Leadership on Opioids

Anyone who proposes an easy solution to the overdose epidemic is either a simpleton or a politician.  But far too many people entrusted with the power and responsibility to set priorities decry the number of overdose deaths, then stigmatize and demonize every effort to save lives.   “Suboxone can be diverted.”   “Someone might drive impaired after methadone.”  “Needle exchange programs attract drug dealers.”    Meanwhile the number of deaths from overdose make clear that current solutions are not working.  Small community newspapers have story after story about the increasing number of deaths, but the silence in Washington is deafening.    I picture a cruise ship leaving  one after another drowning passenger in it’s wake, while the ship’s captain dines at the captain’s table, pausing between bites to tell dinner guests that all is well.
Statistics and numbers don’t tell a story unless put into context, so some simple comparisons help demonstrate the magnitude of the ‘opioid problem.’  My perception is skewed after sitting with so many people affected by addiction, but we seem to have a huge blind spot for one of the leading killers of young people.  Consider the issues our country’s leaders talk about and our news reporters write about.   I think we all know the things that get our President’s undies in a bundle… but did I miss the Presidential Summit on Opioid Dependence?  This would not be the first time that our leaders missed the elephant in the living room, of course— but it may be one of the first times a President has been given a pass after missing this big an elephant for this long.  I’m old enough to remember the media soundly criticizing Reagan for failing to create a sense of urgency over AIDS.  And so I wonder… When is Obama going to express urgency about opioids?  Where is the media criticism of his lack of urgency?   Today he told reporters he ‘will leave everything on the field during his last year in office,’ just before he took off for another Christmas in Hawaii.  Will that time on the field include some concern for people killed by overdose?
I don’t get the impression that our President lies awake all night worrying about overdose deaths.  But maybe he should.  We heard a great deal from Obama about the need to bring troops home from Iraq a few years ago.  And all of the networks kept a running tally of US deaths in Iraq in the lower right corner of the screen during the evening news.   So let’s compare priorities.  Let’s add up all of the deaths of US troops during Iraq II during two administrations of Bush and the 1 and 3/4 Obama administrations.  Let’s add the deaths from the World Trade Center attacks, the recent terrorist attacks in France and California, and the mass shootings at Sandy Hook and Columbine.  How does that number compare to the impact of opioid dependence?
I don’t intend to lessen the honor of fallen military servicemen and women, or downplay the horror experienced by victims of 911 and other violent attacks.   I chose these numbers because the horror of each situation prompted speeches by our leaders, rallies by our citizens, and headlines in National news media.   The speeches and commitments of our President and the coverage by news anchors are supposed to be a reflection of what our citizens care about.
The number of deaths from overdose in 2013 alone– one year– was over four times greater than the complete count of US deaths in Iraq, plus all of the horrible events listed above.   US deaths in the Iraq war?  About 4500.  The Trade Center attacks killed almost 3000 people.   In 2013, over 30,000 US citizens died from overdose.  Surprised?  I was.  On average about 100 people in the US die from overdose every day– day after day.
As I wrote above, I remember the reporters calling out Reagan over AIDS.  Activists claimed that Reagan avoided talking about HIV because of the stigma associated with ‘homosexuals’, the people hit the hardest by the initial outbreak of HIV.   They say that the people who died were ‘second class citizens’ who didn’t have a voice, and it was easier for Reagan to pretend that the problem didn’t exist.  Many people believe that if Reagan spoke about AIDS in his speeches or directed National attention toward the outbreak of the virus, that fewer people would have died.   Maybe those people were right.
If they were, what’s Obama’s excuse?

Obsessed with Suboxone Diversion? Raise the Cap!

Last week, HHS Secretary Sylvia Burwell announced that the cap on buprenorphine patients will be raised above the current limit of 100 patients per doctor.  This move, should it actually occur, will potentially save tens of thousands of young lives per year, given that over 30,000 people die from narcotic overdose each year.  But instead of cheering the good news, some doctors used the occasion to rant about diversion.  Those doctors get on my nerves, and I’ll explain why.
Buprenorphine, the active ingredient in Suboxone, prevents opioid withdrawal in heroin addicts while at the same time blocking the effects of heroin and narcotic pain medications.  Many heroin addicts keep a dose or two of buprenorphine handy for times when the heroin supply, or money to buy heroin, runs low.  Other opioid addicts use buprenorphine in attempts to detox off opioid agonists.  Their efforts almost always fail, as freeing one’s self from addiction is much more complicated than getting through withdrawal.  But the statistics don’t keep addicts from trying, over and over again.  After all, the belief in personal power over substances is part of the addictive mindset.
Buprenorphine is viewed as just one more drug of abuse when viewed through the superficial lens of news reporters. Even some buprenorphine prescribers fail to understand the important differences between buprenorphine and opioid agonists. But the differences are important.  While over 30,000 people die from overdose of opioid agonists each year, less than 40 people die each year with buprenorphine in their bloodstream.  Of those deaths, most were caused by opioid agonists, and would have been prevented by more buprenorphine in the bloodstream!
I admit to a great deal of irritation when I hear doctors who should know better spreading ignorance and stigma about buprenorphine—an ideal medication for the current epidemic of overdose deaths.  To you doctors:  Really? 40 deaths per year—deaths not even caused by the drug— are the horrible cost to society that you are complaining about?  The same number of people die from lightning strikes!  Maybe, while you are at it, you should complain about tall trees on golf courses!
Forty deaths.  FORTY!
I think of fields of medicine where doctors take the lead to guide society to do the right thing.  Getting insurers to treat AIDS was the right thing.  But when overdose is the biggest killer of young adults, my colleagues spread fear about buprenorphine?!
Buprenorphine diversion is a complicated issue. Contrary to the media-propagated image of addicts getting ‘high’, opioid addicts always, eventually, become desperate and miserable. Some miserable addicts learn about buprenorphine, a medication that almost instantly blocks the desire to use heroin or other opioids.  When buprenorphine was approved for treating addiction, a cap was placed on the number of patients treated by each physician.  Reasons for the cap range from a desire to prevent ‘treatment mills’ to political compromises.  But whatever the reason, treatment caps and other restrictions prevent doctors from prescribing buprenorphine.  In the absence of legitimate prescribers, addicts purchase buprenorphine at a street price determined by supply and demand.
Some patients sell their prescribed buprenorphine medications.  Such sales are against the law, just as selling Oxycontin or Vicodin is a crime.  But in a world where heroin can be purchased more cheaply than Suboxone, and where pain pills kill tens of thousands of people each year, I’m sorry if I don’t get hysterical about the ‘buprenorphine problem’.  If there was any evidence or suspicion that buprenorphine serves as a gateway into opioid dependence (there isn’t), I’d think differently. But use of buprenorphine, at this point anyway, is confined to miserable heroin addicts looking for a way out of active addiction, who can’t find legitimate prescribers of the medication.
So to the people who wrote on government websites over the last week that ‘it makes no sense to treat one addictive drug with another’: You don’t have a clue.  Buprenorphine has unique properties that treat the essence of addiction—the compulsion to use ‘more’. And addiction is a chronic illness that deserves treatment as much as any other chronic illness.
And to the doctors who prescribe buprenorphine products and get their undies in a bundle about greater access to buprenorphine:  With all due respect, you must be doing something wrong.  I have 100 patients right now who tell me, at each visit, that I saved their lives.  I credit the medication, since the unique properties of buprenorphine are far more important than anything I have to say!  But I know that something saved their lives, because their former friends are dead, and they are alive– working jobs, raising families, and occasionally reaching out to lucky friends who survived long enough to hear them talk about the wonders of buprenorphine.
To those same doctors:  How can you not be excited by a medication that has saved so many of your patients?  If you don’t have such patients, I suggest you give some thought to what you’re doing wrong!  In this field, with this medication, saving lives isn’t that difficult. After 20 years in medicine (including 10 years as an anesthesiologist), I’ve never had the opportunity to benefit human life as much as with these patients, with this medication.
I hate to mess up a passionate article with talk about neurochemistry, but a couple facts deserve clarification. Diverted buprenorphine is not a ‘pleasure’ drug.  I’ve heard stubbornly-ignorant doctors compare buprenorphine to heroin, as if their stubborn beliefs alone can turn an opioid partial-agonist into an opioid agonist.  Surely they know that if someone with a tolerance from regular use of heroin takes buprenorphine, the drug will precipitate severe withdrawal?!  And if the same person injects buprenorphine, the withdrawal will be even more severe!  On the other hand, if someone addicted to heroin goes without heroin for over 24 hours and then injects buprenorphine, the buprenorphine will reduce the withdrawal.  But since the maximum effect of buprenorphine is far below the maximum effect of heroin, there is no way for the person to get ‘high’ from buprenorphine.  This is all simple neurochemistry! When a person injects buprenorphine, opioid withdrawal will be relieved more quickly.  But that’s a far cry from thinking that buprenorphine causes a ‘high’ similar to the effects of heroin!
After treating hundreds of patients over the years and talking at length about every aspect of their drug use, including their use of buprenorphine products intravenously before they found prescribers of the medication, I have always heard the same thing: that buprenorphine relieved their opioid withdrawal.
When I ask why in the world they injected buprenorphine, I hear the same reason– because the drug is expensive, and lasts five times longer if they inject it.  That answer, by the way, is consistent with the 25% bioavailability of submucosal buprenorphine.
How depressing that patients with addictions are treated like idiots… when they have a better understanding of neurochemistry than some doctors!

Raising the Suboxone Patient Cap

HHS Secretary Sylvia Burwell announced yesterday that the cap on buprenorphine patients would be raised in the near future.  Details were not released, but she emphasized that measures would be taken to increase availability of this life-saving treatment, while at the same time taking caution to prevent misuse of the medication.   Anyone who works with buprenorphine understands the importance of her announcement.  I only hope that her actions are swift, and not overloaded with regulations that reduce practical implementation of whatever increases are allowed.
I have been at the cap for years, unable to accept new patients for buprenorphine treatment.  My office receives 3-4 calls each day on average from people addicted to heroin, begging for help.  Patients on buprenorphine (the active substance in Suboxone) are much less likely to die from overdose than are patients not taking buprenorphine– even in the absence of perfect compliance.  Some doctors, in my opinion, over-emphasize the ‘diversion’ of buprenorphine medications.  At least in my part of the country, ‘diversion’ of buprenorphine amounts to heroin addicts trying to stop heroin, taking ‘street buprenorphine’ because of the absence of legitimate treatment spots.    Of the few new patients I’ve been able to take this year, almost all have histories of using buprenorphine products on their own, without prescriptions.  They are very happy to finally have a reliable source of the medication– and to have the medication covered by their health insurance!
Let’s hope the increase in the cap happens sooner rather than later.  After all, lives are literally hanging in the balance.

What's Up with Buprenorphine?

I think about a joke my dad used to tell over and over.  A guy is upset because his kid has never talked in his entire life.  He has taken his kid to all the specialists, but nobody has an answer.  Then at his 18th birthday party the kid blurts out “we’re having ham AGAIN?!’    His family breaks out in tears of joy, and eventually his dad asks him why he hasn’t talked for so long. The kid pauses, and then says “up to now, everything was OK.”
A dumb joke… but then again I just saw a PBS show about the life of Joan Rivers, and I was struck by how so many comedians make a living by saying things that are simply disgusting, and passing them off as ‘comedy’.  Joan’s disciples all have the same type of humor… what’s the name of that red-headed woman who did a brief stint on Seinfeld?  Just say something shockingly rude to a crowd who paid to see you, and they laugh.
Got off track.  My point was that I’m sorry for being gone so long, and I wish the reason was because there was nothing to complain about.  Unfortunately, there are still plenty of things to complain about…. the cap on doctors prescribing buprenorphine products, the large number of overdose deaths, the spread of hepatitis C and other blood-borne illnesses, the ignorance of the media and among some DA’s and law enforcement agencies…
Frankly, I took a break from writing because I was tired of being so angry all the time.  But over the past few months, I’ve received daily messages from people suffering from addiction and looking for answers.  I appreciate those of you who continue to stop by the web site and the Forum, and I’ll try to get over my anger and get some new content out here.
I have at least a few things that I’d like to address at this point– but please feel free to help me out by sharing a question, an interesting situation, or anything else that you find interesting.. and I’ll use it as a starting point for a post.  Send me an email, or leave a comment… and I’ll be back!
BTW, hope everyone had a nice summer!

The Overdose Report

I set up a new site today that collects newsfeeds related to the epidemic of opioid dependence and posts links to the articles.  Some of the news stories strike a sensational tone, as opposed to the somber nature of the content— and my intention was not to create a website fashioned after an episode of ‘Cops’.   But there is an epidemic going on, and many of the articles refer to efforts to stem the tide through legislation at the state level throughout the country.  Feel free to check it out…  and I hope it doesn’t come across as insensitive because of the title.
Overdose Report

Treatment? Or Murder?

I subscribe to Google news alerts for the phrase ‘overdose deaths.’  Google Alerts are a great way to follow any topic; subscribers receive headlines from newspapers and web sites for certain keywords from around the world. One thing that has become clear from my subscription is that there is no shortage of stories about deaths from opioids! Every day I see one article after the next, as news reporters notice the loss of more and more of their communities’ young people.
Along with the reports of overdoses are stories about doctors who are increasingly being prosecuted for the deaths of their patients. In an earlier post I described the case of Dr. Schneider and his wife, a nurse, who were tied to a number of overdose deaths in Kansas. That case stood out by the sheer number of deaths; the State charged the couple with the deaths of 56 patients. Cases involving fewer patients have become relatively common. The latest case that I’ve read about is a doctor in Iowa, who is accused of causing or contributing to the deaths of 8 people.
I try to present both sides of the argument when I write about this topic. I have been faced with the difficult decision over whether or not to prescribe narcotics many times, and I understand a doctor’s dilemma. The doctor sees a person who is in pain, and knows that there is a pill that will reduce that pain. But the doctor also knows, or SHOULD know, that initiating a prescription for narcotic pain medication always has unintended consequences, no matter how good the intentions of both doctor and patient.
In the Iowa case, the dilemma over narcotic-prescribing is very clear. The prosecution states that the doctor prescribed pain medication to drug addicts.  On the surface, that sounds bad, right? One gets the mental picture of dirty, lazy people, dissolving tablets in a spoon, over a candle, and then injecting the mixture. But reality is much more complicated. Patients with histories of opioid dependence do not always have track marks. And even if we tattooed the letter A across their chests, there are addicts who are in need of pain treatment. Are we to decide that every person who has become addicted to pain medication gives up the right to pain treatment?  And we know that many of the patients addicted to opioids became addicted through the course of pain treatment from their physician— so I would expect that on average, patients addicted to opioids would have a higher incidence of chronic pain, and vice versa.
I do not find it reasonable to make patients with addiction histories endure pain that would be treated in other patients.  Father than singling out some patients for ‘special non-treatment,’ we should prepare for the risks from opioids in ALL patients—a set of ‘universal precautions for opioid treatment,’ similar to the way we use a different set of universal precautions to avoid transmission of blood-borne infections.
There are times when doctors have to tolerate being the bad guys.  Some patients have been taught, through careless prescribing, that all pain should be treated with narcotics. Those patients are not happy when told, after paying several hundred dollars, that they do not ‘need’ narcotic pain medication– and so many of their doctors have a hard time saying ‘no.’ After all, doctors studied hard to do well in school, and usually receive praise for what they do. It is much easier to write a prescription and hear ‘thank you’ than to be called an unsympathetic jerk! But doctors are paid the big bucks to tolerate such things, and to keep the long-term health of patients in mind. And for many people with chronic pain, opioids will provide a good month or two, but for the price of many years of misery.
I’ve been told by patients “I don’t care about the risks, doc– I’d rather have three good months and then die, then have twenty years in pain.” I reply, “that’s why these medications require a doctor to consider things very carefully, and a good doctor would not allow someone to make that decision.” I’m sure that some people will be angered by that attitude. But the approach is similar to how we handle many other illnesses, where we encourage patients to tolerate short-term misery for long-term benefits. Many patients would refuse chemotherapy and give up on life if not pushed to move forward. And to depressed patients, suicide can appear a reasonable option. I’m a fan of free will, but I recognize that we don’t always choose our paths through life with full insight.
Even with full knowledge of the reasons to avoid narcotics, some doctors really struggle over withholding opioids.  I find it somewhat ironic that the doctors who are too ‘kind-hearted’—i.e. who want to please patients so much that they cannot deny even that which is bad for them—are the ones who end up getting into trouble.  The Iowa doctor is being sued over several of the deaths, likely by relatives of the patients who pled the hardest for pain pills!  Talk about good deeds not going unpunished!
But there are aspects of the case in Iowa that do not argue well for the doctor. Several of the patients who died were only seen once, but treated with narcotics for years. The DEA requires that patients are prescribed no more than 90 days of narcotic medication at one time (divided on three monthly prescriptions). I presume that patients were picking up scripts every three months, without having appointments each time. Such a practice is not strictly illegal (not that I am aware of, anyway), but the standard of care would be to evaluate patients on potent opioids every three months, or even more frequently. And one news article stated that the doctor had tens of thousands of pain patients. As a full-time practitioner with less than 1000 patients, I wonder how so many patients could be managed by one physician.
When I write about this topic I receive angry comments from some readers. Some attack me personally with comments like “I’m glad I’m not YOUR patient!” or “I hope YOU have to suffer with horrible pain some day!” I realize that this is a very hot topic, and my only intent is to educate and inform, to help people understand what is happening in the minds of physicians. Of course, the care of patients should not be determined by the need for doctors to protect their own interests. But at the same time, it is understandable that doctors are affected by headlines announcing the imprisonment of other doctors facing the same treatment decisions.
Bottom line– there are very good reasons to avoid using opioids for nonmalignant chronic pain. Just giving patients what they want, and ignoring the danger of opioids, will likely result in criminal and civil prosecution. But that reason is secondary to the most important thing– the promise all doctors make to first, do no harm. And patients should realize that their doctors may be withholding narcotics for that reason alone.

Pill Mill Prosecution and the Pain Relief Network

Wow. I just read an email about a story that I was vaguely aware of– about a doctor in Kansas and his wife, who were together linked to scores of overdose deaths. But that is just the beginning. The doctor was supported, during his trial, by Siobhan Reynolds, founder of a nonprofit advocacy group called ‘Pain Relief Network.’  She started the group back in 2003, when her ex-husband was suffering from severe pain from a congenital connective tissue disorder.Reynold's Billboard
He (the ex-husband) found relief in combinations of high-dose opioids and benzodiazepines, at least until his doctor, Virginia pain specialist William Hurwitz, was convicted on 16 counts of drug trafficking.  The ex died, by the way, in 2006.  Are you still with me?
The trial of the Kansas doctor, Stephen Schneider, went on for years.  During the trial, Ms. Reynolds apparently helped support what she considered to be a ‘dream team’ of attorneys.  She used the case as an opportunity to increase her visibility, encouraging the Schneiders to aggressively fight the charges against them on the basis of ‘patient rights.’  Ms. Reynolds, through the Schneiders, argued that suffering patients are being denied appropriate care because of a war, waged by overly-aggressive prosecutors, against doctors who prescribe pain medication.
Ms. Reynolds even paid for a billboard adjacent to the road to the courthouse, so that jurors could see, en route, the statement “Dr. Schneider Never Killed Anyone.”  Some might see the billboard as ‘free speech’, but the judge presiding over the case was not amused.  At the eventual sentencing, the judge gave both Dr. Schneider and his wife over 30 years in prison, hoping that the sentences would “curtail or stop the activities of the Bozo the Clown outfit known as the Pain [Relief] Network, a ship of fools if there ever was one.”
We already have enough drama for a made for TV movie.  Actually there already is one, made by Ms. Reynolds, about her ex’s struggle over finding appropriate pain treatment.  The hour-long film is called ‘The Chilling Effect,’ and can be found here— along with a number of vignettes about the efforts of the Pain Relief Network.
Make that the former Pain Relief Network.  Ms. Reynolds was investigated by a Grand Jury, led by the same prosecutor who led the efforts against Dr. Schneider.  After years of what she considered to be ‘vindictive efforts,’ she closed down Pain Relief Network, saying that the organization’s finances ‘were in shambles.’
Within weeks of closing PRN, Ms. Reynolds lost her life in a plane crash.  Piloting the plane, and also killed, was Kevin Byers– Ms. Reynold’s romantic partner and also– get this attorney for the wife of Dr. Schneider.
Our story ends in typical, made for TV fashion, with all of the loose ends tied up.  The Pain Relief Network is gone, tragically missed by some, and considered ‘good riddance’ by others.  Ms. Reynolds, tireless advocate or misguided fanatic, has left this world for the next.  Left behind are the story-tellers;  I will provide links to both sides, so that readers can have a true, balanced perspective.  From the PRN side, simply go to their former web site, and you will find links to the archives.  The archives contain links to stories in a number of publications, including Slate and the NYT– places where David and Goliath stories are repeated without much challenge, particularly for the Davids.
On the other side is a woman named Marianne Skolek, writer for the Salem News online site, who has little positive to say about Ms. Reynolds and PRN.  For years she has chronicled the epidemic of deaths from Oxycontin, and she has also written a number of articles about the Schneiders, Reynolds, and PRN.  One of the most chilling points in a story by M. Skolek is a a list of the patients who saw Dr. Schneider and who died shortly afterward.  The pattern is clear; people in sudden possession of large numbers of pain pills, who took amounts sufficient to end their lives:

Name

Age

On or about 1st Office Visit

On or about Last Office Visit

On or about Date of Death

Heather M 28 Aug. 27, 2001 Feb. 8, 2002 Feb. 9, 2002
Billie R 45 Oct. 19, 2001 May 2, 2002 May 4, 2002
William M 36 Nov. 12, 2002 Jan. 28, 2003 Feb. 4, 2003
Leslie C 49 April 9, 1996 Feb. 9, 2003 Feb. 14, 2003
David B 47 Nov. 18, 2002 March 12, 2003 March 15, 2003
Terry C 48 Oct. 12, 2001 April 8, 2003 April 14, 2003
Lynnise G 35 May 23, 2002 April 23, 2003 April 30, 2003
Mary S 52 Feb. 6, 2003 June 11, 2003 June 16, 2003
Dustin L 18 June 26, 2003 June 26, 2003 June 27, 2003
Marie H 43 Dec. 24, 2002 May 28, 2003 June 30, 2003
Jessie D 21 March 4, 2003 June 27, 2003 July 11, 2003
Boyce B 59 June 29, 2003 July 23, 2003 July 25, 2003
Kandace B 43 July 10, 2003 Nov. 12, 2003 Nov. 14, 2003
Katherine S 46 July 9, 2003 Nov. 19, 2003 Nov. 25, 2003
Robert S 31 June 2, 2003 Dec. 7, 2003 Dec. 8, 2003
Deborah S 44 Jan. 3, 2003 May 5, 2003 Feb. 5, 2004
Shannon Mi 38 July 27, 2003 Dec. 9, 2003 Feb. 23, 2004
Danny C 35 April 21, 2003 March 5, 2004 March 6, 2004
Vickie H 53 June 26, 2003 March 16, 2004 April 11, 2004
James C 33 March 3, 2004 June 8, 2004 June 9, 2004
Shannon Me 25 July 24, 2003 June 4, 2004 June 22, 2004
Ancira W 45 Sept. 25, 2002 June 15, 2004 July 12, 2004
Darrell H 24 Nov. 12, 2002 July 15, 2004 July 17, 2004
Michael H 37 March 9, 2004 Aug. 26, 2004 Sept. 12, 2004
Patricia C 43 Nov. 8, 2001 Oct. 4, 2004 Oct. 6, 2004
Jon P 36 April 23, 2004 Oct. 8, 2004 Oct. 20, 2004
Tresa W 43 Sept. 15, 2003 Nov. 29, 2004 Dec. 16, 2004
Jeff H 45 Jan. 10, 2003 Dec. 8, 2004 Dec. 29, 2004
Russell H 24 Aug. 23, 2003 Jan. 12, 2005 Jan. 19, 2005
Michael B 48 Sept. 30, 2004 Jan. 28, 2005 Feb. 2, 2005
Amber G 22 Aug. 13, 2003 Jan. 3, 2005 Feb. 26, 2005
Christine B 45 Dec. 11, 2001 Dec. 3, 2004 April 7, 2005
Victor J 48 Jan. 24, 2005 April 15, 2004 April 22, 2005
Randall P 44 March 10, 2005 April 22, 2005 May 3, 2005
Michael F 49 Jan. 10, 2005 May 9, 2005 May 11, 2005
Deborah M 52 Feb. 23, 2005 May 4, 2005 May 15, 2005
Patricia G 49 Feb. 1, 2003 June 18, 2005 June 20, 2005
Dustin B 22 Jan. 20, 2005 Feb. 27, 2005 June 21, 2005
Jerad M 24 July 9, 2004 June 13, 2005 June 22, 2005
Earl A 29 Sept. 22, 2004 June 29, 2005 July 3, 2005
Brad S 53 Oct. 15, 2004 June 30, 2005 July 11, 2005
Clifford C 39 July 23, 2003 June 29, 2005 July 27, 2005
Sue B 38 Oct. 21, 2002 May 12, 2005 Aug. 1, 2005
Jason P 21 Aug. 19, 2003 June 29, 2005 Sept. 4, 2005
Randall S 52 April 27, 2005 Nov. 12, 2005 Nov. 19, 2005
Thomas F 46 Feb. 15, 2005 Jan. 5, 2006 Jan. 9, 2006
Toni W 37 Dec. 30, 1999 Feb. 16, 2006 Feb. 18, 2006
Marilyn R 39 Aug. 16, 2004 March 16, 2006 April 5, 2006
Dalene C 45 Aug. 25, 2003 April 19, 2006 April 21, 2006
Eric T 46 June 2, 2003 April 19, 2006 April 23, 2006
Jo Jo R 46 Feb. 26, 2005 June 5, 2006 June 7, 2006
Mary Sue L 55 Jan. 30, 2002 June 13, 2006 June 14, 2006
Pamela F 42 March 31, 2003 July 21, 2006 July 22, 2006
Deborah W 53 July 18, 2003 Sept. 7, 2006 Sept. 9, 2006
Jeffrey J 39 May 5, 2004 Oct. 23, 2006 Oct. 24, 2006
Ronald W 56 June 29, 2004 March 20, 2007 March 23, 2007
Evelyn S 50 Dec. 12, 2004 April 16, 2007 April 17, 2007
Robin G 45 July 13, 2004 May 11, 2007 May 15, 2007
Ralph S 44 Jan. 16, 2003 May 15, 2007 July 23, 2007
Patsy W 49 Dec. 2, 1999 July 16, 2007 July 26, 2007
Donna D 48 Dec. 27, 2005 July 19, 2007 Aug. 16, 2007
Lucy S. 61 Aug. 29, 2003 Aug. 23, 2007 Aug. 28, 2007
Gyna G 33 Feb. 10, 2004 Oct. 4, 2007 Oct. 7, 2007
Casey G 28 Sept. 4, 2007 Sept. 13, 2007 Oct. 23, 2007
Julia F 50 June 20, 2007 Nov. 20, 2007 Nov. 28, 2007
Rebecca T 54 May 2, 2006 Nov. 17, 2007 Dec. 24, 2007
Jane E 40 Jan. 8, 2003 Jan. 12, 2008 Jan. 26, 2008
John D 52 June 23, 2003 Jan. 3, 2008 Feb. 10, 2008

 
The story is not quite over.  The Schneiders are now appealing their convictions, claiming insufficient counsel– namely that the romantic involvement of one of their attorneys with Ms. Reynolds created a conflict that led to poor counsel.  In other words, they may have asked for mercy, had Ms. Reynolds not been cheering them and their attorney to place everything on the line.
As I’ve written many times, the use of opioids for chronic pain is a complicated issue, with no clear ‘good’ or ‘bad’ side. As in most of life’s challenges, the extremes of each position appear…. extreme.  Ms. Reynolds believed that the Controlled Substances Act should be repealed;  I find it difficult to understand how any educated person would adopt such an approach.  But the extreme opposite side leads to enough fear, in physicians, to stifle the use of narcotic pain relievers in people who truly need such relief.  As for me, I keep trying to straddle the wide middle.