A HIPAA violation, a $1.8 million verdict, and three takeaways

http://www.pharmaciststeve.com/?p=10780

Second, a HIPAA violation may amount to malpractice. A violation can be as dangerous and as costly as a misfilled prescription. Under federal law, patients cannot directly sue under HIPAA. There is no “right of private action” by the law. HIPAA can, however, be evidence of the pharmacist’s standard of practice. A violation of HIPAA is negligence and may be used to establish duty. Violation of duty along, with an injury caused by that violation, may amount to malpractice…

Legally and ethically, a patient’s records may be used only for the benefit of the patient…

If this was really true, then the use of PDMP databases — freely accessed by law enforcement, other government agencies, and state medical boards — would be both illegal and unethical. Not that those two concerns make any difference to the DEA or state medical boards.

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Congress to VA: More Oversight Needed for Vets in Pain

http://www.medpagetoday.com/Washington-Watch/Washington-Watch/52086?xid=nl_mpt_DHE_2015-06-12&eun=g875301d0r

A subcommittee to the House Committee on Veteran Affairs questioned the Department of Veteran’s Affairs about the unrelenting tide of soldier suicides and mismanagement of opioid prescriptions at a hearing on Wednesday. Some representatives suggested the two crises might be intertwined.

“I’m concerned that a potentially deadly mix of opioid use, mental health disorders, and lack of oversight is contributing to our high rate of veteran suicide,” said ranking member Ann McLane Kuster (D-N.H.).

In her opening statement, she cited the Centers for Disease Control and Prevention’s description of opioid abuse as “the worst drug addiction epidemic in the country’s history.” Yet, half a million veterans are taking the potent medications to manage serious pain problems, she said.

You can use statistics like this, that half a million veterans are taking opioids, but that doesn’t even begin to identify the problem.  In fact, when you break down these statistics, it may very well show that chronic pain is being under-treated and mistreated, with weak medications and drugs like mood stabilizers. Everyone can keep blaming opiates for addiction and suicides, but as long as the blame is being misplaced, nothing will get better.  And how come nobody addresses the high rates of alcohol abuse in this patient population?

Have there been cases where opioids were the only cause of an overdose or suicide?  If so, I haven’t read about it.  But I have read about veterans who have committed suicide because their pain medications were reduced or taken away — to be replaced with nothing.

A recent report from the Government Accountability Office questioned the VA’s efforts both to address veterans’ mental health problems and to properly oversee prescriptions. The report noted that the VA doesn’t have an accurate count of the number of veterans with depression because of “inappropriate coding.”

-VA data may “understate prevalence of major depressive disorder” in veterans treated at VA centers
-VA centers neglected to use standard assessment tools within 4 to 6 weeks of beginning antidepressants, VA’s own clinical practice guidelines (CPGs)
-VA reports of clinical and demographic data related to veterans’ suicides were flawed

With regard to opioid abuse, the Department of Veterans Affairs said it is helping to combat overuse of prescription drugs. Since the implementation of an opioid abuse prevention program 2 years ago, 100,000 fewer patients have been receiving opioids and another 34,000 fewer patients were given opioids and benzodiazepines together — because of known drug interactions. Another 75,000 patients were asked to take urine tests to ensure that veterans are using the drugs and not “diverting” or selling them.

You take away the drugs that work, and you don’t expect the suicide rates to increase?  Why? And how many drug test results were inaccurate?  How many veterans were abandoned because of this?

In trying to rein in one problem the VA may have created another. Rep. Beto O’Rourke (D-Texas) said that because of new policies aimed at reducing prescription abuse, some veterans’ prescriptions were cut off without notice and without the kind of tapering that patients taking such powerfully addictive drugs require.

You can correctly taper patients off these drugs, but then what kind of treatments can successfully replace them?  Surgery or acupuncture?  They’re not addressing the complete picture of treating chronic pain and are only concerned about addiction.

Other veterans, who must visit their doctors monthly in order to refill their prescriptions — another safety provision — aren’t able to get appointments, he said…  “So they go without or they go with something that they shouldn’t have that perhaps they buy on the street,” O’Rourke said. “At minimum they’re suffering, and in some cases I would connect that suffering to the suicides that we see in El Paso,” he added.

Lack of access to mental health care exacerbates this problem, said O’Rourke, who noted a 24% vacancy rate in mental health providers at veteran centers in El Paso, where mental health services for veterans are ranked 157 out of 158.

Tim Walz ( D-Minn.) reminded the VA that some of the questions plaguing the agency were answered by the Military Pain Care Act of 2008, which he helped author. Walz asked Carolyn Clancy, MD, interim undersecretary for Health at the Department of Veterans Affairs, why a bill designed 7 years ago to target the same issues in pain managment was never fully implemented. The bill expired 8 months ago. Three months ago, Walz sent a letter and still hasn’t received a response. “This might not have been the fix, but why didn’t we do it?… Why hasn’t it been done?”

Congress doesn’t follow up on implementation or the letters they write, and then allows a bill to expire — so where does the blame fall?

(2014) Musculoskeletal Pain Relief With Stem Cell Injections

http://www.medscape.com/viewarticle/832501

The evidence on the therapy’s efficacy is inconclusive, and the patient-reported levels of improvement typically fall short of a slam-dunk, but their reports of pain relief of at least 50% are relatively consistent — and in the challenging realm of chronic pain treatment, that’s getting somewhere, said Harry Adelson, ND, medical director of Docere Clinics in Park City, Utah.

“To put this into perspective, arthroscopic surgery has been shown to be no better than placebo or conservative medical treatment for arthritis of the knee,” he told Medscape Medical News, “while autologous MSC therapy shows significant benefit 3 years out from treatment.” …

The therapy is based on the potential healing capabilities of MSCs, which contain growth factors and signalling proteins that can instigate the regeneration of damaged tissue, Dr. Adelson explained.

“We’re taking stem cells from where they live and injecting them to where the problem is and then stepping back and letting nature take its course, allowing the body’s natural healing cascade to occur.”

The stem cells can be harvested and concentrated or isolated from bone marrow or fat, respectively, to be reinjected directly into damaged or degenerated tissues.

The therapy is most commonly used to treat such conditions as degenerative disc disease, desiccated discs, spinal stenosis (both central and foraminal), facet arthrosis, sacroiliac joint syndrome, osteoarthritis of any joint, and sports/overuse injuries, Dr. Adelson said.

While Dr. Adelson said he has seen “not a single serious adverse outcome” among the approximately 2000 patients he’s treated, he advised warning patients who undergo bone marrow aspiration from the posterior superior iliac spine not to lie on a hard floor or to do sit ups on a hard floor for at least 2 weeks to avoid formation of a painful spur.

Tricky statistics used against chronic pain patients

http://www.pharmaciststeve.com/?p=10774

Pharmacist Steve says:

Isn’t it amazing how LARGE NUMBERS makes things sound BAD…  but when you break down the numbers, the picture is much different:

259 million Rxs…  Let’s presume that 25% are for acute or intermittent pain. Leaving 195 million Rxs for chronic pain patients. Proper protocol for treating chronic pain is one long acting and one short acting for breakthru. Then most people will get a 30 days supply at a time. That means that about 8 million chronic pain pts could get proper pain management using these numbers. There is a estimated 106 million chronic pain patients…  So this GROSS NUMBER OF 259 million would suggest that <10% of chronic pain patients get proper pain management therapy with oral opiates. So the epidemic… would seem to be a PANDEMIC of DENIAL OF CARE for chronic pain patients.

HHS Secretary: 259 Million Opioid Prescriptions in U.S. in 2012 Outnumbered American Adults

Burwell offered three solutions to the problem of opioid overdose. The first solution, she said, is prescribing. Burwell proposed providing new prescribing guidelines for pain and pain medication and the use of “prescription drug monitoring plans,” which exist in almost all 50 states…

http://consumer.healthday.com/encyclopedia/aging-1/misc-aging-news-10/pain-control-at-the-end-of-life-643650.html

More than half of patients with terminal cancer, for example, suffer from poorly managed pain, according to a report in the American Journal of Hospice and Palliative Care…

For people suffering from severe cancer pain, for example, hospice providers often advise caregivers to give them pain medication at safe, regular intervals to prevent “breakthrough” pain — sudden bouts of relentless, uncontrolled pain. If you wait until the patient asks for pain medication, he or she may already be suffering, and the pain will be harder to get under control…

But when pain gets tough, doctors need to move to the third step on the ladder and prescribe the most effective drugs in their arsenal. That means opioid drugs such as morphine. “Opioids are really essential,” Dahl says, especially for patients with cancer pain. Opioids can also be effective for treating the pain from damaged nerves — doctors call it “neuropathic” pain — that’s often associated with diabetes or other diseases that attack the nervous system, she says…

You need to have cancer or be knocking on death’s door to deserve adequate pain treatment.

What DEA agents do when they retire

http://www.pharmaciststeve.com/?p=10765

In one of the schemes, Whittington posed as a lawyer, and Herrera, who was a real former special agent with the U.S. Drug Enforcement Administration, posed as an FBI agent, prosecutors said. Whittington and Herrera promised the victim they could help him recover losses in fraudulent schemes related to two companies, Pacific Property Assets and Medical Capital Corporation. They claimed they could seize assets from the fraudulent firms if the victim first posted bonds that were purportedly required prior to seizing the assets, prosecutors said.
Whittington told the victim he had obtained a $4 million judgment, and was paid $290,000, some of which he split with Herrera and some of which he used to fund other fraud schemes, according to prosecutors.

In a separate scheme, Whittington allegedly posed as a former federal prosecutor and Herrera as an FBI investigator and offered to help with a victim’s wife’s immigration case. The men were allegedly paid $8,500 for help they never provided.

Whittington was indicted last year for allegedly posing as an attorney and fleecing two victims out of about $165,000 for investments in a phony real estate deal and tech company…