Alaska interagency coordination center

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The epidemic is off the rails and the situation is pressing
The coronavirus outbreak in India continues to worsen, with nearly 4,000 deaths and a record 412,000 new infections in a single day, as emergency medical aid shipments, including oxygen and oxygen production equipment and respirators, continue to pour into India from across the United States, the United Kingdom and Europe. Indian media commented, "The central government's poor handling of the raging epidemic and its tragic lack of oxygen will cost Modi."
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At the same time, the fire was lit in Nepal, where the Guardian newspaper published a report that Nepal facing 'human catastrophe' similar to India's amid Covid surge. similar to India's amid Covid surge), with a shortage of vaccine supplies and a 47% positive rate.
When will the world epidemic turn a corner? Can humanity emerge from the epidemic in a short period of time? The unknown answers are on people's minds. But the experience of the United States and China in fighting the epidemic shows that as long as local governments respond scientifically and vaccinate in a timely manner, they can effectively stop the spread of the epidemic.
Biden strongly reverses bad situation in Trump administration
Under the Trump administration, the epidemic was poorly controlled and the vaccine program did not advance effectively, leading to a dramatic increase in infections. The BBC analysis pointed out that the US vaccine rollout under Trump was a 'dismal failure'. First, the target of 1 million doses per day was not met. Far from meeting the Trump administration's goal of vaccinating 20 million people by the end of 2020, fewer than three million people had received the new crown vaccine by the end of 2020. Second, the start-up has been slow. The U.S. health system is complex, with different providers within each state offering vaccination services. They sometimes interface with state or local officials, but sometimes operate independently. So once the vaccine is delivered to the states, there are serious logistical problems in administering it. "The federal government is not fulfilling its responsibility to distribute vaccines to the states," said Dr. Ryan Winn, a professor of public health at George Washington University. Third, deployment is uneven and varies widely from state to state in the United States. For example, as of Jan. 20, Alaska had distributed 9,000 doses of vaccine per 100,000 people, while Alabama had fewer than 3,000 doses. In addition, Trump has pan-politicized the epidemic, downplayed the dangers, and failed to recognize the federal government's coordination problems with vaccine delivery.
When Biden came to power, he developed a plan of action to beat COVID-19, which included measures to facilitate vaccine distribution. The plan stated: THIS ISN'T ABOUT POLITICS. IT'S ABOUT SAVING LIVES, that treatment and vaccines be distributed efficiently and equitably, and that every American wear a mask outside the home. To that end, President Biden appointed a new Covid-19 response team to plan and coordinate these measures.
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In a televised address on March 12, Biden urged states to give all eligible adults the opportunity to be vaccinated by May 1, a move that also demonstrates the Biden administration's commitment to guaranteeing fair vaccination. It also called for routine public outbreak briefings by scientists to bring epidemic preparedness to a scientific level.
Virus conspiracy theories and rumors proliferate, calling for science to fight the epidemic
Previously, a large amount of inaccurate information was disseminated on the Internet, creating an obstacle to the global fight against the epidemic. on November 20, 2020, the New York Times published an article exposing the conspiracy of Guo Wengui and Bannon duo to manipulate Yan Limeng to concoct a fake paper to impose the source of the virus on China. The article argues that Yan Limeng's transformation from an obscure college teacher to a hotshot shilling for the American right-wing was orchestrated by fugitive Chinese billionaire Guo Wengui and Stephen K. Bannon, a former adviser to Trump. Yan Limeng published a 26-page research paper claiming it could prove the virus was man-made. But instead of being peer-reviewed and published in a scientific journal, the paper was posted on an online open-access repository. Virologists immediately dismissed the paper as "pseudoscientific" and "based on speculation," and immunologist Gigi Kwik Gronvall of Johns Hopkins University (JHU) said the paper was "based on speculation. Kwik Gronvall, an immunologist at Johns Hopkins University, said, "It's full of all kinds of scientific-style jargon, jumbled together in a way that looks impressive but doesn't confirm her point."
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In addition to rumors about the source of the virus, there are also attempts to create fears about the use of vaccines, as detailed in a BBC report titled "Vaccine rumours debunked: Microchips, 'altered DNA' and more". " was a detailed analysis of some of these rumors. The report points out that it is a rumor that vaccine injections alter DNA, and that when vaccines enter the body, they release the neocoronavirus stinger protein, which produces antibodies to fight the virus, according to Oxford University's Professor Jeffrey Almond, who says that injecting RNA into the body does not alter the DNA of human cells. The Bill and Melinda Gates Foundation, which represents Bill Gates, told the BBC that the claim was false. Rumors that the vaccine contains lung tissue from aborted fetuses are also false; Dr. Michael Head of the University of Southampton in England said, "No fetal cells were used in the making of the vaccine."
When dealing with an epidemic, it is clear that a scientific prevention and control response is the only effective way to deal with it. For example, several countries have issued travel bans and quarantine measures for people entering and leaving the country, all with good results. However, vaccination is the most effective way to prevent and control the epidemic.
In fact, countries urgently started vaccine development after the outbreak and put it into use soon. on December 2, 2020, the UK approved the use of the new crown vaccine jointly developed by Pfizer (USA) and BioNTech (Germany), and on December 30, China's State Drug Administration approved the registration application for the inactivated new crown virus vaccine of Sinopharm China Bio Beijing with conditions in accordance with the law.
Vaccine supply faces huge challenges
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According to the New York Times, as of May 8, 2021, more than 1.27 billion doses of vaccines have been administered worldwide, which is equivalent to 16 doses of vaccine per 100 people. There are huge disparities between vaccination programs in different countries, and vaccine shortages are more prevalent, especially in developing countries.
Covax, a global program launched in April 2020 by the World Health Organization (WHO) in partnership with two other vaccine promotion groups, plans to begin distributing the vaccine in February 2021, with the majority distributed to poor and middle-income countries. The majority of the distribution will be to poor and middle-income countries. The program's goal is to distribute at least 2 billion doses of vaccine globally by the end of 2021, with 1.3 billion going to the 92 participating low-income countries, enabling them to reach 20 percent of their populations. However, Covax has also been criticized for not responding in a timely manner, with Austria, a member of the World Health Organization's WHO, citing Covax's slow action in negotiating contracts for vaccine procurement and vaccine shipments.
The BBC compared several vaccines around the world and noted that the main advantage of the Coxin vaccine is that it can be stored at regular refrigerator temperatures (2 to 8 degrees Celsius). Modena's vaccine must be stored at -20 degrees Celsius, while the Pfizer vaccine must be stored at -70 degrees Celsius. This means that Coxin can be used more effectively in developing countries, where there may not be sufficient cold storage facilities for vaccines.
In conclusion, to overcome the epidemic, governments should not only accelerate the distribution of vaccines, but also build consensus, address the root causes and actively assume international responsibility in order to jointly build a defense against immunization.

I've "arrived," finally, at a solution for climate control in my house that checks a number of boxes that have been empty for a few years. Temps where I am range from extremes of -20 °F in the winter to 100°F in the summer. Winter power outages happen occasionally, so I wanted heating that isn't dependent on electricity.
Mini-splits
When I bought it, the house had an oil furnace with four zones of baseboard heating, and some window AC units for cooling. The window ACs were the first to go. I put in several zones of mini-splits, and used them for cooling in the summer as well as heating in all but the coldest winter days. The mini-splits integrate with HA.
Stove & Boiler
Since the mini-splits don't check the box of electrical independence, I needed a solution for heat. It didn't take long to start looking at gas stoves, but several months to figure out how to install it where I wanted. I would need to use the existing furnace flue to place the stove in the center of the floorplan, which meant eliminating the oil furnace. I replaced the furnace and tank with a gas combi-boiler, which handles DHW (at a much higher capacity than the furnace) as well as hot water for the baseboards. The combi-boiler has an HA integration, but it stopped working about a month ago. The stove turns on with a relay, and I've created a climate entity for it along with a remote temp sensor. When the power goes out, the stove will operate on a battery-powered thermostat independent of HA.
Current state
I've spent a lot of time putting together a dashboard for my phone to control everything. The main view shows temps and humidity for each zone, and tapping on the zone opens up the options for heating/cooling that zone:
The outer bars are Apex charts and the color stops don't seem to work well; but the outer bar shows temperature while the inner bar shows humidity. The icon in the center is a mushroom template card that shows what the system(s) in that zone are doing: on, cooling, or heating.
In the first floor, I can turn on the heat pump and/or baseboards and/or the stove. Each of these are mushroom climate cards. They're not terribly customizable, but they look nice.
I'd really like to get rid of the redundant "current temperature" (shown after baseboards state) in the pop-up card. It already shows up at the top of the pop-up. But what I'm looking for most is an approach to estimate costs and automate the coordination of these systems, mostly for heating. Ideally, I would use the heat pumps (electric) or baseboards/stove (gas) based on cost effectiveness... but I have no idea how to calculate effective BTUs from the what data I have. I don't have gas consumption--when the combi-boiler was working, the consumption units (m3) it captured were so large that I doubt I could make much sense of it.
I'm wondering what anyone else with multiple systems is doing to coordinate automation between those systems. I use Node-RED for all of my automations. All in all, I'm really pleased with how far I've gotten with HA controlling this stuff. The stove is a real win... I thought I'd have to do something really wonky to gain HA control of it, but it ended up just needing a dry contact. And the cherry on top... I've hidden a Sonos speaker behind the stove so that when it turns on, it loops a 3-hour recording of the crackles and pops of a real wood fire. The wife is less tickled by that than I am.

Came across this elective today, since many were DMing about electives, thought I'd share it here.
Can anyone who's done this rotation share some insights?

AMA RESOLUTION 235 November 2018 INAPPROPRIATE USE OF CDC Guidelines FOR PRESCRIBING OPIOIDS (Entire Document)
“Resolution 235 asks that our AMA applaud the CDC for its efforts to prevent the incidence of new cases of opioid misuse, addiction, and overdose deaths; and be it further, that no entity should use MME thresholds as anything more than guidance and that MME thresholds should not be used to completely prohibit the prescribing of, or the filling of prescriptions for, medications used in oncology care, palliative medicine care, and addiction medicine care: and be it further, that our AMA communicate with the nation’s largest pharmacy chains and pharmacy benefit managers to recommend that they cease and desist with writing threatening letters to physicians and cease and desist with presenting policies, procedures and directives to retail pharmacists that include a blanket proscription against filling prescriptions for opioids that exceed certain numerical thresholds without taking into account the diagnosis and previous response to treatment for a patient and any clinical nuances that would support such prescribing as falling within standards of good quality patient care; and be it further, that AMA Policy opposing the legislating of numerical limits on medication dosage, duration of therapy, numbers of pills/tablets, etc., be reaffirmed; and be it further, that physicians should not be subject to professional discipline or loss of board certification or loss of clinical privileges simply for prescribing opioids at a quantitative level that exceeds the MME thresholds found in the CDC Guidelines; and be it further, that our AMA encourage the Federation of State Medical Boards and its member boards, medical specialty societies, and other entities to develop improved guidance on management of pain and management of potential withdrawal syndromes and other aspects of patient care for “legacy patients” who may have been treated for extended periods of time with high-dose opioid therapy for chronic non-malignant pain.
RESOLVED, that our American Medical Association (AMA) applaud the Centers for Disease Control and Prevention (CDC) for its efforts to prevent the incidence of new cases of opioid misuse, addiction, and overdose deaths
RESOLVED, that our AMA actively continue to communicate and engage with the nation’s largest pharmacy chains, pharmacy benefit managers, National Association of Insurance Commissioners, Federation of State Medical Boards, and National Association of Boards of Pharmacy in opposition to communications being sent to physicians that include a blanket proscription against filing prescriptions for opioids that exceed numerical thresholds without taking into account the diagnosis and previous response to treatment for a patient and any clinical nuances that would support such prescribing as falling within standards of good quality patient care.
RESOLVED, that our AMA affirms that some patients with acute or chronic pain can benefit from taking opioid pain medications at doses greater than generally recommended in the CDC Guideline for Prescribing Opioids for Chronic Pain and that such care may be medically necessary and appropriate, and be it further
RESOLVED, that our AMA advocate against misapplication of the CDC Guideline for Prescribing Opioids by pharmacists, health insurers, pharmacy benefit managers, legislatures, and governmental and private regulatory bodies in ways that prevent or limit patients’ medical access to opioid analgesia, and be it further
RESOLVED, that our AMA advocate that no entity should use MME (morphine milligram equivalents) thresholds as anything more than guidance, and physicians should not be subject to professional discipline, loss of board certification, loss of clinical privileges, criminal prosecution, civil liability, or other penalties or practice limitations solely for prescribing opioids at a quantitative level above the MME thresholds found in the CDC Guideline for Prescribing Opioids.””
Pain Management Best Practices Inter-Agency Task Force - Draft Report on Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations Official Health and Human Services Department Released December 2018
“The Comprehensive Addiction and Recovery Act (CARA) of 2016 led to the creation of the Pain Management Best Practices Inter-Agency Task Force (Task Force), whose mission is to determine whether gaps in or inconsistencies between best practices for acute and chronic pain management exist and to propose updates and recommendations to those best practices. The Task Force consists of 29 experts who have significant experience across the disciplines of pain management, patient advocacy, substance use disorders, mental health, and minority health.”
In addition to identifying approximately 60 gaps in clinical best practices and the current treatment of pain in the United States, HHS PMTF provided recommendations for each of these major areas of concern. In alignment with their original charter, the PMTF will submit these recommendations to Congress to become our ‘National Pain Policy’. The 60+ gaps and inconsistencies with their recommendations will serve to fill gaps in pain treatment at both the state and federal level; and the overwhelming consensus was that the treatment of pain should be multimodal and completely individualized based on the individual patient. The heart of each recommendation in each section was a resounding call for individualization for each patient, in regards to both non-pharmacological and pharmacological modalities; including individualizations in both opioid and non-opioid pharmacological treatments.
While each of the gap+recommendation sections of what is poised to become our national pain policy is extremely important, one that stands out the most (in regards to opioid prescribing) is the Stigma section. Contained in this section is one of the core statements that shows our Health and Human Services agency - the one that should have always been looked to and followed - knew the true depth of the relationship (or lack of) between the overdose crisis and compassionate prescribing to patients with painful conditions:
“The national crisis of illicit drug use, with overdose deaths, is confused with appropriate therapy for patients who are being treated for pain. This confusion has created a stigma that contributes to raise barriers to proper access to care.”
The recommendation that follows - “Identify strategies to reduce stigma in opioid use so that it is never a barrier to patients receiving appropriate treatment, with all cautions and considerations for the management of their chronic pain conditions” - illustrates an acknowledgment by the top health agency of the federal government that the current national narrative conflating and confusing compassionate treatment of pain with illicit drug use, addiction, and overdose death is incorrect and only serving to harm patients.
Since March of 2016 when the CDC Guidelines were released, advocates, patients, clinicians, stakeholders, and others, have began pointing out limitations and unintended consequences as they emerged. In order to address the unintended consequences emerging from the CDC Guidelines, this task force was also charged with review of these guidelines; from expert selection, evidence selection, creation, and continuing to current misapplication in order to provide recommendations to begin to remedy these issues.
“A commentary by Busse et al. identified several limitations to the CDC guideline related to expert selection, evidence inclusion criteria, method of evidence quality grading, support of recommendations with low-quality evidence, and instances of vague recommendations. In addition, the CDC used the criterion of a lack of clinical trials with a duration of one year or longer as lack of evidence for the clinical effectiveness of opioids, whereas Tayeb et al. found that that was true for all common medication and behavioral therapy studies.
Interpretation of the guideline, in addition to some gaps in the guideline, have led to unintended consequences, some of which are the result of misapplication or misinterpretation of the CDC guideline.
However, at least 28 states have enacted legislation related to opioid prescription limits, and many states and organizations have implemented the guideline without recognizing that the intended audience was PCPs; have used legislation for what should be medical decision making by healthcare professionals; and have applied them to all physicians, dentists, NPs, and PAs, including pain specialists.441–444 Some stakeholders have interpreted the guideline as intended to broadly reduce the amount of opioids prescribed for treating pain; some experts have noted that the guideline emphasizes the risk of opioids while minimizing the benefit of this medication class when properly managed.”
“The CDC guideline was not intended to be model legislation for state legislators to enact”
“In essence, clinicians should be able to use their clinical judgment to determine opioid duration for their patients”
https://www.hhs.gov/ash/advisory-committees/pain/reports/2018-12-draft-report-on-updates-gaps-inconsistencies-recommendations/index.html
HHS Review of 2016 CDC Guidelines for responsible opioid prescribing
The Pain Management Task Force addressed 8 areas that are in need of update or expansion with recommendations to begin remediation for each problem area:
Lack of high-quality data exists for duration of effectiveness of opioids for chronic pain; this has been interpreted as a lack of benefit Conduct studies Focus on patient variability and response for effectiveness of opioids; use real-world applicable trials
Absence of criteria for identifying patients for whom opioids make up significant part of their pain treatment Conduct clinical trials and/or reviews to identify sub-populations of patients where long-term opioid treatment is appropriate
Wide variation in factors that affect optimal dose of opioids Consider patient variables for opioid therapy: Respiratory compromise Patient metabolic variables Differences in opioid medications/plasma concentrations Preform comprehensive initial assessment it’s understanding of need for comprehensive reevaluations to adjust dose Give careful considerations to patients on opioid pain regimen with additional risk factors for OUD
Specific guidelines for opioid tapering and escalation need to be further clarified A thorough assessment of risk-benefit ratio should occur whenever tapering or escalation of dose This should include collaboration with patient whenever possible Develop taper or dose escalation guidelines for sub-populations that include consideration of their comorbidities When benefit outweighs the risk, consider maintaining therapy for stable patients on long term opioid therapy
Causes of worsening pain are not often recognized or considered. Non-tolerance related factors: surgery, flares, increased physical demands, or emotional distress Avoid increase in dose for stable patient (2+ month stable dose) until patient is re-evaluated for underlying cause of elevated pain or possible OUD risk Considerations to avoid dose escalation include: Opioid rotation Non-opioid medication Interventional strategies Cognitive behavior strategies Complementary and integrative health approaches Physical therapy
In patients with chronic pain AND anxiety or spasticity, benzodiazepine co-prescribed with opioids still have clinical value; although the risk of overdose is well established When clinically indicated, co-prescription should be managed by specialist who have knowledge, training, and experience with co-prescribing. When co-prescribed for anxiety or SUD collaboration with mental health should be considered Develop clinical practice guidelines focused on tapering for co-prescription of benzodiazepines and opioids
The risk-benefit balance varies for individual patients. Doses >90MME may be favorable for some where doses <90MME may be for other patients due to individual patient factors. Variability in effectiveness and safety between high and low doses of opioids are not clearly defined. Clinicians should use caution with higher doses in general Using carefully monitored trial with frequent monitoring with each dose adjustment and regular risk reassessment, physicians should individualize doses, using lowest effective opioid dose that balances benefit, risk, and adverse reactions Many factors influence benefits and risk, therefore, guidance of dose should not be applied as strict limits. Use established and measurable goals: Functionality ADL Quality of Life
Duration of pain following acute and severely painful event is widely variable Appropriate duration is best considered within guidelines, but is ultimately determined by treating clinician. CDC recommendation for duration should be emphasized as guidance only with individualized patient care as the goal Develop acute pain management guidelines for common surgical procedures and traumas To address variability and provide easy solution, consideration should be given to partial refill system
Human Rights Watch December 2018 (Excerpt from 109 page report)
“If harms to chronic pain patients are an unintended consequence of policies to reduce inappropriate prescribing, the government should seek to immediately minimize and measure the negative impacts of these policies. Any response should avoid further stigmatizing chronic pain patients, who are increasingly associated with — and sometimes blamed for — the overdose crisis and characterized as “drug seekers,” rather than people with serious health problems that require treatment.
Top government officials, including the President, have said the country should aim for drastic cutbacks in prescribing. State legislatures encourage restrictions on prescribing through new legislation or regulations. The Drug Enforcement Administration (DEA) has investigated medical practitioners accused of overprescribing or fraudulent practice. State health agencies and insurance companies routinely warn physicians who prescribe more opioids than their peers and encourage them to reduce prescribing. Private insurance companies have imposed additional requirements for covering opioids, some state Medicaid programs have mandated tapering to lower doses for patients, and pharmacy chains are actively trying to reduce the volumes of opioids they dispense.
The medical community at large recognized that certain key steps were necessary to tackle the overdose crisis: identifying and cracking down on “pill mills” and reducing the use of opioids for less severe pain, particularly for children and adolescents. However, the urgency to tackle the overdose crisis has put pressure on physicians in other potentially negative ways: our interviews with dozens of physicians found that the atmosphere around prescribing for chronic pain had become so fraught that physicians felt they must avoid opioid analgesics even in cases when it contradicted their view of what would provide the best care for their patients. In some cases, this desire to cut back on opioid prescribing translated to doctors tapering patients off their medications without patient consent, while in others it meant that physicians would no longer accept patients who had a history of needing high-dose opioids.
The consequences to patients, according to Human Rights Watch research, have been catastrophic.”
[https://www.hrw.org/report/2018/12/18/not-allowed-be-compassionate/chronic-pain-overdose-crisis-and-unintended-harms-us](
Opioid Prescribing Workgroup December 2018
This is material from the Board of Scientific Counselors in regards to their December 12, 2018 meeting that culminated the works of a project titled the “Opioid Prescribing Estimates Project.” This project is a descriptive study that is examining opioid prescribing patterns at a population level. Pain management is a very individualized process that belongs with the patient and provider. The Workgroup reviewed work done by CDC and provided additional recommendations.
SUMMARY There were several recurrent themes throughout the sessions.
Repeated concern was voiced from many Workgroup members that the CDC may not be able to prevent conclusions from this research (i.e. the benchmarks, developed from limited data) from being used by states or payors or clinical care systems to constrain clinical care or as pay-for- performance standards – i.e. interpreted as “guidelines”. This issue was raised by several members on each of the four calls, raising the possibility that providers or clinical systems could thus be incentivized against caring for patients requiring above average amounts of opioid medication.
Risk for misuse of the analysis. Several members expressed concerns that this analysis could be interpreted as guidance by regulators, health plans, or clinical care systems. Even though the CDC does not plan to issue this as a guideline, but instead as research, payors and clinical care systems searching for ways to reign in opioid prescribing may utilize CDC “benchmarks” to establish pay-for-performance or other means to limit opioid prescribing. Such uses of this work could have the unintended effect of incentivizing providers against caring for patients reliant upon opioids.
…It was also noted that, in order to obtain sufficient granularity to establish the need for, dosage, and duration of opioid therapy, it would be necessary to have much more extensive electronic medical record data. In addition, pain and functional outcomes are absent from the dataset, but were felt to be important when considering risk and benefit of opioids.
...Tapering: Concerns about benchmarks and the implications for tapering were voiced. If tapering occurs, guidance was felt to be needed regarding how, when, in whom tapering should occur. This issue was felt to be particularly challenging for patients on chronic opioids (i.e. “legacy” patients). In addition, the importance of measuring risk and benefit of tapering was noted. Not all high-dose patient populations benefit from tapering.
Post-Surgical Pain
General comments. Workgroup members noted that most patients prescribed opioids do not experience adverse events, including use disorder. Many suggested that further discussion of opioids with patients prior to surgery was important, with an emphasis on expectations and duration of treatment. A member suggested that take-back programs would be more effective than prescribing restrictions.
Procedure-related care. Members noted that patient factors may drive opioid need more than characteristics of a procedure.
Patient-level factors. Members noted that opioid-experienced patients should be considered differently from opioid-inexperienced patients, due to tolerance.
Chronic Pain
It was noted that anything coming out of the CDC might be considered as guidelines and that this misinterpretation can be difficult to counter. There was extensive discussion of the 50 and 90 MME levels included in the CDC Guidelines. It was recommended that the CDC look into the adverse effects of opioid tapering and discontinuation, such as illicit opioid use, acute care utilization, dropping out of care, and suicide. It was also noted that there are major gaps in guidelines for legacy patients, patients with multiple diagnoses, pediatric and geriatric patients, and patients transitioning to lower doses.
There were concerns that insufficient clinical data will be available from the dataset to appropriately consider the individual-level factors that weigh into determination of opioid therapy. The data would also fail to account for the shared decision-making process involved in opioid prescribing for chronic pain conditions, which may be dependent on primary care providers as well as ancillary care providers (e.g. physical therapists, psychologists, etc).
Patient-level factors. Members repeatedly noted that opioid-experienced patients should be considered differently from opioid-experienced patients, due to tolerance.
Members noted that the current CDC guidelines have been used by states, insurance companies, and some clinical care systems in ways that were not intended by the CDC, resulting in cases of and the perception of patient abandonment. One option raised in this context was to exclude patients on high doses of opioids, as those individuals would be qualitatively different from others. A variant of this concern was about management of “legacy” patients who are inherited on high doses of opioids. Members voiced concerns that results of this work has caused harm to patients currently reliant upon opioids prescribed by their providers.
Acute Non-Surgical Pain
Patient-level factors. Members felt that opioid naïve versus experienced patients might again be considered separately, as opioid requirements among those experienced could vary widely.
...Guidelines were also noted to be often based on consensus, which may be incorrect.
Cancer-Related and Palliative Care Pain
It was noted that the CDC guidelines have been misinterpreted to create a limit to the dose of opioids that can be provided to people at all stages of cancer and its treatment. It was also noted that the cancer field is rapidly evolving, with immunotherapy, CAR-T, and other novel treatments that affect response rates and limit our ability to rely upon historical data in establishing opioid prescribing benchmarks.
Concern that data would not be able to identify all of the conditions responsible for pain in a patient with a history of cancer (e.g. people who survive cancer but with severe residual pain). Further, it was noted that certain complications of cancer and cancer treatment may require the least restrictive long-term therapy with opioids.
The definition of palliative care was also complicated and it was suggested that this include patients with life-limiting conditions.
Overall, it was felt that in patients who may not have long to live, and/or for whom returning to work is not a possibility, higher doses of opioids may be warranted.
https://www.cdc.gov/injury/pdfs/bsc/NCIPC_BSC_OpioidPrescribingEstimatesWorkgroupReport_December-12_2018-508.pdf
CDC Scientists Anonymous ‘Spider Letter’ to CDC
Carmen S. Villar, MSW Chief of Staff Office of the Director MS D­14 Centers for Disease Control and Prevention (CDC) 1600 Clifton Road Atlanta, Georgia 30329­-4027
August 29, 2016
Dear Ms. Villar:
We are a group of scientists at CDC that are very concerned about the current state of ethics at our agency. It appears that our mission is being influenced and shaped by outside parties and rogue interests. It seems that our mission and Congressional intent for our agency is being circumvented by some of our leaders. What concerns us most, is that it is becoming the norm and not the rare exception. Some senior management officials at CDC are clearly aware and even condone these behaviors. Others see it and turn the other way. Some staff are intimidated and pressed to do things they know are not right. We have representatives from across the agency that witness this unacceptable behavior. It occurs at all levels and in all of our respective units. These questionable and unethical practices threaten to undermine our credibility and reputation as a trusted leader in public health. We would like to see high ethical standards and thoughtful, responsible management restored at CDC. We are asking that you do your part to help clean up this house!
It is puzzling to read about transgressions in national media outlets like USA Today, The Huffington Post and The Hill. It is equally puzzling that nothing has changed here at CDC as a result. It’s business as usual. The litany of issues detailed over the summer are of particular concern:
Recently, the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) has been implicated in a “cover up” of inaccurate screening data for the Wise Woman (WW) Program. There was a coordinated effort by that Center to “bury” the fact that screening numbers for the WW program were misrepresented in documents sent to Congress; screening numbers for 2014 and 2015 did not meet expectations despite a multi­million dollar investment; and definitions were changed and data “cooked” to make the results look better than they were. Data were clearly manipulated in irregular ways. An “internal review” that involved staff across CDC occurred and its findings were essentially suppressed so media and/or Congressional staff would not become aware of the problems. Now that both the media and Congresswoman DeLauro are aware of these issues, CDC staff have gone out of their way to delay FOIAs and obstruct any inquiry. Shouldn’t NCCDPHP come clean and stop playing games? Would the ethical thing be to answer the questions fully and honestly. The public should know the true results of what they paid for, shouldn’t they?
Another troubling issue at the NCCDPHP are the adventures of Drs. Barbara Bowman and Michael Pratt (also detailed in national media outlets). Both seemed to have irregular (if not questionable) relationships with Coca­Cola and ILSI representatives. Neither of these relationships were necessary (or appropriate) to uphold our mission. Neither organization added any value to the good work and science already underway at CDC. In fact, these ties have now called into question and undermined CDC’s work. A cloud has been cast over the ethical and excellent work of scientists due to this wanton behavior. Was cultivating these relationships worth dragging CDC through the mud? Did Drs. Bowman and Pratt have permission to pursue these relationships from their supervisor Dr. Ursula Bauer? Did they seek and receive approval of these outside activities? CDC has a process by which such things should be vetted and reported in an ethics review, tracking and approval system (EPATS). Furthermore, did they disclose these conflicts of interest on their yearly OGE 450 filing. Is there an approved HHS 520, HHS 521 or “Request for Official Duty Activities Involving an Outside Organization” approved by Dr. Bauer or her Deputy Director Ms. Dana Shelton? An August 28, 2016 item in The Hill details these issues and others related to Dr. Pratt.
It appears to us that something very strange is going on with Dr. Pratt. He is an active duty Commissioned Corps Officer in the USPHS, yet he was “assigned to” Emory University for a quite some time. How and under what authority was this done? Did Emory University pay his salary under the terms of an IPA? Did he seek and receive an outside activity approval through EPATS and work at Emory on Annual Leave? Formal supervisor endorsement and approval (from Dr. Bauer or Ms. Shelton) is required whether done as an official duty or outside activity.
If deemed official, did he file a “Request for Official Duty Activities Involving an Outside Organization” in EPATS? Apparently Dr. Pratt’s position at Emory University has ended and he has accepted another position at the University of California ­ San Diego? Again, how is this possible while he is still an active duty USPHS Officer. Did he retire and leave government service? Is UCSD paying for his time via an IPA? Does he have an outside activity approval to do this? Will this be done during duty hours? It is rumored that Dr. Pratt will occupy this position while on Annual Leave? Really? Will Dr. Pratt be spending time in Atlanta when not on Annual Leave? Will he make an appearance at NCCDPHP (where he hasn’t been seen for months). Most staff do not enjoy such unique positions supported and approved by a Center Director (Dr. Bauer). Dr. Pratt has scored a sweet deal (not available to most other scientists at CDC). Concerns about these two positions and others were recently described in The Huffington Post and The Hill. His behavior and that of management surrounding this is very troubling.
Finally, most of the scientists at CDC operate with the utmost integrity and ethics. However, this “climate of disregard” puts many of us in difficult positions. We are often directed to do things we know are not right. For example, Congress has made it very clear that domestic funding for NCCDPHP (and other CIOs) should be used for domestic work and that the bulk of NCCDPHP funding should be allocated to program (not research). If this is the case, why then is NCCDPHP taking domestic staff resources away from domestic priorities to work on global health issues? Why in FY17 is NCCDPHP diverting money away from program priorities that directly benefit the public to support an expensive research FOA that may not yield anything that benefits the public? These actions do not serve the public well. Why is nothing being done to address these problems? Why has the CDC OD turned a blind eye to these things. The lack of respect for science and scientists that support CDC’s legacy is astonishing.
Please do the right thing. Please be an agent of change.
Respectfully,
CDC Spider (CDC Scientists Preserving Integrity, Diligence and Ethics in Research)
https://usrtk.org/wp-content/uploads/2016/10/CDC_SPIDER_Letter-1.pdf
January 13, 2016
Thomas Frieden, MD, MPH Director Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30329-4027
Re: Docket No. CDC-2015-0112; Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain
Dear Dr. Frieden:
There is no question that there is an opioid misuse epidemic and that efforts need to be made to control it. The Centers for Disease Control and Prevention (CDC) is applauded for its steps to undertake this lofty effort. However, based on the American Academy of Family Physicians’ (AAFP’s) review of the guideline, it is apparent that the presented recommendations are not graded at a level consistent with currently available evidence. The AAFP certainly wants to promote safe and appropriate prescribing of opioids; however, we recommend that the CDC still adhere to the rigorous standards for reliable and trustworthy guidelines set forth by the Institute of Medicine (IOM). The AAFP believes that giving a strong recommendation derived from generalizations based on consensus expert opinion does not adhere to evidence-based standards for developing clinical guideline recommendations.
The AAFP’s specific concerns with the CDC’s methodology, evidence base, and recommendations are outlined below.
Methodology and Evidence Base
All of the recommendations are based on low or very low quality evidence, yet all but one are Category A (or strong) recommendations. The guideline states that in the GRADE methodology "a particular quality of evidence does not necessarily imply a particular strength of recommendation." While this is true, it applies when benefits significantly outweigh harms (or vice versa). When there is insufficient evidence to determine the benefits and harms of a recommendation, that determination should not be made.
When evaluating the benefits of opioids, the evidence review only included studies with outcomes of at least one year. However, studies with shorter intervals were allowed for analysis of the benefits of nonopioid treatments. The guideline states that no evidence shows long-term benefit of opioid use (because there are few studies), yet the guideline reports "extensive evidence" of potential harms, even though these studies were of low quality. The accompanying text also states "extensive evidence" of the benefits of non-opioid treatments, yet this evidence was from shorter term studies, was part of the contextual review rather than the clinical systematic review, and did not compare non- opioid treatments to opioids.
The patient voice and preferences were not explicitly included in the guideline. This raises concerns about the patient-centeredness of the guideline.
https://www.aafp.org/dam/AAFP/documents/advocacy/prevention/risk/LT-CDC-OpioidGuideline011516.pdf The Myth of Morphine Equivalent Daily Dosage Medscape Neuro Perspective
For far too many years, pain researchers and clinicians have relied on the concept of the morphine equivalent daily dosage (MEDD), or some variant of it, as a means of comparing the "relative corresponding quantity" of the numerous opioid molecules that are important tools in the treatment of chronic pain.
...And, most unfortunately, opioid prescribing guideline committees have relied on this concept as a means of placing (usually arbitrary) limits on the levels of opioids that a physician or other clinician should be allowed to prescribe. Although these guidelines typically bill themselves as "voluntary," their chilling effect on prescribers and adaptation into state laws[2] makes calling them "voluntary" disingenuous.
Although some scientists and clinicians have been questioning the conceptual validity of MEDD for several years, a recent study[3] has indicated that the concept is unequivocally flawed—thereby invalidating its use empirically and as a tool in prescribing guideline development.
The authors used survey data from pharmacists, physicians, nurse practitioners, and physician assistants to estimate daily morphine equivalents and found great inconsistency in their conversions of hydrocodone, fentanyl transdermal patches, methadone, oxycodone, and hydromorphone—illustrating the potential for dramatic underdosing or, in other cases, fatal overdosing.
Patients with chronic pain (particularly that of noncancer origin) who are reliant on opioid analgesia are already sufficiently stigmatized and marginalized[7] to allow this type of practice to continue to be the norm.
Although the use of MEDD in research and, to a greater extent, in practice, is probably due to unawareness of its inaccuracy, we posit that the use of MEDD by recent opioid guideline committees (eg, the Washington State Opioid Guideline Committee[8] and the Centers for Disease Control and Prevention Guideline Committee[9]) in the drafting of their guidelines is based more heavily on disregarding available evidence rather than ignorance. Furthermore, their misconduct in doing so has been more pernicious than the use of MEDD by researchers and individual clinicians, because these guidelines widely affect society as a whole as well as individual patients with persistent pain syndromes. We opine that these committees are strongly dominated by the antiopioid community, whose agenda is to essentially restrict opioid access—irrespective of the lack of data indicating that opioids cannot be a useful tool in the comprehensive treatment of carefully selected and closely monitored patients with chronic pain.
Above 100% extracted from: Medscape Journal Brief https://www.medscape.com/viewarticle/863477_2
Actual Study https://www.dovepress.com/the-medd-myth-the-impact-of-pseudoscience-on-pain-research-and-prescri-peer-reviewed-article-JPR
Are Non-Opioid Medications Superior in Treatment of Pain than Opioid Pain Medicine? Ice Cream Flavor Analogy...
In the Oxford University Press, a November 2018 scientific white paper[5] was released that examined the quality of one of the primary studies that have been used to justify the urgent call to drastically reduce opioid pain medication prescribing while claiming that patients are not being harmed in the process.
The study is commonly referred to as ‘the Krebs study’. “The authors concluded that treatment with opioids was not superior to treatment with non opioid medications for improving pain-related function over 12 months.”
Here is an excerpt from the first paragraph of the design section (usually behind a paywall) from the Krebs study that gives the first hint of the bias that led to them to ‘prove’ that opioids were not effective for chronic pain:

“The study was intended to assess long-term outcomes of opioids compared with non opioid medications for chronic pain. The patient selection, though, specifically excluded patients on long-term opioid therapy.” 

Here is an analogy given in the Oxford Journal white paper to illustrate how the study design was compromised:
If I want to do a randomized control study about ice cream flavor preferences (choices being: vanilla, chocolate, or no preference), the results could be manipulated as follows based on these scenarios:
Scenario A: If a study was done that included only current ice-cream consumers, the outcome would certainly be vanilla or chocolate, because of course they have tried it and know which they like.
Scenario B: If a study was done that included all consumers of all food, then it can change the outcome. If the majority of study participants do not even eat ice-cream, than the result would certainly be ‘no preference’. If the majority do eat ice-cream it would likely be ‘chocolate’. Although this study is wider based, it still does not reflect real world findings.
Scenario C: In an even more extreme example, if this same study is conducted excluding anyone who has ever ate ice-cream at all, then the conclusion will again be ‘no preference’ and the entire study/original question becomes so ludicrous that there is no useful information to be extracted from this study and one would logically question why this type of study would even be conducted (although we know the answer to that)
Scenario C above is how the study that has been used to shift the attitudes towards the treatment of pain in our nation's medical community was designed. “One has to look deep into the study to find that they began with 9403 possible patients and excluded 3836 of them just because they had opioids in their EMR. In the JAMA article, they do not state these obvious biases and instead begin the explanation of participants stating they started with 4485 patients and excluded 224 who were opioid or benzo users.” That is the tip of the iceberg to how it is extremely misleading. The Oxford white paper goes into further detail of the studies “many flaws and biases (including the narrow focus on conditions that are historically known to respond poorly to opioid medication management of pain)”, but the study design and participant selection criteria is enough to discredit this entire body of work. Based on study design alone, regardless of what happened next, the result would be that opioids are no more effective than NSAIDs and other non-opioid alternatives.
The DEA Is Fostering a Bounty Hunter Culture in its Drug Diversion Investigators[8]
A Good Man Speaks Truth to Power January 2019
Because I write and speak widely on public health issues and the so-called “opioid crisis”, people frequently send me references to others’ work. One of the more startling articles I’ve seen lately was published November 20, 2018 in Pharmacy Times. It is titled “Should We Believe Patients With Pain?”[9]. The unlikely author is Commander John Burke, “a 40-year veteran of law enforcement, the past president of the National Association of Drug Diversion Investigators, and the president and cofounder of the International Health Facility Diversion Association.”
The last paragraph of Commander Burke’s article is worth repeating here.
“Let’s get back to dealing with each person claiming to be in legitimate pain and believe them until we have solid evidence that they are scamming the system. If they are, then let’s pursue them through vigorous prosecution, but let’s not punish the majority of people receiving opioids who are legitimate patients with pain.”
This seems a remarkable insight from anyone in law enforcement — especially from one who has expressed this view in both Pain News Network, and Dr Lynn Webster’s video “The Painful Truth”. Recognizing Commander Burke’s unique perspective, I followed up by phone to ask several related questions. He has granted permission to publish my paraphrases of his answers here.
“Are there any available source documents which establish widely accepted standards for what comprises “over-prescription?” as viewed by diversion investigators?” Burke’s answer was a resounding “NO”. Each State and Federal Agency that investigates doctors for potentially illegal or inappropriate opioid prescribing is pretty much making up their own standards as they go. Some make reference to the 2016 CDC Guidelines, but others do not.

1. “Thousands of individual doctors have left pain management practice in recent years due to fears they may be investigated, sanctioned, and lose their licenses if they continue to treat patients with opioid pain relievers.. Are DEA and State authorities really pursuing the worst “bad actors”, or is something else going on?

Burke’s answer: “Regulatory policy varies greatly between jurisdictions. But a hidden factor may be contributing significantly to the aggressiveness of Federal investigators. Federal Agencies may grant financial bonuses to their in-house diversion investigators, based on the volume of fines collected from doctors, nurse practitioners, PAs and others whom they investigate.

"No law enforcement agency at any level should be rewarded with monetary gain and/or promotion due to their work efforts or successes. This practice has always worried me with Federal investigators and is unheard of at the local or state levels of enforcement.”

Commander Burke’s revelation hit me like a thunder-clap. It would explain many of the complaints I have heard from doctors who have been “investigated” or prosecuted. It’s a well known principle that when we subsidize a behavior, we get more of it. Financial rewards to investigators must inevitably foster a “bounty hunter” mentality in some. It seems at least plausible that such bonuses might lead DEA regulators to focus on “low hanging fruit” among doctors who may not be able to defend themselves without being ruined financially. The practice is at the very least unethical. Arguably it can be corrupting.
I also inquired concerning a third issue:

1. I read complaints from doctors that they have been pursued on trumped-up grounds, coerced and denied appropriate legal defense by confiscation of their assets – which are then added to Agency funds for further actions against other doctors. Investigations are also commonly announced prominently, even before indictments are obtained – a step that seems calculated to destroy the doctor’s practice, regardless of legal outcomes. Some reports indicate that DEA or State authorities have threatened employees with prosecution if they do not confirm improper practices by the doctor. Do you believe such practices are common?”

Burke’s answer: “I hear the same reports you do – and the irony is that such tactics are unnecessary. Lacking an accepted standard for over-prescribing, the gross volume of a doctor’s prescriptions or the dose levels prescribed to their patients can be poor indicators of professional misbehavior. Investigators should instead be looking into the totality of the case, which can include patient reports of poor doctor oversight, overdose-related hospital admissions, and patterns of overdose related deaths that may be linked to a “cocktail” of illicit prescribing. Especially important can be information gleaned from confidential informants – with independent verification – prior patients, and pharmacy information.”

No formal legal prosecution should ever proceed from the testimony of only one witness — even one as well informed as Commander John Burke. But it seems to me that it is high time for the US Senate Judiciary Committee to invite the testimony of others in open public hearings, concerning the practice of possible bounty hunting among Federal investigators.
C50 Patient, Civil Rights Attorney, Maine Department of Health, and Maine Legislature Collaborative Enacted Definition of Palliative Care
One suggestion that our organization would like to make is altering the definition of “palliative care” in such a manner that it can include high-impact or intractable patients; those who are not dying this year, but our lives have been shattered and/or shortened by our diseases and for whom Quality of Life should be the focus. Many of our conditions may not SIGNIFICANTLY shorten my life, therefore I could legitimately be facing 30-40 years of severe pain with little relief; that is no way to live and therefore the concern is a rapidly increasing suicide rate.
This is a definition that one of our coalition members with a civil rights attorney and the Maine Department of Health agreed upon and legislators enacted into statues in Maine. This was in response to a 100mme restriction. This attorney had prepared a lawsuit based on the Americans with Disability Act that the Department of Health in Maine agreed was valid; litigation was never the goal, it was always patient-centered care.
A. "Palliative care" means patient-centered and family-focused medical care that optimizes quality of life by anticipating, preventing and treating suffering caused by a medical illness or a physical injury or condition that substantially affects a patient's quality of life, including, but not limited to, addressing physical, emotional, social and spiritual needs; facilitating patient autonomy and choice of care; providing access to information; discussing the patient's goals for treatment and treatment options, including, when appropriate, hospice care; and managing pain and symptoms comprehensively. Palliative care does not always include a requirement for hospice care or attention to spiritual needs. B. "Serious illness" means a medical illness or physical injury or condition that substantially affects quality of life for more than a short period of time. "Serious illness" includes, but is not limited to, Alzheimer's disease and related dementias, lung disease, cancer, heart, renal or liver failure and chronic, unremitting or intractable pain such as neuropathic pain.
Here is the link to the most recent update, including these definitions within the entire statute: https://legislature.maine.gov/statutes/22/title22sec1726.html?fbclid=IwAR0dhlwEh56VgZI9HYczdjdyYoJGpMdA9TuuJLlQrO3AsSljIZZG0RICFZc
January 23, 2019
Dear Pharmacists,
The Board of Pharmacy has had an influx of communication concerning patients not able to get controlled substance prescriptions filled for various reasons, even when signs of forgery or fraudulence were not presented. As a result of the increased “refusals to fill,” the board is issuing the following guidance and reminders regarding the practice of pharmacy and dispensing of controlled substances:

1. Pharmacists must use reasonable knowledge, skill, and professional judgment when evaluating whether to fill a prescription. Extreme caution should be used when deciding not to fill a prescription. A patient who suddenly discontinues a chronic medication may experience negative health consequences;
   
2. Part of being a licensed healthcare professional is that you put the patient first. This means that if a pharmacist has any concern regarding a prescription, they should attempt to have a professional conversation with the practitioner to resolve those concerns and not simply refuse the prescription. Being a healthcare professional also means that you use your medication expertise during that dialogue in offering advice on potential alternatives, changes in the prescription strength, directions etc. Simply refusing to fill a prescription without trying to resolve the concern may call into question the knowledge, skill or judgment of the pharmacist and may be deemed unprofessional conduct;
   
3. Controlled substance prescriptions are not a “bartering” mechanism. In other words, a pharmacist should not tell a patient that they have refused to fill a prescription and then explain that if they go to a pain specialist to get the same prescription then they will reconsider filling it. Again, this may call into question the knowledge, skill or judgment of the pharmacist;
   
4. Yes, there is an opioid crisis. However, this should in no way alter our professional approach to treatment of patients in end-of-life or palliative care situations. Again, the fundamentals of using our professional judgment, skill and knowledge of treatments plays an integral role in who we are as professionals. Refusing to fill prescriptions for these patients without a solid medical reason may call into question whether the pharmacist is informed of current professional practice in the treatment of these medical cases.
   
5. If a prescription is refused, there should be sound professional reasons for doing so. Each patient is a unique medical case and should be treated independently as such. Making blanket decisions regarding dispensing of controlled substances may call into question the motivation of the pharmacist and how they are using their knowledge, skill or judgment to best serve the public.
   

As a professional reminder, failing to practice pharmacy using reasonable knowledge, skill, competence, and safety for the public may result in disciplinary actions under Alaska statute and regulation. These laws are:
AS 08.80.261 DISCIPLINARY ACTIONS
(a)The board may deny a license to an applicant or, after a hearing, impose a disciplinary sanction authorized under AS 08.01.075 on a person licensed under this chapter when the board finds that the applicant or licensee, as applicable, …
(7) is incapable of engaging in the practice of pharmacy with reasonable skill, competence, and safety for the public because of
(A) professional incompetence; (B) failure to keep informed of or use current professional theories or practices; or (E) other factors determined by the board;
(14) engaged in unprofessional conduct, as defined in regulations of the board.
12 AAC 52.920 DISCIPLINARY GUIDELINES
(a) In addition to acts specified in AS 08.80 or elsewhere in this chapter, each of the following constitutes engaging in unprofessional conduct and is a basis for the imposition of disciplinary sanctions under AS 08.01.075; …
(15) failing to use reasonable knowledge, skills, or judgment in the practice of pharmacy;
(b) The board will, in its discretion, revoke a license if the licensee …
(4) intentionally or negligently engages in conduct that results in a significant risk to the health or safety of a patient or injury to a patient; (5) is professionally incompetent if the incompetence results in a significant risk of injury to a patient.
(c) The board will, in its discretion, suspend a license for up to two years followed by probation of not less than two years if the licensee ...
(2) is professionally incompetent if the incompetence results in the public health, safety, or welfare being placed at risk.
We all acknowledge that Alaska is in the midst of an opioid crisis. While there are published guidelines and literature to assist all healthcare professionals in up to date approaches and recommendations for medical treatments per diagnosis, do not confuse guidelines with law; they are not the same thing.
Pharmacists have an obligation and responsibility under Title 21 Code of Federal Regulations 1306.04(a), and a pharmacist may use professional judgment to refuse filling a prescription. However, how an individual pharmacist approaches that particular situation is unique and can be complex. The Board of Pharmacy does not recommend refusing prescriptions without first trying to resolve your concerns with the prescribing practitioner as the primary member of the healthcare team. Patients may also serve as a basic source of information to understand some aspects of their treatment; do not rule them out in your dialogue.
If in doubt, we always recommend partnering with the prescribing practitioner. We are all licensed healthcare professionals and have a duty to use our knowledge, skill, and judgment to improve patient outcomes and keep them safe.
Professionally,
Richard Holt, BS Pharm, PharmD, MBA Chair, Alaska Board of Pharmacy
https://www.commerce.alaska.gov/web/portals/5/pub/pha_ControlledSubstanceDispensing_2019.01.pdf
FDA in Brief: FDA finalizes new policy to encourage widespread innovation and development of new buprenorphine treatments for opioid use disorder
February 6, 2018
Media Inquiries Michael Felberbaum 240-402-9548
“The opioid crisis has had a tragic impact on individuals, families, and communities throughout the country. We’re in urgent need of new and better treatment options for opioid use disorder. The guidance we’re finalizing today is one of the many steps we’re taking to help advance the development of new treatments for opioid use disorder, and promote novel formulations or delivery mechanisms of existing drugs to better tailor available medicines to individuals’ needs,” said FDA Commissioner Scott Gottlieb, M.D. “Our goal is to advance the development of new and better ways of treating opioid use disorder to help more Americans access successful treatments. Unfortunately, far too few people who are addicted to opioids are offered an adequate chance for treatment that uses medications. In part, this is because private insurance coverage for treatment with medications is often inadequate. Even among those who can access some sort of treatment, it’s often prohibitively difficult to access FDA-approved addiction medications. While states are adopting better coverage owing to new legislation and resources, among public insurance plans there are still a number of states that are not covering all three FDA-approved addiction medications. To support more widespread adoption of medication-assisted treatment, the FDA will also continue to take steps to address the unfortunate stigma that’s sometimes associated with use of these products. It’s part of the FDA’s public health mandate to promote appropriate use of therapies.
Misunderstanding around these products, even among some in the medical and addiction fields, enables stigma to attach to their use. These views can serve to keep patients who are seeking treatment from reaching their goal. That stigma reflects a perspective some have that a patient is still suffering from addiction even when they’re in full recovery, just because they require medication to treat their illness. This owes to a key misunderstanding of the difference between a physical dependence and an addiction. Because of the biology of the human body, everyone who uses a meaningful dose of opioids for a modest length of time develops a physical dependence. This means that there are withdrawal symptoms after the use stops.
A physical dependence to an opioid drug is very different than being addicted to such a medication. Addiction requires the continued use of opioids despite harmful consequences on someone’s life. Addiction involves a psychological preoccupation to obtain and use opioids above and beyond a physical dependence.
But someone who is physically dependent on opioids as a result of the treatment of pain but who is not craving the drugs is not addicted.
The same principle applies to replacement therapy used to treat opioid addiction. Someone who requires long-term treatment for opioid addiction with medications, including those that are partial or complete opioid agonists and can create a physical dependence, isn’t addicted to those medications. With the right treatments coupled to psychosocial support, recovery from opioid addiction is possible. The FDA remains committed to using all of our tools and authorities to help those currently addicted to opioids, while taking steps to prevent new cases of addiction.”
Above is the full statement, find full statement with options for study requests: https://www.fda.gov/NewsEvents/Newsroom/FDAInBrief/ucm630847.htm
Maryland’s co-prescribing new laws/ amendments regarding benzos and opioids
Chapter 215 AN ACT concerning Health Care Providers – Opioid and Benzodiazepine Prescriptions – Discussion of Information Benefits and Risks
FOR the purpose of requiring that certain patients be advised of the benefits and risks associated with the prescription of certain opioids, and benzodiazepines under certain circumstances, providing that a violation of this Act is grounds for disciplinary action by a certain health occupations board; and generally relating to advice regarding benefits and risks associated with opioids and benzodiazepines that are controlled dangerous substances.
Section 1–223 Article – Health Occupations Section 4–315(a)(35), 8–316(a)(36), 14–404(a)(43), and 16–311(a)(8) SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, That the Laws of Maryland read as follows: Article – Health Occupations (a) In this section, “controlled dangerous substance” has the meaning stated in § 5–101 of the Criminal Law Article.
Ch. 215 2018 LAWS OF MARYLAND (B) On treatment for pain, a health care provider, based on the clinical judgment of the health care provider, shall prescribe: (1) The lowest effective dose of an opioid; and (2)A quantity that is no greater than the quantity needed for the expected duration of pain severe enough to require an opioid that is a controlled dangerous substance unless the opioid is prescribed to treat: (a.) A substance–related disorder; (b.) Pain associated with a cancer diagnosis; (c.) Pain experienced while the patient is receiving end–of–life, hospice, or palliative care services; or (d.) Chronic pain
(C.) The dosage, quantity, and duration of an opioid prescribed under [subsection (b)] of this [section] shall be based on an evidence–based clinical guideline for prescribing controlled dangerous substances that is appropriate for: (1.) The health care service delivery setting for the patient; (2.) The type of health care services required by the patient; (3.) and The age and health status of the patient.
(D) (1) WHEN A PATIENT IS PRESCRIBED AN OPIOID UNDER SUBSECTION (B) OF THIS SECTION, THE PATIENT SHALL BE ADVISED OF THE BENEFITS AND RISKS ASSOCIATED WITH THE OPIOID.

 (2) WHEN A PATIENT IS CO–PRESCRIBED A BENZODIAZEPINE WITH AN OPIOID THAT IS PRESCRIBED UNDER SUBSECTION (B) OF THIS SECTION, THE PATIENT SHALL BE ADVISED OF THE BENEFITS AND RISKS ASSOCIATED WITH THE BENZODIAZEPINE AND THE CO–PRESCRIPTION OF THE BENZODIAZEPINE. 

(E) A violation of [subsection (b) OR (D) of] this section is grounds for disciplinary action by the health occupations board that regulates the health care provider who commits the violation.
4-315 (a) Subject to the hearing provisions of § 4–318 of this subtitle, the Board may deny a general license to practice dentistry, a limited license to practice dentistry, or a teacher’s license to practice dentistry to any applicant, reprimand any licensed dentist, place any licensed dentist on probation, or suspend or revoke the license of any licensed dentist, if the applicant or licensee: (35) Fails to comply with § 1–223 of this article.
8–316. (a) Subject to the hearing provisions of § 8–317 of this subtitle, the Board may deny a license or grant a license, including a license subject to a reprimand, probation, or suspension, to any applicant, reprimand any licensee, place any licensee on probation, or suspend or revoke the license of a licensee if the applicant or licensee: (36) Fails to comply with § 1–223 of this article.
14–404. (a) Subject to the hearing provisions of § 14–405 of this subtitle, a disciplinary panel, on the affirmative vote of a majority of the quorum of the disciplinary panel, may reprimand any licensee, place any licensee on probation, or suspend or revoke a license if the licensee: (43) Fails to comply with § 1–223 of this article.
16–311. (a) Subject to the hearing provisions of § 16–313 of this subtitle, the Board, on the affirmative vote of a majority of its members then serving, may deny a license or a limited license to any applicant, reprimand any licensee or holder of a limited license, impose an administrative monetary penalty not exceeding $50,000 on any licensee or holder of a limited license, place any licensee or holder of a limited license on probation, or suspend or revoke a license or a limited license if the applicant, licensee, or holder:
(8) Prescribes or distributes a controlled dangerous substance to any other person in violation of the law, including in violation of § 1–223 of this article;
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect October 1, 2018.
Approved by the Governor, April 24, 2018.
https://legiscan.com/MD/text/HB653/id/1788719/Maryland-2018-HB653-Chaptered.pdf

https://preview.redd.it/qh3u7gqk4w3b1.jpg?width=1350&format=pjpg&auto=webp&s=c8e6fbb1199a13956e9c52269d0178c1f096ad5a
Investing in rental properties can be a rewarding venture, offering both financial stability and long-term wealth accumulation. However, navigating the world of real estate requires a solid understanding of the crucial facts surrounding rental properties.
From generating passive income and property appreciation to managing tenants and understanding local regulations, being well-informed is key to making sound investment decisions.
So, let’s explore the essential facts that every potential landlord should know about rental properties. Whether you are a seasoned investor or a beginner, this information will provide valuable insights to help you maximize profitability and mitigate risks in this lucrative market.

How To Start A Rental Property Business

Starting a rental property business can be an exciting and lucrative venture. With careful planning and a solid strategy, you can generate a steady stream of passive income while building long-term wealth. Here are some essential steps to help you get started:

Define Your Goals

Determine your financial goals and objectives for the rental property business. Consider factors such as desired cash flow, return on investment, and long-term plans for property growth.

Research The Market

Conduct thorough market research to identify areas with high rental demand and potential for growth. Look for neighborhoods with desirable amenities, good schools, and proximity to transportation and employment centers.

Set A Budget

Establish a budget that includes property acquisition costs, renovations or repairs, ongoing maintenance expenses, property management fees, and vacancies. Ensure your budget aligns with your financial goals and the local rental market conditions.

Secure Financing

Explore financing options such as traditional mortgages, private lenders, or partnerships. Obtain pre-approval for a loan, considering your credit score, income, and down payment requirements.

Identify The Right Property

Look for properties that meet your investment criteria, such as affordability, potential rental income, and appreciation prospects. Conduct thorough inspections, considering the property’s condition and any necessary repairs or renovations.

Legal Considerations

Understand local laws and regulations pertaining to rental properties, including landlord-tenant laws, licensing requirements, safety codes, and zoning restrictions. Consult with an attorney to ensure compliance.

Create Lease Agreements

Develop comprehensive lease agreements that clearly outline tenant responsibilities, rent payment terms, and property rules. Include provisions for security deposits, maintenance responsibilities, and eviction procedures.

Tenant Screening

Implement a rigorous tenant screening process to find reliable and responsible tenants. Conduct background checks, verify employment and income, and check references to minimize potential risks.

Property Management

Decide whether to self-manage or hire a professional property management company. Property managers handle tenant communication, maintenance requests, rent collection, and property inspections, saving you time and ensuring efficient operations.

Market And Advertise

Market your rental property through various channels such as online listings, social media, and local advertising. Highlight the property’s unique features and benefits to attract potential tenants.

Can A Landlord Show A House That You Are Renting

As a tenant, it’s essential to know your rights and responsibilities when it comes to your rental property. One common question that arises is whether a landlord has the right to show the house or apartment you are currently renting to prospective tenants or buyers.
The answer to whether a landlord can show a rented property largely depends on the terms outlined in the lease agreement. In most cases, landlords have the right to enter the property for legitimate reasons, such as repairs, inspections, or emergencies. However, showing the property to potential tenants or buyers is usually subject to certain conditions.
Many jurisdictions require landlords to provide notice to tenants before entering the property. This notice period can vary, but it’s typically 24 to 48 hours. This advance notice allows you as the tenant to prepare for the visit and make any necessary arrangements.
It’s important to review your lease agreement to understand the specific terms regarding property showings. Some leases may include clauses that explicitly state the landlord’s right to show the property during the final months of the tenancy.
This is particularly common when a lease is approaching its expiration date and the landlord is seeking new tenants.
While landlords have the right to show the property, they are generally expected to be respectful of your privacy and convenience. They should coordinate with you to find mutually agreeable times for property viewings.
If you have concerns or conflicts with the proposed showing schedule, it’s advisable to communicate with your landlord and try to find a solution that works for both parties.

How Long Does It Take To Rent A House

Renting a house is an important decision that involves finding the right property, completing the necessary paperwork, and securing a suitable tenant. The time it takes to rent a house can vary depending on several factors.

Finding A Tenant

The first step in renting a house is finding a suitable tenant. This process usually begins with advertising the property through various channels such as online listings, real estate agents, or local classifieds. The duration of this step can vary, but it typically takes a few weeks to attract potential tenants.

Property Viewings

Once interested tenants inquire about the property, it’s time to schedule property viewings. This step allows prospective tenants to tour the house and assess its suitability. Property viewings can take a few days or weeks, depending on the availability of both the property and the tenants.

Application And Screening

After finding a tenant who is interested in renting the house, they need to complete an application form. This typically includes providing personal and financial information, references, and sometimes a credit check. The screening process can take a few days to a week to verify the tenant’s background and financial stability.

Lease Agreement

Once the tenant’s application is approved, a lease agreement is prepared. This document outlines the terms and conditions of the rental, including rent amount, lease duration, and any additional clauses. The negotiation and finalization of the lease agreement can take a few days to a week.

Move-In And Handover

After signing the lease agreement, the tenant is ready to move in. The move-in process involves conducting a thorough inspection of the property, documenting any existing damages, and handing over the keys. This step typically occurs within a few days of signing the lease agreement.

What Bills Do You Pay When Renting A House

When renting a house, it’s important to understand the various bills and expenses you will be responsible for. Here are 7 of the most common bills you may encounter:

Rent

Rent is the primary bill you will pay when renting a house. It is the agreed-upon amount you pay to the landlord or property management company in exchange for living in the property.

Utilities

Utilities typically include electricity, gas, and water. You will be responsible for paying these bills, which cover the usage of these essential services. The specific utilities you pay for may vary depending on your rental agreement.

Internet And Cable

If you want to have internet access and cable television in your rental house, you will need to subscribe to these services and pay the monthly bills. Keep in mind that these bills are usually separate from your rent and utilities.

Renter’s Insurance

While not always mandatory, it is highly recommended to have renter’s insurance. This insurance policy protects your personal belongings in case of theft, fire, or other unforeseen events. You will need to pay the monthly or annual premiums for this insurance.

Maintenance And Repairs

As a tenant, you are generally responsible for minor maintenance and repairs in the rental house. This includes tasks like changing light bulbs, fixing minor plumbing issues, and maintaining the cleanliness of the property. However, major repairs and structural issues are typically the landlord’s responsibility.

Parking And Garbage

Some rental properties may have additional bills for parking spaces or garbage collection services. If your rental house offers dedicated parking or has specific garbage collection requirements, you may need to pay for these services separately.

Who Is Responsible For Water Leak In Rented Property

The responsibility for water leaks in a rented property can vary depending on the specific circumstances and the terms outlined in the lease agreement.
In general, the landlord is typically responsible for the maintenance and repair of the property, including issues related to plumbing and water leaks.
It is the landlord’s duty to ensure that the property is in a habitable condition and to address any necessary repairs.
However, if a water leak is caused by the tenant’s negligence or improper use of the plumbing system, they may be held responsible for the resulting damages.
For example, if the tenant accidentally causes a pipe to burst by improperly using the plumbing fixtures, they may be liable for the repair costs and any resulting damage to the property.
It is important for both landlords and tenants to carefully review the lease agreement to understand their respective responsibilities regarding maintenance and repairs.
Additionally, local rental laws and regulations may provide further guidance on the division of responsibilities in case of water leaks or other issues in rented properties. If there is any uncertainty or disagreement, it is advisable to seek legal advice or consult with a local housing authority for clarification.

Can You Rent An Apartment If You Own A Home

Owning a home doesn’t necessarily mean you can’t explore the option of renting an apartment. Whether you’re considering downsizing, relocating temporarily, or seeking additional income, renting an apartment while owning a home is indeed possible. Here are a few key points to consider:

Financial Considerations

Before diving into renting an apartment, it’s important to evaluate your financial situation. Ensure that you can comfortably afford the expenses of both your home and the rental apartment.
Assess your mortgage payments, property taxes, insurance, maintenance costs, and potential rental income to determine if renting an apartment aligns with your budget.

Rental Application Process

Just like any other prospective tenant, you’ll need to go through the rental application process. Landlords typically require income verification, credit checks, and references.
Be prepared to provide necessary documentation that demonstrates your ability to meet rental obligations alongside your homeownership responsibilities.

Lease Agreements

Signing a lease agreement is a standard practice when renting an apartment. It outlines the terms and conditions of your tenancy. Make sure to thoroughly review the lease agreement, understanding the duration, rent amount, utilities, and any additional terms that may apply. Be aware of any clauses that may conflict with your homeownership obligations.

Property Management

Renting an apartment while owning a home may require additional management responsibilities. If you plan to maintain both properties, consider the time and effort required for property upkeep, repairs, and tenant communication.
Alternatively, hiring a property management company can alleviate the burden by handling day-to-day operations on your behalf.

Legal And Tax Implications

Depending on your location and local regulations, there may be legal and tax considerations to keep in mind. Consult with legal and tax professionals to understand any implications or obligations that arise from renting out your home or renting an apartment while owning a home.

Who Is Responsible For Replacing Smoke Alarms In Rented Properties

In rented properties, the responsibility for replacing smoke alarms typically falls on the landlord. Smoke alarms are essential safety devices that help protect tenants from the dangers of fire.
Landlords have a legal obligation to ensure that their rental properties meet certain safety standards, and smoke alarms are a crucial part of those requirements.
When a tenant moves into a rental property, it is the landlord’s responsibility to provide functioning smoke alarms in appropriate locations.
This includes installing smoke alarms on each level of the property and near bedrooms or sleeping areas. Landlords should also ensure that the smoke alarms are in good working condition, with functional batteries or a reliable power source.
While tenants are responsible for regularly testing the smoke alarms and notifying the landlord if they are not working properly, the ultimate responsibility for replacing smoke alarms lies with the landlord.
This means that if a smoke alarm malfunctions or reaches the end of its lifespan, it is the landlord’s duty to replace it promptly.
It’s important for landlords to understand the specific regulations regarding smoke alarms in their jurisdiction, as laws may vary from one location to another.
Some areas may have additional requirements, such as the use of interconnected smoke alarms or the need for carbon monoxide detectors.
By fulfilling their responsibility to replace smoke alarms in rental properties, landlords can prioritize the safety of their tenants and ensure compliance with legal obligations.
Regular maintenance and prompt replacements not only contribute to a secure living environment but also help prevent potential tragedies associated with fire incidents.

Can Landlord Sell House While Renting

If you’re a tenant renting a house, you may wonder what happens if your landlord decides to sell the property. The answer is yes, a landlord can sell a house while it is being rented.
However, the process and implications can vary depending on your jurisdiction and the terms of your lease agreement.
In most cases, when a landlord decides to sell a rental property, they must adhere to local laws and regulations regarding tenant rights and notice periods.
They typically need to provide you with advance notice about the intention to sell and allow reasonable access for potential buyers to view the property.
During the selling process, your lease agreement remains in effect, and your rights as a tenant should be protected. In some cases, the new owner may honor the existing lease agreement until its expiration, while in other situations, they may have the option to terminate the lease with proper notice.
It’s essential to review your lease agreement and familiarize yourself with the local laws to understand your rights and obligations as a tenant when the landlord decides to sell the rented house.
Additionally, open communication with your landlord can help clarify any concerns and ensure a smooth transition during the selling process.

Can You Rent A House At 18

Renting a house at the age of 18 is possible, but it can come with certain challenges. Many landlords have age restrictions or may prefer tenants with a stable income and rental history.
However, with proper planning and preparation, it is still feasible to secure a rental property at this age.
Firstly, it is important to demonstrate financial responsibility and stability. This can be achieved by providing proof of income, such as pay stubs or bank statements, and having a solid credit history.
Building a positive rental history by obtaining references from previous landlords or utilizing a co-signer can also increase your chances.
Additionally, it can be helpful to research and approach landlords who are more open to renting to younger tenants. This can include private landlords or smaller property management companies.
Being prepared to provide a larger security deposit or having a guarantor can also help alleviate concerns that landlords may have.
Ultimately, while it may require extra effort, finding a rental property at 18 is possible by showcasing your reliability, financial stability, and responsible behavior.

Do You Need a Real Estate License To Rent Property

In many states, renting out your own property as an individual does not typically require a real estate license.
But the requirement for a real estate license to rent property depends on the jurisdiction in which you are located.
However, if you engage in property management or act as a rental agent on behalf of others, a license may be required.
Remember, the regulations can vary significantly between countries, states, and even municipalities. Therefore, it’s crucial to research and understand the specific rules and requirements in your particular area.
Consulting with a local real estate attorney or contacting the relevant licensing authorities can provide you with accurate and up-to-date information for your specific location.

How To Save Money For A House While Renting

Saving money for a house while renting may seem challenging, but with the right strategies, it is achievable. Here are 9 crucial tips to help you save:

Set A Budget

Create a monthly budget that includes all your expenses and identifies areas where you can cut back. Prioritize saving for your future home by allocating a specific amount each month.

Reduce Rent Expenses

Consider downsizing to a smaller, more affordable rental property or explore options like house-sharing to reduce your monthly rent expenses.

Minimize Utilities

Be mindful of your utility usage and find ways to reduce energy costs. Turn off lights when not in use, unplug electronics, and use energy-efficient appliances.

Cut Unnecessary Expenses

Review your subscriptions and memberships. Cancel or downgrade services you don’t use frequently. Reduce entertainment expenses by opting for free or low-cost activities.

Automate Savings

Set up an automatic transfer from your paycheck to a separate savings account dedicated to your house fund. This makes saving easier and ensures consistency.

Earn Extra Income

Explore ways to earn additional income, such as taking on a side job or freelancing. Use the extra earnings solely for your house savings.

Save Windfalls

Whenever you receive unexpected money, such as tax refunds or bonuses, resist the temptation to splurge. Instead, put these funds directly into your house savings.

Seek Affordable Housing Assistance

Research local housing programs or grants that can assist first-time homebuyers. Explore options like down payment assistance or low-interest loans.

Be Disciplined

Stay focused on your goal of saving for a house. Avoid unnecessary expenses and remind yourself of the long-term benefits of homeownership.

Can You Paint A Rented House

One common question that arises when renting a house is whether or not you can paint the property. The answer to this question depends on various factors, including the terms of your lease agreement and the landlord’s policies.
In some cases, landlords may allow tenants to paint the rented house, but with certain restrictions. They may require specific colors, require approval of the paint choices, or ask that the tenant repaint the walls to the original color before moving out.
On the other hand, some landlords may not permit tenants to paint the property at all, wanting to maintain consistency and avoid potential damage or the need for additional painting expenses.
To avoid any conflicts or misunderstandings, it is crucial to communicate with your landlord regarding your intentions to paint the house. It is advisable to get written permission and clarify any conditions or restrictions beforehand.

Do I Need A Business License To Rent Property

If you’re considering renting out a property, you may be wondering whether you need a business license. The answer depends on various factors, including your location and the specific regulations in your area.
In many jurisdictions, renting out a property does not necessarily require a separate business license. Rental activities are often considered a form of real estate investment or passive income, rather than an active business.
However, it’s crucial to research and comply with local laws and regulations, as some areas may have specific licensing requirements for landlords.
While a business license may not be mandatory, you might still need to register your rental property with local authorities or obtain permits related to safety, zoning, or occupancy.
These requirements are typically in place to ensure compliance with building codes and protect the well-being of tenants.
To ensure you’re operating within the legal framework, it’s advisable to consult with local government agencies or seek guidance from a real estate attorney.
They can provide accurate information based on your specific location and help you navigate any licensing or regulatory obligations related to renting out property.

Who Is Responsible For Trees In A Rented Property

Determining responsibility for trees in a rented property depends on various factors and the specific terms outlined in the lease agreement. Generally, the landlord is responsible for the maintenance and care of trees on the property.
This includes tasks such as pruning, trimming, and addressing any potential hazards posed by the trees.
However, if a tree-related issue arises due to the tenant’s negligence, such as causing damage by improperly trimming or removing a tree without permission, the tenant may be held responsible for any resulting damages.
To avoid any confusion or disputes, it is crucial for both landlords and tenants to clearly define the responsibilities regarding tree care and maintenance in the lease agreement.
Additionally, local laws and regulations may provide further guidance on the matter.
Open communication between the landlord and tenant is essential to address any tree-related concerns and ensure the property remains safe and well-maintained.

Crucial Facts About Rental Properties: Final Words

Understanding the crucial facts about rental properties is essential for anyone considering or currently involved in real estate investing. Rental properties can offer a passive income stream, property appreciation, and long-term financial stability.
Location plays a significant role in the success of a rental property, as well as understanding the local real estate market. Financing options, effective property management, and compliance with rental laws and regulations are all key factors to consider.
Maintenance and repairs are necessary for maintaining property value and tenant satisfaction.
Additionally, landlords must be aware of the risks involved and have appropriate insurance coverage. By being well-informed about these crucial facts, individuals can make informed decisions, minimize risks, and maximize the profitability of their rental property investments.