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NORMAN J CLEMENT RPH., DDS, NORMAN L. CLEMENT PHARM-TECH, MALACHI F. MACKANDAL PHARMD, BELINDA BROWN-PARKER, IN THE SPIRIT OF JOSEPH SOLVO ESQ., INC., SPIRIT OF REV. IN THE SPIRIT OF WALTER R. CLEMENT BS., MS, MBA. HARVEY JENKINS, MD, PH.D., IN THE SPIRIT OF C.T. VIVIAN, JELANI ZIMBABWE CLEMENT, BS., M.B.A., IN THE SPIRIT OF THE HON. PATRICE LUMUMBA, IN THE SPIRIT OF ERLIN CLEMENT SR., EVELYN J. CLEMENT, WALTER F. WRENN III., MD., JULIE KILLINGSWORTH, RENEE BLARE, RPH, DR. TERENCE SASAKI, MD LESLY POMPY MD., CHRISTOPHER RUSSO, MD., NANCY SEEFELDT, WILLIE GUINYARD BS., JOSEPH WEBSTER MD., MBA, BEVERLY C. PRINCE MD., FACS., NEIL ARNAND, MD., RICHARD KAUL, MD., IN THE SPIRIT OF LEROY BAYLOR, JAY K. JOSHI MD., MBA, AISHA GARDNER, ADRIENNE EDMUNDSON, ESTER HYATT PH.D., WALTER L. SMITH BS., IN THE SPIRIT OF BRAHM FISHER ESQ., MICHELE ALEXANDER MD., CUDJOE WILDING BS, MARTIN NJOKU, BS., RPH., IN THE SPIRIT OF DEBRA LYNN SHEPHERD, BERES E. MUSCHETT, STRATEGIC ADVISORS

understanding The Voice of Conscience in Nazi Germany

In the heart of the Third Reich, a small group of university students and their professor mounted one of the most courageous acts of intellectual opposition to the Nazi regime. Known as the White Rose, they authored and distributed a series of leaflets that called upon the German people to awaken their conscience and resist the tyranny of National Socialism. 

THE SEVEN LEAFLETS OF THE WHITE ROSE

For those of you who are entirely unfamiliar with the story of the White Rose, one of the best ways to get a feel for their heroism is to read what they wrote.

The first four leaflets (Leaflets of the White Rose) were written between March 1942 and July 1942. The authors were Hans Scholl and Alexander Schmorell, though it is possible that Sophie Scholl and Christoph Probst contributed to the texts. Their voices seem to echo on the pages. We also know that one of Hans Scholl’s discussion with Traute Lafrenz was memorialized in leaflet IV.

LEAFLET-1

In Leaflet 1, they seek to conjure up images of Goethe and the glorious Germany of days gone by to up the consciences of those living under National Socialism. Failure to act will result in destruction – and shame.

LEAFLET-2

In Leaflet 2, they poke fun at Hitler’s bad German and delineate the crimes that Germans are committing in the name of National Socialism.

LEAFLET-3

In Leaflet 3, they develop the arguments for claiming that National Socialism is an evil regime. Probably the most famous of the first four leaflets, this is the one in which they clearly define what passive resistance looks like – what the man on the street can sabotage to bring the war machine to its knees.

LEAFLET-4

In Leaflet 4, they narrowed the appeal to target devout Lutherans (pietists like Magdalena Scholl) and religious Catholics. Instead of quoting Goethe, Schiller, Aristotle, or Lao-Tse as in earlier leaflets, they concentrated on King Solomon’s Proverbs (from the Bible) and Novalis’ strong Catholic imagery. This leaflet is most remembered for its assurance that they were not in the pay of a foreign power, and even more so for its ending: We are your bad conscience…

LEAFLET-5

Leaflet 5 appeared after a six-month silence. Hans, Alex, and Sophie had taken counsel of more experienced “propaganda” writers by this time – specifically Falk Harnack. This leaflet – Call to All Germans! – demonstrates greater maturity. It is not nearly as verbose or poetic; as a result, it delivers a far more powerful punch. In this leaflet, they looked beyond the end of the war and dreamed a new Europe.

LEAFLET-6

Leaflet 6 was written by Prof. Kurt Huber. The language is gorgeous – the original German is unsurpassed for its sly wit and incisive “dialog” with the reader. He drew on the overwhelming grief following the defeat at Stalingrad in an attempt to stir patriotic feelings that superseded National Socialism. Brilliant piece of prose. [Ruth Sachs: It is hard for a translation to do justice to the power of the original.] It is only marred by the later realization that Huber meant the freedoms to apply to Aryans.

LEAFLET-7

Leaflet 7 was the ill-fated document that cost Christoph Probst his life. He did not stand a chance once his Gestapo interrogators read the line praising President Roosevelt!

These leaflets and additional commentary are included in the book Gestapo Transcripts Volume I: Scholl, Schmorell and Graf. This book contains the complete interrogation transcripts for Hans and Sophie Scholl, along with “ZC13267” materials for Alexander Schmorell and Willi Graf; evidence the Gestapo collected against them; an analysis of the leaflets by a Gestapo expert (brilliant analysis – for just one moment you forget he was with the Gestapo); the indictments and verdicts; and miscellaneous correspondence.

One of the most amusing tangents involves the portable Remington typewriter used in the production and distribution of the leaflets, and the owner’s attempts to retrieve it.

See series Leaflets Part#2 of the White Rose

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REFERENCES:

Briefing Document: COMPUTER LEAFLET-1, DESCRIBING Inappropriate Use of CDC Guidelines for Prescribing Opioids

Subject: Concerns regarding the misapplication of the CDC’s “Guideline for Prescribing Opioids for Chronic Pain” by pharmacies, PBMs, and insurers, leading to restricted patient access to necessary pain medication.

Source: Report of the Board of Trustees (B of T Report 22-A-19) to the American Medical Association (AMA) House of Delegates.

Date: [Inferred from content: 2019, following up on the 2018 Annual Meeting]

Key Themes and Ideas:

• Opposition to Blanket Restrictions: The AMA actively opposes policies from pharmacy chains, PBMs, and health insurers that impose blanket restrictions on opioid prescriptions based on numerical thresholds (e.g., Morphine Milligram Equivalents – MME) without considering individual patient needs and clinical context. The original resolution prompting this report arose from a concern about communications sent to physicians that included a “blanket proscription against filling prescriptions for opioids that exceed numerical thresholds without taking into account the diagnosis and previous response to treatment for a patient and any clinical nuances that would support such prescribing as falling within standards of good quality patient care.”
• Misinterpretation and Misapplication of CDC Guidelines: A central argument is that the CDC’s 2016 Guideline, intended as voluntary guidance for primary care providers managing acute pain, is being incorrectly applied as a rigid standard, particularly for chronic pain patients. The report emphasizes, “It is important to note that CDC Guideline Recommendations 5 and 6 were intended guidelines for acute pain episodes, not a hard threshold, and not intended for chronic pain patients.”
• Disruptive Interference in the Patient-Physician Relationship: The report highlights instances of pharmacists questioning prescriptions, demanding patient records, recommending alternative medication strategies, and even refusing to fill prescriptions based on perceived CDC guideline violations. The report notes concerns from physicians and patients about “the disruptive nature of health plan, pharmacy chain or PBM interference in the patient-physician relationship.” This interference undermines the therapeutic relationship and can harm patients.
• The Importance of Individualized Patient Care: The AMA emphasizes the need for patient-centered care and opposes “one-size-fits-all” approaches to opioid prescribing. They advocate for policies that consider “patient individuality” rather than “hard thresholds.”
• Physician-Pharmacist Collaboration (Generally Supported, but with Caveats): The AMA generally supports pharmacists as key partners in medication safety, but objects to instances where pharmacists overstep their bounds and interfere with physician’s clinical judgement. The report states, “The AMA also supports pharmacists as key partners in helping ensure medication safety and as part of the patient-physician-pharmacist therapeutic triad.” However, the report also details concerns when pharmacists misinterpret guidelines and create barriers to patient care.
• Walmart’s “Blacklist” Policy: The report specifically calls out Walmart for sending “blacklist” letters to physicians, informing them that their controlled substance prescriptions will no longer be filled at Walmart pharmacies. The AMA has been unable to get a meaningful response from Walmart regarding this policy. “Specifically, Walmart has sent an unknown number of what can be considered “blacklist” letters to physicians… [Walmart] determined that we will not be able to continue filling your controlled substance prescriptions.”
• Payer Restrictions: The AMA is aware of health insurance companies implementing hard-threshold guidelines based on the CDC guideline. The AMA raised concerns about these payer policies directly to the National Association of Insurance Commissioners (NAIC). “AMA is acutely aware of health insurance companies implementing hard-threshold guidelines based on the CDC guideline.”

• Advocacy and Policy: The AMA has a long history of advocating for better pain care and opposing arbitrary restrictions, including engaging with organizations like the National Association of Boards of Pharmacy (NABP) and the Federation of State Medical Boards (FSMB). The AMA has extensive policy in support of ensuring patients receive optimal pain care and removal of arbitrary restrictions on the provision of that care. This includes having AMA “oppose legislative or other policies that arbitrarily restrict a patient’s ability to receive effective, patient-specific, evidence-based, comprehensive pain care.”
• Recommendations: The Board recommends that the AMA support balanced opioid-sparing policies that are not based on hard thresholds, but on patient individuality. The Board also recommends that the AMA oppose the use of “high prescriber” lists used by national pharmacy chains, pharmacy benefit management companies or health insurance companies when those lists do not provide due process and are used to blacklist physicians from writing prescriptions for controlled substances and preventing patients from having the prescription filled at their pharmacy of choice.

LEAFLET-2: Quotes from the CDC Guideline:

The report references the following statements from the CDC Guideline:

• “[T]he recommendations in the guideline are voluntary, rather than prescriptive standards. They are based on emerging evidence, including observational studies or randomized clinical trials with notable limitations. Clinicians should consider the circumstances and unique needs of each patient when providing care.”
• “When opioids are started, clinicians should prescribe the lowest effective dosage… should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥ 50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥ 90 MME/day or carefully justify a decision to titrate dosage to ≥ 90 MME/day.”
• “When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.”

Proposed Action:

The Board recommends that the House of Delegates adopt resolutions that:

1. Support balanced opioid-sparing policies based on patient individuality, not hard thresholds.
2. Oppose the use of “high prescriber” lists that lack due process and lead to blacklisting of physicians.

This briefing document summarizes the key aspects of the AMA Board of Trustees report regarding the inappropriate application of the CDC’s opioid prescribing guidelines and the resulting negative impact on patient care.

LEAFLET-3:

Study Guide: Addressing Inappropriate Application of Opioid Prescribing Guidelines

I. Short Answer Quiz

1. What was the primary concern that led to the AMA addressing the use of the CDC guidelines?
2. How have health insurance companies, national pharmacy chains, and PBMs used the CDC guidelines?
3. According to the document, what is the AMA’s stance on physician-pharmacist interactions regarding opioid prescriptions?
4. What are the two specific recommendations from the CDC guideline that are often cited in pharmacy, payer, and PBM policies?
5. What caution did the U.S. Department of Health and Human Services Interagency Pain Care Task Force make regarding opioid prescription limits?
6. What specific example does the AMA President share regarding inappropriate denial of opioid prescriptions?
7. What was the outcome of the AMA’s early discussions with the National Association of Boards of Pharmacy (NABP) and the Federation of State Medical Boards (FSMB)?
8. What actions has Walmart taken that concern the AMA?
9. How has the AMA engaged with the National Association of Insurance Commissioners (NAIC) regarding payer policies?
10. What specific AMA policies support optimal patient pain care and removal of arbitrary restrictions?