Pentagon Declares War on Poppy Seeds

By Pat Anson, PNN Editor

The U.S. Department of Defense is escalating its war against opioids beyond just oxycodone, hydrocodone and other pain medications.

In a February 17 memo, a top Pentagon official warned all military service members that eating foods containing poppy seeds could result in a failed drug test.

“Recent data suggests poppy seeds varieties may have higher codeine contamination than previously reported. Consumption of poppy seed products could cause a codeine positive urinalysis result and undermine the Department’s ability to identify illicit drug use. Out of an abundance of caution, I find protecting Service members and the integrity of the drug testing program requires a warning to avoid poppy seeds,” wrote Gilbert Cisneros, Jr., the Undersecretary of Defense for Personnel and Readiness.

Cisneros did not specific what the “recent data” was or where it came from. Tiny black seeds from the poppy plant – most of which come from Afghanistan -- can become contaminated during harvesting with trace amounts of codeine, morphine and other opiates. Drug users have found they can then use unwashed seeds to make a potent homemade tea to relieve pain.

Given how widely used washed poppy seeds are in muffins, cookies, salad dressings and cosmetics, the threat posed by them may sound rather comical. But some organizations take it very seriously.

The Center for Science in the Public Interest (CSPI) has petitioned the Food and Drug Administration to set a safe threshold for opiate alkaloids in imported poppy seeds, citing a study that claimed 19 people in the U.S. suffered fatal overdoses after ingesting poppy seeds in recent years.

“The time is overdue for the FDA to establish standards that will protect U.S. consumers from ingesting dangerous levels of opiates through the food supply,” said Peter Lurie, MD, President of CSPI.  

In 2019, the Drug Enforcement Administration even classified unwashed poppy seeds as a Schedule II controlled substance, claiming they were “qualitatively similar” to opioid pain medications.

“Unwashed poppy seeds are a danger to the user and their abuse may result in unpredictable outcomes including death,” the DEA said.

Eating poppy seeds could be risky for someone taking a drug test.  A 2020 study found that consuming just few seeds in a muffin or bagel could result in a positive drug test – a finding that could get a patient dismissed by their doctor or an employer refusing to hire a job applicant.

The Pentagon may also be trying to save money with its new directive. Simple urine drug screens performed in a doctor’s office are relatively cheap – and often wrong. False positive results should be confirmed with a mass spectrometry test performed in a laboratory, but those tests usually cost thousands of dollars.  It’s cheaper to just tell military personnel to stop eating bagels.

“The Military Departments are hereby directed to notify Service members to avoid consumption of all poppy seeds to include food products and baked goods containing poppy seeds. Service members are directed to work with their local legal office for any related concerns with urinalysis results,” Cisneros wrote in his memo.

The Pentagon and Department of Veterans Affairs (VA) have long taken a dim view of opioids. In recently updated medical guidelines, the agencies recommend that opioid medications not be used to manage non-cancer chronic pain.   

Limiting Supply of Rx Opioids Fails to Achieve Goals

By Pat Anson, PNN Editor

Limiting initial prescriptions for opioid pain medication to 5-days’ supply did not reduce the rate at which patients in New Jersey transitioned to long-term opioid use, according to a new study at Rutgers University.

In 2017, New Jersey became one of the first states in the country to impose a mandatory 5-day limit on initial opioid prescriptions for acute pain. If a patient needed more, their doctor would have to write a new prescription, enroll them in a pain management program, and counsel them on the risks of opioid addiction.

At least 38 other states adopted similar laws, with the goal of reducing opioid diversion, misuse and overdose. Six years later, there is little evidence that New Jersey’s 5-day limit saved lives or accomplished any of its goals.

“This policy’s apparent failure to achieve its goals illustrates the extreme difficulty of solving healthcare problems by dictating physician behavior,” said senior author Stephen Crystal, PhD, director of the Rutgers Center for Health Services Research.

Crystal and his colleagues analyzed pharmacy data for over 130,000 New Jersey Medicaid patients who were prescribed opioids for the first time between 2014 to 2019. Their findings, recently published in the Journal of General Internal Medicine, show that new opioid prescriptions fell at a monthly rate of less than one percent (0.76%) after the 5-day limit was imposed, a decline that was about half the monthly rate (1.62%) prescriptions were falling before the limit took effect.

Doctors were writing fewer prescriptions for opioids in New Jersey and other states long before limits on the supply were even passed. Opioid prescriptions nationally are now at their lowest level in over 20 years.

“Opioid prescribing was already decreasing before this policy went into effect,” said lead author Peter Treitler, a research project manager at the Rutgers Institute for Health, Health Care Policy and Aging Research. “And so, by the time this New Jersey policy went into effect, it really didn’t change prescribing practices very much, at least in the New Jersey Medicaid population.”

An earlier study by the Rutgers research team found that medically treated overdoses in the Medicaid population tripled in New Jersey after the 5-day limit was imposed. Most of the overdoses involved illicit fentanyl and other street drugs, not prescription opioids.

Less than a third of New Jersey’s overdose survivors were even diagnosed with a chronic pain condition, suggesting the state’s focus on limiting pain medication was misdirected. Most people who overdose suffer from substance abuse disorder, depression or other mental health issues. And most overdoses involve illicit fentanyl and other street drugs, not prescribed medication.

In 2022, there were nearly 2,900 drug deaths in New Jersey – about 30% more than the number that overdosed in 2016, the year before the state’s 5-day limit became law.  

New VA Guideline: Opioids Should Not Be Used for Chronic Pain

By Pat Anson, PNN Editor

The U.S. Department of Defense (DoD) and Department of Veterans Affairs (VA) have doubled down on a guideline first released in 2017 that strongly recommends against the use of opioids for chronic pain.

In an updated clinical practice guideline, the agencies continue to recommend that opioids not be used to manage chronic non-cancer pain, especially in younger patients, and that long-acting opioids not be used to treat patients with short-term, acute pain.

The VA/DoD guideline will potentially affect millions of service members, veterans and their families. Nearly 1.5 million Americans serve in the armed forces and over 800,000 in the National Guard and Reserves. The Veterans Administration provides health services to another 6 million veterans and their families.

The updated guideline was quietly released in May 2022, but is only drawing attention now in a mostly favorable review published in the Annals of Internal Medicine.

“Compared with the 2017 recommendation against initiation of long-term opioid therapy, the updated recommendation against opioid therapy in general for chronic pain is broader and reflects the evidence that opioid therapy for any duration may be harmful,” wrote lead author James Sall, PhD, Director of VA’s Office of Evidence-Based Practice.

“Ultimately, despite finding some evidence for a small improvement in musculoskeletal and noncancer neuropathic pain, the guideline development group maintained that the potential for catastrophic harms of opioids and serious adverse events, especially with long-term use, outweighed any potential benefits of temporarily improved pain severity and functional status in patients with chronic pain.”

‘Potentially Transformative’ for U.S. Healthcare

The updated opioid guideline has 20 recommendations, nine of which are based on weak or inconclusive evidence. Unlike the recently revised CDC opioid guideline, there were no public hearings or opportunities for the public to comment or provide input. There is also no discussion of dose thresholds or morphine milligram equivalents (MME), suggesting the authors believe that any dose of opioids is potentially risky.

Three new recommendations in the new VA/DoD guideline involve opioid tapering, mental health evaluations, and the use of buprenorphine to treat pain.

The guideline urges doctors to consider using buprenorphine instead of full agonist opioids for patients needing opioids daily for chronic pain. Although the quality of the evidence for this recommendation was deemed “insufficient,” the VA/DoD believe buprenorphine as a partial agonist has less risk for overdose and misuse, and is less likely to cause euphoria.

Buprenorphine is a Schedule III opioid that is FDA approved for pain when used alone. Buprenorphine is also used to treat opioid use disorder when combined with naloxone in drugs like Suboxone. The DEA recently eliminated the “X-Waiver” program for buprenorphine, which is likely to significantly increase the number of doctors that prescribe it and the number of patients that receive it.

An editorial published in the Annals of Internal Medicine called the recommendation that buprenorphine be used for pain “potentially transformative” and "likely to expand into the greater U.S. healthcare system."

"The updated VA/DoD guideline is both conservative and radical," wrote co-authors Chinazo Cunningham, MD, and Joanna Starrels, MD, both from Albert Einstein College of Medicine. "Although the VA/DoD guideline recommends that buprenorphine be prescribed for chronic pain if daily opioids are prescribed, the recommendation itself is likely to change decision-making about whether opioids should be prescribed."

Although several recent studies have found that opioid tapering significantly raises the risk of an overdose, withdrawal or mental health crisis, the VA/DoD guideline found there is “insufficient evidence to recommend for or against any specific tapering strategies.” It only recommends that doctors and patients “collaborate” on reducing opioid doses and that tapering not be forced.

“The potential benefits of opioid tapering outweighed the potential harms of opioid withdrawal,” the guideline claims.

Before opioids are prescribed for either acute or chronic pain, the guideline recommends that the mental health of patients be evaluated for depression, anxiety, psychotic disorders and suicide. Although some patients may resent being screened for mental health problems, the guideline says “it is better for providers to know about underlying behavioral health comorbidities than to initiate long-term opioids without this clinical knowledge.”

The revised guideline reaffirms previous recommendations that benzodiazepines not be co-prescribed with opioids and that patients on long-term opioid therapy be regularly screened with urine drug tests “to decrease the risk of self-directed violence.”

Opioid prescribing to veterans, family members and those on active duty has declined significantly in recent years, as it has for the rest of the population. The revised VA/DoD guideline notes – without a hint of irony – that reduced prescribing has led to an increased use of illicit opioids by veterans and higher overdose rates.

Opioid Tapering Disrupts Healthcare and Worsens Doctor-Patient Relationships

By Pat Anson, PNN Editor

Tapering patients on long-term opioid therapy results in more emergency department visits and hospitalizations, according to a large new study that found reduced opioid use was particularly disruptive to the healthcare of pain patients with diabetes and high blood pressure.

The study by researchers at University of California Davis is the latest to document the “unintended negative consequences” of policies that limit opioid prescribing. A previous study by the same research team found that tapering raises the risk of an overdose and mental health crisis.

In their latest study, UC Davis researchers analyzed health data for over 113,000 patients who were on opioid therapy for at least 12 months, comparing those who were not tapered to those who had their dose reduced by 15% or more.

Their findings, published in JAMA Network Open, showed that tapering significantly increased hospitalizations and ED visits, while at the same time reducing the number of primary care (PC) visits. Researchers think the latter is at least partially due to “ruptures in relationships” with primary care providers (PCPs) due to patient dissatisfaction with tapering.

Opioid tapering was also associated with a significant reduction in patients taking medication for hypertension or diabetes – even though their blood pressure and blood sugar levels rose when their opioid doses were reduced.

“Tapering may be associated with reduced medication adherence due to an increased patient focus on managing pain and psychological distress due to the taper, disruption in PC due to more frequent ED visits and hospitalizations, or fracture of the PCP-patient relationship,” wrote lead author Elizabeth Magnan, MD, a family medicine physician at UC Davis Medical Center.

“Although cautious interpretation is warranted, these outcomes may represent unintended negative consequences of opioid tapering in patients who were prescribed previously stable doses.” 

Opioid prescribing has fallen dramatically in the U.S. over the past decade, particularly after the release of the CDC’s 2016 opioid guideline. Although millions of patients were affected by the guideline’s recommendations, few efforts were made at the federal level to see what happened to patients who had their opioid doses reduced or even stopped.

A recent study found the number of cancer patients seeking treatment for pain in emergency departments has doubled. Of the 35 million ED visits made by cancer patients, over half were deemed preventable – meaning the visits could have been avoided if the patient has received proper care earlier.

Mexican Pharmacies Sell Counterfeit Drugs to U.S. Tourists

By Pat Anson, PNN Editor

With opioid pain medication increasingly harder to obtain in the United States, a growing number of Americans are heading south of the border to get painkillers and other prescription drugs in Mexico.  That’s a risky activity, according to UCLA researchers, who found it was fairly common for Mexican pharmacies to sell counterfeit medication to unsuspecting tourists.

The researchers visited 40 pharmacies in Northern Mexico and purchased samples of oxycodone, hydrocodone, Xanax and Adderall, most of which were obtained without a prescription. Immunoassay testing strips were then used to check each pill for the presence of fentanyls, benzodiazepines, amphetamines and methamphetamines.

Eleven of the 40 pharmacies were found to be selling counterfeit drugs. Of the 27 “oxycodone” tablets purchased, 11 were made with either illicit fentanyl or heroin. One pill sold as “Vicodin” only contained lactose and the weaker opioid tramadol.

Nine of the 11 “Adderall” pills contained methamphetamine, while none of the Xanax pills were found to be counterfeit.  

The study findings were first reported online in medRxiv, a website that publishes new medical research before it is peer-reviewed.

FAKE OXYCODONE PILLS

“It is not possible to distinguish counterfeit medications based on appearance, because authentic and counterfeit versions are often sold in close geographic proximity and are visually and otherwise indistinguishable from one another. Nevertheless, US tourists may be more trusting of controlled substances purchased directly from pharmacies,” the UCLA researchers said, noting that overdoses are poorly monitored in Mexico, making it difficult to know how many people have died from taking counterfeit pills.

Researchers say the growing trade in counterfeit drugs – both north and south of the border – is due in part to a decade-long crackdown on prescription opioids. Since 2010, opioid prescriptions in the U.S. have fallen by nearly 50 percent.

“These decreases have been shown to have affected many patients with known painful chronic conditions, including terminal cancer, and other palliative care patients. Many patients have been rapidly tapered off opioid regimens, which has been associated with increased rates of suicide and drug overdose. A large unmet demand for diverted and legitimate prescription opioids has led to widespread consumption of counterfeit opioids in the US by witting and unwitting consumers,” researchers said.

One such case involves Jessica Fujimaki, a 42-year-old intractable pain patient, who lost access to opioids after the DEA suspended her doctor’s license to prescribe controlled substances last November. Desperate for relief and going into withdrawal, Fujimaki and her husband made two trips to Mexico from their home in Arizona to buy opioids, but were uncertain of the quality of drugs they purchased. She died in December.   

‘These Are Really Strong!’

Perhaps the most widely available counterfeit drug is “Mexican Oxy” – small blue pills that are designed to look like 30mg oxycodone pills. One of the UCLA researchers asked for oxycodone when he visited a Mexican pharmacy:

“We head into the pharmacy and ask for Oxy. The pharmacy employee flashes us a smile and says ‘I have Mexican Oxy or I have American Oxy. American Oxy is 35$ for 20mg, and Mexican Oxy is 20$ for 30mg.’

‘Why is the Mexican Oxy stronger and cheaper?’ I ask.

‘Oh the Mexican oxy is very strong, but it’s cheaper because they give it to us for cheaper,’ he says. ‘You should only take half, and even that’s going to be a lot. The full one might be too dangerous.’

I say, ‘Okay, we’ll take the Mexican Oxy.’ He goes under the counter and pulls out a cardboard box full of syringes. He reaches underneath the needles, and pulls up this false bottom on the box, and the bottom is full of these little blue pills, just loose in the box.

He takes one out of the pile and puts it in a little plastic bag for us. As he hands it to me. He’s says, ‘Okay guys, these are really strong! Please be careful.’”

When that “Mexican Oxy” pill was analyzed later, it tested positive for fentanyl.  

Two reporters for the Los Angeles Times recently found how easy it is to get counterfeit medication in Mexico when they visited pharmacies in Tijuana, Cabo San Lucas and several other northwestern cities. The reporters found that 71% of the 17 pills they purchased were fake. The “oxycodone” and “hydrocodone” pills tested positive for fentanyl, while pills sold as “Adderall” tested positive for methamphetamine.

Asked to comment on the Times investigation, the U.S. State Department, DEA and the White House Office of National Drug Control Policy failed to respond to repeated inquiries. Local and national government agencies in Mexico also ignored requests for comment.

Most of the drug experts interviewed by the Times said they’d never before heard of pharmacies selling counterfeit pills.

“I haven’t seen anything like that,” said Cecilia Farfán-Mendez, a researcher at UC San Diego’s Center of U.S.-Mexican Studies. “I think it speaks to the lack of law enforcement monitoring what’s happening in the pharmacies.”

Most Antidepressants Ineffective for Chronic Pain

By Pat Anson, PNN Editor

Most of the antidepressant drugs that are prescribed for chronic pain are either ineffective or the evidence supporting their use as pain relievers is weak, according to a new analysis published in The British Medical Journal (BMJ).

The use of antidepressants such as duloxetine (Cymbalta) and fluoxetine (Prozac) has doubled in recent years, with much of the increase due to their off-label prescribing to treat conditions such as fibromyalgia, neuropathy and back pain.

But in a review of 26 studies on the analgesic effects of antidepressants, Australian researchers found little evidence to support their use in pain management. The data on side effects was also weak, meaning the safety of antidepressants was also uncertain. Nearly half of the studies had ties or funding from the pharmaceutical industry.

“Recommending a list of antidepressants without careful consideration of the evidence for each of those antidepressants for different pain conditions may mislead clinicians and patients into thinking that all antidepressants have the same effectiveness for pain conditions. We showed that is not the case,” said lead author Giovanni Ferreira, PhD, from The Institute for Musculoskeletal Health at the University of Sydney.

“Some antidepressants were efficacious for some pain conditions; however, efficacy appears to depend on the condition and class of antidepressant. The findings suggest that a more nuanced approach is needed when prescribing antidepressants for pain.”

Ferreira and his colleagues say no study provided high quality evidence on the effectiveness of antidepressants for any pain condition. 

But they did find moderate quality evidence supporting the use of serotonin-norepinephrine reuptake inhibitors (SNRIs) for back pain, postoperative pain, fibromyalgia and neuropathic pain. Low-quality evidence suggested that SNRIs could be used for pain linked to breast cancer treatment, depression, knee osteoarthritis, and pain related to other underlying conditions.

The researchers say only low-quality evidence supports the use of selective serotonin reuptake inhibitors (SSRIs) for depression and pain related to other conditions; and tricyclic antidepressants (TCAs) as a treatment for irritable bowel syndrome, neuropathic pain, and chronic tension-type headaches. 

Antidepressants ‘Disappointing’ for Most Pain Patients

An accompanying editorial, also published in The BMJ, said the study adds to growing evidence that many medications prescribed for pain – not just antidepressants – are only modestly effective.

“Their findings suggest that for most adults living with chronic pain, antidepressant treatment will be disappointing. This is important given emerging concerns about increases in the prescribing of antidepressants and the challenges patients describe when trying to withdraw from treatment,” wrote Cathy Stannard, MD, UK National Health Service, and Colin Wilkinson, a pain patient and consultant at Centre for Pain Research, University of Bath.

“Clinicians continue to prescribe medicines for which the evidence is poor because they observe that some people respond to them, albeit modestly. But all medicines carry risk of harm and there are other, less potentially harmful options more likely to help people to live well with pain.”

Stannard and Wilkinson said exercise and physical activity might be better options than medication for some patients.

Ironically, a little over a year ago, the UK’s National Institute for Health and Care Excellence (NICE) released new guidelines that recommend antidepressants for adults with chronic primary pain, even when they are not depressed. NICE said antidepressants may help with quality of life, pain, sleep and psychological distress.

The NICE guideline is at odds with other studies that found antidepressants are minimally effective for back pain and osteoarthritis and often have adverse side effects. A common complaint of patients who take Cymbalta, for example, is how quickly they became dependent on the drug and have severe withdrawal symptoms when they stop taking it.

Medical Cannabis Reduced Opioid Use in High Dose Patients

By Pat Anson, PNN Editor

In recent years, there have been several studies and surveys – most of them anecdotal -- suggesting that cannabis reduces the need for opioid pain medication. A large new study takes that research a step further, finding direct evidence that chronic pain patients, including those on high doses, significantly reduced their opioid use once they started using medical cannabis.

Researchers with the New York State Department of Health and University of Albany School of Public Health followed over 8,100 patients on long-term opioid therapy (LOT) after they began using medical cannabis. All of the patients had been on opioids for at least 120 days, including some on relatively high daily doses of 90 or more morphine milligram equivalents (MME).

Researchers found that average daily doses declined significantly over time, especially for patients on high opioid doses. After eight months of using medical cannabis (MC), patients taking over 90 MME saw their daily doses fall by nearly 70 percent, compared to a 29% reduction in those getting 50 to 90 MME and a 15% reduction in those on 50 MME or less.

“This cohort study found that receiving MC for longer was associated with opioid dosage reductions. The reductions were larger among individuals who were prescribed higher dosages of opioids at baseline. These findings contribute robust evidence for clinicians regarding the potential benefits of MC in reducing the opioid burden for patients receiving LOT and possibly reduce their risk for overdose,” researchers reported in JAMA Network Open.

The study has some weaknesses. Researchers did not track the pain levels of patients or the types of pain conditions they suffered from. Also unknown is the dose or types of cannabis products they consumed.   

Although the study was conducted at a time when patients nationwide were losing access to opioids or having their doses reduced, researchers say it is “highly unlikely” that impacted their findings because the dosage decline for their patients didn’t begin until they started consuming cannabis.  

Marijuana advocates cheered the study findings.  

“The relationship between cannabis and opioid use is among of the best-documented aspects of marijuana policy,” Paul Armentano, Deputy Director of NORML, said in a statement. “In short, the science demonstrates that marijuana is a relatively safe and effective pain reliever — and that patients with legal access to it consistently reduce their use of prescription opioid medications.” 

A similar study of over 500 chronic pain patients being treated at medical cannabis clinics found a significant decline in their pain levels. And 85% of patients reported they either reduced or stopped using opioids.

DEA Lifts Limits on Buprenorphine Use

By Pat Anson, PNN Editor

After years of strict limits on the number of patients that a provider can treat with buprenorphine, it’s suddenly a lot easier to prescribe the drug for opioid use disorder (OUD). The Drug Enforcement Administration has eliminated the “X-Waiver” program for buprenorphine, a move required by Congress under the 2023 Appropriations Act.  

Elimination of the X-Waiver removes all patient caps and significantly increases the number of providers that can treat OUD with buprenorphine, a long-acting opioid similar to methadone. When combined with naloxone, an overdose prevention drug, buprenorphine reduces opioid cravings and eases withdrawal. Prescriptions for Suboxone and other buprenorphine/naloxone combinations now only require a provider to get a standard DEA registration for controlled substances.

“DEA fully supports this significant policy reform. ln this moment, when the United States is suffering tens of thousands of opioid-related drug poisoning deaths every year, the DEA 's top priority is doing everything in our power to save lives. Medication for opioid use disorder helps those who are fighting to overcome opioid use disorder by sustaining recovery and preventing overdoses,” DEA Administrator Anne Milgram wrote in a January 12 letter to providers.

The DEA is also developing a new mandatory eight-hour training program for providers to help them identify and treat OUD when they apply for or renew their registrations. The new training will be required on June 21.

“I think this is overdue. Buprenorphine can reduce the risks of overdose by 60% and is much safer than methadone,” says Lynn Webster, MD, an expert in pain management who is a Senior Fellow at the Center for U.S. Policy. “It would be controversial, but I believe low-dose buprenorphine should be OTC as a harm reduction measure. At least there should be a discussion about the potential benefit vs risk.”

Pressure to Prescribe

It remains to be seen how the elimination of the X-Waiver will affect pain patients. Over the years, we’ve heard complaints from patients who say they were coerced by their doctors into taking Suboxone, even though it’s not approved as a treatment for pain. With patient caps removed and more doctors able to prescribe buprenorphine, there could be added pressure on pain patients to take Suboxone – whether they show signs of OUD or not.

“I understand the pressure to use buprenorphine for pain rather than traditional opioids. It is a much safer opioid than most, so it should be considered as a first line therapy,” says Webster. “However, that is the rub. It is not effective or tolerated in many patients.  Patients have a legitimate concern that they may be coerced to transition to buprenorphine when their existing medications are working and there are no signs of abuse.     

“I don't think the change in regulations will mean more doctors will push their patients to use buprenorphine, because the mind-set is already there.” 

A little-known aspect of buprenorphine is that it blocks other opioids from working – meaning anyone who is taking it should be aware that if they have acute pain from an accident, trauma or surgery, they’ll have to rely on non-opioid pain relievers.  

While often touted as the most effective medication for OUD, most people who take buprenorphine relapse and starting taking opioids again. About two-thirds of the patients who receive Suboxone stop filling prescriptions for it after just three months. 

Although it’s difficult to get high on buprenorphine, it can still be misused. A 2021 study found the misuse rate for buprenorphine was over two times higher than misuse rates for hydrocodone, oxycodone and other opioid pain medications.

Doctor Convicted of Illegal Opioid Prescribing Imprisoned Before Sentencing

By Pat Anson, PNN Editor

A Louisiana doctor who federal prosecutors labeled as a "drug dealer in a white coat" has been taken into custody, weeks before he was scheduled to be sentenced for improperly prescribing opioid pain medication.

A jury found Randy Lamartiniere guilty last month on 20 counts of illegally distributing controlled substances outside the usual course of a medical practice. The 64-year old doctor was out on bail and scheduled for sentencing on March 30, but prosecutors wanted him taken into custody immediately after his conviction. A judge denied their motion, pending another court hearing on Tuesday, January 17.

“Needless to say this hearing is about as scary as it gets as I may or may not be taken into custody then. Kind of impossible to prepare for being incarcerated for 5-10 years in this situation,” Lamartiniere posted on his Facebook account prior to the hearing.

“There is no justification for pre-sentencing incarceration of course. I have an excellent chance of an appeal and a new trial and am hoping to stay out of prison altogether. Could use some support and kind thoughts at this extremely trying time. I’m more anxious about this than prior to my trial.”

Lamartiniere’s fears were justified, as the judge reversed his previous decision and had him taken into custody. According to Lamartiniere’s sister, he is now in a crowded holding cell with 18 other men, awaiting transfer to another facility.

Dr. Randy Lamartiniere

Lamartiniere faces up to 400 years in prison when he’s sentenced in March – 20 years for each count – but is likely to get less under federal sentencing guidelines. It’s also possible he could be freed on bail again, pending his appeal.

Lamartiniere’s legal troubles date back several years. The Louisiana State Board of Medical Examiners issued an emergency order in 2015 suspending his license to prescribe opioids and other controlled substances. Despite the suspension, Lamartiniere kept writing “medically unnecessary prescriptions,” according to prosecutors, charging patients $100 to $300 per visit and taking payments only in cash. Baton Rouge police arrested him in 2016, but legal delays prevented his trial until last year.

As he awaited trial, Lamartiniere became active in the pain community, giving advice and encouragement to patients unable to find good pain care. Beau Brindley, Lamartiniere’s defense attorney, told jurors during closing arguments that he prescribed drugs in “good faith” to people he believed were in real pain.

“Taking the patient at face value is not a crime,” Brindley said, according to The Advocate. “He was an old-school doctor trying to manage patients in a new age world. … He was trying, and trying makes him not guilty. There is no way to prove that he was not making an honest effort.”

That “honest effort” will form the basis of Lamartiniere’s appeal, which is based in part on a recent U.S. Supreme Court decision in favor of two doctors who were also convicted of overprescribing opioids. Writing for the majority in that case, Justice Stephen Breyer said it was up to prosecutors to prove that doctors “knowingly or intentionally acted in an unauthorized manner" under the Controlled Substance Act.

So far the high court’s decision has had a mixed impact on other doctors in similar situations. Earlier this month, Dr. Lesley Pompy was acquitted by a Michigan jury of charges that he illegally distributed opioids and committed health care fraud. The charges stemmed from an investigation of Pompy that began in 2016.

More recently, the DEA suspended the license of Dr. David Bockoff, a California physician who was treating patients with severe pain conditions who required high-dose opioids. At least three people have died as a result of that suspension. Bockoff is currently appealing the DEA’s suspension.

Emergency Room Visits Soar for Cancer Patients Needing Pain Relief

By Pat Anson, PNN Editor

The number of cancer patients seeking treatment for pain in U.S. emergency departments has doubled in recent years, according to a large new study that further documents the harm caused to patients by misguided efforts to reduce opioid prescribing.

The study, conducted by a team of cancer researchers, looked at health data from 2012 to 2019 for millions of patients who had a cancer diagnosis and were not in remission.  Of the 35 million visits made to an emergency department (ED) by those patients, over half were deemed preventable – meaning the visits could have been avoided if the patient has received proper care earlier.

By a wide margin, pain was the most likely reason for a preventable ED visit. The number of cancer patients who went to an ED for poorly controlled pain rose from nearly 1.2 million in 2012 to 2.4 million in 2019. About a quarter of them had pain so severe they were admitted.  

“Consistent with previous studies, we found that pain was the most common presenting symptom (36.9%) in ED visits among patients with cancer and that the number of patients with cancer who visited an ED because of pain more than doubled over the study period,” lead author Amir Alishahi Tabriz, MD, a research scientist at the Moffitt Cancer Center in Florida, reported in JAMA Network Open.

“A possible explanation could be the unintended consequences of the efforts within the past decade to decrease overall opioid administration in response to the opioid epidemic.”

“I am not at all surprised by their result, as they are consistent with what I’m hearing from colleagues across the U.S.,” says Chad Kollas, MD, a palliative care physician and longtime critic of the 2016 CDC opioid guideline, which discouraged the prescribing of opioids for pain.

The CDC guideline was only intended for primary care physicians treating non-cancer pain, but it was quickly adopted throughout the U.S. healthcare system, including the field of oncology. Previous studies have documented how opioid prescriptions and doses declined for cancer patients, with the Cancer Action Network warning in 2019 that there has been “a significant increase in cancer patients and survivors being unable to access their opioid prescriptions.”

One of the most egregious cases involved April Doyle, a California woman with Stage 4 terminal breast cancer.  In 2019, Doyle posted a tearful video online after a pharmacist refused to fill her opioid prescription. She died about a year later, after the cancer metastasized into her lungs, spine and hip. 

“Unfortunately, the systematic misapplication of the 2016 Guideline created harms for patients due to reduced access to pain care and increased risk of suicide after nonconsensual or excessively rapid opioid tapers. These harms are predictable features of policy changes based on misguided calls for unfocused reductions in opioid prescribing,” Kollas told PNN.

Even if a cancer patient goes to an emergency room for pain relief, the odds of them — or any other patient — getting an opioid is dwindling. A new study by the National Center for Health Statistics found that the percentage of ED visits that ended with an opioid prescribed at discharge fell from 21.5% in 2010 to just 8.1% in 2020.

‘I Blame the CDC’

After years of complaints and bureaucratic delays, the CDC finally revised its opioid guideline in 2022 to more explicitly exclude patients undergoing cancer treatment, palliative care and end-of-life care. But many cancer patients felt it was too little, too late.

“My Mother had stage 4 terminal lung cancer. She was in horrible bone pain and her cancer doctor told her to take Tylenol for pain. We made several trips to the ER in the middle of the night just to manage her pain,” one woman told us. “She could not even enjoy her last moments on this earth with her family because of horrible cancer pain. As it spread all over, I could not help her. I am a nurse who watched her die miserably and I blame the CDC.”

“I live with stage 4 cancer and can't get any pain medication. I can't get any doctors to help me treat my pain,” another nurse told PNN. “My experience helps me understand why people become suicidal because they can't live with the pain anymore.”

“Stop making doctors afraid to treat pain adequately! I need a higher strength opioid for my chronic pain and my doctor will not up my strength because of that fear,” said another patient. “My husband has Stage 4 cancer and they refuse to up his strength as well. This is a crime against humanity!”

“Over the past decade, there has been a seismic shift in prescribing practices and sharp declines in access to these medications for patients with cancer.”

— Dr. Andrea Enzinger, Harvard Medical School

In another large study that looked at racial and ethnic disparities in the treatment of Medicare patients with advanced cancer, researchers saw a steady decline in opioid prescriptions and a rapid expansion in urine drug testing from 2007 to 2019. Their findings, published in the Journal of Clinical Oncology, show that less than a third of late-stage cancer patients received an opioid for pain control in 2019 and only 9.4% received a long-acting opioid near the end of life.

Black and Hispanic cancer patients were less likely to receive opioids than their White counterparts. They were also more likely to get smaller doses than White patients.

"Over the past decade, there has been a seismic shift in prescribing practices and sharp declines in access to these medications for patients with cancer,” said lead author Andrea Enzinger, MD, a gastrointestinal oncologist and assistant professor at Harvard Medical School. “Our findings are startling because everyone should agree that cancer patients should have equal access to pain relief at the end of life."

The Real Hoax About Prescription Opioids

By Barby Ingle, PNN Columnist

How many have to die? How many have to be denied? How many have to suffer unnecessarily?

Those are some of the questions I’m asking after reading a recent article in The Guardian about the CDC’s revised opioid guideline. The article has a few misstatements about prescription opioids that I have issues with. 

Before I share my take, I want readers to know that I do not take opioid medications myself. I have taken them in the past, but found other treatments that were more effective, so I stopped taking opioids in 2009. I also have an allergy to OxyContin, which I discovered after a knee surgery.

In 2018, I underwent pharmacogenomic testing, which I highly recommend for anyone who has chronic physical conditions. It has given me the best precision care available. I still live with multiple chronic pain and rare diseases, and will need treatment for the rest of my life.

You may be aware that I recently stepped down as president and a board member of the International Pain Foundation (iPain). It was a completely volunteer position. I have been advocating through many nonprofits since 2006 and have always been transparent about any funding that the charity or I received. I also have a degree from George Mason University in Psychology.

Which brings me back to the claims about addiction, opioids and patient advocacy that Dr. Andrew Kolodny, president of Physicians for Responsible Opioid Prescribing (PROP), made in The Guardian article. This quote is from Kolodny about patient suicides:

“This is a really serious issue. But what the opioid advocates, many with industry ties, disclosed or undisclosed, pushed was this false narrative about an epidemic of suicide and so there was a manufactured backlash against the CDC guidelines.

“The notion that there are patients losing access to an effective treatment, and therefore they have no choice but to kill themselves because they’re in so much pain now, that’s a hoax. But the idea that someone in the context of acute withdrawal would kill themselves, that certainly could be real because it’s so excruciating.”

From the perspective of a pain patient and a former nonprofit board member, I want to set the record straight about Kolodny’s alleged “hoax.” Yes, addiction is a serious issue. Under-treatment of chronic pain is also a serious issue. Any mistreatment of people with chronic care challenges is an issue.

The healthcare system in the U.S. is working as it was designed and needs to be thrown out. We are all individuals and should be treated by the providers of our choosing to get the care that we need — not as the healthcare system dictates. Not every provider is great, not every patient is great, and no treatment works for everyone. 

In America, we live in a “free” society. I believe we should be able to choose our own care and moral stance. But I wonder why Kolodny believes his moral stance should supersede what a provider and patient feel is best, whether it’s addiction treatment, pain management or any particular choice of care.

We should have full access to whatever we are willing to do to our own bodies. I have said many times over the years that I do not want to be a guinea pig anymore. I work hard to manage my pain levels, my surroundings, my energy pennies, and the people around me.

‘Advocates With Industry Ties’

Kolodny claims that many “opioid advocates” have industry ties and manufactured a false narrative about patient suicides in a backlash against the CDC guideline.

As a patient advocate who has been working with nonprofits for almost 20 years, I believe that the pharmaceutical industry should be giving money to the pain community to help us with tools and resources that make our lives better.

People think it’s easy for advocacy groups to get funding from Pharma, but that is not true, at least for the small funding that I was involved with. I know firsthand the many checks and balances that are needed before any grant money is provided. It did not matter if it was $100 or $10,000. Nonprofits have to account for it on their tax returns and through audits.

Since 2015, grant money from Pharma for iPain completely stopped, even the small amounts that we were getting. We went from completing over 200 grant applications a year, and getting less than 5 percent of them approved, down to a 0% success rate. There is nothing to report when you receive nothing, which is how it is going now for most patient advocacy organizations and support groups.

Receiving nothing from Pharma did not change our opinions or goals. We found other ways to accomplish them on a shoestring budget. I wish it was easier, but being hard does not stop the movement, because it is a matter of life or death in too many cases. Our work at iPain continued, because it was never about spreading whatever Pharma wanted. It was always about helping patients get individualized care. And all options, including opioids, should be on the table.  

Our work continued on a smaller scale and more creatively than if we had a large budget to get things done. At about the same time that our funding dried up, social media took off and it became easier to reach more people and actually be heard. We were still able to accomplish our goals, at less cost and with less funding.

I do not have the time, energy or space in this column to go into the many financial ties — disclosed and undisclosed — that Kolodny and PROP have with law firms involved in opioid litigation, which funded their efforts to take opioids away from patients. Good God, what is the point of him being so moral in his own eyes, that he does not let other people choose what is best for them?  

Patients losing access to treatment is real. So are patients dying or contemplating suicide. I receive emails and calls from them regularly, even since stepping down from iPain.

The first patient I lost due to being cut off from medication was in 2012. She was one of my best friends at the time. I talked to her often. She was on a medication that was helping. The provider cut her off and put her on a different drug. Neither were opioids. She was stable and doing well with the first medication, but not on the second one. My friend decided that jumping out of a 10-story window to her death would be better than not having the medication that was giving her more quality of life.

Kolodny says someone in acute withdrawal might kill themselves because it is so excruciating. Yes, Dr. Kolodny, withdrawal is hard and you are forcing it on people who are already in pain, who did not need or ask for your opinion. That is the real hoax.

Barby Ingle is a reality TV personality living with multiple rare and chronic diseases. She is a chronic pain educator, patient advocate, motivational speaker, and best-selling author on pain topics. Barby has received over 25 awards for her advocacy efforts over the years. You can follow her at www.barbyingle.com 

DEA Warns About Fentanyl As It Draws Criticism for Crackdown on Doctors

By Pat Anson, PNN Editor

The Drug Enforcement Administration has issued another public warning about the growing risk of counterfeit opioids and other medications made with illicit fentanyl. Over two-thirds of the drug deaths in the U.S. involve synthetic opioids like fentanyl, which is 50 to 100 times more potent that morphine.

Last year the DEA seized over 50 million counterfeit pills laced with fentanyl and more than 10,000 pounds of fentanyl powder. The seizures represent more than 379 million potentially deadly doses of fentanyl, according to the DEA, enough to kill every man, woman and child in the United States.

Over 56,000 American deaths last year involved fentanyl, nearly the number that died in the Vietnam War, and the crisis appears to be escalating. In 2021, a DEA laboratory analysis estimated that 4 out of 10 counterfeit pills laced with fentanyl contained a potentially lethal dose. The DEA now estimates that six out of ten fake pills contain a deadly dose of fentanyl. Just two milligrams of fentanyl, enough to fit on the tip of a pencil, is considered a potentially lethal dose.

“More than half of the fentanyl-laced fake prescription pills being trafficked in communities across the country now contain a potentially deadly dose of fentanyl. This marks a dramatic increase – from four out of ten to six out of ten – in the number of pills that can kill,” DEA Administrator Anne Milgram said in a public safety alert. “Never take a pill that wasn’t prescribed directly to you. Never take a pill from a friend. Never take a pill bought on social media. Just one pill is dangerous and one pill can kill.”

In an effort to bring more public attention to the fentanyl crisis, the DEA launched its One Pill Can Kill campaign, which highlights the similarities between real medications like oxycodone and alprazolam and their fake counterparts. The counterfeit pills are mass produced by drug traffickers in the U.S. and Mexico, using chemicals largely sourced from China.

Backlash Against DEA

As the DEA grapples with the fentanyl crisis, it’s coming under growing criticism about its efforts to reduce the supply of legal prescription opioids. Recent articles in USA Today, The New York Times, Los Angeles Times and VICE News – many based on stories that first appeared on PNN – suggest that the mainstream media is slowly coming to recognize the harm caused to pain patients by the DEA’s enforcement actions against doctors who prescribe opioids.

“Law enforcement agencies, especially the Drug Enforcement Administration, are out of control, with the DEA routinely caught releasing ‘safety plans’ for the patients of arrested physicians that simply direct pain patients to the nearest emergency room,” wrote Peter Pischke, a disabled freelance journalist, in a USA Today op/ed.

“American medicine and law enforcement continue to fight the last war. Policymakers still operate under the assumption that too many opioids are being prescribed. Overdose deaths — including those among adolescents — are now overwhelmingly caused by street fentanyl, not prescription medications,” Maia Szalavitz wrote in The New York Times.

The backlash against the DEA produced a backlash of its own in Newsweek, in an op/ed by a former deputy chief of staff at the DEA. Rather than doing fewer enforcement actions against doctors, Jim Crotty believes there should be more.

“With the U.S. drug crisis reaching unprecedented levels, and many opioid use disorders starting with prescription drugs, now is not the time to increase their availability,” wrote Crotty, who said the recent deaths of patients who lost access to opioids when their doctor’s license was suspended do not justify a change in DEA policy.

“These isolated incidents, however tragic, should not be used to upend otherwise sound drug policies designed to protect the American public from drug addiction and abuse,” said Crotty. “The U.S. is making slow but steady progress in rolling back the opioid crisis, but there is much work to be done. The threat of prescription opioids still looms large and requires continued vigilance from DEA and its partners to protect Americans' health and safety. We should be asking them to do more, not less.”

Crotty said over 13,000 Americans have died from overdoses involving prescription opioids in the last 12 months – a fraction of the number dying from fentanyl -- and repeated the old saw about the U.S. being “the world's largest consumer of prescription opioids.” That may have been true a decade ago, but no longer is. The U.S. now ranks 8th in per capita opioid consumption, behind Canada, Australia and several European countries

Letters to Doctors Reduced Their Opioid Prescribing for a Year

By Pat Anson, PNN Editor

Many doctors in the U.S. have scaled back or stopped prescribing opioid pain medication because they fear scrutiny or even imprisonment by the DEA and other law enforcement agencies.

A team of USC researchers believes there’s a better way to address risky opioid prescribing: have coroners and medical examiners notify all doctors by letter when a patient dies from an overdose.  

“This is not meant to be a law enforcement exercise but a simple nudge. The point is not to scare, blame or shame doctors, but to make them aware of real risks in their patient cohorts, risks they may not be aware of otherwise,” says Jason Doctor, PhD, Professor and Chair of Health Policy and Management at USC’s Sol Price School of Public Policy.

Doctor and his colleagues found that when 809 prescribers received a letter from San Diego county’s medical examiner notifying them about the overdose death of a patient, they reduced the doses of opioid prescriptions they wrote for up to a year afterward. Their findings, published in JAMA Network Open, builds upon a previous study that found the same clinicians reduced their prescribing for three months after receiving such a letter.

"Clinicians don't necessarily know a patient they prescribed opioids to has suffered a fatal overdose," said Doctor. “We knew closing this information loop immediately reduced opioid prescriptions. Our latest study shows that change in prescribing behavior seems to stick."

Nationwide, opioid prescribing has fallen dramatically over the past decade. But USC researchers found the reduction was faster and more extensive among clinicians who received the letter. After one year, their prescriptions were 7.1% lower in morphine milligram equivalent units (MME) than clinicians who hadn't received the letter. The number of new patients they prescribed opioids to also fell by two percent.

"The new study shows this change is not just a temporary blip and then clinicians went back to their previous prescribing," said Doctor. "This low-cost intervention has a long-lasting impact."

Other Drugs Often Involved

There are three major caveats to the USC study. The first is that other substances besides prescription opioids – such as illicit drugs -- were involved in many of the overdose deaths. That’s because the criteria for the study were broad and subjective, including any patient who died when "prescription drug overdose was the primary cause or contributed to the cause of death."

Second, clinicians were included in the study if they had written any opioid prescription within 12 months of the patient’s death. That would explain why 809 prescribers received letters about the overdoses of 166 patients. Doctors received a letter even if a patient was no longer under their care and without conclusive evidence that the prescription they wrote was involved in the death.

Third, the study does not address the growing number of deaths caused by illicit fentanyl, which is now responsible for the vast majority of U.S. overdoses. Letters to doctors are unlikely to have any major effect on overdoses involving street drugs. A 2022 study confirmed there is very little correlation between overdoses, prescription opioids and MME dosage levels.

There have been several previous efforts to rein in opioid prescribing by sending warning letters to doctors. Federal prosecutors in Wisconsin and other states have done it, telling high-dose prescribers they could face prosecution, even when they have not been charged with a crime or linked to an overdose.

The Medical Board of California’s “Death Certificate Project” sent threatening letters to doctors about overdoses that occurred months or years after an opioid prescription was written -- an effort that some likened to a “witch hunt.” Some doctors were targeted even when multiple drugs were involved or the cause of death was suicide.

USC’s Doctor says a gentler “nudge” is needed, not threats. And he wishes the letters sent to San Diego doctors were mandatory statewide.

“That was a terrible approach to delivering letters that the medical board carried out,” Doctor wrote in an email. “We had none of the outcry or problems the (board) did because we were supportive and met clinicians on a professional level.”

A Third of Chronic Pain Sufferers Used Cannabis for Pain Relief

By Pat Anson, PNN Editor

Nearly a third of U.S. adults (31%) with chronic pain have used cannabis as an analgesic, according to a new survey that found over half of those who used cannabis said it enabled them to decrease their use of opioid medication and other pain therapies.

The survey findings, published JAMA Network Open, involved 1,724 people with chronic non-cancer pain who live in the 36 states (and Washington DC) that have legalized medical marijuana.

Unlike other studies that only focused on cannabis reducing opioid use, this survey found that over half of pain sufferers using cannabis also reduced or stop using non-opioid prescription pain relievers and over-the-counter analgesics. Many respondents also reported decreasing their use of physical therapy (39%), cognitive behavioral therapy (26%) and meditation (19%).  

“Most persons who used cannabis as a treatment for chronic pain reported substituting cannabis in place of other pain medications including prescription opioids,” wrote lead author Mark Bicket, MD, an Assistant Professor in the Department of Anesthesiology, University of Michigan School of Medicine.

“The high degree of substitution of cannabis with both opioid and nonopioid treatment emphasizes the importance of research to clarify the effectiveness and potential adverse consequences of cannabis for chronic pain. Our results suggest that state cannabis laws have enabled access to cannabis as an analgesic treatment despite knowledge gaps in use as a medical treatment for pain.”

The survey did not ask whether respondents smoked, vaped or ingested cannabis products, so there’s no way to tell which method was more effective at reducing pain. Nevertheless, it adds to a growing body of evidence that cannabis reduces pain and helps pain sufferers decrease their use of medications and other therapies.  

“Cannabis has established efficacy in the treatment of multiple conditions, including chronic pain, and it possesses a safety profile that is either comparable or superior to other controlled substances,” said Paul Armentano, Deputy Director of NORML, a marijuana advocacy group.

“So it is no wonder that those with legal access to it are substituting cannabis in lieu of other, potentially less effective and more harmful substances. As legal access continues to expand, one would expect the cannabis substitution effect to grow even more pronounced in the future.”

Several previous studies have also found that cannabis users often reduce their use of prescription opioids. A large survey conducted last year found that most medical marijuana users either stopped (42%) or reduced (37%) their use of opioids. A small number were also able to stop using psychiatric medications for anxiety, depression and PTSD.  

Another recent study at Cornell University found that legalization of recreational marijuana in 11 states led to significantly reduced prescribing for Medicaid patients for a broad range of medications used to treat pain, depression, anxiety, seizures and other health conditions.

A 2021 Harris Poll found that twice as many Americans are using cannabis or CBD to manage their pain than opioids.

Judge Won’t Stop DEA Despite Patient Deaths

By Pat Anson, PNN Editor

A federal judge in California has refused to grant a temporary restraining order that would have allowed Dr. David Bockoff to resume prescribing opioid medication to hundreds of pain patients at his practice in Beverly Hills. 

The Drug Enforcement Administration suspended Bockoff’s license to prescribe controlled substances on November 1, claiming five of his patients were in “imminent danger” because he prescribed high doses of opioids and kept inadequate medical records. Since the DEA’s suspension, however, at least two of Bockoff’s patients have died -- not because of his medical care, but from the lack of it.

Danny Elliott and his wife were so distraught over his inability to find another doctor and get opioid treatment that they both committed suicide on November 7.  Four weeks later, Jessica Fujimaki died at her home, apparently from complications caused by pain and opioid withdrawal. Both Elliott and Fujimaki had incurable conditions that cause severe pain and needed high dose opioids to have any quality of life.

Despite those deaths and the threat posed to other sick patients who can’t find new providers, Judge Stanley Blumenfeld, Jr. sided with the DEA, saying the “potential impact” on Bockoff’s patients was outweighed by the DEA’s concerns about his record keeping.

“The need for careful evaluation, monitoring, and control in these circumstances is obvious; and the combination of high dosages and the lack of documentation justifying those dosages and demonstrating proper evaluation and oversight is troubling,” Blumenfeld wrote in his 7-page ruling.

“As for the public interest, the Court is certainly concerned about the potential impact on vulnerable patients who need treatment to manage their pain. This concern, however, must be evaluated in the context of a case in which the DEA is asserting abusive prescription practices and its decision is entitled to deferential review.”

Bockoff has practiced medicine for over 50 years in California without any prior record of disciplinary action or complaints. The DEA provided no evidence that any of Bockoff’s patients – including the five said to be in “imminent danger” – were harmed while under his care.

One of the five – who is only identified in court records as “EC” – has lived with severe pancreatic pain for over 15 years. Bockoff gave her prescriptions for methadone and fentanyl, a potent synthetic opioid. In its emergency suspension order, the DEA said that use of fentanyl was “not consistent with FDA approved use,” and put EC at higher risk for addiction, overdose and death.

However, in an email provided to the judge, EC said she needed high doses of fentanyl to be able to work and eat food.

“I have exacerbated pain anytime I smell food, eat food, digest food, or sometimes just randomly,” EC wrote. “This pain medication allows me to practice law and serve as a prominent traumatic brain injury litigator and managing attorney for the largest personal injury law firm in California.

“I am able to rise to this level of practice because Dr. Bockoff counsels me on how to manage my pain and prescribes medication for me that allows me to manage my pain so I can be a contributing member of society.”

Judge Blumenfeld dismissed the email, essentially saying that EC’s medical records were more important than her ability to eat and work.

“While proper pain management can have significant benefits, E.C’s email does not fully address the allegations that she was prescribed controlled substances without proper medical evaluation, monitoring, and documentation,” the judge wrote.

‘More Deaths Could Be Imminent’

Several other patients – whose full names were redacted -- also provided testimonials about their care under Bockoff.

“I want to say I appreciate Dr. David Bockoff as the rarest of physicians that actually cares about my health and well-being,” MC wrote in a letter. “If I no longer could receive my pain medication from Dr. Bockoff I would not be able to walk, do house chores, continue part time consulting work, go to school, drive, not be able to get out of bed or walk even in the house.”

“I suffer from a great deal of pain and without medication my life would be awful. I would not be able to move, stand or do any of the activities that I do perform,” said SH. “Dr. Bockoff has helped me tremendously and I need his service in order to have some quality of life.”

“Dr. Bockoff’s practice is already filled with patients who are in a dangerous medical predicament, with no medicine. As more patients run out of their last month’s medication, more deaths could be imminent,” warned DL.

Judge Blumenfeld rejected those claims as well, saying Bockoff’s attorney, Ashli Summer McKeivier, provided no evidence that Bockoff’s medical practice faced “irreparable harm” from to his suspension or that the DEA erred in suspending his license.  

“Plaintiff has not responded by producing substantial evidence to refute claims that he has been improperly dispensing high dosages of the controlled substances at issue,” Blumenfeld wrote. “Nor has Plaintiff shown that there are no other available providers able to properly treat patients who can no longer receive a prescription from him.”

“I’m very disappointed in the judge’s ruling,” McKeivier told PNN.

Munzing Testimony

Much of the government’s case against Bockoff is dependent on the opinions of Dr. Timothy Munzing, a family practice physician who has created a lucrative second career for himself by working as a consultant for the DEA and DOJ. According to GovTribe, a website that tracks federal contracts, Munzing has made over $3.4 million in the last 8 years working for the government and testifying in dozens of cases against doctors.

“Dr. Munzing will testify that Dr. Bockoff’s patient care fell below the standard of care in California and the prescriptions resulting from several examinations were not for a legitimate medical purpose,” the DEA said in court documents. Munzing was not called to testify before Judge Blumenfeld.

McKeivier says the DEA failed to prove there was any “imminent danger” or harm done to Bockoff’s patients, even though Munzing reviewed three years of his medical records.

“The government made an argument that basically disproved itself,” she said. “If you’ve got 3 years of records and in those 3 years of records you cannot point to one example of death, overdose, bodily injury or diversion, then that disproves the fact that any of the danger based on those things is imminent. If for three years you have a track record of it never happening, then how can it be imminent to happen now?”  

Bockoff is pursuing another legal avenue by appealing his suspension to a DEA Administrative Law Judge, who will begin hearings in Washington DC on January 19. That hearing process is expected to take nine days. A final decision on the suspension could be weeks or months after that.