February 2007

News from Attorneys General Offices

  1. Florida Attorney General Bill McCollum has announced that an owner of a trailer park, Pearl Westmoreland, has been sentenced to nine years? imprisonment after a jury convicted her of exploiting an elderly victim in her care. He has also announced the arrest of a nursing home employee for the alleged abuse of a disabled resident, a result of an investigation by the Attorney General?s Medicaid Fraud Control Units Patient Abuse, Neglect and Exploitation (PANE) team, and the arrest of the owner of a group home for neglect of an elderly resident.
  2. Kentucky Attorney General Greg Stumbo announced this month that the Kentucky Bureau of Investigation is training other law enforcement groups in the techniques and tactics developed to fight Internet drugs. He also announced the arrest of five individuals for trafficking in Hydrocodone, Alprazolam, Oxycodone, and Methadone.
  3. Nebraska Attorney General Jon Bruning filed a petition for disciplinary action last month against Omaha Dr. Robert N. Brown whose license and registration were suspended. The basis for the action was the death of two patients under Brown?s care, allegedly due to an overdose of oxycodone.
  4. Vermont Attorney General William H. Sorrell announced this month that a licensed registered nurse at Berlin Health and Rehabilitation Center was convicted on two felony charges of obtaining a regulated drug by deceit and making a false statement in records. She admitted to stealing fentanyl from used patches that had been given residents.

Judicial Developments

  1. Testimony has begun in a wrongful-prolongation-of-life case in Florida. Family members are accusing a medical center and its director of ignoring a living well and advance directive, which stipulated that no life-prolonging measures be administered. Instead, when Madeline Neumann became unconscious at a nursing home, a breathing tube was inserted.

Legislative Developments

  1. Florida Senator Burt Saunders has proposed a bill, S.B. 518, which would require the Florida Department of Health to establish an electronic system to monitor the prescribing and dispensing of controlled substances by practitioners. In an editorial published in naplesnews.com, Senator Saunders noted that illegally used prescription drugs were directly responsible for 2,181 overdose deaths in Florida in 2004. The bill has received the endorsement of Kentucky Attorney General Greg Stumbo and Governor Ernie Fletcher.
  2. The Kansas legislature is considering H.B. 2176 which would apply to those who have a court-appointed guardian. Under the proposed legislation, people would have to express in writing their wish to have nutrition and hydration withdrawn, creating a presumption that the patient desires water and nutrition. A copy of the proposed legislation is available on the Center for Practical Bioethics? website.
  3. The Kentucky Senate has passed S.B. 88 and sent it to the General Assembly for consideration. The bill would hold pharmacies as well as physicians and others accountable for their involvement in illegal drug trafficking. The bill requires an in-person examination of a patient and will connect Kentucky pharmacies electronically and record pseudoephedrine purchasing data at the point of sale.
  4. S.B. 75, the Advanced Health Care Directive Act, has been introduced in the Utah legislature. The bill would clarify the authority of decision makers and spells out more clearly who gets to make decisions when no designee is available.

Pain Management

  1. One of the sessions at the annual assembly of the American Academy of Hospice and Palliative Medicine discussed managing pain in those with addiction disorders. Ronald Crossano, M.D., area medical director, VistaCare Hospice, Temple, Texas, noted that some modifications to the care plan may be warranted, but it is important to avoid undertreating pain in those patients. Another session was a presentation by Eric Prommer, MD, director of palliative medicine at Mayo Clinic, Scottsdale, Arizona, who noted that some patients whose pain can not be controlled despite repeated opioid dose increases may have overstimulation of their N-methyl-D-aspartate (NMDA) receptor. The best strategy in those cases is to switch to an NMDA antagonist. Other sessions described how poor drug absorption can thwart effective pain management with opioids and how the failure to assess patients? and families? concerns about pain management can interfere with appropriate opioid use. Bruce Chamberlain, MD, director, Palliative Consulting, Orem, Utah, presented a paper concerning the optimal approach to treating chronic pain patients.
  2. At the American Academy of Pain Medicine?s meeting in New Orleans, Louisiana, this month, a study was presented showing that the Internet might not be the primary source that abusers of illegal opioid medications rely upon. The vast majority of addicted individuals indicate that the primary source of the abused drugs is a dealer. Researchers also presented findings that demonstrated that an interactive, Internet-based medical education program was effective in training primary care physicians in appropriate pain management techniques, and that opioid analgesic abuse is growing in popularity among teenagers. The complete program is available on the Academy?s website and a synopsis of some of the topics covered is available on the blog ?Alcohol & Addiction & Illegal Drugs Articles.?
  3. Two articles from the September 2006 issue of the journal Canadian Family Physician discuss opioid use and misuse. One notes that opioids are safe and effective for managing chronic pain. The other notes that all chronic pain patients should be asked about a family history of addiction and that physicians should be vigilant in prescribing and watching for signs of opioid misuse.
  4. Advance for Physician Assistants carried an article concerning the prescribing of opioid analgesics for chronic pain. It includes references to recent studies concerning the efficacy of opioid use as well as a brief summary of when these should be used and how patients should be monitored.
  5. The blog ?How to Cope With Pain,? is written by Sarah Whitman, a psychiatrist who specializes in pain management and is, herself, a chronic pain sufferer. Recently, she has posted excerpts from an article she co-wrote with a colleague that was printed in the journal Practical Pain Management, titled ?Surviving a Loved One?s Chronic Pain.?
  6. The Polyanalgesic Consensus Panel has issued new guidelines for pain management via intraspinal infusion. Among the panel?s recommendations is that ziconotide can be used as an alternative to first-line opioids and as a seconline treatment in combination with hydromorphone or morphine.
  7. Texas television station KFDM broadcast a segment on how to choose a reputable pain clinic.

Prescription Drug Diversion

  1. The federal government has issued new guidelines for proper disposal of prescription drugs that are intended to reduce the diversion of medicine for illegal use and protect the environment. Consumers are urged not to flush unused drugs down toilets unless information accompanying the prescription specifically says it is safe to do so. The guidelines also urge that unused prescription drugs be mixed with an undesirable substance such as coffee grinds, placed in nondescript containers, and thrown in the trash. Where available, unused drugs may also be returned to pharmaceutical take-back locations.
  2. The Centers for Disease Control and Prevention issued a report this month noting that deaths from accidental overdoses is now the second leading cause of accidental death in the United States. The rate of overdose deaths among teens and young adults rose 113 percent from 199 to 2004.
  3. Dr. Everett Echols of Greensboro, North Carolina, is one of fourteen individuals who, along with seven companies, was indicted for illegally trafficking in prescription drugs through Internet pharmacies. The indictments were handed down by a West Palm Beach, Florida, grand jury in early February.
  4. In an article published on-line on February 1 in Pain Medicine, the authors researched how drug users obtain controlled substances. The authors concluded that the sources of abused prescription drugs are extremely diverse, ranging from doctor shopping to ?stealing from grandma?s medicine cabinet.?
  5. The California Community Colleges Satellite Network broadcast a program in late February discussing prescription drug diversion, the scope of the problem, and the difficulties law enforcement personnel have in attacking the problem.

Other Developments of Interest

  1. A report released by a panel appointed by Pennsylvania Governor Ed Rendell calls for the state to better ensure that a patient?s documents concerning end of life wishes be transferred when a patient is moved. Other recommendations included improve education and training in palliative care and providing patients greater access to home care.
  2. The Worcester, Massachusetts, on-line Telegram and Gazette had a story about how the free Pediatric Palliative Care Program, a provision of the state?s health care reform law passed last year, is working for a local couple whose two sons have a rare form of cancer, pleural pulmonary blastoma.
  3. The Vermont Department of Health has announced the availability to Vermonters of an electronic registry for advance directives.
  4. The Salt Lake City, Utah, annual meeting of the American Academy of Hospice and Palliative Medicine included several interesting topics: (1) Karen Kavanaugh, RN, professor of nursing and co-director, Advanced Practice Palliative Care Nurse Training Program, University of Illinois presented the results of a study that found that physicians can and do play a key role in the decision making process regarding life support for extremely premature infants; and (2) Rosemary Chacko, MD, palliative medicine physician at Methodist Hospital, San Antonio, Texas, spoke on the benefits of earlier ICU palliative care consultation. This includes identifying the cause of the pain and then retitrating doses frequently with continual reassessment of the effectiveness of the medication. Patients with severe, persistent pain should be treated with long-acting opioids in concert with short-acting drugs for breakthrough pain. The keynote address by Harvey Max Chochinov, a palliative-care specialist at the University of Manitoba, stressed the importance of dignity and maintaining a sense of self and worth as death approaches; patients need to see their value reflected in the eyes of caregivers.
  5. The February 10 issue of the Journal of Clinical Oncology includes an article noting that, although spiritual support is associated with better quality of life for those with advanced cancer, these patients? spiritual needs are not supported by religious communities or the medical system. An article in USA Today discussed this study. The February 20 issue reports a study from Australia that found that providing a question- prompt list assists terminally ill cancer patients and their caregivers to ask questions and promote discussion about prognosis and end-of-life issues without creating patient anxiety.
  6. The February 21 issue of the Journal of the American Medical Association contains the results of a new study that empirically exams the stage theory of grief. Counter to the popularly-accepted stage theory, the researchers found that yearning, not disbelief, was the initial, dominant grief indicator.
  7. The Hospice Foundation of America is hosting its 14th annual National Bereavement Teleconference. ?Living with Grief: Before and After the Death? will explore the most current theoretical perspectives on loss and grief. Those interested in attending can go to the Foundation?s website to find a location close to them that is hosting the teleconference.
  8. The British Medical Journal?s February 3d issue included an article titled ?Defining Limits in Care of Terminally Ill Patients.? The article deals with a doctor?s decision-making regarding clinical intervention at the end of life and the critical need for effective communication skills and cultural sensitivity.
  9. The Penn State online newspaper, The Daily Collegian, featured an article in its February 6 issue on the new Pennsylvania law regarding living wills. Students are urged in the article to discuss their end of life wishes with their parents who, under the law, will be making decisions for their unmarried children should their children be unable to do so.

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