2019 was a hard year for NLMB, losing members back to back to different opps and starting a new bloody war with DeathRow, in 2020 the war will slow down due to a lot of factors. Most members who put in work in that war will get locked up and NLMB will focus on other opps just like DeathRow, we will come back in the summer of 2022 to that beef.

Willie "Ghost 🕊️" Coker

08/31/2019
I didn't had space to include Ghost in the last part so i decided to do it here, it's not that important to the NLMB/DeathRow beef so it's ok if i include it at the beginning.
Ghost also known as Rat was a respected OG from GME, i am not sure if he was the target or not but DeathRow and Lakeside dissed him a lot, Fa Fa Fa said they killed Ghost and ever since then GME didn't do anything for him, ignore the video from the store, that's not Ghost, it's a mistake by the one who made the post, the one who died in the store was an innocent as far as i know and it happen way after Ghost died. This happen in the same month DeathRow killed Willie, DeathRow was sliding a lot in 2019.
Ghost was outside with multiple people in his own hood when shots rang out from an unknown direction, he was shot multiple times in the chest and he died at the hospital.
"Ghost got hit up" 0:58

Michael "Aero 🕊️" Portis

01/05/2020
One of the reasons i believed Savo 🕊️ was killed by kings was Aero death, months after Savo died, Aero was sliding with FatLord 🔒 on some kings, which made sense at least during that time, Savo died in a hood cool with the kings, Aero is sliding on the kings, it was making sense into my head that Aero died trying to get revenge for Savo + that's what i was told, again i was wrong. As i said in my previous post, Savo was killed by NLMB, Aero was just a hothead who was sliding on his opps, nothing weird.
Aero was on the frontline and did a lot of dirt for DeathRow, he earned the nickname "23" for a reason, in my previous post i put a screenshot with Fa Fa Fa straight up saying Aero killed G Dottie 🕊️. I know a lot of people believed Aero killed an innocent, but people told me that Garcia 🕊️ was a known king, why would Aero and FatLord slide on some innocents and specifically target them?
Aero and FatLord were driving a turquoise SUV when they made a U-turn at the end of the street and parked in the block close to a king hood, both got out of the SUV with armed 9-mm handguns and approached Garcia and his neighbor as they were outside talking, they opened fire hitting the neighbor in the arm and hitting Garcia multiple times, Garcia returned fire with his own weapon striking Aero multiple times who died at the scene, FatLord was also shot multiple times, FatLord left Aero there and went to a hospital with the SUV in the same clothes that CPD saw on the footage. Garcia was pronounced dead at the hospital, police recovered 19 9-mm shell casings and 10 .40-caliber shell casings from the crime scene.
This is a very controversial situation because at first, people said after FatLord recovered from his wounds, he told the police what happen and also snitched on BD 🕊️ but now they saying free him, they saying that someone else ratted and not him, but according to this article, CPD is using FatLord as a source, FatLord was the one who allegedly was the driver on the Willie hit, FatLord is still locked up so who knows.
The scanner also confirms that they was sliding on some kings because they was having problems lately, it could be possible that some kings gave the location of Savo to NLMB, Savo was killed right at his home so NLMB probably got the drop from someone.
NLMB and ABK will diss Aero hard because he killed G Dottie, someone also recorded Aero on the ground, which was heavily mocked by his opps.
"Lil Aero a dumbass got hit on a hit" 0:23

Tristan "Tedo G 🕊️" Rogers

04/05/2020
NLMB first loss in 2020 but not because of gun violence, Tedo was from the MuskegonBoyz clique, he was killed by a car in DucciWay 🔱 hood, there is not a lot to say about him, he was a respected OG who was either related to Kobe 🕊️ or close to him.

Shianne "Anna 🕊️" Reynolds

04/19/2020
Anna was a very loved member from MTG 079 now more known as BiyoBlock, she was Biyo 🕊️ sister, at first people believed that she was not gangbanging but that's false, there is a lot of captions with her saying she was using guns to slide, i don't think she was active when she died in that life and she probably was not the target either. However, she probably was active in the past and as we all know, the past is catching up to you, her vigil was also shot, allegedly by NLMB again.
What i know is this, allegedly NLMB saw some MTG 079 members in traffic in SirconnCity 🔱 hood, they sped up behind them and shot the whole car, Anna was just unlucky since she was in the car with them, she was hit in the head and CPD pronounced her dead at the scene. This was one of the first getback NLMB got for Capo, but it will not stop here, NLMB will get more getback for Capo months later.
2020 was a hard year for MTG 079, they lost 4 members, Anna 🕊️, Pook 🕊️ who was not killed by any opps, LB 🕊️ an original who was also close to Biyo, LB was killed in DrillCity 📶🔱🅱️ hood, last one is Jeezy Snow 🕊️, we will get later to him.

Anthony "C-Note 🕊️" Smith

04/27/2020
C-Note was an OG from NLMB, to be more specific he was from the MuskegonBoyz clique, from what i know he passed away from natural causes, nothing to do with gun violence. He was born in 1985 so he was old compared to a lot of main members from MuskegonBoyz clique like G Farro for example, you could say he was from that White Folks generation.

Junius "BoBo 🕊️" Thurston

05/07/2020
BoBo was a very loved member from ABK, he was one of the main faces from there. BoBo was also a rapper, one of his best songs Pigs Hot where you can see a lot of ABK members including Yogi 🕊️, BoBo was close to NLMB as well, he did a song with Juvie and before his death you could see him around G Herbo.
BlackMobb was having a field day when BoBo was killed, even though BoBo left that life behind while starting a truck company, it's not like your opps will forgive you or forget that you did dirt in the streets or hurt their people, that shit is stucked until you die, even if you are 30, 40, as long as you put yourself in danger(go back to the city) you can get killed anywhere.
BoBo exit his car and went to a gas station in a relatively safe area far away from any hood, a black Audi pull up and a rear passenger open fire, he ran north from the station but then a gunman got out of the car and chased after him, firing more shots. BoBo collapsed and the gunman caught up to him standing over him and fired more shots, BoBo was pronounced dead at the hospital, police said he was shot multiple times.
BlackMobb were not the only ones having a field day with his death, PocketTown also dissed him:
"BoBo got his ass smoked, 20 bullets took his soul" 2:45
It is sad because BlackMobb and ABK were like this, but friends are turning to enemies and both sides lost main members in this war.

Lee "KTS Rio 🕊️" Cameron

07/12/2020
If you follow the drill scene, then you know who was KTS Rio, one of the main faces from PocketTown and Lil Los 🔒 little brother, he was a huge loss for PocketTown, after his death a lot of stuff went down.
Rio was driving a vehicle with two other teenagers near a gas station in KakiWorld 🔱🅱️⭐️✊🏿 hood when a silver SUV pulled up and someone inside started shooting, Rio was shot multiple times and he was pronounced dead at the hospital. The 14-year-old boy was shot in the back and a 17-year-old boy was hit in the right arm, both were taken to the hospital in good condition.
After his death PocketTown goes by "RioGang" in his honour, Rio was also one of their main rappers, one of his most known song is NLMBK, Faro dissed him in a song after he died:
"Rio got hit and they left his ass twitching" 0:38
"Rio got hit, y'all ain't get your getback" 1:05
A lot of people are saying NLMB killed KTS Rio but if you watch Freeband BoBo 🕊️ video that CH88 made, it is very clear that NLMB didn't do anything to Rio, because the war started when Lil Greg 🕊️ was killed, that's also what BoBo said. The beef was not serious until Lil Greg died, BoBo also said the whole war started because of a bitch, Lil Greg wanted to call his guys to kill BoBo because of a girl. Feel free to watch the video, it's explaining a lot of stuff.
Remember there is a difference between "twitter beef" like disses and blood beef, KTS Dre did dirt on NLMB but he did that for Lakeside while PocketTown was his second hood(he started to claim PocketTown after KTS Von died), so Lil Greg was the first guy to die in that beef, we will get later to him.
Now honestly it is not known who killed KTS Rio, but one of the most plausible theory is that SirconnCity killed him, months after KTS Rio died, PocketTown lost KDawg 🕊️, another top member while sliding on SirconnCity hood, his article doesn't mention anything about sliding but both sides said that.
"We doing hits without hoodies and masks, Rio got hit, he got stretched like an elastic" 1:08
"KDawg got hit on a hit, he dead" 0:24
They are main opps but since PocketTown top members were sliding, i think that means something, especially after Rio died.
This won't stop at KTS Rio, this year would be the most hardest year for PocketTown, they will lose 6 members in one year and they was all top members, but not all of them were killed by opps.
Big Glizzy/Lil James 🕊️ (June 07 2020), killed at a party in Robbins, a suburb of Chicago.
KTS Rio 🕊️ (July 12 2020), KDawg 🕊️ (September 27 2020), Nuke 30 🕊️ (November 25 2020), killed OT, LA Glizzy/Lil Ant 🕊️ (January 12 2021), killed OT, Killa Spook 🕊️ (March 26 2021), we will get later to Killa Spook.
"They lost 6 niggas in one year, tryna make the rest of them disappear" 1:53

Antoine "BT 🕊️" Rose

08/22/2020
BT was a very loved member from NLMM and 358Gang, he claimed both sets, he was also close to NLMB, one of the reasons he died. Even though NLMB and 358Gang are opps, as i said in my previous parts, NLMM was always a set focusing on money, they was never known to slide like that, so that's probably why he was close to NLMB and cool with NLMB opps, 358Gang. BT also appeared on the Maurice show.
I think everyone knows that Fa Fa Fa straight up said they killed BT, so why they killed him? Well even though BT was not involved in their beef, it doesn't matter, he was close to NLMB and 358Gang killed Mook 🕊️ in 2019, so DeathRow got their getback for him. I don't think BT was the specific target because the shooting occured in TheBush 👑🦁 territory, which are opps to DeathRow. BT was shot in the head and in the abdomen, CPD pronounced him dead at the scene, a 32 year old man was also shot in the abdomen and in the leg, he was taken to the hospital in critical condition.

Sean "Cello Da Shoota 🕊️" Wilson

09/07/2020
There was a lot of back and forth between NoGood and NLMB, mainly because NLMB killed Montae 🕊️ and it was forever stuck there, even though NoGood and NLMB are old opps, that beef was really inactive compared to Lakeside for example, but this all changed when Montae was killed, Montae was very loved by NoGood and like Jeff Fort said "there is not going to be any killing without killing" Cello was not really a main face from NLMB, he was from the NoLimit clique but his original hood was JBG 🔱 also known as MoneGang.
Cello was driving with someone else in the car in NoGood ⭐️✊🏿 hood, Jay Savage and Deonte 🔒 fired shots and the person in the backseat fired back, hitting one of them in the forearm, Cello was hit in the neck and died at the hospital, the other person was listed in good condition after being shot in his thigh, he has a license to carry his gun. Jay Savage and Deonte were both charged with his murder, both were from NoGood and close to Montae.

Deshawn "Jeezy Snow 🕊️" Fletcher

10/15/2020
Jeezy was in ABK 4️⃣🍸⭐️✊🏿🔱 hood driving his car when Mally 🔒 opened fire from the sunroof of a silver Chrysler 300, he was shot multiple times in the head, neck and upper torso, he died at the hospital two days later. There is a lot of contradiction of the car used in the murder, what we know for sure is that Mally shot from the sunroof. Mally also searched the murder on google to see if Jeezy died.
This was a a crazy hit for many reasons, one of them is that Lil Wet was driving the car, Lil Wet did this two months after he beat his quadruple murder case, the case is complicated but to this day Mally is still locked up for it. The full foia if you want to read more, from what i know the case is very strong against Mally but let's be real, Lil Wet beat a quadruple murder, everything is possible in Chicago, so i won't be surprised if he is beating it.
Lil Wet also hinted in his song "Nun Stop" about the hit, the music video was deleted or made private, but the audio version is still up.
"Gotta ride for my gang, Steph got the wheel, Lil Mally might come out the roof " 0:44
Jeezy was actually very close to DoggPound 🅱️, you can see him around them in old videos and i think he was related to some members from there too, i am not sure if he was claiming DoggPound at one point but members from there still say rip to him, again it doesn't mean every DoggPound member was close to him. It is a complicated situation but this was another getback NLMB got for Capo, a top member from MTG 079 and very loved.

Gregory "Lil Greg 🕊️" Jackson III

01/28/2021
The death that started all and guess what caused this? Well if you didn't guess it, it was a bitch, Lil Greg 🕊️ got into his feelings because BoBo 🕊️ was messing with a girl that he liked so when Lil Greg saw him, he tried to get the green light from other members to come and kill him right there, allegedly NLMB told him BoBo is not an opp and that he is staying out of the way, Lil Greg tried to call other members but it was too late.
PocketTown members got the drop from BoBo and went to kill Lil Greg who was in a barbershop far away from EastSide, Lil Don 🔒 walked up to him and shot Lil Greg in the face inside the barbershop, he was pronounced dead shortly after at the hospital, CK was actually charged because they found him in the same car that was used in the murder, he stayed solid and beat the case, CK was the one driving.
Lil Greg was a very loved member from NLMB and a main face from there, he was from the MuskegonBoyz clique but very close to G Herbo and even celebrities like 21 Savage paid respects to him, he was respected because he was a trapper making money from drugs to raise his kids, his death hurt a lot of people and you could say that his death made "DrenchGang" more famous because the getback was huge in terms of impact on the media, i am of course speaking about KTS Dre, his death was international news because of the way he died + Killa Spook, we will get later to them.
"Me and Gregg was sharin' clothes, but we weren't really bros" 0:18
"Lil Greg died, that started some shit, but how many checked after broski got hit?" 0:36 he is also upping 4 fingers, which is probably a reference to Killa Spook, KTS Dre, BoBo and probably Lil Don from PaxTown.
Moowop 🔒 also confirmed 3 opps died for Lil Greg, again most likely a reference to Killa Spook, KTS Dre and BoBo. Lil Don was also shot multiple times but he survived
NLMB was hurt but the opps were dissing Lil Greg hard, especially Lil Don:
Lil Don called Lil Greg biggest score of 2021
This started a new bloody war in the EastSide which caused a lot of damage, members getting locked up, members getting killed, members getting shot and so on, PocketTown was also unlucky to get hit with a "RICO" and most of their top members got locked up, there is barely any main faces out there besides Denny G and Lil Ant, they also have internal beef now.
The indictment also mentions they found the gun which was used in Lil Greg murder, the whole situation was fucked up for PocketTown, they lost like 10 members to this indictment + Lil Don got locked up + internal beef, the whole hood was hit hard by this indictment and a lot of "snitching" rumours are in the air.
The members who got locked up are Lil Rah 🔒, EJ(he was released), Rello 🔒, Dreski 🔒 MT Larry🔒 who actually shot back when Spook died, Corey Got Clout 🔒, PacMigo 🔒, Dwight 🔒 and DreadHead Larry 🔒

Dante "Killa Spook 🕊️" Thomas

03/26/2021
Killa Spook was like a leader in PocketTown, he had a lot of respect and his name says it all "Killa Spook" it's not a name you earn for doing nothing, he was a known killer who did a lot for PocketTown, him and KTS Von 🕊️ went to slide on Lamron in the past, he was very active, him and Denny G were sliding on SirconnCity as well.
Spook 🕊️ was partying with a lot of members inside StainCity🔱⭐️✊🏿 hood, it was a party for their fallen member KDawg 🕊️ who was killed sliding on SirconnCity in 2020, two shooters(this might be PocketTown shooting back but i personally think those are the offenders), NLMB and GME got the drop from a bitch and shot the whole party up, Killa Spook was shot by a stray bullet through a window, he was pronounced dead at the scene, Lord was shot in the head and he was taken to the hospital in critical condition, Denny G was taken to the hospital in critical condition and he recovered after some time, other members got shot as well but it was nothing serious like the ones i mentioned above.
Right after the party got shot up, PocketTown went to slide on NLMB and hit someone in the leg, there are a lot of things that points NLMB for doing this hit but it is confirmed that GME was also involved, Lil B from GME was arrested by CPD with the car used in the murder, he was released because CPD didn't had proof that he did the murder.
There are many names around Spook death, Faro, Lil Ro, Twino 🕊️, EMoe from GME, 7Moe 🕊️ from GME, it is not known exactly who killed Spook but it is hard to tell, what should be confirmed for sure is that it was a NLMB/GME hit, even CPD and FBI believes that. In case you guys don't know, FBI was trying to build a RICO but their main suspect Max 🕊️ was killed, so i think the case is really not that strong anymore. I do think FBI is monitoring what is going on between NLMB and PocketTown now.
PocketTown was hurt to the core by his death, NLMB and GME were dissing like crazy and celebrating Lil Greg a lot, it's a lot of disses that i am sure most of you saw, if you want way more details, watch CH88 video.

Londre "KTS Dre 🕊️" Sylvester

07/10/2021
Dre was getting out of prison after his fiancee paid his $5,000 bond on Friday, for some reason Dre decided to leave only on Saturday, what Dre didn't knew is that his decision will cost him his life and potentially the life of two other innocent females. Dre was shot around 64 times by multiple shooters from two different vehicles far away from EastSide in every side of his body, a 60 year old female was shot in the knee and a 35 year old female suffered a graze to her mouth while walking by, both were taken to the hospital in good condition. Dre was DOA and his death will have a huge impact in the streets, after his death the president of America, Joe Biden, was forced to do a meeting to slow the violence in Chicago, this was because his death had an immense impact in the international news because of the way that he died.
I would leave in the comments a list of some the countries news speaking about KTS Dre, because it would take too much space in the post.
Dre was an upcoming rapper in the drill scene, his most famous song being a feature with Rio called "NLMBK Pt. 2" but in the drill scene he mostly became known for punching Kyro, one of the many reasons Kyro diss him a lot. Dre was very active in the streets before his death, he did a lot of dirt and a lot of his opps wanted him gone. Dre was also suspected by CPD for killing Magic 🕊️ in 2019. He was originally from LakeSide but he started to claim PocketTown after the death of his brother in 2015, he is what people believe Von was, don't get me wrong, Von was active in the streets but Dre was something else.
I heard many names around Dre death, Faro, the DrenchGang Twins, Moowop, Kyro, Lil Hot, honestly i am not sure who killed Dre but NLMB and even PocketTown/LakeSide made it known who did it on social media. Faro being pretty clear that this was a getback for Lil Greg.
Losing so many people in such a short time affected PocketTown in many ways, a lot of them decided to step down because when shit gets real, you need to think about your life too, most of them have families, it might be a coward way but can you blame them? 10 members locked up for indictment, 9 top members killed between 2020-2022, Denny G was almost killed, Meechie was almost killed, Lil Don got locked up, Lil Art barely survived after being shot 20 times, Lord was left in critical condition, this is the worst period for PocketTown and Lil Don also confirmed that his people are scared and he only got four guys who are willing to slide.
Sadly the ones who will suffer the most is the family, his mom was devastated that she can't even give him a proper funeral because of the way that he died.

Christopher "Gucci 🕊️" Daniels

08/05/2021
Gucci was near the sidewalk in GhettoWorld 4️⃣🍸 hood when a vehicle passed by and someone fired shots at him, he was shot in the chest and he was pronounced dead at the hospital.
This is one month after Dre was killed, Gucci was a member from the MuskegonBoyz clique, i didn't saw PocketTown or LakeSide celebrating anything, in fact they still say "getback got no date" for Spook and Dre, it might be other opps that NLMB have, remember NLMB beefs with 30+ sets, it could also be personal beef, mistaken identity and so on.

Felder "Stro Dolla 🕊️" Tatum Jr.

08/15/2021
Stro Dolla was with a group of people inside GottiWorld 🔱 hood when someone opened and hit him in the chest, he was pronounced dead at the hospital, a 34 year old woman was also shot in the leg, she was taken to the hospital in good condition. Again i don't think he was the target but who knows, i didn't saw any opps celebrating, Stro Dolla was claiming NLMM but he was close to NLMB.He was also close to BT 🕊️ who was killed in 2020 by DeathRow, he was also a rapper, most likely Stro Dolla was just at the wrong time, wrong place, to my knowledge GottiWorld and NLMM or NLMB don't have beef. GottiWorld are actually opps to PocketTown.

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VW warranty class action overview:
Who: A VW owner is suing the automaker.
Why: The plaintiff says VW failed to properly identify and pay for the diagnosis, repair, and replacement of in tank fuel pumps in certain Partial Zero Emissions Vehicles for 15-years or 150,000-miles.
Where: The VW warranty class action lawsuit was filed in a California federal court.
VW skirted its legal responsibility to pay for the repair and replacement of in tank fuel pumps in certain Partial Zero Emissions Vehicles in California, a new class action lawsuit alleges.
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Plaintiff Nicole Rosser filed the class action lawsuit against Volkswagen Group of America Inc. (VW) on Feb 16. in a California federal court, alleging violations of California consumer law.
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According to the lawsuit, VW failed to properly identify and pay for the diagnosis, repair, and replacement of in tank fuel pumps in certain Partial Zero Emissions Vehicles (PZEVs) for 15-years or 150,000-miles, pursuant to the California Code of Regulations Title 13 relating to Partial Zero Emissions Vehicles and Super Ultra Low Emissions Vehicles.
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VW has received Emissions Credits from the California Air Resources Board for the vehicles and has declared Partial Zero Emissions Vehicle qualification with the board, the plaintiffs say.
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Under the California Emissions Warranty, defects which increase regulated emissions in PZEV vehicles, defects which cause PZEV vehicles to fail California emissions tests, and defects which cause the check engine light on PZEV vehicles to illuminate, shall be covered under warranty for 15-years or 150,000-miles, the lawsuit states.
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The class vehicles have tank defects that increase regulated emissions, cause the MIL to illuminate, and cause the vehicle to fail a California smog check, the plaintiffs say.
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“Therefore, the in tank fuel pumps in Class Vehicles should be covered by the California Emissions Warranty.”
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Drivers are paying out of pocket for fixes that should be covered under warranty, they say
However, VW does not provide proper warranty coverage for in tank fuel pumps in the vehicles, meaning the plaintiffs are continuing to pay out of pocket for repairs that should be covered under the California Emissions Warranty, they say.
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Their claims relate to all vehicles distributed by VW that are PZEV vehicles and for which VW does not provide 15-years or 150,000- miles coverage relating to in tank fuel pumps.
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“VW has failed to extend California Emissions Warranty coverage to in tank fuel pumps in Class Vehicles as required by the CCR… this is an unlawful and unfair business practice.”
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The plaintiffs seek to represent anyone in California who have been owners or lessees of the vehicles and whose in tank fuel pumps are not covered for 15-years or 150,000-miles
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They allege violations of California consumer laws and seek certification of the class action, an order forcing VW to cover the in tank fuel pumps, damages, fees, costs and a jury trial.
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Meanwhile, Volkswagen has failed to offer a solution to owners of 3G connected vehicles even as wireless carriers are shutting down 3G networks, leaving certain important features inoperable, a 2022 class action lawsuit alleges.
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Do you own one of the vehicles mentioned in this VW lawsuit? Let us know in the comments!
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They are represented by Adam Rose, Robert L. Starr and Manny Starr of The Law Office of Robert Starr Frontier Law Center.
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The Volkswagen class action lawsuit is Nicole Rosser et al., v. Volkswagen Group of America Inc, Case No. 2:23-cv-01171 in the U.S. District Court for the Central District of California.
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Source: topclassactions

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