NORMAN J CLEMENT RPH., DDS, NORMAN L.CLEMENT PHARM-TECH, MALACHI F. MACKANDAL PHARMD, BELINDA BROWN-PARKER, IN THE SPIRIT OF JOSEPH SOLVO ESQ., IN THE SPIRIT OF REV. C.T. VIVIAN, JELANI ZIMBABWE CLEMENT, BS., MBA., IN THE SPIRIT OF THE HON. PATRICE LUMUMBA, IN THE SPIRIT OF ERLIN CLEMENT SR., WALTER F. WRENN III., MD., JULIE KILLINGWORTH, WILLIE GUINYARD BS., JOSEPH WEBSTER MD., MBA, BEVERLY C. PRINCE MD., FACS., RICHARD KAUL, MD., LEROY BAYLOR, JAY K. JOSHI MD., MBA, ADRIENNE EDMUNDSON, ESTER HYATT PH.D., WALTER L. SMITH BS., IN THE SPIRIT OF BRAHM FISHER ESQ., MICHELE ALEXANDER MD., CUDJOE WILDING BS, MARTIN NDJOU, BS., RPH., IN THE SPIRIT OF DEBRA LYNN SHEPHERD, BERES E. MUSCHETT, STRATEGIC ADVISORS
WALTER F. WRENN MD
Doctors in America (PHYSICIANS, PHARMACISTS, DENTISTS, NURSES PRACTITIONERS) are under assault. They have become victims of rules and regulations established by non-medical individuals.
These individuals have determined and established rules from how we bill insurance companies for our services to what prescriptions we can write for our patients.
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If we don’t spend a certain amount of time with our patients and bill under the wrong code we have committed insurance fraud and can be arrested, charged, and incarcerated.
If we see a person on a Monday but the bill for the services on Tuesday we again are guilty of insurance fraud and subject to punishment. With electronic records which we were forced to adopt we again can be found guilty of not spending the required minutes for a specific billing code because we exported the previous note.
The note had all the pertinent information but according to law enforcement, we didn’t spend the required amount of time with the patient. Insurance companies have been allowed to set fees based on those billing and procedure codes.
If a physician is to participate as a provider they must accept the fee that the insurance company is willing to pay.
They can’t bill the patient for the difference between what they charge for the visit and what the insurance company pays for the visit. Even with Medicare, a physician has to accept as payment what Medicare has established as their reimbursement rate.
They can however bill for the 20 percent not covered by Medicare. If a physician is unwilling to be governed by these rules they can’t participate in the Medicare or insurance program.
No profession or industry that I am aware of has these types of control.
In the early 2000s old problems that had been ignored in black neighborhoods began to be noticed in white neighborhoods. People were dying from opiate drug overdoses.
We now had an opiate epidemic and like most perceived crises we began to pass laws before we had any understanding of the problem. To this day the vast majority of individuals still don’t understand the problem.
In 1803 Morphine was synthesized from a plant. From then until now various formulations of opiates have been produced. During this same period using these medications to treat pain also evolved. Some felt you should use short-acting opiate pain medication.
Others felt you should use long-acting opiate pain medication and use short-acting opiate pain medication only for breakthrough pain. Then the unthinkable happened. Pharmaceutical companies and physicians were accused of fueling the opiate epidemic by overproducing and overprescribing opiate pain medication.
Both federal and state DOJ/DEA began to arrest, charge and convict health care providers who prescribed opiate pain medication. In 2016 the CDC issued guidelines for Primary Care Physicians who were starting opiate pain medication for the first time. In the guidelines, they mentioned that the dose should be between 50 and 90 Morphine Milligram Equivalents( MME’s).
The term MME was unfamiliar and not understood by most health care providers. After all, we prescribe medication in milligram doses, not MME’S. Even though the CDC indicated that these were guidelines and not rules or laws health care providers all over the United States were arrested charged and convicted of prescribing opiate pain medication that exceeded the 90 MME’S mentioned in the 2016 CDC guidelines.
In the April 24 2019 issue in the New England Journal of Medicine, the CDC published an article about the misapplication of their guidelines. In it, they clarified that they were guidelines. They said that these guidelines did not apply to patients on high doses of opiate pain medication or who had been on opiate pain medication for a long period of time.
They also warned about the harm done by rapid reduction of a patient’s dose or the abrupt cessation of opiate pain medication altogether. They further said that reduction of a patient’s opiate pain medication should only be done at the request of the patient. Why was this article necessary?
The CDC, AMA, and other medical organizations were alarmed at the damage being done to patients who became victims of this hysteria and misinterpretation of these guidelines.
In a Veterans Administration study in 2017, 67 percent of veterans who had their opiate pain medication stopped were found to have overdosed on illicit street drugs and died. Thirty-one percent alone were found to have committed suicide.
MASS INCARCERATION OF PHYSICIANS
While health care providers all around the country who prescribed opiate pain medication were getting arrested and having their medical license and DEA license seized.
Patients taking opiate pain medication couldn’t find a health care provider who would treat them. Insurance companies instituted roadblocks in the form of prior authorizations.
When a patient is taking opiate pain medication they take their last tablet on the day of their appointment or several days before their appointment. When they come to the doctor’s office it is closed. They can’t get their medication. They soon experience withdrawal symptoms go to the streets for relief, overdose, and die.
While these individuals are a large percentage of those who die from a drug overdose as are individuals who commit suicide are conveniently ignored by DOJ/DEA.
The other charge that accompanied the 90 MME charge was that the medication was not prescribed for a professional purpose and for a legitimate medical reason. This charge was present in 100 percent of all the cases against physicians.
Because the Controlled Substance Act says that health care providers can prescribe a controlled medication as long as it is for a professional purpose and for a legitimate medical reason.
The DOJ/DEA has without a license to practice medicine or explanation of what is a professional purpose and legitimate medical reason have brought these charges and secured convictions.
I mentioned in my opening statement that laws were passed and actions taken before the problem of opiate addiction was understood.
When an individual takes any medication, the medication goes somewhere in the body where it acts. It is then metabolized and eliminated from the body.
THE OPIOID SYSTEM
The same is true of opiate pain medication. In 1972 the first opiate receptor was discovered. This receptor is called the Mu receptor. Since then two other opiate receptors have been identified. They are Kappa, Sigma, and Delta receptors. These receptors are found in the brain and other parts of the body.
The Mu receptor is responsible for euphoria and most likely this euphoria leads to addiction. Fortunately, most people who take opiate pain medication don’t become addicted.
When an individual takes an opiate pain medication it attaches to the opiate receptors and relieves the individual of their pain. Depending on what we call the half-life, that is the amount of time the medication is actively performing its function, the medication leaves the receptor goes to the liver where it is metabolized and is eliminated in the urine.
The rate of metabolism differs from individual to individual. The first time an individual takes an opiate pain medication the liver is unfamiliar with it and metabolism and elimination are slow.
However, this process of metabolism speeds up over time and requires higher and more frequent dosing. A person taking opiate pain medication may experience withdrawal symptoms or cravings relieved only by taking more medication.
The action of heroin and other opiate synthetics such as fentanyl on the opiate receptors are the same as that of opiate pain medication.
I mentioned earlier that terms such as overprescribing and highly addictive have been used to target pharmaceutical companies and physicians.
a) Addiction is not dose-dependent.
b) An individual can become addicted to any dose of opiate pain medication.
Another misunderstanding concerning opiates and the addicted individual is that they continue to take the opiate because they want to get high. Euphoria or the so-called high is a one-time occurrence. The reason that the opiate-addicted individual continues to take the opiate is to prevent what is known in the streets as “dope sickness, ” we call that withdrawal.
The reason individuals who have been detoxified from opiates begin to take them again is because of cravings. Cravings are the reason relapse occurs and why opiate addiction should be classified as a chronic disease and treated as such.
For years the treatment for opiate addiction was methadone. Most individuals attending the methadone clinic are court-ordered. During the week you attend the clinic daily.
On the weekends you get your daily methadone dose to take home. Individuals attending methadone clinics call methadone ” liquid handcuffs “. In addition to coming daily for their methadone, they have to attend counseling 3 days a week.
The requirements that an individual has to attend counseling to me is another indication that we don’t understand opiate addiction.
c) You can’t counsel a receptor.
d)You can’t change how a receptor works.
e) You can’t cure opiate addiction.
Several years ago a new medication was introduced to treat opiate addiction. This medication was called Suboxone (buprenorphine/naloxone). Like methadone, it prevented withdrawal symptoms. Unlike methadone, the patient could be seen at a doctor’s office.
The patient could be given a prescription for Suboxone for 30 days. The patient self-medicates. While the medication was to be taken along with counseling it was apparent to those of us treating these patients that counseling should be voluntary not mandatory.
The biggest advantage Suboxone had over methadone is it didn’t make you high. Patients were able to return to work. Patients were able to return to school. In other words, patients were able to return to normal function. It is my opinion that unless a person is allergic to Suboxone, every opiate-addicted individual should be prescribed Suboxone.
There is now once-a-month injectable buprenorphine the opiate ingredient in Suboxone, called Sublocade. Individuals who are incarcerated for non-violent crimes committed to support their addiction should be released from jail to a treatment facility and be treated with Sublocade. At the proper dose, all symptoms of withdrawal and cravings are eliminated.
Just think about the benefits. No relapse and no crime. A decrease in overdose deaths. It would be ideal if we could detoxify an individual addicted to opiates, a process that takes a week.
The problem is that 98 percent relapse and resume using opiates. Like all chronic diseases lifetime treatment is needed. As is the case in all criminal cases, physicians of color are charged and convicted at a higher percentage than their white counterparts.
The black patients therefore also suffer at a higher percentage.
We need a congressional hearing to evaluate the Criminalization of physicians and the real effect it has on patients and the practice of medicine.
Walter F Wrenn III M.D.
FOR NOW, YOU ARE WITHIN