medicalcondition:pain

  • ’Endless trip to hell’: Israel jails hundreds of Palestinian boys a year. These are their testimonies - Israel News - Haaretz.com

    (C’est sous paywall)

    https://www.haaretz.com/israel-news/.premium.MAGAZINE--1.7021978

    They’re seized in the dead of night, blindfolded and cuffed, abused and manipulated to confess to crimes they didn’t commit. Every year Israel arrests almost 1,000 Palestinian youngsters, some of them not yet 13

    #palestine #israel #enfants #violence

    • ’Endless trip to hell’: Israel jails hundreds of Palestinian boys a year. These are their testimonies
      They’re seized in the dead of night, blindfolded and cuffed, abused and manipulated to confess to crimes they didn’t commit. Every year Israel arrests almost 1,000 Palestinian youngsters, some of them not yet 13
      Netta Ahituv | Mar. 14, 2019 | 9:14 PM | 2

      It was a gloomy, typically chilly late-February afternoon in the West Bank village of Beit Ummar, between Bethlehem and Hebron. The weather didn’t deter the children of the Abu-Ayyash family from playing and frolicking outside. One of them, in a Spiderman costume, acted the part by jumping lithely from place to place. Suddenly they noticed a group of Israeli soldiers trudging along the dirt trail across the way. Instantly their expressions turned from joy to dread, and they rushed into the house. It’s not the first time they reacted like that, says their father. In fact, it’s become a pattern ever since 10-year-old Omar was arrested by troops this past December.

      The 10-year-old is one of many hundreds of Palestinian children whom Israel arrests every year: The estimates range between 800 and 1,000. Some are under the age of 15; some are even preteens. A mapping of the locales where these detentions take place reveals a certain pattern: The closer a Palestinian village is to a settlement, the more likely it is that the minors residing there will find themselves in Israeli custody. For example, in the town of Azzun, west of the Karnei Shomron settlement, there’s hardly a household that hasn’t experienced an arrest. Residents say that in the past five years, more than 150 pupils from the town’s only high school have been arrested.

      At any given moment, there are about 270 Palestinian teens in Israeli prisons. The most widespread reason for their arrest – throwing stones – does not tell the full story. Conversations with many of the youths, as well as with lawyers and human rights activists, including those from the B’Tselem human-rights organization, reveal a certain pattern, even as they leave many questions open: For example, why does the occupation require that arrests be violent and why is it necessary to threaten young people.

      A number of Israelis, whose sensibilities are offended by the arrests of Palestinian children, have decided to mobilize and fight the phenomenon. Within the framework of an organization called Parents Against Child Detention, its approximately 100 members are active in the social networks and hold public events “in order to heighten awareness about the scale of the phenomenon and the violation of the rights of Palestinian minors, and in order to create a pressure group that will work for its cessation,” as they explain. Their target audience is other parents, whom they hope will respond with empathy to the stories of these children.

      In general, there seems to be no lack of criticism of the phenomenon. In addition to B’Tselem, which monitors the subject on a regular basis, there’s been a protest from overseas, too. In 2013, UNICEF, the United Nations agency for children, assailed “the ill treatment of children who come in contact with the military detention system, [which] appears to be widespread, systematic and institutionalized.” A report a year earlier from British legal experts concluded that the conditions the Palestinian children are subjected to amount to torture, and just five months ago the Parliamentary Assembly of the Council of Europe deplored Israel’s policy of arresting underage children, declaring, “An end must be put to all forms of physical or psychological abuse of children during arrest, transit and waiting periods, and during interrogations.”

      Arrest

      About half of the arrests of Palestinian adolescents are made in their homes. According to the testimonies, Israel Defense Forces soldiers typically burst into the house in the middle of the night, seize the wanted youth and whisk him away (very few girls are detained), leaving the family with a document stating where he’s being taken and on what charge. The printed document is in Arabic and Hebrew, but the commander of the force typically fills out the details in Hebrew only, then hands it to parents who may not be able to read it and don’t know why their son was taken.

      Attorney Farah Bayadsi asks why it’s necessary to arrest children in this manner, instead of summoning them for questioning in an orderly way. (The data show that only 12 percent of the youths receive a summons to be interrogated.)

      “I know from experience that whenever someone is asked to come in for questioning, he goes,” Bayadsi notes. She’s active in the Israeli branch of Defense for Children International, a global NGO that deals with the detention of minors and promotion of their rights.

      “The answer we generally get,” she says, “is that, ‘It’s done this way for security reasons.’ That means it’s a deliberate method, which isn’t intended to meet the underage youth halfway, but to cause him a lifelong trauma.”

      Indeed, as the IDF Spokesman’s Unit stated to Haaretz, in response, “The majority of the arrests, of both adults and minors, are carried out at night for operational reasons and due to the desire to preserve an orderly fabric of life and execute point-specific actions wherever possible.”

      About 40 percent of the minors are detained in the public sphere – usually in the area of incidents involving throwing stones at soldiers. That was the case with Adham Ahsoun, from Azzun. At the time, he was 15 and on his way home from a local grocery store. Not far away, a group of children had started throwing stones at soldiers, before running off. Ahsoun, who didn’t flee, was detained and taken to a military vehicle; once inside, he was hit by a soldier. A few children who saw what happened ran to his house to tell his mother. Grabbing her son’s birth certificate, she rushed to the entrance to the town to prove to the soldiers that he was only a child. But it was too late; the vehicle had already departed, headed to an army base nearby, where he would wait to be interrogated.

      By law, soldiers are supposed to handcuff children with their hands in front, but in many cases it’s done with their hands behind them. Additionally, sometimes the minor’s hands are too small for handcuffing, as a soldier from the Nahal infantry brigade told the NGO Breaking the Silence. On one occasion, he related, his unit arrested a boy “of about 11,” but the handcuffs were too big to bind his small hands.

      The next stage is the journey: The youths are taken to an army base or a police station in a nearby settlement, their eyes covered with flannelette. “When your eyes are covered, your imagination takes you to the most frightening places,” says a lawyer who represents young Palestinians. Many of those arrested don’t understand Hebrew, so that once pushed into the army vehicle they are completely cut off from what’s going on around them.

      In most cases, the handcuffed, blindfolded youth will be moved from place to place before actually being interrogated. Sometimes he’s left outside, in the open, for a time. In addition to the discomfort and the bewilderment, the frequent moving around presents another problem: In the meantime many acts of violence, in which soldiers beat the detainees, take place and go undocumented.

      Once at the army base or police station, the minor is placed, still handcuffed and blindfolded, on a chair or on the floor for a few hours, generally without being given anything to eat. The “endless trip to hell” is how Bayadsi describes this process. Memory of the incident, she adds, “is still there even years after the boy’s release. It implants in him an ongoing feeling of a lack of security, which will stay with him for his whole life.”

      Testimony provided to Breaking the Silence by an IDF staff sergeant about one incident in the West Bank illustrates the situation from the other side: “It was the first night of Hanukkah in 2017. Two children were throwing stones on Highway 60, on the road. So we grabbed them and took them to the base. Their eyes were covered with flannelette, and they were handcuffed in front with plastic cuffs. They looked young, between 12 and 16 years old.”

      When the soldiers gathered to light the first candle of the Hanukkah holiday, the detainees remained outside. “We’re shouting and making noise and using drums, which is a kind of company thing,” the soldier recalled, noting that he assumed the kids didn’t know Hebrew, although maybe they did understand the curses they heard. “Let’s say sharmuta [slut] and other words they might know from Arabic. How could they know we aren’t talking about them? They’ll probably thought that in another minute we were going to cook them.”

      Interrogation

      The nightmare can be of differing duration, the former detainees relate. Three to eight hours after the arrest, by which time the youth is tired and hungry – and sometimes in pain after being hit, frightened by threats and not even knowing why he’s there – he’s taken in for interrogation. This may be the first time the blindfold is removed and his hands freed. The process usually starts with a general question, such as, “Why do you throw stones at soldiers?” The rest is more intense – a barrage of questions and threats, aimed at getting the teen to sign a confession. In some cases, he’s promised that if he signs he’ll be given something to eat.

      According to the testimonies, the interrogators’ threats are directed squarely at the boy (“You’ll spend your whole life in jail”), or at his family (“I’ll bring your mother here and kill her before your eyes”), or at the family’s livelihood (“If you don’t confess, we’ll take away your father’s permit to work in Israel – because of you, he’ll be out of work and the whole family will go hungry”).

      “The system shows that the intention here is more to demonstrate control than to engage in enforcement,” suggests Bayadsi. “If the boy confesses, there’s a file; if he doesn’t confess, he enters the criminal circle anyway and is seriously intimidated.”

      Imprisonment

      Whether the young detainee has signed a confession or not, the next stop is prison. Either Megiddo, in Lower Galilee, or Ofer, north of Jerusalem. Khaled Mahmoud Selvi was 15 when he was brought to prison in October 2017 and was told to disrobe for a body search (as in 55 percent of the cases). For 10 minutes he was made to stand naked, along with another boy, and in winter.

      The months in detention, waiting for trial, and later, if they are sentenced, are spent in the youth wing of the facilities for security prisoners. “They don’t speak with their families for months and are allowed one visit a month, through glass,” Bayadsi relates.

      Far fewer Palestinian girls are arrested than boys. But there is no facility specially for them, so they are held in the Sharon prison for women, together with the adults.

      The trial

      The courtroom is usually the place where parents have their first sight of their child, sometimes several weeks after the arrest. Tears are the most common reaction to the sight of the young detainee, who will be wearing a prison uniform and handcuffs, and with a cloud of uncertainty hovering over everything. Israel Prisons Service guards don’t allow the parents to approach the youth, and direct them to sit on the visitors’ bench. Defense counsel is paid for either by the family or by the Palestinian Authority.

      At a recent remand hearing for several detainees, one boy didn’t stop smiling at the sight of his mother, while another lowered his eyes, perhaps to conceal tears. Another detainee whispered to his grandmother, who had come to visit him, “Don’t worry, tell everyone I’m fine.” The next boy remained silent and watched as his mother mouthed to him, “Omari, I love you.”

      While the children and their family try to exchange a few words and looks, the proceedings move along. As though in a parallel universe.

      The deal

      The vast majority of trials for juveniles ends in a plea bargain – safka in Arabic, a word Palestinian children know well. Even if there is no hard evidence to implicate the boy in stone-throwing, a plea is often the preferred option. If the detainee doesn’t agree to it, the trial could last a long time and he will be held in custody until the proceedings end.

      Conviction depends almost entirely on evidence from a confession, says lawyer Gerard Horton, from the British-Palestinian Military Court Watch, whose brief, according to its website, involves “monitoring the treatment of children in Israeli military detention.” According to Horton, who is based in Jerusalem, the minors will be more prone to confess if they don’t know their rights, are frightened and get no support or relief until they confess. Sometimes a detainee who does not confess will be told that he can expect to face a series of court appearances. At some stage, even the toughest youth will despair, the lawyer explains.

      The IDF Spokesman’s Unit stated in response: “The minors are entitled to be represented by an attorney, like any other accused, and they have the right to conduct their defense in any way they choose. Sometimes they choose to admit to guilt within the framework of a plea bargain but if they plead not guilty, a procedure involving hearing evidence is conducted, like the proceedings conducted in [civilian courts in] Israel, at the conclusion of which a legal decision will be handed down on the basis of the evidence presented to the court. The deliberations are set within a short time and are conducted efficiently and with the rights of the accused upheld.”

      Managing the community

      According to data of collected by the British-Palestinian NGO, 97 percent of the youths arrested by the IDF live in relatively small locales that are no more than two kilometers away from a settlement. There are a number of reasons for this. One involves the constant friction – physical and geographical – between Palestinians, on the one hand, and soldiers and settlers. However, according to Horton, there is another, no less interesting way to interpret this figure: namely, from the perspective of an IDF commander, whose mission is to protect the settlers.

      In the case of reported stone-throwing incidents, he says, the commander’s assumption is that the Palestinians involved are young, between the ages of 12 and 30, and that they come from the nearest village. Often the officer will turn to the resident collaborator in the village, who provides him with the names of a few boys.

      The next move is “to enter the village at night and arrest them,” Horton continues. “And whether these youths are the ones who threw the stones or not, you have already put a scare into the whole village” – which he says is an “effective tool” for managing a community.

      “When so many minors are being arrested like this, it’s clear that some of them will be innocent,” he observes. “The point is that this has to be happening all the time, because the boys grow up and new children appear on the scene. Each generation must feel the strong arm of the IDF.”

      According to the IDF Spokesperson’s Unit: “In recent years, many minors, some of them very young, have been involved in violent incidents, incitement and even terrorism. In these cases, there is no alternative but to institute measures, including interrogation, detention and trial, within the limits of and according to what is stipulated by law. As part of these procedures, the IDF operates to uphold and preserve the rights of the minors. In enforcing the law against them, their age is taken into account.

      “Thus, since 2014, among other measures, in certain instances, the minors are invited to the police station and are not arrested at home. In addition, proceedings relating to minors take place in the military court for juveniles, which examines the seriousness of the offense that’s attributed to the minor and the danger it poses, while taking into consideration his young age and his particular circumstances. Every allegation of violence on the part of IDF soldiers is examined, and cases in which the soldiers’ actions are found to be flawed are treated sternly.”

      The Shin Bet security service stated in response: “The Shin Bet, together with the IDF and the Israel Police, operates against every element that threatens to harm Israel’s security and the country’s citizenry. The terrorist organizations make extensive use of minors and recruit them to carry out terrorist activity, and there is a general tendency to involve minors in terrorist activity as part of local initiatives.

      “Interrogations of suspected terrorists are conducted by the Shin Bet under the law, and are subject to supervision and to internal and external review, including by all levels of the court system. The interrogations of minors are carried out with extra sensitivity and with consideration of their young age.”

      Khaled Mahmoud Selvi, arrested at 14 (October 2017)

      “I was arrested when I was 14, all the boys in the family were arrested that night. A year later, I was arrested again, with my cousin. They said I burned tires. It happened when I was sleeping. My mother woke me up. I thought it was time for school, but when I opened my eyes I saw soldiers above me. They told me to get dressed, handcuffed me and took me outside. I was wearing a short-sleeved shirt and it was cold that night. My mother begged them to let me put on a jacket, but they didn’t agree. Finally, she threw the jacket on me, but they didn’t let me put my arms in the sleeves.

      “They took me to the Karmei Tzur settlement with my eyes covered, and I had the feeling that they were just driving in circles. When I walked, there was a pit in the road and they pushed me into it, and I fell. From there they took me to Etzion [police station]. There they put me in a room, and soldiers kept coming in all the time and kicking me. Someone passed by and said that if I didn’t confess, they would leave me in jail for the rest of my life.

      “At 7 A.M., they told me the interrogation was starting. I asked to go to the toilet before. My eyes were covered and a soldier put a chair in front of me. I tripped. The interrogation went on for an hour. They told me that they saw me burning tires and that it interfered with air traffic. I told them it wasn’t me. I didn’t see a lawyer until the afternoon, and he asked the soldiers to bring us food. It was the first time I had eaten since being arrested the night before.

      “At 7 P.M., I was sent to Ofer Prison, and I remained there for six months. In that period, I was in court more than 10 times. And there was also another interrogation, because a friend of mine was told while being questioned that if he didn’t confess and inform on me, they would bring his mother and shoot her before his eyes. So he confessed and informed. I’m not angry at him. It was his first arrest, he was scared.”

      Khaled Shtaiwi, arrested at 13 (November 2018)

      Khaled’s story is told by his father, Murad Shatawi: “On the night he was arrested, a phone call from my nephew woke me up. He said the house was surrounded by soldiers. I got up and got dressed, because I expected them to arrest me, on account of the nonviolent demonstrations I organize on Fridays. I never imagined they’d take Khaled. They asked me for the names of my sons. I told them Mumen and Khaled. When I said Khaled, they said, ‘Yes, him. We’re here to take him.’ I was in shock, so many soldiers showed up to arrest a boy of 13.

      “They handcuffed and blindfolded him and led him east on foot, toward the settlement of Kedumim, all the while cursing and hitting him a little. I saw it all from the window. They gave me a document showing that it was a legal arrest and I could come to the police station. When I got there, I saw him through a small hole in the door. He was handcuffed and blindfolded.

      “He stayed like that from the moment they arrested him until 3 P.M. the next day. That’s a picture that doesn’t leave me; I don’t know how I’ll go on living with that picture in my head. He was accused of throwing stones, but after four days they released him, because he didn’t confess and there was no other evidence against him. During the trial, when the judge wanted to speak to Khaled, he had to lean forward in order to see him, because Khaled was so small.

      “What was it like to see him like that? I am the father. That says it all. He hasn’t talked about it since getting out, three months ago. That’s a problem. I’m now organizing a ‘psychology day’ in the village, to help all the children here who have been arrested. Out of 4,500 people in the village, 11 children under the age of 18 have been arrested; five were under the age of 15.”

      Omar Rabua Abu Ayyash, arrested at age 10 (December 2018)

      Omar looks small for his age. He’s shy and quiet, and it’s hard to talk to him about the arrest, so members of his family recount the events in his place.

      Omar’s mother: “It happened at 10 A.M. on Friday, when there is no school. Omar was playing in the area in front of the house, he threw pebbles at birds that were chirping in the tree. The soldiers, who were in the watchtower across the way here, picked up on what he was doing and ran toward him. He ran, but they caught him and knocked him down. He started to cry, and he wet his pants. They kicked him a few times.

      “His grandmother, who lives here below, immediately went out and tried to take him from the soldiers, which caused a struggle and shouts. In the end, they left him alone and he went home and changed into dry pants. A quarter of an hour later, the soldiers came back, this time with their commander, who said he had to arrest the boy for throwing stones. When the other children in the family saw the soldiers in the house, they also wet their pants.”

      Omar’s father takes up the story: “I told the commander that he was under 12 and that I had to accompany him, so I rode with him in the jeep to the Karmei Tzur settlement. There the soldiers told him not to throw stones anymore, and that if he saw other children doing it, he should tell them. From there they took him the offices of the Palestinian Authority in Hebron. The whole story took about 12 hours. They gave him a few bananas to eat during those hours. Now, whenever the children see a military jeep or soldiers, they go inside. They’ve stopped playing outside since then. Before the incident, soldiers used to come here to play soccer with the children. Now they’ve stopped coming, too.”

      Tareq Shtaiwi, arrested at 14 (January 2019)

      “It was around 2 P.M. I had a fever that day, so Dad sent me to my cousin next door, because that’s almost the only place in the village with a heating unit. Suddenly soldiers showed up. They saw me watching them from the window, so they fired shots at the door of the building, knocked it down and started to come upstairs. I got scared, so I ran from the second floor to the third, but they stopped me on the way and took me outside. The soldiers wouldn’t let me take my coat, even though it was cold and I was sick. They took me on foot to Kedumim, handcuffed and blindfolded. They sat me on a chair. I heard doors and windows being slammed hard, I think they were trying to scare me.

      “After a while, they took me from Kedumim to Ariel, and I was there for five-six hours. They accused me of throwing stones a few days earlier with my friend. I told them I hadn’t thrown any stones. In the evening they moved me to the Hawara detention building; one of the soldiers told me I would never leave there. In the morning I was moved to Megiddo Prison. They didn’t have prisoners uniforms in my size, so they gave me clothes of Palestinian children who had been there before and left them for the next in line. I was the youngest person in the prison.

      “I had three court hearings, and after 12 days, at the last hearing, they told me that it was enough, that my father would pay a fine of 2,000 shekels [$525] and I was getting a three-year suspended sentence. The judge asked me what I intended to do after getting out, I told him I would go back to school and I wouldn’t go up to the third floor again. Since my arrest, my younger brother, who’s 7, has been afraid to sleep in the kids’ room and goes to sleep with our parents.”

      Adham Ahsoun, arrested in October 2018, on his 15th birthday

      “On my 15th birthday, I went to the store in the village center to buy a few things. Around 7:30 in the evening, soldiers entered the village and children started to throw stones at them. On the way home with my bag, they caught me. They took me to the entrance of the village and put me in a jeep. One of the soldiers started to hit me. Then they put plastic handcuffs on me and covered my eyes and took me like that to the military base in Karnei Shomron. I was there for about an hour. I couldn’t see a thing, but I had the feeling that a dog was sniffing me. I was afraid. From there they took me to another military base and left me there for the night. They didn’t give me anything to eat or drink.

      “In the morning, they moved me to the interrogation facility in Ariel. The interrogator told me that the soldiers caught me throwing stones. I told him that I hadn’t thrown stones, that I was on my way home from the store. So he called the soldiers into the interrogation room. They said, ‘He’s lying, we saw him, he was throwing stones.’ I told him that I really hadn’t thrown stones, but he threatened to arrest my mother and father. I panicked. I asked him, ‘What do you want from me?’ He said he wanted me to sign that I threw stones at soldiers, so I signed. The whole time I didn’t see or talk to a lawyer.

      “My plea bargain was that I would confess and get a five-month jail sentence. Afterward, they gave me one-third off for good behavior. I got out after three months and a fine of 2,000 shekels. In jail I tried to catch up with the material I missed in school. The teachers told me they would only take into account the grades of the second semester, so it wouldn’t hurt my chances of being accepted for engineering studies in university.”

      Muhmen Teet, arrested at 13 (November 2017)

      “At 3 A.M., I heard knocking on the door. Dad came into the room and said there were soldiers in the living room and wanted us to show ID cards. The commanding officer told my father that they were taking me to Etzion for questioning. Outside, they handcuffed and blindfolded me and put me in a military vehicle. We went to my cousin’s house; they also arrested him. From there we went to Karmei Tzur and waited, handcuffed and blindfolded, until the morning.

      “In the morning, they only took my cousin for interrogation, not me. After his interrogation, they took us to Ofer Prison. After a day there, they took us back to Etzion and said they were going to interrogate me. Before the interrogation, they took me into a room, where there was a soldier who slapped me. After he hit me in one room, he took me to the interrogation room. The interrogator said I was responsible for burning tires, and because of that the grove near the house caught fire. I said it wasn’t me, and I signed a document that the interrogator gave me. The document was also printed in Arabic, but the interrogator filled it out in Hebrew. I was taken back to Ofer Prison.

      “I had seven hearings in court, because at the first hearing I said I hadn’t intended to confess, I just didn’t understand what I signed and it wasn’t true. So they sent me back for another interrogation. Again I didn’t confess. Then they sent me to interrogation another time and again I didn’t confess. That’s what it was like in three interrogations. In the end, my lawyer did a deal with the prosecutor that if I confessed in court – which I did – and my family would pay 4,000 shekels, they would release me.

      “I’m a good student, I like soccer, both playing and watching it. Since the arrest I hardly wander around outside.”

      Khalil Zaakiq, arrested at age 13 (January 2019)

      “Around 2 A.M. someone knocked on the door. I woke up and saw a lot of soldiers in the house. They said we should all sit in the living room sofa and not move. The commander called Uday, my big brother, told him to get dressed and informed him that he was under arrest. It was the third time they arrested him. My father was also once under arrest. Suddenly they told me to put my shoes on too and go with them.

      “They took us out of the house and tied our hands and covered our eyes. We went like that on foot to the base in Karmei Tzur. There they sat me on the floor with hands tied and eyes covered for around three hours. At about 5 A.M., they moved us to Etzion. On the way there in the jeep they hit us, they slapped me. In Etzion, I was sent to be checked by a doctor. He asked if I had been beaten and I said yes. He didn’t do anything, only checked my blood pressure and said I could stand up to an interrogation.

      “My interrogation started at 8 A.M.. They asked me to tell them which children throw stones. I said I didn’t know, so the interrogator gave me a slap. The interrogation went on for four hours. Afterward, they put me into a dark room for 10 minutes and then took me back to the interrogation room, but now they only fingerprinted me and put me into a detention cell for an hour. After an hour, Uday and I were moved to Ofer Prison. I didn’t sign a confession, neither about myself nor about others.

      “I got out after nine days, because I wasn’t guilty of anything. My parents had to pay 1,000 shekels for bail. My little brother, who is 10, has been really afraid ever since. Whenever someone knocks at the door, he wets his pants.”


  • FDA takes fresh look at whether opioids are effective for chronic pain - The Washington Post
    https://www.washingtonpost.com/national/health-science/fda-takes-fresh-look-at-whether-opioids-are-effective-for-chronic-pain/2019/02/25/227a5fe6-3917-11e9-a06c-3ec8ed509d15_story.html

    The Food and Drug Administration will require drug companies to study whether prescription opioids are effective in quelling chronic pain — another step in the government’s efforts to rein in use of the narcotics that spawned the drug epidemic.

    Some studies already indicate that opioids are ineffective for pain beyond 12 weeks and many experts say long-term use can cause addiction, by prompting patients to build up tolerance to the drugs and seek higher doses. But conclusive, controlled research is scarce.

    A finding of ineffectiveness in more rigorous studies supervised by the FDA could allow the agency to change the labeling on some opioids, impose special rules for prescribing, dispensing and taking them, and even prohibit their use in some cases, according to FDA Commissioner Scott Gottlieb.

    But at least one longtime critic of the FDA’s response to the opioid crisis expressed frustration with the move. Andrew Kolodny, director of Physicians for Responsible Opioid Prescribing, said the FDA already has all the research it needs — and authority under existing law — to tighten restrictions on the use of opioids for chronic pain by changing instructions for how they should be prescribed.

    “Here we go again,” Kolodny said in an interview. “That’s exactly what the FDA said to us in 2013. . . . Five years later, we don’t have the studies and another FDA commissioner says, ‘We’re going to do the studies.’ ”

    In 2013, after Kolodny’s group complained that opioids should be labeled unsafe and ineffective for chronic pain, the FDA ordered similar research, including an attempt to determine whether painkillers cause hyperalgesia. Gottlieb said those studies were difficult to carry out because, at the time, the FDA had authority only to require post-market studies of safety, rather than effectiveness.

    On Sunday, the CBS program “60 Minutes” explored the FDA’s decision in 2001 to allow long-term use of OxyContin despite the lack of research showing it was safe and effective. Gottlieb conceded that “it’s regrettable we didn’t do this many years ago.”

    The vast majority of opioid prescriptions written in 2017 were for generic versions of the drugs. The research would be required only of companies that produce brand-name narcotics; generic producers would be required to adopt the same changes.

    #Opioides #USA #FDA #Efficacité


  • How These Companies Are Using #cbd #technology To Solve Pain Relief
    https://hackernoon.com/how-these-companies-are-using-cbd-technology-to-solve-pain-relief-403a50

    Image sourceNo one should have to live with chronic pain. There are pharmaceutical options to help give you some relief, but depending on your body, these might come with side effects and require varying dosages. Many people are turning to plant-based CBD oil as an alternative: several brands are all-natural, organic, and you cannot build a tolerance for it.CBD — short for cannabidiol — comes from #cannabis. Unlike marijuana, though, which contains the psychoactive THC that gets you high, CBD is derived from the hemp branch of cannabis. While further research is necessary, there is evidence suggesting that CBD products (such as oil and tinctures) can relieve pain symptoms, help with anxiety and depression, smooth the skin when applied topically, and provide other various benefits. Floyd’s of (...)

    #cannabis-medical #cbd-oils


  • Watch: These drug company execs actually used rap video parody to push high-dose fentanyl sales – Alternet.org
    https://www.alternet.org/2019/02/watch-these-drug-company-execs-actually-used-rap-video-parody-to-push-high

    Back in 2015, as the country was deep in the midst of the ongoing opioid crisis, at least one major pharmaceutical company thought its sales reps weren’t doing enough to push higher doses of its highly potent fentanyl product, so company executives produced a parody rap video to spur them on.

    The video emerged last week during the trial in Boston of Insys Therapeutics Inc. founder John Kapoor and four of his former executives on charges they conspired to pay bribes and kickbacks to doctors to get them to prescribe the company’s fentanyl spray, which was designed to treat cancer patients with severe pain.

    One of those executives was a former stripper hired as a regional sales manager even though prosecutors said she had no pharmaceutical experience. She was good at providing lap dances for doctors, though.

    More than 900 people have died from Insys’ fentanyl spray since it was approved in 2012.

    The video, “Great by Choice,” features suit-and-tie wearing sales reps rapping to the tune of an A$AP Rocky song, but with lyrics focused on getting doctors to gradually increase the doses of fentanyl spray they prescribed to patients, a process known as titration.

    “I love titrations, yeah, that’s not a problem. I got new patients and I got a lot of ’em,” the sales reps rap. “Build relationships that are healthy. Got more docs than Janelle’s got selfies.”

    And, of course, a shout-out to the boss:

    “What we built here can’t be debated. Shout to Kapoor for what you’ve created,” they rap. “While the competition just making noise. We’re making history because we’re great by choice.”

    The video also includes a cameo from former Insys vice-president of sales Alec Burlakoff. He pleaded guilty to racketeering conspiracy in November and is expected to testify against Kapoor in the current trial. He enters dressed up as a bottle of fentanyl spray before unveiling himself as the company’s hard-charging sales cheerleader.

    The video is just the latest explosive revelation from the trial, which is expected to last for several more weeks, and, while not as titillating as the lap-dancing sales exec, does as much to demonstrate the craven corporate culture fostered by Kapoor in his bid to turn a profit off pain medications.

    And now, Kapoor and his former top execs are turning on each other. Burlakoff and another key witness, former CEO Michael Babich, who pleaded guilty last month, are pointing fingers at Kapoor. Babich testified last week that Kapoor pushed sales reps to get doctors to put patients on higher doses, and Burlakoff is expected to echo that testimony.

    Kapoor’s attorneys, though, are portraying Burlakoff and Babich as liars seeking reduced sentences and blaming Burlakoff for any criminal activity. Is there no honor among pharma execs?

    #Opioides #Fentanyl #Insys


  • An Honest Review About The Benefits of CBD Products
    https://hackernoon.com/an-honest-review-about-the-benefits-of-cbd-products-b73c346443e0?source=

    Cannabidiol (CBD) is a naturally-occurring constituent of cannabis plants. It is the most abundant non-psychoactive cannabinoid found in cannabis and is being scientifically investigated for numerous reasons which we will further discuss.A huge hype is surrounding CBD products as it is believed to be able to treat anxiety, epilepsy, acne, pain, schizophrenia, and many other ailments. Nowadays, we can find a variety of products ranging from oils, wax, to CBD-infused foods. In fact, an entire site, CBDSailor, is dedicated just to ranking the best CBD products.Of course, not everyone is sold. With scant research on effectiveness or side effects, some doctors remain skeptical, and there are users who say they don’t feel a thing when using CBD products. The products also aren’t regulated by (...)

    #health #lifestyle #efficiency #entrepreneurship #leadership


  •  » Israeli Soldiers Kill One Palestinian, Injure 30, Near Ramallah
    IMEMC News - January 26, 2019 6:39 PM
    http://imemc.org/article/israeli-soldiers-kill-one-palestinian-injure-30-near-ramallah

    Israeli soldiers killed, Saturday, one Palestinian and injured at least 30 others, after a group of illegal colonialist settlers attempted to invade the northern part of the al-Mughayyir village, east of the central West Bank city of Ramallah, and were intercepted by the villagers.

    The Palestinian Health Ministry said the Palestinian, identified as Hamdi Taleb Sa’ada Na’san , 38, was shot with a live round in his back, and the bullet was logged in the upper abdomen.

    The Palestinian was rushed to Palestine Medical Complex, in Ramallah, but died from his very serious wounds.

    The soldiers also injured at least thirty other Palestinians, among them six who were shot with live fire, including one who suffered a very serious injury.

    One of the wounded Palestinians was shot with a live round in his mouth, before he was rushed to the Istishari hospital, in Ramallah, in a moderate-but-stable condition.

    ““““““““““““““““““““““““““““““
    PCHR
    https://pchrgaza.org/en/?p=11937

    A Palestinian Civilian Killed by Israeli Settlers

    At approximately 15:30 on Saturday, 26 January 2019, a group of Israeli settlers moved into al-Moghayer village, northeast of Ramallah, and rioted on the streets while opening fire at several houses; 2 of them belonged to Jamal ‘Ali al-Na’asan and ‘Abdullah al-Na’asan, breaking all the houses’ windows.
    Meanwhile, dozens of Palestinian young men gathered to throw stones, empty bottles and Molotov Cocktails at them. In response, the settlers immediately and randomly fired a barrage of bullets, wounding Hamdi Taleb al-Na’asan (38) with a bullet that entered his lower back, hit the lungs and then exited from the chest. As a result, Hamdi fell on the ground and was immediately taken via an ambulance belonging to the Palestine Red Crescent Society (PRCS) to Palestine Medical Complex in Ramallah, where his death was declared in the ED due to arriving in a very critical condition.

    Following that, the Israeli forces moved into the village to provide protection for settlers and opened fire at the Palestinian protestors. As a result, 22 civilians were wounded with bullets and shrapnel; 8 of them were taken to the Palestine Medical Complex, 6 were taken to the Istishari Arab Hospital in al-Rihan Suburb, north of Ramallah, and 8 were taken to the medical center in nearby Termes’aya village. It should be mentioned that Hamdi al-Na’asan was a former prisoner in the Israeli jails, where he served an 8-year sentence. He was also married with 4 children; the youngest is only 1 year old.

    #Palestine_assassinée

    • Welcome to the Palestine Circus
      Gideon Levy Jan 27, 2019 3:38 AM
      https://www.haaretz.com/opinion/.premium-welcome-to-the-palestine-circus-1.6874241

      A lethal weekend for Palestinians — four killed, from Rafah in the Gaza Strip to Ramallah in the West Bank — ended Saturday with the death of a farmer in his olive orchard, in the central West Bank village of Al-Mughayyir.

      It was the afternoon. Hamdi Na’asan and a few fellow villagers were about to finish tilling their fine olive orchard, downhill from the virulent outpost of Adei Ad. It is plowing season and the farmers were turning over the earth on their beautifully terraced orchard. At around 4 P.M., a group of armed settlers approached from the direction of Adei Ad and began attacking them in an effort to chase them off their land.

      That is the routine here in the land of the outposts, especially in Al-Mughayyir. I was in the village last week, and I saw the still and bleeding remains of 25 olive trees planted 35 years ago, cut down by electric saws, tree after tree, on Friday January 11, three days before the Jewish holiday of Tu Bishvat, sometimes called Jewish Arbor Day.

      Footprints led to the Mevo Shiloh outpost, whose residents took over a half-abandoned army barracks on the hill above Al-Mughayyir’s fields. For the past two months, villagers had gathered every Friday at their land to demand the removal of Mevo Shiloh. Its settlers graze their flocks on the village’s land and have carried out so-called price tag attacks in the village, vandalizing cars.

      On Saturday they came from Adei Ad. A few days before, villagers said they had somehow learned to live with Adei Ad, and their problem was with Mevo Shilo. This weekend it became clear to them that it was a choice between plague and cholera. One week the evil came from the east, from Mevo Shilo, a week later from the north, Adei Ad — a rotation of hate crimes coming from the outposts. You should have seen the fear of the residents as we drove to their orchards last week as we approached Mevo Shilo, to see the atmosphere of threats and terror with which they live.

      After the settlers came down and attacked them, the farmers phoned for help. They were utterly helpless: The army will always side with the settlers, of course. The residents also called the Palestinian liaison bureau but didn’t get any help. Military forces arrived, and soldiers and settlers began shooting live ammunition toward the farmers.

      Villagers deny claims that the settlers were attacked by farmers. Anyone familiar with the Shiloh Valley knows how difficult, impossible really, it is to believe such claims. The settlers descend upon fields that aren’t theirs for the sole purpose of evicting residents from their land and striking fear. That’s the aim, that’s the goal.

      The farmers and villagers who rushed to help them fled south, toward the village, as soldiers and settlers fired first tear gas, that enveloped the homes, and then live ammunition. They shot at them as they fled. Na’asan was shot in the back. The Israel Defense Forces said Saturday night that he was shot by a settler. It took an hour to bring him to the government hospital in Ramallah. An additional 15 villagers were wounded. Nine were admitted to the Ramallah hospital; three needed surgery.

      The view from Al-Mughayyir is gorgeous this time of year, a fertile valley, cultivated amazingly. Brown earth sprouting blossoming olive orchards and green fields. And here are the photographs of Na’asan’s death: His dead face and closed eyes, the small hole in his back, near his spine. He was 38, a father of four, a relative of Abed al Hai Na’asan, the owner of the orchard whose trees were cut down, with whom we went last week to witness the damage and his pain.

      Thus fell the village’s first victim since the start of its popular protest, and he will probably not be the last.

    • UN Mladenov condemns Israeli settler killing of Palestinian father
      Jan. 27, 2019 12:36 P.M. (Updated: Jan. 27, 2019 1:08 P.M.)
      http://www.maannews.com/Content.aspx?id=782366

      BETHLEHEM (Ma’an) — The United Nations Special Coordinator for the Middle East Peace Process, Nikolay Mladenov, condemned in a tweet the Israeli settlers’ killing of a Palestinian father during an attack on al-Mughayyir village, on Saturday.

      Mladenov posted in a tweet, “Today’s violence in al-Mughayyir is shocking and unacceptable!”

      He added, “Israel must put an end to settler violence & bring those responsible to justice.”

      “My thoughts and prayers go out to the family of the #Palestinian man killed and those injured… All must condemn violence, stand up to terror,” he stressed.

    • Hamdi Naasan, un père de quatre enfants, assassiné par les colons
      Annelies Keuleers - 28 janvier 2019 – Al-Jazeera – Traduction : Chronique de Palestine
      http://www.chroniquepalestine.com/hamdi-naasan-un-pere-de-quatre-enfants-assassine-par-les-colons

      Nikolay Mladenov, l’envoyé des Nations Unies au Moyen-Orient, appelle Israël à traduire en justice les assassins du Palestinien Hamdi Naasan.

      L’envoyé de l’ONU au Moyen-Orient a qualifié le meurtre d’un Palestinien par les colons israéliens en Cisjordanie occupée de « choquant et inacceptable ».

      Nikolay Mladenov a appelé dimanche Israël à « mettre fin à la violence des colons et à traduire les responsables en justice ».

      Hamdi Naasan, âgé de 38 ans, a succombé à ses blessures samedi près du village d’Al Mugheir après que des colons israéliens de la colonie illégale d’Adei Ad, située à proximité, aient tiré des coups de feu.

      Selon le ministère palestinien de la Santé, Naasan aurait reçu une balle de fusil dans le dos. Selon l’agence de presse Maan, au moins 30 autres Palestiniens ont été blessés, dont six par des tirs à balles réelles.

      Des milliers de personnes se sont rassemblées dans le village d’al-Mugheir pour assister aux funérailles de Naasan.

      L’armée israélienne a temporairement empêché les personnes en deuil d’atteindre le lieu de sépulture en érigeant un barrage routier entre l’autoroute et une route menant au village. Lors d’un affrontement qui a suivi, l’armée israélienne a kidnappé deux adolescents palestiniens.


  • The sadists who destroyed a decades-old Palestinian olive grove can rest easy
    Another Palestinian village joins the popular protest, its inhabitants no longer able to bear attacks by settlers. Vandals have butchered a grove of 35-year-old olive trees in the village. The tracks led to a nearby settler outpost
    Gideon Levy and Alex Levac Jan 24, 2019
    https://www.haaretz.com/israel-news/the-sadists-who-destroyed-a-decades-old-palestinian-olive-grove-can-rest-ea

    Vandalism in an olive grove in the West Bank village of Al-Mughayyir. Credit Alex Levac

    Who are the human scum who last Friday drove all-terrain vehicles down to the magnificent olive grove owned by Abed al Hai Na’asan, in the West Bank village of Al-Mughayyir, chose the oldest and biggest row, and with electric saws felled 25 trees, one after another? Who are the human scum who are capable of fomenting such an outrage on the soil, the earth, the trees and of course on the farmer, who’s been working his land for decades? Who are the human scum who fled like cowards, knowing that no one would bring them to justice for the evil they had wrought?

    We’re unlikely ever to get the answers. The police are investigating, but at the wild outposts of the Shiloh Valley, and Mevo Shiloh in particular, where the perpetrators’ tracks led, they can go on sleeping in peace. No one will be arrested, no one will be interrogated, no one will be punished. That’s the lesson of past experience in this violent, lawless, settlers’ country.

    The story itself makes one’s blood boil, but only the sight of the violated grove brings home the scale of the atrocity, the pathological sadism of the perpetrators, the depth of the farmer’s pain upon seeing that his own God’s little acre was assaulted by the Jewish, Israeli, settlers, believers, destroyers – just three days before Tu B’Shvat, the Jewish Arbor Day, the holiday of the trees celebrated by the same people who destroyed his grove. This is how they express their love for the land, this is a reflection of the encroacher’s fondness for the earth and for nature.

    And on a boulder at the far end of the grove they left their calling card, smeared on a rock: a Star of David smeared in red, shamefaced, shameful, a Mark of Cain that stigmatizes everything it stands for, and next to it, the word “Revenge.” Revenge for what?

    The 25 felled trees lie like corpses after a massacre on the fertile brown, plowed earth. Twenty-five thick trunks stand bare and decapitated, their roots still deep in the earth, their tops gone, the work of a malicious hand – now mere dead lumber after years of having been tended, cultivated and irrigated. It was the most impressive row of trees in the grove; the destroyers moved along it with satanic deliberateness, sawing mercilessly. When, walking amid the stumps in the grove, the distraught owner Na’asan said that for him the act was tantamount to murder, his words made perfect sense. When we were just arriving there, his wife had phoned and begged him not to visit the grove, for fear he would not be able to abide the sight. Na’asan has cancer.

    In the briefcase of documents he always carries with him is a copy of the official complaint he submitted to the Binyamin district station of the Israel Police, despite the fact that he knows nothing will ever come of it, that it will be buried like every such complaint. Anyone who wanted to apprehend the rampagers could have done it that same day: Mevo Shiloh, where the tracks of the all-terrain vehicles led, is a small settler outpost – violent and brazen.

    The way to Al-Mughayyir, located south of Jenin, passes through the affluent town of Turmus Ayya, many of whose residents live most of the year in the United States, only visiting their splendid homes in the summer. The village, with a population of 3,500, is separated from the town by pasture land where sheep are now grazing. Everything is lushly green.

    Abed al Hai Na’asan, with a butchered olive tree. The people of Al-Mughayyir say their problems have never been with the army, only with the settlers. Credit : Alex Levac

    In the center of Al-Mughayyir, a few men are standing next to an official vehicle of the Palestinian Authority. Personnel from the Palestinian Ministry of Agriculture have arrived to assess the damage suffered by the farmers; at best the ministry gives them a symbolic amount of compensation. Such is the deceptive semblance of a government that supposedly protects helpless farmers.

    Everyone in the village knows that the PA can do nothing. So, about two months ago, the residents launched a popular protest, just as citizens of other villages before them have done – from Kaddoum, Nabi Saleh, Bil’in, Na’alin and others. Every Friday, they gather on their land, which lies on the eastern side of the Allon Road, and are confronted by a large number of army and Border Police forces, who disperse them with great quantities of tear gas that hangs like a pall over Al-Mughayyir, and with rubber bullets, rounds of “tutu” bullets (live 0.22-caliber bullets). Then come the nighttime arrests. Overnight this past Sunday, the troops arrested another seven villagers who took part in the demonstrations; 35 locals are currently in detention. This is the method Israel uses to suppress every popular protest in the territories.

    According to the villagers, their sole demand is removal of the Mevo Shiloh outpost, which was established without a permit on a half-abandoned Israel Defense Forces base that overlooks their fields. The settlers burn the Palestininans’ fields, allow their sheep to graze on their land without permission, chase away the villagers’ flocks and perpetrate various “price tag” operations – hate crimes – against them.

    In the previous such assault, on November 25, eight cars were damaged. The graffiti, documented by Iyad Hadad, a field researcher for the Israeli human rights organization B’Tselem, leave little to the imagination: “Death to the Arabs,” “Enough administrative orders,” “Revenge,” “Price Tag” – and also the unfathomable “Regards to Nachman Rodan.”

    The people of Al-Mughayyir say their problems have never been with the army, only with the settlers. Here the war is for control of the land. It is a primeval, despairing war in which law, property rights and ownership play no part – what counts is the violence that can be perpetrated, under the aegis of the occupation authorities. When, one day, these people are forced to give up their land in the wake of the violence, the settlers will chalk up yet another impressive achievement in their effort to chop up the West Bank into separate and disconnected slices of territory. This week, when we drove across village land toward Mevo Shiloh, the villagers who rode with us begged us to turn around at once. So great is their fear of the settlers, that even when they crossed their fields in a car with Israeli plates, accompanied by Israelis, they were seized by dread.

    The home of Amin Abu Aaliya, head of the village council, is perched atop a high hill, overlooking all the houses in his village and the fertile valley where his lands lie. In the winter sun that shines on the holiday of the trees, he serves a local pastry stuffed with leaves of green za’atar (wild hyssop), baked by his wife, who doesn’t join us. When we ask him to “Tell her it was delicious,” he replies, “She mustn’t get a swelled head.”

    The view from the roof of his elegant home is indeed stunning. Scratchy music that blares from an old Citroen Berlingo down below heralds the arrival in the village of a vendor selling the sweet cotton candy known here as “girls’ hair.” In the middle of the village, young people are decorating one of the houses with flags of Fatah and Palestine: A resident of the village is due to return home today after serving two years in an Israeli prison, and a festive welcome is being prepared for him.

    The Allon Road, which was paved in the 1970s and runs north to south in the eastern part of the West Bank, with the aim of severing its territories from the Kingdom of Jordan, also separated Al-Mughayyir from most of its land, about 30,000 dunams (7,500 acres), located east of the road. The villagers grew used to that over the years. They also forgave the expropriation of land for the road and afterward for its widening. There is no safe place for them to cross the Allon Road with their herds, to access their land but they grew used to that, too. Sometimes the army blocks the dirt road that leads from the village to their land and they are cut off from it, unless they decide to take a long bypass route there. A matter of routine.

    The people of Al-Mughayyir also learned how to live with the former existence of the military base of Mevo Shiloh, which dominated their land. They even came to terms with the Adei Ad outpost, whose members also assaulted them. But then the IDF evacuated the base and the settlers seized it. An internet search reveals that the settlers were ostensibly removed from this outpost a few years ago. But mobile homes sprout from the high hill that overlooks the village’s fields, and alongside them, large structures used for farming. Mevo Shiloh is alive and kicking.

    The villagers say that the Civil Administration, a branch of the military government, promised them in the past that the outpost would be evacuated, but that didn’t happen. Lacking the funds to wage a legal battle, and not believing it would produce results anyway, they embarked on their Friday demonstrations.

    I asked whether they had first consulted with other locales that have waged similar struggles. “There was no need to,” the council head said. “You don’t need consultation when you are in the right. We feel unsafe on our own land. How are we to protect ourselves and our lands? It’s a natural reaction: Either to turn to violence or to popular protest. We chose the path of popular protest.”

    The dirt path that leads east from the village toward the Allon Road reflects the events here in the past two months. Empty canisters of the tear gas fired at the demonstrators hang from electrical cables, the ground is strewn with the remnants of scorched tires and with stone barriers. During the Friday protest two weeks ago, 30 villagers were wounded by rubber-coated metal bullets. The troops film the demonstrators and raid the village at night to arrest them – standard procedure in the villages of the struggle. Close to 100 residents have been detained during the past two months.

    A dense cloud of tear gas hangs over Al-Mughayyir during the demonstrations and, according to council head Aaliya, even wafts upward to his house high on the hill. In some cases the settlers join the security forces to disperse the demonstrations, throwing stones at the protesters.

    Na’asan, whose trees were ravaged, arrives at Aaliya’s house and shows him a copy of the complaint he filed with the Binyamin police: “Confirmation of submission of complaint.” The space for the details of the incident is empty. The space for the place of the event contains the following, word for word: “Magir RM in the forest, nursery, grove, field.” The charge: “Damage to property maliciously.” Hebrew only, of course. “File No. 31237.”

    The police arrived at the grove last Friday, two hours after Na’asan discovered what had happened and reported it to the Palestinian Coordination and Liaison office. They said the ATV tracks seemed to lead to Mevo Shiloh. According to Na’asan, while the police were in the grove, a few settlers stood on the hill opposite and watched. The police are now investigating.

    About 20 members of Na’asan’s extended family subsist thanks to this grove, which before the attack boasted a total of 80 trees of different ages, all meticulously cultivated. Standing here now, he says he’ll have to clear away those that were felled and bandage the stumps against the cold. That’s the only way they will perhaps sprout new branches, which he will have to tend. It will take another 35 years for the grove to return to its former state. Na’asan is 62. This grove grew together with his children, he says. He knows there’s little chance he’ll be around to see it recover.


  • Zuckerberg San Francisco General’s aggressive tactics leave patients with big bills - Vox
    https://www.vox.com/policy-and-politics/2019/1/7/18137967/er-bills-zuckerberg-san-francisco-general-hospital

    On April 3, Nina Dang, 24, found herself in a position like so many San Francisco bike riders — on the pavement with a broken arm.

    A bystander saw her fall and called an ambulance. She was semi-lucid for that ride, awake but unable to answer basic questions about where she lived. Paramedics took her to the emergency room at Zuckerberg San Francisco General Hospital, where doctors X-rayed her arm and took a CT scan of her brain and spine. She left with her arm in a splint, on pain medication, and with a recommendation to follow up with an orthopedist.

    A few months later, Dang got a bill for $24,074.50. Premera Blue Cross, her health insurer, would only cover $3,830.79 of that — an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay, which the hospital threatened to send to collections in mid-December.

    [...]

    Zuckerberg San Francisco General (ZSFG), recently renamed for the Facebook founder after he donated $75 million, is the largest public hospital in San Francisco and the city’s only top-tier trauma center. But it doesn’t participate in the networks of any private health insurers — a surprise patients like Dang learn after assuming their coverage includes a trip to a large public ER.

    #prix #santé #etats-unis


  • The roundabout revolutions

    The history of these banal, utilitarian instruments of traffic management has become entangled with that of political uprising, #Eyal_Weizman argues in his latest book

    This project started with a photograph. It was one of the most arresting images depicting the May 1980 #Gwangju uprising, recognised now as the first step in the eventual overthrow of the military dictatorship in South Korea. The photograph (above) depicts a large crowd of people occupying a roundabout in the city center. Atop a disused fountain in the middle of the roundabout a few protestors have unfurled a South Korean flag. The roundabout organised the protest in concentric circles, a geometric order that exposed the crowd to itself, helping a political collective in becoming.

    It had an uncanny resonance with events that had just unfolded: in the previous year a series of popular uprisings spread through Tunisia, Egypt, Bahrain, #Oman, Yemen, Libya, and Syria. These events shared with Gwangju not only the historical circumstances – they too were popular protests against military dictatorships – but, remarkably, an urban-architectural setting: many of them similarly erupted on roundabouts in downtown areas. The history of these roundabouts is entangled with the revolutions that rose from them.

    The photograph of the roundabout—now the symbol of the “liberated republic” – was taken by #Na_Kyung-taek from the roof of the occupied Provincial Hall, looking toward Geumnam-ro, only a few hours before the fall of the “#Gwangju_Republic”. In the early morning hours of the following day, the Gwangju uprising was overwhelmed by military force employing tanks and other armed vehicles. The last stand took place at the roundabout.

    The scene immediately resonates with the well-known photographs of people gathering in #Tahrir_Square in early 2011. Taken from different high-rise buildings around the square, a distinct feature in these images is the traffic circle visible by the way it organises bodies and objects in space. These images became the symbol of the revolution that led to the overthrow of President Hosni Mubarak in February 2011 – an event described by urban historian Nezar AlSayyad as “Cairo’s roundabout revolution”. But the Gwangju photograph also connects to images of other roundabouts that erupted in dissent in fast succession throughout the Middle East. Before Tahrir, as Jonathan Liu noted in his essay Roundabouts and Revolutions, it was the main roundabout in the capital of Tunisia – subsequently renamed Place du 14 Janvier 2011 after the date on which President Zine el-Abidine Ben Ali was forced to flee the country. Thousands of protesters gathered at the roundabout in Tunis and filled the city’s main boulevard.

    A main roundabout in Bahrain’s capital Manama erupted in protests shortly after the overthrow of Mubarak in Egypt. Its central traffic island became the site of popular protests against the government and the first decisive act of military repression: the protests were violently broken up and the roundabout itself destroyed and replaced with a traffic intersection. In solidarity with the Tahrir protests, the roundabouts in the small al-Manara Square in Ramallah and the immense Azadi Square in Tehran also filled with protesters. These events, too, were violently suppressed.

    The roundabouts in Tehran and Ramallah had also been the scenes of previous revolts. In 2009 the Azadi roundabout in Iran’s capital was the site of the main protests of the Green Movement contesting President Mahmoud Ahmadinejad’s reelection. Hamid Dabashi, a literature professor at Columbia University and one of the most outspoken public intellectuals on these revolutions, claims that the Green Movement was inspirational for the subsequent revolutionary wave in the Arab world. In Palestine, revolt was a permanent consequence of life under occupation, and the al-Manara roundabout was a frequent site of clashes between Palestinian youth and the Israeli military. The sequence of roundabout revolutions evolved as acts of imitation, each building on its predecessor, each helping propel the next.

    Roundabouts were of course not only exhilarating sites of protest and experiments in popular democracy, but moreover they were places where people gathered and risked their life. The Gwangju uprising is, thus, the first of the roundabout revolutions. Liu wrote: “In all these cases, the symbolism is almost jokingly obvious: what better place to stage a revolution, after all, then one built for turning around?” What better way to show solidarity across national borders than to stage protests in analogous places?

    Why roundabouts? After all, they are banal, utilitarian instruments of traffic management, certainly not prone to induce revolutionary feeling. Other kinds of sites – squares, boulevards, favelas, refugee camps – have served throughout history as the setting for political protest and revolt. Each alignment of a roundabout and a revolution has a specific context and diverse causes, but the curious repetition of this phenomenon might give rise to several speculations. Urban roundabouts are the intersection points of large axes, which also puts them at the start or end of processions.

    Occupying a roundabout demonstrates the power of tactical acupuncture: it blocks off all routes going in and out. Congestion moves outward like a wave, flowing down avenues and streets through large parts of the city. By pressuring a single pivotal point within a networked infrastructure, an entire city can be put under siege (a contemporary contradistinction to the medieval technique of surrounding the entire perimeter of a city wall). Unlike public squares, which are designed as sites for people to gather (therefore not interrupting the flow of vehicular traffic) and are usually monitored and policed, roundabout islands are designed to keep people away. The continuous flow of traffic around them creates a wall of speeding vehicles that prohibits access. While providing open spaces (in some cities the only available open spaces) these islands are meant to be seen but not used.

    Another possible explanation is their symbolic power: they often contain monuments that represent the existing regime. The roundabouts of recent revolutions had emblematic names – Place du 7 Novembre 1987, the date the previous regime took power in Tunisia; “Liberty” (Azadi), referring to the 1979 Iranian Revolution; or “Liberation” (Tahrir), referring to the 1952 revolutions in Egypt. Roundabout islands often had statues, both figurative and abstract, representing the symbolic order of regimes. Leaders might have wished to believe that circular movement around their monuments was akin to a form of worship or consent. While roundabouts exercise a centripetal force, pulling protestors into the city center, the police seek to generate movement in the opposite direction, out and away from the center, and to break a collective into controllable individuals that can be handled and dispersed.

    The most common of all centrifugal forces of urban disorganisation during protests is tear gas, a formless cloud that drifts through space to disperse crowds. From Gwangju to Cairo, Manama to Ramallah, hundreds of tear-gas canisters were used largely exceeding permitted levels in an attempt to evict protesters from public spaces. The bodily sensation of the gas forms part of the affective dimension of the roundabout revolution. When tear gas is inhaled, the pain is abrupt, sharp, and isolating. The eyes shut involuntary, generating a sense of disorientation and disempowerment.

    Protestors have found ways to mitigate the toxic effects of this weapon. Online advice is shared between activists from Palestine through Cairo to Ferguson. The best protection is offered by proper gas masks. Improvised masks made of mineral water bottles cut in half and equipped with a filter of wet towels also work, according to online manuals. Some activists wear swim goggles and place wet bandanas or kaffiyehs over their mouths. To mitigate some of the adverse effects, these improvised filters can be soaked in water, lemon juice, vinegar, toothpaste, or wrapped around an onion. When nothing else is at hand, breathe the air from inside your shirt and run upwind onto higher ground. When you have a chance, blow your nose, rinse your mouth, cough, and spit.


    https://www.iconeye.com/opinion/comment/item/12093-the-roundabout-revolutions
    #révolution #résistance #giratoire #carrefour #rond-point #routes #infrastructure_routière #soulèvement_politique #Corée_du_Sud #printemps_arabe #Egypte #Tunisie #Bahreïni #Yémen #Libye #Syrie #Tahrir

    Du coup : #gilets_jaunes ?

    @albertocampiphoto & @philippe_de_jonckheere

    This project started with a photograph. It was one of the most arresting images depicting the May 1980 #Gwangju uprising, recognised now as the first step in the eventual overthrow of the military dictatorship in South Korea. The photograph (above) depicts a large crowd of people occupying a roundabout in the city center. Atop a disused fountain in the middle of the roundabout a few protestors have unfurled a South Korean flag. The roundabout organised the protest in concentric circles, a geometric order that exposed the crowd to itself, helping a political collective in becoming.

    –-> le pouvoir d’une #photographie...

    signalé par @isskein

    ping @reka



  • I feel no sympathy for the settlers
    Beneath the veil of sanctimonious and hypocritical unity, and the media’s fake show of national grief to advance its own commercial goals, the truth must be told: Their tragedy isn’t ours
    Gideon Levy | Dec 16, 2018 2:32 AM
    https://www.haaretz.com/opinion/.premium-i-feel-no-sympathy-for-the-settlers-1.6746199

    I do not sympathize with people who profiteer from tragedy. I have no sympathy for robbers. I have no sympathy for the settlers. I have no sympathy for the settlers not even when they are hit by tragedy. A pregnant woman was wounded and her newborn baby died of its wounds – what can be worse than that? Driving on their roads is frightening, the violent opposition to their presence is growing – and I feel no sympathy for their tragedy, nor do I feel any compassion or solidarity.

    They are to blame, not I, for the fact that I cannot feel the most humane sense of solidarity and pain. It’s not just that they’re settlers, violators of international law and universal justice; it’s not just because of the violence of some of them and the settling of all of them – it’s also the blackmail with which they respond to every tragedy, which prevents me from grieving with them. But beneath the veil of sanctimonious and hypocritical unity, and the media’s fake show of national grief to advance its own commercial goals, the truth must be told: Their tragedy isn’t ours.

    Their tragedy isn’t ours because they’ve brought the tragedy upon themselves and the entire country. It’s true that the main blame goes to the governments that gave into them, either eagerly or out of weakness, but the settlers cannot be absolved of blame, either. The extorter – and not just those who have given into extortion – is also to blame. But they are there, generations born on stolen land, children raised in an apartheid existence and trained to think it is biblical justice, and with government support. Perhaps we cannot blame those who are sitting on land usurped by their parents. But their tragedy is not ours because they exploit every tragedy to advance their aims in the most cynical of ways.

    When a baby dies they install trailer homes, when soldiers are killed defending them – they do not seek forgiveness from the families of these soldiers, despite their blame for the lives that have been cut short – they only present demands so as to whitewash their crimes. And with these demands the appetite for revenge grows: to imprison even more of their neighbors, to destroy their homes, to kill, to arrest, block roads and exact more revenge. And if that, too, is not enough, their own wild militias raid the Palestinians, throw stones at their vehicles, set their fields on fire and wreak terror on their villages. They are not satisfied with the collective punishment imposed by the army and the Shin Bet security service, exercised with cruelty and sometimes criminality. The settlers’ lust for revenge is never satisfied. How is it possible to identify with the grief of people who behave like that?

    It’s impossible to identify with their bereavement, because Israel has decided to avoid looking at all that is done there in the land of Judea. When you are capable of being indifferent to the execution of a psychologically impaired young man by soldiers, you can also be indifferent to the shooting of a pregnant woman by Palestinians. When you ignore the goings on at the Tulkarm refugee camp, you can also ignore what takes place at the Givat Assaf junction. It’s moral blindness to everything. Yesha isn’t here, that’s the price being paid for the lack of interest in what is going on in the territories and for ignoring the occupation, under whose sponsorship the settlements are based. Giant budgets are poured out there without any public opposition – so there is also indifference to the fate of the settlers and their tragedies. The piece of land they have taken over doesn’t interest most Israelis living in the land of denial, and that’s the price.

    We have no reason to apologize for the lack of interest and identification. The settlers have brought it on themselves. Those who have never shown any interest in the suffering of their Palestinian neighbors, which they have caused, those who preach all the time that the iron fist must always be tightened, to torture them even more – don’t deserve to be identified with, not even in the hour of their grief. I take no joy in their suffering but I have no sympathy for their pain. The real pain is borne by their victims, those who moan submissively and those who take their fate in their hands and try to resist a violent reality violently and sometimes also murderously. The Palestinians are the victims deserving of pity and solidarity.


  • The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774

    Un article scientifique de 2009 sur le marketing d’Oxycontin.

    OxyContin’s commercial success did not depend on the merits of the drug compared with other available opioid preparations. The Medical Letter on Drugs and Therapeutics concluded in 2001 that oxycodone offered no advantage over appropriate doses of other potent opioids.3 Randomized double-blind studies comparing OxyContin given every 12 hours with immediate-release oxycodone given 4 times daily showed comparable efficacy and safety for use with chronic back pain4 and cancer-related pain.5,6 Randomized double-blind studies that compared OxyContin with controlled-release morphine for cancer-related pain also found comparable efficacy and safety.7–9 The FDA’s medical review officer, in evaluating the efficacy of OxyContin in Purdue’s 1995 new drug

    application, concluded that OxyContin had not been shown to have a significant advantage over conventional, immediate-release oxycodone taken 4 times daily other than a reduction in frequency of dosing.10 In a review of the medical literature, Chou et al. made similar conclusions.11

    The promotion and marketing of OxyContin occurred during a recent trend in the liberalization of the use of opioids in the treatment of pain, particularly for chronic non–cancer-related pain. Purdue pursued an “aggressive” campaign to promote the use of opioids in general and OxyContin in particular.1,12–17 In 2001 alone, the company spent $200 million18 in an array of approaches to market and promote OxyContin.❞

    From 1996 to 2001, Purdue conducted more than 40 national pain-management and speaker-training conferences at resorts in Florida, Arizona, and California. More than 5000 physicians, pharmacists, and nurses attended these all-expenses-paid symposia, where they were recruited and trained for Purdue’s national speaker bureau.19(p22)

    In much of its promotional campaign—in literature and audiotapes for physicians, brochures and videotapes for patients, and its “Partners Against Pain” Web site—Purdue claimed that the risk of addiction from OxyContin was extremely small.43–49

    Purdue trained its sales representatives to carry the message that the risk of addiction was “less than one percent.”50(p99)

    In 1998, Purdue distributed 15 000 copies of an OxyContin video to physicians without submitting it to the FDA for review, an oversight later acknowledged by Purdue. In 2001, Purdue submitted to the FDA a second version of the video, which the FDA did not review until October 2002—after the General Accounting Office inquired about its content. After its review, the FDA concluded that the video minimized the risks from OxyContin and made unsubstantiated claims regarding its benefits to patients.19

    When OxyContin entered the market in 1996, the FDA approved its original label, which stated that iatrogenic addiction was “very rare” if opioids were legitimately used in the management of pain. In July 2001, to reflect the available scientific evidence, the label was modified to state that data were not available for establishing the true incidence of addiction in chronic-pain patients. The 2001 labeling also deleted the original statement that the delayed absorption of OxyContin was believed to reduce the abuse liability of the drug.19 A more thorough review of the available scientific evidence prior to the original labeling might have prevented some of the need for the 2001 label revision.

    #Opioides #Marketing #Purdue_Pharma


  • Reports Warn of Growing Senior Opioid Crisis
    https://www.webmd.com/mental-health/addiction/news/20180919/reports-warn-of-growing-senior-opioid-crisis

    WEDNESDAY, Sept. 19, 2018 (HealthDay News) — Against the backdrop of an unrelenting opioid crisis, two new government reports warn that America’s seniors are succumbing to the pitfalls of prescription painkillers.

    Issued by the Agency for Healthcare Research and Quality (AHRQ), the reports reveal that millions of older Americans are now filling prescriptions for many different opioid medications at the same time, while hundreds of thousands are winding up in the hospital with opioid-related complications.

    “These reports underscore the growing and under-recognized concerns with opioid use disorder in older populations, including those who suffer from chronic pain and are at risk for adverse events from opioids,” said Dr. Arlene Bierman. She is the director of AHRQ’s Center for Evidence and Practice.

    At the same time, AHRQ’s second report found that nearly 20 percent of seniors filled at least one opioid prescription between 2015 and 2016, equal to about 10 million seniors. And more than 7 percent — or about 4 million seniors — filled prescriptions for four or more opioids, which was characterized as “frequent” use.

    The challenge, said Bierman, “is safe-prescribing for those who need opioids for pain, while avoiding overuse or misuse.”

    Clinicians, she advised, could address that concern “by using non-opioid pain medications and non-pharmacologic treatments before considering the use of opioids.” And she suggested that if and when opioids are needed, “the lowest possible dose should be used.”

    #Opioides


  • United States Patent : 9861628
    http://patft.uspto.gov/netacgi/nph-Parser?Sect1=PTO1&Sect2=HITOFF&d=PALL&p=1&u=%2Fnetahtml%2FPTO%2Fsrchnum.htm&r=1&f=G&l=50&s1=98,61,628.PN.&OS=PN/98,61,628&RS=PN/98,61,628

    Buprenorphine-wafer for drug substitution therapy

    Abstract

    The present invention relates to oral pharmaceutical dosage forms comprising buprenorphine with the dosage form releasing buprenorphine instantly upon oral, preferably sublingual, application of the dosage form. The present invention also relates to the use of such dosage forms for treating pain in a human or animal or for drug substitution therapy in drug-dependent human subjects.

    BACKGROUND OF THE INVENTION

    Chronic pain, which may be due to idiopathic reasons, cancer or other diseases such as rheumatism and arthritis, is typically treated with strong opioids.

    Over the last decades prejudices in the medical community as to the use of strong opioids for treating chronic pain in patients has significantly decreased. Many of the se prejudices were due to some of the characteristics being inherent to opioids.

    While opioids have always been known to be useful in pain treatment, they also display an addictive potential in view of their euphorigenic activity. Thus, if opioids are taken by healthy human subjects with a drug seeking behaviour they may lead to psychological as well as physical dependence.

    These usually undesired characteristics of opioids can however become important in certain scenarios such as drug substitution therapies for drug addicts. One of the fundamental problems of illicit drug abuse by drug addicts (“junkies”) who are dependent on the constant intake of illegal drugs such as heroin is the drug-related criminal activities resorted to by such addicts in order to raise enough money to fund their addiction. The constant pressures upon addicts to procure money for buying drugs and the concomitant criminal activities have been increasingly recognised as a major factor that counteracts efficient and long-lasting withdrawal and abstinence from drugs.

    Therefore, programmes have been developed, particularly in the United States and western European countries, in which drug addicts are allowed to take prescription drugs under close supervision of medical practitioners instead of illegal drugs such as street heroin.

    The aim of drug substitution theory is thus to first enable addicts to lead a regular life by administering legal drugs to prevent withdrawal symptoms, but because of their legal character and prescription by medical practitioners do not lead to the aforementioned described drug-related criminal activities. In a second and/or alternate step in the treatment of drug addiction may be to slowly make the drug addict less dependent on the drug by gradually reducing the dose of the substitution drug or to bridge the time until a therapy place in a withdrawal programme is available.

    The standard drug used in drug substitution therapy programmes has for a long time been methadone. However, in recent years the potential of other opioids as substitution drugs in substitution therapy has been recognised. A particularly suitable drug for that purpose is the opioid buprenorphine, which is a mixed opioid agonist/antagonist.

    Nowadays, buprenorphine preparations are administered in drug substitution programmes in the form of a tablet for sublingual administration. One of the reasons that the tablets are formulated for sublingual administration is that this the preferred route of administration for buprenorphine. Furthermore, if a patient swallows such tablets they will not provide euphorigenic activity.

    One example of sublingual tablets for drug substitution therapy is the preparation Subutex.RTM. (being marketed in Germany by Essex Pharma).

    Nevertheless, drug addicts sometimes still try to divert these sublingual buprenorphine tablets by removing them from the mouth when the supervising healthcare professional’s attention is directed to other activities. Later the tablets may be sold or the active agent buprenorphine isolated/extracted to apply it parenterally.

    Another buprenorphine preparation aimed at preventing this potential possibility of abuse has recently gained administrative approval in the United States (Suboxone.RTM.). The Suboxone.RTM. preparation comprises buprenorphine hydrochloride and the opioid antagonist naloxone hydrochloride dihydrate. The presence of naloxone is intended to prevent parenteral abuse of buprenorphine as parenteral co-administration of buprenorphine and naloxone in e.g. an opioid-dependent addict will lead to serious withdrawal symptoms.

    However, there remains a need for other diversion and/or abuse-resistant dosage forms of buprenorphine, which can be used in drug substitution therapy as described above. Additionally, it would be desirable to have a buprenorphine preparation available which is diversion and/or abuse-resistant in cases where the preparation is used for drug substitution therapy and which could also provide efficient analgesia in cases where the preparation is administered to alleviate pain in a patient.

    OBJECT AND SUMMARY OF THE INVENTION

    It is an object of the present invention to provide an oral pharmaceutical dosage form of the active agent buprenorphine that is less prone to diversion and/or abuse in drug substitution therapy. It is another object of the present invention to provide an oral dosage form of the active agent buprenorphine that can be used for drug substitution therapy and/or pain treatment.

    In one embodiment the present invention relates to an oral pharmaceutical dosage form comprising at least buprenorphine or a pharmaceutically acceptable salt thereof with a dosage form releasing buprenorphine or said pharmaceutically acceptable salt thereof instantly upon or oral, preferably sublingual, application of the dosage form. It is, however, understood that the invention and its various embodiments which are set out below, can be extended to any opioid or analgesic whose preferred route of administration is oral, prefereably sublingual, as is the case for buprenorphine.

    An instant release of buprenorphine or a pharmaceutically acceptable salt thereof upon oral, preferably sublingual, application means that substantially all of the buprenorphine or said pharmaceutically acceptable salt thereof will be released within less than three minutes, preferably within less than two minutes or less than one minute. Even more preferably, substantially all of the buprenorphine or said pharmaceutically acceptable salt thereof will be released within less than thirty seconds, twenty seconds, ten seconds or even within less than five seconds after oral, preferably sublingual, application of the dosage form. In one of the preferred embodiments these oral dosage forms will comprise between approximately 0.1 mg and approximately 16 mg buprenorphine or the equivalent amounts of a pharmaceutically acceptable salt thereof.

    In a further preferred embodiment these oral pharmaceutical dosage forms will achieve an average C.sub.max of between 1.5 ng/ml and approximately 2.25 ng/ml in the case of a dose of 0.4 mg buprenorphine hydrochloride being administered. In the case of a dose of 8 mg buprenorphine HCl being administered, the C.sub.max will typically be between approximately 2.5 and 3.5 ng/ml and if a dose of 16 mg buprenorphine hydrochloride is administered the C.sub.max will preferably be between 5.5 to 6.5 ng/ml.

    Yet another preferred embodiment of the invention relates to oral pharmaceutical dosage forms which may provide for the above-mentioned characteristics and/or an average Tmax of from approximately 45 to approximately 90 minutes.

    In a particularly preferred embodiment the dosage forms will additionally comprise an opioid antagonist, preferably naloxone or a pharmaceutically acceptable salt thereof.

    In yet a further preferred embodiment, the pharmaceutical dosage form will comprise buprenorphine and the opioid antagonist, which preferably is naloxone, in a weight ratio of from approximately 1:1 to approximately 10:1.

    One embodiment of the present invention also relates to oral pharmaceutical dosage forms, which may have some or all of the aforementioned characteristics and wherein the dosage form has a film-like or wafer-like shape.

    Another embodiment relates to a method of manufacturing the afore-mentioned described dosage forms.

    Embodiments of the present invention also relate to the use of the afore-described oral, preferably sublingual, pharmaceutical dosage forms in the manufacture of a medicament for treating pain in a human or animal and/or for drug substitution therapy in drug-dependent human subjects.

    One aspect of the invention also relates to a method of drug substitution therapy in drug-dependent human subjects wherein the aforementioned oral pharmaceutical dosage forms are administered to a drug-dependent subject in need thereof.

    #Opioides #Sackler #Brevet #Cynisme #Capitalisme_sauvage


  • Opioid billionaire granted patent for addiction treatment | Financial Times
    https://www.ft.com/content/a3a53ae8-b1e3-11e8-8d14-6f049d06439c
    https://www.ft.com/__origami/service/image/v2/images/raw/http%3A%2F%2Fprod-upp-image-read.ft.com%2F9a83636a-b263-11e8-87e0-d84e0d934341?s

    Purdue owner Richard Sackler listed as inventor of drug to wean addicts off painkillers
    Richard Sackler’s family owns Purdue Pharma, the company behind the opioid painkiller OxyContin © Reuters

    David Crow in New York

    A billionaire pharmaceuticals executive who has been blamed for spurring the US opioid crisis stands to profit from the epidemic after he patented a new treatment for drug addicts.

    Richard Sackler, whose family owns Purdue Pharma, the company behind the notorious painkiller OxyContin, was granted a patent earlier this year for a reformulation of a drug used to wean addicts off opioids.

    The invention is a novel form of buprenorphine, a mild opiate that controls drug cravings, which is often given as a substitute to people hooked on heroin or opioid painkillers such as OxyContin.

    The new formulation as described in Dr Sackler’s patent could end up proving lucrative thanks to a steady increase in the number of addicts being treated with buprenorphine, which is seen as a better alternative to other opioid substitutes such as methadone.

    Last year, the leading version of buprenorphine, which is sold under the brand name Suboxone, generated $877m in US sales for Indivior, the British pharmaceuticals group that makes it.

    Before the opioid crisis, the Sackler family was primarily known for its philanthropy, emerging as one of the largest donors to arts institutions in the US and UK. But the rising number of addictions and deaths has highlighted the family’s ownership of Purdue, which some members have tried to shy away from.

    It’s reprehensible what Purdue Pharma has done to our public health
    Luke Nasta, director of Camelot

    Dr Sackler’s patent, which was granted by the US Patent and Trademark Office in January, acknowledges the threat posed by the opioid crisis, which claimed more than 42,000 lives in 2016.

    “While opioids have always been known to be useful in pain treatment, they also display an addictive potential,” the patent states. “Thus, if opioids are taken by healthy human subjects with a drug-seeking behaviour they may lead to psychological as well as physical dependence.”

    It adds: “The constant pressures upon addicts to procure money for buying drugs and the concomitant criminal activities have been increasingly recognised as a major factor that counteracts efficient and long-lasting withdrawal and abstinence from drugs.”

    However, the patent makes no mention of the fact that Purdue Pharma has been hit with more than a thousand lawsuits for allegedly fuelling the epidemic — allegations the company and the Sackler family deny.

    “It’s reprehensible what Purdue Pharma has done to our public health,” said Luke Nasta, director of Camelot, an addiction treatment centre in Staten Island, New York. He said the Sackler family “shouldn’t be allowed to peddle any more synthetic opiates — and that includes opioid substitutes”.

    Buprenorphine is prescribed to opioid addicts in tablets or thin film strips that dissolve under the tongue in less than seven minutes. These “sublingual” formulations are used to stop drug abusers from hoarding a stockpile of pills they can sell or use to get high at a later date.

    The patent describes a new, improved form of buprenorphine that would come in a wafer that disintegrated more quickly than existing versions — perhaps in just a few seconds.

    The original application was made by Purdue Pharma and Dr Sackler is listed as one of the inventors alongside five others, some of whom work or have worked for the Sackler’s group of drug companies.

    “Drug addicts sometimes still try to divert these sublingual buprenorphine tablets by removing them from the mouth,” the patent application stated. “There remains a need for other . . . abuse-resistant dosage forms.”
    Recommended
    US opioid epidemic
    What next for the Sacklers? A pharma dynasty under siege

    In June, the Massachusetts attorney-general filed a lawsuit against Dr Sackler and seven other members of the Sackler family, which accused them of engaging in a “deadly, deceptive scheme to sell opioids”.

    Purdue and the family deny the allegations and Purdue said it intends to file a motion to dismiss. The company points out that OxyContin was, and still is, approved by the US Food and Drug Administration.

    “We believe it is inappropriate for [Massachusetts] to substitute its judgment for the judgment of the regulatory, scientific and medical experts at FDA,” it said in a recent statement to the Financial Times.

    Andrew Kolodny, a professor from Brandeis University who has been a vocal advocate for greater use of buprenorphine to battle the opioid crisis, said the idea Dr Sackler “could get richer” from the patent was “very disturbing”. He added: “Perhaps the profits off this patent should be used to pay any judgment or settlement down the line.”

    Earlier this week, Purdue donated $3.4m to boost access to naloxone, an antidote given to people who have just overdosed on opioids.

    #Opioides #Cynisme #Capitalisme_sauvage #Brevets #Sackler


  • The Opioid Crisis Is Also a Crisis of Speech - Pacific Standard
    https://psmag.com/social-justice/the-opioid-crisis-is-also-a-crisis-of-speech

    Ca ressemble beaucoup à du travail de Public Relation pour contrer la prise de conscience de la crise des opioides. L’American Academy of Pain Medicine est la seule organisation citée... et elle ne semble pas blanc-bleu.

    In particular, chronic pain patients are silenced thanks to the War on Drugs—and, especially in the last few years, in the name of the opioid crisis. Opioid addiction is a serious problem in the United States; 42,000 people died from opioid overdoses in 2016, according to the Department of Health and Human Services, and the U.S. has seen an increase of more than 500 percent in heroin-related deaths since 2002. The understandable desire to reduce America’s number of opioid addicts, though, has had catastrophic consequences for chronic pain patients. Walmart, for example, has limited opioid prescriptions so that patients have to get refills every week, rather than filling them a month at a time. Insurance companies have also placed limits on the amount of opioid medication they will cover. Some pharmacies won’t handle prescriptions over the phone, and sometimes aren’t even allowed to tell patients if the medicine is in stock.

    #Opioides


  • #hacking the Whole #body Approach to #health
    https://hackernoon.com/hacking-the-whole-body-approach-to-health-64b31a8278e?source=rss----3a81

    Eastern and Western approaches to medical practice have often been seen as complete opposites. In fact, many studies have show this view to be folly, and Eastern, also known as Traditional Chinese Medicine (TCM), practices are proven to help alleviate ailments ranging from arthritis, gynecological pain, and migraines to cancer treatment side effects. It has been a mystery why exactly the implementation of acupuncture, yoga, and other TCM practices seem to work, but a new scientific discovery is clearing up the Eastern medicine phenomena that has puzzled Western practitioners.This past March, a team of doctors led by researcher and doctor of pathology Neil Theise of NYU’s Langone School of Medicine discovered what they are referring to as a new organ.It’s name―the interstitium.Using pCLE, (...)

    #healthcare #tech


  • Back pain: how to live with one of the world’s biggest health problems | Society | The Guardian
    https://www.theguardian.com/society/2018/jun/14/back-pain-how-to-live-with-one-of-the-worlds-biggest-health-problems

    This month, the Lancet published a series of three papers written by a large, international group of experts who came together to raise awareness of the extent of the problem of low back pain and the evidence for recommended treatments. The authors were scathing about the widespread use of “inappropriate tests” and “unnecessary, ineffective and harmful treatments”.

    The papers tell us low back pain is an “extremely common symptom, experienced by people of all ages”, although it peaks in mid-life and is more common in women than in men. There are 540 million people affected globally at any one time and it is the main cause of disability worldwide.

    The six-year investigation that began as an attempt to find relief from her own pain and ended up exposing an exploitative, corrupt and evidence-free $100bn industry, is fittingly described in the title of her book: Crooked.

    The camera lies … MRI scans show up disc degeneration but unfortunately most people will have some. Photograph: HadelProductions/Getty Images

    The proliferation of unnecessary and risky interventions has been far worse in the US, with its insurance-based healthcare system, than in the NHS. But the UK is far from immune. When a healthcare system functions as a marketplace, there will inevitably be incentives for certain treatments to be pursued over others, for services that can generate a surplus. It is a struggle for patients and clinicians everywhere to resist pain medication that is incredibly effective in the short term, even if it is incredibly harmful in the long term.

    “Nearly everybody gets back pain at some point in their life,” says Martin Underwood, co-author of the Lancet series, a GP and a professor at Warwick Medical School. “For most people, it’s a short-term episode that will resolve over a period of days or weeks, without the need for any specific treatment. They catch or twist or stretch something, and it’s awful, and then it gets better.” Of those who experience a new episode of back pain, under 1% will have serious causes that need specific treatment for issues such as cancer in the spine, a fracture, diseases or infection, he says. But there is another group, in which, “after the natural period of healing – normally six weeks for most things – people go on to get pain lasting months and years, which can be very disabling, even though the original cause of the pain is no longer there. We would label this as nonspecific low back pain, simply because we don’t know what is causing the pain.”

    “At best, these spine surgeons define success as a 38% improvement in pain and function,” says Ramin, “but if a hip or a knee surgeon had a 38% success rate, that physician would no longer do that surgery. And 38%? I think that’s really optimistic.” In her book, she describes the scandal of the Pacific Hospital in Long Beach, California, which carried out more than 5,000 spinal fusion surgeries. “Surgeries were being performed on large numbers of patients who were often immigrants – Spanish-speaking labourers – and being billed to workers’ compensation insurance or public health insurance. Could you do worse than butcher these Latino field workers who don’t understand what’s happening to them, but are being told they can get free medical care?”

    We like to think that this could never happen in the UK, and Underwood admits there is a huge difference between the two healthcare systems. “Most spinal surgeons in the UK will avoid operating for nonspecific low back pain because they’re aware of all these problems,” he says. “But there is still pressure from patients for something to make them better, and some people are still getting operated on. My advice for anybody is: don’t have surgery for back pain unless there is a clear, specific indication.”

    When I ask Underwood what works, he tells me: “Whatever you do for a patient at a time when their back is really bad, the chances are they’re going to be a lot better three weeks later. So we treat people and we see them getting better and we ascribe their improvement to the treatment we’ve given, but we know that natural improvement over time is always much larger than the positive effect you get from the treatment.” The evidence is strongest for therapist-delivered interventions such as the cognitive behavioural approach, based on the same principles as CBT, exercise treatment and physiotherapy. He has also worked on a trial that showed training physiotherapists to deliver the cognitive behavioural approach in a group, combining movement and reassurance about movement, is helpful to patients and could be delivered in the NHS at low cost.

    #Mal_de_dos #Opioides #Médecine


  • Valium: It’s more addictive than heroin, with horrifying side-effects, so why is it still given to millions? | Daily Mail Online
    http://www.dailymail.co.uk/femail/article-2289311/Valium-Its-addictive-heroin-horrifying-effects-given-millions.html

    One of the first - and most infamous - of the ‘benzos’ was Valium. Launched in the 1960s it quickly became the pill for every ill, dished out in profligate quantities to anyone struggling with the travails of daily life. Sixty per cent of users were women and Valium was soon dubbed ’mother’s little helper’.

    But Valium and the other benzos are derived from chemical compounds which make some of them more addictive even than heroin.

    And their legacy is a vast group of people suffering appalling withdrawal symptoms so severe they are unfit for work, relationships or even independent living. Some have also been left with permanent effects, including memory loss.

    Increasingly worried about what the drug might be doing to her after six years on it, Baylissa started researching clonazepam-type drugs on the internet and was shocked by what she read. People reported memory loss, dementia, paranoia, hallucinations and excruciating pain, either as a result of being on the drug or coming off it.

    Valium’s pernicious legacy has touched everyone from schoolgirls and poverty stricken single mothers to middle-class divorcees and wealthy socialites. In some cases, distraught addicts resort to suicide: Department of Health figures show the drug is implicated in 300-500 deaths a year in this country.

    But the scale of the problem has been largely ignored. Despite guidelines dating back to 1988, which warn doctors to limit the prescribing of this potent and controversial drug, clinicians have found it an effective way to handle many hard-to-diagnose, hard-to-treat patients.

    There are now 183 different formulations of Valium-derived medications. Doctors in Britain issue almost 18 million prescriptions a year for benzodiazepiones, and every GP has at least 180 long-term users on their books.

    Despite being highly addictive and having alarming side-effects, Valium had become one of the world’s best-selling drugs by the mid-Seventies. It was originally manufactured by Hoffmann La Roche, but the company lost its patent protection in 1985. Some 500 different versions of the drug were subsequently marketed by different companies worldwide.

    It was on a holiday to France in April 2011 that Fiona made the life-changing decision to stop taking Valium. ’I didn’t take enough with me — I don’t know if that was on purpose or not — and we were sitting in a cafe one day when I had a panic attack, mewling like a puppy.

    ’People were staring and it was awful, but it took about three weeks for the real withdrawal symptoms to appear. By then I was whimpering and shaking the whole time, I couldn’t sleep, I was depressed and just exhausted.’

    Back home, with no further help from her GP, Fiona sought information about Valium withdrawal on the internet and tackled her long-term dependency by gradually reducing her dose to zero over five months.

    ’It was absolute hell,’ she says. ’I felt sick, I had long periods of shaking uncontrollably, excruciating muscle cramps, and all the symptoms of severe flu. I couldn’t go out, leave the house at all, or do anything at all.’

    #Opioides #Sackler #Valium


  • America’s opioid epidemic began more than a century ago – with the civil war | Science | The Guardian
    https://www.theguardian.com/science/2017/dec/30/americas-opioid-epidemic-began-more-than-a-century-ago-with-the-civil-w

    An estimated two million people abused opiates during the war, after using drugs disseminated by healthcare providers, doctors and nurses to stem pain

    For many Americans, it was the prescription of a well-meaning physician that sent them down the dark road.

    Aggressive marketing and over-prescribing of painkillers touched off a scourge of opiate addiction and Congress, pushed by the destruction it had wrought, introduced a new law to reform painkiller prescribing.

    It was 1915 and Congress was considering what would become the first law to criminalize drug use, the Harrison Narcotic Act. By this time, addiction had already touched middle-class housewives, immigrants, veterans and even physicians hoping to soothe their own aches and pains. Between the 1870s and 1880s, America’s per capita consumption of opiates had tripled.

    More than a century later, Americans are fighting some of the same demons.

    Since 1999, more than half a million Americans have died of drug overdoses. Recent data shows the trend accelerated in 2016, when 63,600 people were killed by overdoses and the rate of Americans dying increased by 21%.

    “There was a massive opioid epidemic after the civil war,” said Robert Heimer, a professor of epidemiology and pharmacology at Yale University School of Public Health. “Except is wasn’t a black market – it was a perfectly legal market filled with patent medicines that contained not just cocaine and opiates, morphine mostly, but also alcohol.”

    Laudanum, Heimer said, “was commonly taken as a relief of colds, coughs, and in stronger form was particularly good for lung diseases such as tuberculosis, which was common at the time, in addition to being widely used in combat situations to facilitate amputations”.

    Where Purdue Pharma marketed Oxycontin to doctors as a “continuous around-the-clock analgesic” formulation of semi-synthetic oxycodone great for chronic pain, Mrs Winslow’s Soothing Syrup marketed morphine and alcohol to parents as a “perfectly harmless and pleasant” way to produce “quiet sleep, by relieving the child from pain”.

    History, Courtwright said, offers some “grounds for optimism”. Beginning in the 1890s, physicians began to criticize colleagues who reached for the prescription pad when patients had aches and pains; pharmacists refused to sell heroin or cocaine (then both legal); and in 1906 muckraking journalists and campaigners successfully argued for reforms to end the sale of patent medicines.

    By 1915, Courtwright argues in the New England Journal of Medicine, “the Harrison Act closed the barn door after the horse was back in”. Problematically, the Harrison Act also became the first law to criminalize drug use and opiate maintenance therapies, such as methadone and buprenorphine.

    #Opioides #Histoire #Addiction #Laudanum


  • How Advertising Shaped the First Opioid Epidemic | Science | Smithsonian
    https://www.smithsonianmag.com/science-nature/how-advertising-shaped-first-opioid-epidemic-180968444

    hen historians trace back the roots of today’s opioid epidemic, they often find themselves returning to the wave of addiction that swept the U.S. in the late 19th century. That was when physicians first got their hands on morphine: a truly effective treatment for pain, delivered first by tablet and then by the newly invented hypodermic syringe. With no criminal regulations on morphine, opium or heroin, many of these drugs became the “secret ingredient” in readily available, dubiously effective medicines.

    In the 19th century, after all, there was no Food and Drug Administration (FDA) to regulate the advertising claims of health products. In such a climate, a popular so-called “patent medicine” market flourished. Manufacturers of these nostrums often made misleading claims and kept their full ingredients list and formulas proprietary, though we now know they often contained cocaine, opium, morphine, alcohol and other intoxicants or toxins.

    Products like heroin cough drops and cocaine-laced toothache medicine were sold openly and freely over the counter, using colorful advertisements that can be downright shocking to modern eyes. Take this 1885 print ad for Mrs. Winslow’s Soothing Syrup for Teething Children, for instance, showing a mother and her two children looking suspiciously beatific. The morphine content may have helped.

    • Purdue Pharma provided physicians with starter coupons that gave patients a free seven to 30-day supply of the drug . The company’s sales force—which more than doubled in size from 1996 to 2000—handed doctors OxyContin-branded swag including fishing hats and plush toys. A music CD was distributed with the title “Get in the Swing with OxyContin.” Prescriptions for OxyContin for non-cancer related pain boomed from 670,000 written in 1997, to 6.2 million in 2002.
      But even this aggressive marketing campaign was in many ways just the smoke. The real fire, Alexander argues, was a behind-the-scenes effort to establish a more lax attitude toward prescribing opioid medications generally, one which made regulators and physicians alike more accepting of OxyContin.

      “When I was in residency training, we were taught that one needn’t worry about the addictive potential of opioids if a patient had true pain,” he says. Physicians were cultivated to overestimate the effectiveness of opioids for treating chronic, non-cancer pain, while underestimating the risks, and Alexander argues this was no accident.

      Purdue Pharma funded more than 20,000 educational programs designed to promote the use of opioids for chronic pain other than cancer, and provided financial support for groups such as the American Pain Society. That society, in turn, launched a campaign calling pain “the fifth vital sign,” which helped contribute to the perception there was a medical consensus that opioids were under, not over-prescribed.

      #opioides #sackler


  • The Opioid that Made a Fortune for Its Maker — and for Its Prescribers - The New York Times
    https://www.nytimes.com/interactive/2018/05/02/magazine/100000005878055.app.html

    For Insys, Chun was just the right kind of doctor to pursue. In the late 1990s, sales of prescription opioids began a steep climb. But by the time Subsys came to market in 2012, mounting regulatory scrutiny and changing medical opinion were thinning the ranks of prolific opioid prescribers. Chun was one of the holdouts, a true believer in treating pain with narcotics. He operated a busy practice, and 95 percent of the Medicare patients he saw in 2015 had at least one opioid script filled. Chun was also a top prescriber of a small class of painkillers whose active ingredient is fentanyl, which is 50 to 100 times as powerful as morphine. Burlakoff’s product was a new entry to that class. On a “target list,” derived from industry data that circulated internally at Insys, Chun was placed at No. 3. The word inside the company for a doctor like Chun was a “whale.”

    In the few months since Subsys was introduced, demand was not meeting expectations. Some of the sales staff had already been fired. If Burlakoff and Krane could persuade Chun to become a Subsys loyalist, it would be a coup for them and for the entire company. The drug was so expensive that a single clinic, led by a motivated doctor, could generate millions of dollars in revenue.

    Speaker programs are a widely used marketing tool in the pharmaceutical business. Drug makers enlist doctors to give paid talks about the benefits of a product to other potential prescribers, at a clinic or over dinner in a private room at a restaurant. But Krane and some fellow rookie reps were already getting a clear message from Burlakoff, she said, that his idea of a speaker program was something else, and they were concerned: It sounded a lot like a bribery scheme.

    But the new reps were right to be worried. The Insys speaker program was central to Insys’ rapid rise as a Wall Street darling, and it was also central to the onslaught of legal troubles that now surround the company. Most notable, seven former top executives, including Burlakoff and the billionaire founder of Insys, John Kapoor, now await trial on racketeering charges in federal court in Boston. The company itself, remarkably, is still operating.

    The reporting for this article involved interviews with, among other sources, seven former Insys employees, among them sales managers, sales reps and an insurance-authorization employee, some of whom have testified before a grand jury about what they witnessed. This account also draws on filings from a galaxy of Insys-related litigation: civil suits filed by state attorneys general, whistle-blower and shareholder suits and federal criminal cases. Some are pending, while others have led to settlements, plea deals and guilty verdicts.

    The opioid crisis, now the deadliest drug epidemic in American history, has evolved significantly over the course of the last two decades. What began as a sharp rise in prescription-drug overdoses has been eclipsed by a terrifying spike in deaths driven primarily by illicitly manufactured synthetic opioids and heroin, with overall opioid deaths climbing to 42,249 in 2016 from 33,091 in 2015. But prescription drugs and the marketing programs that fuel their sales remain an important contributor to the larger crisis. Heroin accounted for roughly 15,000 of the opioid deaths in 2016, for instance, but as many as four out of five heroin users started out by misusing prescription opioids.

    By the time Subsys arrived in 2012, the pharmaceutical industry had been battling authorities for years over its role in promoting the spread of addictive painkillers. The authorities were trying to confine opioids to a select population of pain patients who desperately needed them, but manufacturers were pushing legal boundaries — sometimes to the breaking point — to get their products out to a wider market.

    Even as legal penalties accrued, the industry thrived. In 2007, three senior executives of Purdue Pharma pleaded guilty in connection with a marketing effort that relied on misrepresenting the dangers of OxyContin, and the company agreed to pay a $600 million settlement. But Purdue continued booking more than $1 billion in annual sales on the drug. In 2008, Cephalon likewise entered a criminal plea and agreed to pay $425 million for promoting an opioid called Actiq and two other drugs “off-label” — that is, for unapproved uses. That did not stop Cephalon from being acquired three years later, for $6.8 billion.

    Subsys and Actiq belong to a class of fentanyl products called TIRF drugs. They are approved exclusively for the treatment of “breakthrough” cancer pain — flares of pain that break through the effects of the longer-acting opioids the cancer patient is already taking around the clock. TIRFs are niche products, but the niche can be lucrative because the drugs command such a high price. A single patient can produce six figures of revenue.

    Fentanyl is extremely powerful — illicitly manufactured variations, often spiked into heroin or pressed into counterfeit pills, have become the leading killers in the opioid crisis — and regulators have made special efforts to restrict prescription fentanyl products. In 2008, for instance, the F.D.A. rebuffed Cephalon’s application to expand the approved use for a TIRF called Fentora; in the company’s clinical trials, the subjects who did not have cancer demonstrated much more addictive behavior and propensity to substance abuse, which are “rarely seen in clinical trials,” F.D.A. officials concluded. An F.D.A. advisory committee reported that, during the trials, some of the Fentora was stolen. The agency later developed a special protocol for all TIRF drugs that required practitioners to undergo online training and certify that they understood the narrow approved use and the risks.

    Despite these government efforts, TIRF drugs were being widely prescribed to patients without cancer. Pain doctors, not oncologists, were the dominant players. This was common knowledge in the industry. Although it is illegal for a manufacturer to promote drugs for off-label use, it is perfectly legal for doctors to prescribe any drug off-label, on their own judgment. This allows drug makers like Insys to use a narrow F.D.A. approval as a “crowbar,” as a former employee put it, to reach a much broader group of people.

    That points to a major vulnerability in policing the opioid crisis: Doctors have a great deal of power. The F.D.A. regulates drug makers but not practitioners, who enjoy a wide latitude in prescribing that pharmaceutical companies can easily exploit. A respected doctor who advocates eloquently for wider prescribing can quickly become a “key opinion leader”; invited out on the lucrative lecture circuit. And any doctor who exercises a free hand with opioids can attract a flood of pain patients and income. Fellow doctors rarely blow the whistle, and some state medical boards exercise timid oversight, allowing unethical doctors to continue to operate. An assistant district attorney coping with opioids in upstate New York told me that it’s easy to identify a pill-mill doctor, but “it can take five years to get to that guy.” In the meantime, drug manufacturers are still seeing revenue, and that doctor is still seeing patients, one after another, day after day.

    Kapoor believed that he had the best product in its class. All the TIRF drugs — for transmucosal immediate-release fentanyl — deliver fentanyl through the mucous membranes lining the mouth or nose, but the specific method differs from product to product. Actiq, the first TIRF drug, is a lozenge on a stick. Cephalon’s follow-up, Fentora — the branded market leader when Subsys arrived — is a tablet meant to be held in the cheek as it dissolves. Subsys is a spray that the patient applies under the tongue. Spraying a fine mist at the permeable mouth floor makes for a rapid onset of action, trials showed.

    Once the F.D.A. gave final approval to Subsys in early 2012, the fate of Insys Therapeutics rested on selling it in the field. The industry still relies heavily on the old-fashioned way of making sales; drug manufacturers blanket the country with representatives who call on prescribers face to face, often coming to develop personal relationships with them over time.

    The speaker events themselves were often a sham, as top prescribers and reps have admitted in court. Frequently, they consisted of a nice dinner with the sales rep and perhaps the doctor’s support staff and friends, but no other licensed prescriber in attendance to learn about the drug. One doctor did cocaine in the bathroom of a New York City restaurant at his own event, according to a federal indictment. Some prescribers were paid four figures to “speak” to an audience of zero.

    One star rep in Florida, later promoted to upper management, told another rep that when she went in search of potential speakers, she didn’t restrict herself to the top names, because, after all, any doctor can write scripts, and “the company does not give a [expletive] where they come from.” (Some dentists and podiatrists prescribed Subsys.) She looked for people, she said, “that are just going through divorce, or doctors opening up a new clinic, doctors who are procedure-heavy. All those guys are money hungry.” If you float the idea of becoming a paid speaker “and there is a light in their eyes that goes off, you know that’s your guy,” she said. (These remarks, recorded by the rep on the other end of the line, emerged in a later investigation.)

    As a result of Insys’s approach to targeting doctors, its potent opioid was prescribed to patients it was never approved to treat — not occasionally, but tens of thousands of times. It is impossible to determine how many Subsys patients, under Kapoor, actually suffered from breakthrough cancer pain, but most estimates in court filings have put the number at roughly 20 percent. According to Iqvia data through September 2016, only 4 percent of all Subsys prescriptions were written by oncologists.

    Insys became the year’s best-performing initial public offering, on a gain of over 400 percent. That December, the company disclosed that it had received a subpoena from the Office of the Inspector General at Health and Human Services, an ominous sign. But a CNBC interviewer made no mention of it when he interviewed Babich a few weeks later. Instead he said, “Tell us what it is about Insys that has investors so excited.”

    In 2014, the doctors each averaged one prescription for a controlled substance roughly every four minutes, figuring on a 40-hour week. A typical pill mill makes its money from patients paying in cash for their appointments, but Ruan and Couch had a different model: A majority of their scripts were filled at a pharmacy adjacent to their clinic called C&R — for Couch and Ruan — where they took home most of the profits. The pharmacy sold more than $570,000 of Subsys in a single month, according to Perhacs’s criminal plea. Together the two men amassed a collection of 23 luxury cars.

    Over dinner, according to the Boston indictment, Kapoor and Babich struck a remarkable agreement with the pharmacists and the doctors, who were operating a clinic rife with opioid addiction among the staff: Insys would ship Subsys directly to C&R Pharmacy. An arrangement like this is “highly unusual” and a “red flag,” according to testimony from a D.E.A. investigator in a related trial. As part of the terms of the deal, the pharmacy would make more money on selling the drug, with no distributor in the loop. And there would be another anticipated benefit for all involved: Everyone could sell more Subsys without triggering an alert to the D.E.A.

    The local medical community felt the impact of the raid. Because refills are generally not allowed on controlled substances, patients typically visited the clinic every month. For days, dozens of them lined up outside in the morning, fruitlessly trying to get prescriptions from the remaining staff or at least retrieve their medical records to take elsewhere. But other providers were either booked up or would not take these patients. “Nobody was willing to give the amount of drugs they were on,” a nurse in the city said. Melissa Costello, who heads the emergency room at Mobile Infirmary, said her staff saw a surge of patients from the clinic in the ensuing weeks, at least a hundred, who were going through agonizing withdrawal.

    Two months after the raid in Mobile, Insys’ stock reached an all-time high.

    Insys itself is still producing Subsys, though sales have fallen considerably. (Overall demand for TIRFs has declined industrywide.) The company is now marketing what it calls the “first and only F.D.A.-approved liquid dronabinol,” a synthetic cannabinoid, and is developing several other new drugs. Some analysts like the look of the company’s pipeline of new drugs and rate the stock a “buy.” In a statement, the company said its new management team consists of “responsible and ethical business leaders” committed to effective compliance. Most of its more than 300 employees are new to the company since 2015, and its sales force is focused on physicians “whose prescribing patterns support our products’ approved indications,” the company said. Insys has ended its speaker program for Subsys.

    #Opioides #Pharmacie #Bande_de_salopards


    • US : Poor Medical Care, Deaths, in Immigrant Detention

      Poor medical treatment contributed to more than half the deaths reported by US Immigration and Customs Enforcement (ICE) during a 16-month period, Human Rights Watch, the American Civil Liberties Union, Detention Watch Network, and National Immigrant Justice Center said in a report released today.

      Based on the analysis of independent medical experts, the 72-page report, “Code Red: The Fatal Consequences of Dangerously Substandard Medical Care in Immigration Detention,” examines the 15 “Detainee Death Reviews” ICE released from December 2015 through April 2017. ICE has yet to publish reviews for one other death in that period. Eight of the 15 public death reviews show that inadequate medical care contributed or led to the person’s death. The physicians conducting the analysis also found evidence of substandard medical practices in all but one of the remaining reviews.

      “ICE has proven unable or unwilling to provide adequately for the health and safety of the people it detains,” said Clara Long, a senior US researcher at Human Rights Watch. “The Trump administration’s efforts to drastically expand the already-bloated immigration detention system will only put more people at risk.”

      12 people died in immigration detention in fiscal year 2017, more than any year since 2009. Since March 2010, 74 people have died in immigration detention, but #ICE has released death reviews in full or in part in only 52 of the cases.

      Based on the death reviews, the groups prepared timelines of the symptoms shown by people who died in detention and the treatment they received from medical staff, along with medical experts’ commentary on the care documented by ICE and its deviations from common medical practice. The deaths detailed in the report include:

      Moises Tino-Lopez, 23, had two seizures within nine days, each observed by staff and reported to the nurses on duty in the Hall County Correctional Center in Nebraska. He was not evaluated by a physician or sent to the hospital after the first seizure. During his second seizure, staff moved him to a mattress in a new cell, but he was not evaluated by a medical practitioner. About four hours after that seizure, he was found to be unresponsive, with his lips turning blue. He was sent to the hospital but never regained consciousness and died on September 19, 2016.
      Rafael Barcenas-Padilla, 51, had been ill with cold symptoms for six days in the Otero County Processing Center in New Mexico when his fever reached 104, and nurses recorded dangerously low levels of oxygen saturation in his blood. A doctor, consulted by phone, prescribed a medication for upper respiratory infections. The ICE detention center didn’t have the nebulizer needed to administer one of the medicines, so he did not receive it, and he showed dangerously low oxygen readings that should have prompted his hospitalization. Three days later, he was sent to the hospital, where he died from bronchopneumonia on April 7, 2016.
      Jose Azurdia, 54, became ill and started vomiting at the Adelanto Detention Facility in California. A guard told a nurse about Azurdia’s condition, but she said that “she did not want to see Azurdia because she did not want to get sick.” Within minutes, his arm was numb, he was having difficulty breathing, and he had pain in his shoulder and neck – all symptoms of a heart attack. Due to additional delays by the medical staff, two hours passed before he was sent to the hospital, with his heart by then too damaged to respond to treatment. He died in the hospital four days later, on December 23, 2015.

      “Immigrant detention centers are dangerous places where lives are at risk and people are dying,” said Silky Shah, executive director of Detention Watch Network, a national coalition that exposes the injustices of the US’ immigration detention and deportation system. “The death toll amassed by ICE is unacceptable and has proven that they cannot be trusted to care for immigrants in their custody.”

      In fiscal year 2017, ICE held a daily average of nearly 40,500 people, an increase of nearly 500 percent since 1994. The Trump administration has asked Congress to allocate $2.7 billion for fiscal year 2019 to lock up a daily average of 52,000 immigrants in immigration detention facilities, a record number that would represent a 30 percent expansion from fiscal year 2017.

      “To the extent that Congress continues to fund this system, they are complicit in its abuses,” said Heidi Altman, policy director at the National Immigrant Justice Center, a nongovernmental group dedicated to ensuring human rights protections and access to justice for all immigrants, refugees, and asylum seekers. “Congress should immediately act to decrease rather than expand detention and demand robust health, safety, and human rights standards in immigration detention.”

      The new report is an update of a 2017 Human Rights Watch report that examined deaths in detention between 2012 and 2015, as well as a 2016 report by the American Civil Liberties Union, the Detention Watch Network, and the National Immigrant Justice Center that examined deaths in detention between 2010 and 2012.

      The medical experts who analyzed the death reviews for the groups include Dr. Marc Stern, the former health services director for the Washington State Department of Corrections; Dr. Robert Cohen, the former director of Montefiore Rikers Island Health Services; and Dr. Palav Babaria, the chief administrative officer of Ambulatory Services at Alameda Health System in Oakland, California, and assistant clinical professor in Internal Medicine at the University of California, San Francisco.

      Six of the new deaths examined occurred at facilities operated by the following private companies under contract with ICE: #CoreCivic, #Emerald_Correctional_Management, the #GEO_Group, and the #Management_and_Training_Corporation (#MTC).

      “ICE puts thousands of people’s health and lives at risk by failing to provide adequate medical care to the people it detains for weeks, months, and even years,” said Victoria Lopez, senior staff attorney at the American Civil Liberties Union.


      https://www.hrw.org/news/2018/06/20/us-poor-medical-care-deaths-immigrant-detention
      #privatisation #mourir_en_rétention #mourir_en_détention_administrative

      https://www.youtube.com/watch?v=VL9IKGoozII


  • Pain Management and the Intersection of Pain and Opioid Use Disorder - Pain Management and the Opioid Epidemic - NCBI Bookshelf
    https://www.ncbi.nlm.nih.gov/books/NBK458655

    This chapter addresses the scope of the problem of pain in the United States and its association with opioids, and the effectiveness of pharmacologic (both opioid and nonopioid) and nonpharmacologic treatments that may, alone or in combination, help individuals manage pain. The first section summarizes the scope of the problem of pain, focusing in particular on chronic, or persistent, pain, the form most associated with problematic use of opioids. The chapter then presents a detailed discussion of the various pain treatment modalities, reviewing in turn opioid analgesics, nonopioid pharmacologic treatments, interventional pain therapies, and nonpharmacologic treatments. This section is particularly important in helping to contextualize the evidence of effectiveness and limitations for various treatments for pain, given the burden of pain, the risks associated with undertreatment, and the pervasiveness of opioid use and related dose-dependent risks. The next section examines differences in pain experiences and treatment effectiveness among subpopulations, and the final section briefly addresses the intersection between pain and opioid use disorder (OUD) (discussed in greater detail in Chapter 3). A main objective of this chapter is to situate opioids within the broader armamentarium of treatments available for management of pain and to identify potential opportunities for reduced reliance on these medications.

    The very real problems of underdiagnosis and undertreatment of pain are valid concerns, but it would be a mistake to infer that greater utilization of opioids would ameliorate these problems. As discussed below, opioids have long been used for the effective management of acute pain (e.g., acute postsurgical and postprocedural pain), but available evidence does not support the long-term use of opioids for management of chronic noncancer pain. On the other hand, evidence indicates that patients taking opioids long-term are at increased risk of OUD and opioid overdose, as well as a number of other adverse outcomes (e.g., cardiovascular events, fractures) (Baldini et al., 2012; Chou et al., 2015; Krashin et al., 2016). Nevertheless, opioids often are used in the management of chronic noncancer pain. As discussed in Chapter 1, for many years physicians prescribed opioids for chronic noncancer pain, sometimes in very high doses, because of the incorrect belief that the risk for the development of substance use disorders and addiction was low (Krashin et al., 2016). Emphasis was appropriately placed on inadequate recognition and treatment of pain. However, these concerns often were not balanced by a similar emphasis on precautions to avoid adverse effects, such as the development of addiction (Kolodny et al., 2015), and the increase in opioid prescribing that began during the 1990s was associated with a parallel increase in opioid-related substance use disorders and opioid-related deaths (Dowell et al., 2016; Kolodny et al., 2015; SAMHSA, 2015). It is estimated that opioid pain relievers (excluding nonmethadone synthetics) directly accounted for more than 17,500 deaths in 2015, up from approximately 6,160 in 1999 (NCHS, 2016). Moreover, these figures do not account for deaths from related conditions (e.g., bloodborne infections associated with OUD; see Chapters 4 and 5 for further detail). There are indications that opioid prescribing is decreasing, but as recently as 2015, tens of millions of opioids were dispensed by U.S. outpatient retail pharmacies (see Figure 1-1 in Chapter 1). The United States consumes the vast majority of opioids worldwide (Hauser et al., 2016).

    #Opioides #Utilisation_médicale #Douleurs_chroniques


  • How Your Brain Is Wired to Just Say ’Yes’ to Opioids | Alternet
    https://www.alternet.org/drugs/how-your-brain-wired-just-say-yes-opioids-opiates-heroin-fentanyl

    Brain scientists have known for decades that opioids are complex and difficult substances to manage when it comes to addiction. The National Institute on Drug Abuse reports that more than 20 percent of the patients prescribed opioids for chronic pain misuse them, and between 8 and 12 percent of those who use prescription opioids develop a use disorder.

    Given how addictive these drugs are, doctors should have foreseen the looming danger of prescription opioids long before their use was liberalized for non-cancer related pain in the 1990s. Opioid abuse has instead ballooned over the last decade. In 2014, federal officials estimated nearly 2 million people in the United States suffer from substance use disorders related to prescription opioid pain medicines. Each day, more than 1,000 people are treated in emergency rooms for misusing prescription opioids, the CDC reports.

    Brain science is only one part of an addiction problem, but, I believe an important one deserving of more consideration than we’ve shown in past drug abuse crises. NIH Director Francis S. Collins has recognized this in his leadership of the medical and scientific response to the opioid use epidemic.

    The NIH is taking important steps in building a public-private partnership that will seek scientific solutions to the opioid crisis, including the development of non-opioid painkillers. Collins has committed his agency’s resources in this quest, including implementing the Fast Track and Breakthrough Therapy designations that exist to facilitate development and expedite review of products that address an unmet medical need. The agency is calling for more emphasis on non-drug alternatives for pain, such as medical devices that can deliver more localized analgesia.

    #Opioides #Neurosciences