
The Department of Health will not begin registering doctors and pharmacists until Oct 1, nor will they be able to get information out of the database until Oct. 17. In my opinion the registration and training process should start now and be phased in either by region, or other criteria to be determined by the Department to allow for a smooth transition and to motivate doctors to use the system. Its not too late to do that but leaving it until October 1st is cutting it too short.
Yours
Bernd

Pill Mills Under Pressure

2011-09-01T19:48:00.001-07:00

Attached a link http://www.nytimes.com/2011/09/01/us/01drugs.html to today's New York Times front page article titled "Florida Shutting ‘Pill Mill’ Clinics."
The article highlights the accomplishments made despite the initial resistance by the current administration in Tallahassee.:

As of July, Florida doctors are barred, with a few exceptions, from dispensing narcotics and addictive medicines in their offices or clinics. As a result, doctors’ purchases of Oxycodone, which reached 32.2 million doses in the first six months of 2010, fell by 97 percent in the same period this year.
One indication that law enforcement officials are choking the supply of prescription drugs sold illegally in Florida is that the price of Oxycodone on the streets here has nearly doubled from last year, to $15 per pill from $8.
On Commercial Boulevard, a major street in Broward County, the number of pain clinics has fallen in the past year from 29 to one.
The fallout from the tougher laws may include an increase in pharmacy robberies, a problem that has been worse in Florida than any other state since 2007 (there were 65 armed robberies of pharmacies here last year).

As of today any health care practitioner who has dispensed a Schedule II-IV controlled substance, as defined in section 893.03, F.S. (i.e., OxyContin®, Percocet®, Vicodin®, Klonopin®, Xanax®, and Valium®), is required to report dispensing information to the Prescription Drug Monitoring Program’s database within seven (7) days after dispensing, in accordance with section 893.055, F.S. This includes pharmacies licensed under chapter 465, F.S., and dispensing health care practitioners licensed under chapter 458, 459, 461, 462, or 466, F.S
Now we must push to start educate physicians on how to use the PDMP and to encourage accessing the database to identify "doctors shoppers."
I am optimistic that we can achieve our goals.
Yours
Bernd

Drug Testing for Welfare Recipients

2011-08-27T06:06:00.001-07:00

Attached some food for thought regarding the mandatory drug testing for welfare recipients:

When Florida Gov. Rick Scott (R) signed the law requiring welfare recipients to pass annual drug tests to collect benefits, he justified the likely unconstitutional law by saying it would save the state money by keeping drug users from using public money to subsidize their drug habits. Drug use, Scott claimed, was higher among welfare recipients than among the rest of the population.According to preliminary results from the state’s first round of testing, however, has seemingly proven both of those claims false. Only 2 percent of welfare recipients failed drug tests, meaning the state must reimburse the cost of the $30 drug tests to the 96 percent of recipients who passed drug tests (two percent did not take the tests). After reimbursements, the state’s savings will be almost negligible, the Tampa Tribune reports:
Cost of the tests averages about $30. Assuming that 1,000 to 1,500 applicants take the test every month, the state will owe about $28,800-$43,200 monthly in reimbursements to those who test drug-free.
That compares with roughly $32,200-$48,200 the state may save on one month’s worth of rejected applicants.
Net savings to the state: $3,400 to $5,000 annually on one month’s worth of rejected applicants. Over 12 months, the money saved on all rejected applicants would add up to $40,800 to $60,000 for a program that state analysts have predicted will cost $178 million this fiscal year.
This should serve as an example that our government in Florida seems to base its decisions on ideological assumption instead on rational thought and consideration.
Yours

Bernd

Bernd Wollschlaeger,MD,FAAFP,FASAM
16899 NE 15th Avenue
North Miami Beach,FL 33162
Phone: (305) 940-8717
Fax: (305) 940-8871
Web Site: www.miamihealth.com
Blog: http://floridadocs.blogspot.com
Twitter: http://www.twitter.com/dadedoc

Feds Crack Down on Pill Mills

2011-08-24T19:40:00.001-07:00

Attached a link to an article published in today's Miami Herald http://www.miamiherald.com/2011/08/23/2371284/federal-authorities-announce-south.html
reporting that

" For the first time in Florida’s war on prescription drug abuse, investigators are pursuing pill mills as organized crime enterprises — and corrupt doctors as murderers. After a three-year investigation, federal authorities announced the details of Operation Oxy Alley, a sweeping indictment charging 32 people under racketeering statutes for their involvement in South Florida-based pill mills that doled out 20 million oxycodone pills and profited more than $40 million dollars from illegal sales of controlled substances. In a companion indictment, local authorities charged a doctor with first-degree murder in the death of a West Palm Beach man who died within hours of filling a prescription for a painkiller."

"The indictment brought Florida’s prescription medication abuse problem — described by investigators as a homegrown drug epidemic — into sharp focus. Last week, the state’s Medical Examiners Commission released its annual report showing deaths caused by prescription drugs in 2010 were up by about 8 percent. Oxycodone was the cause of death for 2,710 people, about a 28 percent increase since 2009. And about 85 percent of all oxycodone sold comes from Florida."

Its about time!!

Yours
Bernd

The Blues Treatment For Mental Health Providers

2011-08-15T19:49:00.001-07:00

Attached a very troublesome article I just received today reporting that on July 27, 2011 Blue Cross Blue Shield of Florida began notifying ALL of their mental health providers (licensed social workers, licensed mental health counselors, psychologists, and psychiatrists) that effective November 30th, 2011 they would be terminated, without cause.
They were also notified that that if providers would like to join the new companythey are partnering with, New Directions, so that they can provide services to their patrons, they would need to complete a new contract (sent under separate cover) within 15 days and agree to significant cuts (35-55%) in reimbursement rates, as well as other disturbing clauses such as only being able to refer to in-network providers, etc.
Since BCBS is considered to be one of the largest providers of insurance for mental/behavioral health in Florida, this termination could potentially place hundreds/thousands of providers in a position of being underemployed and/or unemployed, and worse, leave thousands of patients without coverage or access to mental health/psychological treatment.

CNN producer note
iReport -
On July 27, 2011 Blue Cross Blue Shield of Florida began notifying ALL of
their mental health providers (licensed social workers, licensed mental
health counselors, psychologists, and psychiatrists) that effective Nov 30,
2011 they would be terminated, without cause. That is, they will no longer
be providers for BCBS-FL. In this notice, current providers were also
instructed to notify BCBS subscribers/patients of this coming termination
directly and on behalf of BCBS-FL.

BCBS-FL also indicated that if providers would like to join the new company
they are partnering with, New Directions, so that they can provide services
to their patrons, they would need to complete a new contract (sent under
separate cover) within 15 days and agree to significant cuts (35-55%) in
reimbursement rates, as well as other disturbing clauses such as only being
able to refer to in-network providers, etc.

Interestingly, New Directions appears to be a subsidiary of BCBS-FL. So, as
if it isn't horrible enough that ALL of the mental/behavioral health
providers have been "fired" at the same time and patients will likely find
themselves with poor quality care or no care at all, it appears that they
(the same company-BCBS-FL) fired its contractors and then offered them the
oportunity to reapply for rehire within the same week, but only if they
agree to sign a new contract, with entirely different terms.

This action (termination of providers only in one area) also seems to be a
possible violation of the Federal Mental Health Parity Law which protects
against the discrimination of mental health services. It does not appear
that any of the other healthcare providers or "medical" providers had their
contracts terminated.

Since BCBS is considered to be one of the largest providers of insurance for
mental/behavioral health in Florida, this termination could potentially
place hundreds/thousands of providers in a position of being underemployed
and/or unemployed, and worse, leave thousands of patients without coverage
or access to mental health/psychological treatment.

The ripple effect of these actions by BCBS-FL could be deadly to the people,
communities, and businesses throughout FL. leaving many unable to make a
reasonable living and thousands (including Seniors with BCBS as a secondary
policy) unable to access and/or pay for mental health treatment and
psychological services.

--
Bernd Wollschlaeger,MD,FAAFP,FASAM
16899 NE 15th Avenue
North Miami Beach,FL 33162
Phone: (305) 940-8717
Fax: (305) 402-2989
Web Site: www.miamihealth.com
Blog: http://floridadocs.blogspot.com
Twitter: @dadedoc

Stoned Drivers

2011-07-24T19:16:00.001-07:00

Attached an article http://www.sun-sentinel.com/news/nationworld/la-na-pot-drivers-20110703,0,7871314.story entitled "Stoned driving is uncharted territory" which was initially published in the Los Angeles Times highlighting the problem of impaired driving, especially as it pertains to the legal and illegal use of marijuana. The most recent assessment by the National Highway Traffic Safety Administration, based on random roadside checks, found that 16.3% of all drivers nationwide at night were on various legal and illegal impairing drugs, half them high on marijuana. The article clearly points out that "As the medical marijuana movement has gained speed — one-third of the states now allow such sales — federal officials are pursuing scientific research into the impairing effects of the drug. The issue is compounded by the lack of a national standard on the amount of the drug that drivers should be allowed to have in their blood. While 13 states have adopted zero-tolerance laws, 35 states including California have no formal standard, and instead rely on the judgment of police to determine impairment. Even the most cautious approach of zero tolerance is fraught with complex medical issues about whether residual low levels of marijuana can impair a driver days after the drug is smoked. Marijuana advocates say some state and federal officials are trying to make it impossible for individuals to use marijuana and drive legally for days or weeks afterward."
Several studies are underway to determine if marijuana can impair drivers and increases the risk for car crashes. A $6-million study in Virginia Beach, Va., is attempting to remove any doubt that users of pot and other drugs are more likely to crash. Teams of federal researchers go to accident scenes and ask drivers to voluntarily provide samples of their blood. They later return to the same location, at the same time and on the same day of the week, asking two random motorists not involved in crashes for a blood sample. The project aims to collect 7,500 blood samples to show whether drivers with specific blood levels of drugs are more likely to crash than those without the drugs, said John Lacey, a researcher at the nonprofit Pacific Institute for Research and Evaluation. In other projects, test subjects are being given marijuana to smoke and then examined under high-powered scanners or put in advanced driving simulators to gauge how it affects their brains and their ability to drive.
But questions remain: Does it mean that there is no amount of marijuana that a person can consume and drive safely immediately afterward? Can we determine whether it is possible to set limits on "safe" marijuana use with, or without, a combination of other substances such as alcohol? An open discussion is indicated to reach an evidence-based answer.

Yours
Bernd

Seroquel and Methadone

2011-07-20T19:35:00.000-07:00

Attached a link to an article published in the New York Times (July 19th, 2011) http://www.nytimes.com/2011/07/19/health/19drug.html reporting that at the request of the Food and Drug Administration, AstraZeneca is adding a new heart warning to the labels of Seroquel, its blockbuster antipsychotic.
The revised label emphasizes that drug.Seroquel and extended-release Seroquel XR “should be avoided” in combination with at least 12 other medicines linked to a heart arrhythmia that can cause sudden cardiac arrest.The previous Seroquel labels had mentioned the risk of a prolonged QT interval, but had not identified other drugs to avoid, Stephanie Andrzejewski, a spokeswoman for AstraZeneca, said Monday. The new warning also is separated from other warnings and precautions on the label, she said, “to provide some additional guidance to physicians” treating patients ”who are already at risk of QT prolongation.”
The new label lists the other drugs to avoid as antiarrhythmic drugs like quinidine, procainamide, amiodarone and sotalel; antipsychotic drugs like ziprasidone, chlorpromazine and thioridazine; antibiotics like gatifloxacin and moxifloxacin; the anti-infective drug pentamidine; and synthetic opioids like levomethadyl acetate and methadone. The label also raises caution about use by the aged and people with heart disease. As addiction professionals we should know that Seroquel has a potentially deadly interaction with methadone in regard to the QT interval, even though the FDA is downplaying this risk!
Methadone use and deaths have increased drastically in recent years as more doctors prescribe it for chronic pain. The number of methadone prescriptions for pain in the United States rose to 4.3 million in 2010 from 2.2 million in 2006, IMS Health, an industry data firm, said Monday. The use for pain has surpassed that for heroin withdrawal and maintenance.

Yours
Bernd

Bath Salts Abuse Increasing

2011-07-18T19:39:00.001-07:00

Attached a link to an interesting article http://www.nytimes.com/2011/07/17/us/17salts.html entitled "An Alarming New Stimulant, Legal in Many States" highlighting the growing abuse of bath salts containing chemicals like mephedrone and methylenedioxypyrovalerone, or MDPV, also known as substituted cathinones. Both drugs are related to khat, an organic stimulant found in Arab and East African countries that is illegal in the United States. Bath salt users so agitated that they often do not respond to large doses of sedatives.Poison control centers around the country received 3,470 calls about bath salts from January through June, according to the American Association of Poison Control Centers, up from 303 in all of 2010.
At least 28 states have banned bath salts, which are typically sold for $25 to $50 per 50-milligram packet at convenience stores and head shops under names like Aura, Ivory Wave, Loco-Motion and Vanilla Sky. Most of the bans are in the South and the Midwest, where the drugs have grown quickly in popularity. But states like Maine, New Jersey and New York have also outlawed them after seeing evidence that their use was spreading. Law enforcement officials said they had been shocked by how quickly bath salts turned into a major problem. As addiction professionals we need to stay informed on how to diagnose and treat patients who are under the influence of these powerful synthetic drugs. We also should call for tough regulatory measures including, whether to make MDPV and mephedrone controlled Schedule I drugs like heroin and ecstasy, to stop the sale and consumption of these drugs.
Yours
Bernd

Heroin Use Surges

2011-07-08T19:34:00.001-07:00

Attached a link to an article http://www.miamiherald.com/2011/06/30/2292618/as-poppy-fields-flourish-in-mexico.html#storylink=misearch published on the Miami Herald web site pointing out that that Mexico has surpassed Myanmar as the world's second-largest poppy cultivator and produces 7 percent of the world's heroin, mostly for the U.S. market. The State Department and the United Nations say that Mexican poppy production has nearly tripled since 2007, though Mexico strongly disputes that estimate. "They brought in experts, chemists, folks from Asia who taught them how to produce better heroin," said a U.S. law enforcement official based in Mexico City, who spoke only on the condition of anonymity for security reasons. "You saw purity levels climb from 40 to 50 percent up to 90 percent." He said Mexican heroin now might hold two-thirds of the U.S. market. "You're seeing it everywhere. It's cheap. The market base is teenagers. They are the target consumers," the official said. At about $15 a hit, heroin is a lot cheaper than prescription painkillers such as oxycodone (known by its brand name, OxyContin), which can cost $50 to $80 a tablet on the black market. Both opiates, they have similar highs and Heroin can be snorted and inhaled, too.
As addiction professionals we should get prepared for an avalanche of new opioid users who switch from prescription drugs to Heroin and teenagers who start their using "career" with Heroin.
Yours
Bernd

Drug Testing for Welfare Recipients

2011-07-02T17:48:00.001-07:00

Drug Test Law May Face Costly Legal Challenges:

Attached a link http://www.orlandosentinel.com/health/os-drug-tests-welfare-20110630,0,5410762.story to an article published in today's Orlando Sentinel pointing out that a new state law requiring welfare applicants to be drug-tested goes into effect today.

The law stipulates that parents with minor children who request temporary cash assistance must undergo a drug test. The average benefit check per family is $240 a month with a lifetime limit of 48 months.

About 4,000 Floridians each month may be affected by the new law. The 93,000 state residents already receiving such benefits would not be affected unless they reapply. In addition all parents who test positive for drugs — including legal drugs not prescribed for the parent — will be reported automatically to the state's abuse hotline. Applicants will have to pay for the drug tests themselves, though those who test negative will be reimbursed in the first benefit check they receive. Those who test positive also would have the chance to get a second, more-sophisticated screening — at their own expense of up to $100 — and have an official medical review of the testing (MRO) . It is still unclear whether those expenses would be reimbursed if the applicant is ultimately cleared. The law may violate the constitutional standard requiring that the government must have reason to believe an individual is using drugs before demanding a test. Michigan, the only other state to pass a similar law, had it struck down in court. Therefore, it most probably will face a costly legal challenge on taxpayers expense!! Furthermore, by implementing this policy the state government should have provided drug treatment options for those welfare recipients with children who test positive for drugs. The new law falls shot of this option, too.

In my opinion this new law is a bad idea which will face a long and costly court battle and will further divert scarce state resources from more important issues such as drug use prevention and treatment programs.

Happy 4th of July,

Yours

Bernd

New-Onset Psychosis and Synthetic Marijuana

2011-06-30T20:53:00.000-07:00

Attached you find a link to a very interesting article http://www.familypracticenews.com/single-view/new-onset-psychosis-linked-to-use-of-fake-pot/99bbe3bc19.html reporting that synthetic marijuana may be associated with new-onset psychosis in patients with NO psychiatric histories. Synthetic marijuana is usually a mix of cannabinoid receptor agonists. They are generally full agonists, which distinguishes them from the active ingredient in actual marijuana, tetrahydrocannabinol (THC), which is a partial cannabinoid agonist. The chemicals originally were developed to help locate cannabinoid receptors and as experimental pain relievers – uses that did not pan out, he said. Plant material is dipped into the chemicals, or sprayed with them, and sold on the Internet or in drug paraphernalia shops as K2, Blaze, RedXdawn, and other brands. Spice is usually smoked, but is beginning to be sold as a crystalline powder. Users have no way of knowing how potent a particular product is. On March 1, the U.S. Drug Enforcement Agency temporarily designated five synthetic cannabinoids as Schedule I substances, pending further action, "because they pose a threat to public health," according to the order.

Yours
Bernd

Counterfeit-Proof Prescription Pads

2011-06-30T20:33:00.000-07:00

Just want to remind all of you that as of tomorrow, July 1st, 2011, counterfeit-proof prescription blanks MUST be used by all physicians for prescribing of ANY controlled substances. A list of approved vendors of counterfeit-proof prescription pads can be found on the Department of Health web site at http://www.doh.state.fl.us/mqa/counterfeit-proof.html.It is also important o know that approved vendors are required to provide monthly reports to the DOH, documenting who purchased the prescription pad or blanks and how many were purchased.
Have spoken today with one of the vendors and was assured that they make every efforts to expedite deliveries of counterfeit-proof prescription pads.

Yours
Bernd

Synthetic Marijuana is back!!

2011-06-27T18:49:00.001-07:00

Attached a link to today's Miami Herald article http://miami.pointslocal.com/story/miami/393245/incense-makers-thwart-bid-to-weed-out-fake-pot reporting that the clever manufacturers of synthetic marijuana have changed the chemical compounds just enough to skirt the ban by the U.S. Drug Enforcement Administration and a new Florida law. Mr. Nice Guy, once one of the main brands of the “incense” that authorities targeted, is no longer sold. But on its website, the manufacturer promotes the brand Barely Legal, announcing it is “Legal in all 50 states. ”Local police say Barely Legal is one of the new generation of synthetic marijuana products formulated to beat the ban. Synthetic marijuana is labeled and sold as incense or potpourri, but law enforcement officials say people know what it’s really for: smoking to get high. Its packaging says, “Not for human consumption.” Moreover, the new chemical formula is stronger than the old one, according to Mr. Nice Guy’s website and local police.

Legislation helps but isn’t the answer, said state Rep. Darryl Rouson, D-St. Petersburg, who co-sponsored the synthetic-marijuana bill.“They’ll always come up with a slightly different type of strain,” Rouson said. “The creator of this drug has over 100 different strains.“This problem will only be solved by education and prevention. Not legislation, not incarceration, not punishment. We can legislate, we can [impose] punishment and hopefully, by punishment, there’s deterrence.”
I look forward to your responses and comments.
Yours
Bernd

Governor Scott Suspends Drug Testing Order

2011-06-16T19:33:00.001-07:00

Attached a link to an article from today's Sun Sentinel http://www.sun-sentinel.com/health/fl-scott-suspends-employee-drug-testi20110616,0,6797555.story reporting that Governor Scott has suspended the order he signed earlier this year requiring random drug tests of all state employees in light of an ACLU law suit. The governor had signed the order for so-called "suspicion-less" drug tests – so termed because all state employees would be subject to them, regardless of their job or whether they were suspected of using drugs – in March. He also successfully urged the Legislature to require drug tests of all new applicants for welfare assistance, which the ACLU is also expected to challenge.
I encourage all of you to speak up loudly against the mandatory drug testing of welfare recipients which will be challenged in court, too.
Yours
Bernd

The Big Rip-Off

2011-06-07T20:13:00.001-07:00

In today's Miami Herald http://www.miamiherald.com/2011/06/06/2254083/prescription-for-healthcare-shopping.html#storylink=misearch John Dorschner points out a painful truth: healthcare consumers are being ripped off every day by healthcare service providers.
According to Alan Sager, a healthcare policy expert at Boston University, “Anytime I’ve read reports of patients or journalists seeking comparison pricing, they’ve encountered the same inconsistency, confusion, frustration and often misleading information,” he said. “When we go into a big supermarket, we all pay the same price for a gallon of milk. In healthcare, there are multiple prices in the same place.”
I myself have a hard time to find out the REAL costs of my own healthcare needs. Recently my daughter had to do undergo laboratory testing for which I was charged a $900 co-pay. I tried to appeal and as a result my case was immediately referred to a collection department. I barely saved my credit rating and paid. Its outrageous! The profit margins are beyond belief exceeding 1000 percent!! The so-called "free-market" argument is a joke!! An article in today's Wall Street Journal points out that in a survey of 1,000 British Medical Association members - all doctors - 80% of those surveyed were "mostly or very unwelcoming" towards the idea of privatization of the National Health Service. Meanwhile, American doctors and politicians continue to support the private health care market model. There is NO health care market but an aggregation of monopolies suffocating the average health care consumers.
Its time to fight back! We should demand a single-payer system with uniform and transparent pricing structure.
Yours
Bernd

Governor Scott Signs Pill Mill Bill into law

2011-06-04T19:47:00.000-07:00

After initially fighting one of its key provisions, Gov. Rick Scott signed a bill Friday aimed at cracking down on clinics that frivolously dispense pain pills, feeding a nationwide prescription drug abuse epidemic. The bill tightens reporting requirements to the database from 15 days to seven days, a change critics said the program needed to make it more effective. The measure also increases penalties for overprescribing Oxycodone and other narcotics, tracks wholesale distribution of some controlled substances, and provides $3 million to support law enforcement efforts and state prosecutors. It also bans most doctors who prescribe narcotics from dispensing them, requiring prescriptions to be filled at certain types of pharmacies. Scott has been under pressure from elected officials throughout the country to do something about the proliferation of so-called "pill mills" in Florida that attract people from other states seeking easy access to highly addictive, powerful painkillers.
We should now urge the Department of Health to provide education and training programs for physicians and other healthcare professionals on how to use the Prescription Drug Monitoring Program and to fund those necessary efforts.

For more information see http://www.miamiherald.com/2011/06/03/2249936/scott-signs-pill-mill-bill-into.html

ACLU Sues Governor Scott Over Drug test Rule

2011-06-04T19:35:00.000-07:00

ACLU Florida has filed a lawsuit against Gov. Rick Scott over his executive order to force drug testing on state employees. The suit argues that Scott's order is an unreasonable search of the government that violates the Fourth Amendment of the U.S. Constitution.The ACLU maintains that the mandatory random drug testing Scott has ordered on about 100,000 workers is only allowed under special circumstances, such as workers who carry firearms or railroad workers involved in accidents.
I urge all medical professionals involved in federal workplace drug testing procedures to await the outcome of this lawsuit BEFORE deciding on their participation in the proposed state wide drug testing for state employees.

For more information and the complete text of the law suit see http://www.tampabay.com/blogs/the-buzz-florida-politics/content/aclu-sues-gov-scott-over-drug-testing-order

Physicians Challenge Florida Goverment

2011-06-04T18:28:00.000-07:00

Attached an article highlighting an issue which is going to be resolved in court. Unfortunately, Governor Scott signed HB 155 into law which will bar physicians from asking patients about gun ownership. Florida is the only state in the nation to have such a law which was pushed by the NRA.
Sadly, the Florida Medical Association does not oppose the new law exposing its members to charges of harassment if they "dare" to provide their patients information about gun safety. Any alleged violation of the new law will expose physicians to disciplinary action and even license revocation!
Now its time to stop government intrusion into the patient-physician relationship.
I encourage doctors to pay attention to this issue and to take action.
Yours
Bernd

PalmBeachPost.com

By DARA KAM

Palm Beach Post Staff Writer

Updated: 10:58 p.m. Thursday, June 2, 2011

Posted: 8:19 p.m. Thursday, June 2, 2011

Three groups of doctors are suing Gov. Rick Scott over a bill he signed into law Thursday restricting health care workers from asking patients questions about guns.

Lawyers representing members of Florida chapters of the American Academy of Pediatrics, the American Academy of Family Physicians and the American College of Physicians asked Scott last week to veto the measure (HB 155) and threatened to sue if he signed it into law.

The Florida Medical Association does not oppose the new law.

Bruce Manheim of the Washington-based Ropes & Gray law firm said Thursday he would file the lawsuit immediately after Scott signed the law.

Doctors say the law infringes on their First Amendment constitutional right to free speech by barring them from asking about gun ownership, something they say is necessary to do their jobs.

It will "have a muzzling effect on doctors" who routinely ask parents and teenagers about swimming pools, dangerous drugs, bicycle helmets and car seats as well as about firearms in the home, pediatrician Tommy Schechtman said.

Under the law, doctors and other health care professionals will face sanctions including fines and losing their licenses if they ask patients about guns in the home without a direct belief that the inquiry is relevant to the patient's safety or health.

"It is my job. It is my responsibility. I have a moral obligation, an ethical obligation to be doing this," said Schechtman, who has offices in Palm Beach Gardens, Jupiter and Boca Raton.

But Scott spokesman Lane Wright said the first-term governor is confident he is on solid legal ground by signing the bill.

"Others would argue it would be an infringement of a citizen's rights who owns a gun to have a doctor ask those questions," Wright said. "Why should any law abiding citizen have to report to a doctor that they have a gun?"

Florida is the only state in the nation to have such a law, according to National Rifle Association lobbyist Marion Hammer, a former president of the gun rights organization.

Hammer said some health care professionals are pushing anti-gun messages to their patients under the guise of home safety questionnaires. The measure was prompted by complaints from gun owners following an incident this summer in which an Ocala-area physician told a couple to find another pediatrician after they refused to answer questions about whether they owned a gun and how it was stored.

The NRA and other supporters don't object if doctors routinely distribute safety brochures to all patients that give instructions on swimming pools, firearms or other safety-related issues, Hammer said.

"But doctors should not be spending the time that patients are paying for to talk to them about matters they're not there for. They come to doctors for medical care and medical treatment, not to have politics in the examining room and not to be lectured on firearms. They are medical doctors; they are not firearms instructors," she said.

But Mannheim said the new law is so vague about when questions are permissible that it would have a chilling effect on health care practitioners fearful of having to defend themselves before the Board of Medicine.

"Questions about firearm safety, as innocuous as they may be to the ordinary person, could be construed by someone as constituting harassment by a physician and simply on the basis of that judgment a physician could be taken through these disciplinary proceedings," he said. "It immediately chills the speech of our clients and their members and accordingly we intend to move very quickly with a lawsuit."

Schechtman said the new law won't stop him, however. More than 1,500 children die each year from household gun-related injuries, he said.

"Some of us won't shut up. Sometimes you have to decide to do the right thing which is what I will do. It's not going to stop me from doing anything," he said.

But other physicians may feel it's not worth the risk.

"It will have its intended effect. That's the thing that's scary to me. And that's why I think we have to take this off the books. I think it's sending a wrong message that people shouldn't have to worry about guns," Schechtman said.

PDMP Update

2011-05-22T16:21:00.001-07:00

Attached an update regarding the implementation status of the Florida Prescription Drug Monitoring Program.
We are slowly but steadily moving forward.
Yours
Bernd

PDMP Update

Contract: On Monday, May 16, 2011 DOH delivered the contract to Health Information Designs, Inc. (HID). DOH will receive the customized off the shelf database within 90 days from the execution of the contract, approximately September 1, 2011. Although tested and operational when received, the users have to be notified and trained on how to register and download data to the database. The RFP allows an additional 30 days (120 days from the execution of the contract) for HID to provide beta testing for providers on how to register and download data.

The following is an estimated timeline for implementation:

· Contract execution date: June 1

· Delivery Database: September 1

· Go Live/Receive data: October 1

DSO: HB 7095 removed references to the Office of Drug Control and reassigns the duties of the Office of Drug Control to DOH and the State Surgeon General.

Funding: The PDMP is funded by three sources: (1) DSO, (2) Federal Grants, (3) Private Grants. HB 7095 prohibits the use of funds provided by prescription drug manufacturers to implement the program. The PDMP is currently funded through September 2012 with federal and private grants, and donations from the DSO. The PDMP projects to spend $485,965 in FY 12/13.

Grants: PDMP submitted its application for the 2011 Harold Rogers Prescription Drug Monitoring Program (PDMP) Enhancement Grant, to request funding to improve its existing PDMP. PDMP requested $398,287, under this grant application to implement the enhancements outlined below. This proposal is in response to a competitive grant announcement by the U.S. Department of Justice (DOJ), Office of Justice Programs (OJP), Bureau of Justice Assistance (BJA).

PDMP will improve its program by: (1) enhancing collaborations with law enforcement to establish a comprehensive PDMP strategy; and (2) enhancing the PDMP’s ability to analyze and use collected data to identify drug abuse trends, identify and address sources of diversion, and increase the number of PDMP users. These improvements will align Florida PDMP with the 2010 National Drug Control Strategy of establishing a balanced approach to drug use by expanding efforts for the 3 critical ways that the problem can be addressed: prevention, treatment, and law enforcement. Specifically, it will strengthen efforts to prevent drug use in communities by fostering collaboration between public health and public safety organizations.

In addition, our request to extend the project period by one year for Grant Award Number 2009-PM-BX-4004 has been approved by BJA.

Addicted Babies

2011-05-15T18:54:00.001-07:00

Attached a link to an an article published in the 05/13/2011 edition of the Miami Herald http://www.miamiherald.com/2011/05/13/2216300/state-seeks-end-to-crisis-of-babies.html reporting that at St. Joseph’s Women’s Hospital in Tampa 15 to 20 percent of the babies admitted to the neonatal intensive care unit are treated for withdrawal from prescription drugs like oxycodone. Statewide, an estimated 1,300 babies were treated for withdrawal in 2010, a 30 percent increase from the previous year. These troubling data were presented at a roundtable discussion with top officials from BayCare Health System, AG Pam Bondi and Senate President Mike Haridopolos to discuss the enormity of the problem and what can be done to stop it. Babies born with prescription drugs in their systems often spend the first weeks of their lives in hospital NICUs getting weaned off their addiction. Mindy Young, a nurse and manager of St. Joseph’s NICU, said it’s a painful process that can take up to 30 days. We definitely need to do more to identify and treat pregnant opioid-dependent women to stop this epidemic. The article only refers to Methadone as a treatment modality and omits mentioning the use of Buprenorphine (SUBUTEX) as a treatment option.

Yours

Bernd

Pill Mills in the News

2011-05-15T18:38:00.001-07:00

Attached a link to an interesting article published in today's (05/15/2011) Sun Sentinel http://www.sun-sentinel.com/news/broward/fl-pillbillies-crime-20110516,0,1515459.story reporting that “ out-of-state travelers called 'pillbillies' who are visiting South Florida to score prescription drugs are doing not only that, they're also adding to the local criminal population.” This adds additional workload to an already overburdened judicial system and the costs for jailing those criminals are mounting, too. Once the prescription drug monitoring program is up and running drug dealers and doctor shoppers will realize that Florida is not open for their business anymore. Therefore, we have to make sure that doctors are receiving the training to use the program and to fight for continuous funding for the PDMP.
Lets make it happen!

Yours

Bernd

Gun Law and Physicians

2011-05-08T16:54:00.000-07:00

The new gun law makes Florida the first state in the nation to prohibit doctors from asking patients if they own guns. HB 155 entitled "Privacy of Forearm Owners" passed the Florida House and will be signed into law by Governor Scott. NPR featured this law in a recent story http://www.npr.org/2011/05/07/136063523/florida-bill-could-muzzle-doctors-on-gun-safety. Having read the entire bill http://www.flsenate.gov/Session/Bill/2011/0155/BillText/er/PDF I am trying to understand what I am allowed to ask my patients and how I can protect myself from those who exercise their constitutional right to carry guns. Here are the some of the problems the bill presents us with:

* The bill states that “A health care practitioner licensed under chapter 456 or a health care facility licensed under chapter 395 may not intentionally enter any disclosed information concerning firearm ownership into the patient's medical record if the practitioner knows that such information is not relevant to the patient's medical care or safety, or the safety of others."

Question: How do I know whats relevant to the patients safety? Actually, I was taught to be concerned about "anticipatory guidance" — teaching parents how to safeguard their children against accidental injuries. Like pediatricians family doctors ask about bike helmets, seat belts, and GUNS. That means I cannot counsel a parents how to secure a gun to prevent accidental injury and death? Shall I delete those questions from my patient intake form? Shall I NEVER ask those questions? Will I be disciplined if I dare asking those questions?

* But in the next paragraph the bill also states that " Notwithstanding this provision, a health care practitioner or health care facility that in good faith believes that this information is relevant to the patient's medical care or safety, or the safety of others, may make such a verbal or written inquiry."

Question: So what is correct and prevents my exposure to disciplinary action? Shall I adhere to a don't ask, don't tell policy?

* The bill contains other confusing language such as " A health care practitioner licensed under chapter 456 or a health care facility licensed under chapter 395 shall respect a patient's legal right to own or possess a firearm and should refrain from unnecessarily harassing a patient about firearm ownership during an examination."

Question: What if a gun owner claims to feel "harassed" by a doctor and files a complaint with the Board of Medicine then a physician has to answer and file a response. That requires legal advice and consultation which costs $$$. Facing such a dilemma precludes ANY questions about guns. That's what the NRA wanted, the legislators did and the FMA endorsed!

* The bill goes further stating " A health care provider or health care facility may not discriminate against a patient based solely upon the patient's exercise of the constitutional right to own and possess firearms or ammunition."

Question: What if the patient has a concealed weapon permit and carries a concealed weapon in the medical office and I discover such a weapon during the exam? It happened to me several times!! Can I ask the patient to leave and return without the weapon without him/her claiming that I harass them? Can I establish a policy prohibiting patients to carry guns on my premises?

* Furthermore, the bill contains an entire paragraph about patients rights BUT NOT a single sentence about physicians rights and safety!! That's what the NRA wanted, the legislators did and the FMA endorsed!

Yours
Bernd

Mandatory Drug Testing

2011-05-06T19:40:00.001-07:00

The Miami Herald reports in today's edition http://www.miamiherald.com/2011/05/06/2204093/welfare-drug-test-bull-heads-to.html that a measure requiring the mandatory drug testing for all welfare recipients is headed to Gov. Rick Scott for signature , who called it one of his legislative priorities.

HB 353 requires all adult recipients of federal cash benefits — the Temporary Assistance for Needy Families program — to pay for the tests, which are typically around $35. The screen would be for all controlled substances and applicants would have to disclose any legal prescriptions. Recipients who test positive for drugs would lose their benefits for a year. If they fail a second time, they lose the benefits for three years. Parents who test positive must designate another adult to receive benefits on behalf of their children. Those who pass would be reimbursed by having their benefits increased by the cost of the test.

Personally, I consider this as an intolerable government intrusion which far exceeds all previous measures to reduce the demand for illicit drugs and controlled substances.!!

As a Medical Review Officer I am also concerned that the bill does not contain ANY references to formal written drug testing policy, standards of training for drug testing, or provisions for self-referral to treatment. Furthermore, the bill does not differentiate between regulated and non-regulated testing, procedures regarding verification testing to determine and to exclude false-positive or false-negative testing, and cut-off values for substances tested.

It also fails to take into consideration that gas-chromatography testing is required to verify the drug test results which can add additional costs exceeding the estimated $35 per test. For example, an synthetic opioid panel costs at least $85.

In addition the bill contains NO reference to the role of a Medical Review Officer (MRO) who makes the final and definitive verification decision for each drug test results and should report the results.

In summary: this bill must be challenged in court and will not hold up legal scrutiny.

Yours

Bernd

Controlled Substances

2011-04-20T20:22:00.000-07:00

In an interesting article entitled “US Seeks To Rein in Painkillers” http://www.nytimes.com/2011/04/20/health/20painkiller.html the authors report that the Obama administration seeks legislation requiring doctors to undergo training before being permitted to prescribe powerful painkillers like OxyContin. This appears to be the most aggressive step taken by federal officials to control both the use and abuse of the drugs. Among the drugs that would most probably fall under a stricter licensing measure are OxyContin, fentanyl, hydromorphone and methadone. They are considered critical to pain treatment. But they also have been associated in recent years with a national epidemic of prescription drug abuse and addiction and thousands of overdose-related deaths. Proponents of the training argue that it would help doctors better identify patients who would benefit from treatment with long-acting narcotics, and help them unmask patients feigning pain to get drugs they then abuse. Opponents say a training requirement will reduce the number of doctors prescribing pain drugs and hamper patient care. The F.D.A. released new regulations on Tuesday that would require the makers of long-acting or extended release painkillers to provide training to doctors but would not require doctors to take such courses. This proposal is similar to the one rejected as too weak in last year’s debate. Dr. Janet Woodcock, who heads the F.D.A. Center for Drug Evaluation and Research, indicated that the new agency rules were effectively a placeholder until legislation was passed or were to be used if a relevant bill failed.

In my opinion additional education and training requirements for controlled substances prescribing are long overdue! Most physicians have no, or very limited knowledge, of the appropriate indication, pharmacology and adverse drug interactions of controlled substances. I often see patients who were prescribed Methadone, a long-acting opioid, at a four-times daily dosage schedule. These physicians seem to be clueless about the fact that Methadone metabolism rates vary greatly between individuals, up to a factor of 100! These metabolism rates can range from as few as 4 hours to as many as 130 hours, or even 190 hours. This variability is apparently due to genetic variability in the production of the associated enzymes. Ignoring these pharmacological facts can lead to accidental overdose and death.

Additional training requirements should be implemented to protect our patients and our families.

Yours

Bernd

Prescription Drug Monitoring Program Update

2011-04-17T18:55:00.001-07:00

Attached links to several interesting articles regarding the so-called "pill mill database:

* A Sun Sentinel Editorial entitled “ Opposition to pill mill data base dissolves” http://www.sun-sentinel.com/news/opinion/editorials/fl-pill-mills-editorial-dl-20110417,0,5137083.story correctly points out that the latest change to HB 7095 includes support for a prescription drug monitoring program and restores tough regulations on pain management clinics that House leaders had threatened to strip from the bill. Thew new bill is far from perfect! Small pharmacies complain that the new version puts them at a disadvantage to the larger big-box drug chains where most medications are prescribed. More importantly, people who need these medications may find the bill creates new hurdles to getting them. Lawmakers should take the greatest care to make sure that that is not the case.
* Another article published in today's Sun Sentinel “ Why, and how, South Florida pill mills must be shut down” http://www.sun-sentinel.com/news/outlook/fl-nscol-pill-mills-prosecute-sanadi-20110417,0,5970691.story written by Nabil El Sanadi,MD points out that the newly formed pill mill" Multilateral Task Force should mandate that: That said, the task force should mandate that:
* The Board of Medicine exercise its power on licensees — physicians — to register as pain management specialists and to monitor each prescriber's activity to ensure compliance with 64B 9.013.
* The prescription drug database should be used to track doctor-shoppers and to detect over-prescribers, so that the attorney general, local law enforcement and the DEA can get these criminals off the streets.
* Physicians should be mandated to report suspected doctor-shopping and possible drug diversion, just like we have to report child abuse and certain communicable diseases.
* Physicians and pharmacists should be required to use the database when prescribing or dispensing narcotics.

I am concerned that mandated reporting and the required use of the database may trigger significant political backlash from physician organizations and Republican legislators. I suggest focusing instead on allocating funds to educate physician on how to use the database and on how to identify doctor-shoppers. Subsequently, physicians will recognize that the exclusion of doctor-shoppers is good business.
* An additional article published in today's Sun Sentinel “ New Database Blocks Sales of Cold Medications” http://articles.sun-sentinel.com/2011-04-16/health/fl-cold-medicine-database-20110416_1_meth-labs-ephedrine-products-pain-pill-database highlights the success of the National Precursor Log Exchange database which went live in January, and through late March, has blocked more than 40,000 illegal ephedrine sales in Florida. lorida joined 11 states last year in passing legislation that forces pharmacies to track ephedrine products in a database. "It has been among the most successful laws we've had in reducing meth production," said Jim Hall, director of the Center for the Study and Prevention of Substance Abuse at Nova Southeastern University in Fort Lauderdale.The system has been compared to the pain-pill monitoring system that's been under fire in Tallahassee, which aims to crack down on pain-pill trafficking across Florida. Both systems track consumer information to show patterns of abuse, and both aim to stop people from doctor shopping or pharmacy hopping. Police and sheriff's associations pushed for the ephedrine database after reporting an alarming number of meth lab explosions in North Florida in 2009. Several people, including a baby, were severely burned. The rising popularity of the "shake and bake" meth-making method is largely to blame, authorities said. People have discovered how to make the narcotic in a 2-liter soda bottle, which builds with pressure and often erupts into flames. Although meth labs are more prevalent in North and Central Florida, a surprising number of blocked ephedrine sales in South Florida indicates that "smurfers" have been driving south to stock up, Beasley said. A smurfer is an individual who find and/or gather the raw materials for their dealer to make more drugs.FDLE launched the database as a pilot program in 2008 in North Florida. In one year, law enforcement agencies reported that it contributed to 133 arrests. The system flags people who try repeatedly to buy ephedrine over the legal limit, and police use those leads to open drug investigations. Investigators with the South Florida High Intensity Drug Trafficking Area use it to help local police find possible "smurfers." They look through the system for suspicious activity and alert respective agencies.

Yours
Bernd

Fla. House panel OKs compromise pill mill bill

2011-04-14T20:48:00.000-07:00

Finally, the future for a prescription drug monitoring program is looking better every day. According to an April 12th Miami Herald article http://www.miamiherald.com/2011/04/12/2163473/fla-house-panel-oks-compromise.html compromise legislation designed to combat "pill mills" that supply prescription painkillers to drug dealers and addicts cleared a House committee Tuesday after the panel took out Gov. Rick Scott's proposal to repeal Florida's prescription monitoring system. The revised bill (HB 7095) instead would strengthen the database by giving pharmacies only seven days rather than 15 to submit prescription information to the state. Unchanged from the original legislation is a ban on dispensing controlled drugs by most doctors. That means patients would have to get prescriptions filled only at pharmacies. Doctors who violate the ban would face up to five years in prison. The House Appropriations Committee unanimously approved the revised bill. It next goes to the House floor. House Speaker Dean Cannon, R-Winter Park, also pushed for the database repeal, arguing that a ban on dispensing by doctors would be more effective, but Bondi said he's also supporting the compromise and helped bring it about. Bondi and Senate President Mike Haridpolos, R-Merritt Island, have been strong supporters of the tracking system, and the Senate's pill mill bill (SB 818) did not include the repeal.
I urge you to continue pushing your legislators to support the House ( HB7095) and Senate bill (SB818).
The battle is not over yet !!
Yours

Green Light for Prescription Drug Monitoring Program!!

2011-04-08T20:09:00.001-07:00

Attached a link to an article http://www.miamiherald.com/2011/04/08/v-fullstory/2157716/span-classboldprescription-drug.html reporting the long awaited launch of the prescription drug monitoring program. The article highlights that:

"The Department of Health on Friday issued a final order in a months long bid dispute between two vendors, giving the program a green light... with the program mandated by statute, there is little opponents can do to stop it now that the legal issues surrounding it have been resolved."

This is indeed good news and I want to thank all of the many activists who invested so much time and efforts to support this noble cause.
Yours
Bernd

Governor Scott and Mandatory Drug Testing

2011-04-02T21:04:00.001-07:00

Governor Scott and Mandatory Drug Testing:

A recent article published in the Miami Herald http://www.miamiherald.com/2011/03/27/v-fullstory/2137314/gov-rick-scotts-drug-testing-order.html reports that Governor Scott signed an executive order last week that requires drug testing for many current state workers and job applicants. According to the article “Scott’s order applies to all employees and prospective hires in agencies that answer to the governor, and could affect as many as 100,000 people. Scott also supports a state Senate bill that requires all cash-assistance welfare recipients over the age of 18 to pay for and receive a drug test, a policy that could affect about 58,000 people.”

But is this executive order legal?

* In April 2000 U.S. District Court Judge Kenneth L. Ryskamp ruled that governments cannot require prospective employees to take drug tests unless there is a “special need,’’ such as safety. Ryskamp’s ruling led other South Florida cities, such as Pembroke Pines, to abandon their policy of drug testing all job applicants.
* Random drug-testing of current government workers also has been limited to those in jobs that affect public safety and to cases where a reasonable suspicion of abuse exists, according to a December 2004 federal court ruling in a case that involved Florida’s Department of Juvenile Justice. In that case, U.S. District Court Judge Robert Hinkle ruled that the DJJ violated the Fourth Amendment in ordering random drug-testing of all the agency’s 5,000-plus employees.
* State agencies already are allowed, but not required, to screen job applicants for drugs, under the Florida Drug-Free Workplaces Act. The law allows state agencies to test employees if there is a reasonable suspicion that workers are on drugs. But that suspicion must be well-documented and employees must be informed of the policy prior to testing.
* Howard Simon, executive director of the ACLU of Florida, said Scott is taking a “simplistic” approach to the law, pitting the public’s expectation of a “right to know” against each individual state worker’s right to privacy.

The article concludes that though no legal challenge to the governor’s order has been filed, one will be forthcoming.
I urge all of you to support the ACLU of Florida in their efforts to fight back against government intrusion into our lives camouflaged in the shroud of transparency.

Yours
Bernd

Pill Mill Issue

2011-03-28T20:50:00.001-07:00

Attached a link to an article http://www.tampabay.com/news/health/gov-rick-scott-announces-plan-to-combat-pill-mills/1160274 reporting that Gov. Rick Scott on Monday launched his own initiative to fight the problem. At a news conference where he was flanked by Attorney General Pam Bondi and a handful of law enforcement officers, Scott announced a statewide drug trafficking "strike force." Florida Department of Law Enforcement Commissioner Gerald Bailey will lead the effort, coordinating with local law enforcement agencies. Scott directed the FDLE to use $800,000 in unspent federal grant money to help pay for overtime and other costs associated with the effort. State Senator Fasano, a strong supporter of the Prescription Drug Monitoring Program, said he found it curious that the governor was able to come up with $800,000 for the law enforcement effort but not for the database. AG Bondi, who supports the database, acknowledged that she and the governor have a difference of opinion. But she praised the governor for taking action on the law enforcement front. "We need more tools for all these people standing behind us," she said. Later, Bondi said she considers the database one of those "essential" tools.
Further legislative update regarding the PDMP:
The state House of Representatives, at the urging of Speaker Dean Cannon, has proposed eliminating the database. But Senate President Mike Haridopolos has said that proposal won't make it through his chamber. In fact, fellow Republican Sen. Rene Garcia got nowhere in a Senate committee Monday with a bill amendment that would have killed the database. The amendment was dropped without even being put up for a vote.

Yours
Bernd

Florida gets the profits, Kentucky gets the problem

2011-03-27T20:36:00.000-07:00

“We’ve got more people dying of prescription drug overdoses than car accidents,’’
U.S. Rep Hal Rogers.

Attached a link to a great article published in today's Miami Herald http://www.miamiherald.com/2011/03/27/v-fullstory/2135476/kentucky-the-other-end-of-the.html again focusing on the unresolved pill mill issue in Florida.
The sobering facts speak for themselves:

* As far back as 2002, early in the epidemic, one fourth of all OxyContin-related deaths in the country took place in eastern Kentucky.
* According to a study by the Substance Abuse and Mental Health Services Administration, there was a fourfold increase nationally in treatment admissions for prescription pain pill abuse during the past decade. The increase spans every age, gender, race, ethnicity, education, employment level and region. Nearly every family in eastern Kentucky has been touched by prescription-drug addiction and death.
* In Kentucky some harbor a deep resentment at Florida’s unwillingness to crack down on pill sales, for instance, at its refusal to set up a prescription database similar to those in other states to ensure that customers are not “doctor shopping’’ – scooping up some pills here, more pills there – by dealing with multiple physicians.

Meanwhile, dozens of people die every day in Florida and Kentucky but Governor Rick Scott and many of his political friends are stonewalling.

Yours,

Bernd

Florida is Open for (Drug) Business

2011-03-14T20:34:00.001-07:00

Attached a link to a Miami Herald article from Friday, March 11th http://www.miamiherald.com/2011/03/10/2107891/house-kills-plan-for-drug-monitoring.html reporting that with little debate Thursday morning, the House health and human services committee voted to eliminate the state’s plan for prescription drug monitoring database.Before the vote to eliminate the database, the committee passed a bill that would prohibit doctors from dispensing narcotics, making the drugs largely available only at pharmacies. It would would require wholesale distributors of narcotics to report who they are selling the drugs to so law enforcement officials can identify unusually large purchases. The bill calls for appropriating $1.5 million to track down the large, non-pharmacy dispensaries and return the drugs to wholesalers.
Our legislators also decided to eliminate registration and inspection of pain clinics, and a ban on felons owning pain clinics.
Obviously, the committee chairman,Robert Schenck (R-Spring Hill) and his fellow legislators believe that our already burdened law enforcement officers will do a better job to crack down on drug dealers in white coat and the OxyCartel. But even Broward County Sheriff Al Lamberti pointed out that we cannot arrest ourselves out of the problem! Meanwhile, the drug dealers can rest assured that Florida is wide open for their business and that no one will bother them anymore to ask for clinic registration or physician ownership verification. Maybe we should post a sign at the state border: Felons welcome!
Something is rotten in the state of Florida.
Yours
Bernd

DOH wins PDMP Bid Protest

2011-03-08T18:27:00.003-08:00

Attached you find a link to the Recommended Order by an Administrative Law Judge regarding the Prescription Drug Monitoring Program (PDMP) bid protest.
Let me explain briefly the circumstances for or those who may not know all the details:
The Department of Health (DOH) issued a Request for Proposals (RFP) for companies interested in bidding for the PDMP contract. The loosing bidder (Optimum Technology ) protested TWICE the DOH decision to award the contract to a competitor (Health Information Design).
An administrative law judge recommended today that the DOH enter a final order dismissing the Formal Written Protest.
That means the DOH WON the bid protest and may move ahead with the PDMP implementation.
I would expect that the DOH follows state law, awards the contract and moves to implement the PDMP. The only obstacles are the Legislature and the Governor who at this point in time defy state law!
Yours
Bernd

http://www.doah.state.fl.us/internet/search/docket.cfm?RequestTimeout=500&CaseNo=11-000257&Petitioner=OPTIMUM%20TECHNOLOGY%2C%20INC%2E&Respondent=DEPARTMENT%20OF%20HEALTH&URLString=Count%3D1%26BPCount%3D1%26DWH%3D1%26Pet%3DOptimum

Pill Mill and PDMP Issue

2011-03-06T10:19:00.001-08:00

In the last 2 days a series of articles were published in the Miami Herald and Sun Sentinel focusing on the "pill mill" and PDMP repeal issue.
I am hopeful that the heightened publicity will put pressure on our legislators to act.
Yours
Bernd

Drug monitoring program worth saving, By Al Lamberti and Marcelo Llorente
Read more: http://www.sun-sentinel.com/news/opinion/fl-prescription-drug-forum-20110305,0,2826266.story

"On behalf of Floridians, we are pleading with Gov. Scott, Attorney General Bondi and legislative leaders not to sacrifice vital initiatives such as the PDMP in an effort to achieve a balanced budget. Too many lives are at risk, and the consequences are too great to eliminate the PDMP."

Sons and daughters, lost to a pill epidemic FRONT PAGE STORY
Read more: http://www.miamiherald.com/2011/03/05/2100118/sons-and-daughters-lost-to-a-pill.html#ixzz1FqNyNtUh
http://www.miamiherald.com/2011/03/05/2100118/sons-and-daughters-lost-to-a-pill.html

Florida pill mills: Different drugs, same faces
http://www.miamiherald.com/2011/03/05/2099419/florida-pill-mills-different-drugs.html

"Felons can’t get a license in Florida as a pest-control operator. Colangelo can’t be a private detective or paramedic or title insurance agent or bail bondsman or labor union business agent. He can forget about employment with the Florida Lottery. Or qualifying as a notary.
“In Florida, this guy couldn’t own a liquor store,” said Broward Sheriff Al Lamberti. Yet according to the DEA, Vincent Colangelo, who couldn’t kill bugs, serve cocktails or tail a cheating husband, could operate seven pain clinics and a pharmacy in Broward and Miami-Dade counties. His pill mills peddled more than 660,000 doses of oxycodone in just two years. The feds calculated Vinny’s proceeds at $22,392,391."

Drug epidemic: Monitoring program a necessity, by Bruce Grant
http://www.sun-sentinel.com/news/opinion/fl-drugs-oped0306-20110306,0,6995046.story

"It's time to quit posturing and doing nothing while people die. If there is a better solution to the monitoring program, then let's hear it. Currently, 38 other states have an operational program, and another five have passed the law and are awaiting implementation. What do they know that we don't? Worse yet, Florida now has other states chastising us over our deadly inaction.
Florida must implement the monitoring program now. It is the single most-effective mechanism we have to stop the epidemic of prescription drug abuse. Inaction on the program or its repeal is an option that would only result in further deaths, greater human suffering, and tremendous human and economic costs we cannot afford. Let's put aside rhetoric and put this program into operation. Lives depend on it."

Governor Scott and the PDMP: Accusations replace Facts

2011-02-24T19:19:00.001-08:00

Unfortunately, Governor Scott pulls out all the stops to attack the supporters of the PDMP including the PDMP Foundation.
These are indeed groundless accusations without factual evidence to support the arguments made.

http://www.palmbeachpost.com/opinion/editorials/scott-makes-it-up-again-accusations-against-group-1276631.html?sms_ss=email&at_xt=4d6663c1bb07e380%2C0

Excerpt from the article above:

Gov. Rick Scott is inventing another excuse for opposing a statewide prescription pill database.

Without offering any evidence, the governor this week accused the private foundation that is raising money for the database of wasting donations. "It's come to my attention that thousands of dollars have been spent on lawyers, travel, meals for board members," Gov. Scott told reporters on Tuesday. "I believe it's an invasion of privacy. And right now with that database, it appears that the money's been wasted."

In fact, board members of the Prescription Database Monitoring Program haven't charged a single expense to the foundation. A private company started by the former chairman of the foundation's board has picked up most of the legal expenses. "The first communication from the governor's office to our foundation was a baseless accusation. It's desperate," said foundation Vice Chairman Rene Bruer. He is a financial analyst who worked for the director of Florida's drug control office under Gov. Jeb Bush. "We're rising up above the politics. We just want to deal with the problem."

http://www.palmbeachpost.com/news/state/fla-drug-database-fund-raiser-disputes-gov-scotts-1273905.html?page=2&viewAsSinglePage

Excerpt from article above:

Scott's attack on the foundation took Bruer [Vice-Chairman of PDMP Foundation] by surprise, he said.

"We've never ever had anybody from Rick Scott's office ask us questions, join one of our phone calls. Nothing. Ever. There has been no dialogue between us. We welcome that," he said.

The foundation is caught in the middle of a political battle of wills, Bruer said.

"The PMDP Foundation is not here to play political ping-pong. We're strictly here to look at the overarching issue which is people dying from prescription drug abuse and doing what we can within the letter of the law to make sure that one of Florida's worst public health epidemics is dealt with," he said.

Tip of the Iceberg

2011-02-23T19:40:00.001-08:00

Attached an article from today's Miami Herald highlighting the arrest of several oxycontin dealers, wrongly called "doctors", Unfortunately, they represent just a tiny sample of the hundreds of drug dealers in white coat in South Florida who make millions in ill-gotten profits.
Meanwhile, the Oxy-Cartels are reinventing their business model and open "life style enhancement" and " wellness" clinics.
We have to stop them now!
Yours
Bernd

The Miami Herald
Posted on Wed, Feb. 23, 2011
Pill-mill arrests hit right target: doctors

Fred Grimm
fgrimm@MiamiHerald.com
Law enforcement tested a promising antidote for Florida’s oxy epidemic Wednesday – doctors in handcuffs.

Arrests of so many drug-addled users and low-rent street dealers hardly matters. Not compared to that ignominious image of Dr. Zvi Harry Perper led out of a “pain management clinic” in Delray Beach Wednesday. That stuck at the very nub of the pill-mill industry. In tan scrubs and steel cuffs. Dr. Perper on a perp walk.

Fifteen pill mills were raided in Broward, Miami-Dade and Palm Beach counties. A few oxy street dealers and a handful of clinic employees were arrested, all replaceable entities in the pill-mill business model. But five doctors were busted. Seven others “voluntarily” surrendered their federal license to prescribe narcotic medicines. Doctors, cranking out oxycodone prescriptions for phantom pain and fake injuries, are the essential elements.

While a doctor may be a crucial to a pill mill, actual doctoring is just a bother. Undercover agents, posing as patients, were prescribed hundreds of oxycodone pills without so much as an examination by Dr. Jeffrey Lipman at Midtown Pain Management in Miami-Dade, according to Lipman’s arrest warrant.

It was easy to see why the DEA might have been suspicious of Lipman’s bedside manner. In the first six months of 2010, he ordered up 288,560 oxy pills for his patients. (There are more prolific oxy docs in the United States. All 39 of them work out of South Florida pill mills.)

The agents told the doc of prior drug abuse and taking oxy with alcohol. They described only minimal pain. In Dr. Lipman’s waiting room, another patient, who said he planned to sell his pills in North Carolina, asked an agent (who he thought was from Tennessee), “How easy was it to sell up there?” The doctor even discussed the “street value” of the oxy he was dispensing with the undercover agents. He figured $8 to $16 a pill.

Medical experts cited in the arrest warrant described Lipman’s clinic as “consistent with those of the usual pill mill, where cash is the only form of payment, patients often travel from long distances and sell prescribed controlled substances , physical examinations are not performed . . . and controlled substances are prescribed in excessive dosages and potentially fatal combinations.”

The raids came the day after Gov. Rick Scott reiterated his fervent, ideological opposition to a drug database, designed to prevent oxy shoppers from filling multiple prescriptions, moving from one pill mill to another – circumstances captured nicely by the pain clinics raided Wednesday.

The warrants noted how the pill mills flourish in Florida with minimal regulations, without the tracking system used in most states. “Consequently, individuals have been able to obtain unlimited and unmonitored quantities of controlled substances from multiple pain clinics for either personal consumption or resale in Florida and elsewhere.”

The raids only reinforced the notion, widely held by law enforcement and most of the state’s medical associations, that without a monitoring system, Florida invites criminal operations in the guise of medical clinics.

But after Wednesday, the pill mill industry will be forced to limp along with a dozen fewer doctors.

© 2011 Miami Herald Media Company. All Rights Reserved.
http://www.miamiherald.com

Read more: http://www.miamiherald.com/2011/02/23/v-print/2082013/pill-mill-arrests-hit-right-target.html#ixzz1EqMoYvC7

The Stubborn Rejection of Common Sense

2011-02-13T19:38:00.001-08:00

Rick Scotts decision to derail the Prescription Drug Monitoring Program (PDMP) is either based on ideological rigidity, or plain simple ignorance.

The attached articles and editorials clearly highlight the absolute necessity to declare a public health emergency and to implement the PDMP immediately!

1. More babies born addicted to pain drugs http://articles.sun-sentinel.com/2011-02-12/health/fl-prescription-drugs-born-addicted-20110211_1_newborns-prescription-drug-winnie-palmer-hospital

a. In 2009, nearly 1,000 babies born in Florida hospitals were treated for drug withdrawal syndrome. The most recent data show no signs of a slowdown. During the first half of 2010, 635 cases were reported.

b. From 2006 to 2009, there was a 173 percent increase in newborns treated at Florida hospitals for drug withdrawal syndrome, according to Agency of Health Care Administration records obtained by the Orlando Sentinel.

2. Why does Gov. Scott oppose Florida prescription drug database? http://articles.sun-sentinel.com/2011-02-12/news/fl-rick-scott-pills-mayocol-b021311-20110211_1_pain-clinics-prescription-drug-pill-mill-epidemic

a. “Scott's move to scrap a prescription narcotic database intended to temper the excesses of South Florida's rogue pain clinics makes no sense. Unless the governor somehow likes the drug tourism, overdoses and other human wreckage spawned by our pill-friendly culture. If it's not government's role to monitor controlled substances, then why bother monitoring anything? Let's just do away with driver's licenses, vehicle registrations and concealed weapons permits too, since cars and guns are legal. The database had support from just about everyone — legislators, law enforcement, responsible doctors and pharmacists and legitimate pain clinics.”

3. Pill mills: Scott, legislators undermining efforts, by Mike Fasano and Nan Rich http://www.sun-sentinel.com/news/opinion/fl-pills-oped0213-20110213,0,3980383.story

a. “Legislature is essentially allowing unneeded deaths to continue. It is, therefore, imperative that the legislature get out of the business of approving rules for bills that it has already passed. In the case of the Board of Medicine's rules, lives are at stake. Finally, the governor has eliminated the Office of Drug Control, which provides an important focus on the problem of drug abuse, and coordinates the numerous state agencies affected by this issue. State agencies across the board must deal directly or indirectly with the consequences of drug abuse, including our courts, law enforcement, prisons, foster care system, Veterans' Administration, health departments, mental health programs and even port security agencies. That's why the work of the ODC to coordinate the drug control efforts of each of these agencies is imperative, and why we're disappointed to see Gov. Scott unilaterally shut down this agency by laying off its entire staff. We therefore hope our legislative colleagues will consider taking immediate action to put our tough new pill mill regulations into action, and that the governor will put the Office of Drug Control back to work, and preserve the Prescription Drug Monitoring Program. This issue isn't about bureaucracy or the size of government — it's literally a matter of life and death.”

We should not ponder the question why our new Governor is not getting it. Instead, we should take action and develop a collaborative network of allies and supporters across the political spectrum to push back. Now its time to act! You can follow me on Twitter www.twitter.com/dadedoc or at http://floridadocs.blogspot.com

Yours truly,

Bernd Wollschlaeger.MD

Governor Scott and the PDMP

2011-02-08T20:05:00.001-08:00

Governor Scott and the PDMP:

The Governors proposal to eliminate the Prescription Drug Monitoring Program (PDMP) surprised many supporters of this project. Currently, the PDMP implementation has been stalled by a protest from a software company, which bid for the contract and lost.

The PDMP would require doctors and pharmacies to enter and report each and every prescription for controlled substances. With the help of the database healthcare professionals and, under very restricted and monitored circumstances, the police could then crosscheck the database for anyone who has received multiple prescriptions of narcotic drugs from multiple sources, a common practice among addicts and drug dealers who amass large quantities of drugs from so-called “pain clinics.”

The law establishing the PDMP clearly stipulated that it to be financed without tax dollars. It would be run with more than $500,000 raised from drug makers, foundations and federal grants, which would have to be returned.

Without a functioning PDMP unscrupulous pill-mill owners and their drug dealer cronies in white coat can obscure and conceal the dispensation of millions of prescription narcotics taking place behind the pain-mill walls.

Governor Scott argues, "That program has not been working," even though is has yet to be implemented! The fact that NO tax dollars have been or will be used for developing and deploying the PDMP one is left to ponder the question what is driving our Governor to make such a foolish decision?

The reason is clear: ideological blinders prevent him from realizing that seven (7) Floridians die every day from prescription narcotic overdose. He firmly believes that government can do only harm and that regulations will prevent business to thrive and prosper. That includes drug dealers, fraudsters and thieves too!!

The time has come to stand up and speak up. We cannot allow him to dismantle the product of years of hard work. Lets not waste this opportunity to protect our public health and safety.

Yours truly,

Bernd

AG Bondi and Pill Mills

2011-02-04T19:45:00.001-08:00

During a news conference in Panama City today Florida Attorney General Pam Bondi outlined her strategy to address the pain clinic issue and related prescription drug abuse. She announced four recommendations:

A mandatory six-month suspension and $10,000 fine for doctors who violate standards of care when prescribing controlled substances.

A third-degree felony charge for those who use fraud or misrepresentation to register as a pain clinic.

Escalating criminal penalties for doctors who fail to perform a physical examination before dispensing 72-hours worth of controlled substances.

Require anyone maintaining an inventory of controlled substances to report the discovery of theft to local law enforcement or the Florida Department of Law Enforcement within 48 hours or risk fines and administrative penalties.

She also called for strict enforcement of current laws and aggressive prosecution of violators.
I applaud AG Bondi for her efforts but prosecution and regulations alone won't solve the issue.
State Attorney Glenn Hess (Panama City) is correct stating that the penalties might not discourage the doctors because of the affluence of the doctors and the substantial($$$$$) profits they stand to make dispensing the pills. This explains why the number of registered pain clinics statewide increased to 932 , but police say many violators are unregistered. The Florida Department of Law Enforcement counts 1,167 "pill mills" in the state.
Vague language will also make some of the recommendations difficult to prosecute. Defining “standards of care” and a “physical exam” then showing how a doctor violated those requirements before writing a prescription will be a challenge.
AG Bondi omitted mentioning the most important linchpin of a successful strategy: a Prescription Drug Monitoring Program (PDMP) which can provide a valuable tool for physician to identify doctor shoppers and to safely prescribe narcotics to patients who often do not disclose other source of prescription drugs. The PDMP implementation is currently stalled due to a contested bid. Shortly after Statute 893.055 , which mandates the creation of the PDMP, was passed in early 2009, the Department of Health opened bidding on the contract to create the Prescription Drug Monitoring Program. When bidding closed this summer, the losing bidder contested the winner, and the DoH opened bidding again. The same loser, Optimum Technology, lodged another complaint -- this one about the terms of the bidding themselves. Which means construction of the database has yet to get underway. Meanwhile, seven Floridians die every day from a prescription drug overdose, 49 per week, 200 per month.
AG Bondi could resolve this issue by declaring a public health emergency, thereby enforcing the immediate implementation of the PDMP.
I hope she will listen and we should ask her to show the courage to make this decision.

Yours

Bernd

Bernd Wollschlaeger,MD,FAAFP,FASAM

Florida Health Grades

2011-02-02T18:29:00.001-08:00

Attached links to two articles which made me feel ashamed being a Floridian. Why do our elected officials wage their ideological battles on the back of those in need. Its clear to me who will loose: our children and the most needy in our state.

* "Florida Official sends back $1M " http://www.healthnewsflorida.org/index.cfm/go/public.articleView/article/21614 reporting that state Insurance Commissioner Kevin McCarty said Tuesday he will forfeit a $1 million federal grant that was supposed to go toward beefing up oversight of health-insurance rates.McCarty's disclosed the decision to give up the $1 million grant during the conference call and also sent a letter Tuesday to a top federal health official. The Office of Insurance Regulation was awarded the grant last year to hire workers and upgrade technology. McCarty gave a brief explanation for his decision, saying he was concerned about intrusiveness of the federal government. He also pointed to a Pensacola judge's ruling. He did not give any indication whether Gov. Rick Scott influenced the move, though Scott said earlier in the day that the state will not spend much time or money carrying out the law until court challenges are resolved. Tuesday's decision was not the first time Florida has foregone federal funding that could help carry out the law. The state did not apply last year for money in what is known as the "Consumer Assistance Program" --- which is designed to help people with insurance decisions and information. Goodhue said that program could have provided $2 million to Florida, which was one of about 15 states that did not receive a grant. It also is unclear whether the state Agency for Health Care Administration will apply for a newly available grant to prepare for creating a health-insurance exchange, which would provide a sort of marketplace where consumers could shop for coverage. AHCA did not respond to repeated questions during the past two weeks from Health News Florida about whether it would apply for the exchange grant. Late Tuesday afternoon, AHCA referred all questions about the federal health law to the governor's office, which did not return a phone call.
* "Uninsured kids propel Florida's low health care rating" http://jacksonville.com/news/florida/2011-02-02/story/uninsured-kids-propel-floridas-low-health-care-ratin. It's a good thing for Texas, Arizona, Mississippi and Nevada.
Without those states' abysmal child health systems, Florida's would rank last in the nation, according to a new analysis Read the complete study http://news.jacksonville.com/documents/020111scorecard.pdf compiled by the Washington-based Commonwealth Fund. Still, at 47th overall, the Sunshine State's efforts to ensure that children receive timely, effective health care fall far short of the national standard. The group's report card included all 50 states as well as the District of Columbia. Individual state scores were based on 20 health indicators. They include a state's insurance coverage rates, typical premium costs to families, the percentage of children who see a regular doctor, infant mortality rates and childhood obesity statistics. Insurance rates depended not only on geography but also race: Florida's uninsured rate of more than 20 percent among black children was the highest in the country, according to the report. Florida's low ranking was driven by its high rate of uninsured children, said Cathy Schoen, one of the report's authors. The state's 17.8 percent was second only to Texas, with 18 percent. Both states could dramatically lower their uninsured rates if they raised the maximum a family could earn to be eligible for Medicaid and the Children's Health Insurance Program, Schoen said. Both cap incomes at up to 200 percent of the federal poverty level, or $44,100 for a family of four. How Florida's children rank vs. nation
50th - Percentage of insured children
51st - Percentage of children with a preventive dental visit in past year
15th - Percentage of young children receiving all doses of six key vaccines
35th - Percentage of children aged 10-17 overweight or obese
32nd - Infant mortality rate
0 - Rankings among 20 indicators in which Florida is in top 5

Yours

Bernd

How We Can Curb Prescription Drug Abuse

2011-01-30T21:05:00.000-08:00

Attached an article published in Internal Medicine News reporting that the combined efforts of local physicians and the statewide prescription drug monitoring program successfully reduced prescription narcotic diversion.
This article should serve as an example that we CAN curb prescription drug abuse.
So what are we waiting for?
Yours
Bernd

Pain Management Program Cut Prescription Narcotics Diversion

By: M. ALEXANDER OTTO, Internal Medicine News Digital Network
01/04/11

Bookmark and Share |

SAN ANTONIO – A primary care initiative combining patient pledges with random pill counts and urine screens significantly reduced prescription narcotics diversion in North Carolina’s rural Caldwell County.

Dr. Ed Bujold worked with law enforcement and social service agencies to create a registry that helped reduce by 300% the number of prescription narcotics seizures in one rural North Carolina county.

As part of the program, most primary care patients with chronic, nonmalignant pain sign a contract agreeing to those measures – and pledging not to doctor-shop for narcotics – prior to receiving their prescriptions, explained Dr. Ed Bujold, a family physician in the Caldwell County town of Granite Falls who helped spearhead the initiative.

Physicians in the western North Carolina county began to use the contracts in 2007, which coincided with a 300% drop in prescription narcotics seizures by county law enforcement between 2005 and the end of that year.

"I believe most of the impact on the 300% decrease took place in [2007]," Dr. Bujold said at the Society of Teachers of Family Medicine Conference on Practice Improvement.

There’s been no evidence the measures keep patients who truly need narcotics from getting them, he added.

In fact, patients "are in complete agreement with this. I have had several say, ‘I am so thankful you are doing this. I don’t want these drugs to go out to places they are not supposed to be,’?" Dr. Bujold said.

Dr. Bujold said he is also more confident prescribing Percocet (oxycodone and acetaminophen), OxyContin (oxycodone), Vicodin (hydrocodone and acetaminophen), and other narcotics to the few hundred chronic pain sufferers among his roughly 3,500 patients. A survey found other primary care physicians participating in the initiative are as well.

"I feel very comfortable treating patients now, because I know that I am not dealing with the riffraff," Dr. Bujold said. "This system pretty much takes them out of the picture."

The idea was born in 2006 after a church service, when the Caldwell County sheriff approached Dr. Bujold, a fellow parishioner.

The sheriff confided in him that prescription narcotics threatened to become the county’s main drug problem, ahead of methamphetamine and cocaine. Local law enforcement officials recently had found two houses stocked with prescription narcotics for street sale, he added.

A few local physicians had been too trusting, prescribing narcotics "without even thinking some might end up on the street," Dr. Bujold explained.

Over the next year, Dr. Bujold, two county narcotics officers, a pharmacist, a community nurse, and the regional director of Community Care of North Carolina worked on a solution.

The contract was its centerpiece, downloaded from the American Society of Anesthesiologists Web site. Patients who sign it pledge to get their narcotics from one physician and one pharmacy, and submit to random pill counts and urine drug screens.

Once the plan was in place, the nurse visited local primary care practices to explain the diversion problem and contract initiative.

At the same time, North Carolina created an online narcotics registry accessible to doctors and pharmacists.

"It closed the loop for us. If we have somebody who comes in as a new patient, and their story sounds a little fishy, we can go to the narcotics registry," explained Dr. Bujold. "If they’re getting prescriptions from 10 physicians and 5 pharmacists, we know right away that this is not somebody we are probably going to work with."

By 2008, narcotics officers reported cocaine and methamphetamine were again the main drug problems in Caldwell County. There were also reports that drug-seeking patients were leaving the county.

Currently, around 90% of local physicians use the contracts, and patients submit to urine screens and pill counts about twice a year when their names come up on a randomly generated list.

Not finding narcotics in the urine of patients prescribed narcotics is a red flag. Marijuana detection is, too, because it’s not legal in North Carolina for medical purposes, though "we try to make a decision based on the individual’s circumstances," Dr. Bujold said.

If patients violate their contract, they are cut off from narcotics, something that happens about twice a month in Dr. Bujold’s practice, he said.

Copyright © 2011 International Medical News Group, LLC. All rights reserved.
This page was printed from www.InternalMedicineNews.com . For reprint inquires, call 877-652-5295, ext. 102.

The Pill Mills Issue and Politicians

2011-01-30T19:01:00.001-08:00

Attached you find an excellent commentary by Carl Hiaasen entitled " Hey, gov: Don't give pill mills license to kill."
The commentary speaks for itself and I 100% agree with its content and tone.
I am angered and frustrated that many physicians in the state of Florida have chosen a hands-off approach regarding this issue. Some even ague that we should wait and see to avoid antagonizing the new Attorney General and Governor. Well, I beg to differ! I still remember when organized medicine first and foremost dedicated its efforts to protect the public health and NOT only the financial interest of doctors. I also remember the time when organized medicine spoke up to protect the interest of those who had no voice to speak. Now we have to opportunity to rise to the challenge to defend the lives and well-being of our families and patients. Now is the time to demand from our elected officials to declare a public health emergency to stop the epidemic prescription drug abuse killing seven Floridians every day! We should not let this opportunity slip away. We must stop the drug dealers in white coats who chose profits before their professional oath.
Yours
Bernd

The Miami Herald
Posted on Sat, Jan. 29, 2011
Hey, gov: Don’t give pill mills license to kill

By Carl Hiaasen
chiaasen@MiamiHerald.com
Florida attorney general Pam Bondi speaks at a news conference on Wednesday, Jan. 19, 2011 in Tallahassee, Fla.
Steve Cannon / AP
Florida attorney general Pam Bondi speaks at a news conference on Wednesday, Jan. 19, 2011 in Tallahassee, Fla.
Florida Attorney General Pam Bondi called a press conference last week to ban a new party drug known as MDPV, which is being sold in head shops around the country as “bath salts.”

Most users snort the stuff, which doctors say can cause wild hallucinations and violent behavior. Peddled as fake cocaine, MDPV has been linked to several deaths and suicides.

Said Bondi, “I frankly had a nightmare last night that someone was going to overdose on this and we hadn’t done anything.”

Interestingly, she didn’t mention having any nightmares about Florida’s storefront pain clinics, which are still handing out Vicodins like Tic-Tacs, and overdosing customers at the rate of seven fatalities per day — more than heroin, crystal meth and cocaine combined.

Florida has become one of the nation’s favored destinations for prescription-drug dealers, who travel here to load up their car trunks and head north with the pills, which are sold on the black market for up to $30 each.

More oxycodone is dispensed here than anywhere else in the country. During one especially bountiful six-month stretch of 2008, Broward doctors prescribed 6.5 million doses, almost four pills for every resident of the county.

Efforts to shut down the unscrupulous clinics have been stymied by Bondi’s Republican colleague, newly elected Gov. Rick Scott. One of his first acts was to eliminate the state Office of Drug Control, which had been coordinating the war on pill mills.

Scott’s executive order freezing all new regulations was another blessing for sleazy clinic owners, who’d been facing a slate of tough licensing standards from state medical officials. Now some of those restrictions will be delayed until the financial impact is assessed, in accordance with Scott’s “accountability” process.

This is a fantastic development for those who prey on drug addicts, though it’s bad news for healthcare providers, law enforcement and taxpayers who are picking up the tab for most overdose admissions to emergency rooms.

Certainly that’s not what the Legislature had in mind last spring when it took aim at the hundreds of pill mills that had sprung up throughout the state, especially in South Florida. Most of the clinics are still open today, churning out oxycodone prescriptions like confetti.

Lawmakers had mandated that the state’s medical boards make strict new rules for the clinics, including penalties for violations. Legitimate pain-clinic operators and pharmacies generally supported the reforms.

Not so fast, said the rule-hating governor.

So the killer pill mills remain open, while Scott’s new “Office of Fiscal Accountability and Regulatory Reform” ponders the potential financial impact of urinalysis.

Really.

Last week, the Florida Board of Medicine unanimously passed four rules aimed at curbing prescribing abuses at in-and-out clinics. But first the state had to pay for a quickie economic study that calculated the pain-clinic rules would cost the private sector about $69 million the first year, most of it for urinalysis.

The tests are relatively inexpensive (about $17-per-pee), and would help clinics determine whether the customers were painkiller addicts or patients with true medical problems. The customers themselves would pay for the testing.

For the governor’s staff to be meddling in such a clear-cut issue is a waste of time and resources. Apparently, seven dead Floridians a day isn’t enough evidence to convince Scott that there’s a crisis.

Everyone else seems to get it, from the U.S. Drug Enforcement Administration to local police agencies that have witnessed the pill clinics proliferate, and documented the convoys of dope mules arrive from other states.

The Legislature in 2008 passed a law authorizing a computer data base to track narcotics prescriptions, which would help identify pill-peddling physicians as well as drug dealers who shop from one doctor to another.

Yet the monitoring system still isn’t in place, and might not be until summer. Florida remains one of only 12 states without such a data network.

More legislation took effect in October, in advance of Scott’s election. Before then, basically anyone could own a pain clinic, felons included. Now each clinic must show that it’s owned by a state-licensed physician, or conform to licensing standards as hospitals do.

True, tough laws and rules won’t stop all crooked clinic owners and shady doctors, who can be as creative as they are greedy. But without something on paper to enforce, authorities can only peck at the problem.

Many officials in Tallahassee do seem to grasp the nightmarish scope of the prescription-painkiller epidemic. To Bondi’s credit, she appointed former state Sen. Dave Aronberg to pursue pill-peddling operations statewide.

But, like everyone else, Aronberg can’t do much until Scott’s little truth squad gets around to deciding (among other things) whether urine tests present an undue financial burden for Vicodin buyers.

The governor wasn’t kidding when he said Florida is open for business. Just ask the creeps at your neighborhood pill mill.

© 2011 Miami Herald Media Company. All Rights Reserved.
http://www.miamiherald.com

Read more: http://www.miamiherald.com/2011/01/29/v-print/2041020/hey-gov-dont-give-pill-mills-license.html#ixzz1CZgZQfyq

Airline Safety Record Can Serve As An Example

2011-01-24T20:11:00.001-08:00

While waiting in line for a cup of coffee at a Dunkin Donuts I glimpsed at the front-page of USA TODAY reading that for two consecutive years not a single airline passenger died in a U.S. carrier crash! No passengers died in accidents in 2007 and 2008, a period in which commercial airliners carried 1.5 billion passengers on scheduled airline flights, according to a USA TODAY analysis of federal and industry data. That’s indeed great news! So why is that happening? Because government requirements during the past two decades have made planes safer in violent impacts and fires, reducing the likelihood of deaths,technology improvements led to the development of more reliable aircraft and better training of airline personnel contributed to this impressive record too.
In contrast a recent OIG (Office of Inspector General of the US Department of Health) study http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf found that one in seven Medicare patients were harmed by the care they received in the hospital during a month studied by the agency. The study shows that hospital patients are harmed much more frequently than previously estimated and points to the need for mandatory validated public reporting of medical errors, according to Consumers Union, the nonprofit publisher of Consumer Reports. The OIG study was based on a physician review of the medical records of a nationally representative sample of 780 Medicare patients during October 2008. It found that 134,000 hospitalized Medicare patients experienced medical harm in that month. The OIG calculated that Medicare patients harmed during that month required an additional $324 million in hospital care. The study estimated the annual cost for these events in hospital care alone at $4.4 billion. According to the OIG, an estimated 15,000 Medicare patients experienced medical errors in the hospital that contributed to their deaths each month. That amounts to about 180,000 patients annually. 25 states and the District of Columbia collect data from hospitals on the incidence of certain medical errors. But only six states have disclosed hospital-specific medical error information to the public. Even worse, half of all states do not have any medical error reporting requirements in place. In most states, hospital-specific information is kept secret and hospitals can get away with under-reporting errors because there is no effort made to systematically validate the data that hospitals are required to report.
So whats the conclusion? Its safer to receive medical care while flying? Maybe. Or, should we apply the experience gained in the airline industry to the medical industry? Would we better off establishing the medical equivalent of the FAA (Federal Aviation Administration)? I believe we should?
Maybe now is the time to reevaluate our approach to medical error prevention and to reconsider our resistance to report medical errors from which we all could learn from. But maybe I just like flying too much.

Yours
Bernd

Airlines go two years with no fatalities

By Alan Levin, USA TODAY
For the first time since the dawn of the jet age, two consecutive years have passed without a single airline passenger death in a U.S. carrier crash.

No passengers died in accidents in 2007 and 2008, a period in which commercial airliners carried 1.5 billion passengers on scheduled airline flights, according to a USA TODAY analysis of federal and industry data.

One major accident occurred during that time, last month's crash of a Continental Airlines jet in Denver.

Going without a crash fatality for a full year has been rare. Only four years since 1958 have passed without a passenger fatality, the analysis found. That makes the two-year string even more impressive, aviation safety experts say.

"It's a new record," says Arnold Barnett, a Massachusetts Institute of Technology professor who has written extensively about airline fatality risks.

"While it doesn't mean risk is now non-existent," Barnett says, "it certainly means they have done a fantastic job at keeping all these threats at bay."

Barnett calculates that it's more likely for a young child to be elected president in his or her lifetime than to die on a single jet flight in the USA or in similar industrial nations in Europe, Canada or Japan.

"It's just more evidence of what has been the improving safety record that we've seen over the past several years," says Bill Voss, president of the Flight Safety Foundation, a non-profit group that promotes aviation safety around the world.

Overall risks of death on an airline flight have dropped dramatically.

Fatality risk fell to 68 per billion fliers this decade, less than half the risk in the 1990s, according to National Transportation Safety Board (NTSB) data. Since 2002, the risks of dying on a flight plunged to 19 per billion, an 86% drop from the 1990s.

The fiery Continental Airlines crash Dec. 20 in Denver shows it can still be hazardous to fly. The jet turned off a runway while attempting to take off, breaking apart and bursting into flames.

All 115 people aboard escaped as jet fuel burned through the right side of the jet. The crash injured 38 people, five seriously, the NTSB said.

The crash helps illustrate why death rates have fallen, Voss says.

Government requirements during the past two decades have made planes safer in violent impacts and fires, reducing the likelihood of deaths, he says.

Technology improvements, more reliable aircraft and better training also have helped reduce accidents, Voss says.

The lack of fatal crashes creates new challenges for federal regulators and the airline industry. Further safety improvements must come from studying the minor anomalies of everyday flight.

"What we're looking at now is the risks before they manifest themselves into accidents," says Basil Barimo, with the Air Transport Association.

Pain Clinics: Board of Medicine Calls For Rules Implementation

2011-01-22T19:16:00.001-08:00

There are (mixed) good news to report in the struggle to curb the explosive growth of pain clinics in Florida.
According to a SunSentinel article published today the Florida Board of Medicine on Friday unanimously passed pain-clinic rules that will impose an estimated $65 million in costs despite Gov. Rick Scott's edict to ban rule-making this year.
Board members asked their staff to send letters to both the Legislature and the governor's Office of Fiscal Accountability and Regulatory Reform, explaining the need for immediate implementation of these rules, given the significant threat to public health and safety that some "pill mills" have created in the state. The four rules adopted on Friday set out the requirements for standards of care, inspections,accreditation and training in pain-management practices.
Several members, who met by conference call, mentioned that they support Scott's call for a halt to rule-making to make sure that the process doesn't unduly impose a burden on small businesses and the public. In fact, the board voted unanimously to suspend rule-making other than the regulations on pain clinics. The Department of Health commissioned a study by the Center for Economic Forecasting and Analysis at Florida State University after the Legislature required them for all pending rules with at least a $200,000 impact on business. The Center churned out the study in just one month in order to leave time for the board to decide whether to submit the rules by the Feb. 4 deadline for consideration during this year's legislative session. I still do not understand why "pain clinics" count as legitimate business entities!!!
Unfortunately, neither the Senate nor the House leadership are willing to call for a special session to pass these rules, therefore causing further implementation delay.
How many Floridians have to die before legislators understand that this is a public health emergency requiring a drastic and quick response?
Declaring a public health emergency would also allow for the immediate implementation of the Prescription Drug Monitoring Program which is hold up by a bidder protest.
The time to act is now!!!

Yours

Bernd

South Florida Sun-Sentinel.com Med board to legislators: End delay on pill mill rules

Rules would cost pain clinics, patients $65 million a year

By Bob LaMendola, Sun Sentinel

January 21, 2011

Florida regulators trying to stop the illicit flow of narcotic pills from rogue pain clinics called Friday for the state Legislature to quickly approve stricter rules.

The Florida Board of Medicine was ready to adopt new pain clinic rules but then legislators passed a law in November saying no rules could take effect until approved by the state House and Senate. Legislative action is not expected on any rules until the annual session starts March 8.

Friday, the medical board sent the rules to lawmakers and urged fast action. One board member, Dr. Steven Rosenberg of West Palm Beach, suggested a special session as early as next week, when most legislators are in Tallahassee for meetings.

"It would only take them a few minutes," Rosenberg said. "We can't afford to wait until the regular session in March. That's [hundreds more] people who will die as a result of the pill mills."

Officials estimate that seven Floridians die every day from prescription drug overdoses, some of those due to pill mills – unscrupulous pain clinics concentrated in South Florida that peddle large quantities of painkillers to dealers and addicts.

Don't expect any action before March, legislative officials said.

"A special session? That's not going to happen," said David Bishop, a spokesman for Senate President Mike Haridopolos, R-Indialantic. Legislators need time to review the details, he said.

Katy Betta, a spokeswoman for House Speaker Dean Cannon, R-Winter Park, said the medical board spent more than a year writing the rules, so a legislative subcommittee would spend a few weeks reviewing them.

The rules would let the state inspect pain clinics and punish clinic doctors for violations. The doctors would have to examine every patient before writing a prescription, give drug tests to patients and cut off pain pills to patients who abuse them.

The rules face another potential roadblock from Gov. Rick Scott, who this month froze all proposed rules for a review by his advisers. But officials said they did not think he would hold them up.

Rosenberg and other supporters said they worry that some pain clinic owners and physicians who oppose aspects of the rules might lobby legislators to change the wording and send the rules back to square one.

As part of its action in November, the Legislature ordered state officials to estimate the cost of every new rule. A report for the medical board found that pain clinic rules would cost about $65 million in the first year and $61 million a year in the future. Each of the 923 pain clinics – a state-high 117 in Broward County, 113 in Palm Beach County, 49 in Orange County – would pay $69,000 a year.

About $60,000 of that would be charged to patients, who will have to pay $17 each for urine tests twice a year, the report said.

Paul Sloan, a Venice pain clinic owner who is president of Florida Society of Pain Management Providers, said the cost is a little higher than expected but worth it.

The Florida Academy of Pain Medicine favored the rules and the cost Friday, but said the strongest part of crack down – a statewide database of pain pill prescriptions so police and doctors can track pill abusers – also is stalled. The database was to start Dec. 1 but is held up by a bidder's protest.

Bob LaMendola can be reached at blamendola@SunSentinel.com or 954-356-4526.

Copyright © 2011, South Florida Sun-Sentinel

Doctors and Guns

2011-01-15T18:41:00.000-08:00

Attached a link http://www.nwfdailynews.com/news/-36599--.html to an article reporting that state Representative Jason Brodeur (R-Sanford) and State Senator Greg Evers (R-Baker) introduced a legislative proposal ( HB 155 http://richmedia.onset.freedom.com/nwfdn/leze4b-14gunbill.pdf) which would make it a felony for a physician or staff member to ask patients or family members of patients if they own guns or store guns at home. If found guilty, the medical provider could be fined up to $5 million or face up to five years in jail.
I hope that I do not go too far to call this measure INSANE and hope that our FSAM will speak up strongly against it!! What's next? Prohibiting us from asking patients about their drug use?
When do our legislators stop stepping in between us and our patients? I wholeheartedly agree with Dr. Scott Needle from Naples who said “Pediatricians have a right and a responsibility to ask appropriate questions as to a child’s safety and well-being, even if these questions might be uncomfortable to the parents. Likewise, however, no parent can be legally compelled to answer such questions.”

Yours
Bernd

New measure would bar doctors from asking patients if they own guns:

TALLAHASSEE — Doctors and other medical providers in Florida would be barred from asking patients — or the parents of child patients — if they have guns in their home under a measure that promises a major showdown between powerful lobbying groups.

The National Rifle Association’s top Florida lobbyist and a Florida Medical Association member both say the issue is among the top priorities for the upcoming legislative session, with the groups holding diametrically opposed positions on what doctors and their patients and families should be allowed to discuss during a medical visit.

Sponsored by state Rep. Jason Brodeur, R-Sanford, the bill (HB 155) would make it a felony for a physician or staff member to ask patients or family members of patients if they own guns or store guns at home.

If found guilty, the medical provider could be fined up to $5 million or face up to five years in jail.

State Sen. Greg Evers, R-Baker, introduced an identical Senate version of the bill on Thursday.

Gun rights groups say the measure was prompted by complaints from gun owners following an incident last summer in which an Ocala-area physician told a couple to find a new pediatrician after they refused to answer questions about whether they had guns in their home and how they were stored.

Marion Hammer, executive director of United Sportsmen of Florida and a former national NRA president, said the gun rights groups have no opposition to a physician’s office handing out brochures on gun safety, but the direct questioning on whether there are guns in the home of a patient and how they store them goes too far.

“Simply, it’s none of their business,” Hammer said.

Critics of the measure say it inappropriately puts a wedge between doctors and their patients by restricting what can be discussed. They say questions regarding gun ownership and how weapons are secured within homes are much like a pediatrician asking the parents of a child if their electric outlets have protective covers, or whether their pool is fenced in.

“No other area of physician inquiry has been deemed off-limits by the Legislature,” said Naples pediatrician Scott Needle.

“Pediatricians have a right and a responsibility to ask appropriate questions as to a child’s safety and well-being, even if these questions might be uncomfortable to the parents. Likewise, however, no parent can be legally compelled to answer such questions.”

Mental Health Care Aids Substance Abuse Treatment

2011-01-06T20:09:00.001-08:00

Mental Health Care Aids Substance Abuse Tx
Family Practice News

Volume 40, Issue 20, Pages 60-61 (December 2010)

Major Finding: BDI-II scores decreased by an additional 6.3 points after 3 months and 4.6 points after 6 months in the intervention group, compared with usual care.

Data Source: A quasi-experimental study with 299 participants.

Disclosures: Dr. Watkins reported having no financial conflicts of interest regarding this study.

BOSTON — Integrating cognitive behavioral therapy for depression with residential substance abuse treatment leads to improvements in mood and substance use outcomes in clients with persistent depressive symptoms, a study has shown.

The findings support the delivery of evidence-based mental health care within substance abuse treatment programs, Dr. Katherine Watkins said at the meeting.

Depression often goes hand in hand with substance abuse, yet few individuals in public-sector substance abuse treatment facilities have access to effective depression treatment, according to Dr. Watkins, senior natural scientist at RAND in Santa Monica, Calif.

To determine whether integrating cognitive behavioral therapy (CBT) for depression into the usual-care cognitive model for substance use would improve outcomes in residential substance abuse treatment, she and her colleagues conducted a quasi-experimental study to compare the efficacy of a 16-session, evidence-based CBT intervention plus usual care to that of usual care alone in 299 clients (age range, 18-63 years) with depression being treated in a single public-sector residential alcohol or other drug (AOD) treatment center.

The primary and secondary outcome measures were, respectively, depressive symptoms as measured by the Beck Depression Inventory II (BDI-II) and improved functioning measured by the Short Form 12 (SF-12) health survey at 3 and 6 months after intervention relative to baseline. All patients had baseline BDI-II scores greater than 17 (mean total was 33.5, indicating scores in the clinically severe range), she said.

Of the 299 study participants, 140 received usual care and the group CBT intervention – Building Recovery by Improving Goals, Habits, and Thoughts (BRIGHT) – delivered by a trained substance abuse treatment counselor; and 159 received usual care.

The CBT program included discussions of the connection between mood and substance use and provided strategies for identifying and modifying harmful thoughts, activities, and interactions with people related to both mood and substance use.

To be consistent with CBT, each session had a prescribed agenda of announcements, practice (homework) review, new topics, key messages, assignment of new practice, client feedback, and a description of the next session. New topics were reinforced by embedding interactive activities, such as writing down harmful thoughts the last time they wanted to drink, into each session.

At 3- and 6-month follow-ups, the BDI-II scores decreased by an additional 6.3 and 4.6 points in the BRIGHT group compared with usual care, and the SF-12 scores increased by 6.3 and 4.6 points, respectively, Dr. Watkins reported. “BRIGHT clients reported fewer drinking days and fewer days of problem substance use at 6 months,” she noted.

Group CBT for depression appears to be effective for persistent depression in individuals undergoing treatment for substance use disorders. “The results provide support for a new model of integrated care, in which access to effective depression treatment is increased and outcomes improved by developing the capacity of substance abuse treatment programs to deliver evidence-based mental health care,” she said.

Prescription Drug Abuse Epidemic

2011-01-06T19:24:00.001-08:00

Our elected representatives seem to have forgotten that prescription drug abuse has morphed into a public health problem of epidemic proportions.
Attached a link http://www.nytimes.com/2011/01/06/health/06drugs.html to an article from today's New York Times entitled, "Prescription Drug Abuse Sends More People to the Hospital."
Here are some highlights:

* The number of emergency room visits resulting from misuse or abuse of prescription drugs has nearly doubled over the last five years,even as the number of visits because of illicit drugs like cocaine and heroin has barely changed.
* 1.2 million visits to emergency rooms involving pharmaceutical drugs in 2009, compared with 627,000 in 2004. This does NOT include visits due to adverse drug reactions.
* The number of people seeking treatment for addiction to painkillers jumped 400 percent from 1998 to 2008.
* In a growing number of states, deaths from prescription drugs now exceed those from motor vehicle accidents, with opiate painkillers like Vicodin, Percocet and OxyContin playing a leading role.

The question remains: what are we going to do about it?

Bernd

The End To Public Hospitals

2011-01-02T19:50:00.001-08:00

Attached a link http://www.miamiherald.com/2010/12/30/v-fullstory/1994541/need-for-public-hospitals-to-be.html to an interesting article published in the Miami Herald reporting that the governor-elect's transition team has recommended creation of a panel to study whether government-owned hospitals -- Miami-Dade's Jackson Health System and Broward's two hospital districts among them -- are necessary. Rick Scott has promised to run the government like a business and government support for hospital does not fit into his ideological paradigm.
But, as the Sun Sentinel reports in an article today, " .. companies exist to make profits, while governments are charged with performing services for a wide variety of people, including the needy."
I guess Rick Scott is used to firing people and thinks that we can just "fire" 500,000 Uninsured in Miami-Dade County too. Meanwhile, the State of Florida has failed so far to deliver promised Medicaid reforms, and stands to lose $350 million in special funding from the federal government unless it can get an extension of a waiver! These funds, called the Lower Income Pool, are crucial to Jackson Memorial fiscal survival, which received $258 million from the pool last year. But Rick Scott wants to keep distance from the federal government and we can kiss this waiver good-by too. Furthermore, in his ideological world the Unemployed are also at fault for their own calamity and need to shape up or commit themselves to community services. But how can they afford healthcare if they have no access to public healthcare services, no job and no money to pay the escalating healthinsurance premiums? I see those patients every single day. Hard working, decent American citizens abandoned by their own government! Guess, Rick Scott also indulges in nostalgic reminiscence of the "good old times" before government helped to protect workers from exploitation by industrialists, abolished child labor and unions successfully struggled for fair wages.
We definitely should not let him to drag our State backwards. We must save Jackson Memorial hospital and preserve our already strained public health system.

Yours

Bernd

AG Pam Bondi Focuses on Prescription Drug Abuse

2011-01-01T07:54:00.001-08:00

Happy New Year to all of you. An article in today's Miami Herald http://www.miamiherald.com/2010/12/31/1995960/pam-bondi-sets-stage-for-attorney.htmlreports that Florida's new Attorney General, Pam Bondi, named former state Senator Dave Aronberg to a new post focusing on prescription drug abuse.

`What I want to do is bring people together on all sides who all care about the issue,'' she (AG Pam Bondi) said.
The position is the only post Bondi has created in an organization with more than 1,100 employees. She is otherwise streamlining the office by eliminating three high-level jobs to trim $250,000 from the budget.
Shortly after her election, Bondi signaled she planned to make pain clinics that excessively dole out prescription drugs -- so-called pill mills -- a focus of her office. She set up a transition team that included Aronberg to examine the problem.
`We're at a critical point in our state regarding the number of pill mills. The numbers are staggering. We've got to do something to stop it,'' Bondi said. `Just the other day I had someone say that a friend's child overdosed. I said, `It was Oxycontin, wasn't it?' They said, `How did you know?' It's so widespread in our state. That's something we don't want to be known for.''
Bondi's move is likely to come as good news to people concerned that Gov.-elect Rick Scott opted to cut the Office of Drug Control. Aronberg will be based in South Florida and earn $92,000 a year as special counsel for the pill mill initiative.

We should definitely support the new AG in her efforts to curb prescription drug abuse but should point out that with the abolishment of the Offiice of Drug Control we have lost the organizational capability to coordinate all necessary efforts to execute and implement an effective plan to stop drug dealers in a white coat to perpetuate their business.
Furthermore, we do NOT have to start all over to study the problem! We have done so already and know what to do.
Its now time to walk the walk and not talk the talk. We should call upon AG Pam Bondi to act now and declare a public health emergency and implement the Prescription Drug Monitoring Program immediately which is being hold up in a petty bidding dispute.
Now is the time to act and not to reconsider. Meanwhile, 7 Floridians die every day from prescription drug overdose and we must stop the bleeding.
Yours
Bernd

Pill Mills are Gearing up for Big Business

2010-12-28T18:58:00.001-08:00

Thanks to the ideological rigidity of our legislature and almost monoptic "vision" of our Governor-Elect the Prescription Drug Monitoring Program is almost dead before even going online. The Office of Drug Control is being dissolved and all employees are gone by January 3rd!
In today's Miami Herald editorial the issues at hand are being pointed out as they are.
Dr. Viamonte Ross, one of the few agency heads asked to resign, has the final opportunity to declare a public health emergency thereby forcing the state to approve an existing PDMP vendor contract. Unfortuantely, the Attorney General (and the Board of Medicine) do not believe that the current status quo justifies such an emergency order. The rate of prescription drug overdose death increased to 7 Floridians a day. So whats the "magic" number 10,20, 100...?
I urge all of you to contact your legislator to support an immediate declaration of a public health emergency.
Yours
Bernd

The Miami Herald
Posted on Tue, Dec. 28, 2010
Pill mills still going strong

When it comes to the unsavory and downright illegal, South Florida owns the market in healthcare scams. Miami-Dade County is the nation's epicenter of Medicare fraud. Broward County is the state's biggest black market in prescription pain killers like oxycodone. By now, many of the pill mills should have been shut down. They're not.

Thanks to lax state oversight, walk-in pain clinics have flourished in Florida in the last three years. A 2009 Miami Herald series highlighted the proliferation of these pill mills. Broward clinics alone sell more oxycodone than is sold in several states. Anyone can get hundreds of pain pills from these clinics. The powerful narcotics are then resold on the street.

The growth of pain clinics, often run by discredited doctors, is causing an epidemic of prescription overdose deaths, says Florida drug czar Bruce Grant. The rate of deaths is about seven per day -- a shocking number that's preventable.

By now, these clinics were supposed to be regulated under tough new rules. Instead, most reforms are in limbo thanks to a contract dispute and a blunder by the Legislature during its November special session.

In 2009, the Legislature passed a bill to create a statewide database of all prescription narcotics sold by doctors and pharmacists to prevent patients from ``doctor shopping'' -- going to multiple clinics and doctors for pills to later resell. Tougher rules governing doctors working in pain clinics and who could own them are also in the new law.

The due date for the database was Dec. 1. The deadline came and went, however, because a company bidding on the project has legally challenged the contract award. Mr. Grant has asked Florida's surgeon general, Dr. Ana M. Viamonte Ros, to approve the contract on an emergency basis to protect public health.

Dr. Viamonte Ros is one of the few agency heads told to resign by Gov.-elect Rick Scott. But she is on the job till Jan. 3. Given those seven daily drug overdoses, Dr. Viamonte Ros should set the database in motion.

The other big glitch in moving forward with the regulations happened because of GOP lawmakers' zeal to override outgoing Gov. Charlie Crist's vetoes. They revived an anti-regulation bill requiring any new rules that may cost businesses or the government more than $200,000 a year to be subjected to legislative review before implementation.

This has stalled many pill-mill regulations, which now must await lawmakers' scrutiny in 2011. In vetoing the bill in its first incarnation, Gov. Crist wisely warned that the law would have required almost every new rule -- which can number in the hundreds in one year alone -- to await mandated review before being applied. What a nightmare.

Despite the setbacks, the state health department commendably has enforced a few rules. In November, state officials began inspecting pain clinics for the first time. So far, 17 clinics have been shut down.

That's a start, but as of November, there were 142 registered clinics in Broward and 94 in Miami-Dade. So much more could be happening right now to prevent more unnecessary deaths.

© 2010 Miami Herald Media Company. All Rights Reserved.
http://www.miamiherald.com

Read more: http://www.miamiherald.com/2010/12/28/v-print/1990879/pill-mills-still-going-strong.html#ixzz19SfYkR8i

Closing the Office of Drug Control is Bad For Business

2010-12-22T19:47:00.001-08:00

Governor-Elect Rick Scott notified all four full-time employees working in the governor's Office of Drug Control that their services will no longer be needed after he takes office next month. The office will be dissolved and all its duties turned over to the departments of Health and Law Enforcement.
Rick Scott has pledged to cut waste in state government and the annual budget of about $551,300 for funding the operations of the Office of Drug Control is considered "waste" that needs to be eliminated too.
But lets analyze and examine the facts:

* The Office of Drug Control was created by then Governor Jeb Bush in 1999 and is authorized by state statutes.
* The Office collaborates with other agencies on the implementation of a three-pronged approach of Prevention, Treatment and Law Enforcement to eliminate the devastation of substance abuse rampant in Florida's diverse communities.
* The Office issued a series of excellent reports http://www.flgov.com/drugcontrol/odc_statsreports.php documenting the increasing problem of drug abuse in Florida.
* The Office was instrumental in getting legislation passed that is intended to help curb prescription drug abuse — one bill targeting pain management clinics, which are often disguises for "pill mills," and another that establishes a prescription drug monitoring program.
* The Office championed the creation of a Prescription Drug Monitoring Program, which almost reached the point of going on-line.
* Prohibited by law to use state funds to pay for the PDMP Director Bruce Grant and his superb staff successfully obtained the necessary funding through federal grants and other sources

The current political leadership in Tallahassee seems to be under the impression that we DO NOT have a significant drug problem in Florida.
Governor Scott's spokesman Brian Burgess was quoted in an article that "I don't think we're going to have cocaine bales stacking up on the docks of Miami if we close this office."
Obviously, he did not bother to check the facts:

· Years of lax state laws and a plethora of pain clinics have made Florida a destination for prescription drug traffickers, drug peddling doctors and abusers.

· The DEA, using its most recent data, says that 49 out of 50 of the top oxycodone prescribers are located in Florida.

· The number of deaths caused by at least one prescription drug increased more than 100 percent from 2003 to 2009.

· Mark Fontaine, executive director of the Florida Alcohol and Drug Abuse Association, said a recent study showed that substance abuse has a $43 billion negative impact on the state economy due to loss of job productivity, and costs associated with hospital and emergency room visits and incarceration. Fontaine said about 65 percent of Florida inmates have substance abuse problems.

· A 2009 Florida Department of Law Enforcement study concluded seven people in Florida die every day- ALMOST 2500 FLORIDIANS A YEAR - due to prescription drug abuse.

YES, WE DO HAVE A DRUG PROBLEM IN FLORIDA AND YES IT HAS REACHED EPIDEMIC PROPORTIONS WITH ADVERSE SOCIAL AND ECONOMIC RAMIFICATIONS.

Is cutting $500,000 of "wasteful" spending is worth more than all of the above listed adverse impacts of substance abuse and diversion?
Isn't it penny wise and pond foolish to close the Office of Drug Control? Shouldn't such decisions be based on recommendation made as the result of a careful review process involving experts?

SAVING $500,000 IS A BAD BUSINESS DECISION!
I am certain that closing the Office of Drug Control will have a significant adverse impact on our efforts to combat and control substance abuse and diversion forcing the allocation of much higher funding of law enforcement to deal with the consequences of a failed policy.

GOVERNOR-ELECT RICK SCOTT PLEASE RECONSIDER THIS DECISION!

THE ELIMINATION OF THE OFFICE OF DRUG CONTROL IS BAD FOR BUSINESS AND BAD FOR OUR GREAT STATE OF FLORIDA.

Bernd Wollschlaeger,MD,FAAFP,FASAM
Family Physician& Addiction Specialist

Marijuana Debate

2010-12-18T19:53:00.001-08:00

Attached an interesting letter to the editor published in the Miami Herald.
As addiction professionals we need to be able to respond to questions posed regarding Marijuana use and abuse.
We should gather the facts and discuss the issue openly and objectively.
Maybe the attached letter can contribute to stimulate the discussion.
Looking forward to your feedback.
Yours
Bernd

The Miami Herald
Posted on Tue, Dec. 14, 2010
Marijuana is not the `safer' drug

Re the Dec. 2 story Presidential hopeful: Legalize marijuana: Former New Mexico governor Gary Johnson's statement, ``Marijuana is a lot safer than alcohol,'' cannot go unchallenged and should be debated in a larger context. One important factor, often left out of the conversation, is that marijuana use (especially in young adults) can lead to or aggravate mental illness.

Studies support findings that risk of schizophrenia doubles in young abusers. Pot is also a gateway drug, leading abusers to graduate to harder drugs such as heroin and methamphetamine.

I am a certified addiction specialist specializing in adolescent substance-abuse, and my message is this: Beware marijuana's potency, no matter the arena of debate. Whether one discusses the medical merits or legal ramifications, one must also consider real-life implications.

• The medical debate: The medical merits of THC, the main ingredient in marijuana, have been identified, and THC is available in pill-form as Marinol and Cesamet. However, according to proponents of legalizing medical marijuana, the medical merits of THC are best experienced by smoking it -- absent FDA approval or review.

• The legal debate: The legal merits of marijuana cannot be supported. One argument is to tax the drug and collect revenue. According to Joseph Califano Jr., CASA founder and chairman of Center on Addiction and Substance Abuse (CASA), for approximately every $1 of tax revenue, there could be as much as $7 incurred in medical costs.

Califano also points out that legalizing marijuana means easier availability to children, and the debate is already contributing to teens' softening attitude about drugs, specifically marijuana. According to CASA findings, ``Despite reported declines in teen marijuana use -- in 2007 almost 11 million teens report using marijuana -- marijuana is a major substance abuse among teens, more than five times the increase in such findings for all other substance abuse.''

Here's the real debate: Today's marijuana is not the pot of the 1970s. Its THC potency, the amount of psychoactive ingredient found in the drug, has more than doubled since 1983. This decade has brought a 175-percent increase in pot potency. According to a 2008 analysis from the University of Mississippi's Potency Monitoring Project, the drug's potent effects have severe consequences. Marijuana's growing potency not only affects the risk of addiction and increased experimentation to harder drugs, but also the ``risk of psychological, cognitive and respiratory problems.'' In addition, the study found that marijuana abuse increases the risk of developing mental disorders by 40 percent -- another serious side effect that's rarely reported.

There are several issues in the marijuana debate. We must consider all of them.

MARINO E. CARBONELL, South Miami

Florida Legislators and Pain Clinics

2010-12-08T19:41:00.000-08:00

Posted on Wed, Dec. 08, 2010; Miami Herald

State lawmakers must not give `pill mills' a pass

The Dec. 3 editorial, Tallahassee's pill mills, correctly points out how the Republican-dominated state Legislature voted to delay the implementation of tough new pain-clinic regulations.
Consequently, unscrupulous clinic operators and drug dealers in white coats, wrongly called ``doctors,'' can continue to churn out prescriptions for powerful painkillers.
Legislators seem more concerned with ideological correctness and purity than the sobering facts detailed in a report released in June by the Florida Department of Law Enforcement. It indicated that an average of seven Floridians a day die from prescription-drug overdose.

Our lawmakers seem to live in another universe than most of us. In their world, reality has to be adapted to fit political theory. In their world, government regulation can only do harm and never do good. In their world, pain clinics are successful businesses contributing to the overall economy, and more regulations will drive them away from our state.

Legislators forget that the regulations were carefully crafted by Democrats and Republicans to protect Floridians from these unscrupulous businesses.

Now, the proposed rules must be submitted to the Legislature by Feb. 4 to qualify for consideration. Those that don't make it would have to wait until the 2012 legislative session.

I am outraged by this political checkmate and concerned about its adverse impact on public health. This issue is too important to allow politicians to gamble away the lives of Florida residents. We need to return to pragmatism and sound reasoning to address and resolve the problem of prescription-drug abuse in the state. Ideological grandstanding will only worsen the situation. We do not have much time left -- and the clock is ticking.

Bernd Wollschlaeger,MD
North Miami Beach

http://www.miamiherald.com

Read more: http://www.miamiherald.com/2010/12/08/v-print/1963311/state-lawmakers-must-not-give.html#ixzz17a0ATueT

Pain Clinic Regulations Stalled

2010-12-04T20:54:00.001-08:00

Attached some troubling updates regarding the pain clinic regulation issues:

1. A letter to the editor published in the Sun-Sentinel http://articles.sun-sentinel.com/2010-12-03/news/fl-pain-clinics-letter-1203-20101203_1_pain-clinics-prescriptions-for-powerful-painkillers-prescription-drug
2. Article about persistent over dose deaths in Florida http://www.sun-sentinel.com/health/os-deaths-florida-report-20101202,0,1564941.story
3. Medical Board Yanks License of Pediatrician http://www.sun-sentinel.com/health/fl-doctor-discipline-20101203,0,5563711.story
* Several troubling statements taken from the article:
* "On a related matter, a medical board panel decided not to take emergency action to initiate a strict set of pain clinic rules that have been delayed by legislative action. Legislators last month passed a law saying rules with substantial impact on small business cannot take effect until lawmakers give approval. The medical board could have declared the pill mill problem to be an emergency and put the rules into effect, but the panel found no grounds to do so."
* What other grounds do we need to declare an emergency??

Yours
Bernd

Tallahassee's Pill Mills

2010-12-04T20:50:00.001-08:00

Attached a stinging editorial published in yesterday's Miami Herald and my response in the form of a letter to the editor.

Yours
Bernd

The Miami Herald
Posted on Fri, Dec. 03, 2010
Tallahassee's pill mills

Lawmakers don't usually side with pill traffickers. But that's what the Florida Legislature unwittingly did during its brief, vengeance-fueled special session last month.

In the lust to override lame-duck Gov. Charlie Crist's vetoes on a handful of bills, the overwhelmingly Republican Legislature passed a law that requires legislative approval for any new government rules that cost more than $1 million over five years.

The law was touted as a measure to help stop the government from imposing excessive restrictions on business. All well and good. But it turns out the measure had a nasty side effect: It also halted the imposition of new regulations on the state's pill mills, which help feed an illegal pill pipeline.

How embarrassing. And predictable.

Lawmakers ignored warnings

Pill mills cause real suffering for addicts and their families, but lawmakers were more interested in the politics of punishing Gov. Crist for leaving the Republican Party than they were on studying what's good for the state and its residents. They ignored warning bells and rushed to pass a new law without understanding its implications.

Two years ago, lawmakers vowed to get serious about regulating pill mills -- after a Miami Herald series of articles spotlighted South Florida as the pill-mill capital of the United States. Doctors at these pain clinics, many in Broward County, served dual roles as pain and addiction specialists. The black market for painkillers in Florida flourished, spawning an epidemic of overdose deaths in Kentucky, Ohio, West Virginia, Tennessee and other states.

The new regulations, which were set to kick in Nov. 28, would have helped to curb some aspects of the abuse, specifying basic standards for pain clinics and surprise inspections each year, among other provisions.

Victims of the pain pill business counted the legislation a victory. And then lawmakers got the bright idea to override Gov. Crist's veto of the rule-making bill.

In his veto, Gov. Crist warned that nearly every rule would have to wait for the Legislature's approval under the new law, a mind-boggling thought given the number of rules that government can propagate. As of right now, there are roughly 600 proposed rules that have yet to take effect. No one knows how many of them now will require final legislative approval.

One, for sure: pill mill regulation.

Little opposition

There were a few voices of dissent amid the cry to override Gov. Crist's veto. Sen. Mike Fasano, R-New Port Richey, voted against the rule-making bill, saying it needed more study. Mr. Fasano was also the sponsor of the pill mill legislation.

Re-imposing the regulations may be delayed until the 2011 legislative session in the spring. The state Board of Medicine will discuss the regulations at its December meeting in Orlando.

For now, until lawmakers fix this unintended consequence of their own haste, the pill pushers win.

© 2010 Miami Herald Media Company. All Rights Reserved.
http://www.miamiherald.com

Read more: http://www.miamiherald.com/2010/12/03/v-print/1954918/tallahassees-pill-mills.html#ixzz176r4uQ3s

An editorial in today's Miami Herald entitled “Tallahassee's pill mills” correctly points out how the Republican dominated legislature voted to delay the implementation of tough new pain clinic regulations. Subsequently, the unscrupulous clinic operators and drug dealers in white coats, wrongly called “doctors,” can continue to churn out prescriptions for powerful painkiller. The legislators seem to be more concerned with ideological correctness and purity than the somber facts detailed in a recent report from the Florida Department of Law Enforcement released June 30th 2010 indicating that an average of seven Floridians per day die from prescription drug overdose! It appears that our legislators seem to live in another universe than most of us have to live in. In their world reality has to be adapted to fit political theory. In their world government regulation can only do harm and never do good. In their world pain clinics are successful businesses contributing to the overall economy and more regulations will drive them away from our state. They seem to forget that the regulations were carefully crafted by Democrats and Republicans to PROTECT our citizens from those unscrupulous businesses, which contribute to the DEATH of seven Floridians a day!! Now, the proposed rules must be submitted to the Legislature by Feb. 4 to qualify for consideration. Those that don't make it would have to wait until the 2012 legislative session. I am not only outraged by this political checkmate but also deeply concerned about its adverse impact on public health. This issue is too important to allow politicians to gamble away the lives of Florida’s citizen. We need to return to pragmatism and sound reasoning to address and resolve the problem of prescription drug abuse in Florida. Ideological grandstanding will only worsen the situation. We do not have much time left and the clock is ticking.

Bernd Wollschlaeger,MD,FAAFP,FASAM

Board certified Family Physicians & Addiction Specialist

16899 NE 15th Avenue, North Miami Beach,FL 33162 Phone: (305) 940-8717

E-mail: info@miamihealth.com

Member of the Prescription Drug Monitoring Implementation and Oversight Task Force

Siberia in Florida: GOP Senator Gets the Cold Shoulder

2010-11-26T21:36:00.001-08:00

It used to be you'd have to start every debate thinking: compromise. Now, the only constraint is their good judgment.''

Former Rep. Tom Feeney, R-Orlando, who Speaker of the Florida House from 2000 to 200.

Today’s Miami Herald article “Veteran senator won’t toe the line,” http://www.miamiherald.com/2010/11/25/1943608_p2/veteran-senator-wont-toe-the-line.html clearly points out the power shift in Tallahassee. The new GOP leadership is flexing its ideological muscles. No one will be allowed to think or act independently. Its the party line or political exile. Senator Fasano, a strong supporter of Governor’s Christ Senate campaign, had to endure the punishment straying from the ideological talking points. Fasano took to the Senate floor during last week's half-day special session and railed against a GOP blueprint for fixing Medicaid. The symbolic ``memorial'' resolution informs Congress that Florida plans to steer its Medicaid patients into managed care networks, an idea that has gained popularity in the state House. ``This is more than intent. We are setting policy today by doing this,'' scolded Fasano, a 16-year legislative veteran. ``This should have gone through committees. If you think you got a few phone calls last year, put people in an HMO and the phones will be ringing off the hook.''

But Fasano's protests were quickly drowned out by a GOP stampede in favor of the bill. In the new Senate, where newcomers value business and economic development over Fasano's populist consumerism, he has morphed from conservative stalwart to moderate maverick.

Lets not forget that Senator Fasano was also the sponsor of the pain clinic legislation that cracked down on facilities freely dispensing medications that are being used by drug abusers who were doctor-shopping. Fasano also was critical of the Legislature for passing the new rule-making bill, arguing it needed more study. As a result the state Department of Health now must determine whether the new rules exceed the threshold and require a legislative sign-off -- if they have a $1 million adverse impact over five years on economic growth, competitiveness, employment, investment, job creation or regulatory costs. For now, the upshot is that the rules are stalled. What will happen in the meantime? "What's going to happen is nothing," said Sen. Mike Fasano, R-New Port Richey. "And seven more people will die each and every day until the Legislature ratifies these rules that are being approved by the Board of Medicine and the Department of Health."

I wish we would have more outspoken politicians in Florida like Senator Fasano who think and act according to their conscience and not according to party discipline.

History provides a treasure trove of failed attempts to scuttle dissent and to impose rigorous party discipline. I hope that Floridian’s learn soon to regret their electoral choices. Otherwise we will be in big trouble.

Yours truly,

Bernd

Florida Legislature Delays Crackdown on Pain Clinics

2010-11-20T20:27:00.001-08:00

In today’s Sun Sentinel front page article entitled “Crackdown on pain clinic stalls again” http://articles.sun-sentinel.com/2010-11-19/health/fl-hk-pain-clinic-rules-delayed-20101119_1_millions-of-narcotic-pills-pain-clinic-pills-for-drug-dealers Bob LaMendola reports how the Republican dominated legislature voted to delay the implementation of tough new pain clinic regulations. Subsequently, the unscrupulous clinic operators and drug dealers in white coats, wrongly called “doctors,” can continue to churn out prescriptions for powerful painkiller. As a result an average of seven Floridians per day will die from prescription drug overdose. The legislators seem to be more concerned with ideological correctness and purity than the somber facts detailed in a recent report from the Florida Department of Law Enforcement released June 30th 2010 http://www.fdle.state.fl.us/Content/News/June-2010/2009-Report-by-Florida-Medical-Examiners-Commissio.aspx:

• Prescription drug deaths monitored by the state Medical Examiner's Office continued to climb to 2,488 last year. That's an average of seven deaths per day.
• Oxycodone was the cause of 1,185 state deaths in 2009, a 26 percent increase from the year before and a whopping 249 percent increase from 2005.
• Deaths caused by some illegal drugs declined. Heroin deaths decreased by 20 percent to 111. And cocaine deaths decreased by 18.4 percent to 529.Law enforcement officials have attributed the opposing trends to the fact that prescription drugs are much easier and cheaper to obtain than illegal drugs.
• Prescription drugs account for 79 percent of all drug occurrences in this report when Ethyl Alcohol is excluded. Oxycodone occurrences increased by 23.8 percent in 2009 and deaths caused by Oxycodone also rose by 25.9 percent when compared to the previous year.

So what happened? According to the article the Legislature on Tuesday had taken action to override Gov. Charlie Crist's veto of HB 1565 that was passed during the 2010 legislative session. The bill, which now becomes law, says that proposed rules having significant financial impact – more than $1 million over five years – on small businesses such as pain clinics could not take effect until legislators ratified the rules. Because the pain clinic rules were not in effect on Tuesday, state officials said they cannot be enforced. One of the law's sponsors, Rep.Matt Gaetz, R-Fort Walton Beach, said he was not thinking about pill mills. The law aims to scrutinize rules that drive up regulatory costs and stop businesses from coming to Florida. As for the impact on pill mill rules, Gaetz said: "The benefits of the rulemaking bill outweighs some of the modest inconveniences." It appears to me that Mr. Gaetz lives in another universe than most of us have to live in. In his world reality has to be adapted to fit his political theory. In his world government regulation can only do harm and never do good. In his world pain clinics are successful businesses contributing to the overall economy and more regulations will drive them away from our state. He seems to forget that the regulations were carefully crafted by Democrats and Republicans to PROTECT our citizens from those unscrupulous businesses, which contribute to the DEATH of seven Floridians a day!! Now the proposed rules must be submitted to the Legislature by Feb. 4 to qualify for consideration. Those that don't make it would have to wait until the 2012 legislative session. I am not only outraged by this political checkmate but also deeply concerned about its adverse impact on public health. This issue is too important to allow politicians to gamble away the lives of Florida’s citizen. We need to return to pragmatism and sound reasoning to address and resolve the problem of prescription drug abuse in Florida. Ideological grandstanding will only worsen the situation. We do not have much time left and the clock is ticking.

Bernd Wollschlaeger,MD,FAAFP,FASAM
Board certified Family Physicians & Addiction Specialist
Member of the Prescription Drug Monitoring Implementation and Oversight Task Force

Synthetic Cannabinoid Testing

2010-11-19T22:06:00.001-08:00

Attached some important information regarding synthetic cannabinoid testing.
Yours
DrBW

Redwood Toxicology Laboratory announces oral test for three synthetic cannabinoids

(11/18/2010)
News release
Santa Rosa, CA - Redwood Toxicology Laboratory, Inc. (RTL) announced it now offers one of the first lab-based tests for the detection of synthetic cannabinoids JWH-018, JWH-073 and JWH-250 in oral fluid/saliva.

Synthetic cannabinoids are compounds functionally similar to Δ9-tetrahydrocannabinol (THC), the principle active ingredient of cannabis, and are widely abused throughout the U.S. These chemicals are sprayed on herbal material and sold as "synthetic marijuana" under a variety of brand names.

RTL currently tests for synthetic cannabinoids JWH-018 and JWH-073 metabolites in urine, and very high positive rates (30 - 35%) have been found in court-ordered juvenile probation departments throughout the U.S. RTL's percent positive information and epidemiological data should prove useful to policymakers trying to pass legislation to control and ban the distribution, sale and use of synthetic cannabinoids.

The manufacturers of these products are constantly changing the psychoactive ingredient(s) to get around existing laws, and synthetic cannabinoids like JWH-250, JWH-019, JWH-081 and CP47 497-C8 are now found in various preparations. However, RTL's high positivity rate on JWH-018 and JWH-073 indicate they are still the main psychoactive chemicals used.

RTL's new synthetic cannabinoid oral fluid test will utilize the most sophisticated, sensitive and specific equipment and technology available, LC/MS/MS (liquid chromatography/mass spectrometry/mass spectrometry) to provide parent drug confirmation of JWH-018, JWH-073 and JWH-250.

"The high positivity rates that we are finding in urine really emphasize the need to offer more laboratory analytical solutions to detect the predominant synthetic cannabinoids in biological fluids," said Sumandeep Rana, Scientific Director, RTL. "That's why we developed and validated an analytical method to detect JWH-018, JWH-073 and JWH-250 in saliva."

Added Rana: "A wide array of parent synthetic cannabinoids can be detected in saliva, and we are working on adding more compounds to the saliva test. Saliva is easier, more convenient and less invasive to collect than blood and urine. It's difficult to adulterate or dilute and ideal for recent-use detection. Plus, the use of saliva allows us to stay current with the ever-changing array and combinations of synthetic cannabinoids being manufactured and distributed by designer drug 'chemists'."

Wayne Ross, Chief Toxicologist for RTL said, "Our lab is at the forefront of researching and identifying synthetic cannabinoids. In an effort to monitor and deter use and abuse of these compounds, RTL is continually testing products distributed on the Internet and in outlets such as gas stations and 'head shops'."

More information, including a list of synthetic cannabinoids, is available athttp://www.redwoodtoxicology.com/services/synthetic_cannabinoid_testing.html.

New Synthetic Drugs: What Do You Need To Know?

2010-10-30T20:16:00.001-07:00

Attached a link http://online.wsj.com/article/SB10001424052748704763904575550200845267526.html to a very interesting article published in today's Wall Street Journal entitled "In Quest for 'Legal High,' Chemists Outfox Law."
In the article the reporter describes how a wave of laboratory-adept European entrepreneurs see gold in the gray zone between legal and illegal drugs and in 2009 have produced in Europe 24 new "psychoactive substances" , almost double the number reported in 2008, according to the Lisbon-based European Monitoring Centre for Drugs and Drug Addiction, or EMCDDA .New substances tend to hit Europe before the U.S. and other markets, in part because European consumers are more accustomed to buying drugs online. Strong trade links between Europe and southeast Asia, where many of the drugs are made, also play a role. According to the narcotic experts quoted in the article many of the novel drugs are manufactured in China, where they say lax regulation makes it easy for companies to produce and export a cornucopia of chemicals. Les Iversen, chairman of the U.K.'s Advisory Council on the Misuse of Drugs, which advises the government on new substances, says customs officials at Heathrow Airport recently seized a large shipment of white powder from China that was labelled "glucose" but contained mephedrone. China also supplies raw ingredients to manufacturers located elsewhere. Mr. Llewellyn says he buys his raw ingredients online from Chinese suppliers, who charge rock-bottom prices and ask few questions about his business. The powders and liquids arrive by plane in 1-kilogram sacks and 25-liter drums and go to a warehouse in Glasgow before being shipped to his labs. Chinese officials say the country is taking steps to control the flow of new drugs. On September 1, China began regulating mephedrone as a "category I psychotropic substance," which means anyone importing or exporting it needs a special license. In a written statement, China's State Food and Drug Administration said it has "strengthened monitoring of the situation in the country," and is ready to work with other countries to "exchange information, share resources and jointly respond to new emerging problems of drug abuse."
What can we do? Stay informed and educated about those "new wave" synthetic drugs, how to recognize their effects and how to test for their presence in urine toxicology or hair sampling tests.
Looking forward to your comments.
Yours
Bernd

DMT in the News

2010-10-24T20:23:00.001-07:00

Attached a link http://www.cnn.com/2010/CRIME/10/23/dc.georgetown.meth/index.html?iref=allsearch to a very interesting article posted on CNN.

The report states that

"Authorities have arrested two Georgetown University students and another person in connection with a suspected drug lab found inside a dormitory Saturday morning, the Metropolitan Police Department said. The three males, each at least 18, face charges of possession of drug paraphernalia, said Officer Hugh Carew, a spokesman for the police department. The third individual was a campus visitor. None was identified. Police said that shortly before 6 a.m., they received a call about a foul odor at Georgetown's Harbin Hall. Initially, police thought the lab was for producing meth but later said it was used to make Dimethyltryptamine, a hallucinogenic drug commonly known as DMT."

What is DMT?

N,N-Dimethyltryptamine (DMT) is a naturally occurring hallucinogenic drug of the tryptamine family. This drug is found not only in many plants,[3]but also in trace amounts in the human body, where its natural function remains undetermined. Structurally, it is analogous to the neurotransmitterserotonin (5-HT) and other hallucinogenic tryptamines such as 5-MeO-DMT, bufotenin (5-OH-DMT), and psilocin (4-HO-DMT). DMT is created in small amounts by the human body during normal metabolism by the enzyme tryptamine-N-methyltransferase.

How does it work?

DMT can produce powerful entheogenic experiences including intense visuals, euphoria, even true hallucinations (perceived extensions of reality). DMT is generally not active orally unless it is combined with a monoamine oxidase inhibitor (MAOI) such as a reversible inhibitor of monoamine oxidase A (RIMA), e.g., harmaline. Uninhibited, the human body metabolizes DMT too rapidly for oral administration to be effective. Other means of ingestion such as smoking or injecting the drug can produce powerful hallucinations and entheogenic activity for a short time (usually less than half an hour), as the DMT reaches the brain before it can be metabolized by the body's natural monoamine oxidase. Taking a MAOI prior to smoking or injecting DMT prolongs and potentiates the effects.

How can we test for DMT?

I am not aware of any drug tests that would show DMT usage. It is not one of the SAMHSA-5 standardly tested for in the basic drug test, nor is it included in the extended drug tests. It is not chemically similar to any of the drugs tested for, so should not trigger the tests as another substance.

I look forward to your comments , input and suggestions.

Yours

Bernd

Malpractice Reform; A Fresh Start

2010-10-23T19:07:00.001-07:00

Attached an interesting article published in the New York Times on October 20th, 2010.
In this article Peter Orszag, the former director of the White House Office of Management and Budget, emphasizes that Congress (Democrats AND Republicans alike) " missed an important opportunity to shield from malpractice liability any doctors who followed evidence based guidelines in treating their patients." He argues that malpractice reform, i.e.liability insurance reform, could encourage doctors to adopt new evidence more quickly.
He continues stating that instead of imposing caps on liability a far better strategy would be to provide safe harbor for doctors who follow evidence based guidelines. In such circumstances ANYONE who could demonstrate that he/she has followed the recommended course for treating a specific illness or condition could NOT be held liable! To successfully transform our broken malpractice system he suggests taking the following steps:

1. Organizations like the American Medical Association and the Institute of Medicine could also be called upon to issue the needed evidence-based standards for malpractice immunity.
2. Approach to reform will require larger investments in research into what works and what doesn’t. Fortunately, both the health care reform act and the 2009 economic stimulus act provided additional financing for such comparative effectiveness medical research, and the health care act provides for a Patient-Centered Outcomes Research Institute to coordinate the work.
3. Develop and fund information technology solutions that quickly suggest best-practice methods of treatment.
4. Align financial incentives for delivering higher-quality care and and to shift Medicare’s payments toward “fee for quality” rather than “fee for service.”

In my opinion we should discuss these ideas, ask for federal funding to start pilot projects and to actively support any such initiatives.
Unfortunately, organized medicine is focusing on liability caps as the ONLY solution for malpractice reform ignoring and discarding ANY other approaches to address and resolve this important issue. At this point in time progressive physicians and other healthcare professionals should form partnerships and alliance to counter this dogmatic position. Healthcare professionals should consider seeking representation in partnership with ALL participants in the healthcare delivery process including PAs,ARNPs,Nurses and hospital administrators and to engage in strategic planning sessions to develop rational responses to increasing complex problems.
This requires new leadership with the ability to listen, to tolerate other opinions and to seek a compromise based on the most common denominator.
Discussing malpractice reform also requires the inclusion of legal professionals and to engage the trial bar in the deliberations.
We must move from confrontation to collaboration and to stop dividing the world into "friends" and "enemies" of medicine.
Maybe just a dream but the opportunity to change is still present.
Yours
Bernd

October 20, 2010
Malpractice Methodology
By PETER ORSZAG

The health care legislation that Congress enacted earlier this year, contrary to much of today’s overheated rhetoric, does many things right. But it does almost nothing to reform medical malpractice laws. Lawmakers missed an important opportunity to shield from malpractice liability any doctors who followed evidence-based guidelines in treating their patients.

As President Obama noted in his speech to the American Medical Association in June 2009, too many doctors order unnecessary tests and treatments only because they believe it will protect them from a lawsuit. Instead, he said, “We need to explore a range of ideas about how to put patient safety first, let doctors focus on practicing medicine and encourage broader use of evidence-based guidelines.”

Why does this matter? Right now, health care is more evidence-free than you might think. And even where evidence-based clinical guidelines exist, research suggests that doctors follow them only about half of the time. One estimate suggests that it takes 17 years on average to incorporate new research findings into widespread practice. As a result, any clinical guidelines that exist often have limited impact.

How might we encourage doctors to adopt new evidence more quickly? Malpractice reform could help — possibly a lot.

The academic literature tends to play down the role of medical liability laws in driving up health care costs. Doctors themselves, however, almost universally state that malpractice statutes lead to extraneous testing and treatment.

It is also conceivable that because such laws usually focus on “customary practice” — that is, a doctor who has treated a patient the way most other doctors in the area would is considered safe from accusations of malpractice — they create a strong contagion effect among doctors. The laws, no matter how weak or stringent, may therefore explain why doctors in some parts of the country generally adopt much more intensive approaches than those in other areas do.

The traditional way to reform medical malpractice law has been to impose caps on liability — for example, by limiting punitive damages to something like $500,000. A far better strategy would be to provide safe harbor for doctors who follow evidence-based guidelines. Anyone who could demonstrate that he has followed the recommended course for treating a specific illness or condition could not be held liable.

The health care reform act that Congress passed earlier this year included a modest set of state pilot projects, including one in Oregon that is intended to experiment with this approach. But these pilots are small; the project in Oregon, for example, has only $300,000 in financing.

What’s needed is a much more aggressive national effort to protect doctors who follow evidence-based guidelines. That’s the only way that malpractice reform could broadly promote the adoption of best practices.

Congress has taken a step in this direction before. As Prof. James Blumstein of Vanderbilt University Law School has pointed out, a little-known provision in the Social Security Act amendments of 1972 provides immunity from malpractice liability to doctors who treat patients in conformity with the standards set forth by so-called quality improvement organizations — nonprofits under contract with Medicare that work to improve care. The provision remains in force, though those organizations have yet to set such standards.

Organizations like the American Medical Association and the Institute of Medicine could also be called upon to issue the needed evidence-based standards for malpractice immunity. But no matter which body is put in charge of certification, this approach to reform will require larger investments in research into what works and what doesn’t. Fortunately, both the health care reform act and the 2009 economic stimulus act provided additional financing for such comparative effectiveness medical research, and the health care act provides for a Patient-Centered Outcomes Research Institute to coordinate the work. It’s a good start.

Better technology would help, too. Your doctor’s computer should be able to not only pull up your health records (after you have approved such access) but also quickly suggest best-practice methods of treatment. The doctor should then be able to click through to read the supporting research. Subsidies in the stimulus act help doctors pay for this kind of technology.

A final step toward improving standard medical practice will be to better align financial incentives for delivering higher-quality care. Hospitals now lose Medicare dollars, for example, if they succeed in reducing readmissions. Medical professionals should be given incentives for better care rather than more care.

The health care reform act already includes measures that enable policymakers to shift Medicare’s payments toward “fee for quality” rather than “fee for service.” My next column will discuss these measures, which get far less credit than they should, in more detail.

Opponents of the act are generally off base in criticizing investments in improved care. In complaining about the missed opportunity to reform medical malpractice laws to promote evidence-based medical practice, on the other hand, the critics are entirely on target.

Peter Orszag, the director of the White House Office of Management and Budget from 2009 to 2010 and a distinguished visiting fellow at the Council on Foreign Relations, is a contributing columnist for The Times.

Keep it Simple and Stupid: Rick Scott's Healthcare Plan and the FMA

2010-10-12T19:32:00.001-07:00

“Florida is not a physician-friendly state to practice medicine because of the high cost of medical liability insurance and excessive lawsuits,....the FMA PAC supports Rick Scott for Governor because he shares our goal of increasing access to quality health care for all of Florida’s citizens. Rick Scott is not afraid of taking on personal injury lawyers and shaking up the status quo in order to get things done for the people of Florida.”

President of the FMA PAC, Dr. Madelyn Butler

I tried to understand Rick Scott's healthcare plan and ideas, which convinced the Florida Medical Association Political Action Committee to endorse him as Gubernatorial Candidate.
First, I searched on his web site and found the following:

* On Abortion: "I believe that abortion is wrong and Roe versus Wade should be overturned."
o What shall I tell a woman who is pregnant but unmarried, unemployed, on food stamps and lives with friends or relatives?
o Teenagers who were raped or married women who were sexually attacked by their husbands?
o Should government tell women and doctors what to do and how to lives their lives?
* On Health Care:
o "As a businessman, I know I am held accountable for results, and I held the people in my company accountable for results, too. Delivering quality care at a lower cost to patients was a top priority when I ran Columbia/HCA, and when I started Solantic urgent care facilities here in Florida....In the 1990’s, we were able to transform the hospital industry and prove that free market health care can deliver high quality care at a lower cost to patients."
+ That’s it? We just have to emulate the Columbia/HCA model and open a couple of Solantic Urgent Care centers and we solve all healthcare problems? Guess, I can shred all my healthcare economics test books and magazines, join Rick Scott's model and everything will be just fine. How naive or stupid can anyone be to believe that? Obviously, the FMA PAC does!
o "Rick believes that our health care system should focus on choice, competition, accountability and personal responsibility."
+ So I will have the choice of choosing between an unaffordable health insurance policy or none?
+ Accountability and personal responsibility only applies to the consumers of healthcare but not Rick Scott who just made " some mistakes in his life."

o "Most recently, Rick led the fight to defeat President Obama’s government-run public option. As the founder of Conservatives for Patients’ Rights (CPR), an advocacy group dedicated to the free market principles of choice, competition, accountability and personal responsibility in health care, he was instrumental in defeating the public option plan that would have led to socialized medicine."
+ Fear mongering and painting the government as the boogeyman trying to enslave citizens is a silly and dangerous tactic which just reveals that Rick Scott and friends have no other arguments to offer to resolve the critical problem facing us today and in the near future: how to provide affordable healthcare for an aging population suffering from chronic diseases that consume already 75% of all health care spending.
* On healthcare management experience:
o " I’ve made mistakes in my life...I learned very hard lessons from what happened and those lessons have helped me become a better businessman and leader."
+ That’s it! Mistakes imply taking personal responsibility and not blaming others (i.e. Columbia/HCA) for it. These are the lessons he brings to the table and those character traits make him the knight in shining armor for the FMA PAC?

So what can I say about the FMA PAC decision to endorse Rick Scott? A sad day for Florida's doctors. A sad day for medicine.

Yours

Bernd

Prescription Drug Prices

2010-10-03T20:38:00.000-07:00

In todays Miami Herald State Representative Juan C. Zapata calls for a mandated use of generic drugs for Medicaid and other state-funded programs http://www.miamiherald.com/2010/10/03/1854185/mandate-use-of-generic-drugs-for.html . He is correct saying that the use of generic drugs will slow down the predicted explosive growth of Medicaid expenditures but the mandated use of generic drugs addresses only ONE aspect of the problem. According to a New York Times article , Drug Makers Accused of Ignoring Price Law,” http://www.nytimes.com/2010/10/03/us/03drug.html , drug manufacturers consistently defy complying with a federal law that requires them to provide the government with pricing data needed to calculate discounts on medications prescribed for Medicaid recipients. More than three-fourths of drug manufacturers did not fully comply with the law requiring them to provide price data. They are supposed to file monthly and quarterly reports on what wholesalers paid them for drugs eventually sold to retail pharmacies. Without price data, the federal government cannot compute rebates, and states may be unable to collect them. As a condition of having their drugs covered by Medicaid, pharmaceutical companies must agree to provide discounts in the form of rebates. Drug companies pay the rebates to state Medicaid programs. The federal government and the states share the cost of Medicaid — roughly $400 billion in the last year — and share the savings that result from the rebates. Under the health care law, the minimum rebate on brand-name drugs dispensed to Medicaid recipients was increased to 23.1 percent of the average manufacturer price, from 15.1 percent. The minimum rebate on generic drugs was increased to 13 percent, from 11 percent. The Congressional Budget Office estimates that the changes could save the federal government more than $35 billion over 10 years. Major drug companies are already reporting adverse effects on their revenues. However, drug companies stand to gain many customers with the scheduled Medicaid expansion in 2014. What can be done to address this problem? Under federal law, the government can impose penalties of $10,000 a day on a drug manufacturer that fails to provide the information “on a timely basis. According to the Inspector General at the Department of Health and Human Services the federal government has had this authority since 1990 but has not used it! Why not? We must control and limit the rising healthcare costs and drug manufactures must understand that they can be either be part of the problem, or part of the solution. We also should lift the limitation on prescription drug re-importation and stop the unscrupulous use of antipsychotic drugs, which generate over $14 billion in revenue for drug manufacturers. Otherwise, we have no choice but to resort to rationing of healthcare services and prescription drugs.

Yours
Bernd

Prescription Drug Monitoring Program

2010-09-11T19:50:00.000-07:00

Update:

Last month I presented at the Prescription Drug Abuse Summit in Tampa (see attached article)
I also serve on the Program Implementation and Oversight Task Force and we prepare the launch of the Prescription Drug Monitoring Program on December 1st. We will have a Taskforce meeting in Tallahassee next week to discuss details of the pending launch.
Lots of work has to be done to educate doctors and to lower the resistance threshold. Unfortunately, we are facing push-back from the medical community regarding the prescription drug monitoring program. Those who resist its implementation raise privacy issues and (of course) consider it as "further government intrusion into the practice of medicine." I want to emphasize that this is NOT a Republican vs. Democrat issue but a PATIENT SAFETY and PUBLIC HEALTH issue!! We all should stand together in support of the program and work towards its successful implementation.
Attached you also find the rule which implements the Prescription Drug Monitoring Program.
Again, we need to convince doctors to use the program, otherwise we won't resolve the problem and many more Floridians will die!!
Yours
Bernd

August 27, 2010

Prescription drug abuse summit held in Tampa
By Nicole Hutcheson, St. Petersburg Times Staff Writer
At a summit in Tampa, medical professionals air concerns about a new state tracking program.

TAMPA - Come December, medical professionals will have a new tool to determine whether a patient is abusing prescription drugs.

But some worry that the Prescription Drug Monitoring Program, a new state system that tracks narcotic dispensing, will add a burden to their already heavy workload. Others question the privacy aspect of the new rules.

"Many physicians are very concerned about another regulatory issue," said Dr. David Weiland, vice president of medical affairs at Bayfront Medical Center in St. Petersburg. "To me, any regulation can be a barrier to real patients receiving adequate treatment for their pain."

The monitoring program was a hot topic at this year's Drug Abuse Summit hosted by Associates in Emergency Medical Education, a Lutz company that trains medical professionals. More than 140 people - including doctors, prosecutors, law enforcement officials and drug abuse counselors from across the country - attended the daylong event Friday at the Marriott Waterside in downtown Tampa.

"The goal is to come up with answers as a whole," said Sharon Kelley, executive director of Associates in Emergency Medical Education. "There is no one solution to this, you have to bring all the players together."

The drug monitoring program dominated many of the event's sessions, including how doctors should use the system and how to comply with federal privacy laws. The legislation, sponsored by Sen. Mike Fasano, R-New Port Richey, is meant to cut down on doctor shopping and overprescribed narcotics.

Here's how it would work: When doctors or pharmacist dispense pain pills, such as oxycodone, amphetamines and Xanax, they must report it to a centralized database. When the database goes online, pharmacists and doctors statewide will be able to search it to determine if their patients have received a similar prescription in the past. They have 15 days to report to the system, and failure to do so is a misdemeanor.

"A doctor will be able to look at the prescription history of their patient no matter which doctor they've been to," said Bruce Grant, director of the Governor's Office of Drug Control. "It's an added safety measure."

The statewide database is expected to cost about $12 million to get up and running by December. The Department of Health is implementing the system, but the law prohibits using state money for implementation. A combination of federal grants and private money raised by the Prescription Drug Monitoring Program Foundation is being used to fund the program. Funding is on track, Grant said.

More than 40 other states have such a system.

But there remained an air of hesitance among some at Friday's event. Their questions included: What would stop a patient from traveling across state lines to receive pain medicine? Would it violate any privacy laws? And how will law enforcement access the database?

Claude Shipley, project director for the state's Office of Drug Control, tried to quell concerns.

"There is this urban legend myth that you will be in violation of HIPAA (Health Insurance Portability and Accountability Act) using PDM (prescription drug monitoring)," Shipley said. "There is no civil liability. The statue is very clear on that."

Law enforcement would be able to get information from the system if it has an open investigation involving a doctor or patient.

Dr. Bernd Wollschlaeger, a family practitioner in North Miami, spoke in support of the monitoring program. He has been using an electronic prescription system for the past seven years.

On Friday, he told of a 47-year-old woman who needed help ending an oxycodone addiction.

Wollschlaeger started her on Suboxone, a medicine that helps patients with opiate withdrawal symptoms.

After researching his electronic prescription system, he learned that the woman was still receiving hydrocodone from her gynecologist. She had withheld that important information. After Wollschlaeger confronted the patient, they began a more honest discussion, he said.

"This served as a tool to start this dialogue. I didn't point the finger at the patient, but this gave me the tools I needed," he said. "(Prescription drug monitoring) will bring transparency, not policing."

Nicole Hutcheson can reached at nhutcheson@sptimes.com or (813)226-3405.

Prescription Drug Monitoring Program Issues

2010-09-11T19:49:00.000-07:00

Comments:

Attached some of my concerns regarding the rules governing the Prescription Drug Program:

* "3) All dispensers will electronically report data to the Program's database not more than 15 days after the controlled substance has been dispensed.."
o Result: Organized drug purchasers and traffickers will go from clinic to clinic to buy drugs within the 15-days period and those clinics will delay reporting to the legal limit to allow their "clients" to purchase drugs because that's were the money comes from. These are the facts on the ground. How can we stop that? By lobbying for a reporting requirement within 24-hour time period. Every time I create an electronic prescription during a routine patient interaction in the exam room the prescription data is automatically being submitted to the e-prescribing database. E-prescribing software vendors (such as Allscripts) should upload all controlled substances directly to the monitoring program.
* "4) Data not accepted by the database system due to a substantial number of errors or omissions shall be corrected and resubmitted to the database by the reporting dispenser within five days of receiving written notice that the submitted data was unacceptable."
o Result: Crafty and clever dispensers may intentionally submit incorrect data, await the written notice and then resubmit the data after five days. Meanwhile, they can continue to serve the commercial drug dealers. Whats the penalty mechanism? How many times can they submit incorrect data without being fined?

Furthermore, one of my colleagues pointed out that the rules do not provide for fines, penalties, license suspension/revocation, or anything else for offenders, and especially for repeat offenders. The item above is limited to "failing to report", but does not cover purposeful misbehavior as described in my comments.
The way this is written,it allows dutiful physicians to look up and see if their patient is trying to scam them. It does NOT provide the department or law enforcement very easy tools to find and prosecute "pill mills", who are actually the real public health problem.

I am looking forward to your comments.
Yours

Bernd

FMA Off Base Fighting Reform

2010-08-22T08:38:00.001-07:00

The recently published OpEd succinctly characterizes the Florida Medical Association's policy vis-a-vis healthcare reform.
The authors concluded that
"The FMA's challenge to the AMA was the old guard denouncing the new. But the new way is what mainstream patients, doctors and the people who pay the bills for care desperately need. It is coming, and the FMA should get on board or out of the way."
In a NEJM (N Engl J Med 2009;360: 2495-2497) article Fisher et al clearly defines the positions we as physicians can take.
“ In the face of this uncertainty, physicians have a choice: to wait and see what happens or to lead the change our country needs. We'd prefer the latter....Physicians can become our most credible and effective leaders of progress toward a new world of coordinated, sensible, outcome-oriented care in which they and their communities will be far better off. Defending the status quo is a bankrupt plan, and physicians have an opportunity to help us all see beyond it."
I wholeheartedly agree with this conclusion.
Yours
Bernd

Guest column: Florida Medical Association is off base fighting reform

Source URL: http://jacksonville.com/opinion/letters-readers/2010-08-19/story/guest-column-florida-medical-association-base-fighting

At an Orlando meeting last week, Florida Medical Association members fumed that their parent, the American Medical Association, isn't adequately representing Florida's private practice doctors.

After talk of secession, they settled for writing a stern letter urging the AMA to straighten up.

The FMA dustup began with a resolution written by Douglas Stevens, a Fort Myers cosmetic surgeon - you can't make this stuff up - complaining that the AMA's support for recent reforms was "a severe intrusion in the patient-physician relationship and allows government control over essentially all aspects of medical care."

He wrote that it will "relegate physicians to the role of government employees ... and essentially end the profession of medicine as we know it."

A St. Petersburg neurological surgeon, David McKalip, added that without AMA support, reform would have died.

Well, no. Stevens might have had two reform provisions in mind.

One uses subsidies to encourage doctors to obtain electronic health record technologies, so patient information can be easily exchanged and unnecessary or redundant services can be reduced.

Some data would be submitted to a federal repository, so doctors can better understand how effectively they practice compared to their peers and how to improve if needed.

Of course, physicians opposed to these rules could opt to avoid patients whose care is paid for with public dollars. But we think most doctors will welcome the opportunity to modernize their care.

The second bone of contention was a well-intentioned but flawed 1997 Medicare formula, the Sustainable Growth Rate, which tied physician payments to the growth of the U.S. economy. If Medicare physician spending exceeded the target in one year, then payment the following year would be reduced.

But every year, Congress has delayed the payment reductions. Now, in 2010, the accumulated cuts would be 21.2 percent.

Congress is reluctant to spend the additional $200 billion to forgive the cuts. American specialists, who make triple the salaries of their primary care colleagues, are bound to see smaller Medicare checks.

In the past, we've had many differences with the AMA, which was often more focused on physicians and their economic prosperity than on patients and theirs, especially as health insurance costs relentlessly grew four times faster than the economy.

Through a specialist-dominated reimbursement advisory committee, the AMA urged Congress to pay specialists more at the expense of primary care physicians. So it is not far-fetched to lay much of the current health care cost crisis at the AMA's feet.

But recently, the AMA became more progressive. It mounted a three-year campaign for universal coverage. It supported government's efforts to reward the meaningful use of modern computerized tools and the best medical science in clinical practice.

They are incredibly important to us, but over the last half century, American physicians have been handsomely, even often excessively, rewarded.

But now, the system that has been hugely wasteful must find ways to reduce costs while improving quality, and make sure that care is accessible to everyone. These imperatives are emerging just as data and information tools are becoming more available. Health care will become more like a market than before.

Medical practice is changing profoundly, mostly for the better. Doctors will still be highly valued, but many may earn less.

The FMA's challenge to the AMA was the old guard denouncing the new. But the new way is what mainstream patients, doctors and the people who pay the bills for care desperately need.

It is coming, and the FMA should get on board or out of the way.

Brian Klepper of Atlantic Beach and David Kibbe, a physician from Chapel Hill, N.C., write on health care policy, market dynamics and technology.

Impaired Physicians

2010-08-15T18:08:00.002-07:00

In a recently published article " Physicians reluctant to report impaired colleagues, study says,"(amednews.com) the author summarizes the findings of a national survey of 2,000 physicians. The survey results were published in the July 14th edition of JAMA " Physicians' Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues."

Unfortunately, the key findings are troubling:

Just 64% of physicians completely agreed that they had an obligation to report all impaired or incompetent doctors. The rest of the physicians either "somewhat agreed" that they were obliged to report problem colleagues or disagreed that they had such a responsibility.
The most common reason for not reporting incompetent or impaired colleagues was physicians "thought someone else was taking care of the problem," the study said. Some physicians said reporting would be fruitless, while 12% feared retribution.

Only 17% of respondents had direct knowledge of an impaired or incompetent physician. The question remains if this is due to ignorance or choice.

What can we do? Doctors need to be better educated on how to report problem colleagues and their ethical responsibility to do so. Those who do report should be kept in the loop on how a colleague's case is progressing, and that the reporting process should be confidential.

Looking forward to your comments.

Yours

Bernd

Prescription Drug Abuse and Impaired Drivers

2010-07-26T18:53:00.001-07:00

Attached you find an article published in the New York Times (July 25th,2010) highlighting the exponentially growing problem of prescription drug abuse as it relates to driving under influence.

The article emphasizes that :

"There is no reliable data on how many drivers are impaired by prescription drugs, but law enforcement officials say the problem is growing so quickly that states are putting hundreds of police officers through special training to spot signs of drug impairment and clamoring for better technology to detect it."

"Even the prevalence of drug-impaired driving is unknown, since many states combine the arrest data with that for drunken driving."

".. persuading a jury to convict someone of impaired driving due to prescription drugs remains difficult except for the most egregious cases ...because most people on the jury will also likely be taking prescription drugs for some ailment."

I recommend reading the article. As addiction treatment professionals we should get involved in guiding law enforcement officials and legal experts to address this growing public health issue.
Looking forward to your comments.
Yours
Bernd

Drivers on Prescription Drugs Are Hard to Convict

By ABBY GOODNOUGH and KATIE ZEZIMA

The accident that killed Kathryn Underdown had all the markings of a drunken-driving case. The car that hit her as she rode her bicycle one May evening in Miller Place, N.Y., did not stop, the police said, until it crashed into another vehicle farther down the road.

The driver could not keep her eyes open during an interview with investigators, according to the complaint against her, and her speech was slow and slurred. But the driver told the police that she had not been drinking; instead, the complaint said, she had taken several prescription medications, including a sedative and a muscle relaxant.

She was charged with vehicular manslaughter and driving under the influence of drugs — an increasingly common offense, law enforcement officials say, at a time when drunken-driving deaths are dropping and when prescriptions for narcotic painkillers, anti-anxiety medications, sleep aids and other powerful drugs are rampant.

The issue is vexing police officials because, unlike with alcohol, there is no agreement on what level of drugs in the blood impairs driving.

The behavioral effects of prescription medication vary widely, depending not just on the drug but on the person taking it. Some, like anti-anxiety drugs, can dull alertness and slow reaction time; others, like stimulants, can encourage risk-taking and hurt the ability to judge distances. Mixing prescriptions, or taking them with alcohol or illicit drugs, can exacerbate impairment and sharply increase the risk of crashing, researchers say.

“In the past it was cocaine, it was PCP, it was marijuana,” said Chuck Hayes of the International Association of Chiefs of Police. “Now we’re into this prescription drug era that is giving us a whole new challenge.”

The police also struggle with the challenge of prosecuting someone who was taking valid prescriptions.

“How do we balance between people who legitimately need their prescriptions and protecting the public?” said Mark Neil, senior lawyer at the National Traffic Law Center, which works with prosecutors. “It becomes a very delicate balance.”

Some states have made it illegal to drive with any detectable level of prohibited drugs in the blood. But setting any kind of limit for prescription medications is far more complicated, partly because the complex chemistry of drugs makes their effects more difficult to predict than alcohol’s. And determining whether a driver took drugs soon before getting on the road can be tricky, since some linger in the body for days or weeks.

Many states are confronting the problem as part of a broader effort to keep so-called drugged drivers, including those under the influence of marijuana and other illegal drugs, off the road.

“We have a pretty clear message in this country that you don’t drink and drive,” said R. Gil Kerlikowske, President Obama’s top drug policy adviser, who wants to reduce drugged-driving accidents by 10 percent over the next five years. “We need very much to have a similar message when it comes to drugs.”

There is no reliable data on how many drivers are impaired by prescription drugs, but law enforcement officials say the problem is growing so quickly that states are putting hundreds of police officers through special training to spot signs of drug impairment and clamoring for better technology to detect it.

Even the prevalence of drug-impaired driving is unknown, since many states combine the arrest data with that for drunken driving. Mr. Kerlikowske points to a 2007 survey by theNational Highway Traffic Safety Administration, which screened 5,900 nighttime drivers around the country and found that 16.3 percent tested positive for legal or illegal drugs.

The tests could not determine which drivers were impaired by drugs, but Mr. Kerlikowske said the results suggested a problem that had “flown below the radar” for too long.

“You don’t want to scare people,” he said, “but you certainly want to make them aware of the dangerousness. You can be as deadly behind the wheel with prescription drugs as you can with over-the-limit alcohol, and you are responsible for your own actions.”

In interviews, law enforcement officials around the country said anyone who drives while taking prescription drugs is at risk of arrest, not only those who drive recklessly. In one recent case near Bangor, Me., a pickup truck on a rural road was not swerving, speeding or otherwise hinting that its driver was impaired. A police officer stopped the truck because of its noisy muffler, then saw that the driver’s eyes were bloodshot and his speech slurred.

A Breathalyzer test found that the driver, Chester Annance, had not been drinking. Yet he was arrested based on the officer’s suspicion that he was on drugs, and a blood test later found opiate painkillers in his system.

Mr. Annance was convicted this month of driving under the influence of drugs. He received seven days in jail, a three-year license suspension and a fine. He is appealing the conviction.

“You don’t need to wait for a crash to happen before you charge someone,” said R. Christopher Almy, the district attorney in Bangor.

Defense lawyers say that in their zeal to make a statement about drug-impaired driving, the police are casting too wide a net and unfairly punishing people who are taking prescriptions as directed.

Tara Jenswold-Schipper, an assistant attorney general in Wisconsin, said she usually stuck to cases where drivers had mixed drugs, exceeded the proper dose or taken controlled medications without a prescription.

In one such case in that state, a former physician slammed his S.U.V. into a Honda Accord in April 2008, killing the pregnant driver and her 10-year-old daughter. Prosecutors said the physician, Mark Benson, had high levels of the sleep aid Ambien in his system, as well as Xanax, an anti-anxiety drug, and oxycodone, an opiate painkiller. Mr. Benson was sentenced to 30 years in prison.

Defendants can try to prove that they did not realize their medication would affect their driving, prosecutors said, but that argument may not hold up if the bottle had a warning label.

“Would you go home and start a chain saw and cut down a tree?” said Lt. Col. Thomas C. Hejl, the assistant sheriff in Calvert County, Md. “Why should you get behind the wheel of a vehicle when the same medication has the same side effects?”

Unable to prove impairment with blood tests, prosecutors in drugged-driving cases rely heavily on the testimony of “drug recognition experts,” law enforcement officers trained to spot signs of impairment in drivers. But there are only about 7,000 such officers nationwide, Mr. Hayes said, not nearly enough to respond to every traffic stop that may involve drugs.

“When they are involved,” he said of the experts, “our chances of convicting people are much higher.”

But persuading a jury to convict someone of impaired driving due to prescription drugs remains difficult except for the most egregious cases, said Douglas F. Gansler, the attorney general in Maryland.

“Because most people on the jury will also likely be taking prescription drugs for some ailment,” Mr. Gansler said, “whether it’s Lipitor or allergy pills or whatever it might be, they might think, ‘I don’t want that to become criminal.’ ”

Use of Synthetic Marijuana on the Rise:

2010-07-11T16:56:00.000-07:00

Attached you find an article from today's New York Times highlighting the increasing use of synthetic marijuana (K-2) and the efforts to curb the metastatic spread of these substances. A food store next to my office sells it as incense to teenagers and I have tried convincing the shop-owner to stop its sale. Her argument " if I stop selling it the kids go to the other guy around the corner and I loose customers."
I urge you to read this article and to consider what actions FSAM can take to suggest state regulation. I would NOT wait for the FMA to step in because government regulation is not part of their political agenda. This is an urgent public health issue and we need to act fast.
Looking forward to your comments.
Yours
Bernd

Factsheet:

+ Often marketed as incense, K2 — which is also known as Spice, Demon or Genie — is sold openly in gas stations, head shops and, of course, online. It can sell for as much as $40 per gram. The substance is banned in many European countries, but by marketing it as incense and clearly stating that it is not for human consumption, domestic sellers have managed to evade federal regulation.
+ K2’s active ingredients are synthetic cannabinoids — research-grade chemicals that were created for therapeutic purposes but can also mimic the narcotic effects of tetrahydrocannabinol, or THC, the active ingredient in marijuana.
+ K2 does not show up on drug tests, and users say that while they would like to know what is in it, they would take their chances if it means a clean urine test.

New York Times, Sunday, July 11, 2010:

Synthetic Marijuana Spurs State Bans
By MALCOLM GAY

ST. LOUIS — Seated at a hookah lounge in the Tower Grove district, Albert Kuo trained his lighter above a marbleized glass pipe stuffed with synthetic marijuana Inhaling deeply, Mr. Kuo, an art student at an area college, singed the pipe’s leafy contents, emitting a musky cloud of smoke into the afternoon light.

Mr. Kuo, 25, had gathered here with a small cohort of friends for what could be the last time they legally get high in Missouri on a substance known popularly as K2, a blend of herbs treated with synthetic marijuana.

“I know it’s not going to kill me,” said Mr. Kuo, who likened the drug’s effects to clove cigarettes. “It’s a waste of time, effort and money to ban something like this.”

On Tuesday, Gov. Jay Nixon, a Democrat, signed a bill prohibiting possession of K2. Missouri is the nation’s eighth state this year to ban the substance, which has sent users to emergency rooms across the country complaining of everything from elevated heart rates and paranoia tovomiting and hallucinations.

Investigators blame the drug in at least one death, and this month, Gov. Mike Beebe of Arkansas, a Democrat, signed an emergency order banning the substance. Similar prohibitions are pending in at least six other states, including Illinois, Louisiana, Michigan, New Jersey, New York and Ohio, according to the National Conference of State Legislatures.

“It’s like a tidal wave,” said Ward Franz, the state representative who sponsored Missouri’s legislation. “It’s almost an epidemic. We’re seeing middle-school kids walking into stores and buying it.”

Often marketed as incense, K2 — which is also known as Spice, Demon or Genie — is sold openly in gas stations, head shops and, of course, online. It can sell for as much as $40 per gram. The substance is banned in many European countries, but by marketing it as incense and clearly stating that it is not for human consumption, domestic sellers have managed to evade federal regulation.

“Everybody knows it’s not incense,” said Barbara Carreno, a spokeswoman for the federal Drug Enforcement Administration. “That’s done with a wink and a nod.”

First developed in the lab of a Clemson University chemist, John W. Huffman, K2’s active ingredients are synthetic cannabinoids — research-grade chemicals that were created for therapeutic purposes but can also mimic the narcotic effects of tetrahydrocannabinol, or THC, the active ingredient in marijuana.

In a statement, Mr. Huffman said the chemicals were not intended for human use. He added that his lab had developed them for research purposes only, and that “their effects in humans have not been studied and they could very well have toxic effects.”

Nevertheless, pure forms of the chemical are available online, and investigators believe that many sellers are buying bulk quantities, mixing them with a potpourrilike blend of herbs and labeling the substance K2.

“It’s not like there’s one K2 distributor — everybody is making their own stuff, calling it K2 and selling it, which is the most unnerving aspect,” said Dr. Christopher Rosenbaum, an assistant professor of toxicology at the University of Massachusetts who is studying the effects of K2 in emergency room patients.

The American Association of Poison Control Centers reports that so far this year there have been 567 K2-related calls, up from 13 in 2009. But investigators add that no one is really certain what is in K2, and people are arriving at emergency rooms with symptoms that would not normally be associated with marijuana or a synthetic form of the drug.

“I don’t know how many people are going for a box of doughnuts after smoking K2, but they’re sure getting some other symptoms,” said Dr. Anthony Scalzo, a professor of emergency medicine at the St. Louis University who first reported a rise in K2-related cases and is collaborating with Dr. Rosenbaum in researching K2’s effects. “These are very anxious, agitated people that are requiring several doses ofsedatives.”

Dr. Scalzo, who is also the medical director for the Missouri Poison Control Center, added that although tests had found cannabinoids in K2, it was unclear “whether the reaction we’re seeing is just because of dose effect, or if there’s something in there we haven’t found yet.”

That question remains at the center of an investigation into the death of David Rozga, an Iowa teenager who last month committed suicideshortly after smoking K2. Mr. Rozga, 18, had graduated from high school one week earlier and was planning to attend college in the fall.

According to the police report, Mr. Rozga smoked the substance with friends and then began “freaking out,” saying he was “going to hell.” He then returned to his parents’ house, grabbed a rifle from the family’s gun room and shot himself in the head.

“There was nothing in the investigation to show he was depressed or sad or anything,” said Detective Sgt. Brian Sher of the Indianola Police Department, who led the investigation. “I’ve seen it all. I don’t know what else to attribute it to. It has to be K2.”

But many users say they are undaunted by reports of negative reactions to the drug. K2 does not show up on drug tests, and users say that while they would like to know what is in it, they would take their chances if it means a clean urine test.

The Missouri ban, which goes into effect Aug. 28, prohibits several cannabinoids that investigators have found in K2 and related products. Nevertheless, investigators and researchers say that bans like the one in Missouri are little more than “Band-Aids” that street chemists can sidestep with a slight alteration to a chemical’s molecular structure.

“Once it goes illegal, I already have something to replace it with,” said Micah Riggs, who sells the product at his coffee shop in Kansas City. “There are hundreds of these synthetics, and we just go about it a couple of them at a time.”

Investigators say that a more effective ban might arise once the Drug Enforcement Administration completes its review of cannabinoids, placing them under the Controlled Substances Act. Currently, however, only one such substance is controlled under the act, though the agency has listed four others as “chemicals of concern.”

“It’s hard to keep up with everything,” said Ms. Carreno of the D.E.A., adding, “The process of scheduling something is thorough and time consuming, and there are a lot of gifted chemists out there.”

Meanwhile, states are largely on their own when it comes to controlling this new breed of synthetic cannabis, which often comes down to a game of cat-and-mouse where law enforcement agents, politicians, users and their families must formulate new responses as each iteration of a drug comes to market.

“Where does a parent go to get answers?” asked Mike Rozga, who said he learned of K2 only after his son’s death. “We talk to our kids about sex. We talk to our kids about drugs, and we talk to our kids about drinking and being responsible. But how can you talk to your kids about something you don’t even know about?”

Raves, Ecstatsy and Overdose Deaths

2010-07-04T18:14:00.000-07:00

Attached two interesting articles of concern:

1. Wall Street Journal, 07/03/2010: Out in the Open: Raves and Ecstasy http://online.wsj.com/article/SB10001424052748704699604575343133677383828.html#

"Twenty years after their heyday as an underground phenomenon, the drug-fueled dance parties known as raves are making a comeback as massive, commercial events. But a recent wave of ecstasy-related deaths and hospitalizations tied to such events have left some officials skeptical about their makeover.Unlike the original raves in the late 1980s and early '90s, which were often staged without permits in hard-to-find patches of desert or abandoned industrial warehouses, today's version has gone aboveground. The drug of choice for many attendees is still ecstasy, an illegal stimulant/hallucinogen also known as MDMA that is often cut with other substances. Taken as a pill or powder, the drug, whose full chemical name is 3,4-methylenedioxymethamphetamine, can induce euphoria and doesn't typically cause the kind of traumatic overdose symptoms associated with drugs such as heroin. But ecstasy can cause dehydration—potentially a serious health problem for people dancing all night in hot, cramped conditions. Doctors say many ecstasy-users end up in emergency rooms because they try to combat dehydration by drinking too much water, causing water intoxication—which can lead to seizure and coma.
This represents another challenge for physicians to diagnose and treat. Hopeffully, we can reduce the adverse publich health effect by educating adolescents in schools and at home.

2. Miami Herald, 07/01/2010, Experts fear new wave of addiction, http://www.miamiherald.com/2010/07/01/1709624/experts-fear-new-wave-of-addiction.html

While drug-related deaths across Florida rose an alarming 20 percent last year over 2008, South Florida saw a notable decrease in two key areas of substance abuse: cocaine and heroin.
Still, addiction experts say, there is an indication that the nation's sixth-largest metro area could be on the verge of a new wave of addiction unseen since the cocaine craze of the early 1980s. Two separate reports released this week by James C. Hall, director of Nova Southeastern University's Center for the Study and Prevention of Substance Abuse, and the Florida Medical Examiners Commission, show more than 8,600 deaths in Florida in 2009 in which victims had at least one prescription drug in their system that contributed to their passing. That's up from about 6,200 drug-induced deaths in 2008.
What's more, both reports say almost all the increase in drug deaths -- especially in Broward and Miami-Dade counties -- is due to a disturbing and relatively new trend of drug abusers mixing opiates and narcotics like heroin and cocaine with opioids -- prescription drugs like oxycodone -- or simply switching indiscriminately from one to the other.
Fort Lauderdale and St. Petersburg far outpaced every other city in Florida in terms of prescription drug deaths.
In Broward County last year, 225 people died with large amounts of oxycodone in their bodies; 57 had morphine in their systems, 60 were high on methadone, 46 on hydrocodone, and 27 on propoxyphone, for a total of 415 opioid-related deaths in Broward, compared to 342 such deaths in 2008.
Among the 2009 Broward County totals, 62 percent took lethal doses of opioids before their deaths, and 91 percent had at least two drugs in their systems at the time of death -- typically a combination of opioids and cocaine.

We must continue to push for a moratorium on narcotic dispensing in doctors offices and support revocation of licensure for ANY physician who prescribes or dispenses scheduled drugs in LARGE quantities WITHOUT treatment rationale. For example: its almost routine for certain "doctors" - or better drug dealers in a white coat- to prescribe 180-500 Oxycontin Tablets for one patient on one prescription for one month!!!
How is that possible? Because everyone involved in this process makes big $$$$.
This has to stop but obviously nobody has the will to stand up and call it what it is: drug dealing!!

Yours
Bernd

Arizona Law For Florida and Medical Practice

2010-06-26T20:05:00.001-07:00

Attached an important and troubling article from today's Miami Herald pointing out that "Florida Republican leaders have begun crafting anti-illegal-immigrant legislation modeled after an Arizona law that has incited widespread protests and fueled national and international debate over U.S. immigration policies.
Under the proposed bill, police would have broad power under state law to ask suspects for proof of legal residency."
I am strongly opposing such legislation and urge my specialty society to raise concerns regarding this bill as it pertains to the way family physicians practice medicine.
I often (even today) encounter patients, mostly uninsured, who are reluctant to go to the hospital because of their residency status fearing a backlash, or possible investigation by the immigration authorities.
Today I referred a Haitian patient to Publix to benefit from a FREE Metformin program. She asked me if she would have to provide a form of identification because she has no papers. I reassured her that she should not worry.
What will happen IF we have such a discriminatory law on the books? More undocumented immigrants will avoid doctors but will be taken by ambulance to emergency rooms for preventable illnesses instead. Who will pay? The taxpayer!
Just the debate of such a law in the legislature will trigger additional pressure on our State which already has to deal with a massive and continuous oil spill, high unemployment and a jittery tourism industry. Do we need anything else to shut down!!
Looking forward to your comments.
Yours
Bernd

Posted on Sat, Jun. 26, 2010
Florida GOP risks Hispanic anger with Arizona-like crackdown

Cristina Silva
Miami Herald/St. Pete Times

TALLAHASSEE — Florida Republican leaders have begun crafting anti-illegal-immigrant legislation modeled after an Arizona law that has incited widespread protests and fueled national and international debate over U.S. immigration policies.
Under the proposed bill, police would have broad power under state law to ask suspects for proof of legal residency, said Rep. William Snyder, a Republican from Stuart who plans to introduce the legislation in November.

"We have significant components from the Arizona bill that I plan to incorporate,'' he said. "We have the beginnings of it.''

The effort, which would be filed for consideration during the March legislative session, is already drawing broad support within the GOP.

Majority leaders in the Florida Senate and House said a new approach is needed to address the federal government's failure to temper illegal immigration.

It has the backing of both leading Republican gubernatorial candidates -- businessman Rick Scott and Attorney General Bill McCollum, whose office is helping to draft the bill.

Snyder, a former police officer, said the proposed legislation is needed to protect undocumented immigrants, who are vulnerable to abusive employers and violent criminals.

"This is a human right issue,'' he said. "They don't enjoy the same rights and privileges that you and I do. The solution is to enforce the laws that currently exist and to discourage people from coming here to `find a better life' when in fact they just come here and are victimized.''

Immigrant advocates and Hispanic lawmakers alike called the measure an unconstitutional assault on minority communities.

"The reaction is, 'What? This is ridiculous,' '' said Neelofer Syed, a Tampa immigration lawyer from Pakistan. "It is supposed to be that you are legal until you are proven guilty. This law is like, `We think you are guilty unless you establish that you are innocent.' ''

Rep. J.C. Planas, a Republican from Miami, called it an election-year stunt.

"I don't understand how anyone can think the Arizona law is good for Florida,'' said Planas, chairman of the Florida Hispanic Legislative Caucus. "It is a huge waste of police resources to start doing these things.''

Senate and House leaders said immigration reform is ripe for passage.

"What we want to do is encourage legal immigration and discourage illegal immigration,'' said incoming Senate President Mike Haridopolos, who cautioned that any changes will be shaped by how the Arizona law is put into practice after it takes effect next month.

Republican leaders in Pennsylvania, Rhode Island, Minnesota, South Carolina and Michigan have made similar vows to mirror Arizona's immigration law, amid growing criticism that the federal government has not adequately protected the nation's borders.

Civil rights groups such as the American Civil Liberties Union have filed legal challenges to the legislation, and President Barack Obama's administration is expected to follow suit.

Critics questioned why Florida lawmakers would consider replicating Arizona's untested immigration strategy while legal challenges are still pending.

"Rep. Snyder's proposal solves nothing, exploits public concern over immigration and just creates new problems,'' said Howard Simon, executive director of ACLU Florida.

The tension has become a rallying point for candidates on both sides of the political spectrum.

Democratic gubernatorial candidate Alex Sink has highlighted her Republican opponents' support of the law in stump speeches.

"She was opposed to the law in Arizona,'' said campaign spokeswoman Kyra Jennings. "She believes it unfairly discriminated against American citizens. She would veto that type of legislation.''

Championing tougher immigration laws is a risky election strategy, said George Gonzalez, a University of Miami political science professor.

"It is a way to channel people's anger and frustration about the labor market onto a group and to take advantage of it, too,'' he said.

But it could also anger Hispanic voters, an important constituency in Florida's increasingly diverse political landscape, Gonzalez said.

Florida's estimated illegal immigrant population ranks third in the nation. Arizona places seventh. But while Florida's undocumented population has dropped by 10 percent during the past decade, Arizona's climbed by 42 percent.

"None of this is foolproof,'' Gonzalez said. "It could blow up in the Republicans' faces either way.''

Snyder said he doesn't want his law to stir up the same accusations of racism that hounded Arizona's decision.

His law would be refined, he said, because it would only allow law enforcement officials to inquire about immigration status during a potential arrest or traffic violation. In Arizona, officers are required to request legal documentation during any lawful stop if ``reasonable suspicion'' exists.

Coming up with the precise language will be difficult, conceded Snyder, who recently defended his views on Fox News. ``Reasonable suspicion makes people nervous,'' he said.

But he vowed his final draft would apply equally to all illegal immigrants, regardless of skin color or ethnicity.

"I've never in my 32 years been accused of using the `N' word or being racially motivated,'' he said. "No one who knows me would say I have a racist bone in my body.''

Shorter Work Days For Doctors

2010-06-26T19:15:00.000-07:00

Attached a link to an important NEJM article http://content.nejm.org/cgi/content/full/NEJMsb1005800 entitled "The New Recommendations on Duty Hours from the ACGME Task Force."The goal of the ACGME's new approach to duty hours is to foster a humanistic environment for graduate medical education that supports learning and the provision of excellent and safe patient care.
At the heart of the ACGME's proposed changes is the recognition that the least-experienced residents need to be treated differently than more experienced ones. The plan recommends that first-year residents be limited to 16-hour shifts, and those in the second year and above work continuously for no more than 24 hours. They can stay an additional four hours to facilitate patient handoffs to another doctor. Currently residents are allowed to work up to 30-hour shifts.
The guidelines also include detailed expectations about direct supervision of younger residents by more experienced ones, in the hopes that a supervising doctor would catch any error before it affects a patient, according to Dr. Nasca.In addition, the ACGME will step up its monitoring and enforcement of the requirements, conducting on-site visits of each institution annually beginning in July 2011. The site visits are likely to cost each institution about $12,000 to $15,000, according to Dr. Nasca.
Those programs that don't comply with the rules could ultimately lose accreditation and be forced to disband.
I strongly support the proposed changes and call upon my colleagues to do the same.
Our patients deserve the same assurance about the quality of service as millions of airline passenger do already: strictly enforced duty hours for pilots, checklists before take-off and landing, elimination of human errors and the relentless pursuit of excellence.
We must change the way we do business! Our patients deserve it!!
Yours
Bernd

Opioid Dependence

2010-06-18T09:30:00.000-07:00

Attached a very interesting article supporting the fact that office based treatment of opioid dependence can decrease illegal activity and incarceration.
Yours
Bernd

Family Practice News

Volume 40, Issue 10, Page 31 (1 June 2010)

Opioid-Dependent Patients Respond to Therapy

DIANA MAHONEY

Article Outline

Major Finding: Office-based buprenorphine/naloxone treatment was associated with a statistically significant decrease in participants reporting illegal activity, from 19% to 2%, and in interacting with the legal system, from 16% to 1%.

Data Source: A secondary analysis of data from a randomized clinical trial of 166 opioid-addicted individuals treated with buprenorphine/naloxone in a primary care clinic.

Disclosures: Dr. Fiellin reported no relevant financial conflicts of interest.

MINNEAPOLIS — Opioid-dependent patients with a history of incarceration do well with office-based buprenorphine/naloxone therapy and have fewer interactions over time with the legal and criminal justice systems, according to a data analysis of a previous randomized, controlled trial.

“Our findings should offer some reassurance for community health care providers about initiating buprenorphine/naloxone treatment in the office setting,” Dr. David Fiellin reported. Office-based buprenorphine/naloxone treatment also can be an avenue for addressing other negative health consequences of chronic addiction, including referral for hepatitis C treatment, when indicated, as well as vocational and mental health programs.

Dr. Fiellin, along with lead investigator Dr. Emily Wang and colleagues at Yale University, New Haven, Conn., performed a secondary data analysis of a previous trial of three levels of psychosocial counseling and medication dispensing in conjunction with buprenorphine/naloxone maintenance treatment in a primary care clinic (N. Engl. J. Med. 2006;355:365-74).

The investigators compared demographics, clinical characteristics, and treatment outcomes for 166 adults receiving primary care–based buprenorphine/naloxone treatment, stratifying by history of incarceration as determined by the legal domain of the Addiction Severity Index.

Of the 166 patients, 52 had previously been incarcerated, Dr. Fiellin reported. Former inmates were more likely than other patients to be older, male, an ethnic minority, and unemployed. Also, they were more likely to have long histories of opioid dependence, have received methadone treatment, and have hepatitis C infection. The mean dose of buprenorphine/naloxone (Suboxone) was 17.9 mg and 18.0 mg for the previously incarcerated and never incarcerated patients, respectively, he said.

Among the previously incarcerated patients, the mean consecutive weeks of opioid abstinence was 6.2 based on opioid-negative urine samples. For other patients, it was 5.9 weeks. Mean treatment duration was 17.9 weeks and 17.6 weeks. The percentage of previously incarcerated patients completing treatment was 38%; for other patients, it was 46%.

Among patients who remained in treatment, a subsequent longitudinal analysis of self-reported illegal activity and interactions with the legal and criminal justice systems, conducted at 4-week intervals, showed “office-based buprenorphine/naloxone treatment was associated with a statistically significant decrease in participants reporting illegal activity, from 19% to 2%, and in interactions with the legal system, from 16% to 1%,” Dr. Fiellin said.

About “25% of all of those dependent on heroin pass through the criminal justice system each year,” Dr. Fiellin said. Correctional facilities provide an obvious opportunity to engage opioid-dependent individuals with treatment. “Unfortunately, less than 0.5% of all opioid-dependent individuals receive treatment while incarcerated, and as such they are more likely to connect with services in office-based programs upon release,” he said.

From the Annual Meeting of the Society of General Internal Medicine

Should We Stop Healthcare Reform Now?

2010-01-23T20:54:00.001-08:00

Should We Stop Healthcare Reform Now?

After the election in Massachusetts many predict the collapse of the health care reform efforts. President Obama seems to seek a scaled back version, which is acceptable for Republicans who are blocking ANY reform efforts. But why do we need health care reform NOW? Lets look at the facts: If nothing will happen healthcare spending will continue to outpace the growth in the rest of the domestic product by at least 2.5% annually. Despite the overall slowdown in national health spending growth in 2008, increases in this spending continue to outpace the growth in the resources needed to pay for it! At that rate health spending will absorb 40% of GDP by 2050! The suggested reform proposal will provide 30 Million uninsured Americans adequate coverage requiring about $800 Billion to $1 Trillion in federal subsidies over the next decade. This represents only 3% of the $35 Trillion projected by actuaries to be spent on U.S. health care in the coming decade in the ABSENCE of reform. The relatively small $ 1 Trillion investment in preventing the surge of neglected chronic disease will save Trillions of healthcare dollars normally spent for the emergency room care needed to serve the growing numbers of uninsured! We need to invest money in order to save money!!!
Furthermore, health care insurance companies know very well that the initial rise in health care stocks, on expectations that the Massachusetts’s vote might derail health care reform, may symbolize a pyrrhic victory only! Even though, the reform package included mandated coverage for everyone, regardless of health status, it also offered to heavily subsidize the health care for 30 million Americans who are currently uninsured. This potential financial windfall may not materialize. Insurance companies are very well aware that selling insurance package to employers has slowed because of rising premiums, which reflect rising health care expenditures. The insurance companies must have an interest to bend the cost curve and to expand insurance coverage to offer competitive products. Insurers may gamble with their financial future by supporting the Naysayer because without an overhaul of the insurance industry and the health care market they may face an even bleaker future, which will force draconian government intervention to cut costs.
Therefore, we must support rational reform efforts and President Obama should stop pandering to the opponents of any meaningful reform efforts. We have to act now to avoid a future financial crisis!

Bernd Wollschlaeger,MD,FAAFP,FASAM

Pain Clinics

2009-12-30T22:25:00.001-08:00

Attached a great article from today's Miami Herald highlighting the issue of pain clinics and Buprenorphine use. The author points out that

"A Miami Herald review of 353 Suboxone-approved doctors in Miami-Dade, Broward and Palm Beach counties found at least 53 of them have been disciplined by state health officials or have been charged with a crime -- about one of every seven doctors."

This is a grave issue of concern!
Yours
Bernd

PS: Have a Happy New Year.

Posted on Tue, Dec. 29, 2009
South Florida pain-clinic doctors also treat drug addicts

BY SCOTT HIAASEN
shiaasen@MiamiHerald.com

CARL JUSTE / MIAMI HERALD STAFF
One of many pain clinics that have sprung up all over South Florida. In the past two years, the region has emerged as the pill-mill capitol of the United States.
State regulators stripped Dr. Michael I. Rose's power to write prescriptions two months ago, after health officials found that the pain-clinic doctor had prescribed enough painkillers to put one patient ``at risk of death from overdose.''
The health department findings are all the more alarming given the North Miami physician's other specialty: drug-addiction treatment.

Rose is one of at least 41 South Florida doctors who straddle the fence between two seemingly opposite disciplines: They treat drug addicts while at the same time giving pain patients addictive drugs that have been blamed for a spike in overdose deaths statewide. Rose declined to comment for this article.

Some of the same clinics offering addiction treatment are often targeted by out-of-state drug couriers seeking painkillers for an illicit black market stretching from South Florida to Appalachia and the northeastern United States.

Many of these doctors who serve as both pain and addiction specialists have been disciplined by state health officials for improper prescribing of drugs -- and some have been convicted of crimes, a Miami Herald review found.

Yet these doctors retain approval from the federal government to prescribe a narcotic called buprenorphine -- a drug used to help wean people addicted to opiates such as oxycodone.

Addiction experts say this mixing of two delicate medical fields has potentially dangerous consequences: Instead of receiving the therapy they need, addicts seeking to get off drugs may simply end up alongside users and drug peddlers who frequently skip from clinic to clinic seeking narcotics to be sold illegally.

`ADDED RISK'

``If you have an environment where you have drug access and availability, then you have an added risk,'' said Dr. Ihsan Salloum, an addiction psychiatrist with the University of Miami's Miller School of Medicine.

``Offering services of this kind is a slap in the face,'' said Dr. Bernd Wollschlaeger, an addiction specialist and past president of the Dade County Medical Association. He suspects many pain clinics are seeking not to help addicts but to boost profits by selling drugs used to curb dependency -- in addition to selling large amounts of potent painkillers.

``It's just a fig leaf to conceal their true nature,'' Wollschlaeger said. ``These pain clinics are pure and simple pill mills. Their goals are pushing huge volumes of prescription pills.''

Clinics offering both pain medications and addiction treatment can also present difficulties for police investigating pill trafficking. Under federal law, doctors approved to provide addiction drugs are afforded special protection from narcotics investigators. Agents need a court order from a federal judge before pursuing undercover investigations of these doctors.

Over the past two years, South Florida has emerged as the pill-mill capital of the United States, the chief supplier of black-market painkillers that spawned an epidemic of overdose deaths in Kentucky, Ohio, West Virginia, Tennessee and other states.

The pills have flowed by the millions through storefront pain clinics that open up almost daily from Miami to Palm Beach County. Broward County alone has at least 115 pain clinics, and is home to 33 of the 50 doctors who dispense the most oxycodone in the country, according to U.S. Drug Enforcement Administration data.

Dozens of clinics entice patients with blaring advertisements in alternative newspapers, offering coupons and discounts and not-too-subtle appeals to out-of-state clients.

In the same ads, many clinics also promote treatment for drug addicts with Suboxone, whose primary ingredient, buprenorphine, is designed to help blunt the affects of heroin, oxycodone or other opiates.

Suboxone and similar drugs are considered highly effective for treating dependency and addiction. It's also proven safer than methadone, once commonly used to treat heroin addicts.

To encourage more addicts to seek treatment, federal regulators in 2002 began allowing doctors to dispense Suboxone from their offices -- unlike methadone, which must be administered in hospital or clinic settings.

But a doctor does not need to be a board-certified addiction specialist to distribute Suboxone. A doctor can receive approval simply by completing an eight-hour online course. About 17,000 doctors nationwide are approved to administer Suboxone, including almost 1,200 in Florida.

TREATMENT METHODS

Addiction experts and federal health officials warn that Suboxone should be given to patients along with counseling and other treatment methods -- methods rarely employed at many pain clinics, where pills are often the only remedy, critics say.

``Use of the medication in and of itself is not a substitute for full addiction treatment,'' said Dr. Louis Baxter, president of the American Society of Addiction Medicine. ``Some of these people that are advertising their services may not be certified, and may not be experienced to do what they say they can do.''

But some doctors say it can be difficult to get many addicts to attend counseling or psychological therapy, which is often more costly than Suboxone treatment.

``The No. 1 reason for someone coming in to do detox is that they can't afford their addiction,'' said Dr. James Milne, who offers both pain management and addiction treatment as part of his general family practice in Fort Lauderdale.

Milne said he believes the need for addiction treatment has increased with the explosion of pain clinics in South Florida. As many as half of his new patients come to him first seeking painkillers -- and many end up as addiction patients, he said.

``Some of these people convert there on the spot. They burst into tears and beg for help,'' he said.

At the Fort Lauderdale Pain Relief Center, the staff emphasizes its detoxification program to its pain patients who may feel they are becoming dependent on pills, said clinic attorney Sandy Topkin.

``They want people to get off these medications more than they want them on them,'' Topkin said.

Though buprenorphine is less dangerous than methadone, a patient could overdose or die if it is mixed with other drugs, Baxter said. The drug is sometimes sold illegally on the street as well, although it doesn't produce the highs of other drugs.

``You want to have it prescribed in legitimate settings, and these pain clinics are not legitimate settings. There is a high probability that they are using this medication inappropriately,'' Wollschlaeger said.

Records show many of the doctors working for South Florida pain clinics have no special certification in either addiction or pain management. And many of the doctors offering both services have troubling professional records.

53 DISCIPLINED

A Miami Herald review of 353 Suboxone-approved doctors in Miami-Dade, Broward and Palm Beach counties found at least 53 of them have been disciplined by state health officials or have been charged with a crime -- about one of every seven doctors.

Among those allowed to dispense drug-treatment narcotics are doctors disciplined for recklessly prescribing addictive drugs, including:

• Dr. Rachael Gittens of Wilton Manors. She was suspended for 90 days and fined $10,000 earlier this year after investigators found 33 blank prescriptions given to patients without including their names or addresses. At the time, Gittens was working at a pain clinic identified by Kentucky investigators as a prime source of illegal pills in that state.

• Dr. Robert Lentz of Lake Worth. He was fined $30,000 and placed on two years' probation earlier this month for prescribing ``very high dosages'' of painkillers to a patient without documenting the medical need. The health department found that Lentz increased the dosage of oxycodone when the patient should have been sent to addiction counseling, records show.

• Dr. Ricardo Sabates of Delray Beach. State health officials suspended his medical license in October for over-prescribing painkillers and anti-anxiety drugs to 10 patients, records show.

Federal officials say the law allows any doctor to prescribe Suboxone, regardless of any disciplinary history, as long as the physician has completed an eight-hour training course, and the doctor has a valid medical license and approval from the DEA to prescribe medications.

``If the physician has a license to practice medicine, we don't have the right to prevent them from prescribing Suboxone,'' said Nick Reuter, a senior policy analyst with the Substance Abuse and Mental Health Services Administration, a branch of the U.S. Department of Health and Human Services that oversees the Suboxone certification program.

The American Society of Addiction Medicine has pushed for greater scrutiny for doctors prescribing medications to drug addicts, and for doctors offering narcotics for pain management, Baxter said. For example, he said, some states like New Jersey require doctors to be board certified in pain management before they can dispense painkillers. Florida has no such requirement.

``There are some renegade physicians that are doing the medication harm by doing unregulated and unorthodox pain and addiction treatment,'' Baxter said.

Pain Clinics: Immediate Action Required

2009-11-21T19:18:00.000-08:00

Attached two recent articles from the Miami Herald and Sun Sentinel highlighting the continuous and growing problem with pain clinics in South Florida.
I also witnessed a new phenomenon: one pain clinic in my area was finally shut down but reopened several days later calling itself "MedClinic" offering ALL medical services INCLUDING pain management. That means they will restart the SAME activities with the SAME management!! Its really frustrating! We have to focus on promoting tough measures as outlined in the grand jury recommendations. Therefore, I ask FSAM to issue a press release supporting the following recommendations and to contact the legislators asking them for their support.

The grand jury recommended to the Legislature 18 new reforms to curb the pain-clinic problem, including closing several loopholes the new state law failed to address. They include:

• Preventing pain clinics from distributing drugs on site until the state database is up and running next year.

• Limiting prescriptions from pain clinics to no more than a three-day supply.

Looking forward to your comments.
Yours
Bernd

Bernd Wollschlager,MD,FAAFP,FASAM
Member of the PRESCRIPTION DRUG MONITORING PROGRAM IMPLEMENTATION AND OVERSIGHT TASK FORCE

Posted on Fri, Nov. 20, 2009
Broward grand jury recommends pain clinic reforms

BY SCOTT HIAASEN
shiaasen@MiamiHerald.com

A Broward County grand jury issued a damning report Thursday bemoaning the explosion of illegal painkillers sold through Broward pain clinics -- and warning that reforms passed by the Legislature may not be enough.
Echoing a Miami Herald investigation earlier this year, the report details how lax state laws spawned a cottage industry of storefront pain clinics across South Florida, which have become the primary source of illegal painkillers in the eastern United States.

In just the past two years, the number of pain clinics in Broward County grew from four to 115, the grand jury found. In one six-month span, Broward pain-clinic doctors dispensed more than 9 million tablets of oxycodone, one of the most powerful and dangerous painkillers on the market -- far more than any other part of the country.

Addicts and drug peddlers routinely hop from clinic to clinic using bogus medical records to pass off fake injuries and obtain prescriptions -- a practice known as ``doctor shopping,'' the grand jury found. The proliferation of clinics attracts carloads of illegal drug buyers from other states, notably Kentucky, Ohio, West Virginia and Tennessee.

While some pain clinics offer legitimate medical services, most are ``rogue clinics putting out pills for cash,'' the report found.

``By the time law enforcement initiates and completes a successful investigation leading to the arrest of a doctor, user or dealer, several new clinics have opened,'' the report said.

WEAKNESSES

In response to the growing problem, state lawmakers approved a new law this spring placing pain clinics under greater scrutiny, and creating a database of prescription drugs sold, so prescribing doctors can better detect ``doctor shopping'' patients.

But the grand jury highlighted weaknesses in the law -- most notably, that the database program has no dedicated source of funding. State officials plan to seek grants to pay for the $4 million program.

The grand jury also criticized a section of the law that allows doctors to record prescriptions in the database within 15 days of their distribution. The grand jurors said drug traffickers could have come and gone by the time their prescriptions are recorded.

CLOSING LOOPHOLES

The grand jury recommended to the Legislature 18 new reforms to curb the pain-clinic problem, including closing several loopholes the new state law failed to address. They include:

• Preventing pain clinics from distributing drugs on site until the state database is up and running next year.

Many clinics advertise that they both prescribe and sell pills on site to attract clients -- another practice the grand jury would ban.

• Limiting prescriptions from pain clinics to no more than a three-day supply.

Clients at pain clinics typically receive a 30-day supply of drugs -- 150 to 240 tablets of oxycodone, often coupled with the painkiller roxycodone and anti-anxiety drugs such as Xanax -- after only one doctor's visit.

CRIMINAL RECORDS

• Barring people with criminal records from owning pain clinics. The Miami Herald investigation found several examples of clinic owners with criminal records, including the owner of a Boca Raton pain clinic who once pleaded guilty to possession of steroids with intent to sell.

• Limiting the number of pain-relief patients to 100 per clinic, and placing limits on the number of out-of-state patients a clinic may have.

Narcotics investigators have said that some pain clinics have as many as 65 patients per day. One Coral Springs doctor indicted on trafficking charges last year had nearly 500 patients from Kentucky.

======================================================================================================================

sun-sentinel.com/news/broward/flgrand-jury-pill-mill-20091119,0,1892598.story

South Florida Sun-Sentinel.com

Grand jury recommends pill mill cleanup

In two years, number in Broward jumped from four to 115, panel finds

By Scott Hiaasen, The Miami Herald

November 19, 2009

A Broward County grand jury issued a damning report Thursday bemoaning the explosion of illegal painkillers sold through Broward pain clinics — and warning that reforms passed by the Legislature may not be enough.

Echoing a Miami Herald investigation earlier this year, the report details how lax state laws spawned a cottage industry of storefront pain clinics across South Florida, which have become the primary source of illegal painkillers in the eastern United States.

In just the past two years, the number of pain clinics in Broward County grew from four to 115, the grand jury found. In one six-month span, Broward pain-clinic doctors dispensed more than 9 million tablets of oxycodone, one of the most powerful and dangerous painkillers on the market — far more than any other part of the country.

Addicts and drug peddlers routinely hop from clinic to clinic using bogus medical records to pass off fake injuries and obtain prescriptions — a practice known as "doctor shopping," the grand jury found. The proliferation of clinics attracts carloads of illegal drug buyers from other states, notably Kentucky, Ohio, West Virginia and Tennessee.

While some pain clinics offer legitimate medical services, most are "rogue clinics putting out pills for cash," according to the report.

"By the time law enforcement initiates and completes a successful investigation leading to the arrest of a doctor, user or dealer, several new clinics have opened," the report said.

In response to the growing problem, state lawmakers approved a new law this spring placing pain clinics under greater state scrutiny, and creating a database of prescription drugs sold, so prescribing doctors can better detect "doctor shopping" patients.

But the grand jury highlighted weaknesses in the law — most notably, that the database program has no dedicated source of funding. State officials plan to seek grants to pay for the $4 million program.

The grand jury also criticized a section of the law that allows doctors to record prescriptions in the database within 15 days of their distribution. The grand jurors said drug traffickers could have come and gone by the time their prescriptions are recorded.

The grand jury recommended to the Legislature 18 new reforms to curb the pain-clinic problem, including closing several loopholes the new state law failed to address. They include:

Preventing pain clinics from distributing drugs on site until the state database is up and running next year. Many clinics advertise that they both prescribe and sell pills on site to attract clients — another practice the grand jury would ban.

Limiting prescriptions from pain clinics to no more than a three-day supply. Clients at pain clinics typically receive a 30-day supply of drugs — 150 to 240 tablets of oxycodone, often coupled with the painkiller roxycodone and anti-anxiety drugs such as Xanax — after only one doctor's visit.

Barring people with criminal records from owning pain clinics. The Miami Herald investigation found several examples of clinic owners with criminal records, including the owner of a Boca Raton pain clinic who once pleaded guilty to possession of steroids with intent to sell.

Limiting the number of pain-relief patients to 100 per clinic, and placing limits on the number of out-of-state patients a clinic may have. Narcotics investigators have said that some pain clinics have as many as 65 patients per day. One Coral Springs doctor indicted on trafficking charges last year had nearly 500 patients from Kentucky.

Governor Crist Appointment

2009-11-12T21:14:00.000-08:00

Governor Crist appoints Past FSAM President to the Prescription Drug Monitoring Program Implementation and Oversight Taskforce.

http://www.flgov.com/release/11150

GOVERNOR CRIST APPOINTS NINE TO THE PRESCRIPTION DRUG MONITORING PROGRAM IMPLEMENTATION AND OVERSIGHT TASK FORCE

November 12, 2009

Contact:

GOVERNOR'S PRESS OFFICE
(850) 488-5394

TALLAHASSEE – Governor Charlie Crist today announced the following appointments:

Prescription Drug Monitoring Program Implementation and Oversight Task Force

· Andre Benson, 62, of Tampa, physician, Operation PAR Inc., appointed for a term beginning November 12, 2009, and ending July 1, 2012.

· Lora “Lorrie” Brown, 44, of St. Petersburg, pain physician, Coastal Orthopedics, appointed for a term beginning November 12, 2009, and ending July 1, 2012.

· Kristen Cortes, 45, of Panama City, Florida Department of Law Enforcement agent, appointed for a term beginning November 12, 2009, and ending July 1, 2012.

· David Craig, 41, of Tampa, clinical pharmacist specialist, H. Lee Moffitt Cancer Center and Research Institute, appointed for a term beginning November 12, 2009, and ending July 1, 2012.

· Joel Kaufman, 57, of Ft. Lauderdale, vice president, United Way of Broward County, appointed for a term beginning November 12, 2009, and ending July 1, 2012.

· Nilesh Patel, 45, of Bradenton, interventional pain management physician, appointed for a term beginning November 12, 2009, and ending July 1, 2012.

· Donnie Reynolds, 41, of Weston, chief operating officer, Automated Healthcare Solutions, appointed for a term beginning November 12, 2009, and ending July 1, 2012.

· Paula “Pepper” Wakeland-Hewitt, 60, of Sarasota, pharmacy manager, Davidson Drugs, appointed for a term beginning November 12, 2009, and ending July 1, 2012.

· Bernd Wollschlaeger, 51, of Miramar, self-employed primary care physician, appointed for a term beginning November 12, 2009, and ending July 1, 2012.

JCAHO and Screeing Issues

2009-09-24T21:03:00.000-07:00

Attached an important e-mail and message from our ASAM Regional Director.
We must make every effort to submit our comments.
Yours
Bernd

=============================================================================
Richard Soper wrote:
>
>
>
>
> Richard Soper wrote:
>
> Chapter Presidents and colleagues;
>
> Last year, the Joint Commission on the Accreditation of Hospitals (JCAHO) called for comments on whether it should create standards for tobacco, alcohol and drug screening and referral for all hospitals. Many of us then wrote to the Joint Commission with our comments. Our efforts were successful. JCAHO has now published a set of proposed standardsfor tobacco, alcohol and drug screening, brief intervention, referral and treatment.
> In my view, publication and adoption of these standards is a fundamentally important recognition that alcohol, tobacco and other drug problems should be identified and treated in all hospital patients as a routine part of care. If adopted, the tobacco, alcohol and drug reporting standards would be among those that hospitals can select for monitoring their own quality and performance.
> Hospital administrators, boards and staff will know what they should be doing about tobacco, alcohol and drugs to help their patients get better.
>
> I am urging all of you to take personal action to achieve the final step in this long journey:
>
> Getting the draft standards adopted.
>
> Please do two important things now:
> 1. Submit Your Comments Online.The Commission has invited public comment until September 30, so you really need to do this NOW.
>
> You will find an online survey formthat asks whether you believe the proposed standards will improve patient care, are clear enough to be implemented, and meet other JCAHO goals for its hospital standards. Your answers will have an impact on whether the standards are adopted. There is a link to full text of the standards on the first page of the survey, and you can also read Join Together's recent feature story summarizing the proposal.
>
>
> 1. Send this Message To other ASAM members, a Colleague, friend. We need as many voices from the field as possible supporting SBI as the routine standard of care. Tell your colleagues about this major opportunity to affect the health care of millions of Americans.
> 2. WE can continue to make a difference and have impact of formation of policy with our combined efforts to guide this process.
>
> Onward,
>
> Rich Soper, JD, MD, FASAM

Updated Directory of Drug and Alcohol Abuse Treatment Programs Now Available

2009-09-04T20:27:00.001-07:00

*FOR RELEASE:* *Contact: SAMHSA Press Office (240) 276-2130* August 6, 2009 http://www.samhsa.gov

*Updated Directory of Drug and Alcohol Abuse Treatment Programs Now Available*

A new, updated guide to finding local substance abuse treatment programs is now available from the Substance Abuse and Mental Health Services Administration (SAMHSA). *"National Directory of Drug and Alcohol Abuse Treatment Programs 2009"* provides information on thousands of alcohol and drug treatment programs located in all 50 states, the District of Columbia, Puerto Rico, and five U.S. territories.

The National Directory includes a nationwide inventory of public and private substance abuse and alcoholism treatment programs and facilities that are licensed, certified, or otherwise approved by substance abuse agencies in each state. The National Directory is organized in a state-by-state format for quick reference by health care providers, social workers, managed care organizations, and the general public and provides information on more than 11,000 community substance abuse treatment

programs.

The directory provides important information on levels of care and types of facilities, including those with programs for adolescents, persons with co-occurring substance abuse and mental disorders, individuals living with HIV/AIDS, and pregnant women. In addition, information is available on forms of payment accepted, special language services available with select providers, and whether methadone or buprenorphine therapy is offered.

The updated directory complements SAMHSA's internet-based *"Substance Abuse Treatment Facility Locator"* -- the online service, which is updated regularly and may contain more current information, provides searchable road maps to the nearest treatment facilities, complete addresses, phone numbers and specific information on services available. The electronic, searchable version of SAMHSA's updated *"National Directory of Drug and Alcohol Abuse Treatment Programs"* is available on the Web at

http://FindTreatment.samhsa.gov/

Hard copies of the National Directory may be obtained free of charge from SAMHSA's Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727). Request inventory number

Controversial Treatment for Opioid Dependence

2009-08-30T14:33:00.001-07:00

Attached an article which you probably have read already. Is anyone considering a response to the study? Its quite controversial and almost negating the current treatment approaches.
I found it especially troublesome that the authors claim that "It could be argued that another opioid-substitution medication, such as buprenorphine, might have been used as a comparison drug instead of methadone. The available evidence does not support this suggestion: a recent Cochrane review concluded that buprenorphine maintenance was significantly less effective than methadone maintenance.Thus, methadone maintenance remains the standard treatment and the proper comparison drug for an experimental substitution therapy."

Looking forward to your comments.

Bernd

Volume 361:777-786 August 20, 2009 Number 8

Diacetylmorphine versus Methadone for the Treatment of Opioid Addiction

Eugenia Oviedo-Joekes, Ph.D., Suzanne Brissette, M.D., David C. Marsh, M.D., Pierre Lauzon, M.D., Daphne Guh, M.Sc., Aslam Anis, Ph.D., and Martin T. Schechter, M.D., Ph.D.

ABSTRACT

Background Studies in Europe have suggested that injectable diacetylmorphine, the active ingredient in heroin, can be an effective adjunctive treatment for chronic, relapsing opioid dependence.

Methods:
In an open-label, phase 3, randomized, controlled trial in Canada, we compared injectable diacetylmorphine with oral methadone maintenance therapy in patients with opioid dependence that was refractory to treatment. Long-term users of injectable heroin who had not benefited from at least two previous attempts at treatment for addiction (including at least one methadone treatment) were randomly assigned to receive methadone (111 patients) or diacetylmorphine (115 patients). The primary outcomes, assessed at 12 months, were retention in addiction treatment or drug-free status and a reduction in illicit-drug use or other illegal activity according to the European Addiction Severity Index.

Results:
The primary outcomes were determined in 95.2% of the participants. On the basis of an intention-to-treat analysis, the rate of retention in addiction treatment in the diacetylmorphine group was 87.8%, as compared with 54.1% in the methadone group (rate ratio for retention, 1.62; 95% confidence interval [CI], 1.35 to 1.95; P<0.001). The reduction in rates of illicit-drug use or other illegal activity was 67.0% in the diacetylmorphine group and 47.7% in the methadone group (rate ratio, 1.40; 95% CI, 1.11 to 1.77; P=0.004). The most common serious adverse events associated with diacetylmorphine injections were overdoses (in 10 patients) and seizures (in 6 patients).

Conclusions:

Injectable diacetylmorphine was more effective than oral methadone. Because of a risk of overdoses and seizures, diacetylmorphine maintenance therapy should be delivered in settings where prompt medical intervention is available. (ClinicalTrials.gov number, NCT00175357 [ClinicalTrials.gov] .)

DISCUSSION:

Discussion:

In this trial, patients assigned to receive injectable diacetylmorphine were more likely to stay in treatment and to reduce their use of illegal drugs and other illegal activities than patients assigned to receive oral methadone. These findings are consistent with the results of European studies that suggest greater effectiveness of diacetylmorphine than methadone as maintenance treatment for long-term, treatment-refractory opioid use.10,12,13 Two of these trials showed no differences between groups in the rate of retention in treatment for addiction. However, the fact that control patients were eligible to receive diacetylmorphine at the end of the study period may have introduced a bias in the observed retention rates. In addition, patients currently enrolled in methadone maintenance treatment were eligible for the European trials but not for the present study. Although the definitions of clinical response varied among the trials, all of them considered the same variables (drug use, illegal activities, health, and social adjustment) and showed greater effectiveness of diacetylmorphine than of methadone for maintenance treatment.

Secondary analyses showed that both groups had significant improvement in many of the variables that were evaluated. The diacetylmorphine group had greater improvements with respect to medical and psychiatric status, economic status, employment situation, and family and social relations. These results are particularly noteworthy in view of the nature of the population and the time frame. The fact that patients who received diacetylmorphine had significant improvement in these areas suggests a positive treatment effect beyond a reduction in illicit-drug use or other illegal activities.

Buprenorphine versus Methadone

2009-08-30T14:32:00.001-07:00

Reading the Cochrane study I found some significant discrepancies in the representation of buprenorphine treatment.

Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence.

Mattick RP, Kimber J, Breen C, Davoli M.

National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia, 2052. r.mattick@unsw.edu.au

BACKGROUND: Buprenorphine has been reported as an alternative to methadone for maintenance treatment of opioid dependence, but differing results are reported concerning its relative effectiveness indicating the need for an integrative review. OBJECTIVES: To evaluate the effects of buprenorphine maintenance against placebo and methadone maintenance in retaining patients in treatment and in suppressing illicit drug use. SEARCH STRATEGY: We searched the following databases up to October 2006: Cochrane Drugs and Alcohol Review Group Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, Current Contents, Psychlit, CORK , Alcohol and Drug Council of Australia, Australian Drug Foundation, Centre for Education and Information on Drugs and Alcohol, Library of Congress databases, reference lists of identified studies and reviews, authors were asked about any other published or unpublished relevant RCT. SELECTION CRITERIA: Randomised clinical trials of buprenorphine maintenance versus placebo or methadone maintenance. DATA COLLECTION AND ANALYSIS: Authors separately and independently evaluated the papers and extracted data for meta-analysis. MAIN RESULTS: Twenty four studies met the inclusion criteria (4497 participants), all were randomised clinical trials, all but six were double-blind. The method of allocation concealment was not clearly described in the majority (20) of the studies, but where it was reported the methodological quality was good.Buprenorphine was statistically significantly superior to placebo medication in retention of patients in treatment at low doses (RR=1.50; 95% CI: 1.19 - 1.88), medium (RR=1.74; 95% CI: 1.06 - 2.87), and high doses (RR=1.74; 95% CI: 1.02 - 2.96). The high statistical heterogeneity prevented the calculation of a cumulative estimate. However, only medium and high dose buprenorphine suppressed heroin use significantly above placebo.Buprenorphine given in flexible doses was statistically significantly less effective than methadone in retaining patients in treatment (RR= 0.80; 95% CI: 0.68 - 0.95), but no different in suppression of opioid use for those who remained in treatment.Low dose methadone is more likely to retain patients than low dose buprenorphine (RR= 0.67; 95% CI: 0.52 - 0.87). Medium dose buprenorphine does not retain more patients than low dose methadone, but may suppress heroin use better. There was no advantage for medium dose buprenorphine over medium dose methadone in retention (RR=0.79; 95% CI:0.64 - 0.99) and medium dose buprenorphine was inferior in suppression of heroin use. AUTHORS' CONCLUSIONS: Buprenorphine is an effective intervention for use in the maintenance treatment of heroin dependence, but it is less effective than methadone delivered at adequate dosages.

Publication Types:

* Meta-Analysis
* Review

PMID: 18425880 [PubMed - indexed for MEDLINE]