Feds Overstepping the Constitution

[kootchman]

That is precisely what the article said…. methadone is being prescribed because it is cheap… dangers be damned. 173 overdose deaths is a lot. And the grouping is in less affluent, state funded medicare and state empolyee health programs. That was pretty unambiguous information. The Times did a very well researched report. I didn’t say ONLY… I quoted the article… and.. bty … because of the Times article… the state has amended it’s drug approval process. Your 1996 cocktail .. preceeded the last eight years where the state HAS pushed methadone because it costs 8 cents per dose.

quote from the article

For the past eight years Washington has steered people with state-subsidized health care — Medicaid patients, injured workers and state employees — to methadone, a narcotic with two notable characteristics. The drug is cheap. The drug is unpredictable.

Right left, moderate.. I can’t see where this gets a pass or an excuse…

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[waterworld]

Kootch: The Seattle Times investigative series on how and why the state pushed Medicaid providers to prescribe methadone for long-acting pain relief was indeed chilling. Clearly, the people making decisions about which drugs were on the preferred list did not understand the risks and some of them seem to have actively avoided understanding the risks.

I don’t think this is just a nanny-state issue, though, as you describe it. Insurance companies employ drug formularies to push doctors to prescribe less-expensive drugs that the insurance company has decided are sufficiently effective and less expensive. Most Americans, whether their health care is bought through private insurance or a government program, are likely to pushed by their insurance companies to medicines that cost less (while drug companies prowl the hospitals and clinics trying to get doctors to prescribe the latest and most expensive thing). Every so often, evidence emerges that, for instance, a generic substitute doesn’t work as well or has side-effects that the brand-name drug doesn’t or is downright dangerous. Sometimes evidence that a preferred drug is dangerous is ignored by both private and government entities until there’s enough pushback from physicians or pharmacists or patients — or class action litigation. My point is that both insurers and the government are pushing patients to less expensive alternatives.

Also, although I am no apologist for the state healthcare regulators, the Times stories omitted some important additional aspects of the methadone overdose issue. One is that over half of the overdose cases involved patients with other conditions who were using other medications that enormously increased the risks associated with using methadone. Another 20% involved illegal drugs on top of the methadone. Also, as the 2009 MMWR report explained, the risk of methadone overdose death was particularly great among a certain subset of Medicaid patients, namely those who were in the Patient Review and Coordination program, a special program for patients who have a demonstrated history of misusing opioids, doctor-shopping, and visiting the ER to obtain opioids.

The 2009 report listed several factors that could help explain the high rate of opioid-related deaths among Medicaid patients in Washington, including that Medicaid patients were prescribed opioids (of any kind) at twice the rate of people on private insurance, that their doses per prescription were higher, that there was a higher prevalence of substance abuse and mental illness in the Medicaid patient population, and that a high percentage of deaths occurred where there were other drugs in the patient’s system, whether legal or illegal. But the report did not single out methadone as an independent risk factor or as an opiate associated with greater risk of causing death. Rather, the report noted there was a lot more of it being prescribed, because it is cheap, and it was showing up more among drugs involved in overdose deaths, both nationally and in state reports. This CDC report obviously should have been taken seriously by state regulators, and it evidently was not. Even if it had been, though, it would not have necessarily led to removal of methadone from the preferred list. More likely, the state would have taken steps to curtail all opioid prescribing to Medicaid patients.

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[JoB]

kootch..

really dude. you place far to much reliance on the scandal of the moment…

i read your link. Then i read the link to the full article. Then i did a little research to see if there had been any substantial changes in the last 10-15 years that i had somehow missed.

methadone and other narcotic pain relievers and their efficacy and their risk is something i actually know a great deal about..

I served on the Oregon panel that looked at research based outcomes and drug interactions and side effects as a patient expert.

yup.. google me.. it’s likely somewhere in the back pages these days.. you know.. old news… i’ve done more interesting things since then… but that one really did impress my pharmacist son.

I learned a great deal about both research and stats from that work.

methadone prescribed accurately as a stand alone drug is actually incredibly reliable, safe, effective and cheap.

here is current long term data from London and Scotland about Methadone’s safety..

http://findings.org.uk/count/downloads/download.php?file=Strang_J_23.txt

and a current analysis of the causes of methadone toxicity in the US

http://www.medscape.com/viewarticle/743289

this is a medscape article..

written by people who actually know about medications

for people who understand medications

and it concludes… we have a dosing problem..

which btw the author of the Seattle Times article dismissed as some kind of justification when given that information ..

“”There’s not one thing that caused this,” Dr. Webster said when first presenting the results of his study. “There are multiple things that all add up.”

A chief reason, his team suggests, is that conversion tables — used by physicians to transition patients from one opioid to another — recommend too much methadone for most patients. For example, Dr. Webster pointed out, through 2006, the US Food and Drug Administration recommended a starting dose of 80 mg per day. That recommendation has since been changed to 30 mg a day.

“For most individuals, starting them at 80 mg per day, they would die,” Dr. Webster said.

“We used to regularly see doses of 40 or 60 mg,” Dr. Cruciani told Medscape Medical News. “This was when methadone was used primarily for addiction, but now that we use it for chronic pain we choose much higher doses.” “

most people i know who use methadone for pain control actually use much smaller does than 40 to 60mg…

but some doctors just plain aren’t well informed about the entire range of pain medications since they haven’t been prescribing them that long.

If you are on a chemical stew of medications

methadone might be a really bad risk for you

I would trust that your doctor knows what he is talking about when it comes to your care.

it’s a really really bad risk for me..

but i have to tell you that for the 3 days i was able to take minute doses before i had a toxicity reaction… it was incredibly effective at returning me to acceptable activity levels.

However, to label methadone a dangerous drug?

and infer that the state is using it to kill off poor people?

sorry Charlie

that simply doesn’t pass muster.

As we learn more about how to control chronic pain with narcotic medications

and as we educate chronic pain patients to reasonable expectations from their pain management

taking what makes you functional

instead of expecting to suddenly be pain free

deaths will decrease.

until then.. all narcotic pain medications currently available carry the risk of death from overdose…

and some of them carry some really nasty side effects at the dosages used to treat chronic pain

the upside of methadone’s slow clearance from the body is that because of the drug’s buildup in your system.. pain can be controlled on much smaller does than needed by narcotics that clear the system more quickly.

but you need to trust in the long term effectiveness of the drug and not take more.. more often.. to make it work faster

or expect it to render you totally pain free.

If you are experiencing chronic pain Kootch..

you really need to educate yourself better on this subject.

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[JoB]

waterworld..

thanks for adding stats from the CDC report..

i believe the biggest problem we have in medicine today is that everyone seems to think that no matter what the problem is.. there is a pill for that..

and.. we are forcing doctors to see more patients during their day which limits the time they have available to take the kind of histories that would alert them to possible risks..

slam bam thank you mam medicine increases the risk of fatal medication interactions..

especially in at risk populations who have histories of medication abuse.

no wonder we have a increased medication death rates

We need to insist that our doctors have time actually practice medicine instead of turning them into glorified pill and surgery pushers.

This is of course, my personal opinion..

but i have been consuming health care now for 60+ years and have seen the changes in what was once considered a healing art to what is now known as an industry.

We are much better for the science and the innovation it has produced. There are so many more options now to help us control conditions that killed our ancestors at very early ages…

but in my opinion, we are not better for insisting our health practitioners pay more attention to efficiency standards than to patients…

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[waterworld]

Job: Totally agree with both of those posts. The only thing I maybe take exception to is the idea that we can “trust our doctor” to know what he or she is talking about. As you pointed out, many doctors are not well-informed about the range of pain medications out there.

In my (admittedly somewhat limited) experience, the typical general practitioner does not know enough about prescribing opiates other than for very short courses of acute pain, or about managing chronic pain treatment. That probably contributes to the problem of patient overdosing, as well. As much as I disagree with the state’s new regulations on pain treatment, I believe that people with chronic pain issues are likely to get better treatment from pain specialists.

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[JoB]

waterworld..

i think you just told me something i didn’t know..

has the state regulated pain specialists for prescribing opiates for chronic pain?

if so. perhaps my insurance will finally pony up for one:)

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[kootchman]

Uh huh… and the reason for inappropriate dosage? Lack of consideration of the full patient history? And you think IPAB cutting the physician reimbursement rates 21% per cent will get you more face time with your primary care physician. It makes no difference what your physician knows or doesn’t know… if the state says you get methadone.. that’s what you get.

I said the state made a choice. The choice was to promote the active use of methadone. What a complete distortion you make JoB .. I said safety was compromised for cost.

The results were 173 deaths, highly concentrated in low income and state sponsored medical networks. I don’t really care if you see the correlations… frankly. In the face of evidence, you will dismiss the most obvious. I won’t be in that plan… and no one in my family who I am responsible for will be either.

There is a great pain management team at Valley Medical Center, and by gosh, I know this because my private insurance paid for the referral and I made the whopping co-pay of $25. My primary doc made the referral. The pain meds were selected for my best benefit.. not to save the state a few bucks. Nope.. I want nothing to do with government health care.

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[kootchman]

Best definition I have ever heard about government health care

“slam bam thank you mam medicine increases the risk of fatal medication interactions..” Slam bam medicine. I left the Swedish group here is WS… because the 15 minute miracle diagnosis and short consults were so flagrant I asked the doctor if he had a quota to fill … “yes” was the answer. Bye bye… I went to the Southlake Group… where I get better care, more attentive care, and I leave the office when I am satisfied… not when my doc thinks we are done.

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[JoB]

kootchman..

do you really think only medicare patients are subjected to shortened visits with their primary care doctors?

All i can do is shake my head.

The negotiation those insurance companies have done to limit their expense has caused medical practices to limit the time their doctors have with each patient to make up in volume what they lose on each individual patient.

As for your assurance that your pain meds were selected for your best benefit… I hope that’s true..

but when i was doing research we found that the pain meds selected for patients in any given practice could be more easily predicted by finding out which pharmaceutical reps regularly visited the clinic than by the patient’s medical diagnosis…

whoops…

but that should still please you..

another instance of that free market you love in action :)

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[waterworld]

JoB: Check out WAC 246-919-850 to 856. These are new regulations passed following the enactment of what is now RCW 18.57.285 (ignore the fact that it’s in the title that pertains to osteopaths). The professional associations of pain doctors opposed the regulations, even though they sort of agree with the intent. The rules apply equally to pain doctors and general practitioners, but the GPs are understandably freaking out about whether they will get in trouble for prescribing long-acting pain medications. As a result, doctors who aren’t pain specialists are dropping out of that area of practice in massive numbers. And the pain specialists, of which there are relatively few, are unable to take on all the new patients — there are just too many of them trying to transfer their care.

So while Kootch and others of us in urban areas may be perfectly happy with the available pain specialists, patients in rural markets are finding there’s nowhere to go.

This is separate, though, from the methadone issue. The statute was passed a couple years ago, and the regulations have been in the works ever since. But the timing is striking — right about when the Times published the stories about methadone prescribing, these new pain regulations went into effect. That just spooked the doctors even more.

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[JanS]

Swedish here in West Seattle has had a quota for years and years. I know of at least one physician who left that practice because of it. That was in the early 90’s. So it’s noting new. That’s Swedish, not Medicare.

I am now on Medicare, and I can attest to the fact that the docs I see take as much time as they need. I don’t feel rushed out the door at all. Maybe those who do simply need to change their PCP.

Of course, as always, this is my experience only. I’m sure it will be discounted by others on here.

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[redblack]

hospitals also employ pharmacists, you know. their job is to advise doctors on the available courses of medication for patients.

like waterworld said, though, rural areas and small towns may not have hospitals or physicians’ groups big enough to justify having a full-time pharmacist on the payroll. i’m guessing that that’s where most mistakes in prescriptions or dosages occur.

but prescribing medications – and correct dosages thereof – isn’t entirely the purview of MD’s, nor is it their job to keep up on all of the latest advances in pharmaceuticals. i imagine that it’s a full-time job just dealing with the pharma reps, which is why more and more medical organizations have pharmacists on the payroll.

where they can afford it, that is.

now, regarding IPAB, this board is doing exactly what congress used to do, kootch. medicare also has an actuary. and if ACA is repealed, there’s MedPAC, which is an advisory board to congress. they take information from the medicare actuary, crunch the budget numbers, and advise congress on where to cut spending, increase spending, or otherwise tweak medicare.

they’re usually ignored, because congress is too busy giving deference to lobbyists. this is how medicare gets screwed up.

IPAB seeks to take out about three middlemen, and it takes decisions about medicare’s budget away from congress, so that congress can spend more time doing what they do best:

tweeting pictures of their abs to constituents, having 3 martini lunches with lobbyists, hiding money in the cayman islands, and chasing secretaries and aides (of no particular gender) around their desks.

you’re seriously going to cry if power over mdeicare’s purse is taken away from those clowns and handed instead to a review board?

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[JoB]

waterworld…

so.. that explains why i got a prescription for way too many long acting pain control pills that came sized too small to cut up when i had surgery..

but am limited to 10 tylenol 3 at a time for serious breakout pain…

a quarter pill puts me out like a light for 10+ hours:)

LOL.. it’s not like i take 10 in a year..

but i have to tell you i find that pretty amusing.

so long story short.. still unlikely to get to the pain clinic

and doctors more afraid than ever to prescribe pain meds…

there is too much reactionary political stuff going on in medicine..

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[kootchman]

In a previous post, and in jury cases, there is the statistical value of life. The death of 35 year old in a negligent auto accident… is valued by potential future earnings (a 400K research scientist vs a Wal Mart greeter) and expected life span and is adjusted accordingly. The same would be true for life medical care.. part of the award will be expected life long care. Are you all ready to hear the federal government cap your healthcare at the statistical life valuation charts. Your average income and life expectancy being the determinants of your coverage?

redblack… that board is as likely to be as political as… say… The national labor relations board… the NLRB is so noted as the fair and impartial arbitrator it has become? Ha ha ha… sure. Wanna bet the NLRB (if it isn;t dissolved) looks a whole lot different under President Romney?

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[redblack]

so, kootch. will IPAB be any more political than congress and industry lobbyists controlling medicare spending?

and, yeah, i know the NLRB would look different under willard romney. which is why he won’t become president.

oops! you guys overreached.

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[JoB]

kootch…

it must be pretty comforting to assemble our argument

and then refute it

if the argument you assembled had any real basis in reality

it might even be informative

but it isn’t.

either accurate or informative

Sorry.. i am so not playing that game with you

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[kootchman]

Overstepping the constitutional is now reaching delusion. The Supreme Court has never weighed in pending congressional legislation before it has passed. It challenges nothing until there is a petitioner, in the case of Obamacare the majority of states have filed suit.. It’s job is singular. Is the law constitutional? A president berating the highest court in the land and accusing them of judicial activism if they overturn Obamacare? He better get his notes out from college days.

Man oh man! This is unprecedented. The 5th Circuit is on record … read this my liberal friends. This prez is so Nixonian it’s scary. Will they even recognize the constitution? The 5th Circuit is about to find out… imagine.. taking the DOJ down a peg..bout time. Of course the court is not elected, exactly as the founders wanted it.. Yoo hoo .. President Obama .. this is what comes out of Harvard these days? Thanks for the ammo Barry. No wonder DOJ wants no voter ID to accompany registration.

http://blogs.wsj.com/law/2012/04/03/dojs-homework-assignment-tell-fifth-circuit-whether-it-supports-judicial-review/?mod=google_news_blog

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[redblack]

The Supreme Court has never weighed in pending congressional legislation before it has passed.

and it still hasn’t. obamacare IS the law. it hasn’t taken full effect yet.

what is interesting, though, is the question of whether the mandate is considered a tax. taxes have never been challenged until after they have been collected. turns out that the petitioners may be jumping the gun on that one.

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[JanS]

re:post 192..have you seen the articles where other judges are saying the 5th circuit court judge is overstepping? What that particular judge did may not be enforceable..(but it does show his bias)..

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[kootchman]

Exactly redblack… the Supreme Court is following the government lead… they said it wasn’t a tax. The Democrats didn’t want to go on record as “raising taxes”… the same reason the Senate won’t submit a budget.. they don’t want to openly vote for Obama’s budgets.

Well this is not The Messiahs first foray into pretending he is omnipotent and above the constitution… remember the state of the union address last year? The court is telling them in no uncertain terms, you are 1/3 of a three part divided government. Back off. Protecting their turf. Right redblack… they neverhave weighed in.. and Obama shouldn’t be weighing in on a judicial review either. I cracked up though…. he can spin a BS story…”overwhelmingly passed congress”..it barely limped across the finish line as was so loaded with bribes and back door deals to get his own party to support “Blinky P”… who could pass it up.

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[redblack]

the same reason the Senate won’t submit a budget.. they don’t want to openly vote for Obama’s budgets.

you’re not getting away with that anymore, kootch.

i told you why the senate budget committee can’t and won’t pass a budget resolution.

and i have no problem with their rationale.

and i’m as american as you are.

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[redblack]

regarding ACA, you have no idea what you’re talking about.

i’m sorry to have to break it to you that way.

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[jamminj]

“If he governed like a republican… we wouldn’t have Obamacare.”

It’s because he tried to govern like a republican is why we are where we are at.

http://bit.ly/Hi2kGA

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[jamminj]

“this is what comes out of Harvard these days? “

you mean the same school Romney attended?

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[HMC Rich]

Orwellian control starting 2015.

http://www.infowars.com/mandatory-big-brother-black-boxes-in-all-new-cars-from-2015/

Why do these legislators always want to control people so much!!!

I think too many of our Presidents come from Harvard.

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