diff --git "a/docket_comments_v3.json" "b/docket_comments_v3.json" new file mode 100644--- /dev/null +++ "b/docket_comments_v3.json" @@ -0,0 +1 @@ +[{"id": "FDA-2019-N-5973", "title": "Agency Information Collection Activities; Proposed Collection; Comment Request; Health Care Providers\u2019 Understanding of Opioid Analgesic Abuse Deterrent Formulations", "context": "2020-09-15T09:27:20Z", "purpose": "Nonrulemaking", "keywords": ["2019-958", "OO", "Notice", "Agency Information Collection Activities", "Proposed Collection", "Comment Request", "Health Care Providers\u2019 Understanding of Opioid", "Analgesic Abuse Deterrent Formulations", "OPEN"], "comments": [{"text": "Please see our attached comment.

Steven D. Passik, PhD
VP, Scientific Affairs
Collegium Pharmaceuticals
Stoughton, MA ", "comment_id": "FDA-2019-N-5973-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-5973-0006", "comment_date": "2020-04-08T04:00:00Z", "comment_title": "Comment from Collegium Pharmaceuticals", "commenter_fname": null, "commenter_lname": null, "comment_length": 141}, {"text": "We support FDAs decision to conduct a comprehensive evaluation of opioid prescribers knowledge, attitudes, perceptions, experiences and behaviors related to Abuse Deterrent Formulations (ADF) and agree with the FDA that new language is needed to better describe and explain ADF. Please see the attached document for the full comment.", "comment_id": "FDA-2019-N-5973-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-5973-0005", "comment_date": "2020-04-08T04:00:00Z", "comment_title": "Comment from National Center for Health Research", "commenter_fname": null, "commenter_lname": null, "comment_length": 333}, {"text": "I believe Phase 2 should include more pharmacists than 10% ratio. Also practitioners chosen should be based on greater prescribing habits. Those practitioners who are the larger rate of treating Chronic Non-Cancer pain with ADF Opioid should be the target of information gathering.", "comment_id": "FDA-2019-N-5973-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-5973-0004", "comment_date": "2020-02-28T05:00:00Z", "comment_title": "Comment from Denise Traficante", "commenter_fname": null, "commenter_lname": null, "comment_length": 281}]}, {"id": "FDA-2015-P-1752", "title": "Requests that the FDA determine that ZUBSOLV (buprenorphine and naloxone sublingual tablets), Eq. 11.4 mg/ 2.9 mg Base was not withdrawn from the market for safety or efficacy reasons. - Closed", "context": "2016-01-15T11:30:52Z", "purpose": "Nonrulemaking", "keywords": ["Open", "CDER", "2015-3613", "Zubsolv", "buprenorphine and naloxone sublingual tablets", "11.4 mg/ 2.9 mg Base", "safety or efficacy", "Market Withdrawal"], "comments": [{"text": "See attached file(s)", "comment_id": "FDA-2015-P-1752-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2015-P-1752-0004", "comment_date": "2015-12-08T05:00:00Z", "comment_title": "Comment from Orexo US, Inc.", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}]}, {"id": "FDA-2022-D-1847", "title": "Exemption and Exclusion from Certain Requirements of the Drug Supply Chain Security Act for the Distribution of FDA-Approved Naloxone Products During the Opioid Public Health Emergency", "context": "2022-11-03T13:44:18Z", "purpose": "Nonrulemaking", "keywords": ["CDER", "2022-329", "Exemption and Exclusion", "from Certain Requirements", "of the Drug Supply Chain Security Act", "for the Distribution", "of FDA-Approved Naloxone Products", "During the Opioid Public Health Emergency", "Open"], "comments": [{"text": "My son died September 11th, 2019 from an accidental overdose. He had overdosed twice before he died and it was only because of Narcan was he able to live another day. I have been talking to pharmacist, doctors, and the public in general and it is unbelievable how little they know about this lifesaving drug. I implore the FDA to please invest in a campaign of awareness concerning Narcan so that we can Save Just One. Someone dies every 5 minutes from an overdose or poisoning in this country. We are losing an entire generation.", "comment_id": "FDA-2022-D-1847-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-D-1847-0004", "comment_date": "2022-11-03T04:00:00Z", "comment_title": "Comment from LeAnne Burdette", "commenter_fname": null, "commenter_lname": null, "comment_length": 530}, {"text": "We are talking about lives here! The lives of the person who tried pot for the first time and it was laced with Fentanyl. The addict who couldn't no more and his overdose was a suicide attempt. We should have vending machines at every corner with Naloxone!. I understand regulations are necessary to keep individuals safe, but the individuals that need Naloxone are those not following regulations. I thank you for absolutely taking the initiative to lift regulations temporarily while we can get these numbers down. We should not limit a lifesaving medication by restricting it to prescription. Have not only harm reduction organizations carry it but recovery community organizations, rehabs, schools, libraries. Make it AVAILABLE! Easily accessible. ", "comment_id": "FDA-2022-D-1847-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-D-1847-0003", "comment_date": "2022-09-29T04:00:00Z", "comment_title": "Comment from Alex Grimes", "commenter_fname": null, "commenter_lname": null, "comment_length": 756}]}, {"id": "FDA-2016-P-2072", "title": "Requests that the FDA guidelines for the Optimal Dose and Pharmacokinetics for any Naloxone Containing Product Intended for the Emergency Treatment of Suspected Opioid Overdose in All Settings (Including Non-Medical Settings) by Individuals (Including Non-Medically Trained Individuals)", "context": "2016-12-14T11:46:08Z", "purpose": "Nonrulemaking", "keywords": ["Citizen Petition", "CDER", "2016-4203", "Adapt Pharma", "Pacific Link Consulting", "FDA Guidelines for the Optimal Dose", "and Pharmacokinetics for any Naloxone", "Containing Product", "Intended for the Emergency", "Treatment of Suspected Opioid", "Overdose in All Settings", "(Including Non-Medical Settings)", "by Individuals", "(Including Non-Medically Trained Individuals)", "OPEN"], "comments": [{"text": "See attached file(s)", "comment_id": "FDA-2016-P-2072-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-P-2072-0006", "comment_date": "2016-12-14T05:00:00Z", "comment_title": "Comment from New York City Department of Health & Mental Hygiene", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "I support the cause of the petition. Opiate overdoses are a huge issue, and if doctors and pharmaceutical companies are going to enable people by prescribing opiates, there needs to be a better way to prevent deaths when there is an overdose.", "comment_id": "FDA-2016-P-2072-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-P-2072-0003", "comment_date": "2016-10-17T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 242}, {"text": "I support Adapt Pharmaceuticals petition. As opioid use rises, and pharmaceutical opiates like Fentanyl are becoming prescribed more regularly, first responders need a faster acting, higher strength medication. According to the Center for Disease Control (CDC), naloxone has been responsible for saving over 10,000 lives between 1996 and 2010.
The lives saved will only increase with the intranasal Narcan becoming more readily available. A higher dose being available can assist when a person overdoses on a more potent opioid such as Fentanyl. According to the National Institute on Drug Abuse, by 2014 overdose deaths from prescription opiates had tripled in the last 20 years, with there being nearly 207million opiate prescriptions written in the United States in 2013.
Studying the way the product Narcan is delivered is a great idea. Having a package that is easily opened, then delivered, in its entirety, will ensure that people are getting their full dose quickly. Also, having the package labeling instructions easily understood by teenagers and by illiterate adults just makes sense. These easy to comprehend package instructions will ensure that almost anyone who has a Narcan kit can effectively deliver a dose in a life-saving moment.
As the CDC explains, over 165,000 people have died from opioid overdose in the US from 1999 to 2014, today over half of these deaths each year are from prescription opioids. Please process Adapt Pharmaceutical's request, and get started on approval of other forms of Narcan. The more opiates are prescribed, the more the US needs a medication like this available to first responders, and other potential witnesses of a likely opiate overdose. Thank you.
Jeremy G.
", "comment_id": "FDA-2016-P-2072-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-P-2072-0004", "comment_date": "2016-12-08T05:00:00Z", "comment_title": "Comment from Jeremy G.", "commenter_fname": null, "commenter_lname": null, "comment_length": 1746}]}, {"id": "FDA-2007-P-0128", "title": "Approve Abbreviated New Drug Applications (ANDA's) and 505 (b)(2) Applications That Reference Drug Products Containing Auto-Injectors-- and to Make Therapeutic Equivalence Designations--Only in Accordance With the Standard Required by law and Described in This Petition-CLOSED", "context": "2021-09-01T01:01:00Z", "purpose": "Nonrulemaking", "keywords": ["pralidoxine", "diazepam", "morphine", "atropine injection", "Atro Pen", "epinephrine injection", "Epi Pen", "equivalence", "therapeutic", "auto-injectors", "anda's", "CDER", "CLOSED"], "comments": [{"text": null, "comment_id": "FDA-2007-P-0128-0007", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2007-P-0128-0007", "comment_date": "2009-08-10T04:00:00Z", "comment_title": "Dey, L.P. - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}]}, {"id": "CDC-2008-0002", "title": "Medical Examination of Aliens \u2013 Revisions to Medical Screening Process", "context": "2014-01-10T20:36:31Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "I am writing to comment on the proposed changes to the medical screening
requirements for admittance to the United States. I urge you to remove the
requirement that aliens be negative for HIV for short-term visits to the United
States. The current policy, refusing entry even for short visits for people
with HIV, does not make sense in today's world. It is known that HIV has
specific methods of transmission, and the likelihood that an HIV-positive
foreign visitor would present an unusual risk of disease is extremely low. In
an economy that is currently struggling, it is not a good idea to refuse
visitors who present a low risk, or to discourage visitors who are HIV-negative,
but visit other places that do not place harsh restrictions.

Additionally, it is extremely close to the change in administration, and I urge
you to postpone the publication of the final rule until after the new
administration is in place in late January, 2009. Because this issue is of a
sensitive and foreign relations matter, the new administration should weigh in
on it.

Thank you.", "comment_id": "CDC-2008-0002-0004", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2008-0002-0004", "comment_date": "2009-02-10T05:00:00Z", "comment_title": "Comment on FR Doc # E8-23485", "commenter_fname": "Susan", "commenter_lname": "DeBardeleben", "comment_length": 1146}, {"text": "The CDC has indicated that this rule will not affect medical examinations of aliens
in the U.S. A plain language reading of section 212(a)(1) of the Immigration and
Nationality Act, and 42 C.F.R. 34.1, 34.3(a)(1), do not support this conclusion.
Even so, this rule would create a dangerous precedent, perhaps one that the CDC
did not intend to happen. The CDC is creating a double standard: an alien in the
U.S. with a newly identified disease would not be found inadmissible but an alien
overseas with the same disease would be found inadmissible. Such a conclusion
does not support the intent of the immigration and public health laws. Aliens in
the U.S. are no less of a danger to the public health. Rather, they are more of a
danger as they are already in the U.S. This rule would, among other things,
encourage aliens to avoid overseas medical examinations and to find ways to
illegally enter the U.S. This rule does not address the issue of what the CDC and
USCIS could or would do if an alien in the U.S. had a newly identified disease.
The CDC and USCIS must be ready, able and willing to deal with such a
consequence. Avoidance of the issue would threaten public health.
The best approach to this issue would be to apply the same standards to medical
examinations performed overseas and those in the U.S. Whether aliens are
overseas or in the U.S., the threat to public health is no different. If the CDC truly
intends to limit this rule to overseas medical examinations, then it should revise 42
C.F.R. 34 to clearly differentiate between overseas medical examinations and
to those in the U.S. Currently, 42 C.F.R. 34.3(c) contradicts the Immigration and
Nationality Act and 42 C.F.R. 34.1, 34.3(a)(1). For medical examinations in the
U.S., the CDC should include an additional regulation to allow civil surgeons to
discretionarily screen for newly identified diseases. If this is not feasible, then the
additional regulation should provide guidance if an alien in the U.S. has a newly
identified disease. While it may not be a common scenario now, it could be
common in the future.", "comment_id": "CDC-2008-0002-0002", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2008-0002-0002", "comment_date": "2009-02-10T05:00:00Z", "comment_title": "Comment on FR Doc # E8-23485", "commenter_fname": null, "commenter_lname": null, "comment_length": 2239}, {"text": "Attached are the comments for the American Immigration Lawyers Association to
the interim final rule published at 73 Fed. Reg 58047 (October 6, 2008).", "comment_id": "CDC-2008-0002-0003", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2008-0002-0003", "comment_date": "2009-02-10T05:00:00Z", "comment_title": "Comment on FR Doc # E8-23485", "commenter_fname": "Luke", "commenter_lname": "Hall", "comment_length": 154}]}, {"id": "DEA-2020-0029", "title": "Registering Emergency Medical Services Agencies under the Protecting Patient Access to Emergency Medications Act of 2017", "context": "2023-01-05T11:22:06Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": ""1304.27 (a) Each emergency medical services agency registered pursuant to 1301.20 of this chapter (including a hospital-based emergency medical services agency using a hospital registration under 1301.20(a)(2) of this chapter) must maintain records for each dose of controlled substances administered or disposed of in the course of providing emergency medical services. The following information shall be included in each record:"

The use of the word dose should be heavily re-considered. EMS units often will administer multiple doses of a drug to a patient. For example, 25mcg of Fentanyl to a geriatric to ensure that they tolerate it well, before administering a second 25mcg dose.

The use of the word dose could make each emergency run require multiple logs for controlled substance administration, adding significantly to the paperwork burden, while creating unseen incentives that impact how often paramedics administer medications that are clinically indicated.

For example, as mentioned above, perhaps the paramedic will be incentivized to administer the full 100mcg vial of Fentanyl to the patient because they want to see the patient's pain controlled, but do not want to make 4 duplicative records for each 25mcg administration. Now, the patient receives the 100mcg and the patient suffers a side effect of vomiting and respiratory depression. The paperwork burden of healthcare is already high enough.

The use of the word dose should be removed, and record requirements should be based on the type of controlled substance per ambulance run. Redundancy as required by the word dose will negatively impact patient care without any significant impact to reducing diversion.

I.E. if the paramedic has a standing order to administer up to 200mcg of Fentanyl for pain in doses of 25mcg-100mcg, and they administer 3 doses of 50mcg and wasted 50mcg. They should be required to create ONE record that indicates that they administered 150mcg of Fentanyl and wasted 50mcg. Not three to four duplicative records.

"1304.27 (a) (2) Finished form of the substance (e.g., 10-milligram tablet or 10-milligram concentration per fluid ounce or milliliter);"

This provision should receive extra consideration. Is the intent to create duplicative records when a patient requires more than one unit dose (container/vial) of a medication? At times medications come in a variety of concentrations due to shortages. At times, patients require more than one unit dose (or container/vial) of the medication during the course of EMS treatment.

Does tracking the finished form of each administration lend more positive impact on preventing diversion than it costs in paperwork burden? I'm inclined to say that it does not.

Again, as noted above in comments on "dose" this provision should be removed.

"1304.27 (a) (7) Initials of the medical director or authorizing medical professional issuing the standing or verbal order;"

This provision should be altered as it will create a significant burden on both the EMS agency and medical professional.

In relation to verbal orders under some medical control systems are from a physician that is located at a central location, or other location that the EMS unit will not be physically present at. To physically or electronically track down the medical professional giving the order, is impractical and problematic.

In relation to standing orders, the medical professional has already signed the order. While a review of the controlled substance administration may be appropriate, a requirement that the medical director initial each administration record is problematic and redundant, as again, this medical director is infrequently physically present in the course of the duties of the paramedic who followed the standing order and administered the controlled substance. The purpose of standing orders is to allow the paramedic to follow the orders without the physical or verbal presence of the medical professional. Tracking an individual down after delivering a patient to the hospital or other location (as is starting to be allowed by billing practices and Medicare) negates the benefit of standing orders to patients and EMS systems who will now have to exert significant effort to obtain two to three letters on paper.

Implementing this rule as written will cause undue burden on the EMS system and medical professionals overseeing them, and will be especially problematic in super rural, and highly busy urban systems; Possibly causing racial disparities in who actually receives these medications in times of need.

I recommend that you replace this provision with a requirement that the paramedic document the name of the medical professional providing the standing or verbal order, with the last name being sufficient.", "comment_id": "DEA-2020-0029-0007", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0029-0007", "comment_date": "2020-10-08T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-21675", "commenter_fname": "Eric", "commenter_lname": "Wanta", "comment_length": 4951}, {"text": "EMS personnel should be required to report and be monitored on their use (patient administration) of scheduled medications to a registry board (much like Prescription Drug Monitoring Program) in hopes to minimize over use (administration) of medications. At this education level (medic) the overall 'whole person' is not considered in patient care. Sadly, in my experience (from a medical perspective), medics tend to medicate and over medicate just for a 'smooth ride' so to say. ", "comment_id": "DEA-2020-0029-0006", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0029-0006", "comment_date": "2020-10-08T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-21675", "commenter_fname": "G", "commenter_lname": "Caruso-Hill", "comment_length": 497}, {"text": "How do these regulations impact those medical directors that are overseeing multiple agencies within their "EMS System", such as in Illinois? Illinois utilizes "EMS Systems" in which an agency must be a part of, according to the Illinois EMS Act. The rules only state "agency" and does not seem to fit into the way EMS is ran in Illinois where there are multiple agencies in one "system". ", "comment_id": "DEA-2020-0029-0027", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0029-0027", "comment_date": "2020-11-25T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-21675", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 434}, {"text": "Regarding the security of controlled substances, "the first option in proposed 1301.80(b)(1) would allow for an EMS agency to store controlled substances in a securely locked, substantially constructed cabinet or safe that cannot be readily removed. This storage component must be located at a secured location, as stated in proposed 1301.80(i). The second option in proposed 1301.80(b)(2) would allow an EMS agency to store controlled substances in an automated dispensing system (ADS) machine, under specific conditions".

Under, WV state law (Policy Number: 4.12-082013), "ALS providers may have medication stored in the ambulance "jump bag". However the "jump bag" must be secured using a device such as a tamper detectable plastic lock. The bag must be stored in a secured locked location on the ambulance or in the Agency Station. ALS providers or the Registrants designated personnel (Power of Attorney as described above) must be in control of the bag at all times when not locked in a secure location."

It appears that the proposed rule would eliminate the possibility of storing controlled substances in a "jump bag" in order for the EMS personnel to have quick access in an emergency situation.

", "comment_id": "DEA-2020-0029-0026", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0029-0026", "comment_date": "2020-11-09T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-21675", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 1283}, {"text": "See attached file(s)", "comment_id": "DEA-2020-0029-0037", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0029-0037", "comment_date": "2020-12-03T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-21675", "commenter_fname": "Timothy", "commenter_lname": "Peterson", "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "DEA-2020-0029-0034", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0029-0034", "comment_date": "2020-12-03T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-21675", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "DEA-2020-0029-0044", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0029-0044", "comment_date": "2020-12-03T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-21675", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "DEA-2020-0029-0033", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0029-0033", "comment_date": "2020-12-03T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-21675", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Section (G)(1) related to standing orders: In Pennsylvania standing orders (statewide protocols) are issues by the Pennsylvania Department of Health. EMS Agency Medical Directors are not permitted to issue their own standing orders (protocols), nor are they permitted to alter a statewide protocol, except as may be permitted within a specific protocol.

Section (G)(1), as currently drafted, creates a conflict with Pennsylvania EMS statute and regulation. The Pennsylvania Emergency Health Services Council, who is the Pennsylvania Department of Health's advisory board on EMS related matters, recommends consideration of the following amended language:

Section (G)(1)
"Standing orders that are developed by a state authority may be issued and adopted by the medical director of an EMS Agency [OR BE AUTOMATICALLY ISSUED AND ADOPTED WHEN REQUIRED BY STATE STATUE OR REGULATION.]"

"Under the Act and proposed regulations, only the medical director of an EMS agency [OR STATE AUTHORITY] is given authority to issue and adopt a standing order"

In our opinion, the recommended language change would not diminish the effectiveness of the proposed regulations with regard to authority, accountability or security.", "comment_id": "DEA-2020-0029-0042", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0029-0042", "comment_date": "2020-12-03T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-21675", "commenter_fname": "Donald", "commenter_lname": "Potter", "comment_length": 1275}, {"text": "1304.27(a) states that, "any EMS personnel who disposes of or administers controlled substances to a patient in the course of providing emergency medical care must record the name of the controlled substance(s) and detailed information about the circumstances surrounding the administration of the controlled substance(s) (e.g., name of the substance, date dispensed, identification of the patient)..."
While sensible in theory, in reality EMS work is often chaotic with back-to-back calls and many distractions between patients, as in the case of a car wreck with multiple victims, or a mass casualty event such as a mass shooting or other accident. In such instances, it may be nearly impossible for an individual to collect and retain such detailed information as the names of those who are administered critical care involving controlled substances, beyond the timeframe of the event, to be recorded properly.
What protections will be put in place for EMS workers who are unable to provide this information due to extenuating circumstances, or who make mistakes in their record keeping after a mass casualty type event?
", "comment_id": "DEA-2020-0029-0036", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0029-0036", "comment_date": "2020-12-03T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-21675", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 1230}]}, {"id": "FDA-2019-P-1783", "title": "Requests that the FDA immediately impose a moratorium on all future approvals of new drug applications (NDAs) for new opioids or new opioid formulations.", "context": "2019-09-16T08:56:20Z", "purpose": "Nonrulemaking", "keywords": ["CDER", "petition", "citizen petition", "Public Citizen", "opioids", "opioid formulations", "NDAs", "open"], "comments": [{"text": "Everyone deserves fresh healthy produces on both both rich and poor communities on the city the people are living. Like in Atlanta neither you're living in Bankhead or Buckhead, both of them deserve equal fresh clean healthy produce and much more on their communities.", "comment_id": "FDA-2019-P-1783-0160", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1783-0160", "comment_date": "2019-09-11T04:00:00Z", "comment_title": "Comment from Jean Pressoir", "commenter_fname": null, "commenter_lname": null, "comment_length": 272}, {"text": "To see how it was that the republicans in Pennsylvania dropped all information on opiate drug's overdose potential and physical addiction potential shows how this is all about the money, selling the drug to uneducated parties in order to deceive them about the drug's nature and dangers. Then in Ohio, a republican leader proposed to limit how many times addicts were to be brought back after an overdose to two times. See? They sell killer dope to us, then limit how many times we are to be brought back after an overdose; in an active addiction. And then plan on a person relapsing 7-10 times if a person has an abuse history. So clearly bringing back a person so affected parasuicidally "a couple of times" is certainly NOT getting the job that needs to be done, done; the services to accomplish that are not substantially out there adequate to the growing need(s). See also article The Mega Group, Maxwell's, and the Mossad on guns for drugs ops (1 of a four part series), child trafficking ops, black market body parts trade (UC-Berkeley Dept. of Anthropology-Organswatch). at www.mintpressnews.com, and large scale secret drug fueled mass murder operations carried out inside war crimes, like Operations Phoenix and Condor. See book The Phoenix Program, by Douglas Valentine and books by Alex Constantine. The first step in these programs is to cut the anti-poverty budgets, creating the original crisis, then lie yuge and say the economic crisis is caused by drug abusers and the homeless in a deliberate big lie program based on what is termed "projective Inversion";blaming the victim/survivors for what the nazi budget cutters, eerrr republicans actually did. Then too, see how opiate drug producers targeted areas that had a lot of consumption and overdoses for greater supplies when it was not used for medical purposes. Kentucky, West Virginia, Ohio, etc..This is clearly a "slow death" program; one of many run by the nazis, eerrr republicans. Harass, cut back benefits, cut benefits off completely-dead client. Just what the nazi doctor ordered. . . . Lyle Courtsal www.3mpub.com-Kissinger wants to reduce population by 2/5ths any means necessary. . . See also Gary Kohl's at www.duluthreader.com and Peter Breggin on "warehousing", rather than receiving care for conditions humanely. . .
PS What we also see is rather than an individual patient specific, patient centered interactive approach to pain management, etc., is instead a swinging between one professional sub-cultural extreme, enough pain pills for the pain and the addiction-no effective support then professional subculture swings to a complete cutoff of access to opiate pain pills that actually did work for the majority of patients out there; opiate medicine cut off completely (by Sessions); patient's situations much worse for those using opiates successfully than before. No more pain meds-patient in new much nastier crisis medically and is probably not getting adequate medical support with or without pain meds-next visit doctor 2 months away?!! ", "comment_id": "FDA-2019-P-1783-0381", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1783-0381", "comment_date": "2019-09-16T04:00:00Z", "comment_title": "Comment from Lyle Courtsal", "commenter_fname": null, "commenter_lname": null, "comment_length": 3099}, {"text": "I urge the FDA to impose an immediate, temporary moratorium on new opioid approvals. The National Academies of Sciences, Engineering, and Medicine issued detailed recommendations for an improved opioid regulatory framework more than two years ago, but the FDA has failed to put this new public health framework in place. Until it does, the moratorium is urgently needed.", "comment_id": "FDA-2019-P-1783-0382", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1783-0382", "comment_date": "2019-09-16T04:00:00Z", "comment_title": "Comment from Erik Schnabel", "commenter_fname": null, "commenter_lname": null, "comment_length": 370}, {"text": "I absolutely support this petition.", "comment_id": "FDA-2019-P-1783-0364", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1783-0364", "comment_date": "2019-09-16T04:00:00Z", "comment_title": "Comment from Adrian Devlin", "commenter_fname": null, "commenter_lname": null, "comment_length": 35}, {"text": "I'm tired of having to worry about whether people are selling their opioid products instead of disposing of them properly. The whole problem needs to be controlled.", "comment_id": "FDA-2019-P-1783-0369", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1783-0369", "comment_date": "2019-09-16T04:00:00Z", "comment_title": "Comment from Carol Caffrey", "commenter_fname": null, "commenter_lname": null, "comment_length": 169}, {"text": "I completely support Public Citizen's petition concerning this critical public safety issue.", "comment_id": "FDA-2019-P-1783-0383", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1783-0383", "comment_date": "2019-09-16T04:00:00Z", "comment_title": "Comment from Paul Netusil", "commenter_fname": null, "commenter_lname": null, "comment_length": 96}, {"text": "I am calling on the FDA to stop approving new opioids until it has adopted the public health opioid regulatory framework recommended in 2017 by the National Academies.

The FDA has recklessly approved dozens of new opioids without adequately assessing either their effectiveness or the likelihood that new products will be diverted into illegal trade and make the opioid addiction crisis still worse. Its up to us to demand the agency impose a freeze on opioid approvals until it adopts a safer approval process.

I am urging the FDA to impose an immediate, temporary moratorium on new opioid approvals. The National Academies of Sciences, Engineering, and Medicine issued detailed recommendations for an improved opioid regulatory framework more than two years ago, but the FDA has failed to put this new public health framework in place. Until it does, the moratorium is urgently needed.", "comment_id": "FDA-2019-P-1783-0385", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1783-0385", "comment_date": "2019-09-16T04:00:00Z", "comment_title": "Comment from Gloria Fooks", "commenter_fname": null, "commenter_lname": null, "comment_length": 905}, {"text": "There are enough drugs already that can KILL and maim people. STOP with the quick release of new ways to get addicted ", "comment_id": "FDA-2019-P-1783-0386", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1783-0386", "comment_date": "2019-09-16T04:00:00Z", "comment_title": "Comment from Barbara Khajavi", "commenter_fname": null, "commenter_lname": null, "comment_length": 118}, {"text": "I support the Citizen Petition from Public Citizen to restrict the sale of opioids.", "comment_id": "FDA-2019-P-1783-0090", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1783-0090", "comment_date": "2019-09-11T04:00:00Z", "comment_title": "Comment from Jeff Nein", "commenter_fname": null, "commenter_lname": null, "comment_length": 83}, {"text": "I support this petition.", "comment_id": "FDA-2019-P-1783-0117", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1783-0117", "comment_date": "2019-09-11T04:00:00Z", "comment_title": "Comment from Cherie Gaines", "commenter_fname": null, "commenter_lname": null, "comment_length": 24}]}, {"id": "FDA-2021-P-0514", "title": "Requests that the FDA declare that Naloxone HC1 Nasal Spray, 8 mg/Spray, is suitable for submission as an ANDA and to introduce a new 8 mg/Spray metered spray strength for prescription use", "context": "2022-04-25T11:42:15Z", "purpose": "Nonrulemaking", "keywords": ["Suitability Petition", "CDER", "HYMAN, PHELPS & MCNAMARA, P.C.", "for prescription use", "metered spray strength", "introduce a new 8 mg/Spray", "Approved Drug Products with", "Orange Book", "Therapeutic Equivalence Evaluations", "Reference Listed Drug (RLD)", "as an ANDA", "Abbreviated New Drug Application (ANDA)", "is suitable for submission", "8 mg/Spray", "declare that Naloxone HCl Nasal Spray", "OPEN"], "comments": [{"text": "N/A", "comment_id": "FDA-2021-P-0514-0007", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-P-0514-0007", "comment_date": "2022-04-25T04:00:00Z", "comment_title": "Comment from Foley & Lardner, LLP", "commenter_fname": null, "commenter_lname": null, "comment_length": 3}, {"text": "On behalf of Hikma Pharmaceuticals USA, Inc. (“Hikma”), the undersigned submits the following comments pursuant to 21 C.F.R. § 10.30(d) opposing the above-referenced suitability petition.", "comment_id": "FDA-2021-P-0514-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-P-0514-0006", "comment_date": "2021-08-20T04:00:00Z", "comment_title": "Comment from Lassman Law+Policy", "commenter_fname": null, "commenter_lname": null, "comment_length": 204}]}, {"id": "FDA-2023-D-0466", "title": "Clinical Considerations for Studies of Devices Intended to Treat Opioid Use Disorder; Draft Guidance for Industry and Food and Drug Administration Staff; Availability", "context": "2023-10-24T12:29:19Z", "purpose": "Nonrulemaking", "keywords": ["2019-576", "CDRH", "Clinical Considerations for Studies of", "Devices Intended to Treat Opioid Use Disorder", "Draft Guidance for Industry and", "Food and Drug Administration Staff", "Availability", "OPEN"], "comments": [{"text": "See attached file(s)", "comment_id": "FDA-2023-D-0466-0009", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2023-D-0466-0009", "comment_date": "2023-10-18T04:00:00Z", "comment_title": "Comment from Gayatri Aglave", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "FDA-2023-D-0466-0007", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2023-D-0466-0007", "comment_date": "2023-10-18T04:00:00Z", "comment_title": "Comment from Pooja Shende", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "FDA-2023-D-0466-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2023-D-0466-0006", "comment_date": "2023-10-18T04:00:00Z", "comment_title": "Comment from Patnam Jayasri Devi", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "FDA-2023-D-0466-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2023-D-0466-0005", "comment_date": "2023-10-18T04:00:00Z", "comment_title": "Comment from Supriya Gurule", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Clinical Considerations for Studies of Devices Intended To Treat Opioid Use Disorder", "comment_id": "FDA-2023-D-0466-0011", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2023-D-0466-0011", "comment_date": "2023-10-18T04:00:00Z", "comment_title": "Comment from Nikhil Shirsath", "commenter_fname": null, "commenter_lname": null, "comment_length": 84}, {"text": "See attached file(s) ", "comment_id": "FDA-2023-D-0466-0013", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2023-D-0466-0013", "comment_date": "2023-10-18T04:00:00Z", "comment_title": "Comment from Manasi Gawai", "commenter_fname": null, "commenter_lname": null, "comment_length": 21}, {"text": "

The FDA has been actively addressing the opioid overdose crisis by taking measures to reduce unnecessary opioid exposure and support OUD treatment so im going to comment related deficiency & the things which not include in scope of this guidance.

1.The CDRH is committed to contributing to the efforts to combat this national crisis and offers recommendations to ensure the safety and effectiveness of devices intended to treat OUD in the clinical study design process.

2.Some products such as, diagnostic tests for opioid use and devices intended for pain treatment are not falling in this guidance.

3.By which pathway Devices Intended to Treat Opioid Use Disorder should be approved is not given.

4.Guidance should also report what kind subjects used for clinical study additional provide the information about clinical study plan for devices intended to treat Opioid Use Disorder OSD.

", "comment_id": "FDA-2023-D-0466-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2023-D-0466-0004", "comment_date": "2023-10-18T04:00:00Z", "comment_title": "Comment from RUPESH GAIKWAD", "commenter_fname": null, "commenter_lname": null, "comment_length": 1107}, {"text": "See attached file(s)", "comment_id": "FDA-2023-D-0466-0014", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2023-D-0466-0014", "comment_date": "2023-10-23T04:00:00Z", "comment_title": "Comment from Sanjana Talathi", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Comment on Clinical Considerations for Studies of Devices Intended To Treat Opioid Use Disorder", "comment_id": "FDA-2023-D-0466-0010", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2023-D-0466-0010", "comment_date": "2023-10-18T04:00:00Z", "comment_title": "Comment from Pavan Vasu", "commenter_fname": null, "commenter_lname": null, "comment_length": 95}, {"text": "See attached file(s)", "comment_id": "FDA-2023-D-0466-0012", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2023-D-0466-0012", "comment_date": "2023-10-18T04:00:00Z", "comment_title": "Comment from Tejaswini Mergu", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}]}, {"id": "CMS-2021-0167", "title": "Opioid Treatment Program (OTP): CY 2022 Methadone Payment Exception (CMS-1751-IFC)", "context": "2022-06-22T12:14:07Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "It would be irresponsible of CMS to reduce OTP (Opioid Treatment Program) reimbursement for methadone while the current PHE is exacerbating opioid use disorders in the Medicare population. We need more, not less, support for medication-assisted treatment providers, and reducing reimbursement rates for methadone would likely make this drug less available to those who need it most. This is critical to avoid further opioid-related deaths.

Given the growing crisis, CMS should seek options to make methadone treatment more widely available by authorizing it to be dispensed in a pharmacy setting and/or increasing reimbursement rates to existing treatment providers. Given the abundance of pharmacies in most communities, this would capitalize on the existing pharmacy infrastructure and enable Medicare beneficiaries who are otherwise limited in treatment options to pursue medication-assisted treatment such as methadone.
", "comment_id": "CMS-2021-0167-0008", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2021-0167-0008", "comment_date": "2021-12-10T05:00:00Z", "comment_title": "Comment on CMS-2021-0167-0002", "commenter_fname": null, "commenter_lname": null, "comment_length": 939}, {"text": "With the nation in the grips of both the COVID-19 pandemic and the enduring opioid epidemic, it is critical to ensure continued access to recovery from opioid use disorder (OUD) for Medicare beneficiaries. The proposed rule to freeze payment to Opioid Treatment Programs (OTPs) for methadone in calendar year 2022 at the current calendar year 2021 rate should be implemented to protect access to methadone treatment.

Over 1.2 million individuals over the age of 65 struggled with substance use disorder (SUD) in 2019. However, only 23.6 percent received treatment. The number of older adults seeking treatment for OUD specifically increased nearly 54 percent between 2013-2015, as the opioid epidemic began to accelerate, affecting individuals regardless of age, race, income, and other demographics. More than 200,000 Medicare beneficiaries nationwide have died due to opioid overdoses since 2015. Additionally, SUD is associated with many negative outcomes including health complications, accidents due to impairment, and decreased productivity. Individuals ages 65 and over are especially vulnerable during the pandemic.

According to the National Institute on Drug Abuse (NIDA), the effects of many substances, including opioids, such as impaired judgement or coordination, can lead to falls and motor vehicle accidents, which pose a much greater risk for older adults. Additionally, NIDA research shows that older adults are more likely to suffer from mood disorders, heart conditions, and cognitive disorders, all of which can worsen due to SUD, increasing negative health outcomes.

Though rates of opioid use and overdoses were increasing as the pandemic began, they have surged to new highs, with a 28.5 percent increase over the first 12 months of the pandemic. Older adults are more likely to be isolated due to the pandemic and more likely to have access to prescription opioids. Overdoses among Medicare beneficiaries rose by roughly 200 per month during the second half of 2020, during the heights of the pandemic.

With the rates of overdose and OUD rising among Medicare beneficiaries, it is necessary to ensure continued access to OUD treatment. Medication-assisted treatment (MAT), which combines medications such as methadone and Suboxone with individual and group therapy, has proven to be the most effective treatment for OUD, and therefore it is critical to protect and expand access to MAT, especially as the pandemic continues. Many individuals struggle to find openings in existing MAT programs. Others are in communities without access to MAT at all. A 2019 University of Michigan study identified the biggest barriers to MAT treatment, according to providers, are state regulations and reimbursement rates. Additionally, as the opioid epidemic has spread, public support for prevention and treatment of OUD has significantly increase, decreasing stigma, a significant barrier to treatment.

The addition of methadone treatment as a Medicare Part B benefit in January 2020 expanded access to MAT to a large portion of older adults struggling to find recovery. However, a sharp and dramatic decrease in the reimbursement rate for methadone could upend that progress. As stated above, providers have identified reimbursement rates and costs as one of the top barriers to MAT. Slashing the reimbursement rate for methadone, especially with so little data available, could lead to financial impacts for clinics providing methadone treatment, significant cost sharing for Medicare beneficiaries, and other barriers to treatment at a time when the pandemic is fanning the flames of the opioid epidemic.

It is possible that freezing the rate at the current level will still result in some of these negative outcomes, as supply chain and logistics issues have driven up prices across the country and the globe. It is possible an increase is necessary. However, freezing the rate at the current level is a prudent solution for the moment. As stated in the proposed rule, a year will allow CMS additional time to study methadone use among Medicare beneficiaries, the prevalence of the two available methadone formulations, as well as potential alternative reimbursement formulas, given the unique nature of methadone.

Though it is concerning, given widespread inflation, that the rate will remain static in calendar year 2022, CMS’ rationale for this proposed rule is sound, and allows for additional time to study methadone treatment in general, a new benefit for Medicare. The proposed rule prevents a sharp decrease in the reimbursement rate, which could have injected chaos into the already fragile MAT infrastructure. Upon implementation of the proposed rule, it is critical that CMS dedicate significant time and resources to studying methadone treatment and reimbursement, as well as additional MAT options, particularly as the pandemic and opioid epidemic endure.
", "comment_id": "CMS-2021-0167-0009", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2021-0167-0009", "comment_date": "2021-12-15T05:00:00Z", "comment_title": "Comment on CMS-2021-0167-0002", "commenter_fname": null, "commenter_lname": null, "comment_length": 4978}, {"text": "Please continue to keep current payment rates. We struggle as it is to have enough providers to provide these services. Decreasing would greatly impact them.", "comment_id": "CMS-2021-0167-0004", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2021-0167-0004", "comment_date": "2021-12-01T05:00:00Z", "comment_title": "Comment on CMS-2021-0167-0002", "commenter_fname": null, "commenter_lname": null, "comment_length": 157}, {"text": "See attached file(s)", "comment_id": "CMS-2021-0167-0011", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2021-0167-0011", "comment_date": "2022-01-04T05:00:00Z", "comment_title": "Comment on CMS-2021-0167-0002", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See Attached", "comment_id": "CMS-2021-0167-0015", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2021-0167-0015", "comment_date": "2022-01-04T05:00:00Z", "comment_title": "AATOD RE Medicare Exception 01032022", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}, {"text": "PCMA appreciates the opportunity to comment on the U.S. Centers for Medicare & Medicaid Services’ interim final rule related to Opioid Treatment Programs: CY 2022 Methadone Payment Exception (interim final rule). ", "comment_id": "CMS-2021-0167-0012", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2021-0167-0012", "comment_date": "2022-01-04T05:00:00Z", "comment_title": "Comment on CMS-2021-0167-0002", "commenter_fname": null, "commenter_lname": null, "comment_length": 224}, {"text": "On behalf of the Medication-Assisted Treatment Leadership Counsel, please accept the attached comments.", "comment_id": "CMS-2021-0167-0014", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2021-0167-0014", "comment_date": "2022-01-04T05:00:00Z", "comment_title": "Comment on CMS-2021-0167-0002", "commenter_fname": null, "commenter_lname": null, "comment_length": 103}, {"text": "This is a very important issue and the action that is being taken is a step in the right direction. Addiction is a ruthless disease and it can happen to anyone.", "comment_id": "CMS-2021-0167-0007", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2021-0167-0007", "comment_date": "2021-12-10T05:00:00Z", "comment_title": "Comment on CMS-2021-0167-0002", "commenter_fname": null, "commenter_lname": null, "comment_length": 160}, {"text": "Thank you for the opportunity to comment. I am a disabled physician. Please maintain or increase rates for reimbursement for treatment of pain and addiction such as with methadone. Lack of access is driving the overdose deaths. Lack of reimbursement and difficulty of practice is driving providers out. ", "comment_id": "CMS-2021-0167-0010", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2021-0167-0010", "comment_date": "2021-12-15T05:00:00Z", "comment_title": "Comment on CMS-2021-0167-0002", "commenter_fname": null, "commenter_lname": null, "comment_length": 307}, {"text": "Eliminating the annual process to review methadone coverage treatment for CY 2022 to avoid implementing a possible decrease in the payment amounts for methadone for Medicare beneficiaries has been welcoming news for many who are indirectly or directly affected. I fully support maintaining the CY 2021 payment rate for methadone to treat opioid use disorders into CY 2022.
While many people might agree simply because it feels like the right thing to do, data across states indicate that this measure is critical for the fight against opioid overdose during the Coronavirus Disease 2019 (COVID-19) pandemic. The Centers for Disease Control and Prevention reported an increase in the use of opioids as the COVID-19 brought about lockdowns and quarantines. Prior to COVID- 19 opioid overdose cases consistently increased, but between May 2019 to May 2020, the United States saw 81,000 overdose deaths, the largest ever recorded.
While some data suggest that steps taken have improved prescription opioid misuse and fatalities, there have been increases with synthetic opioids such as Fentanyl, which is 50 to 100 times more potent than morphine. Prescription opioid misuse among medicare beneficiaries tends to come from chronic pain as they age.
The report states that nearly one million adults age 65 and older live with Substance Use Disorders (SUD). This number is almost certain to have increased over the years, following the increasing trend and the effects of the pandemic. It emphasizes the need to increase OTPs and expand the services offered across all states. Opioid use among older adults can result in excessive sedation, respiratory depression, impairment in vision, attention, coordination, and falls. Currently, falls are the leading cause of injury-related death among adults age 65 and older.
Decreasing the payment rate to Opioid treatment programs from $37.38 to $17.64 would have grave consequences, limiting access to SAMSHA certified and Medicare/Medicaid enrolled Opioid Treatment Programs (OTP). Many programs may choose not to participate due to inadequate funding.
These OTPs also provide psychosocial services. Most of these services have been transitioned to Telemedicine, thereby improving access. Data studying a clinician’s perspective on methadone service delivery indicate that 85 % of OTPs offered Telemedicine for medication management, psychosocial services, or both. These services might not be provided if payment rates are reduced.
Another factor to consider is that a decreased rate may hinder the enthusiasm and motivation of employees at OTPs. Compensation and benefits are directly related to employee motivation. Low employee morale can adversely affect attracting and retaining the best employees and negatively affect productivity.
While this interim final rule (IFC) freezes the payment to OTPs for methadone in CY 2022 at the CY 2021 rate, the annual update to the non-drug component of HCPCS G2067 for CY 2022 as required under § 410.67(d)(4)(iii) will be applied. It is worth noting that the effects of the pandemic on opioid use disorders will be long-lasting, possibly several years.
Much of the data required for evidence-based decision-making has been undermined by poor data collection, tracking, and COVID-19 restrictions. Opioid overdose is a public health crisis requiring increasing public awareness about prescription misuse, overdose, and making safe choices while providing both drug treatments and non-drug therapy.
According to the Centers for Disease Control and Prevention, the U.S. economic cost of opioid use disorder was 471 billion and fatal opioid overdose $550 billion during 2017, a total cost of $1,021 billion
The combined costs varied from $985 million in Wyoming to $1,204 in Hawaii. Federal and state public health agencies can use these data to help guide research, prevention, and resource allocation decisions.

", "comment_id": "CMS-2021-0167-0006", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2021-0167-0006", "comment_date": "2021-12-10T05:00:00Z", "comment_title": "Comment on CMS-2021-0167-0002", "commenter_fname": null, "commenter_lname": null, "comment_length": 3971}]}, {"id": "SAMHSA-2022-0002", "title": "Mandatory Guidelines for Federal Workplace Drug Testing Programs using Urine (UrMG) (Revised)", "context": "2022-06-14T14:07:49Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "Federal workers should absolutely be allowed use medical marijuana with a doctors recommendation just as they can use any other controlled substance with a valid prescription. The a huge portion of federal employees are disabled veterans and should be allowed to use medical marijuana if their doctor deems it an appropriate treatment.

The War on Marijuana is an ridiculous and it’s even more ridiculous that the federal government is proposing this language, as congress is moving towards completely removing cannabis from the controlled substance list. Stop discriminating against federal employees as the majority of states allow medical marijuana and it general direction is towards recreational legalization.", "comment_id": "SAMHSA-2022-0002-0003", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0002-0003", "comment_date": "2022-04-19T04:00:00Z", "comment_title": "Comment on FR Doc # 2022-06884", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 728}, {"text": "Medical cannabis is legal in 37 states, there are many doctors and medical professionals that realize the benefits of cannabis. The federal government is completely out of touch with the American people on the benefits of medical cannabis, and it should be up to a doctor and their patient on its use. I find it disturbing that the Federal government wants to continue the use of urinalysis on their employees, current or prospective, to detect cannabis use when it does not detect intoxication. Continuing to test current or prospective federal employees for cannabis use limits the applicant pool, and will force current employees to retire early, or move to the private sector rather than continue this policy.", "comment_id": "SAMHSA-2022-0002-0004", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0002-0004", "comment_date": "2022-04-19T04:00:00Z", "comment_title": "Comment from John Wurm", "commenter_fname": "John", "commenter_lname": "Wurm", "comment_length": 753}, {"text": "See attached file(s)", "comment_id": "SAMHSA-2022-0002-0006", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0002-0006", "comment_date": "2022-04-19T04:00:00Z", "comment_title": "Comment from Markita Norman-Green", "commenter_fname": "Markita", "commenter_lname": "Norman-Green", "comment_length": 20}, {"text": "Comments of Airlines for America attached.", "comment_id": "SAMHSA-2022-0002-0012", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0002-0012", "comment_date": "2022-06-07T04:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": null, "commenter_lname": null, "comment_length": 42}, {"text": "See attached file(s)", "comment_id": "SAMHSA-2022-0002-0011", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0002-0011", "comment_date": "2022-06-07T04:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "The comments of Laboratory Corporation of America Holdings (Labcorp) are attached.", "comment_id": "SAMHSA-2022-0002-0010", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0002-0010", "comment_date": "2022-06-07T04:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": null, "commenter_lname": null, "comment_length": 82}, {"text": "See attached file(s)", "comment_id": "SAMHSA-2022-0002-0026", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0002-0026", "comment_date": "2022-06-14T04:00:00Z", "comment_title": "Comment on FR Doc # 2022-06884", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "SAMHSA-2022-0002-0027", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0002-0027", "comment_date": "2022-06-14T04:00:00Z", "comment_title": "Comment on FR Doc # 2022-06884", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached", "comment_id": "SAMHSA-2022-0002-0018", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0002-0018", "comment_date": "2022-06-14T04:00:00Z", "comment_title": "Comment on FR Doc # 2022-06884", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}, {"text": "See attached", "comment_id": "SAMHSA-2022-0002-0020", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0002-0020", "comment_date": "2022-06-14T04:00:00Z", "comment_title": "Comment on FR Doc # 2022-06884", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}]}, {"id": "FDA-2005-P-0191", "title": "For patient safety and public health considerations, recommending scheduling tramadol under the Controlled Substances Act", "context": "2021-09-01T01:01:17Z", "purpose": "Nonrulemaking", "keywords": ["substances", "controlled", "tramadol", "fda", "scheduling", "drugs", "food", "CDER"], "comments": [{"text": "See attachment", "comment_id": "FDA-2005-P-0191-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2005-P-0191-0005", "comment_date": "2016-03-22T04:00:00Z", "comment_title": "Comment from Ortho-McNeil, Inc. (Hyman, Phelps & McNamara)", "commenter_fname": null, "commenter_lname": null, "comment_length": 14}]}, {"id": "FDA-2018-D-1334", "title": "Opioid Dependence: Developing Depot Buprenorphine Products for Treatment", "context": "2019-02-07T10:53:56Z", "purpose": "Nonrulemaking", "keywords": ["Opioid Use Disorder", "Developing Depot Buprenorphine", "Products for Treatment", "open", "cder", "2017-1067", "2018-1008", "Opioid Use Disorder", "Developing Depot Buprenorphine", "Products for Treatment", "open", "cder"], "comments": [{"text": "With our rapidly changing society and health care system, opioid addiction has become a major problem all over the United States. The use of depot buprenorphine is one solution to help in decreasing opioid dependence. With the trial being a controlled, blinded study testing the doses seemed to prove to help. The patients that were tested with different characteristics such as new participants to treatment, the already stable patients like if the patient has a relapse, and patients that are not very like to prove effectiveness. Patients that are being seen at least weekly help to keep the studies current and allow for adjusting the dosages to better help to decrease the dependence on opioids. Since they are being checked weekly, it helps to build rapport with the patients making them more willing to come forward with what opioids they may have taken. The endpoints for patients help to better determine the studies effectiveness. With the reduction of cravings, improvement in sleep or mood, or other reported outcomes better helps to demonstrate the benefit of the depot buprenorphine. With the information about cravings, sleep, and mood this could lead to more products like buprenorphine being approved. One study done that was randomized with 428 participants. Forty-eight participants had a reaction at the injection site. With the buprenorphine 17.4% had a good response and 14.4% had a good response with the placebo. (Lofwall & et. el, 2018) If this only helps a few people with opioid dependence it would be worth it. Plus with more studies done it can help even more.

Lofwall & et el. (2018). Weekly and monthly subcutaneous buprenorphine depot formations vs daily sublingual buprenorphine with naloxone for treatment of opioid use disorder: a randomized clinical trial. JAMA Inter Med. 1;178(6):764-73. doi: 10.1001/jamainternmed.2018.1052.", "comment_id": "FDA-2018-D-1334-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-D-1334-0005", "comment_date": "2018-07-06T04:00:00Z", "comment_title": "Comment from Emily Schindler", "commenter_fname": null, "commenter_lname": null, "comment_length": 1880}, {"text": "See attached file(s)", "comment_id": "FDA-2018-D-1334-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-D-1334-0004", "comment_date": "2018-07-06T04:00:00Z", "comment_title": "Comment from Indivior", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "FDA-2018-D-1334-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-D-1334-0003", "comment_date": "2018-07-06T04:00:00Z", "comment_title": "Comment from Anthem, Inc", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}]}, {"id": "FDA-2018-P-1448", "title": "Requests that the FDA refuse to approve any pending NDA for an extended-release oxycodone drug product.", "context": "2018-09-06T14:53:28Z", "purpose": "Nonrulemaking", "keywords": ["Citizen Petition", "CDER", "Hyman, Phelps & McNamara, P.C.,", "Collegium Pharmaceutical, Inc.", "refuse to approve any pending NDA", "for an extended-release", "oxycodone drug product \u2014either an NDA", "submitted pursuant toFDC Act \u00a7", "505(b)(1), or an NDA submitted", "pursuant to FDC Act \u00a7 505(b)(2),", "such as Pain Therapeutics, Inc.\u2019s", "505(b)(2) NDA for REMOXY ER", "(oxycodone)Extended-release Capsules", "OPEN"], "comments": [{"text": "The attached comment is being filed on behalf of Purdue Pharma L.P.", "comment_id": "FDA-2018-P-1448-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-1448-0003", "comment_date": "2018-05-09T04:00:00Z", "comment_title": "Comment from Purdue Pharma L.P.", "commenter_fname": null, "commenter_lname": null, "comment_length": 67}]}, {"id": "FDA-2016-P-4094", "title": "Request that the FDA to (i) require proposed generic versions of Intranasal (IN) naloxone products to provide specific pharmacokinetic (PK), device, stability and Chemistry, Manufacturing and Controls (CMC) data, as set-out herein, within the ANDA, to support the interchangeability of generic IN naloxone and the IN naloxone Reference Listed Drug (RLD); (ii) not to approve any", "context": "2017-05-30T11:27:51Z", "purpose": "Nonrulemaking", "keywords": ["Citizen Petition", "CDER", "2016-6877", "OPNE", "Adapt Pharma Operations Ltd", "Intranasal", "naloxone products", "pharmacokinetic", "device, stability and Chemistry", "Manufacturing and Controls", "interchangeability of generic", "IN naloxone and the IN naloxone"], "comments": [{"text": "See uploaded file. ", "comment_id": "FDA-2016-P-4094-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-P-4094-0004", "comment_date": "2017-05-30T04:00:00Z", "comment_title": "Comment from Erin", "commenter_fname": null, "commenter_lname": null, "comment_length": 19}, {"text": "See attached file(s)", "comment_id": "FDA-2016-P-4094-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-P-4094-0005", "comment_date": "2017-05-30T04:00:00Z", "comment_title": "Comment from Suki Iyer", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}]}, {"id": "SAMHSA-2022-0001", "title": "Mandatory Guidelines for Federal Workplace Drug Testing Programs using Oral Fluid (OFMG) (Revised)", "context": "2022-06-14T14:14:08Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "This is completely absurd and unjust! It is time to move past these destructive policies. If a person's physician believes it is in one's best interest to use a medicine, then the federal government should not be able to hold this against the person due to a failed test. This is very un-American! Cannabis is a very safe, and effective medicine. We should embrace it as such.", "comment_id": "SAMHSA-2022-0001-0007", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0001-0007", "comment_date": "2022-04-13T04:00:00Z", "comment_title": "Comment from Richard Rousseau", "commenter_fname": "Richard", "commenter_lname": "Rousseau", "comment_length": 384}, {"text": "Although I believe Oral Fluid testing is a good thing for quick non dot testing, I think it is offering many opportunities for Cheating for DOT testing. There will be more and more companies that will begin to do their own testing with their Employees which leaves the opportunity for friends and colleagues testing each other and promotes collaboration between Staff and Employee", "comment_id": "SAMHSA-2022-0001-0023", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0001-0023", "comment_date": "2022-04-26T04:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": "Bill", "commenter_lname": "Kincaid", "comment_length": 381}, {"text": "I believe that medical cannabis users should be exempt from fedral drug screen failures.", "comment_id": "SAMHSA-2022-0001-0022", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0001-0022", "comment_date": "2022-04-19T04:00:00Z", "comment_title": "Comment on FR Doc # 2022-06886", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 88}, {"text": "his is slightly insane but a logical outcome of the federal government’s continued refusal to change its outdated, disproven, and harmful categorization of cannabis as a Schedule I drug.", "comment_id": "SAMHSA-2022-0001-0019", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0001-0019", "comment_date": "2022-04-19T04:00:00Z", "comment_title": "Comment on FR Doc # 2022-06886", "commenter_fname": "Alexi", "commenter_lname": "Martinez", "comment_length": 192}, {"text": "This rule is founded on completely archaic ideas about cannabis and how it affects an individual. There is no science backing up the non-legitimacy of medical use cases for cannabis where in many circumstances, actually improves the life of the person who uses it. Personally I have suffered from high anxiety/depression and PTSD and using cannabis before bed helps me immensely to calm down and get good rest. Without it I typically have night sweats/terrors that severely affects my performance the next day. Using cannabis before bed however allows me to function fully the next day and show up to work and other responsibilities with a clear and balanced mind. The harmless nature of this drug truthfully should allow it to be legal federally. Even for non medical patients, it is far safer to be taken recreationally than something like alcohol. Having cannabis be a schedule 1 drug is completely erroneous but while states have laws allowing it to be used medically, we should honor that and not move retroactively. Progress needs to be made here to establish facts about cannabis instead of digging in our heels based off assumptions made by politicians from decades ago. More and more research is coming out showing the benefits of cannabis and how truly harmless it can be. We need to be a country that creates rules based off these facts in order to maintain the sense of freedom that we cherish here. ", "comment_id": "SAMHSA-2022-0001-0021", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0001-0021", "comment_date": "2022-04-19T04:00:00Z", "comment_title": "Comment from Eric Florence", "commenter_fname": "Eric", "commenter_lname": "Florence", "comment_length": 1412}, {"text": "SAMHSA 2022-0001 is a throwback to a relic of reefer-madness legislature. All of this is the politically neurotic outcome of the federal government’s continued refusal to change its outdated, targeted, and medically harmful categorization of cannabis as a Schedule I drug. Please look yourself in the mirror and explain this, “a physician’s authorization or medical recommendation for a Schedule I substance is not an acceptable medical explanation for a positive drug test.” I'll help, it's a back asswards loophole to apply to try to regulate an innoxious substance. It's also funny how the most addictive substances known to man are considered safe enough to assign to Schedule II; live with yourself knowing that you helped fuel a crisis that ruins lives and kills people because of a nonsensical mindset of ignorance, greed, and fear. You won't read it but here's to you, cheers; https://www.npr.org/2022/02/25/1082901958/opioid-settlement-johnson-26-billion, https://www.newsnationnow.com/health/where-do-us-opioid-trials-settlements-stand/.", "comment_id": "SAMHSA-2022-0001-0011", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0001-0011", "comment_date": "2022-04-19T04:00:00Z", "comment_title": "Comment on FR Doc # 2022-06886", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 1091}, {"text": "As a qualified SAP from 05 to present I am in support for Oral Fluid Testing but with the following caveats: 1) ONLY Urine Testing should be used for the RTD Return to Duty test. 2) There should be no change to the SAP being the sole author of any employee's mandatory Follow up Testing Plan. The SAP is the one in the entire RTD process who is spending up to hours of time providing a clinical assessment and applying diagnostic criteria with backend recommendations for education or treatment or both. Thus, upon any employee compliance the SAP should be the only Service Agent type deciding the amount of Follow-up Tests but also if they recommend ORAL or URINE for Follow-up tests. I would advise that all Follow up Tests are URINE TESTS only. The Oral Test appear from what I read to be the way to go for Pre-employment Test, Random's, Reasonable Suspicion, Post Accident etc but the RTD and Follow up Test should ALWAYS be Urine based. If there is a choice on either for Oral and Urine testing for RTD and Follow-up Testing this call should ONLY be for the contracted SAP to make and never the employer or 3rd party TPA. ", "comment_id": "SAMHSA-2022-0001-0027", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0001-0027", "comment_date": "2022-05-05T04:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": null, "commenter_lname": null, "comment_length": 1135}, {"text": "Comment on SAMHSA 2022-06884

I am an operations manager at a public transit authority and think adding the ability to conduct drug testing using oral fluids will be a benefit felt across the board. Our organization would certify staff to be able to self administer oral fluid testing as well as use a clinic. Drivers would still have to go to a clinic for BAC testing, so we would not self administer that test. It takes a lot of planning and resources to pull drivers off route for random testing, send them to the clinic, wait at the clinic, then coordinate getting them back on route. Being able to self administer random testing will simplify the process and make it more convenient to test at all times of service.
Our practice would be to use urine tests for pre-employment, return to duty, and follow up. In the cases of shy bladders or the inability to produce a large enough specimen, we would be open to transitioning from urine to oral fluids before exhausting the time limit. We prefer pre, return, and follow-up to be more structured through a clinic and to use urine, especially for return and follow-up.
In response to the question of whether or not to allow opposite gender techs to observe urine collection, our team was split. The male point of view was it makes no difference. The human resources and female recommendation was to have it observed by the same gender. Past experiences show female staff were already stressed about being observed. To have the collection observed by a male would further exacerbate the situation. Just because someone is going through the follow up process doesn't mean they should lose their dignity. We understand in smaller communities it may be harder to find same gender techs to observe urine collections, but we don't have the issue in our area.
In response to the question of whether or not refusing an opposite gender observer constitutes a refusal to test, we assumed that the regulation wouldn't require same gender observers. We would recommend calling that a refusal to test. If your test requires observing, you must have already tested positive. We cannot give someone the ability to cheat the system if they know there aren't many same gender techs.
In summary, let's get oral fluid testing up and running and relieve some of the burden placed on organizations to maintain compliance with drug testing. A separate soap box issue I would like to see movement on is THC levels testing to remove the current zero tolerance policy that can last for up to 60 days after last contact/consumption. Safety sensitive industries need a better answer than zero tolerance when cannabis products and marijuana use are rising as fast as they are now. Zero tolerance is hurting staff retention and recruiting. ", "comment_id": "SAMHSA-2022-0001-0030", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0001-0030", "comment_date": "2022-05-05T04:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": null, "commenter_lname": null, "comment_length": 2811}, {"text": "Comments of Airlines for America attached.", "comment_id": "SAMHSA-2022-0001-0040", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0001-0040", "comment_date": "2022-06-07T04:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": null, "commenter_lname": null, "comment_length": 42}, {"text": "Official comment from OraSure Technologies, Inc. is attached.", "comment_id": "SAMHSA-2022-0001-0038", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2022-0001-0038", "comment_date": "2022-06-07T04:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": null, "commenter_lname": null, "comment_length": 61}]}, {"id": "FDA-2014-N-1359", "title": "Development and Regulation of Abuse-Deterrent Formulations of Opioid Medications; Public Meeting", "context": "2015-04-16T15:33:59Z", "purpose": "Nonrulemaking", "keywords": ["cder", "2014-701", "CDER2014175", "Opioid"], "comments": [{"text": "Attached please find the American Pharmacists Association's comments regarding abuse-deterrent formulations of opioid medications.", "comment_id": "FDA-2014-N-1359-0026", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-1359-0026", "comment_date": "2015-01-27T05:00:00Z", "comment_title": "Comment from the American Pharmacists Association", "commenter_fname": null, "commenter_lname": null, "comment_length": 134}, {"text": "See attached file(s)", "comment_id": "FDA-2014-N-1359-0017", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-1359-0017", "comment_date": "2015-01-16T05:00:00Z", "comment_title": "Comment from Anne Pritchett, PhRMA and BIO", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Please find comments provided by Par Pharmaceutical, Inc., Spring Valley, NY. This submission includes a cover letter and Appendix which contains Par's responses.", "comment_id": "FDA-2014-N-1359-0024", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-1359-0024", "comment_date": "2015-01-27T05:00:00Z", "comment_title": "Comment from Par Pharmaceutical Inc", "commenter_fname": null, "commenter_lname": null, "comment_length": 167}, {"text": "
With 100 million Americans experiencing chronic pain we need to find safer and more effective therapies. Research has begun to suggest that abuse-deterrent opioids are safer than those without such properties.

Therefore, I urge the FDA to require all extended-release opioid formulations on the market to have a minimum level of abuse-deterrent properties. This would not eliminate all abuse, addiction and overdose deaths related to opioids. It would, however, be a small but significant step forward.

Industry and payers will need time to adjust to this required safety measure. Therefore, I urge the FDA to set a date perhaps 2020 for this requirement to take effect.

But the FDA must not stop there. Payers are reluctant to encourage use of these safer products because of added cost. And as long as opioids without abuse-deterrent properties are available, industry has no incentive to create these safer analgesics. To eliminate these barriers, the FDA must remove all extended-release opioid formulations without abuse-deterrent properties from the market by a set date, perhaps 2020.

But there is another serious issue to consider. A move to more expensive abuse-deterrent formulations could lead to the less expensive methadone being prescribed for post-operative, cancer and chronic pain. Methadone represents less than 3% of all opioids prescribed for pain but is associated with 25-30 % of all unintentional overdose deaths. More methadone could lead to more overdose deaths. This would be a terrible unintended consequence.

Research has shown that many of the deaths associated with methadone are due to physician errors in prescribing. This is usually due to a knowledge deficit. If payers wish to keep methadone available because it is inexpensive, those payers should have to demonstrate that providers are trained to prescribe it. Such payers would include Medicare, Medicaid and workers compensation.

Since the FDA cannot require physician education I recommend that methadone be removed from the market for the treatment of pain until manufacturers or payers can demonstrate that prescribers have the minimum competency to prescribe it. The rationale is that methadone must not remain the only low-cost option. The mechanism for demonstrating competency is not yet clear, and a process and criteria would need to be established.

To be clear methadone should remain available for the treatment of addiction. My suggestion applies only to methadone prescribed for the treatment of pain.

To sum up, I urge the FDA to:

Require abuse-deterrent properties in all extended-release opioid formulations on the market by 2020
Remove extended-release opioid formulations without abuse-deterrent properties from the market, also by 2020
Simultaneously, remove methadone for pain from the market until adequate training of prescribers can be demonstrated.
Thank you.
Lynn Webster MD
VP Scientific Affairs
PRA Health Sciences
Salt Lake City, Utah
801-892-5140
WebsterLynn@PRAHS.com
", "comment_id": "FDA-2014-N-1359-0013", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-1359-0013", "comment_date": "2015-01-13T05:00:00Z", "comment_title": "Comment from Lynn Webster, MD, PRA Health Sciences", "commenter_fname": null, "commenter_lname": null, "comment_length": 3250}, {"text": "See attached file(s)", "comment_id": "FDA-2014-N-1359-0022", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-1359-0022", "comment_date": "2015-01-27T05:00:00Z", "comment_title": "Comment from Mark Tyndall, Mallinckrodt Pharmaceuticals", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "FDA-2014-N-1359-0019", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-1359-0019", "comment_date": "2015-01-27T05:00:00Z", "comment_title": "Comment from the American Osteopathic Association", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "FDA-2014-N-1359-0020", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-1359-0020", "comment_date": "2015-01-27T05:00:00Z", "comment_title": "Comment from Daniel Wang, PinneyAssociates", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Please see the attached file for ASHP's comments", "comment_id": "FDA-2014-N-1359-0021", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-1359-0021", "comment_date": "2015-01-27T05:00:00Z", "comment_title": "Comment from Christopher Topoleski, ASHP", "commenter_fname": null, "commenter_lname": null, "comment_length": 52}, {"text": "Please see attached comment from the RADARS System.", "comment_id": "FDA-2014-N-1359-0028", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-1359-0028", "comment_date": "2015-01-27T05:00:00Z", "comment_title": "Comment from Denver Health and Hospital Authority", "commenter_fname": null, "commenter_lname": null, "comment_length": 51}, {"text": "See attached file(s)", "comment_id": "FDA-2014-N-1359-0016", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-1359-0016", "comment_date": "2015-01-13T05:00:00Z", "comment_title": "Comment from Julian Phillips, US Pain Foundation", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}]}, {"id": "DEA-2020-0035", "title": "Partial Filling of Prescriptions for Schedule II Controlled Substances", "context": "2023-07-21T08:48:17Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "I live with a person who suffers from chronic pain and takes her prescription as directed by her pain management doctor. Even with the help of her prescription, she is not fully pain free and often can not leave the house to take care of her personal needs. Having to make multiple trips to her pharmacy would put her in a situation where she may have to travel while in a great deal of pain; this would be unfair to her.
The amount of medication prescribed to a patient should be made at the discretion of treating doctors. Furthermore, enough medication should be prescribed to a responsible patient to minimize the financial burden and health risks associated with multiple trips to a pharmacy. The potential abuse of schedule II medication by some irresponsible individuals should not negatively impact patients who use their prescriptions responsibly and rely on them to help them live as close to a normal life as possible.

", "comment_id": "DEA-2020-0035-0006", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0035-0006", "comment_date": "2020-12-16T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-26291", "commenter_fname": "Eric", "commenter_lname": "Parks", "comment_length": 945}, {"text": "See attached file(s)", "comment_id": "DEA-2020-0035-0009", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0035-0009", "comment_date": "2021-01-14T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-26291", "commenter_fname": "Sue", "commenter_lname": "Mears", "comment_length": 20}, {"text": "Proposal Comment: Docket No. DEA-469
Under the proposed rules for Partial Filling of Prescriptions for Schedule II Controlled Substances-Proposed Rule by DEA on 12/04/2020 ID: DEA-2020-0035, the DEA must take steps to provide alternatives to the opioid crisis by creating partial refill options that can be opted by the provider or client in order to better customize legitimate opioid prescriptions to minimize deterrence and burdensomeness on providers, clients and our society, given the opioid epidemic plaguing our country. Between 2006 and 2016, average days of supply per prescription increased from 13.3 to 18.3 days, an overall relative increase of 37.6% (CDC, 2018). Although this is a steady decrease in gradual reductions of average days of supply per prescription since 2006, the progress has been slow. This trend could be greatly impacted by this proposal with the potential reduction of excess in-home opioids which this proposed rule would cultivate.
At a minimum, a patient should be able to direct their decision to obtain fewer opioids than the full prescription in order to mitigate concerns for opioid overuse by themselves, family or other community aspect. Consuming opioids beyond the experienced management period for which they are intended can set up a patient to have beginnings of new dependence issues. Furthermore, this practice would parallel the inpatients' prerogative when they choose the minimum level of pain medication for adequate pain management.
In regard to provider notification by the pharmacist, as a DNP graduate student I believe that the potential increase in costs and clinicians time do not warrant this action. I do agree that a partial refill upon dispensation does warrant an electronic pharmacy record depicting the controlled substance dispensation quantity and the requesting party be it the provider or patient.

Reference
Centers for Disease Control and Prevention (2018). 2018 Annual surveillance report of drug-related risks and outcomes. https://www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug-surveillance-report.pdf

", "comment_id": "DEA-2020-0035-0021", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0035-0021", "comment_date": "2021-01-28T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-26291", "commenter_fname": "Madonna", "commenter_lname": "Reece", "comment_length": 2120}, {"text": "I am in support of Docket No. DEA-469 for Partial Filling of Prescriptions for Schedule II-Controlled Substances for several reasons. One, this proposal should have a positive economic impact on individuals. I suggest partial fillings should result in lower copay with the additional partial filling copay, if needed, to not exceed the amount of one full prescription fill. Unused prescriptions drive demand for opioids and the reduction of such medications could presumably decrease drug prices. Secondly, allowing the individual the opportunity to opt for a partially filed prescription promotes patient-centered care allowing them to contribute to their own treatment plan. Partially-filled prescriptions will decrease the number of unused medications diminishing the opportunity for drug diversion and misuse. Increased prescribing practices from providers has contributed to the growing epidemic (AAFP, 2020). With limited data to support the effectiveness of long-term opioid analgesic use for pain management, limiting the supply for potential abuse should be promoted. In response, to the alternative approaches I believe allowing the pharmacist to dispense the partial fill as requested without consent or notification to the prescribing practitioner is the most appropriate and cost-effective approach. Agreeably, a situation arising in which a provider refusing a partial fill seems nonexistent. As we attempt to confront the opioid epidemic plaguing our country, we must find effective, evidence-based alternatives to adequately manage pain and not consequently create more opioid abusers in the process.

American Academy of Family Physicians (2020). Chronic pain management and opioid misuse. A public health concern (position paper). https://www.aafp.org/about/policies/all/chronic-pain-management-opiod-misuse.html", "comment_id": "DEA-2020-0035-0022", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0035-0022", "comment_date": "2021-02-01T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-26291", "commenter_fname": "Connor", "commenter_lname": "Rezzonico", "comment_length": 1851}, {"text": "Please see the attached comments of the American Pharmacists Association (APhA). ", "comment_id": "DEA-2020-0035-0033", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0035-0033", "comment_date": "2021-02-03T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-26291", "commenter_fname": "Karin", "commenter_lname": "Bolte", "comment_length": 81}, {"text": "Partial Filling of Prescriptions for Schedule II Controlled Substances, Docket No. DEA-469
Although the Drug Enforcement Agency (DEA) regulations provide three exceptions, generally speaking, a pharmacist cannot partially fill a controlled-II prescription for a patient (Heesters, 2020). The DEA is, however, proposing to amend the regulations where a pharmacist would be able to partially fill a controlled-II prescription as authorized under the Comprehensive Addiction and Recovery Act (CARA). According to the Wyoming Department of Health (2021), 65 people died in Wyoming from an opioid overdose in the year 2018. An estimated 10.3 million people aged 12 and older misused opioids in the year 2018 (HHS, 2020). Misuse of prescription drugs is a problem both nationally and state-wide. If permitted, this will expand opportunities for a partial filling of schedule II-controlled substances in certain instances which will ultimately reduce waste, lower the use of controlled substances, and reduce the potential for addiction, overdose, and diversion. Thus, I support the DEA’s proposed rule for partial filling of prescriptions for schedule II-controlled substances.

References
Heesters, M. (2020). DEA proposes rule to expand partial filling of schedule II prescriptions; Will the benefit be cost-effective. https://www.fdalawblog.net/2020/12/dea-proposes-rule-to-expand-partial-filling-of-schedule-ii-prescriptions-will-the-benefit-be-cost-
effective/
U.S. Department of Health and Human Services (HHS). (2020). Opioid crisis statistics. https://www.hhs.gov/opioids/about-the-epidemic/opioid-crisis-statistics/index.html#:~:text=In%202018%2C%20an%20estimated%2010.3,and%20808%2C000%20people%20used%20heroin.
Wyoming Department of Health. (2021). Opioids. https://health.wyo.gov/publichealth/prevention/substanceabuseandsuicide/opioid-information-wyoming/
", "comment_id": "DEA-2020-0035-0025", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0035-0025", "comment_date": "2021-02-01T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-26291", "commenter_fname": "Raegan", "commenter_lname": "Kartupelis", "comment_length": 1902}, {"text": "After reviewing the proposed rule for Partial Filling of Scheduled II Controlled Substances, from the patient perspective I agree with the cost savings and safety aspects of partially filling. The patient may only wish to fill part of a prescription based on monetary and/or safety factors. This gives the patient an option regarding their own health care and outcomes, and can lend to patient empowerment and engagement. The partial filling option may also increase community safety, decrease waste, and potentially decrease abuse of schedule II prescriptions. However, these choices are often left to the patient and proper education will be required to reap benefits from such a rule. From the provider's perspective, I question if this additional option results in time, cost and waste savings. It is difficult to estimate how many unused medications are currently in homes, therefore estimating safety, cost, and waste benefits is not exact. Further, how likely will patients choose to utilize a partial fill when they are suffering from an acute problem that would require two trips to the pharmacy in 72 hours versus one trip. How often will a patient choose to fill one week at at time or 3 days at time, within a 30 day fill period. There are some instances in which a patient might choose this route, though I believe it is the exception not the rule. From the provider's perspective, I believe this rule increases the amount of time a provider will spend writing and sending prescriptions, and it increases the amount of education required for the patient to properly understand the available options regarding schedule II substances. Visit time required for the provider to understand the patient's circumstances and needs if the patient is willing to utilize the partial fill option should be considered and calculated. I believe the majority of providers have the patient's best interests and health at heart. I also believe most providers will do what they can to facilitate best practices and patient safety, with or without the proposed rule. The proposed ruling embodies these concepts; however, ultimately this rule relies on patient understanding and compliance. The DEA is estimating over $640 million in costs savings with this propsed rule. While economics are always a driving factor, time is at a premium. I question if this rule will facilitate the desired change and cost savings. ", "comment_id": "DEA-2020-0035-0028", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0035-0028", "comment_date": "2021-02-01T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-26291", "commenter_fname": "Sonia", "commenter_lname": "Klein", "comment_length": 2425}, {"text": "Please see the attached comments of the National Association of Chain Drug Stores to the Drug Enforcement Administration regarding RIN 1117-AB45; Docket No. DEA-469; Partial Filling of Prescriptions for Schedule II Controlled Substances. We appreciate the agency considering our feedback on this rulemaking.", "comment_id": "DEA-2020-0035-0032", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0035-0032", "comment_date": "2021-02-03T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-26291", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 307}, {"text": "See attached file(s)", "comment_id": "DEA-2020-0035-0038", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0035-0038", "comment_date": "2021-02-03T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-26291", "commenter_fname": "Maureen", "commenter_lname": "Schanck", "comment_length": 20}, {"text": "Being a nurse and student, I see people come in every day who are addicted to schedule II substances. Many of these patients were seen by an older family practice MD who would prescribe these medications without assessing other options first. Practitioners who I have recently worked with have attempted discontinuance of these schedule II substances, but patients have not tolerated the change well, requiring the need for a renewed prescription.

Allowing partial fill of medications eliminates the possibility of extra medication be stored for potential future use. Preuss, Kalava, & King (2020) report that 55-65% of people obtain schedule II-controlled substances from a friend or relative that received the prescription in the past. In hopes of making changes in the future, assessing the new proposed rule of partial filling of prescriptions for schedule II-controlled substances would allow patients the option of lower cost prescriptions, decrease chances of medication dependence or overdose, and reduce the frequency of medication use from people other than the individual prescribed.

One question I do have is if the patient fills a partial prescription and then fills the other portion of the prescription at a later date, would the patient be charged two separate co-pays?

Preuss, C., Kalava, A., & King, K. (2020). Prescription of controlled substances: Benefits and risks. StatPearls. https://www. ncbi.nlm.nih.gov/books/NBK537318", "comment_id": "DEA-2020-0035-0012", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0035-0012", "comment_date": "2021-01-25T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-26291", "commenter_fname": "Caitlyn", "commenter_lname": "Nitsch", "comment_length": 1487}]}, {"id": "ONDCP-2020-0001", "title": "Designation of Emerging Drug Threats in the United States ", "context": "2022-06-22T12:26:41Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "The United States has failed to recognize or act upon marijuana as a drug threat, despite clear violation of international treaties. The health harms are more apparent and societal and environmental harms will outstrip alcohol and tobacco. Never before has there been such a public health and safety concern over a plant, which at one time, was fairly benign, but now, with rising potencies is associated with violence, driving fatalities, increased youth access, use, and addiction, and negative impacts to the unborn. The United States must act accordingly and reign this in quickly before we lose generation of youth, destroy our environment, and to protect the public health and safety.", "comment_id": "ONDCP-2020-0001-0014", "comment_url": "https://api.regulations.gov/v4/comments/ONDCP-2020-0001-0014", "comment_date": "2020-06-19T04:00:00Z", "comment_title": "06 19 20 Kenneth Finn", "commenter_fname": "Kenneth", "commenter_lname": "Finn", "comment_length": 693}, {"text": "I'm a 59 year old chronic pain patient with 4 autoimmune diseases. I've bad 20 surgeries in 17 years. There are no cures for the diseases I have. I've have tried multiple modalities to help ease my pain. I started with a pain management doctor 10 years ago. My pain had been kept to a tolerable level when I'm on pain medication. I have some quality of life now, but it's not as good as it could be since the CDC guidelines came out. My medicines were changed and dosages lowered. I try to stay active visiting a gym. I'm not expecting my pain medication to take away all my pain.I Just want to be able to do a few things. I've had to give up so many things because of the pain I suffer everyday. It's Not just me and my Doctor in the exam room anymore. Now the government is telling my doctor what he can and can't prescribe. I do not have an addictive personality or do my pain meds make me "high". I always pass my drug screenings and pill counts. I haven't done anything wrong but I'm being treated like a criminal. Please let doctors be doctors again and use the DEA to clean up our streets where the "illegal " heroin and fentanyl are killing people. My heart breaks for all the chronic pain patients who are suffering to the point of wanting just to die so the pain will stop. I chose to do this anonymously because I don't want anymore restrictions put on my medical history. I'm scared to death this has gone way too far with patients. ", "comment_id": "ONDCP-2020-0001-0018", "comment_url": "https://api.regulations.gov/v4/comments/ONDCP-2020-0001-0018", "comment_date": "2020-06-19T04:00:00Z", "comment_title": "06 19 20 - Kerry", "commenter_fname": "Kerry", "commenter_lname": "Anonymous", "comment_length": 1519}, {"text": "See attached", "comment_id": "ONDCP-2020-0001-0011", "comment_url": "https://api.regulations.gov/v4/comments/ONDCP-2020-0001-0011", "comment_date": "2020-06-05T04:00:00Z", "comment_title": "06 03 20 David G. Evans email", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}, {"text": "ONDCP's criteria that enables the country to be proactive in monitoring and identifying emerging drug threats to avoid public health crises has the potential to reverse destructive drug trends. The implementation of the sliding scale, both individually and holistically, allows for a more complete threat evaluation. There are three areas in which we can improve these criteria in order to prevent another crisis similar to the opioid epidemic. The first would be to prioritize or re-categorize these criteria to focus on the proactive measures, such as monitoring online discussions. Secondly, we must avoid the racial disparity experienced with the opioid crisis. Lastly, our outdated approach of smothering drug markets to force prohibition should be at the forefront when developing and implementing these criteria.

It would benefit all to prioritize or re-categorize these criteria based on preventive measures versus compiling data of newly diagnosed substance use disorders or measuring morbidity or mortality, when the damage has been done. Through identifying these avenues of discussion or activity early, we can increase interventions to keep the emerging drug threat at bay.

We also want to avoid racial divide over potentially criminalizing by prioritizing based on racial characteristics. "The narrative that today's heroin users are largely white and that heroin suppliers are largely black and Latino has contributed to the public's willingness to address opioid use less punitively" (Werle and Zedillo, 2018, p. 326). This has created massive disparities in our prison system. We must not prioritize criteria or use language that unfairly highlights a particular racial or ethnic group more than another.

Lastly, we must eliminate our reaction to smother drug markets, which actually makes the problem worse. Look at the Volstead Act during prohibition. Werle and Zedillo (2018) state that it "did far more to change what Americans drank than how much" (p. 330). Just as with the opioid crisis, eliminating access just pushes production, transportation, sale, and use underground. In addition, "overdoses are more common following cessation of naltrexone treatment than among either untreated heroin users or maintenance users" (Werle and Zedillo, 2018, p. 328). This may slightly benefit Big Pharma by allowing continuation of production and supply of a potentially dangerous drug; however, as a public-health focus, it is more dangerous if we try to eliminate the drug completely. We would benefit by removing or revising criteria that encouraged suppression that lead to illicit products, such as heroin, fentanyl, or synthetic opioids.

Some may object that this approach of rehabilitation versus criminalization by lowering access thresholds would "risk providing a[n] acceptable means for people to initiate drug use" (Werle and Zedillo, 2018, p. 338). However, this has not held true in countries, such as Switzerland, taking this public-health approach.

With these aspects in mind, we should re-categorize and reword the criteria, basing it on priority, equality, and a public-health approach instead of criminalized suppression. Through this proposed policy, we will see lives saved and decreased healthcare costs.", "comment_id": "ONDCP-2020-0001-0020", "comment_url": "https://api.regulations.gov/v4/comments/ONDCP-2020-0001-0020", "comment_date": "2020-06-19T04:00:00Z", "comment_title": "06 19 20 Kerska", "commenter_fname": "Brian", "commenter_lname": "Kerska", "comment_length": 3344}, {"text": "See attached file(s)", "comment_id": "ONDCP-2020-0001-0013", "comment_url": "https://api.regulations.gov/v4/comments/ONDCP-2020-0001-0013", "comment_date": "2020-06-19T04:00:00Z", "comment_title": "06 19 2020 Jesse LeBlanc", "commenter_fname": "Jesse", "commenter_lname": "LeBlanc", "comment_length": 20}, {"text": "The White House Drug policy has been completely off base for several years now. Due to relentless efforts by a Bloomberg influenced group of illegal lobbyists, PROP (Physicians for Responsible Opioid Prescribing), the Opioid Epidemic was adopted by the Trump Administration. This inadvertently helped profit a few severely corrupt and compromised individuals. The White House opioid policy was adopted upon corrupt and falsified CDC policy adopted in 2016. The US government went on full attack against prescribed opioids while overdose death continued to rise, unaffected, by the draconian opioid prescribing policies and laws being adopted at the federal and state level. These restrictions were promoted to the extreme detriment of pain patients numbering at least 50 million nationally. Fact: Studies show that prescription opioids comprise a very small percentage of all drug overdoses...usually under 5%. The real cause of deaths is counterfeit fentanyl in street drugs. That is why the White House attack on prescription opioids failed in a big way, because doctors do not prescribe counterfeit fentanyl -- drug dealers sell them.
The White House was misled by falsified policies that were adopted by the CDC due to illegal lobbying and other corrupt manipulations by Dr. Andrew Kolodny of PROP (Physicians for Responsible Opioid Prescribing). Kolodny who regularly steps aside from his Presidency position at PROP in order to appear uncompromised, was caught omitting information from his CDC disclosures. He is the founder of PROP, an agency that he claims is a non-profit. PROP is historically funded by rehab sources like Steve Rummler Hope Foundation and the Phoenix House. Kolodny launched the relentless attack on public opioid policy to benefit himself and his benefactors. PROP is the single force behind the promotion of the catastrophic CDC guidelines. His group was secretly inserted into the CDC guideline writing process in 2016, when Kolodny's former NY Health Dept. boss, Tom Frieden, appointed PROP members to misdirect public policy to accept the scientifically unfounded idea of 90 mme unit opioid limits. These limits were used to falsely suggest that prescription opioids were behind a rash of recent overdoses. The goal was to demonize opioid prescribers, manufacturers and patients into rehab treatment and to Suboxone. The Kolodny/PROP connections to past direct Suboxone marketing programs cannot be denied. Kolodny personally marketed Suboxone until 2005 for the city of New York under Mayor Bloomberg and now former CDC Director Frieden (then the NYC Health Director). He Marketed Suboxone by teaching Suboxone licensing classes until around 2017 (without disclosure.) Kolodny even promoted "Suboxone prescribed here" on the glass window of his personal psychiatric practice in New York. Kolodny holds two licenses for Suboxone prescribing and has given numerous interviews on the media suggesting that prescription opioids were to blame for the opioid epidemic and Suboxone is the cure. Kolodny even suggested in one article that he may have personally lost a great deal of money when Suboxone manufacturer, Reckitt Benckiser/Indivior was prosecuted by the DOJ for a variety of shady business practices including patent jumping. They were fined billions of dollars. But Kolodny didn't stop there. He promoted himself as an "opioid expert" and began testifying against opioid manufacturers in court for enormous fees of up to $750 per hour. He has continued to tamper with the CDC by recently submitting a letter comment urging the CDC not to correct the false opioid narrative that he, Frieden and PROP members promoted illegally via their participation in the leaked "Core Group" secretly assembled by Frieden to write the poorly conceived 2016 CDC Opioid Prescribing Guidelines. The guidelines were based on shoddy science with the 90 mme limit having absolutely no studies to back their usage whatsoever. 90 mme was based on category B, section 4 evidence...which is basically nothing more than conjecture. Kolodny's attempt to lobby the FDA on the 90 mme failed. The existence of counterfeit fentanyl as a primary threat to human life was ignored by the Core Group, but their tainted guidelines were pushed into effect with an illegally shortened public comment period.
Thousands of patients in pain have been harmed through the PROP corrupted CDC guidelines...losing jobs, homes, marriages and dignity. People who need surgeries are now avoiding these procedures due to the non-treatment of pain. People with hip surgeries are given Tylenol and ignored by desperate doctors. Hundreds have committed suicide -- desperate victims of untreated disease. Caring doctors are maliciously hounded by the DEA and mislead by false threats into giving up their DEA licenses to prescribe. Most have done nothing wrong and have no hope to appeal. The ONDC needs to research Kolodny and adjust for the corrupt CDC. I have attached a new PROP attempt to influence policy. ", "comment_id": "ONDCP-2020-0001-0017", "comment_url": "https://api.regulations.gov/v4/comments/ONDCP-2020-0001-0017", "comment_date": "2020-06-19T04:00:00Z", "comment_title": "06 19 20 Robert Redfield", "commenter_fname": "Kirsten", "commenter_lname": "Klang", "comment_length": 5048}, {"text": null, "comment_id": "ONDCP-2020-0001-0024", "comment_url": "https://api.regulations.gov/v4/comments/ONDCP-2020-0001-0024", "comment_date": "2020-06-29T00:00:00Z", "comment_title": "06 29 20 Todd Gillum (1)", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "ONDCP-2020-0001-0021", "comment_url": "https://api.regulations.gov/v4/comments/ONDCP-2020-0001-0021", "comment_date": "2020-06-19T00:00:00Z", "comment_title": "06 20 20 Luna-Ly_Federal-Public-Comment - email", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": "This comment addresses the Office of National Drug Control Policy (ONDCP) specifically 21 CFR Part 1401 (RIN 3201-AA02) entitled Criteria for Designation of Emerging Drug Threats in the United States. To determine the emerging drug threats a committee was created and established 11 proposed criteria to identify emerging drug threats and I would like to propose an additional criteria to specifically address the vulnerable population of children aged 12-18, for whom drug abuse can be particularly debilitating, by examining federal, state, local and tribal data for the emergence of use of new or evolving drug, class of drugs, or other substances in this population. This new proposed criterion should exclude substance abuse disorder because waiting for children to develop a substance abuse disorder as written in criteria 7 will prove to be too late.

This additional criterion is important because drug misuse has been shown to increase with age starting in early adolescence and peaking in early adulthood (McGorry et al., 2011). With this fact in mind, interventions that aim to stop or postpone the onset of drug use should be targeted to a specific population before or during adolescence (McGorry et al., 2011). In order to effectively decrease the burden of emerging drug trends and its effect on medical and public health, the ONDCP must be able to carefully consider the adolescence population and quickly determine patterns to avoid another opioid crisis. Many are aware of the health hazard that adult opioid abuse poses in the United States, however the effect of opioid abuse on children is often overlooked. Opioid abuse is a major public health issue for children in the United States and is clearly evident with the increasing number of emergency department visits by young children and adolescents for poisoning by prescription opioids (Allareddy & Rampa, 2017). Emerging drugs threats in adolescence must be identified and action must be taken early to prevent future public health hazards.

References:
Allareddy, V., & Rampa, S. (2017). Opioid abuse in children: an emerging public health crisis in the United States. Pediatric Research, 82(4), 562-563.
McGorry, P., Purcell, R., Goldstone, S., Amminger, G. (2011). Age of onset and timing of treatment for mental and substance use disorders: Implications for preventive intervention strategies and models of care. Current Opinion in Psychiatry, 24(4), 301-306.
", "comment_id": "ONDCP-2020-0001-0033", "comment_url": "https://api.regulations.gov/v4/comments/ONDCP-2020-0001-0033", "comment_date": "2020-06-30T04:00:00Z", "comment_title": "06 30 20 Leiber", "commenter_fname": "Nicole", "commenter_lname": "Lieber", "comment_length": 2478}, {"text": "See Attached", "comment_id": "ONDCP-2020-0001-0032", "comment_url": "https://api.regulations.gov/v4/comments/ONDCP-2020-0001-0032", "comment_date": "2020-06-30T04:00:00Z", "comment_title": "06 30 20 Goodwin", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}]}, {"id": "CMS-2009-0058", "title": "Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2010", "context": "2016-07-11T09:27:52Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "Please see attached Word document.", "comment_id": "CMS-2009-0058-8305", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2009-0058-8305", "comment_date": "2016-01-28T05:00:00Z", "comment_title": "CA-- Shah, Vikas", "commenter_fname": null, "commenter_lname": null, "comment_length": 34}, {"text": "See attachment", "comment_id": "CMS-2009-0058-8253", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2009-0058-8253", "comment_date": "2016-01-28T05:00:00Z", "comment_title": "TN-- Estes, Megan", "commenter_fname": null, "commenter_lname": null, "comment_length": 14}, {"text": "Attached, please find my document related to teaching rules and Medicare anesthesia payment.", "comment_id": "CMS-2009-0058-10830", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2009-0058-10830", "comment_date": "2016-05-02T04:00:00Z", "comment_title": "FL-- Beary, Alice", "commenter_fname": null, "commenter_lname": null, "comment_length": 92}, {"text": "Please see attached comment supporting AACVPR position on proposed Medicare regulation changes to Cardiac Rehabiitation programs.", "comment_id": "CMS-2009-0058-8285", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2009-0058-8285", "comment_date": "2016-01-28T05:00:00Z", "comment_title": "CA-- Griffith, Carla", "commenter_fname": null, "commenter_lname": null, "comment_length": 129}, {"text": "Thanks for your consideration of the attached file.

Respectfully Submitted,

Jeff Brown, CRNA
President
The Alabama Association of Nurse Anesthetists", "comment_id": "CMS-2009-0058-8331", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2009-0058-8331", "comment_date": "2016-01-28T05:00:00Z", "comment_title": "AL--The Alabama Association of Nurse Anesthetists", "commenter_fname": null, "commenter_lname": null, "comment_length": 175}, {"text": "see the attached file/letter please.", "comment_id": "CMS-2009-0058-8368", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2009-0058-8368", "comment_date": "2016-01-28T05:00:00Z", "comment_title": "MI", "commenter_fname": null, "commenter_lname": null, "comment_length": 36}, {"text": "See attached letter", "comment_id": "CMS-2009-0058-8404", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2009-0058-8404", "comment_date": "2016-01-28T05:00:00Z", "comment_title": "PA-Hanover Hospital", "commenter_fname": null, "commenter_lname": null, "comment_length": 19}, {"text": "Please open the attached file.", "comment_id": "CMS-2009-0058-8386", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2009-0058-8386", "comment_date": "2016-01-28T05:00:00Z", "comment_title": "CA-CSCR", "commenter_fname": null, "commenter_lname": null, "comment_length": 30}, {"text": "I am writing to offer comments on the proposed rule for the 2010 Physician
Fee Schedule. As a practicing anesthesiologist, I am particularly
concerned about the portion of the proposed rule relating to Section 139:
Improvements for Medicare Anesthesia
Teaching Programs.

In 2008, Congress passed, as part of MIPPA, the Medicare Anesthesiology
Teaching Funding Restoration Act to restore full Medicare payment to
academic anesthesiology programs. Before passage of the bill, Medicare
payment to our programs had been cut in half each time an attending
oversaw two residents on cases that overlapped. To this end, I am very
pleased that the proposed rule appropriately recognizes this statutory
change and proposes to pay the full Medicare fee for cases involving a
teaching anesthesiologist and one or two residents (that are not
concurrent to other cases) or one resident case that is concurrent to
another case paid under medical direction payment rules. I strongly believe
that CMS made the correct decision for these cases.

I further believe that CMS made the correct decision with respect to
payment for anesthesia services furnished by a teaching nurse anesthetist
with a student nurse anesthetist, as well as the payment policy for an
anesthesiologist, or an anesthesiologist and nurse anesthetist jointly, with
a student nurse anesthetist. It is encouraging to see that CMS recognizes
the “significant differences in experience, education and other
qualifications between anesthesia residents and student nurse
anesthetists.”

However, I am disappointed that after acknowledging “We do not have data
on the extent to which anesthesia handoffs occur during resident or other
cases, or whether quality of anesthesia care is affected” CMS chose
to “narrowly interpret the law and require that only one individual teaching
anesthesiologist be present during all of the key or critical portions of the
anesthesia procedure.”

“Anesthesia handoffs” are a common and necessary part of running a
quality and efficient operating room, especially in academic settings where
the cases are often longer and more complex than in smaller, non-teaching
settings, and where medical expertise is often needed to teach a particular
skill or to staff a particular case at any given time. To arbitrarily raise this
issue now directly contradicts anesthesiology’s nationally recognized
patient safety record, as well as the Congressional intent of providing full
funding for overlapping cases as they are currently staffed in every
academic program in the country.

Anesthesiology is proud of its reputation for quality and the recognition it
has received for such efforts by the Institute of Medicine and other
sources. We achieved this reputation with current practice, not despite it.
Handoffs are a normal part of anesthesia care. They allow smooth,
seamless and safe treatment of patients. Prohibiting anesthesia handoffs
would have a ripple effect throughout operating rooms by creating staffing
problems in hospitals, which would in turn lead to longer wait times and
generally compromise safe and efficient patient care.

In the final rule please implement the option that was articulated, but not
proposed, and “permit different anesthesiologists in the same anesthesia
group practice to be considered ‘the teaching physician’ for purposes of
being present at the key or critical portions of the anesthesia case.” This
will ensure that anesthesiology residency programs receive full Medicare
payment for overlapping cases, just as Congress intended.

Sincerely,
Jonathan Rhodes, M.D.", "comment_id": "CMS-2009-0058-5087", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2009-0058-5087", "comment_date": "2016-01-14T05:00:00Z", "comment_title": "TX", "commenter_fname": null, "commenter_lname": null, "comment_length": 3955}, {"text": "I am writing to offer comments on the proposed rule for the 2010 Physician Fee
Schedule. As a senior anesthesiology resident, I am particularly concerned about
the portion of the proposed rule relating to Section 139: Improvements for
Medicare Anesthesia Teaching Programs.

In 2008, Congress passed, as part of MIPPA, the Medicare Anesthesiology
Teaching Funding Restoration Act to restore full Medicare payment to academic
anesthesiology programs. Before passage of the bill, Medicare payment to our
programs had been cut in half each time an attending oversaw two residents on
cases that overlapped. To this end, I am very pleased that the proposed rule
appropriately recognizes this statutory change and proposes to pay the full
Medicare fee for cases involving a teaching anesthesiologist and one or two
residents (that are not concurrent to other cases) or one resident case that is
concurrent to another case paid under medical direction payment rules. I strongly
believe that CMS made the correct decision for these cases.

I further believe that CMS made the correct decision with respect to payment for
anesthesia services furnished by a teaching nurse anesthetist with a student
nurse anesthetist, as well as the payment policy for an anesthesiologist, or an
anesthesiologist and nurse anesthetist jointly, with a student nurse anesthetist. It
is encouraging to see that CMS recognizes the “significant differences in
experience, education and other qualifications between anesthesia residents and
student nurse anesthetists.”

However, I am disappointed that after acknowledging “We do not have data on the
extent to which anesthesia handoffs occur during resident or other cases, or
whether quality of anesthesia care is affected” CMS chose to “narrowly interpret
the law and require that only one individual teaching anesthesiologist be present
during all of the key or critical portions of the anesthesia procedure.”

“Anesthesia handoffs” are a common and necessary part of running a quality and
efficient operating room, especially in academic settings where the cases are
often longer and more complex than in smaller, non-teaching settings, and where
medical expertise is often needed to teach a particular skill or to staff a particular
case at any given time. To arbitrarily raise this issue now directly contradicts
anesthesiology’s nationally recognized patient safety record, as well as the
Congressional intent of providing full funding for overlapping cases as they are
currently staffed in every academic program in the country.

Anesthesiology is proud of its reputation for quality and the recognition it has
received for such efforts by the Institute of Medicine and other sources. We
achieved this reputation with current practice, not despite it. Handoffs are a normal
part of anesthesia care. They allow smooth, seamless and safe treatment of
patients. Prohibiting anesthesia handoffs would have a ripple effect throughout
operating rooms by creating staffing problems in hospitals, which would in turn
lead to longer wait times and generally compromise safe and efficient patient care.

In the final rule please implement the option that was articulated, but not
proposed, and “permit different anesthesiologists in the same anesthesia group
practice to be considered ‘the teaching physician’ for purposes of being present at
the key or critical portions of the anesthesia case.” This will ensure that
anesthesiology residency programs receive full Medicare payment for overlapping
cases, just as Congress intended.

Thank you for your time and consideration.

", "comment_id": "CMS-2009-0058-5203", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2009-0058-5203", "comment_date": "2016-01-14T05:00:00Z", "comment_title": "Crawford, Jack", "commenter_fname": null, "commenter_lname": null, "comment_length": 3945}]}, {"id": "DOD-2013-HA-0085", "title": "Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)/\r\nTRICARE: Pilot Program for Refills of Maintenance Medications for TRICARE For Life Beneficiaries through the TRICARE Mail Order Program", "context": "2020-10-22T01:33:13Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "i BELIEVE THE EFFECTIVE DATE OF THE RULE FOR OPTING OUT SHOULD BE EARLY IN 2013 AS MANY OF US BEGIN USING MAIL ORDER AT THAT TIME IN ACCORDANCE WITH THE LAW.....NOW YOU BACK IT OFF UNTIL February 14, 2014. IT WAS NOT THE BENEFICIARY FAULT THAT THE PHARMACY BENEFIT MANAGER WAS NOT READY TO IMPLEMENT THE LAW....ITS A FIVE YEAR PROGRAM AND SOME OF US PLAYED BY THE RULES AND NOW FIND WE ARE PENALIZED. AFTER WELL OVER A YEAR IN THE PROGRAM, THE MAJOR PROBLEM IS THE LACK OF ABILITY TO COMMUNICATE WITH EXPRESS SCRIPTS....IN WELL OVER A YEAR, WE HAVE NOT COMMUNICATED WITH A PHARMACIST OR EVEN A TECHNICIAN. WE HAVE NO IDEA THE QUALIFICATION OF THE SO CALLED ADVOCATES IN PHARMACOLOGY. THE RULES FOR OPTING OUT AND FOR A WAIVER SHOULD BE MUCH MORE SPECIFIC. EXPRESS SCRIPTS WORKS HARD ON KEEPING THE MEDICATIONS ON TIME....BUT GOD FORBID IF THE PHYSICIAN CHANGES THE mg OR THE DRUG....IMPOSSIBLE TO COMMUNICATE THE ISSUE WITH THEM IN TIME TO MEET THE DEMANDS OF THE MEDICATION. I ALSO QUESTION YOUR SAVINGS FROM THE PROGRAM...IN A RECENT DOD/IG REPORT THEY SAY THE PROGRAM IS A WASTE OF MONEY......WHEN AND WHERE WILL THE LIST OF SELECTED MEDICATION FOR MAIL ORDER BE POSTED? .THANK YOU FOR LETTING ME COMMENT. ", "comment_id": "DOD-2013-HA-0085-0002", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2013-HA-0085-0002", "comment_date": "2014-01-17T05:00:00Z", "comment_title": "Comment on DOD-2013-HA-0085-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 1211}, {"text": "See attached file(s)", "comment_id": "DOD-2013-HA-0085-0004", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2013-HA-0085-0004", "comment_date": "2014-02-18T05:00:00Z", "comment_title": "Comment on DOD-2013-HA-0085-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Please see attached comments of the National Association of Chain Drug Stores.", "comment_id": "DOD-2013-HA-0085-0003", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2013-HA-0085-0003", "comment_date": "2014-02-10T05:00:00Z", "comment_title": "Comment on DOD-2013-HA-0085-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 78}, {"text": "Please see attached comments from the Iowa Pharmacy Association.", "comment_id": "DOD-2013-HA-0085-0005", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2013-HA-0085-0005", "comment_date": "2014-02-18T05:00:00Z", "comment_title": "Comment on DOD-2013-HA-0085-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 64}, {"text": "See attached file(s)", "comment_id": "DOD-2013-HA-0085-0007", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2013-HA-0085-0007", "comment_date": "2014-02-18T05:00:00Z", "comment_title": "Comment on DOD-2013-HA-0085-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Please see attached comments from the Pharmaceutical Care Management Association.", "comment_id": "DOD-2013-HA-0085-0006", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2013-HA-0085-0006", "comment_date": "2014-02-18T05:00:00Z", "comment_title": "Comment on DOD-2013-HA-0085-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 81}]}, {"id": "HHS-OS-2019-0003", "title": "Pain Management Task Force Meeting - May 9-10, 2019", "context": "2022-04-22T01:01:23Z", "purpose": "Nonrulemaking", "keywords": null, "comments": [{"text": "Families for Intractable Pain Relief (FIPR) recommends adding a section to 2.7 to address the overlooked condition of constant severe intractable pain. Individuals who have such pain do not experience remissions & frequent relapses. The pain level is extremely severe & it is constant with no remissions. Many of these patients have been treated for long periods of time with opioid pain medications at high doses & have experienced great harm since 2016 due to reduction or cessation of their opioid medications.

2.7.9 Constant Severe Intractable Pain
Constant severe intractable pain is defined as an excruciating, constant pain state without remissions that is not curable by any known means, causes adverse biologic effects on the bodys cardiovascular, hormone, & neurological systems, and leads to a bed- or house-bound state & early death if not adequately treated. This category of pain differs from chronic relapsing pain (addressed in 2.7.5) in that there are no remissions at all; the pain is both very severe & constant. Constant severe intractable pain can be caused by rare illnesses including adhesive arachnoiditis, some autoimmune diseases, Reflex Sympathetic Dystrophy (RSD) (also called Complex Regional Pain Syndrome (CRPS)), & genetic connective tissue disorders such as Ehlers-Danlos Syndrome & Marfan Syndrome.

Gaps and Recommendations
Gap 1: The existence of such pain is not widely accepted, which contributes significantly to its under-treatment. Lack of awareness often makes these patients the victims of stigma & disbelief on the part of physicians. These patients require comprehensive, compassionate palliative care which will likely require opioid pain medications, often at high doses, in addition to adjuvant treatments and therapies. The goal of treatment is to provide life-long pain relief sufficient to normalize physiologic and mental function and enable the patient to independently carry out activities of daily living to the maximum extent possible. Patients with constant severe intractable pain are often met with great hostility and resistance because they are, by definition, incurably disabled and will have to take opioids for a long period, probably for the rest of their lives. In the absence of clarifying guidance about what to do with these seriously ill patients who have already tried and failed standard treatments, pain practitioners accepting such patients for care will be likely to tell them they must lower their opioid doses and essentially start over, requiring them to jump through hoops already tried and failed.
Recommendations:
1a: Educate physicians, pharmacists, law enforcement, and regulatory agencies at all levels to the fact that pain of this nature exists, is totally debilitating, and leads to early death if not adequately treated. Endorse the long-term use of immediate or extended release opioid medications at whatever dose is required to manage the pain, when all efforts at standard care have failed. Practitioners should continue successful treatment protocols for long-term stable legacy patients who have demonstrated that benefits exceed risks. Practitioners should avoid mandating changes to treatment regimens that are succeeding, as changes in medication protocols, once a patient is stable, are frequently destabilizing and very harmful to these complex, often frail patients.
1b: Emphasize the following in educational efforts to combat stigma against these patients:
oPatients who request a specific opioid medication almost certainly know what works best to manage their pain. Such requests should not be construed as drug-seeking behavior. Also, physicians should believe patients who report that a medication isnt working or intolerable side effects are being experienced.
oSuccessful pain care of these patients is best measured by 3 outcome metrics: 1) pain control, 2) functional capability, and 3) quality of life as reported by the patient with confirmation by a family member. A focus on MME is inappropriate as many of these high-dose outlier patients are limited in their ability to metabolize medications due to genetic variance, gastrointestinal malabsorption from diseases and surgeries, or dysfunctional receptors.
oFor successful patients, months or years of effort have likely gone into developing the personalized treatment protocol that works. In these cases, the best practice is to keep doing what works. For these patients, the current protocol represents the pinnacle of individualized, patient-centered care. Forced tapering or forced change in regimen brings about unnecessary suffering, disruption of life, and loss of quality time for patients who have already suffered greatly before finding their successful regimens. Such forced change not only disrupts the lives of these patients during the transition, but may never result in outcomes as good as those produced by the regimen from which the patient is being forced to change. ", "comment_id": "HHS-OS-2019-0003-0388", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0003-0388", "comment_date": "2019-05-15T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-06328", "commenter_fname": "Kristen", "commenter_lname": "Ogden", "comment_length": 5266}, {"text": "May 5, 2019

Re: HHS-OS-2019-0003

Subject: Public Comment for the Pain Management Best Practices Inter-Agency Task Force

Thanks you for this final opportunity to comment on the Task Force draft report. Dr. Singh, I read somewhere that you were encouraging patient and advocate input regarding patients lived experiences. Our lived experience as a couple living with long-term debilitating illness was overall very good for many years. However, unless something changes to remedy our current situation, our lived experience in the future will be unsatisfactory and quite bleak.

When my husband, Louis Ogden, and I wrote to the Task Force on April 1, we were about 6 weeks into the unfortunate and ill-advised process of trying to transition from his former regimen of high-dose OxyContin to an opioid regimen using injectable hydromorphone. Now, at 11 weeks, we are both very dissatisfied, and we feel angry that this change has been forced on him. The hydromorphone does not relieve his pain nearly as well as OxyContin, and the constant experience of pain up, pain down, pain up, pain down, all day every day is destroying his quality of life. For 8 years, he enjoyed remarkably consistent pain relief 24/7 with no dose escalation. This medication protocol, while considered extreme by some, gave him excellent pain relief with no significant side effects, greatly improved function, and a hugely improved quality of life. We were able to travel (with accommodations, of course), he was able to do chores around home, and for the last few years he spent a lot of timing playing music and improving his skill playing guitar and electronic keyboard. At this point, his ability to do almost anything enjoyable is greatly reduced. He spends most of his waking hours sitting on the couch in a reclined position with his head propped on a pillow to try to minimize his head and neck pain. Traveling even a short distance has become much more difficult and more painful for him. He isnt really able to participate in chores or light yard work any longer. While he used to enjoy playing his guitar or keyboard for 2 or 3 hours in a day, he can now only play for a few minutes at a time. The personal satisfaction he gained from playing music, from being able to learn and progress in this creative outlet surely isnt important to the DEA or the Virginia regulatory agencies that have prevented us from being able to fill prescriptions for pain medications here in our home state. He had found an extremely effective care regimen with the help of Dr. Forest Tennant, had accepted the limitations associated with his illness, and found music and other activities that made his life good despite the illness. For now, at least, those days are over.

Many among the current generation of pain care practitioners do not know nearly as much about treating severe intractable pain as the elder generation, and those older, experienced doctors are now being dismissed as out-of-date purveyors of improper care because the well-funded anti-opioid groups, the CDC, the DEA, and state legislators say soeven though prescriptions written and treatments provided were totally legal and the results were very successful in the opinion of the patients and families affected. It is a sad state of affairs when truly gifted physicians are deliberately discredited by the DoJ and DEA in attempts to reduce their influence.

We, and many other families in our situation, need your help! Please adopt the proposed section 2.7.9 submitted by Families for Intractable Pain Relief that addresses constant severe intractable pain. The failure of your draft to address such pain will mean that these patients will continue to lack credibility and will continue to suffer from inadequate care or reversal of their prior highly effective pain care regimens. You will have failed to thoroughly address gaps and inconsistencies in pain care policies and best practices, because you will have failed to acknowledge the existence of those who suffer the worst pain of all.

My husbands future quality of life will largely depend on the output of this Task Force and the actions Congress will take to implement the recommendations. Please dont allow our lives to be ruined by failure to acknowledge constant severe intractable pain. My husband and I, as well as thousands of other families, deserve better!

Sincerely,

Kristen D. Ogden
Co-Founder/Co-Leader, Families for Intractable Pain Relief (FIPR)
", "comment_id": "HHS-OS-2019-0003-0387", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0003-0387", "comment_date": "2019-05-15T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-06328", "commenter_fname": "Kristen", "commenter_lname": "Ogden", "comment_length": 4581}, {"text": " Dear Task Force Members,
I have submitted my Intractable pain story to you previously, See attached file(s). Today I would like to comment on the continuing devastation and torture of chronic pain patients, post operative and hospitalized patients, hospice/cancer patients, Veterans, and all painful disease patients still being inflicted upon by our governmental officials, the insurance industry, physicians, State regulations and Medicare/Medicaid.
The chronic pain community is truly grateful for the clarification of the 2016 CDC guidelines by the CDC, FDA, AMA, The US Surgeon General and others, stating that the nonconsensual tapering and abandonment of chronic pain patients was not the intention or the meaning of the 2016 guidelines. However, these clarifications have had little to no effect in restoring any meaningful restoration of legally prescribed treatment with opioid medications in large part because of the very few medical issues listed in these statements. There are thousands of chronic, severely debilitating, high impact chronic pain conditions that were left out of these statements. Not to mention the fact that most patients suffer from multiple chronic disease/injury conditions.
As a patient who was completely abandoned with the release of the 2016 guidelines, suffering with multiple high impact chronic pain conditions, the clarification statements have done nothing to convince physicians, insurers or government officials in my state to amend their treatment plans for me or millions of others in my situation. After six years of safe, effective legally prescribed opioid medications, being abruptly released by my Pain Management Physician has devastated my quality of life. Despite my many documented, progressive, painful diagnoses, with treatment I was able to work, care for my family, myself, my dog, my household responsibilities as well as lead a happy, satisfying life experience. Since then, I have become home bound, mostly bedridden, totally disabled, financially, physically and emotionally a burden to my family and an utterly miserable, depressed ghost of the person I was with effective pain management. My physical condition and diagnoses have worsened exponentially and the number of diagnosed issues I now suffer as a result of untreated, unrelenting, severe pain (HTN, cardiac arrhythmias, PTSD from disastrous experiences with the medical establishment, severe insomnia/sleep deprivation, IBS, Major Depression) all appearing and diagnosed after the abandonment by my Pain Management Physician.
As long as Congress, the White House, PROP, Insurance Companies and especially the Law Enforcement Agencies and DEA continue to pursue and prosecute patients, pharmacies and especially physicians who legally, ethically and compassionately treat their chronic pain patients with the opioid medications that are truly life saving and life affirming, NOTHING will change or improve for the 50 million chronic pain patients being ignored, tortured and forgotten by our government.
In rural areas, like mine, there are literally NO physicians within a twelve hour drive that will accept and treat chronic pain patients due to fear of prosecution, loss of their License and livelihood. The gestapo like tactics of the DEA, federal/state prosecutors and Law Enforcement against legitimate Physicians using legitimate opioid medications as a part of individualized, patient centered care plans are the reason that millions of the chronic pain community currently and will continue to suffer what amounts to torture and genocide by the government that is supposed to protect and serve ALL Americans, not just the healthy and/or those that suffer with addiction issues.
The ONLY way for true change from this catastrophic weaponization of the 2016 guidelines is to completely rescind and throw out the CDC guidelines and start over with the quality of life for ALL Americans in mind. The CDC has said that they intend to let things stand as they are, with the DEA, insurers, federal and state government officials continuing to pursue and prosecute anyone who violates the weaponized guidelines, watching for months/years to get more data. If that happens, millions more will die, myself probably included. Whether due to suicide due to untreated pain, comorbid deaths due to untreated pain ( like my two sudden cardiac arrests) or due to a myriad of other reasons.
We, the chronic pain community, 50-100 million people strong, humbly beg you to help us in getting the 2016 CDC guidelines completely eradicated and start over with representatives from the chronic pain community, Pain Management Physicians, Addiction Specialists, the AMA, FDA, CDC, members of the multiple Pain Advocacy Organizations, Veterans Organizations, members of Congress, Insurance Companies, Pharmacists, and any others with applicable view points. Actually restart Pain Management services with safe effective opioid medications to those of us who have been abandoned. ", "comment_id": "HHS-OS-2019-0003-0401", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0003-0401", "comment_date": "2019-05-15T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-06328", "commenter_fname": "Andrea", "commenter_lname": "Giles", "comment_length": 5023}, {"text": "There is an astounding amount of misinformation, disinformation, & flat out lies going around about the so-called "opioid crisis." The actual numbers are lower than what frequently appear in headlines; and for all the hysteria & hype, ALL drug deaths combined kill fewer than medical errors, influenza, & far, far fewer (orders of magnitude) than heart disease, cancer, tobacco, hypertension, and many other conditions (CDC's own data). Prescription opiate pain meds do not, and have not, caused the "crisis;" the number of prescriptions have plummeted since 2011, but the number of opioid deaths has gone up considerably. This is because the overwhelming majority of ODs are due to illegal drugs, NOT prescriptions. And unlike alcohol & tobacco, pain meds play a vital part in allowing millions of pain patients to work, function, and live decent lives.

The primary actors in creating the hysteria were the members of PROP; their lying PROPaganda campaign has led to the destruction of millions of lives, caused post-surgical & injured patients to be literally tortured, and millions to die in unnecessary agony. They created this hysteria because they have earned vast amounts of money --and power-- from it.

I have multiple chronic pain conditions,* one extending back to the 70s. I was first advised to apply for disability by my long-term neurologist in 1988; I was able to continue working until 2011 with responsibly prescribed pain meds. I have never abused them, sold them, or done anything nefarious with them. I now have ZERO pain meds; my doctor cut me off because of the opioid hysteria, not because of anything I did wrong or any negative impacts I had from the pain meds. I now am nearly completely unable to function or care for myself. Merely changing the sheets can put in me bed for days.

I worked in basic medical research for many years: I can read and evaluate medical and scientific journal articles and facts. And the facts are, there is no scientific, medical, or simply sane reason for this witch hunt of pain patients. There is no "opioid epidemic" outside of the minds of hysterics and PR-hungry, greedy liars, like Andrew Kolodny, Jane Ballentyne & their ilk.

The CDC has been silent for far too long about the impact of the supposedly "voluntary" guidelines. The guidelines have become weaponized. The DEA is attacking & closing down the few remaining clinics and doctors who are still willing to treat pain patients, probably because it's a great deal easier to look up a doctor's office in the phone book than it is to track down illegal drug dealers. Plus the doctors have all that money sitting in easy-to-access banks, again unlike the drug dealers.

This has become an Age of Institutionalized Sadism. Millions have been forced into unspeakable, unnecessary agony. This trend MUST be stopped. This illegal, immoral, and cruel national crusade to torture this country's own innocent citizens will go down as one of the most shameful periods in our history. I hope it will be history soon, because thousands of pain patients are killing themselves because their doctors have abandoned them. Also, the suicide rate among veterans is appalling, at least partially due to them losing their pain medications --again, FOR NO REASON other than GREED.

My mother was forced to die in unspeakable, untreated agony when she died of leukemia. No doctor would give her any pain relief even though there was absolutely no question she was dying. Her monstrously hideous death did not save one single recreational drug user from using a drug, or from ODing, or from anything else. This story is being repeated daily. Please, stop this madness and reverse the diabolical trend of the torture of innocent civilians & veterans; because it IS pure torture.

*intractable migraines, CRPS (post-surgical), SI joint deterioration, upper back injury, severe carpal tunnel, congenital leg deformity, fibro, severe GI attacks. ", "comment_id": "HHS-OS-2019-0003-0071", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0003-0071", "comment_date": "2019-05-15T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-06328", "commenter_fname": "kelly", "commenter_lname": "howard", "comment_length": 4092}, {"text": "I benefited greatly from the Opioid medication my Nurse Practitioner Primary Care Provider prescribed me. I chose Tylenol/Codeine instead of Hydrocodone due to abdominal sensitivity, voluntarily. For the short time I was approved a prescription. She withdrew the prescription from me. Due to the pain contract rules. The pharmacy did not fill the complete amount of pills to cover the month's supply. Having run out of medicine and in agonizing pain. I used a an old prescription of Hydrocodone. I was given at the Hospital Emergency Room prior to the new pain Prescription.. When given the random U A at my clinic. although I informed the technician. Due to this my pain contract was terminated. This happened nearly three years ago. Although i appealed it I was denied. I had to endure at the time seven months of agony with screaming pain. While my right hip deteriorated into mush. I was at the verge of suicide. Believing in a greater power that i was what kept me alive. And i made it through a total hip replacement. even though I endured the torture I had to go through. I am still to this day living the torture of no relief for my double form of chronic pain. Arthritis on every joint the cause of hip joint disintegration. and Fibromyalgia the cause of chronic pain on every fiber nerve and muscle of my being. I am a self sustaining person. i can't help but think. How much longer can I hold on? How much longer will i be able to continue earning my own living? Managing my Chronic pain with no help means bearing with it for me! How much longer can i live with pain before I totally brake? Speaking for my self and the millions of people through out our nation suffering chronic pain. In some cases, the only thing that allows us to experience a somewhat normal life is Opioids. Let our doctors treat our pain without fear of retaliation by the DEA!
CDC Guidelines should be just that...Guidelines!
Not the law... so dont treat them as such! Establish clear guidelines for Chronic Pain Patients that allow us to be treated by out Pain Management Physician and not by the government! Please take away patient restrictions such as contracts which treat us like we have commited crimes and are on probation or parole.

We are not ADDICTS!
Our doctors are not DEALERS! ", "comment_id": "HHS-OS-2019-0003-0080", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0003-0080", "comment_date": "2019-05-15T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-06328", "commenter_fname": "iris", "commenter_lname": "ayala", "comment_length": 2342}, {"text": "I have had two failed back surgeries, had breast cancer and chemo, the chemo has played havoc on the nerves in my legs. Without pain medication I would be in a wheelchair. I have also been getting injections in my back and neck for the last 12 years, along with the pain meds I can walk. Some days are still worse then others. Basically I feel the government is getting involved where they shouldn't. They should not be able to make a decision on my medical care or the medication that I take. That is between me and my doctor. Period. I am not addicted, I use my medication to get me through my life and I dont feel that is unreasonable, I do not feel anyone besides my doctor should have a say so on my care. We pain patients should not
have to suffer because you guys can't get control of the illegal drugs coming from other countries. We should not be treated with disrespect either because of our medication. You are treating us very unfairly and it's not right. ", "comment_id": "HHS-OS-2019-0003-0078", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0003-0078", "comment_date": "2019-05-15T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-06328", "commenter_fname": "Christy", "commenter_lname": "Ashford", "comment_length": 1001}, {"text": "Im a 39 year old female with Ehlers Danlos Syndrome. Im currently fighting for my life because I have intractable pain thats under-treated. I was barely able to do normal day to day activities before I began opioid therapy 10 yrs ago. I have both c and l spine disk herniations with nerve compression in 2 areas. I systematically tried every non opioid medication and alternative therapy before deciding to take long-acting oxycodone. It literally saved my life and I began to actually function like a normal person! I did some substitute teaching, was able to finally be active with my family, made and sold my artwork, etc. For Joint-type EDS, PT strengthing exercises are the main treatment and I am proud to say I did so well with these during opioid therapy, I was asked by 2 ppl if I was a trainer! A year and a half ago, my trusted pcp was told to refer me to a pain specialist b/c of the cdc guideline. Once in pain mgmt, I was force-tapered down to 1/5 of my therapeutic dose, again, due to the cdc guidelines. I am down to 95 lbs and have been struggling to do basic housework and self care. My joints are dislocating more frequently due to destabilization as I cant do my pt strengthing exercises due to pain. My specialist can not safely do injections as the nerve compression is in the thoracic area, making it a high risk for lung puncture. My life felt full of potential and hope, now I actually wonder if Ill be able to continue. I have little energy left after continually dealing with relentless pain.", "comment_id": "HHS-OS-2019-0003-0327", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0003-0327", "comment_date": "2019-05-15T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-06328", "commenter_fname": "Carrie", "commenter_lname": "J", "comment_length": 1523}, {"text": "I am a 58 year old divorced mother of 4 adult children and 7 grandchildren.

I will never be able to come even close to performing, functioning or have the mindset I once did prior to the implementation of the 2016 CDC guidelines! I'm experiencing abandonment of care! I no longer have access to the instrumental tools, medications that I need for functionality and any semblance of quality to my life! I have called well over fifty different pain management clinics and cannot get into one!

This has been horribly debilitating painful illness not being able to have access to the medications that wants help me function and engage in life the pain causes me extreme depression, frustration, sadness among a gambit of other issues!

I suffer and endure incurable deep-rooted, ceaseless, recurrent, obstinate, ever-present, incessant, continual, lasting persistent, deep-seated AGONIZING, pain, miser, torture, torment, tormenting, hurtful stiffness, soreness, burning, agony, throbbing, piercing, Sharp severe caustic extreme intractable/chronic pain due to arachnoiditis, stiff person syndrome, fibromyalgia, lupus, Parkinson's disease, arthritis, anxiety, depression, insomnia...
This journey this path is incomprehensible for individuals who do not have intractable/chronic pain, 24/7, 365 days a year to understand!

My life and standards of living are incredibly compromised!
In addition, the collateral damage that occurs due to our inability to function, perform, engage in normal tasks/functions that a parent, grandparent or employee should functioning member of society would do our children our grandchildren our workplace do not get the quality and quantity of care and attention that they should!
The individual I once was no longer exist the person that was able to go to work, engage with family, friends, interact with life and sustain a sense of normalcy is gone
I suffer with cognitive difficulties or fibro fog, headaches, sensory sensitivity, exhaustion, muscle tightness, digestive issues, and disabling pain, anxiety and depression I never feel good, lack of control, grief and worry, immune dysfunction, chest pain, inflammation, insomnia, memory loss, my body is now overly sensitive to, well, pretty much everything! Its not that I am emotionally over-sensitive its a psychological thing

Since the implementation of the 2016 CDC guidelines my life has literally declined 98%.
In all respects financially, health related, depression and biggest loss is the quality and quantity of time I was able to spend with family is all but gone!
I no longer can work, engage outside my home in any capacity! My standard of living is well beneath the poverty standard now and I'm in the process of potentially losing my home of 32 years! All of this because I am not able to have access to the essential tools/medications that I need for functionality and any semblance of quality to my life!
The pain is so bad I isolate in my room as not scare my family to the horrible struggles I am going through! This is not living it's barely just existing!
In such a short amount of time my life went from being engaged and happy in life, and being a functional member of society giving to thy fellow man advocating for individuals with autism... to barely existing and living in a painful tortuous hellthis is not living!
I would in a hot second absolutely waive any liability in any way shape or form to receive my lifesaving, life-enhancing and life enriching tools/medications back! It is worth any kind of side effects or consequence to my health! Not having my tools/medications is a death sentence! My organs are starting to shut down, being in constant, continual pain leads to depression and premature death!

When drug addicts use/take drugs their lives decline
spiral out of control
When a intractable pain patient uses their tools/medications
Their functionality and semblance of quality returns to their lives!
Huge difference!
Can not compare the two!

Intractable pain definition, Intractable pain, also known as Intractable Pain Disease or IP, is a severe, constant pain that is not curable by any known means and which causes a bed or house-bound state and early death if not adequately treated, usually with opioids and/or interventional procedures.

Intractable pain - Wikipedia, 2017
I currently have a list of suicides due to pain of 300 + more in the realm of 400 these individuals took their lives because of the Insidious, constant, never ending, tortuous pain they felt 24 7, 365 days a year every minute of every day!
Data from the CDC itself reveals that there is no relationship between rates of opioid prescribing and rates of opioid overdose-related mortality... and there never has been.

Yet the CDC is refusing to analyze its own data or to conduct an outcomes study for the horrendous results of their deeply flawed and biased 2016 guidelines.
", "comment_id": "HHS-OS-2019-0003-0245", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0003-0245", "comment_date": "2019-05-15T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-06328", "commenter_fname": "Cathy", "commenter_lname": "Kean", "comment_length": 5055}, {"text": "Pain is relentless
Pain is cruel
It doesn't discriminate
It can happen to you!
Everyone is just one car accident, surgery, illness away from living the rest of their lives in torturous, stabbing, burning, caustic, incessant intractable pain!
Believe me this is a Journey you do not want it is literally hell on earth!

In memory of those in the intractable pain Community who could not handle their pain anymore due to the 2016 CDC guidelines! Please give us back our tools, medications that give us functionality and any semblance equality to our lives! Without are medications it is a death sentence and torture!
Suicide due to pain videos I have 7 more plus I have to make so many more

https://youtu.be/CSkxF1DMQws

https://youtu.be/0ACgV0aLIAk

https://youtu.be/hRGECrgVPskhttps://

My story published in pain News Network describes my journey!
www.painnewsnetwork.org/stories/2018/7/13/living-with-a-beast", "comment_id": "HHS-OS-2019-0003-0149", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0003-0149", "comment_date": "2019-05-15T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-06328", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 986}, {"text": "Attached please find comments from the American Association of Nurse Anesthetists regarding the HHS Pain Management Best Practices Inter-Agency Task Force meeting on May 9-10, 2019.", "comment_id": "HHS-OS-2019-0003-0391", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0003-0391", "comment_date": "2019-05-15T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-06328", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 181}]}, {"id": "FRA-2019-0071", "title": "Drug and Alcohol Testing of Mechanical Employees\n\n\n", "context": "2022-07-20T14:05:26Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "The control of alcohol and drug use should be enforced in every workplace and for every type of employee regardless of the type of occupation. There are many jobs in society that should require the responsibility and control of alcohol and druge use. Especially when it comes to mechanical employees or those dealing with more serious responsibilites on the job on as daily basis. In agreement, employees who are testing or inspecting railroad rolling equipment should be covered when it comes to the scope of alcohol and drug regulation. Regulated employees should definitely include any MECH employees in order to make sure that they are covered. If this issue is proposed it would help when it comes to accidents as well as fatal accidents to prevent or keep them from continuing to happen as often and if any do happen, these specific employees would be covered and included. This rule would also not affect environmental resources or increased emissions both directly or indirectly so there should be no reason these employees shouldnt be covered. ", "comment_id": "FRA-2019-0071-0013", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2019-0071-0013", "comment_date": "2021-03-10T05:00:00Z", "comment_title": "Comment from Alexandra Canaveral", "commenter_fname": "Alexandra", "commenter_lname": "Canaveral", "comment_length": 1053}, {"text": "I think this rule is necessary in order to make sure the use of ALcohol and drug is legal and will be regulated in any situation. The Mechanical employees and their rights to the previous acts have t be specified in this follow-up rule in order to make sure their rights of alcohol and drug use are legal and working correctly. This rule is giving clarification to many things involved in the previous acts published.", "comment_id": "FRA-2019-0071-0005", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2019-0071-0005", "comment_date": "2021-03-10T05:00:00Z", "comment_title": "Comment from Guangshi(Stone) Chen", "commenter_fname": "Guangshi(Stone)", "commenter_lname": "Chen", "comment_length": 417}, {"text": "I support this proposed rule. The opioid epidemic has become larger than we could've ever predicted and it's a sickness that needs attention and availability. This proposition to expand coverage and redefine regulation is a step in the right direction to addressing the issue directly and transparently.", "comment_id": "FRA-2019-0071-0010", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2019-0071-0010", "comment_date": "2021-03-10T05:00:00Z", "comment_title": "Comment from Joshua Cruzado", "commenter_fname": "Joshua", "commenter_lname": "Cruzado", "comment_length": 311}, {"text": "This proposed rule follows basic common sense on this issue. The rule protects railway workers, engineers, and others as well as the general public. According to the rule, it also saves millions of dollars per year through its deterrence effects. This is a logical step to take to expand the FRA's Congressionally mandated program. It is important for those who are inspected rolling equipment to be in the most sober state of mind they can be while performing their duties, lest they risk not only their own lives, which is commented on in the proposed rule, but the lives of those in the general public if they fail to adequately perofrm their testing/inspection duties due to a substance abuse disorder. ", "comment_id": "FRA-2019-0071-0011", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2019-0071-0011", "comment_date": "2021-03-10T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 711}, {"text": "The work that the people do benefit the country so making it to where the people working the trains and insure that it works properly is beneficial so that they can do the work correctly so that commerce and public transport keep on flowing so the country keeps up with the demand of products needed.", "comment_id": "FRA-2019-0071-0009", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2019-0071-0009", "comment_date": "2021-03-10T05:00:00Z", "comment_title": "Comment from ashtyn bombala", "commenter_fname": "ashtyn", "commenter_lname": "bombala", "comment_length": 300}, {"text": "See the attached file.", "comment_id": "FRA-2019-0071-0003", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2019-0071-0003", "comment_date": "2021-03-10T05:00:00Z", "comment_title": "Comment from NTSB", "commenter_fname": null, "commenter_lname": null, "comment_length": 22}, {"text": "Comments related to Docket No. FRA-2019-0071

Safety-sensitive jobs in relation to Medicinal cannabis use has been a hot topic in legislation. I was recently asked how it made me feel to be an advocate and so open about my medical cannabis treatment? How has it affected my life?
I chose to become a nurse because I love to take care of people. It's my passion and gives me purpose, to care for others and uphold the oath that I took. I have been left with this hollow feeling inside accompanied by waves of mourning and frustration. I continue to advocate for those like myself who either can't Medicate or suffer the repercussions of it.
When the topic comes up how's it affected my life and others seek to help me find solutions to my problem my response is usually to this effect:
I couldn't continue to contribute to the decline of the quality of life of Oklahoman’s at the hands of Oklahoma healthcare in order to obtain a paycheck all the while being scrutinized for my methods of medicating which is much safer and effective when properly maintained and managed. One mistake and a positive drug test for metabolites would immediately flag me for drug abuse and treatment and have to go before the board of nursing in order to gain back licensure.
I was passive-aggressively threatened by an employer whenever I brought up cannabis use for the patients that I was caring for and that we should be supporting them and educating them. I mentioned that there's a degree of liability here as well. The response I was given was nurses who medicate are the only liability so I nodded my head and turned in my resignation letter 3 days later due to extenuating personal circumstances as well.
There are other workforce concerns that go greatly unaddressed while medicinal cannabis remains a negative focal point burn out, lack of adequate sleep, pharmaceuticals etc which completely overlooked.
Stress and each individuals tolerance in managing has a great impact on their work and safety of them and those their work affects.
Programs like Predictive Safety mentioned in the article below should be utilized by employers to monitor changes in ability to perform safely. https://tulsaworld.com/opinion/columnists/lawrence-pasternack-medical-marijuana-and-workplace-safety/article_a55493d6-fed6-522e-b743-191002d46d71.html

Consider the following about stress and as an example the effects of working under safety sensitive conditions.

According to The American Institute of Stress:
About 33 percent of people report feeling extreme stress
77 percent of people experience stress that affects their physical health
73 percent of people have stress that impacts their mental health
48 percent of people have trouble sleeping because of stress

Those in safety sensitive positions should be able to medicate freely on their own time without fear of judgement or retaliation. Cannabis and all of its metabolites should be removed from workplace drug testing as it is an out dated resource and only contributes to stigma. Our bodies hold onto THC in fat cells while other drugs that cannabis is often compared to metabolize within a few days. The reason our bodies hold onto cannabinoids is simple and inarguable. Our bodies want it, need it even. The presence of metabolize does not indicate that there is an active impairment. The people who fall under this category are in some of the most mentally and physically taxing jobs because they are safety sensitive and would greatly benefit from medicinal cannabis after a long stressful day at work.
According to the report, 15.6% of all nurses reported feelings of burnout, with the percentage rising to 41% of “unengaged” nurses. What’s really interesting as well, is that 50% of nurses who reported feeling burned out also reported that they had no plans to leave their organization—pointing to the importance of supporting and meeting nurses where they are at in the workforce.
PTSD is an occupational hazard for nursing. It is estimated that up to 14 percent of the overall general nursing population experience symptoms that meet the criteria to be diagnosed with PTSD, which is 4 times higher than the general adult population.
The stigmatic bias and disregard for the many medicinal qualities of cannabis by many of our leaders is the root of the problem.
I am a nurse and patient and have seen and heard hundreds of testimonies from people some would consider to not be using medicinally.
The fact is that medicinal cannabis is the most safe and effecive treatment option for most of the people who medicate. These people have tried traditional methods of treating their problems only to end up with more complications both short term and long term.
As a medical professional it is of utmost importance that I hold tight to my oath to cause no harm and continue to advocate for medicinal cannabis use where it is applicable and reasonable.

", "comment_id": "FRA-2019-0071-0008", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2019-0071-0008", "comment_date": "2021-03-10T05:00:00Z", "comment_title": "Comment from Kara McCurry", "commenter_fname": "Kara", "commenter_lname": "McCurry", "comment_length": 5113}, {"text": "Given that railroads have such an impact on our nation and communities via general transportation and supporting our economic system. It is obvious that the FRA should expand its scope of alcohol and drug regulation to cover mechanical (MECH) employees who test or inspect railroad rolling equipment. Also, the fact that two MECH employees have passed due to related events furthers the argument that something needs to be done.
", "comment_id": "FRA-2019-0071-0016", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2019-0071-0016", "comment_date": "2021-03-15T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 434}, {"text": " DOCKET NO. FRA-2019-0071

Posted by the Federal Railroad Administration (FRA)

Control of Alcohol and Drug Use: Coverage of Mechanical Employees and Miscellaneous Amendments

Section: II Mechanical Employees, Contractors, and Subcontractors

Dear FRA,

I am writing regarding the proposed rule revisions to FRA Regulations (49 CFR, Part 219). This rule will require random alcohol and drug testing to expand to contractors and subtractors working in the Maintenance of Way (MOW). Before June 12, 2017, only the regulated mechanical employees required pre-employment, post-accident, and random drug and alcohol testing. I support the revisions because these contractors are equally responsible for inspecting the railroad equipment and tracking their signal and communication systems. Train accidents are happening every 3 hours in our country. This data covers railroad employees, distracted drivers, and lack of proper warning signals for pedestrians and drivers.

When an employee becomes involved in a railroad accident, they must provide a specimen within 4 hours unless immediate medical treatment is required. If the worker is delayed based on injuries, an on-duty supervisor must provide documentation to the administration explaining such. The different agencies can go to the FRA website to view the mandated requirements for stand-alone or random drug and alcohol testing. These random screenings are performed quarterly on their roadway workers. The testing is divided into two separate categories, 50% involves testing for drugs and the other 25% involves testing for alcohol usage for annual records.

In closing, my position remains to support the proposed rule that alcohol and drug screening be expanded to "all" roadway workers. Hopefully, this will eliminate some percentage of tragic accidents that we often hear about regarding individuals losing their lives or life-threatening injuries, trying to "outrun" a train when approaching the railroad tracks. The clients in my treatment program are placed on a daily call-in for random drug and alcohol screening. The outcome of relapsing seems to decrease in numbers because of accountability. Therefore, the duties of a railroad worker who repairs our bridges, tracks, and roadways should be accountable for the safety of keeping themselves, our citizens, and co-workers unharmed if preventable. ", "comment_id": "FRA-2019-0071-0018", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2019-0071-0018", "comment_date": "2021-04-13T04:00:00Z", "comment_title": "Comment from Helen KING", "commenter_fname": "Helen", "commenter_lname": "KING", "comment_length": 2457}, {"text": "I am for this proposed rule since it provides a safer work environment for mechanical employees. If I was an employer, I wouldn't want my employees to the intoxicated or under the influence while dealing with machinery or equipment. It can lead to accidents especially if the equipment was dealt with improperly. Under executive summary, It explains incidents that led up to the revision of alcohol and drug regulation. These incidents either caused an injury or death for mechanical employees. If frequent drug tests became a necessary precaution, it will help prevent these kinds of incidents from increasing. ", "comment_id": "FRA-2019-0071-0015", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2019-0071-0015", "comment_date": "2021-03-10T05:00:00Z", "comment_title": "Comment from Nadia Legorreta", "commenter_fname": "Nadia", "commenter_lname": "Legorreta", "comment_length": 618}]}, {"id": "USCBP-2021-0009", "title": "Mandatory Advance Electronic Information for International Mail Shipments", "context": "2022-06-22T12:15:52Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "Please see the attached document providing the views of the Express Association of America, the trade association representing DHL, FedEx and UPS. ", "comment_id": "USCBP-2021-0009-0005", "comment_url": "https://api.regulations.gov/v4/comments/USCBP-2021-0009-0005", "comment_date": "2021-05-13T04:00:00Z", "comment_title": "Comment Submitted by Express Association of America", "commenter_fname": null, "commenter_lname": null, "comment_length": 147}, {"text": "Attached are comments in PDF format.

Steve Pociask
President/CEO
American Consumer Institute
1701 Penn. Ave., NW
Suite 200
Washington, DC 20006", "comment_id": "USCBP-2021-0009-0004", "comment_url": "https://api.regulations.gov/v4/comments/USCBP-2021-0009-0004", "comment_date": "2021-05-12T04:00:00Z", "comment_title": "Incomplete Comment Submitted by American Consumer Institute", "commenter_fname": null, "commenter_lname": null, "comment_length": 173}, {"text": "To the attention of Secretary Mayorkas:

The American Consumer Institute Center for Citizen Research (ACI) would like to take the opportunity to address the Mandatory Advance Electronic Information for International Mail Shipments interim final rule (IFR) issued by the Department of Homeland Security’s U.S. Customs and Border Protection (CBP) to implement portions of the Synthetics Trafficking and Overdose Prevention Act (STOP Act; P.L. 115-271, Title VIII).

The Synthetics Trafficking and Overdose Prevention (STOP) Act was designed to help law enforcement and security agencies to identify and prevent hazardous substances, such as synthetic opioids and other dangerous items, from traveling through the U.S Postal Service (USPS) into the United States. ACI has touted the critical nature of such measures and has previously noted, “The solutions created by the STOP Act will give law enforcement the tools necessary to begin stemming the intrusion of illicit items in the nation’s mail system. Specifically, this entails requirements on the USPS to collect and monitor advanced electronic data on shipments that enter the country. Such responsibilities would parallel the practices used by private delivery companies, which track every package and gather key data on the contents in order to assist coordination with U.S. Customs and Border Protection other federal securities entities.”

The STOP Act as written provides a clear schedule for accelerated levels of compliance that has allotted U.S. institutions to set their own frameworks for operational change and resource adjustments in order to meet objectives. The measures of the law are rightfully thorough in that they establish provisions for the myriad of elements of potentially exploitable delivery. The posture of the IFR as proposed would undermine this comprehensive configuration and thus jeopardize the overall purposes of the STOP Act.

In order to regain the trust of consumer communities in logistics and delivery markets, it is incumbent upon DHS to transparently detail the inflows of mail and packages and correspondingly provide data on the actions taken to assess each item, such that stakeholders and lawmakers can ascertain how exactly USPS and CPB are making good on assurances in this critical arena.

The circumstances surrounding the origin of the law should remain apparent for the Department, and more broadly for the Administration’s awareness. Unfortunately, for a 12-month period ending this past September, more than 87,000 Americans died of a drug overdose, surpassing the toll from any year since the opioid epidemic began in the 1990s. The continuation of such trends heightens the concern for muting policies or laws that are actively working to prevent dangerous substances from entering our country.

In a statement submitted by Robert Cintron Vice President, Logistics of United States Postal Service to the Permanent Subcommittee on Investigations of the Homeland Security and Governmental Affairs Committee, USPS was able to see the advance electronic data (AED) percentage for inbound international packages peak at 67 percent in January 2020, up from almost zero AED in the six years prior. While this is a demonstrated improvement, it is still cause for concern as the law called for an extensive grace period in the lead up to 100 percent compliance by January 1, 2021.

Cintron admitted that AED progress reversed as the coronavirus pandemic affected international shipments but expressed his belief that once international mail recovers, he expects the AED will as well. While there is no accounting for the exact effect the coronavirus pandemic had on this effort, the USPS is still responsible for fulfilling its obligations.

ACI further acknowledges and respects the USPS Inspector General’s role in assessing compliance, however concerns remain about the reticence of transparency and the redactions of key information that remain shielded from public review in their report. Limiting the obfuscation in this regard, wherever feasible, and similarly elucidating the criteria through which foreign nations may be considered for any form exemptions, would represent prudent action on the part of the Department.

In closing, we trust that the Department shall not be unduly influenced by the notions that enforcement of AED obligations could hypothetically prompt retaliation from foreign postal services. Direct causation cannot be automatically assumed and such potential externalities are largely immaterial to actions dictated by the statutes of the law.

Ultimately, the STOP Act provisions must be held up to its full lifesaving potential in service to American consumers. Thank you for your consideration.

Respectfully,

Steve Pociask
President/CEO
American Consumer Institute
1701 Pennsylvania Avenue, NW, Suite 200
Washington, DC 20006

ATTACHMENT: PDF includes footnotes and letterhead

", "comment_id": "USCBP-2021-0009-0006", "comment_url": "https://api.regulations.gov/v4/comments/USCBP-2021-0009-0006", "comment_date": "2021-05-13T04:00:00Z", "comment_title": "Comment Submitted by American Consumer Institute (2nd Comment)", "commenter_fname": null, "commenter_lname": null, "comment_length": 5093}, {"text": "I dissent, 100%, and here's why.
Treatment and education work, prohibition never has. This is a ridiculously convoluted, failure of a proposal. This act is supposed to stop opiods—specifically fentanyl—from entering the country. But it's not.
Instead, I am now getting perfectly legal substances seized, returned to the sender, taking months to arrive, or possibly even scammed. These are supplements like piracetam, choine bitartrate, creatine, PEA (phenylethylamine), and NAC (n-acetyl-cysteine, which literally saved my life when doctors couldn't help me at all.) I have used these items for years; they are completely legal, non-addictive, and safe. I have friends who have had clothing (not imitation clothing either, but simple things like a scarf from a grandmother), pictures, and even raw honey from Europe, be returned to the sender or just disappear. Lost to the backlog at the ISC locations, or maybe just stolen. I'll never know. This is beyond unacceptable. AED has already failed and it has only just started.
Now, there are countries that refuse to ship anything to the United States, and the ones that still do, don't guarantee delivery or provide tracking information, so internet scamming has exploded. The USPS has been pushed past the breaking point. The backlog is insane and unacceptable. The USPS is directly affected to the point that they can't even guarantee next day domestic delivery anymore. Unacceptable.
Need I mention the cost of running this program? You all know the figures. They're ridiculous. Returning parcels to other countries at the expense of the people is not what our taxes are meant for. Especially when we have an exploding homeless population across the country, a failing infrastructure, a police force in desperate need of new and more thorough training so people trust them again and don't fear them, as well as a broken healthcare system that has enslaved us. No longer can we rely on saving money by importing our prescribed medications, but we have to pay the outrageous prices of big pharma so we can stay alive and healthy. We're now slaves to the FDA, discretionary CBP tactics, and big pharmaceutical companies. We have lost yet another freedom.
As for people importing the "research chemicals" that have reportedly intoxicating effects; this is just another form of prohibition, and prohibition has been proven time after time to not work. It only makes criminals. The war on drugs failed long ago and only gave rise to organized crime, money laundering, murder, and the world's largest prison population. People are going to experiment with drugs just as they have all throughout recorded history. At least, before this proposal, they knew what they were getting and where it was coming from so the manufacturer could be held accountable. Now, we will have illegal, underground labs selling chemicals made by a guy that is not trained in chemistry and has no idea what he is doing. People will use his product, they will get sick, injured, or die and he will never be held accountable. And those deaths will be a direct result of AED. AED will make criminals that make poison that kills people. That is a certainty. Bear in mind, these are words coming from a man who has had half his immediate family drink themselves to death or overdose, and understands the situation intimately.
Treatment and education are the only proven methods for success. Not imprisonment, not prohibition, *TREATMENT* and *EDUCATION*.
This was a program that was started to stop opiods, but it's stopping everything. It's ruining the postal system, costing more tax money, costing consumers more money, and severely limiting our freedoms. It's not acceptable and it's not the United States. The United States was founded on the idea of freedom, but it's feeling more like a prison every day. ", "comment_id": "USCBP-2021-0009-0020", "comment_url": "https://api.regulations.gov/v4/comments/USCBP-2021-0009-0020", "comment_date": "2021-06-14T04:00:00Z", "comment_title": "Comment Submitted by Jared Boyes", "commenter_fname": null, "commenter_lname": null, "comment_length": 3947}, {"text": "See attached file(s)", "comment_id": "USCBP-2021-0009-0019", "comment_url": "https://api.regulations.gov/v4/comments/USCBP-2021-0009-0019", "comment_date": "2021-06-09T04:00:00Z", "comment_title": "Comment Submitted by National Association of Manufacturers", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file", "comment_id": "USCBP-2021-0009-0018", "comment_url": "https://api.regulations.gov/v4/comments/USCBP-2021-0009-0018", "comment_date": "2021-06-03T04:00:00Z", "comment_title": "Comment Submitted by Ryan Houser", "commenter_fname": null, "commenter_lname": null, "comment_length": 17}, {"text": "To the attention of Secretary Mayorkas:

The American Consumer Institute Center for Citizen Research (ACI) would like to take the opportunity to address the Mandatory Advance Electronic Information for International Mail Shipments interim final rule (IFR) issued by the Department of Homeland Security’s U.S. Customs and Border Protection (CBP) to implement portions of the Synthetics Trafficking and Overdose Prevention Act (STOP Act; P.L. 115-271, Title VIII).

The Synthetics Trafficking and Overdose Prevention (STOP) Act was designed to help law enforcement and security agencies to identify and prevent hazardous substances, such as synthetic opioids and other dangerous items, from traveling through the U.S Postal Service (USPS) into the United States. ACI has touted the critical nature of such measures and has previously noted, “The solutions created by the STOP Act will give law enforcement the tools necessary to begin stemming the intrusion of illicit items in the nation’s mail system. Specifically, this entails requirements on the USPS to collect and monitor advanced electronic data on shipments that enter the country. Such responsibilities would parallel the practices used by private delivery companies, which track every package and gather key data on the contents in order to assist coordination with U.S. Customs and Border Protection other federal securities entities.”

The STOP Act as written provides a clear schedule for accelerated levels of compliance that has allotted U.S. institutions to set their own frameworks for operational change and resource adjustments in order to meet objectives. The measures of the law are rightfully thorough in that they establish provisions for the myriad of elements of potentially exploitable delivery. The posture of the IFR as proposed would undermine this comprehensive configuration and thus jeopardize the overall purposes of the STOP Act.

In order to regain the trust of consumer communities in logistics and delivery markets, it is incumbent upon DHS to transparently detail the inflows of mail and packages and correspondingly provide data on the actions taken to assess each item, such that stakeholders and lawmakers can ascertain how exactly USPS and CPB are making good on assurances in this critical arena.

The circumstances surrounding the origin of the law should remain apparent for the Department, and more broadly for the Administration’s awareness. Unfortunately, for a 12-month period ending this past September, more than 87,000 Americans died of a drug overdose, surpassing the toll from any year since the opioid epidemic began in the 1990s. The continuation of such trends heightens the concern for muting policies or laws that are actively working to prevent dangerous substances from entering our country.

In a statement submitted by Robert Cintron Vice President, Logistics of United States Postal Service to the Permanent Subcommittee on Investigations of the Homeland Security and Governmental Affairs Committee, USPS was able to see the advance electronic data (AED) percentage for inbound international packages peak at 67 percent in January 2020, up from almost zero AED in the six years prior. While this is a demonstrated improvement, it is still cause for concern as the law called for an extensive grace period in the lead up to 100 percent compliance by January 1, 2021.

Cintron admitted that AED progress reversed as the coronavirus pandemic affected international shipments but expressed his belief that once international mail recovers, he expects the AED will as well. While there is no accounting for the exact effect the coronavirus pandemic had on this effort, the USPS is still responsible for fulfilling its obligations.

ACI further acknowledges and respects the USPS Inspector General’s role in assessing compliance, however concerns remain about the reticence of transparency and the redactions of key information that remain shielded from public review in their report. Limiting the obfuscation in this regard, wherever feasible, and similarly elucidating the criteria through which foreign nations may be considered for any form exemptions, would represent prudent action on the part of the Department.

In closing, we trust that the Department shall not be unduly influenced by the notions that enforcement of AED obligations could hypothetically prompt retaliation from foreign postal services. Direct causation cannot be automatically assumed and such potential externalities are largely immaterial to actions dictated by the statutes of the law.

Ultimately, the STOP Act provisions must be held up to its full lifesaving potential in service to American consumers. Thank you for your consideration.

Respectfully,

Steve Pociask
President/CEO
American Consumer Institute
1701 Pennsylvania Avenue, NW, Suite 200
Washington, DC 20006

", "comment_id": "USCBP-2021-0009-0007", "comment_url": "https://api.regulations.gov/v4/comments/USCBP-2021-0009-0007", "comment_date": "2021-05-13T04:00:00Z", "comment_title": "Duplicate Comment Submitted by American Consumer Institute (3rd Comment)", "commenter_fname": null, "commenter_lname": null, "comment_length": 5034}, {"text": "See attached file(s)", "comment_id": "USCBP-2021-0009-0017", "comment_url": "https://api.regulations.gov/v4/comments/USCBP-2021-0009-0017", "comment_date": "2021-06-01T04:00:00Z", "comment_title": "Comment Submitted by Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Attached please find comments from the Lexington Institute on Docket No. USCBP-2021-0009 pertaining to The STOP Act.", "comment_id": "USCBP-2021-0009-0014", "comment_url": "https://api.regulations.gov/v4/comments/USCBP-2021-0009-0014", "comment_date": "2021-05-17T04:00:00Z", "comment_title": "Comment Submitted by Lexington Institute", "commenter_fname": null, "commenter_lname": null, "comment_length": 116}, {"text": "See attached file(s)", "comment_id": "USCBP-2021-0009-0011", "comment_url": "https://api.regulations.gov/v4/comments/USCBP-2021-0009-0011", "comment_date": "2021-05-17T04:00:00Z", "comment_title": "Comment Submitted by Alliance for Safe Online Pharmacies", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}]}, {"id": "DEA-2019-0007", "title": "Schedules of Controlled Substances: Removal of 6-beta-Naltrexol from Control", "context": "2021-12-02T01:01:29Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "Naltrexone is an opioid receptor antagonists and is commonly used in the treatment of opioid addiction and overdose, without the harmful addictive side effects of the drugs it treats. Currently 6-Naltrexol is a schedule II controlled substance. This proposed rule would allow more patients access to this life saving drug by removing the schedule II rating. We agree with the action as it will save more lives and positively affect individuals and their families who struggle with drugs and alcohol addiction.

Naltrexone is not a narcotic yet is used to help narcotic dependents who have stopped taking narcotics to stay drug-free. It is also used to help alcoholics stay alcohol-free. The medicine is not a cure for addiction. It is used as part of an overall program that may include counseling, attending support group meetings, and other treatment recommended by a health care provider. It will not produce any narcotic-like effects or cause mental or physical dependence however it may block the craving of wanting more.

Naltrexone is prescribed for moderate-to-severe alcohol dependence, such as a patient that consumes five or more drink per day on a regular basis and has alcohol related problems. This medication is appropriate for patients that have tried to quit by abstaining from alcohol for several days before starting the medication. Naltrexone treatment is usually a minimum of 3 to 4 months. The goal is for the patient to be able to abstain from alcohol during this time, if so then treatment can be stopped. If on the other hand the patient continues to consume alcohol then the daily dose can be increased from 50 mg to 100 mg. There is also a monthly injection that is 380 mg and is given intramuscularly. Naltrexone is a drug that saves lives without the fear of addiction, and by removing this schedule II classification, it will become more available to a greater number of patients in need.
", "comment_id": "DEA-2019-0007-0004", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2019-0007-0004", "comment_date": "2019-09-23T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-17630", "commenter_fname": "Karan", "commenter_lname": "Kortlander", "comment_length": 1943}, {"text": "6 Beta Naltrexol, which is an opioid antagonist, meaning, it blocks the bodies receptors preventing the body from responding to endorphins and opioid. This drug should not be listed as a scheduled II substance as science has shown there are no known potentials for abuse in contrast to other schedule II drugs such as, morphine. On the other hand, 6 Beta Naltrexol has shown to work similarly to Naltrexone which was removed from all schedules effective in 1975 because of the lack of evidence to show the risk for abuse potential. While, 6 Beta Naltrexol works like naltrexone it does differ in some aspects, for instance, it has a lower potency, a significantly long half life, and with higher plasma concentrations making it as effective as naltrexone when given by mouth. With the current number of deaths by overdose being 399,000 people from 1999-2017 involving opioids including prescription and illicit. It is imperative that new prevention's including medications like 6 Beta Naltrexol be made available for treatment and provided to those at risk for overdose without the constraints of schedule II drugs.
Centers for Disease Control and Prevention. (2019). Drug overdose. Retrieved from https://www.cdc.gov/drugoverdose/data/statedeaths.html", "comment_id": "DEA-2019-0007-0005", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2019-0007-0005", "comment_date": "2019-09-23T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-17630", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 1264}, {"text": "Its nuts that the majority of States have legalized the use of cannabis for recreational and medical use and the other States will make you a criminal and throw you in jail for years. Federal and States cannot accurately track tax revenues from cannabis sales because it is "cash only" transactions. And every day we get of cannabis is curing and helping people with their ailments from migraines and arthritis to pancreatic cancer (report from Harvard research: https://www.yahoo.com/lifestyle/study-on-cannabis-chemical-as-a-treatment-for-pancreatic-cancer-may-have-major-impact-harvard-researcher-says-165116708.html).

Big Pharma has controlled the narrative with millions of dollars in political donations every year. Removing cannabis from being Schedule 1 drug is long over due and it is time to do what's best for America.

Sincerely,

Fil Lalau
", "comment_id": "DEA-2019-0007-0006", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2019-0007-0006", "comment_date": "2019-09-23T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-17630", "commenter_fname": "Fil", "commenter_lname": "LALAU", "comment_length": 896}, {"text": "I just wanted to make sure that I understood this rule completely. My understanding of the proposed rule is that the DEA wants to declassify a drug that is only available in research labs, not available to the general public or to most physicians for prescription to patients, has no addictive properties, is not being used to for any purpose what so ever, and there is no history of any abuse of the drug, etc. I assume that there are plenty of other classified drugs that fall into the same category as this one. Why not spend more time worrying and combating drugs that are readily available to citizens or that are highly prescribed by physicians rather than wasting time on drugs that no one outside of a lab will ever see or ingest? For the record, I am for stronger drug laws in this country!!!", "comment_id": "DEA-2019-0007-0007", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2019-0007-0007", "comment_date": "2019-09-23T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-17630", "commenter_fname": "Phil", "commenter_lname": "Hanzlik", "comment_length": 801}]}, {"id": "FDA-2021-N-0951", "title": "Reconsidering Mandatory Opioid Prescriber Education Through a Risk Evaluation and Mitigation Strategy (REMS) in an Evolving Opioid Crisis; Public Workshop; Request for Comments", "context": "2021-12-06T16:00:15Z", "purpose": "Nonrulemaking", "keywords": ["OPEN", "Request for Comments", "Public Workshop", "in an Evolving Opioid Crisis", "Evaluation and Mitigation Strategy (REMS)", "Prescriber Education Through a Risk", "Reconsidering Mandatory Opioid", "CDER"], "comments": [{"text": "1-Mandatory education improves appropriate opioid prescribing by teaching the prescriber indications and contraindications for specific opioids. This also leads the prescriber to do their own research on the opioid to ensure they are putting these drugs in the right hands. It would also encourage the prescriber to ask more questions to the patient, to identify risk of misuse prior to dispensing the drug. For pain management and treatment of opioid use disorder, it would provide alternative methods than just prescribing a drug. While these methods might be more intense and could possibly involve therapy or collaboration with other health care professionals, it ensures the patient is getting the best quality care in the long term and not just prescribing a drug because it is easier. Mandatory education would no doubt make education more consistent, efficient, and effective. It would also allow for more innovation surrounding management of opioid use disorder and pain management. With more eyes and variety of knowledge backgrounds, research and development of opioids would improve drastically because the drug manufacturer would be under pressure to create a drug that is ‘the next best thing’. In addition to more research being done, the process would be more efficient because gold standard practices would come out of this education. Lastly, it would hold prescribers accountable, if you have standards and the prescriber is not abiding by them, it is easier to pick out the bad apples and create a network of ethical prescribers. We know overprescribing happens too often with prescription and nonprescription drugs. Education would specifically help opioid prescribing by making the prescriber more aware of the consequences of even prescribing just 1 more pill than needed. The hill to climb is that more burden is put on the prescriber to collaborate with other healthcare professionals or entities. The reality is that by overprescribing, it puts these drugs on the streets and into hands that were never meant to have it. Even with a post-op patient that is given 5 pills, if they only use 3, it takes 1 person to know the drug can be sold on the street for a lot of money. The most important point to come out of mandatory education would be the innovation of alternative treatments. When you are faced with prescribing a drug that is known to have high rate of misuse versus another drug or management plan with low rate of misuse, in most cases the latter would be chosen. Education should not only surround the opioids but also those alternative treatments such as physical therapy, trigger point injections, bioelectric therapy, etc.

2-Core competencies and knowledge gaps that should be addressed are indications/contraindications, implications of drug, side effects, and long term versus short term use. Some clinical challenges are patient compliance, cost, immediate relief, and time constrictions with patient. More intensive screening needs to be mandatory by talking to the patient about their past prescription drug and substance use. This can be used to determine if prescribing a non-opioid can provide favorable results instead of opioids, determining medical history to rule out possible adverse effects, and consider the psychological state of the patient. Spending more time with the patient to get a full picture rather than just a diagnosis will help with overall treatment plans.

3-Goals should include understanding basic ethical obligations to the public and reviewing the oath they took as prescribers, consideration of innovative implementation, and understanding each drug they are prescribing. In ways of measuring the understanding of a drug, a test can be administered and if they do not pass a specific drug/section, they are unable to prescribe that drug. Systems like these seem harsh, but it will provide incentive to the prescriber to be better.

4-Many challenges will arise, but initial challenges include cost of program, personnel to run the program, and how the system will be delivered- online or in person. In cases of counting for continued education, having a system in place to determine how many credits or hours are needed to satisfy requirements. We can learn that without education programs, no standard of practice will be implemented. The same patient could go to different clinics and receive completely different care. We also will learn that patient compliance and trust would increase because they will know that it doesn’t matter where they go, they will receive the best care.

5-Technology platforms can be unreliable at times but for the most part, if the platform is user friendly and keeps the prescriber in mind, I don’t foresee any severe issues that couldn’t be mitigated through technology support. However, with any remote work, you run the risk of dishonesty among the prescriber, but there are ways to ensure when taking knowledge assessments there cannot be any cheating.
", "comment_id": "FDA-2021-N-0951-0023", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0951-0023", "comment_date": "2021-11-02T04:00:00Z", "comment_title": "Comment from Alyssa Cox", "commenter_fname": null, "commenter_lname": null, "comment_length": 5037}, {"text": "Please find enclosed input from the American Society of Addiction Medicine (ASAM).", "comment_id": "FDA-2021-N-0951-0038", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0951-0038", "comment_date": "2021-12-06T05:00:00Z", "comment_title": "Comment from American Society of Addiction Medicine", "commenter_fname": null, "commenter_lname": null, "comment_length": 82}, {"text": "Federal Register Comment
Docket No. FDA-2021-N-0951

In Response to the Food and Drug Administration’s Request for Comment and Public Workshop on Reconsidering Mandatory Opioid Prescriber Education Through a Risk Evaluation and Mitigation Strategy in an Evolving Opioid Crisis

Boston University School of Medicine Continuing Medical/Continuing Nursing Education Office (BUSM CME/CNE) has been offering educational activities on safer opioid prescribing since 2010. Our current opioid REMS program, entitled Safer/Competent Opioid Prescribing Education: SCOPE of Pain, launched in March 2013 and has been operating continually since then. To date, we have educated over 225,000 individuals – including healthcare providers (both prescribers and non-prescribers), affiliated health professionals, public health professionals, and students.

We are grateful for the opportunity to provide a comment on the FDA’s consideration of mandatory prescriber education.

In 2017, we observed the effects of a newly enacted NY state mandate on opioid prescribing education. We partnered with the New York Chapter of the American College of Physicians to offer our SCOPE of Pain program to satisfy the New York requirement. Within three months, over 60,000 New York-licensed clinicians had completed our program. We compared clinicians who completed SCOPE of Pain under the New York state mandate with those who had completed it voluntarily in other states, controlling for profession and specialty. We found that clinicians in the mandated group were less likely to report intention to improve their practice as a result of the education. While trying to put our findings into perspective we found a lack of peer-reviewed published evidence supporting the efficacy of mandated continuing education on any topic.

We are also concerned that mandated training could decrease access to appropriate opioid therapy for patients with severe pain. This concern is based on the experience of mandated training required to prescribe buprenorphine for the treatment opioid use disorder in the Drug Addiction Treatment Act (DATA) 2000 and the Comprehensive Addiction and Recovery Act (CARA) 2016. Since the enactment of these laws, the vast majority of prescribers, including those in primary care, have chosen not to complete the required training and thus not offer the life-saving treatment for patients suffering from OUD. We fear that similarly most prescribers will opt out of an opioid prescribing education mandate and thus not be able to prescribe opioids to patients in need. This decrease in access to appropriate opioid therapy will further increase existing disparities in pain care, and will further marginalize an already highly stigmatized and marginalized patient population.

Finally, if the goal of mandated education is to improve patient care, we suggest that rather than mandating a short-term educational program for everyone, consideration should be given to a mandate for demonstration of competency in safer prescribing of all controlled substances in order to maintain a DEA registration number. This competency requirement would allow those already expert to test out and for those needing education to demonstrate competency after completing the education. By including all controlled substances, it will be less likely that prescribers will opt out as maintaining a DEA registration is essential for clinical practice.
", "comment_id": "FDA-2021-N-0951-0054", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0951-0054", "comment_date": "2021-12-06T05:00:00Z", "comment_title": "Comment from Boston University School of Medicine", "commenter_fname": null, "commenter_lname": null, "comment_length": 3510}, {"text": "see attached", "comment_id": "FDA-2021-N-0951-0039", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0951-0039", "comment_date": "2021-12-06T05:00:00Z", "comment_title": "Comment from Sabrina Gmuca", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}, {"text": "Please see attached letter. Thank you.", "comment_id": "FDA-2021-N-0951-0049", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0951-0049", "comment_date": "2021-12-06T05:00:00Z", "comment_title": "Comment from Verde Environmental Technologies, Inc.", "commenter_fname": null, "commenter_lname": null, "comment_length": 38}, {"text": "I wish to provide insight to your proposed mandatory opioid prescriber education program. Despite the noted decline in opioid prescriptions per 100 individuals, there has been an alarming increase in fatalities stemming from drug abuse. According to CDC data, 2020 witnessed a 29.4% increase in overdose deaths. This data reveals that the decrease in opioid prescriptions has not necessarily translated to fewer overdose fatalities. The proposed uniform, nationwide educational program for prescribers will prove to be a pivotal step towards addressing and reducing opioid addiction.

In addition to substance abuse treatment options, the prescriber educational program should include goals for healthcare providers to initiate conversations on risks of opioid addiction with patients. For example, a patient preparing for surgery should be clearly informed of the potential side effects and risks associated with opioid prescriptions during their pre-operative appointments. They should additionally be equipped with knowledge on how to differentiate between normal, expected postoperative symptoms (including pain) and postoperative discomfort/restlessness (which can stem from either surgery or frequent, continued use of opioids). If the patient were to have difficulty in differentiating between the two, they should feel comfortable to discuss their symptoms with their healthcare provider.

The program should also discuss strategies to monitor patient opioid use. Healthcare providers should always have answers to the following questions in regards to their patients:
How many opioid prescriptions were given to this patient over time?
How large of a prescription has been given to this patient at one time?
How long has it been since this patient has been in chronic pain?
What are other non-medicated strategies that can effectively manage this patient’s pain?

Monitoring patients through frequent, routine follow-up visits to counsel and gradually reduce dependence on opioid prescriptions will be extremely beneficial towards reducing overdoses.

While the consistency of such a program can be challenging, healthcare has largely evolved towards virtual platforms in just the last year; many patients and healthcare staff can now access patient information from the comfort of their homes or offices. Therefore, implementing this program’s educational materials through an online platform will reach a significantly large number of healthcare providers, whilst enabling them to review the information at a time convenient for them.

Given the severity of our opioid crisis, I believe the proposed plan to increase prescriber education surrounding opioid use is of utmost importance and should remain a top priority for FDA. Thank you for your time.
", "comment_id": "FDA-2021-N-0951-0021", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0951-0021", "comment_date": "2021-10-25T04:00:00Z", "comment_title": "Comment from Shivani Dhebar", "commenter_fname": null, "commenter_lname": null, "comment_length": 2838}, {"text": "Prescription opioid medications have contributed to positive experiences for individuals needing pain management; however, physicians over prescription of opioids to patients for decades has caused one of the most pressing issues the nation is facing today. There is no question that the push from big pharmaceutical companies to prescribe opioids for non-cancer related pain in the late 90’s contributed to massive amounts of consumers addicted to prescription pain medications. Free samples were often given to individuals seeking pain relief, leading to addiction in these individuals, some of which were unable to afford the medications turning them to obtain these drugs illegally. This created an epidemic in our country that has been addressed since it was identified but continues to remain a burden on our health system. According to the HHS, more than 760,000 people have died since 1999 from a drug overdose, and appropriate prescribing of opioids is an essential way to protect the health and safety of US citizens.
Education is always an effective and low-cost method of program implementation. It is only logical that prescribers be required to educate themselves on the best practices of prescribing controlled substances, especially those with high abuse potential such as opioid analgesics. If the FDA was previously concerned about implementing mandatory prescriber education programs due to placement of an undue burden on the healthcare delivery system, it should be apparent that the absence of mandatory prescriber education has prolonged an ever-concerning national crisis. The current pandemic has shown us that we are able to provide many services to individuals from the convenience of their own homes. Employment of a mandatory prescriber education program would be highly beneficial and easily conducted virtually to reach as many stakeholders as possible.
To outline a few appropriate goals of a mandatory prescriber education program, we should begin creating a list of topics that should be covered. A good place to start is looking at the blueprint that has been developed by the FDA for prescriber education for ER/LA opioid analgesics. Pulling from those, some necessary topics to be included are:
•Federal requirements for prescribing controlled substances
•Assessment of the patient needs for the medication
•Proper patient counseling on safe use of medications
•Prevention, screening, and signs of addiction
•Alternative options for pain management
•Specific drug information regarding opioid analgesics
This program should aim to educate all prescribers on these topics and ensure complete comprehension prior to completion of the program.
In order to measure the effectiveness of this program, participants should be assessed on the skills they have developed. This can be accomplished through monitored breakout discussions among the participants. The proctors of the discussions can develop questions they believe incorporate the topics that the program set out to inform prescribers on and evaluate the discussion among the participants to determine what skills were learned. The program can also include a segment after educating prescribers in which they complete a self-assessment providing examples of what they learned from each topic that was covered.
Another method to measure the impact of the program is one that would take place over a longer period after the program ended. This would be to monitor the prescribing behavior in the program participants and compare changes from before educating to those afterwards. This is already a common practice in some states that have established prescription drug monitoring programs, making this method of evaluation the most feasible.
Common program evaluation methods can be used to determine the effectiveness of a mandatory prescriber opioid education program, and surveillance data on the numbers of opioid prescriptions given can, over time, reinforce the program’s effectiveness. We can look at the success rates of private and state entities that have implemented educational programs for opioid prescribers and determine that a nationwide standard should be enforced. Unfortunately, the burden the opioid crisis is putting on the nation is of far more concern than the burden the FDA was previously concerned about with requiring prescribers to participate in this educational program. The evidence is clear that we will benefit from applying more efforts towards combating the opioid crisis, one of which is to more extensively educate prescribers of best practices when handling these highly addictive substances. ", "comment_id": "FDA-2021-N-0951-0031", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0951-0031", "comment_date": "2021-12-01T05:00:00Z", "comment_title": "Comment from Jodie Frost", "commenter_fname": null, "commenter_lname": null, "comment_length": 5114}, {"text": "It is interesting to me that this is an FDA workshop that I had never heard of; as an MPH student and someone that had worked in the healthcare field before, I thought it would be something that would be mentioned in class or a professional setting. I do have to say that since 2012 from 84 prescriptions per 100 residents to 67 prescriptions per 100 residents in 2016, and 52 prescriptions per 100 residents in 2018, the rate dropped to 43 prescriptions per 100 U.S. residents in 2020 the implementation of REMS has had quite a successful run, but not as successful as it could be. The issue is that the epidemic isn't over; the numbers have only been rising. Provisional data from CDC's National Center for Health Statistics indicate an estimated 100,306 drug overdose deaths in the United States during the 12 months ending in April 2021, an increase of 28.5% from the 78,056 deaths during the same period the year before. Also, In 2019, an estimated 10.1 million people aged 12 or older misused opioids in the past year. Specifically, 9.7 million people misused prescription pain relievers, and 745,000 people used heroin. (https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm). This goes into the fact that cocaine, heroin, methamphetamine, and benzodiazepines have also become a major indicator of the rise of opioid misuse. That is due to the lack of educational spread and prevention, which is clearly shown in this article and the above numbers. The purpose of the workshop is to make REMS mandatory through risk evaluation and mitigation strategies for healthcare workers that prescribe opioids. The workshop can be attended by anyone who works in healthcare but is specifically targeted to prescribers. The issues start early on with the implementation of the workshop. First, it should've been mandatory for any healthcare provider that even remotely works with opioids, not just prescribers. There are too many "cooks in the kitchen" when it comes to prescribing medication; the pharmacist, any medical provider that the patient sees other than the prescriber, mental health providers, or anyone that the patient sees that helps them with their health. Therefore, REMS should be mandatory for everyone because not every patient is the same, but the goal of healthcare is the same: "to do no harm." If only a certain number of healthcare providers are getting this continuing education opportunity, why can't everyone? The other thing that could've been mentioned here is who gets notified about the workshop. Is it well-known hospitals in well-known areas where the people can afford treatment if they become addicted, or does the notification of the workshop not discriminate? To be even a spark of equality in the healthcare system, there needs to be an accessible and affordable way to educate all. That's where I would love to see that analytical makeup of attendance and where the statistical data presented below is kept. If someone came to the workshop, where do they work, what is their line of profession, what is the population they see compared to others. I think this information is essential to all present to the stakeholders attending the workshop because it shows the pros and cons of not only making it mandatory but also if the FDA keeps it in general care. The final thing that sparked my interest is that the blueprints currently do not include principles for managing opioid use disorder, including treatment with buprenorphine. My curiosity lies in why treatment was not part of the workshop. It's a very crucial part of lowering the number of patients that go into overdose and die. Substance use disorders can be best treated on an outpatient therapy basis or in an inpatient program dedicated to treating people with addiction. Many of these programs use medications to help patients transition from physical dependence on opioids. The medicine buprenorphine also relieves opioid cravings without giving the same high as other opioid drugs. Prescribed by many physicians from office settings, this is typically a daily dose placed under the tongue and can be delivered as a once-a-month injection or through thin tubes inserted under the skin and last six months (https://www.hopkinsmedicine.org/opioids/treating-opioid-addiction.html). Different addiction treatments should be added to the blueprints because if the healthcare provider can't prevent the addiction, they most certainly can treat it. Nevertheless, I thought this approach was fascinating, and I hope through the decisions made in October, a real change can be made in 2022. ", "comment_id": "FDA-2021-N-0951-0027", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0951-0027", "comment_date": "2021-11-26T05:00:00Z", "comment_title": "Comment from Carolina Zatta", "commenter_fname": null, "commenter_lname": null, "comment_length": 4651}, {"text": "Over-prescribing of opioid drugs in the United States has fueled the opioid overdose epidemic, contributing to 200,000 overdose deaths from 1999 to 2017 (Mathis, 2020). It is necessary for all health care providers to do their part in reducing the possibility for opioid abuse in their patients and those that their patients may influence. A mandatory REMS educational program could address the over prescribing of opioids for acute pain through teaching prescribers screening questionnaires, recognizing warning signs of drug abuse, limiting opioid prescriptions, encouraging patients to utilize non-addictive pain management strategies, and recognizing the potential consequences for over prescribing.

In a REMS program, prescribers should be required to learn ways to accurately assess and detect a patient’s levels of pain prior to making the decision of whether to prescribe opioids.
A REMS program can address which types of acute pain may require prescription of opioid drugs, and which may not. Most surgeries and invasive procedures may generally cause more acute pain than acute injuries. Another screening tool, which is required in Massachusetts by law, that can be used is The National Institute on Drug Abuse Quick Screen (Keith, 2020). This is a quick questionnaire that can be used to assess frequency of drug use and risk for potential abuse. Surveys like this should be taught to prescribers in a mandatory program to reduce the chance of prescribing opioids to people prone to abuse.

Early warning signs of prescription drug abuse can be easily detected if prescribers are properly educated on what to look for. Patient and provider communication is key to detecting these early warning signs (Mathis, 2020). Providers should be taught to look for how many providers the patient has seen in the past and if those previous providers were prescribing opioid drugs. “Doctor shopping,” when a patient tries to obtain multiple prescriptions from multiple prescribers at the same time, is a common sign that a patient has been abusing opioid drugs (Keith, 2020). They should note if the patient immediately asks if they can be prescribed opioids and if they frequently ask for refills or “misplace” their medications regularly. Additionally, prescribers should base their decision to prescribe on evaluative measures such as special physical and diagnostic tests for pain rather than relying solely on patient reports. The ability to clinically rule out if someone is over-exaggerating or faking their pain through evidence-based measures makes the prescriber’s decision process easier. These strategies should all be covered in a mandatory REMS program.

Education on prescribing fewer opioids in one singular prescription for acute pain rather than prescribing in excess would be beneficial to include in a REMS program. Healthcare professionals can always prescribe more pain medications if needed. For example, if prescribers are going to prescribe opioids to patients for acute pain, they should only prescribe two to three days’ worth of medication and then encourage use of NSAIDS or acetaminophen to manage pain. If the patient reports that they are still having unbearable pain not manageable through over-the-counter medications, prescribers should then consider an additional prescription of another two to three days of medications.

There are many potential consequences that prescribers may not immediately consider when prescribing opioids to patients. Not only are patients at a higher risk for developing an addiction to the opioid themselves, but one factor that is often overlooked is the possibility of the patient abusing their excess prescription to sell and supply opioids to others. Even if a patient is not abusing their excess prescription themselves, it can still be used to harm others. Not only is selling excess opioids a possible issue, but if drugs are leftover and end up in a medicine cabinet, young adults or children in the household are more likely to abuse these drugs.

It would be extremely beneficial to require a mandatory REMS education program for prescribers to reduce over-prescribing opioid drugs to patients. The simple implementation of this program will help reduce patient drug abuse, the likelihood of other family members to abuse these drugs, and repercussions for doctors if these unfortunate events do occur.

Keith, D. A., & Hernández-Nuño de la Rosa, M. F. (2020). Special Screening Resources: Strategies to Identify Substance Use Disorders, Including Opioid Misuse and Abuse. Dental clinics of North America, 64(3), 513–524. https://doi-org.proxygw.wrlc.org/10.1016/j.cden.2020.03.002

Mathis, S. M., Hagaman, A., Hagemeier, N., Baker, K., & Pack, R. P. (2020). Provider-patient communication about prescription drug abuse: A qualitative analysis of the perspective of prescribers. Substance abuse, 41(1), 121–131. https://doi-org.proxygw.wrlc.org/10.1080/08897077.2019.1635956
", "comment_id": "FDA-2021-N-0951-0029", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0951-0029", "comment_date": "2021-11-29T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 5097}, {"text": "Please see attached comment letter.", "comment_id": "FDA-2021-N-0951-0034", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0951-0034", "comment_date": "2021-12-02T05:00:00Z", "comment_title": "Comment from American Society of Anesthesiologists", "commenter_fname": null, "commenter_lname": null, "comment_length": 35}]}, {"id": "FDA-2018-D-2382", "title": "Opioid Use Disorder: Endpoints for Demonstrating Effectiveness of Drugs for Medication-Assisted Treatment; Draft Guidance for Industry; Availability ", "context": "2020-10-02T12:12:23Z", "purpose": "Nonrulemaking", "keywords": ["CDER", "2018-300", "Opioid Use Disorder: Endpoints for", "Demonstrating Effectiveness of Drugs for", "Medication-Assisted Treatment", "Draft Guidance for Industry", "Availability", "OPEN"], "comments": [{"text": "Please see the attached comments from the New York City Department of Health and Mental Hygiene. ", "comment_id": "FDA-2018-D-2382-0010", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-D-2382-0010", "comment_date": "2018-10-18T04:00:00Z", "comment_title": "Comment from New York City Department of Health and Mental Hygiene", "commenter_fname": null, "commenter_lname": null, "comment_length": 97}, {"text": "Please see the attached letter.", "comment_id": "FDA-2018-D-2382-0014", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-D-2382-0014", "comment_date": "2018-10-18T04:00:00Z", "comment_title": "Comment from Cleveland Clinic", "commenter_fname": null, "commenter_lname": null, "comment_length": 31}, {"text": "I dont think that every person should be treated the same and have to go by the same guidelines! Every person is different and have different problems going on. As a 47 yr old grandmother I believe that i was treated as if i was some kind of drug addict!! I have been on opioid pain medication for several years. i have have several medical problems- which include partly of chronic pain, fibromyalgia, severe bone deterioation, 2 slipped disc in my back, had 2 complete knee replacements, sciatica, and the list goes on. I went to all my appointments, complied with all the rules and was told they needed to cut me back because the according to the fda rules i was over medicated! it became harder and harder for me to get my medication, and i was treated like a common drug addict because of the fda laws and rules! i dont think i was treated fairly by any means!!!! i am almost 50 yrs old and wish my life was not as it is. I am also in end stage renal failure, so i get dialysis 5 days a week and when a person is on dialysis it takes most of the medication out of your system so by the time i had built anything up in my system I would be dialyized so i had to start all over again the next to get anything built up!!!! The fact that i was on dialysis had NO play in the factors of how much medication i was allowed a day.I dont think the same rules should apply to every person since everyone has different circumstances for the reason they are medicated. I wish Jeff Session would have to live a day in my shoes then have someone tell him NOPE your too medicated! So i believe each persons circumstances should be taken into consideration. when they are prescribed pain medication., especially if they have YEARS of medical documentation of reasons fffor being on the the medication. And with all the new rules laws surrounding being on opioids it has made it just about impossible to get any help! Unless I want to pay 100's of $ because many pain doctors do not take insurance anymore", "comment_id": "FDA-2018-D-2382-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-D-2382-0004", "comment_date": "2018-08-14T04:00:00Z", "comment_title": "Comment from S Martin", "commenter_fname": null, "commenter_lname": null, "comment_length": 2004}, {"text": "I dont think that every person should be treated the same and have to go by the same guidelines! Every person is different and have different problems going on. As a 47 yr old grandmother I believe that i was treated as if i was some kind of drug addict!! I have been on opioid pain medication for several years. i have have several medical problems- which include partly of chronic pain, fibromyalgia, severe bone deterioation, 2 slipped disc in my back, had 2 complete knee replacements, sciatica, and the list goes on. I went to all my appointments, complied with all the rules and was told they needed to cut me back because the according to the fda rules i was over medicated! it became harder and harder for me to get my medication, and i was treated like a common drug addict because of the fda laws and rules! i dont think i was treated fairly by any means!!!! i am almost 50 yrs old and wish my life was not as it is. I am also in end stage renal failure, so i get dialysis 5 days a week and when a person is on dialysis it takes most of the medication out of your system so by the time i had built anything up in my system I would be dialyized so i had to start all over again the next to get anything built up!!!! The fact that i was on dialysis had NO play in the factors of how much medication i was allowed a day.I dont think the same rules should apply to every person since everyone has different circumstances for the reason they are medicated. I wish Jeff Session would have to live a day in my shoes then have someone tell him NOPE your too medicated! So i believe each persons circumstances should be taken into consideration. when they are prescribed pain medication., especially if they have YEARS of medical documentation of reasons fffor being on the the medication. And with all the new rules laws surrounding being on opioids it has made it just about impossible to get any help! Unless I want to pay 100's of $ because many pain doctors do not take insurance anymore", "comment_id": "FDA-2018-D-2382-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-D-2382-0005", "comment_date": "2018-08-14T04:00:00Z", "comment_title": "Comment from S Martin", "commenter_fname": null, "commenter_lname": null, "comment_length": 1997}, {"text": "See attached file(s)", "comment_id": "FDA-2018-D-2382-0013", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-D-2382-0013", "comment_date": "2018-10-18T04:00:00Z", "comment_title": "Comment from Biotechnology Innovation Organization", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "There should be clear and unambiguous language that placebo control trials should not be designed. All endpoints should be compared to a standard of care; either buprenorphine or methadone treatment. Superiority or non-inferiority studies should be standard practice. ", "comment_id": "FDA-2018-D-2382-0017", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-D-2382-0017", "comment_date": "2019-03-07T05:00:00Z", "comment_title": "Comment from Jarratt Pytell", "commenter_fname": null, "commenter_lname": null, "comment_length": 268}, {"text": "We approve of the FDA's assistance with the nation-wide epidemic concerning opiods. The guidance set forth by the FDA assist sponsors in developing drugs for a medication-assisted treatment of opiod use disorder, which could greatly reduce the growing number of deaths this nation faces everyday. The trials outlined are closely monitored and the patients are frquently assesed for adverse events, whcih the guidline outlines. The Guideline also specifically outlines the way a sponsor could report an outcome and change in drug use pattern. Overall, the guidance tackles the issue of the opiod epidemic and provides assistance for those trying to help. The guidance also allows for a more uniform breakdown in outcomes of patients and a variety of endpoints that can be reached. We approve of this guidance and the work of those involved to help those in need.", "comment_id": "FDA-2018-D-2382-0008", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-D-2382-0008", "comment_date": "2018-10-09T04:00:00Z", "comment_title": "Comment from Angelique, Abby, Lauren", "commenter_fname": null, "commenter_lname": null, "comment_length": 865}, {"text": "People who abuse drugs and become addicted will always find a way to get high whether the drug is legally prescribed or not . Chronic pain patients shouldn't be punished for addicts bad decisions . You're killing me witholding medicine to improve the quality of my life . I am in control of my actions . I never abused drugs. I never failed drug tests , I am always compliant with pain contracts for 16 yrs ! I am not an addict ! Stop the torturing of people who live their lives in pain. You are destroying my quality of life ! You're destroying my family's quality of life ! Would you watch your mother , Father or your child scream in pain day after day ? I seriously doubt you would .I am a human being ! Treat me like one ! End the ridiculous War on Drugs ! It didn't work for alcohol ! Speaking of alcohol. Not everyone who drinks it becomes an alcoholic .", "comment_id": "FDA-2018-D-2382-0007", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-D-2382-0007", "comment_date": "2018-09-25T04:00:00Z", "comment_title": "Comment from Sharon W", "commenter_fname": null, "commenter_lname": null, "comment_length": 886}, {"text": "Since Subutex is an opioid medication used for medication assisted addiction treatment, I am assuming comments regarding that medication are welxome too. Subutex has saved my life. I was using extremely dangeous amounts of other opiates daily and after receiving Subutex, I have not touched another drug or opiate! Personally, I feel Suboxone, Bunavail and Zubsolv are all a joke. They are NOT as effective as the plain Buprenorphine and I am deathly allergic to them and no one knows the issues the long term use of Naloxone may cause and many people are becoming immune to it which means more people will die from overdose. I feel the Naloxone should be REMOVED from the medications and just plain Buprenorphine be administered.

Another issue is, pharmacies are refusing to fill prescriptions for Buprenorphine for people because they say they dont carry the medication, cannot accept new patients or just because they don't want to. Also many pharmacies REFUSE to accept insurance for Buprenorphine but will accept the same insurance for any other medications they carry and this seems like it should be illegal. I had to go to mail order through OptumRX for this reason and I have to do a few days without my medication. There should be NO LIMIT on the number of patients a pharmacy can have. Also pharmacies should have to bill your insurance for Buprenorphine if they accept the insurance for ANY medication! Another thing is, pharmacies should have to fill prescriptions written by doctors in their state whether the patient resides there or not and a patients home state should honor a prescription written in any state. People seeking treatment cannot get their medications filled and its RIDICULOUS. It's time someone steps in and makws it easier to obtain medication for addiction treatment. Getting a prescription is easy but getting it filled is impossible and more people are going back to street drugs but unfortunately they have no choice.

The FDA needs to step in and help out. These medications with Naloxone need taken off market and some studies done on them. They are terrible medications. Suboxone is a horrid medication that is actually dangerous and so are it's alternatives!

Something needs done with making access to treatment for addiction and getting addiction treatment medications filled at pharmacies easier. The restrictions need lifted and pharmacies need to fill people's medications without the hassle.

I personally checked at 100 different pharmacies in PA, WV, MD and OH trying to get my medication filled with no success. I either had to pay xash when my insurance does pay for it, they said they weren't taking new patients, didn't carry it and refused to order it or just plain refused because they did not want to or because I live in WV or because my doctor is in PA. It's impossible for people trying to actually get clean and better themselves to get their medications! We need help!", "comment_id": "FDA-2018-D-2382-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-D-2382-0003", "comment_date": "2018-08-09T04:00:00Z", "comment_title": "Comment from Amber Adams", "commenter_fname": null, "commenter_lname": null, "comment_length": 2994}, {"text": "Please find attached Indivior comments to FDA Draft Guidance for Industry Opioid Use Disorder: Endpoints for Demonstrating Effectiveness of Drugs for Medication-Assisted Treatment", "comment_id": "FDA-2018-D-2382-0011", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-D-2382-0011", "comment_date": "2018-10-18T04:00:00Z", "comment_title": "Comment from Indivior Inc.", "commenter_fname": null, "commenter_lname": null, "comment_length": 179}]}, {"id": "FDA-2013-P-1711", "title": "Refrain From Submitting the Stated Recommendation to HHS to Reclassify Hydrocodone Combination Products That Contain Hydrocodone Bitartrate in a Strength That is Lower Than 5 mg in Strength Into Schedule II", "context": "2017-03-21T09:22:03Z", "purpose": "Nonrulemaking", "keywords": ["cder", "citizen petition", "2013-10552", "open", "hydrocodone bitartrate", "5 mg", "7.5 mg", "10 mg", "Schedule II"], "comments": [{"text": "I represent The Hawaii academy of Physician Assistants, a constituent organization of the AAPA. We work in a state where PAs are not yet authorized to prescribe Schedule II medications. The Drug Enforcement Administration’s (DEA’s) proposal (Docket No. DEA-389.” ) to reclassify hydrocodone combination products from Schedule III to Schedule II will affect us and the patients we serve. If implemented, the proposed rule will restrict PAs from prescribing hydrocodone combination productions in states where they do not yet have prescribing authority for Schedule II drugs. Reclassifying the medications will impose additional burdens on all patients who need these medications to manage severe pain.

We are opposed to this change and request that hydrocodone not be reclassified as a Schedule II drug.

Fielding Mercer, PA-C
President
Hawaii Academy of Physician Assistants

", "comment_id": "FDA-2013-P-1711-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2013-P-1711-0004", "comment_date": "2017-03-21T04:00:00Z", "comment_title": "Comment from Fielding Mercer", "commenter_fname": null, "commenter_lname": null, "comment_length": 928}]}, {"id": "FDA-2018-P-0673", "title": "Requests that the FDA produce a study on control of alprazolam products in relation to the overall effect on the Opioid crisis in the USA.", "context": "2021-02-17T17:40:12Z", "purpose": "Nonrulemaking", "keywords": ["Citizen Petition", "CDER", "Justice for Jake", "produce a study on control of", "alprazolam products in relation to the overall", "effect on the Opioid crisis in the USA", "OPEN"], "comments": [{"text": "If someone is poisoned by lacing punch, gummie bears or whatever, it is not the drugs fault, it is the person delberately tampering with the food, beverage committing murder. Does the date rape drug take the rap when someone puts it in another persons drink? Is it guilty of the crime?

Despite what ignorant individuals are stating, the only people suffering from the opioid crisis are the people that need the medication to live. The lives of people with horrible medical conditions have been destroyed. The lives of the elderly have been destroyed. The correct od stats are 17k. People do not take the time to fact check the current 'fad." Govt quietly corrects data while continuing to disseminate erroneous data,

MILLIONS OF PEOPLE WITH ILLNESSES WHO PREVIOUSLY WERE ABLE TO FUNCTION, CONTRIBUTE TO SOCIETY ARE NOW INCAPACITARED AND IN EXRUCIATING PAIN. YOU HAVE DESTROYED THEIR LIVES AND THEIR FAMILIES AND WE BY FAR OUTNUMBER THE POOR LITTLE ADDICTS WHO COULD CARE LESS ABOUT ANYTHING OTHER THAN GETTING THEIR ILLEGAL FIX ON THE STREET.

THE SICK ARE NOW COMMITTING SUICIDE DUE TO NONSTOP PAIN.

STOP PICKING ON PEOPLE WITH ILLNESSES OF ANY KIND.

THERE SHOULD NOT BE A SIGN IN A CANCER DOCTORS OFFICE STATING THEY CANNOT GIVE YOU THE MEDICATION YOU NEED FOLLOWING CHEMO AND RADIATION.

THE DEA LIES ABOUT DRUG SHORTAGES FOR THE SICK, WHILE THE FDA WEBSITE LISTS THEM AS SHORT.

IGNORANT AMERICANS YET TO BE AFFECTED BY THE FACT THAT PAIN KILLS CONTINUE TO PREACH WITHOUT KNOWING THE CORRECT STATS OR THE TRUTH.

PERSECUTION OF PEOPLE IN PAIN OR ANY ILLNESS NEEDS TO STOP.

MAKING IT HARDER FOR SOMEONE THAT MEDICALLY NEEDS OPIOIDS OR XANAX IS IRRESPONSIBLE.

Figures Lie and Liars Figure Why the Demographics of the So-Called Prescription Opioid Crisis Dont Work, Richard Lawhern, National Pain Report, 11/17/17
http://nationalpainreport.com/figures-lie-and-liars-figure-why-the-demographics-of-the-so-called-prescription-opioid-crisis-dont-work-8834839.html

CDC Researchers State Overdose Death Rates From Prescription Opioids Are Inaccurately High, CATO INSTITUTE, JEFFREY A. SINGER, 3/22/18
https://www.cato.org/blog/cdc-researchers-state-overdose-death-rates-prescription-opioids-are-inaccurately-high

Are Prescription Opioids Driving the Opioid Crisis? Assumptions vs Facts. Rose ME1.
Pain Med. 2018 Apr 1;19(4):793-807. doi: 10.1093/pm/pnx048.
https://www.ncbi.nlm.nih.gov/pubmed/28402482

B.C. doctors cant limit opioids or discriminate against pain patients
CAMILLE BAINS, VANCOUVER THE CANADIAN PRESS, 6/6/18
https://www.theglobeandmail.com/canada/article-bc-doctors-cant-limit-opioids-or-discriminate-against-pain-patients-2/

The Opioid Epidemic In 6 Charts Designed To Deceive You, ACSH, Josh Bloom, 10/12/17
https://www.acsh.org/news/2017/10/12/opioid-epidemic-6-charts-designed-deceive-you-11935

The truth about the US opioid crisis prescriptions arent the problem
Marc Lewis is a neuroscientist/author on addiction, The Guardian
https://www.theguardian.com/commentisfree/2017/nov/07/truth-us-opioid-crisis-too-easy-blame-doctors-not-prescriptions

Fentanyl & Heroin Deaths Lead Soaring Overdose Rate, 12/21/17, PNN
https://www.painnewsnetwork.org/stories/2017/12/21/fentanyl-heroin-deaths-exceed-overdoses-from-pain-meds

Why Untreated Chronic Pain is a Medical Emergency
1/28/18 by Pharmaciststeve http://www.pharmaciststeve.com/?p=23988

Untreated Chronic Pain can Kill! 6/20/17 Suzanne Stewart, NPR
http://nationalpainreport.com/untreated-chronic-pain-can-kill-8833859.html

CDC Report Ignores Suicides of Pain Patients, June 07, 2018, Pat Anson, PNN
https://www.painnewsnetwork.org/stories/2018/6/7/cdc-report-ignores-suicides-by-pain-patients

Jeffrey M Geurin, Staff Sergeant, United States Air Force 1997-2008
https://www.regulations.gov/document?D=FDA-2018-N-1621-1264

Why Living In Pain Will Eventually Kill You, By Kristin Hayes, RN, 7/27/17
https://www.verywell.com/why-living-in-pain-will-eventually-kill-you-3972227

Response to: FDA-2017-N-5608
by: Stefan G. Kertesz, MD, MSc and Ajay Manhapra, MD
U Alabama at Birmingham School of Medicine & Yale School of Medicine
https://www.regulations.gov/contentStreamer?documentId=FDA-2017-N-5608-0938&attachmentNumber=1&contentType=pdf

Time: Report: Chronic, Undertreated Pain Affects 116 Million Americans
By Maia Szalavitz 6/29/11
http://healthland.time.com/2011/06/29/report-chronic-undertreated-pain-affects-116-million-americans/

10 Myths About the Opioid Crisis, Pnn
https://www.painnewsnetwork.org/stories/2017/12/24/10-myths-about-the-opioid-crisis

The other opioid crisis: hospitals are running short of powerful painkillers
PAULINE BARTOLONE, KAISER HEALTH NEWS
http://www.latimes.com/business/la-fi-opioid-painkiller-hospitals-20180316-story.html#

In the midst of a massive opioid crisis, hospitals are experiencing an opioid shortage
Aaron Schachter, 5/14/18
https://www.marketplace.org/2018/05/14/health-care/midst-massive-opioid-crisis-hospitals-are-experiencing-opioid-shortage", "comment_id": "FDA-2018-P-0673-0007", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-0673-0007", "comment_date": "2018-08-10T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 5323}, {"text": "We highly object. Making it difficult for people who legitimately need medication is not the way to stop overdoses from illegal street drugs which are many times laced with heroin. The majority of deaths are due to ILLEGAL drugs bought on the street. By restricting opioids and in this case xanax, you are only driving up the black market for these illicit drugs. People who actually need these medications are being denied access and in some cases are probably now desperate enough to try impure illegal drugs in order to manage medical conditions. Who benefits? The drug cartels which now have even more people to sell to as restricting access has now driven up demand. Since the crackdown on opioids began, we now have even more ER overdose cases. Guess what, they aren't from legitimate prescriptions, but street laced "copies" especially fentanyl. And for the record, someone could just as easily kill them-self with alcohol (a central nervous system depressant) tobacco, tylenol, aspirin, antihistamines...To combat illegal drugs, you should be looking to the DEA to crack down on drug cartels, pill mills and hey how about looking into those drug and alcohol Rave parties. Children and teens need to be properly educated by their parents. It is time for people to start taking responsibility for themselves and to stop blaming drugs. This is like blaming steak knives for every stabbing death and banning them. What about butter knives? They can kill as well. And knives don't just get up off the table and stab someone, just like drugs don't just jump out of their bottle into people's mouths or up their noses. There will always be something illegal on the street that entices some people to get high. Targeting legitimate prescriptions only creates additional suffering and hardship for those that need the medication, while those abusing it still have access to their illegal supply.", "comment_id": "FDA-2018-P-0673-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-0673-0004", "comment_date": "2018-03-19T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 1926}, {"text": "In order to ensure that Alprazolam (Trade Name Xanax) be more strongly controlled in distribution and use I support moving it from Schedule 4 to Schedule 2.

In the United States the drug continues to show up in overdose cases implicating it as a contributor to overdose situations which lead to hospital visits, temporary or permanent debilitation and death.

I find this petition to be in good order becamse Alprazolam has an actual and growing potential for abuse not only of the drug by itself but in combination with other drugs such as both the natural and synthetic opioids.

Scientific evidence of its pharmacological effect continues to indicate it is a serious mood, mind and body altering drug which must be distributed in only rare cases.

The state of current scientific knowledge regarding the drug's interactions with other drugs, such and natural and synthetic opioids as well as the psychiatric states it can trigger have been recorded in studies that the manufacturers continue to marginalize.

Over the course of its (relatively) brief history a pattern of abuse has arisen for the drug itself and it is now being used in combination with other drugs to create specific life endangering effects.

The scope, duration, and significance of abuse is increasing at a high rate over time. The control of the current supply has clearly been lost.

The risk there is to the public health continues to be loss of mental ability, physical ability and life. The debilitating effects of the drug lead to the curtailing of economic activities by family members which damage growing children, other family members and the entire community in which these tragedies occur. Death is also expensive.

The psychic and physiological dependence liability is clear and warned about. It is hard to manage with an individual of general intelligence and strength let alone someone suffering from the very symptoms this drug is supposed to alleviate.

", "comment_id": "FDA-2018-P-0673-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-0673-0005", "comment_date": "2018-07-25T04:00:00Z", "comment_title": "Comment from Alfred Brock", "commenter_fname": null, "commenter_lname": null, "comment_length": 2027}, {"text": "I am a 55 year old female and disabled since MVA in 2005. I am a RN and worked as a nurse for 35 yrs. I have had multiple surgeries due to the accident and also was diagnosed with Hep C that was contracted in the late 80s from a blood transfusion. I was infected for more than 20 years before being aware and it quietly destroyed my liver. I was blessed to bedcover a perfect match at the very last moment and I have been cured of the Hepc now. However I continue with severe chronic pain and my new liver has complicated my options for pain relief. My doctors had found the best medication for me wS Fentanyl patch. It worked well for me for many years. My life and activities were greatly improved. My liver health had been great for 5 years. Since the opioid rules I have lost two of my PCP because they could not prescribe to me. My liver enzymes have been spiking since they took the patch away. My BP has been extremely high at times. I have allergies to a few pain medications and many I simply cant have for reason of causing harm to my liver. Now being sent your in paon management clinics that insist on painful injections that I was told by my doctors I could not have. I pay huge copays and family must run me to appointments that last for hours. They never put hands involved me nor read my piles of records. They send me for repeated Scans MRIs and such for proof that I already have in my records. I am now on oxycodone pills that they previously took me off due to allergy. I continue to have pinching in my liver and my daily pain is 9-10. I never sleep through the night due to constant pain. I need more oregano surgeries but due to my health now I worry about the risks. My life now is very difficult I am depressed and tearful most days. I have 5 sons and 4 grandchildren and fur to my pain I rarely can participate with them and depression again.Before all of this Opioid crisis my quality of life was good. Pain was minimal and I enjoyed my family had normal relations with my husband. I even thought I could possibly work a few hours a week sitting at a desk. I very much miss my job as a nurse. Even if u could not go back to work at least I felt a timed I could be purposeful. Its no longer the case.all I can do now is happily retire and spend days enjoying life and my grandchildren Burbank thats option is gone. I have to have pain control and the proper medication that does not harm me. Like it or not Fentanyl worked well and I had complications. I seem to put that small percentage that. Policy and lawmakers has not considered. I refuse to have my life taken away after all I have been through. I want my PCP back and not be told he will risk losing his license to care for medical ", "comment_id": "FDA-2018-P-0673-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-0673-0006", "comment_date": "2018-07-25T04:00:00Z", "comment_title": "Comment from Denise R Niemi", "commenter_fname": null, "commenter_lname": null, "comment_length": 2717}, {"text": "I am a 41 year old disabled women. This is ridiculous on how Congress want to restrict the people who really need pain meds even more. I had to get 3 spinal surgeries and still have pain, muscle spasms, permanent nerve damage and pain. It is hard doing everyday activities. In my spine I have 15 titanium rods, 4 cages and 2 spacers. My back is permanently damaged. I have depression and anxiety disorder. It is a hassle to see the doctor and they consumed with the fear of prescribing pain meds. What are the people with real pain going to do? You guys are going at this wrong. Us economically disproportionate patients will suffer. The people with money will have access. I am tired of the lack of care. The state of Florida medical is worse. I am always compliant, get drug tested and go to my appointments. Why do I have to suffer?", "comment_id": "FDA-2018-P-0673-0008", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-0673-0008", "comment_date": "2018-08-10T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 836}, {"text": "I object to this matter.

I have been on alprazolam for 4 years. Obtaining this medication was not simple. I had multiple breathing attacks during the day, I've had my left side go numb, and multiple physical symptoms due to severe anxiety. The stigma already surrounding mental health is a hindrance to individuals who seek care. Why make this more complicated thus increasing the likelihood of self medicating a mental issue? This issue would been seen heavier on other sides such as alcohol as patients self treat anxiety in ways not helpful. Stop hindering the accessibility to mental health, and medications used appropriately are far less likely to be abused, because when someone needs it, they don't feel it. I don't "feel" Xanax. I begin to have a normal heart rate and other symptoms gone. Yes counseling helped give me tools to help, but xanax is also a necessary tool. We deserve a quality of life. We did not choose this. ", "comment_id": "FDA-2018-P-0673-0010", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-0673-0010", "comment_date": "2018-08-14T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 966}]}, {"id": "FDA-2013-D-0045", "title": "Abuse-Deterrent Opioids Evaluation and Labeling", "context": "2019-04-19T10:56:45Z", "purpose": "Nonrulemaking", "keywords": ["cder", "CDER2012192", "draft guidance", "abuse-deterrent opioids", "evaluation and labeling", "opioid analgesic", "2014-643"], "comments": [{"text": "See attached file(s)", "comment_id": "FDA-2013-D-0045-0026", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2013-D-0045-0026", "comment_date": "2013-03-26T04:00:00Z", "comment_title": "CRI Lifetree - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "I am a legitimate pain patient NOT an addict. Ochronosis/Alkaptonuria is what I am suffering with-this disease is definitely in the intractable pain category! The irreparable injury being done to me is, in equity, "the type of harm which no monetary compensation can cure or put conditions back the way they were. What has been done to me is SHAMEFUL and I am going to find a lawyer so they can never do harm to disabled Americans again!! AM NOT SURE HOW MUCH LONGER I CAN GO ON LIKE THIS! For thirty-two years I only saw one doctor along with the surgeons he sent me to, in all that time ,I have tried and tried seeking a specialist for the genetic bone disease they diagnosed me with called Ochronosis/Alkaptonuria- a Rheumatologist who could also help me live with this disease. But, every doctor that my old doctor referred me to- rejected seeing me - saying they could not help, especially now, when they see my medical records and see there is no cure for this disease, that only treatment that is listed for my disease- is pain medication - they have expressed they do not want to risk their livelihoods by taking me on as a patient. THIS DISEASE IS INTRACTABLE PAIN, its turns my bones black, brittle and eats way all the cartilage and the disc between my bones -my body over-produces a homogentisic acid that literally nukes my vertebra and makes them inoperable black bones that look like a Mummies' bones , it causes the nerves down my arms to become paralyzed and eats away at the valves to my heart, attacks the kidneys etc etc etc, BUT beyond all that I was doing as well as a person could. I have to have a chore service person because I can not lift anything more than 10 pounds, and if I sleep wrong I wake wake not being able to use my arms - But I changed my diet I kept my body as strong as I can And most people would never know the pain I live with every day! The irreparable harm that has been done to me and STILL BEING DONE TO ME has NOW caused this disease to spread even further down my back and they only let me have half the medicine I was on, the pain of going without medication has done irreparable damage me!!ALL this is causing my nerves so much stress, that my disease gets worse and worse everyday. why is it they can not see a legitimate patient from a patient who just wants to abuse it. Don't my medical records mean anything?! PLEASE if you know of anyone who could or would help me - would you show them this letter - I do not want to die or end up committing suicide - like all those veterans shooting themselves in the head everyday from being denied their medicine! mahalo nui loa, Virginia Leigh
", "comment_id": "FDA-2013-D-0045-0038", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2013-D-0045-0038", "comment_date": "2019-04-19T04:00:00Z", "comment_title": "Comment from Virginia Brandford", "commenter_fname": null, "commenter_lname": null, "comment_length": 2659}, {"text": "FDA-2017-N-1094

Guidelines need to address legitimate prescription of opioids to people with chronic pain disorders. They SHOULD NOT be
penalized! Any one of us at any time can have an illness or injury that puts us in this situation!
It should not be made more difficult for anyone with legitimate reason to receive relief from pain to live a functioning life.

The whys of abuse/addiction need to be addressed for the remaining population before any cure can be realized and
administered. Lower socio-economic, ethnicity, race are factors for all drug and alcohol abuse.
The areas of the country where this is prevalent have seen extreme economic downturns in the last 8 years or more.

People are in despair!

We need MORE research on Marijuana and its chemical makeup as it shows promise to help chronic pain
without the THC high, we need STEM cell research to find a way to help cure people who have chronic pain.

We also need to be screaming to have our tax dollars go to support these efforts at both State and Federal levels

Rebuilding infrastructure that would create jobs for the ones lost due to factory closures etc.,
would infuse life back into these communities, people WANT to work and support themselves.

Health care needs to be available at a cost that is affordable! A sliding scale based on ability to pay!

Our country appears to be stifled in arguing over these important issues that will affect EVERYONE.

We need to remember you cannot teach a closed mind!

", "comment_id": "FDA-2013-D-0045-0037", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2013-D-0045-0037", "comment_date": "2017-05-10T04:00:00Z", "comment_title": "Comment from Debora Sator", "commenter_fname": null, "commenter_lname": null, "comment_length": 1595}, {"text": "I am a long time chronic pain patient and I am extremely concerned & afraid of what my future will be because of how the new prescribing laws & regulations have affected millions of chronic pain patients ability to get adequate care/medication treatment for their life altering pain conditions.
How in the world do you plan to win the "war on drugs" by eliminating access to medication for people with horrible, debilitating illnesses? Doctors no longer want to treat us because we are too hi "a risk" & it's much easier to be "pushed away" or just "not take the risk." Let's face it, Doctors have plenty of patients!
If opioid medications can include a deterrent to stop abuse and/or improper use, yet still be effective at controlling pain, I believe everyone would support that. But in the crusade to stop abuse, you have successfully removed or significantly reduced, millions of chronic pain patients access to *effective* pain medication dosages that actually have a positive impact on patients lives. Millions of chronic pain patients are on the opioid treatments we're on as a *last line of defense!* We've already had the treatment alternatives, the NSAIDS, the injections, the holistic & even the surgeries! Isn't that in fact the definition of chronic pain, pain that is ongoing, pain that persists in spite of treatment and there is no known cure ? While other treatment therapies may help & I encourage any treatments that are helpful, I know that MOST chronic pain patients would NOT BE ABLE to get themselves washed, dressed & driven to their "alternative treatment" appointments without the help of their opioid medication!
If you want to make opioid medications safer...do it, if you want to provide education to Doctors & Clinicians. ..do it, if you want to improve the "drug epidemic" provide quality, afforable help for those with abuse and addiction issues! However, limiting/removing patients access to opioid medications which is the only thing left for millions of people, that provide any true quality of life, many of whom otherwise, would in all probability contemplate suicide, is beyond my ability to understand!
My final comment, is that the approach to this so called "drug epidemic" will never be successful. The reason? The people whose lives this effects to their very core: It IS the people who suffer with daily, chronic pain issues BUT, WE have been COMPLETELY left out of all of these discussions, regulations, treatment protocols & the media! People who are legitimate chronic pain patients with life altering pain conditions, just want to have a life that's actually worth living! Believe it or not, that can mean having the ability to do the simplest things that are unattainable without the relief opioid medications provide ! Thank-you for allowing me to comment on this very important topic. ", "comment_id": "FDA-2013-D-0045-0035", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2013-D-0045-0035", "comment_date": "2016-07-27T04:00:00Z", "comment_title": "Comment from Denise S", "commenter_fname": null, "commenter_lname": null, "comment_length": 2999}, {"text": "See attached file(s)", "comment_id": "FDA-2013-D-0045-0014", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2013-D-0045-0014", "comment_date": "2013-03-22T04:00:00Z", "comment_title": "Generic Pharmaceutical Association GPhA - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "n/a", "comment_id": "FDA-2013-D-0045-0029", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2013-D-0045-0029", "comment_date": "2013-04-09T04:00:00Z", "comment_title": "Mallinckrodt Covidien - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 3}, {"text": "See attached file(s) - Inflexxion, Inc.", "comment_id": "FDA-2013-D-0045-0013", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2013-D-0045-0013", "comment_date": "2013-03-22T04:00:00Z", "comment_title": "Inflexxion, Inc. - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 39}, {"text": "See attached file(s)", "comment_id": "FDA-2013-D-0045-0019", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2013-D-0045-0019", "comment_date": "2013-03-26T04:00:00Z", "comment_title": "Teva Pharmaceuticals - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "FDA-2013-D-0045-0020", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2013-D-0045-0020", "comment_date": "2013-03-26T04:00:00Z", "comment_title": "Actavis, Inc. - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file.", "comment_id": "FDA-2013-D-0045-0012", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2013-D-0045-0012", "comment_date": "2013-03-22T04:00:00Z", "comment_title": "Richard J. Fanelli, PH.D. (Purdue Pharma L.P.) - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 18}]}, {"id": "FDA-2008-P-0366", "title": "Refrain from Filing & Approving Any 505(b)(2) Application for Remoxy or Any Other Extended Release Oxycodone Product That Does Not Contain Certifications to the Patents-CLOSED", "context": "2022-01-05T01:03:20Z", "purpose": "Nonrulemaking", "keywords": ["remoxy", "oxycontin", "505(b)(1)", "505(b)(2)", "oxycodone", "certifications", "CDER-CLOSED"], "comments": [{"text": null, "comment_id": "FDA-2008-P-0366-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2008-P-0366-0006", "comment_date": "2008-11-24T05:00:00Z", "comment_title": "King Pharmaceuticals, Inc. - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-2008-P-0366-0008", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2008-P-0366-0008", "comment_date": "2008-12-23T05:00:00Z", "comment_title": "Purdue Pharma L.P. - Reply Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}]}, {"id": "DEA-2018-0005", "title": "Controlled Substances Quotas", "context": "2021-12-02T01:00:45Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "See attached file(s)", "comment_id": "DEA-2018-0005-1427", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2018-0005-1427", "comment_date": "2018-05-04T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-08111", "commenter_fname": "Amie", "commenter_lname": "Knauer", "comment_length": 20}, {"text": "See attached comment letter from Senators Durbin (IL) and Kennedy (LA).", "comment_id": "DEA-2018-0005-1434", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2018-0005-1434", "comment_date": "2018-05-04T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-08111", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 71}, {"text": "On behalf of our nearly 38,000 members, the American College of Emergency Physicians (ACEP) appreciates the opportunity to comment on the proposed rule that seeks to strengthen the Drug Enforcement Administrations (DEA) control over diversion of controlled substances and makes other changes to how the DEA sets quotas for the production, manufacturing, and procurement of controlled substances. While ACEP supports the DEAs effort to make sure controlled substances are used only for their intended purposes, it is important to set appropriate production quotas of controlled substances to ensure that hospitals and emergency departments have enough drugs and treatments to care for the patients they serve. Please see attached for our comments. ", "comment_id": "DEA-2018-0005-1421", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2018-0005-1421", "comment_date": "2018-05-04T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-08111", "commenter_fname": "Jeffrey", "commenter_lname": "Davis", "comment_length": 748}, {"text": "See attached file(s) I am a chronic pain patient. As you can see from my photo..I have a lot of issues with just my neck. I have four spinal diseases and three are rare. Klippel-Feil Syndrome, Syringmyelia, Spina Bifida Occulta and Scoliosis, bulging disks and I have pain everyday. Serious pain! By changing the laws you are making it harder for people like me to live a semi normal life. You are taking away my rights to help my medical needs. You have never walked in a chronic pain sufferers day. You would not do this to an animal. It is punishing us for something we have no control over. Do you think we want to have chronic pain and take pain medication just so we can do everyday things like laundry or go to the grocery store? It is cruel and many will choose death over pain because they can not be a burden to their loved ones. There has to be another way. It is hard enough for me to find doctors that have knowledge of my diseases and I have to travel out of state to see the doctors I need, now I cannot get my pain medications. Please rethink this or make medical marijuana legal at the federal level so we can have some relief somehow.", "comment_id": "DEA-2018-0005-1168", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2018-0005-1168", "comment_date": "2018-05-03T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-08111", "commenter_fname": "Yvonne", "commenter_lname": "Anonymous", "comment_length": 1152}, {"text": "EDUCATION, NOT PROHIBITION!! I am one of those intractable (aka "high impact") pain patients. with severe and complex conditions who are only kept stable by high doses of opioids. Yet lately, because of the random musings of others who begin their diatribes against opioids, as a rule, saying, "I'm not a Dr. but...". Then off the non-doctors go on ignorant rants about numbers of pills rather knowing one thing about what those numbers of pills are quelling when used properly as ACTUAL doctors who HAVE studied pain know. By focusing on prescription opioids you are not stopping addicts deaths you are making legitimate pain patients collateral damage in a war that is fighting the wrong enemy.
Even the CDC has said as of May of 2017 that PRESCRIPTION OPIOIDS ARE NO LONGER CAUSING THE OVERDOSE DEATHS!! Please hear those of us who are not addicts but are medically using our prescribed opioids properly.

One of the things I KNOW is "right & true" is that doctors are not getting enough education (because no one is waiting for the NIH studies that ONLY started about 3-4 years ago) about pain as a disease rather than a symptom (as called for in the National Academies [formerly the Institute of Medicine] 2011 pain care study "Relieving Pain in America:" [link: http://bit.ly/2uA2WtY ]. Because of this failing, we have seen millions being incorrectly prescribed opioids (or not prescribed opioids when needed).
Opioids are a tool - that's it. Like guns, they can be used for good or bad. Which is why my motto is EDUCATION, NOT PROHIBITION.

As near as March 2017, Dr. Debra Houry of the CDC testified before the Energy and Commerce Committee, Oversight and Investigations Subcommittee stating this:
"Although prescription opioids were driving the increase in overdose deaths for many years, more recently, the large increase in overdose deaths has been due mainly to increases in heroin and synthetic opioid overdose deaths, not prescription opioids." article entitled "CDC: Painkillers No Longer Driving Opioid Epidemic" [link: http://bit.ly/2w8W9Gz]
Bottom line: If this trajectory of blindly stopping opioid PRESCRIPTIONS from getting to the people who - like me - have severe and complex health histories involving devastating chronic, intractable pain. YOU will be directly responsible for the heart attack and stroke deaths of millions of INNOCENT patients in America who did nothing wrong (who broke no laws, who were not addicts, who followed e-v-e-r-y rule).
You and your subordinates will be responsible for their slow and tortuous deaths due to the unnecessary and inhumane forced reduction of these pain patients opioid pain treatments. You can not assign arbitrary numbers pills or milligrams to individualized people with pain conditions anymore than every cookie-cutter treatment works for every diabetic. Or cancer patient. Or thyroid patient.

Please THINK before responding to trouble with a knee jerk response. Thank you.

", "comment_id": "DEA-2018-0005-0097", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2018-0005-0097", "comment_date": "2018-04-23T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-08111", "commenter_fname": "Radene", "commenter_lname": "Cook", "comment_length": 3085}, {"text": "Hello,

I am attaching comments already made by Dr. Richard Lawhern, PhD urging the DEA to stand down on further restrictions on the production of opioid pain medications. I am writing as both an emergency preparedness professional and a chronic pain patient who is able to enjoy a reasonable quality of life because of stable doses of this type of medication.

Dr. Lawhern's comments make the case much better than I. However, I want to specifically ask the DEA several questions:

1. What data is being used to justify further restrictions?
2. What is the analytical methodology?
3. Who performed the analysis to justify further restrictions?
4. What are their qualifications?

I am also attaching a study I completed on the number of prescriptions issued in Louisiana in 2015. The annual number of prescriptions is often presented as a "shocking" statistic by Louisiana government officials to justify further opioid prescription limits. Simply stated, this view is patently indefensible. My simple model has been reviewed as valid by a number of pain management professionals and medical school faculty.

Bottom line: The DEA has already caused critical shortages of injectable opioids used in hospitals for pain management before and after surgery. Beyond the suffering caused to patients, it has directly contributed to patient deaths due to compounding errors by hospitals attempting to cobble together these important drug regimens. If that was the goal of the DEA restriction - good job.

I am also attaching an article by Jeffrey Singer that debunks the basis of the DEA proposal. You are chasing the wrong problem. Perhaps I would suggest that the DEA focus on their intended mission - stopping illegal drugs. Stand down from torturing chronic pain patients, hospital patients, hospice patients, cancer patients, trauma victims, mothers, and other that absolutely need these medications.

Thank you for the opportunity to comment.

Henry Yennie
312 Lovers Lane
Baton Rouge, LA 70806", "comment_id": "DEA-2018-0005-0134", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2018-0005-0134", "comment_date": "2018-04-23T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-08111", "commenter_fname": "Henry", "commenter_lname": "Yennie", "comment_length": 2093}, {"text": "See attached file(s)
I am writing as a citizen who is outraged by the unnecessary suffering of patients with intractable pain being caused by misguided DEA regulations. The people suffering include veterans, the elderly and productive, law-abiding citizens. Legally prescribed and obtained opioid medications allow intractable pain patients to live productive lives. Further restricting of the supply of these life-saving medications violates the basic human right to not suffer.

Imposing quotas on controlled substances will do nothing to reduce overdose deaths. CDC statistics are flawed at best and do not illustrate that the root cause of overdose deaths is illicit opioids. The DEA and CDC would best serve the citizens of the United States by applying basic root cause analysis and scientific methods to improving the situation. The blanket application of unjust regulations and guidelines causes hundreds-of-thousands of rule following pain patients to suffer for the poor and illegal behavior of others. Statistics clearly show that while the quantity of legally prescribed opioids has declined steadily since 2012, overdose deaths have increased significantly. Obviously, the DEA needs to focus on illicit opioids if they truly want to reverse this trend.

It is obvious that special interests are driving the actions of the DEA. I implore you to cease the war on those suffering intractable pain and their compassionate caregivers. Return to your charter and enforce federal law in the best interest of the People.", "comment_id": "DEA-2018-0005-0167", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2018-0005-0167", "comment_date": "2018-04-23T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-08111", "commenter_fname": "Lawrence", "commenter_lname": "Favero", "comment_length": 1555}, {"text": "Ive been on pain meds for 7 years..as a LAST resort...ive done EVERYTHING recommened by my dr.s and specialists...ive had 4 major spine surgeries...including a total neck replaced...i was in a headon car crash with a big truck..i was in a small car..toyota...no seatbelt..when i was 18...1983...ive NEVER taken pain meds and went to chiropractors 2..3..'s a week...and worked 25 years....in 2004 i fell sideways off a high curb carrying my autistic st son...breaking my back...i had lumbat surgery...and discontinued opioid pain meds...i continued chiropractic care for my neck..
My lumbar surgery totally failed and desperately needed another one...Which i had...a year later...2011...every disc in my neck came out...3 went into spinal cord 3mm...after i bumped my forehead.....an emergency total neck replacement done...i developed tumors/cysts on my sp.cord..and all over my spine in neck..thoracic..lumbar...my discs have deteriorated...bone spurs develpoed....excess swelling in spine...I discovered that BPM...by MEDTRONICS was used in my lumbar...my 1st surgery...which is poison in my spine...highly toxic....i have severe nerve..muscle damage...sevete stenosis..cysts on cord...whole spine arthiritic..fusing together....i am in so much pain....i dont want to live....i was tapered off meds..due to epidemic...This is not right...my doctor had tears in her eyes when she told me that everyone is being tapered off pain meds...by 2018...and ive tried Tramadol....it did NOT help....but hurt my kidneys...i take 20 to 30 ibeprofens a day..plus otc tylenol....i will die soon.....from either lidney failure or heartattack...as my pain is so bad..my BP is extremely high....ive raised 4 children...2 were my step sons...they both have autism..whom had to be placed in foster homes now...because of this...Please listen to us...
Ive heard so many mothers whom lost their teens to prescription drugs...including a cousin of mine...where the teen will become addicted from an injury...or take them right from the cupboard at home...etc...HOW COME THESE PARENTS ARE NOT BEING CHARGED?...EVERY BOTTLE OF OPIOIDS SAY TO "LOCK UP" YOUR MEDS!!!!....etc....why do we..us chronic sufferers...have to pay for it now???....PLEASE LISTEN TO US CHRONIC PAIN SUFFERES....WE JUST WANT TO LIVE...AND NOT SUFFER...WE ARE RESPONSIBLE...AND NOT ADDICTS...Doctors just NEED to be trained better on reading mri s...xrays...medical reports...and trained on how to determine if the patient is in chronic pain.....instead of cutting us all off....i really do not know how much longer i can live like this...ive enclosed a photo of my neck replaced...which is extremely misaligned...causing severe NERVE damage...pain...and a pic.of me..bedridden..swollen neck...with cysts...or tumors...i was taken off my opioid pain meds in this condition...because of this epidemic....its inhumane...abuse...", "comment_id": "DEA-2018-0005-0577", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2018-0005-0577", "comment_date": "2018-04-26T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-08111", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 2897}, {"text": "See attached file(s)
", "comment_id": "DEA-2018-0005-0545", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2018-0005-0545", "comment_date": "2018-04-26T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-08111", "commenter_fname": "Lee", "commenter_lname": "Schlesinger", "comment_length": 25}, {"text": "DEA has no reliable way to determine whether or how much any controlled substance is diverted to non-medical use.
Hospitals are experiencing shortages of scheduled drugs and patients are being endangered because of past unjustified restrictions on production. The DEA is at fault. Restrictions on medical supply are ineffective and unjustified.
Actively managed pain patients are almost never involved in opioid overdose-related deaths, and in the few cases where they are, it id plausibly as a consequence of under-treatment of pain and depression, forcing the patient to seek relief in street markets. DEA has already damaged countless lives by creating a hostile regulatory environment, driving doctors out of pain practice and forcing the discharge or coerced tapering of patients in agony.
Withdraw DEA proposed rule making. It is counter-productive and inhumane.", "comment_id": "DEA-2018-0005-0645", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2018-0005-0645", "comment_date": "2018-04-27T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-08111", "commenter_fname": "Mona", "commenter_lname": "Twocats-Romero", "comment_length": 883}]}, {"id": "FDA-2017-P-6918", "title": "Requests that the FDA amend the FDA contraindication of codeine in children younger than 12 years old.; CLOSED", "context": "2023-08-14T08:50:58Z", "purpose": "Nonrulemaking", "keywords": ["CItizen Petition", "CDER", "St. Jude Children\u2019s Research Hospital", "amend the FDA contraindication of", "codeine in children younger than 12 years old", "CLOSED"], "comments": [{"text": "How is this possible? Why would the FDA deny cough medicine to children? They are very ill, some terminal. This is ludicrous! Codeine has been around for approximately 80 years. Are you going after the sick, disabled children now? Do you realize how this makes you look? You appear to be monsters! Monsters of the type I have never encountered in my 60 years on this planet. CHILDREN!!!", "comment_id": "FDA-2017-P-6918-0020", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-6918-0020", "comment_date": "2018-07-09T04:00:00Z", "comment_title": "Comment from Dee Eeeenst", "commenter_fname": null, "commenter_lname": null, "comment_length": 386}, {"text": "This petition is well thought out and expressed. Please note that the persons signing this, for the most part, are not affiliated with a pharmaceutical company, thereby avoiding conflicts of interest.

The goal is simple: to allow physicians to prescribe codeine to pediatric patients under certain conditions.

Please consider these two points when evaluating this petition.", "comment_id": "FDA-2017-P-6918-0019", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-6918-0019", "comment_date": "2018-07-09T04:00:00Z", "comment_title": "Comment from DeeAnn Visk", "commenter_fname": null, "commenter_lname": null, "comment_length": 393}, {"text": "When used in the correct patient populations, codeine with acetaminophen is a highly effective scheduled 3 agent. It would be a serious detriment to lose this drug in our arsenal when treating sickle cell patients. ", "comment_id": "FDA-2017-P-6918-0018", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-6918-0018", "comment_date": "2018-07-09T04:00:00Z", "comment_title": "Comment from Melinda Tran", "commenter_fname": null, "commenter_lname": null, "comment_length": 216}, {"text": "I support this citizen petition.", "comment_id": "FDA-2017-P-6918-0017", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-6918-0017", "comment_date": "2018-07-09T04:00:00Z", "comment_title": "Comment from Vicky Pratt", "commenter_fname": null, "commenter_lname": null, "comment_length": 32}, {"text": "Why are the children being forced to suffer, it's bad enough the government has tortured millions with the CDC" GUIDELINES". Why do these precious children have to suffer more. I beg you please change the way pain Is Treated today and let these children have some relief. I've lost all hope in humanity now I beg you change these awful rules.it's the only way and the right thing to do. TY for your time", "comment_id": "FDA-2017-P-6918-0021", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-6918-0021", "comment_date": "2018-07-09T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 428}]}, {"id": "DOD-2015-HA-0109", "title": "TRICARE; Mental Health and Substance Use Disorder Treatment", "context": "2020-10-22T01:30:50Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "The accreditation body, CARF is a great partner to the DoD goal of increasing its veterans Behavioral Health benefits, and the Proposed Rule, entitled TRICARE: Mental Health and Substance Abuse Disorder Treatment.
CARF has excellent standards that guides its accredited groups to deliver the highest level of services to all.

I am encouraging the DoD to approve CARF as an accreditor under TRICARE regulations because many groups like MedMark ay be eligible to become part of its network. We see that we may be of service to the area' veterans. We currently serve a handful of veterans that are able to afford paying for this service. Many other veterans will benefits from our service if DoD will approve CARF as an accreditor.

thank you for your efforts!", "comment_id": "DOD-2015-HA-0109-0016", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2015-HA-0109-0016", "comment_date": "2016-02-17T05:00:00Z", "comment_title": "Comment on DOD-2015-HA-0109-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 785}, {"text": "People experiencing substance use disorders are often stigmatized and are less likely to seek assistance without an external motivating factor. This is especially true for our military members and their families, as they are limited to seek services from their virtual employers through the VA system. The proposed changes will benefit our veterans by allowing them greater freedom to seek services at an earlier stage in the addiction process. By offering a variety of treatment programs and modalities, the VA will shift from force fitting an individual into the program available and start matching individuals to programs based on individual needs, strengths, abilities, and interests.

The proposed changes will also have a positive impact on community based providers and enhance local economies by streamlining the requirements for community based institutions to become participating providers. ", "comment_id": "DOD-2015-HA-0109-0025", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2015-HA-0109-0025", "comment_date": "2016-02-17T05:00:00Z", "comment_title": "Comment on DOD-2015-HA-0109-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 915}, {"text": "CARF is the best possible accreditation agency to credential providers to work with TRICARE. We are CARF accredited and am very happy with the quality of the review they provide. I have total confidence in CARF.", "comment_id": "DOD-2015-HA-0109-0032", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2015-HA-0109-0032", "comment_date": "2016-02-17T05:00:00Z", "comment_title": "Comment on DOD-2015-HA-0109-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 213}, {"text": "We at Midwestern Connecticut Council of Alcoholism are responding in support of this Proposed Rule, and the expansion of services for TRICARE beneficiaries. The reduction of barriers to funding of services will expand options and access for veterans and their families needing treatment for mental health and substance use disorder. If aligned with MHPAEA and ACA parity regulations, this a great step forward for this population.

Midwestern Connecticut Council of Alcoholism have received numerous calls from men and women either active in the service or retired that have Tricare as their insurance and are very willing to provide mental health, alcohol and substance abuse treatment to them as well as their family members. We at Midwestern Connecticut would appreciate the opportunity to join the Tricare network of providers and serve the needs of the Tricare members and their families in our community and surrounding areas.

As a CARF accredited facility we additionally support the expansion of accreditation options to meet the accreditation mandate of the Proposed Rule for network providers, and particularly support the approval of CARF International.
", "comment_id": "DOD-2015-HA-0109-0048", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2015-HA-0109-0048", "comment_date": "2016-02-22T05:00:00Z", "comment_title": "Comment on DOD-2015-HA-0109-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 1189}, {"text": "Dear Mr. Levine,

We at Family Service of Rhode Island, accredited by the Council on Accreditation (COA), support the Defense Department's proposed rule, Tricare: Mental Health and Substance Use Disorder Treatment. The expansion of mental health and substance use disorder (SUD) services to more service members and their families is extremely important in helping our organization meet their needs.

Furthermore, we support the acknowledgement of the need for recognition of additional accreditation bodies. While Tricare's comprehensive certification standards were once considered necessary to ensure quality and safety, these comprehensive certification requirements are now proving to be overly restrictive and, at times, inconsistent with current industry-based institutional provider standards. There are currently several geographic areas that are inadequately served because providers in those regions do not meet Tricare certification requirements, even though they may meet the industry standard. The proposed rule seeks to streamline Tricare regulations to be consistent with industry standards for authorization of qualified institutional providers of mental health and SUD treatment. We fully support this change as it will result in an increase in the number of providers and in the geographic areas covered by services.

Reducing administrative barriers and aligning the services and supports with those of other medical/healthcare benefits is the right thing to do for military members and their families.

Sincerely,

Margaret Holland McDuff, CEO
", "comment_id": "DOD-2015-HA-0109-0131", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2015-HA-0109-0131", "comment_date": "2016-03-30T04:00:00Z", "comment_title": "Comment on DOD-2015-HA-0109-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 1621}, {"text": "As a person living with a mental health condition as well as having family members who have served in the military, I want to send my support for these efforts by the DOD to update Tricare to ensure there is parity between physical and mental health / substance use disorders. Removing the barriers and stigma that get in the way of individuals having access to care is a critical step to take.

It is important that ALL Americans, but particularly those who have served our country, have access to the care they need in order to live well.

", "comment_id": "DOD-2015-HA-0109-0179", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2015-HA-0109-0179", "comment_date": "2016-04-06T04:00:00Z", "comment_title": "Comment on DOD-2015-HA-0109-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 560}, {"text": "The proposed rule does not allow for intensive outpatient treatment or partial hospitalization programs for TRICARE beneficiaries who are younger than 13 years of age. My son was five when he first started to see and hear things. By ten he was suicidal. At 14 he made a real attempt, and at 15 he is in his third partial hospitalization. The majority of kids he is in treatment with are half his age. It's these "under 13" kids who without treatment will end up in Judi or worse yet in a pine box. There's no age people "catch" mental illness and there is no cure. It manifests when it wants and therapy is often a parents only hope. It's already hrs enough to get treatment let's not limiti it by some arbitrary age. ", "comment_id": "DOD-2015-HA-0109-0139", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2015-HA-0109-0139", "comment_date": "2016-03-31T04:00:00Z", "comment_title": "Comment on DOD-2015-HA-0109-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 754}, {"text": "See attached file(s)", "comment_id": "DOD-2015-HA-0109-0146", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2015-HA-0109-0146", "comment_date": "2016-04-04T04:00:00Z", "comment_title": "Comment on DOD-2015-HA-0109-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "DOD-2015-HA-0109-0159", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2015-HA-0109-0159", "comment_date": "2016-04-04T04:00:00Z", "comment_title": "Comment on DOD-2015-HA-0109-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "DOD-2015-HA-0109-0163", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2015-HA-0109-0163", "comment_date": "2016-04-04T04:00:00Z", "comment_title": "Comment on DOD-2015-HA-0109-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}]}, {"id": "FDA-2011-P-0869", "title": "Refuse to File Any New Drug Application (NDA) for Buprenorphine/naloxone Drug Product Unless Such NDA References Suboxone\u00ae, the Sublingual Film Formulation of This Product-CLOSED", "context": "2013-11-22T13:02:08Z", "purpose": "Nonrulemaking", "keywords": ["Film Formulation ", "Sublingual Film Formulation", "Suboxone\u00ae", "NDA ", "Buprenorphine/naloxone ", "Refuse to File ", "cder", "closed"], "comments": [{"text": "na", "comment_id": "FDA-2011-P-0869-0007", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-P-0869-0007", "comment_date": "2013-11-22T05:00:00Z", "comment_title": "BioDelivery Sciences International, Inc. (Foley & Lardner LLP) - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 2}, {"text": "N/A", "comment_id": "FDA-2011-P-0869-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-P-0869-0003", "comment_date": "2012-05-25T04:00:00Z", "comment_title": "BioDelivery Sciences International, Inc. (Foley & Lardner LLP) - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 3}]}, {"id": "FDA-2012-P-0818", "title": "Regulate Labeling of Opioid Analgesics - CLOSED", "context": "2016-08-31T11:20:37Z", "purpose": "Nonrulemaking", "keywords": ["cder", "closed"], "comments": [{"text": "na", "comment_id": "FDA-2012-P-0818-0789", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0818-0789", "comment_date": "2013-07-29T04:00:00Z", "comment_title": "Denis Murphy - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 2}, {"text": "With all of the news hype about the number of overdose deaths, which as a researcher I have evaluated by actually reading the documents cited rather than merely accepting a citation as supporting a contention, the lost truth is the never decreasing number of people in chronic pain whose suffering underpins this ongoing and not particularly scientific debate. That some patients develop hyperalgesia does not speak to the multitudes who do not. That some people misuse and abuse opioid and other medications does not address the multitude who do not. Lost in this controversy of vested interests and fear, of prosecution or ignorance or regulatory overload, are the multiple thousands of people who benefit from chronic opioid therapy, and beyond benefiting are able to live functional and productive lives. This proposal ignores the reality that different people have profoundly different tolerances to medications. Pain, in its daily reality is vastly different than it is in theory to some faceless person miles if not thousands of miles away. It is not an imagined event but, rather, a neurobiological cascade with damaging long term consequences which are as dangerous as this now uncontrolled fear of overdose so reminiscent of the fears of Prohibition and the ever escalating war on drugs which we have long since lost. Quite frankly, it fits well with "managed care" with guidelines determined by non-healthcare professionals. However, that is not medicine. It is time to return some autonomy to the doctors who have spent the necessary years in learning to treat suffering, as well it is time to stop reacting and start thinking. It is time to stop twisting statistics to meet the needs of biased arguments and instead start being honest about what is the underlying problem. Surely, there are very few doctors truly acting as the diversion to the streets that everyone from law enforcement to professional licensing boards claims exist. This is too important for the game of act-react.", "comment_id": "FDA-2012-P-0818-0784", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0818-0784", "comment_date": "2013-05-08T04:00:00Z", "comment_title": "Robin G. Dvorkin - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 2010}, {"text": "See attached file(s)", "comment_id": "FDA-2012-P-0818-0187", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0818-0187", "comment_date": "2012-08-20T04:00:00Z", "comment_title": "American Pain Society - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "I emphatically support PROP’s petition. Opioid label changes are needed so that FDA can prevent drug companies from making false claims that opioids are proven safe and effective for chronic, non-malignant pain. Label changes will also reduce overprescribing by sending a clear message to the medical community that benefits may not outweigh risks when opioids are prescribed long-term and in high doses.
As an emergency physician, I feel the medical community has been falsely informed for the last 2 decades. We have created a "culture of pain and disability" prompted by the drug makers and by pain societies. Because of this we are in the midst of an epidemic of opioid dependency which is leading to alarming numbers of deaths and social disruption. Please change the labeling so we can reverse this most disturbing trend. We owe it to our patients and their families.

Gratefully,
Aaron Wohl, MD
Practicing Emergency Physician
Lee Memorial Health System
Fort Myers, FL", "comment_id": "FDA-2012-P-0818-0774", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0818-0774", "comment_date": "2013-04-10T04:00:00Z", "comment_title": "Aaron Anthony Wohl, MD - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1024}, {"text": "I DO NOT support the PROP petition. I have worked as a nurse practitioner in pain management for almost 15 years. I have seen countness patients improve their quality of life with the multidisciplinary treatment options we offer. I have also seen countless patients continue to work that would have ended up on disability. Pain medications are not evil. The evil is the greed of some physicians who see pain management as a profit making business. Physicians who do not have training in pain management (GYN MDs, general surgeons, etc) who have no business doing pain management just like the physicians I work (board certified in anesthesia and pain mgmt) for have no business doing brain surgery. Pain medications are beneficial when done correctly with the right screening, the right degree of monitoring and the right degree of follow-up. Some of these practices are just pill mills and have not real f/u or assessment of risk to prescribe meds. And not every patient is addicted, which is the position addictionologists take with this issue. They have always thought pain meds were evil and shouldn't be used but they see the negative part of opiate abuse and not the positive benefits that it offers. Saying opiates can only be used for 90 days is going to hurt many innocent patients who a benefitting from pain management. The answer is not stopping prescribing but allowing only trained pain management physicians to practice this specialty--not anyone who wants to say they are pain management and to only allow physician owners of pain management practices to ensure that they are not just for profit centers. Taking away a viable treatment option for legitimate patients is cruel. How will these people feel if they need chronic pain management for a legitimate diagnosis in the future and they are limited to 90 days worth of medications. This is a "cutting off the nose to spit the face" reaction to this public health problem.", "comment_id": "FDA-2012-P-0818-0759", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0818-0759", "comment_date": "2013-02-27T05:00:00Z", "comment_title": "Susan E. Daffron - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1955}, {"text": "Given the huge number of addicts who innocently just wanted to be rid of physical pain, intelligent, professionals including medical professionals, something has to be done. I believe the changes in prescribing suggested will help. Ultimately, the docs and nurses need to be much more aware of the long term ramifications to their patients as they write the prescriptions and give appropriate guidance as as the hand over that piece of paper.", "comment_id": "FDA-2012-P-0818-0715", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0818-0715", "comment_date": "2013-02-20T05:00:00Z", "comment_title": "Suzanne Kellner-Zinck - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 442}, {"text": "I completely support PROP's petition. Over prescribing is a major problem in our area and done by good doctors who are not given full information by the drug companies.

I am a pain physician and now spend most of my time trying to get patients off of narcotics prescribed by well meaning physicians. Re labeling is the minimum we can do.

John Hart, DO ", "comment_id": "FDA-2012-P-0818-0758", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0818-0758", "comment_date": "2013-02-27T05:00:00Z", "comment_title": "John Hart - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 376}, {"text": "I am a Nurse, Hospital Administrator of over 26 years in the military where I served as an Auditor making sure medical contracts from medical supplies, Doctor care, prescriptions, medications and Manufacture contracts were in compliance with JACHO and the terms of the contract and laws were upheld.

In my limited duty, I found over six million dollars in error in contracts, Nursing contracts, and medication charges from manufacture.

NOW why does this petition effect me ? I am disabled by a severe disease requiring a three level spinal fusion (taking three discs out of my vertabrae replacing with BAK cages) and I have two rods and seven long screws sticking me.

An approved procedure, Spinal Injections which the FDA does not approve for spinal injection was used on me over twenty times along with eight myelograms and I acquired arachnoiditits from the multiple procedures with an unapproved medication in the epidural spaces. Recently this medication was shown to get fungi, and I was told that I had to have those injections first before I could be on medication management !!! I am sorry for the loss of lives of overdoses but these people should have intervention no Physicians.
Some of the staff of this petition knew their family was mentally sick, being a physician she could have him commited, not blame opoid dosing. So DO I SUFFER with decreased dosage
to account for the deaths of people who knew better and will get it somewhere and kill themselves. There are warnings on the medication inserts. Realize that you are taking pain relief away from Millions to pacify your inadequecy to have programs to assist addicts. Free Pot laws, Death laws for people to kill themselves while you are supposedly wanting responsible opoid dosages (less than manufacturerdoses/PDR dosages) does not make sense. So the uncontrolled pain patients come to Oregon and Washington State and ask for assisted suicide, Nice Policy-You are a death sentence for me.", "comment_id": "FDA-2012-P-0818-0771", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0818-0771", "comment_date": "2013-02-27T05:00:00Z", "comment_title": "Bennie L. Jones - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1995}, {"text": "I am deeply concerned about changing the wording of this document to delete the word moderate and add caps nto the amount of medication a patient may have and the amount of time they may take a medication. A person is the best judge of their pain and they have the right to excellent treatment. We should not deny them treatment because their pain is moderate. It is already difficult enough for the to procure their medication without making it more difficult.
I urge you not to change this rule.
Thank you for your time. ", "comment_id": "FDA-2012-P-0818-0775", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0818-0775", "comment_date": "2013-04-10T04:00:00Z", "comment_title": "Hallie Susan Greenberg - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 534}, {"text": "I am against this change for these reasons:
1. Not everyone can take the same dose, our bodies are not all the same.
2. Chronic Intractable pain never goes away, we live with it for life.
3. Addiction and dependency are two different things, we are not drug addicts, we have no quality of life without the medication.
4. Without medication, most of us can no longer work or take care of our families, we are confined to beds or chairs, unable to have quality life.
5. It is a provable fact that untreated or under treated chronic intractable pain patients often end up divorced, unable to work, have trouble interacting with their children and do commit suicide.
6. To see what a person can accomplish with the right medications, please read this: http://www.foresttennant.com/pdfs/905-Feature-JFK-Tennant.pdf
7. Most patients who take opioids only take them because other medication does NOT work for them.
8. How can physicians decide what is right for a patient when they have never seen or treated them?
9. Do you consider it to be humane to let people suffer in terrible pain because some can not follow directions or blame innocents for their family member taking medication illegally?
10. Do we blame a gun when someone uses it to kill someone?
11. Do we blame the car when the driver is drunk and kills a family while driving that car?
12. There are "NO" new studies on this matter, Physicians for Responsible Opioid Prescribing are using data that is old and incomplete. They are not concerned about chronic intractable pain patients, their spokesman has publicly said we are not important.
13. I agree with PROMPT (Professionals for Rational Opioid Monitoring & Pharmaco Therapy) You received a petition from them on this matter as well.
14. Chronic intractable pain is not a picnic to live with, in many ways it is like a baby, you have to live your life around it. Some days we can't even get out of bed because the pain is so bad, others we are moving around barely. ", "comment_id": "FDA-2012-P-0818-0697", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0818-0697", "comment_date": "2013-02-20T05:00:00Z", "comment_title": "Anonymous - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 2070}]}, {"id": "DEA-2020-0007", "title": "Registration and Reregistration Fees: Controlled Substance and List I Chemical Registrants", "context": "2021-12-02T01:00:58Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "My pharmaceutical company has ended contracts with the Department of the Treasury Internal Affairs Revenue Division. IRS", "comment_id": "DEA-2020-0007-0009", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0007-0009", "comment_date": "2020-05-13T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-05159", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 120}, {"text": "With President Trump it always comes down to numbers. Polls! Electoral college votes! Inauguration crowds! Stock market highs! Unemployment rates!

Due to the Covid-19 pandemic this has become more challenging. But Trump has continued looking for a number he could brag about. First he bragged about America's low number of cases... which is now the highest in the world, in fact higher than the next six countries combined. Then he boasted about our relatively low "mortality rate." Not only is this a bizarre statistic to crow over, the US now has more deaths than the next two countries (soon to be three) - and one of the worst deaths per population ratio on the planet. Lately Trump has bragged about how many tests we've conducted. Brilliant. It's like saying "After the horse left the barn we installed the world's best padlock."

Since all of these numbers have exploded in Trump's fat face, he's shifted to attacking the numbers. Maybe we're over counting Covid-19 deaths, while other countries are under counting. Maybe we're doing too many tests. Maybe the worst case scenario was too low, so Trump should be given credit for saving millions of lives rather than causing over 87,000 deaths. Maybe the bad numbers are all Obama's fault.

There is one number that says it all: 45. That's the number of the Worst. President. Ever.", "comment_id": "DEA-2020-0007-0013", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0007-0013", "comment_date": "2020-05-15T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-05159", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 1422}, {"text": "See attachment", "comment_id": "DEA-2020-0007-0014", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0007-0014", "comment_date": "2020-05-15T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-05159", "commenter_fname": "James", "commenter_lname": "Madara", "comment_length": 14}, {"text": "DEA 501 A", "comment_id": "DEA-2020-0007-0004", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0007-0004", "comment_date": "2020-03-17T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-05159", "commenter_fname": "Mendy", "commenter_lname": "West", "comment_length": 9}, {"text": "RIN 1117-AB51/Docket No. DEA-501

MGP Response to DEA Proposed Registration Fees Increase 05-07-2020

Morton Grove Pharmaceuticals, Inc. (MGP) is a small pharmaceutical manufacturer bordering the northwest side of Chicago that employs 177 people. In addition to our manufacturer registration, MGP has the following registrations:

Analytical Lab
Importer
Exporter
List I Chemical Importer

MGP has a commitment to a vibrant DEA compliance program ensuring all MGP registrations adhere to the laws/regulations of the Controlled Substances Act (CSA). MGP Standard Operating Procedures (SOPs) for DEA compliance are the cornerstone of that commitment, and we continually enhance those SOPs. As a registrant who takes controlled substance compliance very seriously, MGP appreciates this opportunity to express concerns over the proposed increase in registrations fees published on March 16, 2020 in the Federal Register.

The publishing in the Federal Register of a proposed fee increase in the midst of a worldwide Covid-19 Pandemic seriously affecting both public health/safety and the economy was poorly timed. Proposing increased registration fees, especially to small businesses like MGP, during an unprecedented worldwide health pandemic with looming economic uncertainties is not wise in these circumstances. We recommend tabling these proposed fee increases and the comment period until January 2021 at the earliest.

In the interim, MGP proposes two alternative avenues for assessing registration fees: assessing fees based on the size of the business or having registrants with a significant history of CSA violations pay much higher registration fees. Both proposals are discussed in more detail below.

In the first proposal, registration fees would be assessed based on the size of the business (number of employees, annual earnings, etc.) for Type B registrants. As a manufacturer, MGP competes with much larger corporate entities that have multiple facilities and more employees. The proposed annual fee increases for MGP in the following categories amount to substantial increases for a small business:

Manufacturer $3,699.00 from $3,047.00 *$652.00 increase
Analytical Lab $296.00 from $244.00*$52.00 increase
Importer $1,850.00 from $1,523.00*$327.00 increase
Exporter $1,850.00 from $1,523.00*$327.00 increase
List I Importer $1,850.00 from $1,523.00 *$327.00 increase

MGP would pay an extra $1,685.00 annually. Small businesses have to forecast sales revenue and subsequently plan operating costs in advance of their fiscal year. While MGP can modify its operating budget for the increased registration fees, it places a financial burden on a small employer serving an important function manufacturing oral liquid and topical pharmaceutical products.

The second pathway proposed having registrants with a significant history of CSA violations pay dramatically increased registration fees is a viable option worth exploring. Our nation has struggled with an ongoing opioid epidemic for over a decade resulting in thousands of lives lost, many people suffering from their addiction to opiates, heavy burdens on the nation's healthcare system, and significant financial costs to state, county and local governments. It is well documented that specific manufacturers and wholesale distributors contributed to this epidemic by turning a blind eye to CSA laws/regulations allured by sales of opioid medications and profits over their responsibilities as DEA registrants. DEA registrations are issued with the understanding that any registrant must act responsibly with controlled substances. Thus, these registrants could be assessed the significantly higher registration fees. This format rewards compliance for both large scale business model registrants and small business registrants like MGP.

In conclusion, MGP asks that the DEA table the proposed increase in registration fees and its comment period until January 2021 as our nation's priority now is to focus numerous resources on public health/safety measures to fight the Covid-19 Pandemic. At that time, MGP would welcome discussion on the two alternative avenues for assessing registration fees: assessing fees based on the size of the business for Type B registrants and/or having registrants with a significant history of CSA violations pay much higher registration fees.
", "comment_id": "DEA-2020-0007-0007", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0007-0007", "comment_date": "2020-05-11T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-05159", "commenter_fname": "Tim", "commenter_lname": "Lenzi", "comment_length": 5511}, {"text": "See attached.

", "comment_id": "DEA-2020-0007-0008", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0007-0008", "comment_date": "2020-05-11T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-05159", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 23}, {"text": "Please find attached the comments of the National Association of Chemical Distributors.", "comment_id": "DEA-2020-0007-0012", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0007-0012", "comment_date": "2020-05-15T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-05159", "commenter_fname": "Allison", "commenter_lname": "Tuszynski", "comment_length": 87}, {"text": "On behalf of the Healthcare Distribution Alliance, please find attached comments on the proposed rule "Registration and Reregistration Fees: Controlled Substance and List I Chemical Registrants." ", "comment_id": "DEA-2020-0007-0011", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0007-0011", "comment_date": "2020-05-15T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-05159", "commenter_fname": "Anita", "commenter_lname": "Ducca", "comment_length": 206}, {"text": "I am writing against the increased fees. I think the Agency needs to show where and how the money is going in some sort of spreadsheet or that some sort of OIG audit should be done on the DEA fee account, because some of the numbers that are cited in the NPRM seem a bit fishy.

Hiring more people does not seem to be the answer. Enforcement clearly isn't working on the opioid epidemic; policy doesn't seem to be working either, because DEA has made very few of the deadlines Congress set for them, or because they have certain documents floating in the ether that the public needs answers to. The Agency seems to be very reactive instead of proactive, and the agency seems to think that by giving it more money to hire these additional people to carry out these "essential" functions the opioid epidemic will be magically solved.", "comment_id": "DEA-2020-0007-0006", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0007-0006", "comment_date": "2020-04-13T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-05159", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 857}, {"text": "DEA 501 A", "comment_id": "DEA-2020-0007-0002", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0007-0002", "comment_date": "2020-03-17T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-05159", "commenter_fname": "Mendy", "commenter_lname": "West", "comment_length": 9}]}, {"id": "FDA-2019-D-1536", "title": "Opioid Analgesic Drugs: Considerations for Benefit-Risk Assessment Framework; Draft Guidance for Industry; Availability ", "context": "2020-02-26T15:13:28Z", "purpose": "Nonrulemaking", "keywords": ["2018-551", "CDER", "Guidance for Industry", "Opioid Analgesic Drugs", "Considerations for", "Benefit-Risk Assessment Framework", "Open"], "comments": [{"text": "Hello,

I am another chronic pain patient who is paying the price for people who recreationally use opioids and become addicted. By now you know it is not those of us who are prescribed pain medicine and take it as directed by our physicians who become addicted. There is a very small chance of that, and it is not that the opioid is addictive, it is the person's genetics and social, economic, and personal history factors that determine this. This is why denying pain medicine for the population in general does not defeat addiction. The addict will find a replacement drug on the black market, meanwhile law abiding citizens are left to suffer.

What I am asking the FDA to do, please emphasize that opioids are essential medicines, that the benefits outweigh the risks for most patients. The so called opioid epidemic has spread the false narrative that opioids only have risks but no benefits, this needs to be made clear that this is an overdose epidemic involving illicit substances, and polypharmacy. It is reckless use of taking opioids with alcohol, sedatives, cocaine, and multiple other substances that are killing people. Responsible people are paying the price for the recklessness of others. Opioids are valuable, and desperately needed, extremely beneficial medications for the majority of citizens. Again, please emphasize this!

Sincerely, Donna Johnson", "comment_id": "FDA-2019-D-1536-0022", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-D-1536-0022", "comment_date": "2019-08-20T04:00:00Z", "comment_title": "Comment from Donna Johnson", "commenter_fname": null, "commenter_lname": null, "comment_length": 1399}, {"text": "See attached file(s)", "comment_id": "FDA-2019-D-1536-0024", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-D-1536-0024", "comment_date": "2019-08-20T04:00:00Z", "comment_title": "Comment from Esteve Pharmaceuticahs LLC", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Collegium written response to June 2019 FDA draft guidance Opioid Analgesic Drugs Considerations for Benefit-Risk Assessment Framework

Collegium Pharmaceutical is a specialty pharmaceutical company committed to being the leader in responsible pain management. For nearly two decades, Collegium has been focused on developing and commercializing new medicines for pain management that reflect our core values and our commitment to people suffering from pain, providers and our communities. As an integral part of our overall strategy we strongly believe in leading with science. The result of those efforts is a portfolio consisting of Xtampza ER, Nucynta and Nucynta ER, three meaningfully differentiated medications to treat moderate to severe pain.

Collegium Pharmaceutical appreciates the FDAs recent actions in relation to the opioid crisis. These included the recent issuance of Draft Guidance to describe the benefit-risk assessment framework that the Agency uses in evaluating whether applications for opioid analgesic drugs meet the standard for approval under section 505 of the Federal Food, Drug, and Cosmetic Act. In particular, we agree with the Agency that, in light of the ongoing opioid crisis in the U.S., an assessment of opioid analgesic drugs should take into account the broader public health impact of such drugs, including consideration of risks related to misuse, abuse, opioid use disorder, accidental exposure, and overdose. In doing so, it is equally important that the Agency take into consideration the legitimate need of millions of Americans for meaningful relief for their moderate to severe pain when alternative treatments are inadequate. Collegium understands that opioid analgesics carry substantial risks. We are dedicated to supporting responsible pain management that meets the needs of patients, healthcare professionals, and society.

We support FDAs conclusion that it is appropriate when making drug approval decisions to consider the benefits and risks of a product relative to other available analgesic therapies indicated for a specific condition. We acknowledge that FDA has not historically required a showing of superiority to available therapies as a condition of approval under section 505 of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. 355. Although such superiority is not an express requirement for approval under section 505 and would not in most cases necessarily be warranted, we believe the language of the Act provides the Agency with adequate authority to require that sponsors of New Drug Applications (NDAs) for opioid drug products include comparative data in appropriate cases. Specifically, Section 355(d) of the Act provides that FDA should deny approval of any NDA when the application does not include reports of investigations that establish whether or not such drug is safe for use under the conditions prescribed, recommended, or suggested in the proposed labeling thereof. It is well established that the term safe does not refer to absolute safety but rather requires the Agency to determine that the benefits of a drug product outweigh its known risks. This determination cannot be made in a vacuum but implicitly requires consideration of, among other things, the public health landscape into which every proposed product will be launched. Because of the substantial risks that opioid medications present not only to individual patients but also to their household members and their larger communities, it is reasonable for the Agency to conclude that new opioid medications that do not provide a meaningful clinical improvement over existing therapies cannot be viewed as sufficiently safe to merit approval. Such a position would be entirely in keeping with FDAs mission to protect the public health. Adopting such a position would strengthen the Draft Guidance (i.e., lines 155-157), enable the application of the benefit-risk framework, and provide clarity to sponsors.

Collegium Pharmaceutical welcomes the opportunity to discuss these issues regarding the new Draft Guidance further with the FDA. In closing, and as an organization dedicated to leading in responsible pain management, we strongly support the Draft Guidance and we believe that it will provide direction to industry in relation to the development of meaningfully differentiated opioid analgesic drugs.
", "comment_id": "FDA-2019-D-1536-0026", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-D-1536-0026", "comment_date": "2019-08-27T04:00:00Z", "comment_title": "Comment from Collegium Pharmaceuticals", "commenter_fname": null, "commenter_lname": null, "comment_length": 4420}, {"text": "See attached comment from PMRS, Inc.", "comment_id": "FDA-2019-D-1536-0029", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-D-1536-0029", "comment_date": "2019-08-27T04:00:00Z", "comment_title": "Comment from Pharmaceutical Manufacturing Research Services, Inc. (PMRS)", "commenter_fname": null, "commenter_lname": null, "comment_length": 36}, {"text": "Please find attached comments from Kaiser Permanente.", "comment_id": "FDA-2019-D-1536-0025", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-D-1536-0025", "comment_date": "2019-08-27T04:00:00Z", "comment_title": "Comment from Kaiser Permanente (KP)", "commenter_fname": null, "commenter_lname": null, "comment_length": 53}, {"text": "
Guidance to industry on criteria for risk-benefit assessment certainly seems called for in the review and approval process for opioid analgesic drugs. But several fundamental problems are evident in the present draft phrasing of that guidance. The following issues require reconsideration in light of emerging knowledge.

For existing opioid analgesics, todays medical patient is rarely tomorrows non-medical abuser. [1] Risk of opioid use disorder among actively managed medical patients is so low as to be difficult to measure. Large scale studies of post-surgical patients prescribed opioids for the first time reveal incidence of Opioid Use Disorder (OUD) diagnoses of 0.6% or less for follow-up periods averaging 2.5 years. [2] This number is likely a maximum, since many diagnoses are recorded by GPs who lack current training in evaluating patient behaviors that define OUD.

Incidence of protracted opioid prescribing for 13 weeks or longer in post-surgical patients is also less than 1%. Such prescribing may be more closely related to procedure failure than to properties of opioid analgesics per se. Procedures where chronic prescribing is most often observed are also among those in which procedure failures and emergence of chronic pain are highest (e.g. total knee replacement).[3]

There is no reliable relationship between rates of opioid prescribing by physicians versus rates of opioid overdose-related mortality from all sources (legal prescriptions, diversion of prescriptions, or illegal street drugs). There has never been a relationship during the past 20 years. CDC prescribing and demographics directly contradict any such relationship. People over age 55 are prescribed opioids for pain two to three times more often than youth and young adults under age 25; but, age-adjusted overdose related mortality in seniors is the lowest of any age group and has been mostly stable for 20 years, while mortality in youth and young adults has skyrocketed to levels now six times higher than in seniors. [4],[5]

A major missing dimension in the draft Framework must be addressed substantively if drug approvals are to be safe and reliable for the public. Due to naturally occurring genetic polymorphism in six key liver enzymes, there can be no one size fits all minimum dose or risk threshold that applies to all patients. Some patients are natural hyper metabolizers of specific opioids, while others are poor metabolizers. Thus there may be a broad natural range in minimum effective dose levels. [6]

Finally, medical practice and ongoing drug approvals for both established and new opioid formulations must come to grips with emerging evidence that risks of opioid use disorder on short term exposure may be elevated among a small fraction of patients due to effects of an abnormality in the A118G gene. [7]

Emerging evidence of genetic factors in metabolism and mu-receptor response to all opioids has clear implications for the drug approval process. To ensure patient safety, larger and longer trials are clearly needed, with more rigorous documentation of the variations in patient outcomes. Approval of drugs based on 90 day trials in populations of less than 200 patients must become a thing of the past. This change in policy must become explicit in Benefit Risk Frameworks which drive Industry investment in trials.

References:

[1] Singer JA, Sullum JZ, Shatman ME, Todays nonmedical opioid users are not yesterdays patients; implications of data indicating stable rates of nonmedical use and pain reliever use disorder, Journal of Pain Research 2019:12 617620

[2] Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ. 2018;360:j5790.

[3] Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med. 2016;176(9):1286-1293.

[4] Lawhern RA.Over Prescribing Did Not Cause the Opioid Crisis. Blog of Dr. Lynn Webster. Last updated April 5, 2019. http://www.lynnwebstermd.com/over-prescribing/.

[5] Lawhern RA, Tucker JA. Analysis of US Opioid Mortality and ER Visit Data. Last updated April 2019. Available at: http://face-facts.org/atip/analysis-of-us-opioid-mortality-and-er-visit-data-v15-april-2019/.

[6] Richeimer SH, Lee JJ, Genetic Testing in Pain Medicine The Future Is Coming , Practical Pain Management, Volume 16, Issue #8, August 8, 2017. Available at: https://www.practicalpainmanagement.com/treatments/genetic-testing-pain-medicine-future-coming

[7] Kline T, Opioid Facts Are We Getting the Whole Picture? - A Physicians Perspective, Medium, June 14, 2019, https://medium.com/@ThomasKlineMD/opioid-facts-are-we-getting-the-whole-picture-a-physicians-perspective-67cc7e3b0d2e?fbclid=IwAR1uYeo1OXS2lVo0--IKFx5fP_BwmytUExjI65ZbJ2tfqGMvbjLHzHboDsc
", "comment_id": "FDA-2019-D-1536-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-D-1536-0004", "comment_date": "2019-07-15T04:00:00Z", "comment_title": "Comment from Richard Lawhern", "commenter_fname": null, "commenter_lname": null, "comment_length": 5054}, {"text": "Patients with intractable pain are careful with their meds or else they have no pain relief. Thats what gives us a life, not euphoria. We must sign a lengthy contract and if we violate it, we have no pain doctor. The addiction rate is proven to be <1%. The people overdosing on opioids are using heroin and illicit fentanyl. Thats been proven too. How do you explain the major decrease in prescriptions and continued increase in opioid overdose deaths? Its been found patients with chronic/intractable pain who are undertreated or not treated adequately with pain medication will eventually get so desperate due to the pain that they will seek out some type of pain relief whether prescription meds or street drugs. They are then labeled as drug seekers or addicts when they are not. They exhibit symptoms similar such as doctor shopping, stealing others prescriptions, lying or buying illegal street drugs. Even if these patients are prescribed medication in dosages that dont provide them adequate relief, they will still seek out relief. Many patients have had their lives ruined because doctors either dont believe them or dont treat their pain adequately with an appropriate dosage. It happened to me after my first cervical fusion surgery. My surgeon didnt believe me that my pain was worse after the surgery and documented in my medical records that I was a drug seeker even though I was his patient 8 months and never abused my medication. He never mentioned anything about addiction until I told him the pain was worse. I was accused of drug addiction for five years and forced into a detox/rehab program in order to save my RN/Nurse Practitioner license. However, once I completed it, I still wasnt believed and my pain wasnt treated at all. So for seven years , I was either untreated or under treated and I started doctor shopping. Finally a pharmacist intervened and recommended a physician who literally saved my life. I was started on a compounded pain medication with 40mg hydrocodone plus naloxone every six hours. I had adequate pain relief for the first time in eight years. I was finally able to go back to work. I eventually had three more neck surgeries and now have three fusions and another bulging disc. All the years of the rest of my spine working extra hard led to spinal arachnoiditis down my entire spine. My pain gradually increased over the years as did my medication dosages. I now have two neurostimulators and three years ago I had a fentanyl pain pump implanted. Ive also taken tizanidine, a muscle relaxant, it has ruined my teeth. I also had to quit working in 2007 which was devastating. I loved my career and I was one of the first Neonatal Nurse Practitioners licensed in the state of Texas. Anyone who truly knows about intractable pain knows that our brain works different than a drug addict in that we DO NOT experience euphoria, our pain receptors are busy concentrating on pain relief from the pain medication and not euphoria. The last comment about me Ill add is that Im pretty certain if my pain meds were stopped, I would definitely have a heart attack or a stroke because my blood pressure elevates to stroke level anytime my pain is excessive. Either that or Im sure Id consider suicide because I know I cant live like that....pain has already taken everything I ever loved.

With intractable higher doses allow us to at least have a life, nothing compared to what we used to have though. Its better than laying in bed in extreme pain all the time. FDA states that they hear frequently from patients and providers about the need for higher doses. The patients need it for a decent life and the doctors feel like they cant do their job and treat their patients adequately. Statistics show complications in intractable pain patients is extremely low. There is a small amount of diversion, but we are very careful about our medication. The past three years of the patients horrific suffering, deaths and suicides should be enough to answer your questions. A lot of patients feel the CDC and DEA both are responsible with blood on their hands. Im including two short articles written by Red Lawhern PhD. He has dedicated his life to advocating for us. Please read them.

https://www.statnews.com/2019/06/28/stop-persecuting-doctors-legitimately-prescribing-opioids-chronic-pain/

http://face-facts.org/lawhern/congress-clean-up-this-mess/", "comment_id": "FDA-2019-D-1536-0013", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-D-1536-0013", "comment_date": "2019-07-15T04:00:00Z", "comment_title": "Comment from Penny Elmore", "commenter_fname": null, "commenter_lname": null, "comment_length": 4416}, {"text": "

Here's my story, short-version:
I first started having chronic pain when I was 4 months pregnant with my son back in 2007. I toughed it out at first but I ended up seeing my PCP and rheumatologist & getting some treatment for RA & fibromyalgia.
Then in 2009-2010, things got REALLY bad: it was eventually discovered that I had a 9-inch long benign hemangioma tumor going from the spinous process of T4 to my left shoulder blade, which was unbearably painful, but only one neurosurgeon believed me and did a T4 laminectomy & tumor resection. He said this tumor ended up eating away part of this protective coating around my spinal cord and that I would always be in pain from it. Well, the surgery was a success because it took care of most of the pain.
Anyway, fast-forward to today:
I've got another aggressive vertebral hemangioma at T10, but once again, no doctor will believe that I'm one of the rare 1% of patients with symptomatic vertebral hemangiomas!
I've been red-flagged, black-listed, called many different names (besides the usual "drug-seeker" & addict). I've been screamed at by ER nurses (among other verbal abuse), verbally and even physically abused by EMTs (can't prove it, so they've told me...), etc.
The forced tapering off of very effective high dose opioid medications caused me to have a stroke in my early 30s. Afterwards, I lost my successful career and my life has spiraled downhill ever since this started 3-4 years ago.
Today I've got an OK pain doctor, but he's "injection & procedure happy" and has expressed fear of going to jail and such to me in the past. He's reduced my meds to the point they barely touch the pain. 2 of my former pain doctors left pain management out of fear of DEA persecution and I don't blame them.
Like I've said before, I could write a book! This is just a basic outline of my story. If it weren't for Kratom, I would already be dead because the constant pain I would feel without it just isn't compatible with life!

I left out a lot, but I didn't want a ridiculously long post. My basic diagnoses not listed above: OA, DDD, possible CRPS/RSD (disputed by current PM doc), seizure disorder, hx of mild strokes, PE & other blood clots.
It also took doctors 2 years to realize I needed a hysterectomy and a cholecystectomy...but they were too busy accusing me of "drug-seeking" to actually diagnose the real problems I was having. I almost died of sepsis from my gallbladder as they were wheeling me into an emergency cholecystectomy!

No one deserves to be in unbearable pain, especially when patients like me were stable on them (opioids) for a very long time. It's inhumane and it directly goes against my Constitutional rights to life, liberty, and the pursuit of happiness.

We desperately need to find a middle ground in which to prescribe and take opioids, and without government overreach and interference. Our physicians know what they're doing!
Thank you for listening!

Sincerely,
Christina Leann Nunn
7108 Hardwood Trl
Dallas, TX 75249
214-402-3319
jarednunn10@gmail.com

", "comment_id": "FDA-2019-D-1536-0010", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-D-1536-0010", "comment_date": "2019-07-15T04:00:00Z", "comment_title": "Comment from Christina Nunn", "commenter_fname": null, "commenter_lname": null, "comment_length": 3277}, {"text": "Can the FDA please compile a list of FDA approved drugs that are approved for the treatment of pain, especially post-surgical pain, that are NON-opioids and make this available to both physicians and patients so that informed decisions can be made regarding options for treating pain? A useful list would be one that lists all non-opioid FDA approved drugs that have an indication for the treatment of pain and a short explanation of what type of pain they can be used to treat. ", "comment_id": "FDA-2019-D-1536-0036", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-D-1536-0036", "comment_date": "2020-02-26T05:00:00Z", "comment_title": "Comment from Katherine Drakos", "commenter_fname": null, "commenter_lname": null, "comment_length": 479}, {"text": "I would like to tell you a little bit about myself.
I have back, neck, (half of my spine is fused or bulging and degenerated), knee and other problems.
Five fusions in my spine and many other problems causing great pain in my body. I receive very little medication now for my pain. I took opioid pain medicine over 25 years as prescribed and never had any problems.
Over 99% of people that suffer in chronic pain don't have any problems with pain medications. Those that are getting addicted are buying illegal drugs off the streets coming across the boarder, NOT from a doctor.
I watched the HHS Best Practices for Pain Management Prescribing That was approved and also approved by the AMA in May 2019. I'm thinking this would change and I would be able to be treated for pain again. Well I was wrong.
I took it to my Pain Management Doctor. He told me he was following the Task Force Meetings.
His main concern he has is legal issues. He said he is scared of the DEA coming in and shutting him down for 3 months to verify everything and he didn't want to risk losing his patients for 3 months while they investigate.
So he said he won't change till he has protection from the DEA and rules were clear in that area. He even promised when this happens I would get the pain medicine I need.
He is a PMD that practices for Baylor Scott&White. Baylor S&W also has their own set of guidelines and they are concerned about the DEA also.
Is there a way that we can protect and educate for this problem? Also let the health professionals/clinics/hospitals feel assured this type of law enforcement won't happen to them?
If not I won't be able to be treated with the proper pain medicine I need.

How does The National Opioid Pain Card Work

It will allow a person that sufferers in pain get the opioid pain medication he/she needs.

Patient has a proven need ( MRI's and or proper medical diagnosis).

Patient has been prescribed in past with opioids, no history of abuse and low risk.

How does the Pain Card work with the present system we have.

The Pain Management Doctor files for a Pain Card with the diagnosis and the stable amount of pain medicine needed for the patient to have quality of life.s

The Doctor and Pain Patient goes through risk vs benefits and also the patient goes through a training class about opioid risk and locking up opioid prescriptions. Then patient assumes all risk at this point.

Once the patient gets approved (just like the state approves Social Security benefits), gets a number that will allow the patient to be treated without a delay and pick up their pain prescriptions

It allows the Pain Management Doctor to be exempt by points or red flagged by the DEA when prescribing opioid pain medicine to patients that have the Pain Card.

(PDMP) Prescription Drug Monitoring Programs

It is a system that is used by all Pharmacies, Doctors, Healthcare and even the DEA.

It shows all prescriptions a patient is taking and the Doctors name that is prescribing it.

Doctors monitor it to make sure patients are not doctor shopping.

Pharmacies monitor it to make sure patients are not doctor shopping and can see doctors diagnosis and pain treatment plan.

DEA can monitor all (The Patient, The Doctor, The Pharmacies) and look at any wrong doing.
All agencies will see the Pain Card Exemption Number using the PDMP system.

The HHS has already approved their report on: Pain Management Best Practices.

The HHS has written new guidelines in response of the (2016 misguided CDC Guidelines) after seeing the lack of treatment because of those misguided guidelines.

The HHS approved report will allow pain patients to be treated again with proper medication without being discriminated against.

The only problem we have are Doctors are still in fear of the DEA coming in and shutting down their practice for several months, only to find no wrong doing.

This has happen many times.

The Pain Management Doctor is left with negative publicity and no funds or desire in starting their pain practice over again. Most go to work as an MD and quit prescribing opioid pain medicine all together.
This is leaving most people that suffer in pain (cancer or chronic pain patients) with no place to go for treatment.

Unfortunately many have taken their own lives because they just cant bear the pain they have to live with.

The is truly inhumane !

They fear the DEA are not going to follow the New HHS report that was passed on May 9th and supported by the AMA and the CDC.

The Pain Card will allow Pain Management Doctors to be exempt from prescribing proper pain medication and not fear the DEA is going to come in and raid their practice just for treating chronic pain patients.

This is such an easy inexpensive fix with the system we already use daily.


Please help Approve a Pain Card that allow patients who suffer in pain to be treated again with some form of quality of life without all the stigma attached to treatment.", "comment_id": "FDA-2019-D-1536-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-D-1536-0006", "comment_date": "2019-07-15T04:00:00Z", "comment_title": "Comment from John Schoellman", "commenter_fname": null, "commenter_lname": null, "comment_length": 5271}]}, {"id": "DEA-2010-0010", "title": "Electronic Prescriptions for Controlled Substances", "context": "2023-01-05T11:20:14Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "Attached are UnitedHealth Group's comments on the DEA rule on electronic prescribing for controlled substances.", "comment_id": "DEA-2010-0010-0064", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2010-0010-0064", "comment_date": "2010-06-02T04:00:00Z", "comment_title": "Comment on FR Doc # 75 FR 16 236", "commenter_fname": "David", "commenter_lname": "Wichmann", "comment_length": 115}, {"text": "See attached file(s)", "comment_id": "DEA-2010-0010-0069", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2010-0010-0069", "comment_date": "2010-06-02T04:00:00Z", "comment_title": "Comment on FR Doc # 75 FR 16 236", "commenter_fname": "Katherine", "commenter_lname": "Casey", "comment_length": 20}, {"text": "See Attachment", "comment_id": "DEA-2010-0010-0089", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2010-0010-0089", "comment_date": "2010-06-10T04:00:00Z", "comment_title": "Express Scripts Comment on DEA 218", "commenter_fname": "Carolyn", "commenter_lname": "Jones", "comment_length": 14}, {"text": "June 1, 2010

Michele M. Leonhart
Deputy Administrator
Drug Enforcement Administration
DEA Federal Register Representative/ODL
8701 Morrissette Drive
Springfield, Virginia 22152

Re: Final Rule; 21 CFR Parts 1300, 1304, 1306, and 1311; Electronic Prescriptions for Controlled Substances [Docket No. DEA-218]; Vol. 75 Federal Register 16236 (March 31, 2010).

Dear Deputy Administrator Leonhart,

The American Psychiatric Association (APA), the national medical specialty society representing more than 37,000 psychiatric physicians, appreciates the opportunity to submit these comments on the Drug Enforcement Administration’s (DEA) interim final rule (IFR) revising the regulations on the electronic prescription of controlled substances. APA submitted extensive comments on DEA’s proposed rule in conjunction with the American Medical Association (AMA) and many other medical specialty societies. We have again joined the AMA and other specialty groups in comments submitted on May 26, 2010, but would like to emphasize certain points and add several issues in our comments here.

Attached please find our comments.

Thank you for your consideration of our comments and we look forward to working with DEA in the future on these important policy issues. If you have any questions, please contact Jennifer Tassler, Deputy Director, Regulatory Affairs, at jtassler@psych.org or at (703) 907-7842.

Sincerely,

James H. Scully Jr., M.D.
Medical Director and C.E.O., American Psychiatric Association", "comment_id": "DEA-2010-0010-0056", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2010-0010-0056", "comment_date": "2010-06-02T04:00:00Z", "comment_title": "Comment on FR Doc # 75 FR 16 236", "commenter_fname": "James H.", "commenter_lname": "Scully", "comment_length": 1601}, {"text": "For comments or questions, please contact Beki Marshall.", "comment_id": "DEA-2010-0010-0057", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2010-0010-0057", "comment_date": "2010-06-02T04:00:00Z", "comment_title": "Comment on FR Doc # 75 FR 16 236", "commenter_fname": null, "commenter_lname": null, "comment_length": 56}, {"text": "RIN 1117-AA61/Docket No. DEA-218I
", "comment_id": "DEA-2010-0010-0117", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2010-0010-0117", "comment_date": "2020-06-04T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-07085", "commenter_fname": "Naomi", "commenter_lname": "Turner", "comment_length": 38}, {"text": "WENO Exchange LLC, CEO Tina Goodman is submitting a comment regarding a new and serious issue surrounding large chain pharmacies resisting a practitioners right to transmit a valid EPCS order other than via the Surescripts network. It also includes recommendations to resolve.
See attached file(s)", "comment_id": "DEA-2010-0010-0123", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2010-0010-0123", "comment_date": "2020-06-10T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-07085", "commenter_fname": null, "commenter_lname": null, "comment_length": 304}, {"text": "1. The knowledge-based form of the two-factor test is an archaic method of security. For instance, in 2018 the Hawaii emergency agency responsible for a missile scare had their password leaked because it was written on a post-it note on the monitor, and a photo of the monitor circulated the internet. "Passwords" are a faulty method that invites human error too frequently.

An alternative to this form is a call system, where a physician can log-in to the system by dialing a number and a receiver authorizes the first factor of the log-in.

2. Remotely identity proofing to ensure service to rural areas sacrifices security. A major argument for Electronic Prescriptions is efficiency. In rural areas, where the doctor to patient ratio is more manageable than urban areas, the need for efficiency is minuscule.

3. Viewing a driver's license via video for remote identity proofing is not a secure method. Video and photos can be manipulated far too easily with current technology.

4. The record of the changes in the internal audit trail should be compressed to save storage space.

5. A practitioner's access must be revoked also if it is discovered the practitioner accesses the system irregularly, using an algorithm that flags irregular activity.

6. N/A

7. External USB devices should not be used for the two-factor authentication because they can too easily be compromised, and access will be revoked too frequently.

8. Iris scans are a very secure method of identity and the current technology allows for broad use of this technique. This technique should be adopted for authentication.

9. N/A", "comment_id": "DEA-2010-0010-0122", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2010-0010-0122", "comment_date": "2020-06-10T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-07085", "commenter_fname": "Troy", "commenter_lname": "Sims", "comment_length": 1703}, {"text": "Attached please find the comments of Cleveland Clinic. ", "comment_id": "DEA-2010-0010-0149", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2010-0010-0149", "comment_date": "2020-06-22T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-07085", "commenter_fname": "blair", "commenter_lname": "barnhart-hinkle", "comment_length": 55}, {"text": "Just a couple comments from an interested party on the reopened DEA EPCS IFR Comment Period; RIN 1117-AA61/Docket No. DEA-218I .
An open ended question 7 was asked "What types of issues have registrants encountered during the adoption and implementation of EPCS into their workflow, particularly where a prescriber uses an electronic health record (electronic medical record)?" and I would like to make 2 comments for this question.
1)I fully concur with the National Council for Prescription Drug Programs ( NCPDP) comments and add additional verbiage on the 1311.300 Application provider requirements - Third-party audits or certifications. Third Party Audit requirement are costly and burdensome to both the e-prescribing system vendors and the pharmacy management system vendors. Vendors rarely, if ever, make substantive changes in the EPSC system software unless the underlying message standard changes. Until CMS mandated the SCRIPT V2017071 standard effective 01-01-2020, there hadn't been a standards change, i.e. a substantive change to the EPCS processing since 2013, nearly 7 years. However during that time period, vendors may have had to conduct as many as 4 additional audits depending on the timing of their audits. It's costly and burdensome, with limited if any value. I respectively request that the DEA reconsider this requirement and remove the every two years requirement. I would recommend that the new language would state that audits are only required when substantive changes are made to the electronic prescribing of controlled substances functionality.

2)EPCS Renewal Request Issue: Years ago, pharmacies were put at risk when a penalty was accessed to a pharmacy for faxing forms to prescribers which facilitated the ease of prescribers approving refill requests. Basically the pharmacy sent a form, that the prescriber had to sign and return. It was deemed that this form in it's current state could be considered the pharmacy prepopulating the prescription information and was "prescribing".
There has been concern in the industry that this same risk exists with electronic prescribing of controlled substances RxRenewalRequest and RxRenewalResponse transactions, and that this could again put pharmacies at risk. This process when done electronically is a completely different workflow than a faxed refill request. The pharmacy is sending an RxRenewalRequest with fields mandated by the NCPDP SCRIPT standard to the prescriber which contains consistent, relevant information related to the patient and the prescription to enable better decision making on the part of the prescriber. The prescriber cannot "sign" this and send it back to the pharmacy. The response must be an RxRenewalResponse and it is a completely different transaction/message that is constructed and digitally signed by the prescriber and transmitted by it's EHR system to the pharmacy.
Therefore, I would also concur with NCPDP's request that "the DEA confirm the RxRenewalRequest message does not constitute pre-population and the use of this message type supports the DEA's mission to limit prescribing of controlled substances to circumstances of true need while obviating the need to resort to less secure, more vulnerable prescription-writing processes."

", "comment_id": "DEA-2010-0010-0146", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2010-0010-0146", "comment_date": "2020-06-22T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-07085", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 3484}]}, {"id": "FDA-2018-N-3685", "title": "International Drug Scheduling; Convention on Psychotropic Substances; Single Convention on Narcotic Drugs; ADB-FUBINACA; ADB-CHMINACA; Cyclopropyl Fentanyl; Methoxyacetyl Fentanyl; para-Fluoro Butyrfentanyl; Tramadol; Pregabalin; Cannabis Plant and Resin; and 8 additional substances; Request for Comments", "context": "2019-03-04T13:05:41Z", "purpose": "Nonrulemaking", "keywords": ["International Drug Scheduling", "Convention on Psychotropic Substances", "Single Convention on Narcotic Drugs", "ADB-FUBINACA", "ADB-CHMINACA", "Cyclopropyl Fentanyl", "Methoxyacetyl Fentanyl", "para-Fluoro Butyrfentanyl", "Tramadol", "Pregabalin", "Cannabis Plant and Resin", "FRDTS# 2018-820", "CDER", "James R. Hunter", "OPEN"], "comments": [{"text": "See Attached", "comment_id": "FDA-2018-N-3685-8235", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-3685-8235", "comment_date": "2018-11-01T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}, {"text": "See Attached", "comment_id": "FDA-2018-N-3685-10664", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-3685-10664", "comment_date": "2018-11-15T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}, {"text": "Please rethink your stance on medical cannabis. I truly believe in the healing power of a patients right to choose their medicine and more natural is better. I benefit from medical marijuana in my state of Pa. I have overcome opioid addiction and chronic pain and depression issues. Knowing that no matter what medical problems I have in my future, having access to medical marijuana is enough to help me with my pain and anxiety and depression.
", "comment_id": "FDA-2018-N-3685-4850", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-3685-4850", "comment_date": "2018-10-29T04:00:00Z", "comment_title": "Comment from Meghan Thompson", "commenter_fname": null, "commenter_lname": null, "comment_length": 450}, {"text": "In regards to Cannabis Plant and Resin, I believe that anything less than full legalization is criminal. It makes criminals of decent citizens, and it drives the plant to an unregulated black market. With medical legalization prevalent, with growing consensus worldwide that the war on drugs is causing more harm than good, and finally with full legalization approved in Canada I believe that the United States and the world should follow. In doing so forgive the sentences of past and current non-violent cannabis offenders and expunge their cannabis related records. Finally, apologize for the destruction that the war on drugs has caused.

As for the others on this list. I recommend personalized treatment for substance abuse. Follow Portugal's lead and give help to those afflicted, not a criminal record!

May this world come together in peace. For we are far too divided.", "comment_id": "FDA-2018-N-3685-4879", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-3685-4879", "comment_date": "2018-10-29T04:00:00Z", "comment_title": "Comment from Adam Dochow", "commenter_fname": null, "commenter_lname": null, "comment_length": 907}, {"text": "Yes marijuana should be legalized or at the very least not be a schedule 1 drug. Alcohol is terrible, give people a chance to relax with a nice calming drug that you basically can't OD on. Reap the benefits of the tax money while creating a completely new Billion dollar industry. ", "comment_id": "FDA-2018-N-3685-4818", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-3685-4818", "comment_date": "2018-10-29T04:00:00Z", "comment_title": "Comment from Rsy Bartholow", "commenter_fname": null, "commenter_lname": null, "comment_length": 285}, {"text": "Cannabis is a medicinal herb that is well documented through history and is crucial to treating my glioblastoma that is predicted to kill me in six months if I can't access the herb. Classifying it as a schedule I drug is an abrogation of science, and criminalizing access and research is a crime against humanity. The only rational classification for the herb and its natural derivatives is none at all. Pharmaceutical derivatives introduce side effects, greatly increase cost, and significantly diminish the healing effect of the natural plant.

", "comment_id": "FDA-2018-N-3685-4886", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-3685-4886", "comment_date": "2018-10-29T04:00:00Z", "comment_title": "Comment from Carol Hiltner", "commenter_fname": null, "commenter_lname": null, "comment_length": 560}, {"text": "Yes, marijuana should be legalized. This will also accelerate research into the healing properties of the plant, which could lead to more uses for the different plant. ", "comment_id": "FDA-2018-N-3685-4984", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-3685-4984", "comment_date": "2018-10-29T04:00:00Z", "comment_title": "Comment from Derek B", "commenter_fname": null, "commenter_lname": null, "comment_length": 169}, {"text": "Legality aside, schedule reduction for Cannabis Plant and Resin is more than warranted.

THC has a physically unreachable toxicity threshold, and causes no immediate threat to health. Alcohol, a legal and controlled substance, has a toxicity threshold among the lowest of all substances; the CDC reports "During 20102012, an annual average of 2,221 alcohol poisoning deaths (8.8 deaths per 1 million population) occurred among persons aged 15 years in the United States." which makes it one of the leading causes of preventable deaths in the United States for that time frame. Comparatively, cannabis use has caused 0 toxicity related deaths in not only the same time frame, but all of recorded history.
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6353a2.htm

CDC reports pertaining to other drugs currently on the same schedule, and drug overdoses in general:

"During July 2016June 2017, among 11,045 opioid overdose deaths, 2,275 (20.6%) decedents tested positive for any fentanyl analog, and 1,236 (11.2%) tested positive for carfentanil. Fourteen different fentanyl analogs were detected."
https://www.cdc.gov/mmwr/volumes/67/wr/mm6727a4.htm

"In 2016, there were more than 63,600 drug overdose deaths in the United States."
Factually, none of these were caused by the consumption of cannabis. That's 63,600 Americans who died in one year because they consumed too much alcohol, or too much of any other drug. 0 Americans have ever died as a direct result of consuming too much cannabis.
https://www.cdc.gov/nchs/products/databriefs/db294.htm

Setting aside arguments which could be made for recreational legalization at a federal level, and for the theraputic effects of other non-psychoactive substances (such as CBD, cannabinoids, and terpenes; anything not THC) that are present in cannabis, it's plain to see that the drug is not dangerous enough to remain on the Schedule 1 controlled substances list.

If the FDA truly has the American Public's best interests at heart, then cannabis will be removed from the schedule 1 controlled substances list, as a first step in the right direction. ", "comment_id": "FDA-2018-N-3685-5016", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-3685-5016", "comment_date": "2018-10-29T04:00:00Z", "comment_title": "Comment from James Ota", "commenter_fname": null, "commenter_lname": null, "comment_length": 2207}, {"text": "With the now long history of successful cannabis distribution in the medical fields, it no longer makes sense to have it banned as a highly dangerous substance. Coupled with the data showing increased safety and reduction in crime in states with recreational legality, the federal ban is no longer sensible.
With a state level choice by citizens to determine availability and true ability to research usage, we are best able to stop the problematic sides of the issue. Real research can be done to find both the positives and negatives of cannabis usage by the public. Children can be better insulated in the same fashion as they are for alcohol and tobacco plus the criminal justice system will be more efficient. The cost of criminalizing cannabis far outweighs the benefits and the volume of low level prosecutions stops prosecutions for high level crime.
So my opinion is that federal decoupling of legality and state level selective choice makes the most sense for the nation.", "comment_id": "FDA-2018-N-3685-5064", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-3685-5064", "comment_date": "2018-10-29T04:00:00Z", "comment_title": "Comment from Mich D", "commenter_fname": null, "commenter_lname": null, "comment_length": 989}, {"text": "The Cannabis Plant and Resin have already been legalized in many states, with even more putting it to a vote as soon as this coming November in one way or another. The "war on cannabis" happened long before we had our current scientific studying capabilities, and as such it has never had a true chance to be studied as a legitimate medicine. On top of this, the original reasons for its outlawing were highly suspect to begin with, chiefly influenced first by the business motivations of William Randolph Hearst (in conjunction with poorly attended congressional hearings and shoddy scientific studies), and later by the political motivations of the Nixon administration and the then burgeoning pharmaceutical industry, more than scientific merit. It's time we see the writing on the wall: If it won't be legalized for recreation at a federal level, the American people obviously want, at bare minimum, for Cannabis and Cannabis Resin to be changed to a Schedule IV or V drug so that it can be properly studied and the voters can make informed decisions on whether or not to continue its legalization.

Speaking of the current scheduling of Cannabis and Cannabis Resin, it's pretty difficult to make a coherent argument for how these drugs fit the description of other Schedule I narcotic. The definition for Schedule I narcotics per the DEA's website is as follows: "Schedule I drugs, substances, or chemicals are defined as drugs with no currently accepted medical use and a high potential for abuse." Not only do Cannabis and Cannabis Resin have currently accepted medical uses (treating epileptic seizures, for example), but how is it possible to assert that a drug has a high potential for abuse if there's a dearth of coherent, factual, peer-reviewed scientific study on that subject? Without scientific evidence the scheduling must be based on hearsay, and that our government would enact rules or regulations based on hearsay is a terrifying realization.

There are many other reasons why Cannabis and Cannabis Resin should be rescheduled but unfortunately there's simply not enough room in this comment to discuss them all. It's time to do right by the American people, and the ethical core that guides their principles, and reschedule Cannabis and Cannabis Resin to Schedule IV or V so it can be properly studied, after which the American people can finally be allowed to do their job: Make an educated decision on the ongoing legality of the substance.", "comment_id": "FDA-2018-N-3685-5068", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-3685-5068", "comment_date": "2018-10-29T04:00:00Z", "comment_title": "Comment from Jake Sparkman", "commenter_fname": null, "commenter_lname": null, "comment_length": 2528}]}, {"id": "FDA-2016-P-3912", "title": "Requests FDA to (i) require proposed generic versions of Intranasal (IN) naloxone products to provide specific pharmacokinetic (PK), device, stability and Chemistry, Manufacturing and Controls (CMC) data, as set-out herein, within the ANDA, to support the interchangeability of generic IN naloxone and the IN naloxone Reference Listed Drug (RLD); (ii) not to approve any generic", "context": "2017-05-15T10:25:14Z", "purpose": "Nonrulemaking", "keywords": ["Citizen Petition", "CDER", "OPEN", "2016-6743", "Adapt Pharms Operations Ltd", "Intranasal (IN) naloxone products", "pharmacokinetic (PK)", "device, stability and Chemistry", "Manufacturing and Controls (CMC) data", "interchangeability of generic IN naloxone", "Reference Listed Drug (RLD)", "generic application"], "comments": [{"text": "Please keep in mind that there are legit chronic pain patients whom have tried everything with no success. The only relief for some
patients is being on Narcotic medication. Not everyone that takes medications are so called "druggies". There are plenty of patients that
suffer 24/7 and without the medications that they take there life is worthless. some chronic pain patients cannot get out of bed
due to them hurting until they take there medications and feel better. No one wants to be in pain and why should the FDA or the
DEA make them suffer when there are medications that help? This makes NO sense at all. We live in the U.S. and we are suppose to
live in a free Country, however, each day it seems like we are loosing our rights.", "comment_id": "FDA-2016-P-3912-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-P-3912-0005", "comment_date": "2017-05-15T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 770}, {"text": "FDA-2017-N-1847.

Subject: Please preserve compounding substances.

Pharmacy Compounding Advisory Committee,I urge the FDA's PCAC to preserve consumer access to important compounded ingredients. The substances being considered at the May meeting have been used for a long time and have demonstrated safety records. There may be commercial formulations of these substances, but the role of compounding pharmacies is to provide patients with special needs the medicines they require. Some people have environmental sensitivities and cannot have preservatives in their medicines; some have gluten intolerance and cannot have gluten in a pill; others, such as elderly patients and autistic patients, have difficulty swallowing pills. Compounding pharmacies can make special preparations for these patients. Here's what's at stake: Artemisinin is a compound found in sweet wormwood, an herb that has been used in traditional Chinese medicine for centuries. It is most notably used to treat malaria, but it may also be helpful for tuberculosis and a host of other conditions. Considering the rise of drug-resistant TB, which is virtually untreatable and is sending conventional doctors into a panic, it would be lunacy to restrict access to this herb. Ubiquinol is by far the most effective, bioavailable form of CoQ10. Some people may not be able to convert the ubiquinone form of CoQ10 into ubiquinol, which means access to ubiquinol products is extremely important. CoQ10 / ubiquinol has many benefitsit is used for energy production by every cell in the body. It is especially useful for patients on statins since these drugs deplete the body of CoQ10. Nettle has a number of salutary effects. It was used by Roman soldiers to withstand the cold by stimulating blood circulation. It helps the body detoxify itself, alleviates allergic reactions, and promotes healthy blood circulation. Vanadyl sulfate is an insulin mimic and a natural therapy for diabetes and insulin resistance. It is a form of a trace mineral found in mushrooms and shellfish. Nicotinamide adenine dinucleotide (NAD) is a vital compound involved in mitochondrial health and energy metabolism. As NAD levels decline later in life, mitochondrial function is impaired, resulting in various symptoms of aging. NAD is also an essential cofactor of certain key enzymes that are responsible for longevity. Every year we are learning more about how critical NAD is, including for cancer control. Please do not further restrict the medicines that compounding pharmacies can make for their customers. The ability of compounding pharmacies to function, thrive, and produce these crucial supplements plays a crucial role in people's lives.Ron Rattner1998 Broadway Apt 1204San Francisco, CA 94109
", "comment_id": "FDA-2016-P-3912-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-P-3912-0004", "comment_date": "2017-05-05T04:00:00Z", "comment_title": "Comment from Ron Rattner", "commenter_fname": null, "commenter_lname": null, "comment_length": 2789}]}, {"id": "FMCSA-2000-8456", "title": "Conforming Amendments to DOT Drug and Alcohol Rule", "context": "2021-02-10T01:23:42Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": null, "comment_id": "FMCSA-2000-8456-0005", "comment_url": "https://api.regulations.gov/v4/comments/FMCSA-2000-8456-0005", "comment_date": "2001-06-11T04:00:00Z", "comment_title": "Farmland Industries, Inc. - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FMCSA-2000-8456-0003", "comment_url": "https://api.regulations.gov/v4/comments/FMCSA-2000-8456-0003", "comment_date": "2001-05-10T04:00:00Z", "comment_title": "Industrial Health Services Network - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FMCSA-2000-8456-0020", "comment_url": "https://api.regulations.gov/v4/comments/FMCSA-2000-8456-0020", "comment_date": "2001-06-14T04:00:00Z", "comment_title": "Drug and Alcohol Testing Industry Association - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FMCSA-2000-8456-0008", "comment_url": "https://api.regulations.gov/v4/comments/FMCSA-2000-8456-0008", "comment_date": "2001-06-13T04:00:00Z", "comment_title": "Transportation and Small Business Consortium - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FMCSA-2000-8456-0014", "comment_url": "https://api.regulations.gov/v4/comments/FMCSA-2000-8456-0014", "comment_date": "2001-06-14T04:00:00Z", "comment_title": "Community Transportation Association of America - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": "Under 382.107 definitions, DOT agency means... you list parts 653 and 654.; however, the FTA has eliminated these and combined the two in a new section 655. Perhaps the definition should express this as well.

Under Subpart B, 382.201 Alcohol concentration, and 382.301(d)(5) you state the driver cannot work with an alcohol concentration of 0.04 or greater, yet in 382.307(e)(2)(i), you state the driver cannot drive until the concentration is less than 0.02. Also, 382.505(a) states drivers greater than 0.02 and less than 0.04 cannot drive. Should not 302.201 and 382.301 (d)(5) likewise be less than 0.02?
Thank you,
Stuart M. Kagan, MD, MPH
Medical Review Officer
", "comment_id": "FMCSA-2000-8456-0002", "comment_url": "https://api.regulations.gov/v4/comments/FMCSA-2000-8456-0002", "comment_date": "2001-05-08T04:00:00Z", "comment_title": "Stuart Kagan - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 695}, {"text": null, "comment_id": "FMCSA-2000-8456-0006", "comment_url": "https://api.regulations.gov/v4/comments/FMCSA-2000-8456-0006", "comment_date": "2001-06-12T04:00:00Z", "comment_title": "C.F. and Associates - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FMCSA-2000-8456-0011", "comment_url": "https://api.regulations.gov/v4/comments/FMCSA-2000-8456-0011", "comment_date": "2001-06-14T04:00:00Z", "comment_title": "American Trucking Associations - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FMCSA-2000-8456-0010", "comment_url": "https://api.regulations.gov/v4/comments/FMCSA-2000-8456-0010", "comment_date": "2001-06-14T04:00:00Z", "comment_title": "Greyhound Lines, Inc. - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FMCSA-2000-8456-0022", "comment_url": "https://api.regulations.gov/v4/comments/FMCSA-2000-8456-0022", "comment_date": "2001-06-18T04:00:00Z", "comment_title": "American Bus Association, Inc. - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}]}, {"id": "FDA-2013-P-1288", "title": "Refrain From Implementing Neonatal Opioid Withdrawal Syndrome (NOWS)- Related Labeling Changes", "context": "2016-05-17T06:42:54Z", "purpose": "Nonrulemaking", "keywords": ["cder", "2013-8430", "citizen petition", "NAPW", "neonatal opioid withdrawal syndrome", "NOWS"], "comments": [{"text": "Petitioners comments are well-received and should be closely reviewed by the FDA. Pregnant women are particularly vulnerable and have suffered greatly when policy has been built on scientific evidence that was insufficiently scrutinized (e.g. pregnant women have been arrested and incarcerated for testing positive for illicit substances during medical care in many parts of the United States, generally based on concerns of the harms of that substance use on the developing fetus without a strong scientific consensus). The petitioners raise very serious concerns about the language used in the planned labeling changes as they relate to NOWS, including the use of the term "lifethreatening" and language that could easily be used by providers, policymakers, and law enforcement and judicial agencies to restrict access to opioid agonist maintenance treatment or to punish patients receiving such therapy. At this stage, we rely on agonist maintenance therapy as the gold standard for treatment of opioid use disorders, particularly among pregnant women. It is critical that the labeling changes account for this by:

1) emphasizing the essential role of agonist maintenance treatment among pregnant women
and
2) adopting more limited and evidence-based language regarding the nature and risks of NOWS.

I am a board-certified internist and infectious disease specialist as well as a buprenorphine provider. I am an NIH-funded substance use investigator directing clinical trials into pharmacologic and behavioral therapies for substance use as well as studies of programmatic and structural changes to clinical care to minimize the medical sequelae of substance use (including efforts to improve opioid stewardship and minimize opioid-related mortality).", "comment_id": "FDA-2013-P-1288-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2013-P-1288-0005", "comment_date": "2014-02-11T05:00:00Z", "comment_title": "Comment from Phillip Coffin", "commenter_fname": null, "commenter_lname": null, "comment_length": 1791}, {"text": "Please see attached file in support of National Advocates for Pregnant Women's Citizen Petition. ", "comment_id": "FDA-2013-P-1288-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2013-P-1288-0006", "comment_date": "2014-02-11T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 101}, {"text": "The American College of Obstetricians and Gynecologists strongly opposes the black box warning on opioid medications directed toward pregnant women.
Opioid medications are the safest choice for use by pregnant women who experience moderate to severe pain. In addition, women who are pregnant and dependent on opioid medications put their fetus in great danger if withdrawn from these medications during their pregnancy. Neonatal Abstinence Syndrome, which may result from maternal opioid use, is a fully treatable condition without subsequent patho-physiology. The warning proposed by the FDA concerning infant death has not been substantiated. Thank you.", "comment_id": "FDA-2013-P-1288-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2013-P-1288-0004", "comment_date": "2014-02-11T05:00:00Z", "comment_title": "Comment from American College of Obstetricians and Gynecologists", "commenter_fname": null, "commenter_lname": null, "comment_length": 665}]}, {"id": "FDA-2011-N-0802", "title": "Role of Naloxone in Opioid Overdose Fatality Prevention; Public Workshop; Request for Comments", "context": "2015-09-11T10:39:47Z", "purpose": "Nonrulemaking", "keywords": ["cder2011177", "CDER", "Naloxone", "Public Meeting", "Request for Comments", "2015-376", "open", "Exploring", "Uptake and Use"], "comments": [{"text": "Please see the attached letter from the American Association of Nurse Anesthetists.", "comment_id": "FDA-2011-N-0802-0045", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-N-0802-0045", "comment_date": "2015-09-11T04:00:00Z", "comment_title": "Comment from American Association of Nurse Anesthetists (AANA)", "commenter_fname": null, "commenter_lname": null, "comment_length": 83}, {"text": "Please see the attached PDF document for comments submitted by the Drug Policy Alliance in reference to Docket No. FDA-2014-N-0998. Thank you.", "comment_id": "FDA-2011-N-0802-0047", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-N-0802-0047", "comment_date": "2015-09-11T04:00:00Z", "comment_title": "Comment from Drug Policy Alliance", "commenter_fname": null, "commenter_lname": null, "comment_length": 142}, {"text": "I stongly support the increase availability of Naloxone in the prevention of Opioid Overdose. Making naloxone availalble saves lives! I work as a nurse on a adult detox center at the University of Minnesota, Fairivew and we have noticed an alarming upward trend of 18 y o to 28 y o heroin addicts. Most started with abuse of narcotics then switched to heroin. Many are motivated to come to treatment because a friend overdosed and died. Recently I cared for a young male who came in because he himself nearly died of an overdose but a friend did rescue breathing and got him to an ER. Unfortunetly this friend overdosed the next day and died. We just had a high school student overdose on heroin and alcohol and died. As a mother and a nurse I request you make naloxone and needles available to the public. One idea would be to have public health and/ or pharmacy's distribute the medication/syringes after a person views an informational adminstartion/safety video on an i-pad.
As a community in the Twin Cities we organized a multi -agencyOpioid coaltion to fight this horrific trend of young opioid abusers. Availability of Naxolone is one layer of a solution to this problem. Additonal prevention and public education measures are urgently needed for this nation wide epidemic.
Thank you,
Mary Kay Borgstrom RN
Opioid Coalition Prevention Leader
www.opioidcoalition.org", "comment_id": "FDA-2011-N-0802-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-N-0802-0006", "comment_date": "2012-04-12T04:00:00Z", "comment_title": "Mary Kay Borgstrom - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1403}, {"text": "See attached file(s)", "comment_id": "FDA-2011-N-0802-0044", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-N-0802-0044", "comment_date": "2015-09-11T04:00:00Z", "comment_title": "Comment from CVS Health", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Working in Massachusetts on the opioid overdose prevention initiative has been one of the most fulfilling times of my professional life. Teaching a parent or loved one of an opioid addict, who is consumed with the fear of losing their loved one to overdose, how to reverse an overdose with nasal naloxone is unparalleled. Most people are amazed at how easy it is to save someone's life with this medication. There is so much misinformation around naloxone that it is crucial to educate the public on its use and importance in our society. None of us can change the fact that presently we are literally fighting for peoples' lives when we talk about opioid abuse, but we can save people from dying from an overdose. An overdose often opens the door for people to reevaluate their situation and look at treatment as a viable option. I did a focus group a few weeks ago and this came from a participant: "I don’t use drugs, but I have been here a lot, I’m an alcoholic. I have had alcohol poisoning and I was lucky to survive. So when I took your class I thought it was important to get Narcan, because you never know. I left here and went to a sober house. My first day in the house, a young kid overdosed on heroin. I used that Narcan and saved his life. I called 911, they came, they took him to the hospital, no issues. I need to get more Narcan. It’s important that alcoholics know that it does apply to them, it applies to everyone if you can save someone’s life. "", "comment_id": "FDA-2011-N-0802-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-N-0802-0004", "comment_date": "2012-04-12T04:00:00Z", "comment_title": "Hillary Dubois - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1521}, {"text": "Please see the attached PDF for our comments submitted in collaboration with the American Pharmacists Association. Also, the National Alliance of State Pharmacy Associations would like to again express our appreciation for the opportunity to participate in and serve as a panelist at the FDA meeting: Exploring Naloxone Uptake and Use. Thank you.", "comment_id": "FDA-2011-N-0802-0046", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-N-0802-0046", "comment_date": "2015-09-11T04:00:00Z", "comment_title": "Comment from National Alliance of State Pharmacy Associations and American Pharmacists Association", "commenter_fname": null, "commenter_lname": null, "comment_length": 346}, {"text": "Many news and research articles have been decrying escalating trends in overdoses and deaths from opioid analgesics and heroin. Yet, rarely is mention made of the fact that there is an effective and safe antidote for such tragedies — naloxone. Isn’t it time to stop the complaining, and conducting pilot studies, and to start using naloxone on a broad scale to finally address and ameliorate the problems?

Evidence-based comments by Stewart B. Leavitt, MA, PhD, executive director of the Pain Treatment Topics and Opioids911-Safety education projects are in an attached MS Word document.", "comment_id": "FDA-2011-N-0802-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-N-0802-0003", "comment_date": "2012-04-12T04:00:00Z", "comment_title": "Pain Treatment Topics (Pain-Topics.org) - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 608}, {"text": "Hello,

The United States is a leader in preventing overdose deaths with the use of naloxone.

People from all over the world utilize the resources that have been produced in the US about naloxone. The US has the experience, research, and expertise to respond to this preventable epidemic; leading the way for so many other places.

Having naloxone empowers all parties to engage in meaningful and educational dialogue about the risks associated with substances.

", "comment_id": "FDA-2011-N-0802-0016", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-N-0802-0016", "comment_date": "2012-06-13T04:00:00Z", "comment_title": "Erin K Gibson - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 500}, {"text": "Naloxone use by VA Police in a first responder role outside the VA Hospital on VA grounds or City property requires
regulations to outline clear authority for use.
The Minneapolis VA has extended the naloxone rescue kits to providers to prescribe to patients, in addition, seek to
enable our VA police officers to be trained and have clear authority to administer a potential life saving medication for
opioid overdose.

I have been unable to establish authority for VA Police to administer naloxone (prescription medicine) under a
standing order because a standing order for naloxone is for an unknown patient.
I have asked our VA Legal counsel but no information is available.
The VA Police Chief here in Minneapolis wants naloxone rescue kits available in the medical kits used by the VA officers.
Clinical staff want this as well.
VA Police officers are first responders to off-site areas(not in the hospital) that include apartments on this campus
and must call 911 for city ambulance response if needed. Naloxone could be useful.
Past history does include a drug overdose at VA run apartments, sadly naloxone would not have helped in that case.
The Chief anticipates need. Pharmacy Service will commit to training the officers in opioid overdose avoidance, recognition
and response.
", "comment_id": "FDA-2011-N-0802-0040", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-N-0802-0040", "comment_date": "2015-09-11T04:00:00Z", "comment_title": "Comment from Gary Zielke", "commenter_fname": null, "commenter_lname": null, "comment_length": 1372}, {"text": "The FDA should act swiftly to make naloxone available over-the-counter. Increased access to naloxone will help save the lives of opioid users who often do not receive professional medical help because of the fear of police involvement. The majority of studies that compare different reasons for delaying or foregoing a call for assistance find that fear of police involvement is the most commonly cited reason. I attached an additional file which contains more details on the relevant empirical research. These findings make a compelling case for expanding the availability of naloxone. Even if fear of police prevents the seeking of professional medical assistance, the administration of naloxone by a witness can still save a life. And since it is unlikely that the fear of police will be completely eliminated in the near future, naloxone must be a critical part of comprehensive overdose prevention plans. As of April 11, 2012, only six states grant help-seekers and victims limited immunity from prosecution for possession of controlled opioids. Even in states that have enacted these 911 Good Samaritan protections, awareness of the law may remain low. For example, a year after Washington passed their 911 Good Samaritan law, only one of out of six of Seattle police had heard of it and only one out of three opioid users had heard of it. Furthermore, no state has extended Good Samaritan immunity to distribution offenses, despite the fact that most nonmedical opioid users obtain these drugs from friends or relatives who share or sell them. In this context, naloxone must be available to ensure that fear of punishment does not inadvertently condemn overdose victims to a death sentence.", "comment_id": "FDA-2011-N-0802-0007", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-N-0802-0007", "comment_date": "2012-04-12T04:00:00Z", "comment_title": "Jeffrey Joseph Cece - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1706}]}, {"id": "FRA-2009-0039", "title": "Alcohol and Controlled Substance Testing for Maintenance-of-Way Employees", "context": "2021-02-10T01:34:44Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "See attached file(s)", "comment_id": "FRA-2009-0039-0020", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2009-0039-0020", "comment_date": "2014-12-01T05:00:00Z", "comment_title": "American Public Transportation Association - Comments", "commenter_fname": "Michael P.", "commenter_lname": "Melaniphy", "comment_length": 20}, {"text": "I am a licensed prof. counselor in my state. Would I be eligible to work with employees who have violated the rules of their positions? I have a masters degree in counseling and psychology and have performed non-DOT evaluations. I have extensive experience in substance abuse issues as well.", "comment_id": "FRA-2009-0039-0024", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2009-0039-0024", "comment_date": "2015-06-11T04:00:00Z", "comment_title": "Marion Hecht - Comments", "commenter_fname": "Marion", "commenter_lname": "Hecht", "comment_length": 291}, {"text": "Having worked 30 years in the alcohol and drug field EAP programs are great, but the counselors do no have that 24/7 contact with alcohol and drug clients. Also many of them have little alcohol and drug background/experience (i.e there many qualified SAPs too that do not have the alcohol and drug background:social workers, doctors and other professionals) they are great professionals but lack the knowledge on dealing with this population. Also many of them (EAP) are just too close to the companies. Many of these Employers need to stop doing in-house alcohol and drug training themselves, and bring in experienced SAPs with a lot of alcohol and drug background. What happen in 2007,Massachusetts is the result of rare/little testing and poor supervisor alcohol and drug training/ EAP programs that have weak SAPs with little alcohol and drug background.", "comment_id": "FRA-2009-0039-0004", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2009-0039-0004", "comment_date": "2014-08-04T04:00:00Z", "comment_title": "James Armstrong - Comments", "commenter_fname": "James", "commenter_lname": "Armstrong", "comment_length": 861}, {"text": "It is the opinion of the Semo Port Railroad that the small railroad exception in 49 CFR 219 needs to stay the way it is. If there was to be a change it could cause adverse impact on the small railroads in cost and time for the employees to take out of their day to go to the drug testing facility. We have 4 people in the Semo Port office and only 2 could be considered a maintenance of way worker, but their jobs do not revolve around the railroad solely. Three of the four people who work for Semo Port are drug and alcohol symptom certified to where they can determine whether someone was under the influence or not and we all see each other every day so we would know if something was wrong. We have 5 guys on our train crews that we use on a normal basis. Three of them have been here for going on 21 years and the other two have about 2-3 years of experience and there has never been an issue of someone being under the influence of drugs or alcohol. Semo Port Railroad also has an impeccable safety record. For the last 10 years we have received the ASLRRAs Jake Award for Railroad Safety which is no accidents/incidents in a calendar year. We strive to run a safe and effective railroad.

I did some research and a local drug testing firm gave me a quote on what drug tests cost. A DOT drug test through them would be $47/test. If we would have to drug test 50% of our staff it would equate to an extra $376 in expenses and a 25% alcohol test would equate to $188 for a total of $564 in extra expenses per year that we could use elsewhere in the railroad.

As far as the contractors go, if a contractor does work previously for a railroad that does not have the exception then they will have the drug and alcohol policy already in place. It should be up to the contractor to determine if one of their people is under the influence seeing how they should know their workers better than we do.

Again, the 49 CFR 219 small railroad exception should stay the way it is.
", "comment_id": "FRA-2009-0039-0015", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2009-0039-0015", "comment_date": "2014-11-24T05:00:00Z", "comment_title": "Jacqueline Prater - Comments", "commenter_fname": "Jacqueline", "commenter_lname": "Prater", "comment_length": 2007}, {"text": "Please see the attached comments of the Association of American Railroads.", "comment_id": "FRA-2009-0039-0021", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2009-0039-0021", "comment_date": "2014-12-01T05:00:00Z", "comment_title": "Association of American Railroads and American Short Line and Regional Railroad Association - Comments", "commenter_fname": "Sarah", "commenter_lname": "Yurasko", "comment_length": 74}, {"text": "Date: September 15, 2014

Federal Railway Administration

Docket Management Facility,
U.S. DOT, 1200 New Jersey Avenue SE.,
W12140, Washington, DC 20590.

Via Federal eRulemaking Portal, http://www.regulations.gov

Re: Docket No. FRA20090039

The Pacific Southwest Railway Museum Association, Inc., (PSRM) is submitting comments on FRAs proposal to cover Maintenance of Way (MOW) employees in its Part 219 Control of Alcohol and Drug Use program.

Please see attached file.
", "comment_id": "FRA-2009-0039-0009", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2009-0039-0009", "comment_date": "2014-10-02T04:00:00Z", "comment_title": "Pacific Southwest Railway Museum - Comments", "commenter_fname": "Michael", "commenter_lname": "Edwards", "comment_length": 535}, {"text": "Joint comments of the Rail Labor Organizations (ATDA, BLET, BMWED, BRS, IBEW, SMART-TD)", "comment_id": "FRA-2009-0039-0017", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2009-0039-0017", "comment_date": "2014-11-25T05:00:00Z", "comment_title": "American Train Dispatchers Association (ATDA); Brotherhood of Locomotive Engineers and Trainmen (BLET); Brotherhood of Maintenance of Way Empolyes Division (BMWED); Brotherhood of Railroad Signalmen (BRS); International Brotherhood of Electrical Workers (IBEW) and Sheet Metal, Air, Rail and Transportation (SMART) - Comments", "commenter_fname": "Freddie", "commenter_lname": "Simpson", "comment_length": 87}, {"text": "Attachment #1 - Joint Comments of the Rail Labor Organizations (ADTA, BLET, BMWED, BRS, IBEW, SMART-TD)", "comment_id": "FRA-2009-0039-0018", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2009-0039-0018", "comment_date": "2014-11-25T05:00:00Z", "comment_title": "American Train Dispatchers Association (ATDA); Brotherhood of Locomotive Engineers and Trainmen (BLET); Brotherhood of Maintenance of Way Empolyes Division (BMWED); Brotherhood of Railroad Signalmen (BRS); International Brotherhood of Electrical Workers (IBEW) and Sheet Metal, Air, Rail and Transportation (SMART) - Comments", "commenter_fname": "Freddie", "commenter_lname": "Simpson", "comment_length": 103}, {"text": "See attached file.", "comment_id": "FRA-2009-0039-0023", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2009-0039-0023", "comment_date": "2014-12-01T05:00:00Z", "comment_title": "National Railroad Construction & Maintenance Association - Comments", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 18}, {"text": "See attached file(s)", "comment_id": "FRA-2009-0039-0011", "comment_url": "https://api.regulations.gov/v4/comments/FRA-2009-0039-0011", "comment_date": "2014-10-02T04:00:00Z", "comment_title": "SAPlist.com - Comments", "commenter_fname": "Lee", "commenter_lname": "Mauk", "comment_length": 20}]}, {"id": "DEA-2014-0012", "title": "Importer of Controlled Substances Application", "context": "2021-12-02T01:00:48Z", "purpose": "Nonrulemaking", "keywords": null, "comments": [{"text": "See Attached", "comment_id": "DEA-2014-0012-0002", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2014-0012-0002", "comment_date": "2014-07-28T04:00:00Z", "comment_title": "Austin Pharma Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}]}, {"id": "FDA-2013-P-0703", "title": "Request to Foster a Transition to Abuse-Deterrent Opioids and Promoting Greater Access to Treatment for Opioid Addiction and, More Specifically, Medication-Assisted Treatment (\"Mat\"), as set out in the Petition-CLOSED", "context": "2015-03-11T20:19:12Z", "purpose": "Nonrulemaking", "keywords": ["cder", "2013-4480", "medication-assisted treatment", "abuse-deterrent", "opioids", "ANDA", "abuse", "abstinence", "Epidemic", "Prescription Pills", "CDC", "closed"], "comments": [{"text": "I am very disturbed by a recent FDA decision to fail to approve Titan Pharmaceutical's new drug application for Probuphine, a novel implant to aid those who are addicted to opioids in eliminating their dependency and resuming normal and productive lives. With the current epidemic of opioid addiction in the United States and the current emphasis placed on finding ways to combat this addiction while reducing the extreme risk of diversion of these medications, this medication can be pivotal in the process of change. Probuphine met the criteria for approval which the FDA themselves established for the drug to meet- the ADCOM on March 21st rendered a positive vote of 10 members For Approval, 4 Against, with 1 Abstaining- yet the drug was not approved by the FDA on April 30th. The reasons for non-approval make little to no sense, given what the FDA agreed to at the outset of Titan's study in order for approval. Everything the FDA was asking for in their Complete Response Letter to Titan Pharmaceuticals could have been determined post-approval, and Titan could have proceeded forward in changing and saving people's lives immediately. The decision on April 30th by the FDA would suggest something more than mere trepidation on their part. This is a huge step backwards in President Obama's pledge to combat and eradicate this scourge on the American people. I would urge the FDA to look into this matter at their earliest possible convenience. A delay of 6-30 months to gain approval on this drug could cost the lives of many more people who might otherwise be saved here and now by its approval. The opioid addiction epidemic has been well-documented and has become a focus of the current administration- right here, right now is a viable answer and alternative to what is woefully, inadequately available currently.", "comment_id": "FDA-2013-P-0703-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2013-P-0703-0003", "comment_date": "2013-08-15T04:00:00Z", "comment_title": "Jerry E Gundersheimer - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1843}]}, {"id": "CDC-2020-0091", "title": "Medication-Assisted Treatment (MAT) for Opioid Use Disorders Study 0920-1218 Revision ", "context": "2020-10-29T08:07:41Z", "purpose": "Nonrulemaking", "keywords": null, "comments": [{"text": "Regarding the Department of Health and Human Services/Centers for Disease Control and Prevention (hereinafter "the agency") request for additional time to collect patient data regarding opioid addiction, there are a few things to consider. First, the patient recruitment period for this project was extended so it should have been expected that the processing of the collected data would also require some extensions in response. Also, there is practical utility in the information being requested by the agency because without treatment information to battle opioid addiction, we won't know what works and what doesn't. This information is necessary to the functions of the agency in their pursuit to enhance the health and well-being of all Americans. While we are currently in the midst of a global COVID pandemic, we cannot set aside the opioid epidemic that has been ravaging this country for years now. Gathering this information is necessary to continue the fight against addiction in this country. While many Americans are currently out of work and facing economic difficulties due to the COVID pandemic, many may be turning to their addictions to cope. Now more than ever we need as much information as possible to assist in battling this debilitating addiction to opioids be it through medication-assisted treatment, or otherwise. It is imperative to obtain this information to find out what treatment is working and what is not, and what factors can contribute to a successful recovery. The agency has estimated a straightforward and minimal cost to obtaining this information but there are not many details on how this information will be obtained. The questionnaire to be submitted by the patients seems a minimal inconvenience to the patient and of a minimal cost to the agency to process. Due to a lack of details, it could be assumed that this questionnaire would be obtained through electronic means, through the mail, and possibly an in-person pick up or drop off site. An electronic portal would be the most convenient, but not all patients may have access to the technology needed to return the information requested. Having a secure address for each patient and including a self-addressed stamped envelope could go a long way in receiving the information back but also having a site for information pick up and drop off - possibly at the local health department or their treatment site, could all contribute to receiving the information from each patient participant with minimal inconvenience. The information collection costs cited by the agency are extremely low in comparison to the value of the information. When you contrast the costs of the estimated 300 hours it would take to process the returned information versus the recent $8 billion settlement against Purdue Pharma, it could even be argued that these efforts could be increased. Deaths have been on the rise since approximately 2014 and efforts need to be increased in understanding the addiction and what utilities we have available to battle the addiction. This request by the agency should be considered a low cost, inconvenient starting point.", "comment_id": "CDC-2020-0091-0003", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0091-0003", "comment_date": "2020-10-29T04:00:00Z", "comment_title": "Comment from (Anonymous Anonymous)", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 3151}, {"text": "Medication Assisted Treatment (MAT) has been a wonderful option for those in need. I firmly believe that primary care providers should be not only Able to prescribe, but ENCOURAGED TO PROVIDE this option for their patients. In so many areas the access to "clinics" that utilize MAT becomes more than another barrier to treatment- but a giant HURDLE that many folks cannot physically, economically, mentally, emotionally, and quite LITERALLY overcome. We need to end the stigma of being on medications to treat patients. Can you imagine...if everytime that you needed the medication to manage your "blood pressure" or "high cholesterol"... you had to drive 120 miles round trip, DAILY for 90 days, attend "groups" that inform you about the stuff that you already KNOW- or could simply GOOGLE & find out about your medical issue, possibly LOSE ACCESS to the medication because of human error that was made in a routine mandatory lab that you had no control over, & then had to deal with others who don't understand "high blood pressure" JUDGING YOU CONSTANTLY & shaming you for having it?
Or, can we simply let primary care providers DO THEIR JOBS, TREAT THEIR PATIENTS, encourage those who seek treatment, & DEFEND THEIR RIGHT TO ACCESS OF MEDICATION?! One more thing.... the idea that a human being needs to choose which debilitating illness- Acid Reflux (treated effectively with omeprazole) or Hypothyroidism (treated effectively with Synthroid) is insane! Oops....wait..that IS NOT THE CASE! Both of those diagnoses are JUST FINE TO HAVE TOGETHER. I meant these- PTSD/ANXIETY disorder (treated effectively with benzodiazepines) and chronic pain (treated Effectively with opiates). Humans who have established treatment regimens that are effective shouldn't have to suffer because of a non-healthcare provider gets to decide what is best for their health. ", "comment_id": "CDC-2020-0091-0002", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0091-0002", "comment_date": "2020-10-20T04:00:00Z", "comment_title": "Comment from (Anonymous Anonymous)", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 1936}]}, {"id": "DEA-2020-0031", "title": "Implementation of the Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act: Dispensing and Administering Controlled Substances for Medication-Assisted Treatment", "context": "2023-01-05T11:23:11Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "Please see attached comment letter from Partnership to End Addiction. Thank you for the opportunity to submit comments.", "comment_id": "DEA-2020-0031-0026", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0031-0026", "comment_date": "2020-12-15T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-23813", "commenter_fname": "Lindsey", "commenter_lname": "Vuolo", "comment_length": 119}, {"text": "See attached file(s)", "comment_id": "DEA-2020-0031-0037", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0031-0037", "comment_date": "2020-12-29T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-23813", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file.", "comment_id": "DEA-2020-0031-0047", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0031-0047", "comment_date": "2021-01-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-23813", "commenter_fname": "Patrick", "commenter_lname": "Kennedy", "comment_length": 18}, {"text": "To Whom it May Concern,

The Colorado Pharmacists Society, a 501c(6) organization representing pharmacy professionals (pharmacists, technicians and interns) in the state of Colorado would like to take the opportunity to SUPPORT the following with respect to the Interim Final Rule:

Administration of long-acting injectables by non-data waived practitioners. Ask for the DEA to confirm that non-data waived health-care practitioners (HCPs) can administer long acting injectable forms of controlled substances subject to having a prescription data waived HCP.

Pharmacists ability to administer long-acting injectables. Ask the DEA to confirm that pharmacists are considered HCPs and that they can (subject to state laws) administer long-acting forms of injectable controlled substances subject to having a prescription from a data waived HCP for the patient. This confirmation is especially import for rural patients who are more likely close to a pharmacy than a data waived HCP. This also makes sense given the rise of telemedicine that has taken place during the COVID19 pandemic

Thank you,

Emily Zadvorny, PharmD, BCPS
Executive Director
Colorado Pharmacists Society
", "comment_id": "DEA-2020-0031-0045", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0031-0045", "comment_date": "2021-01-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-23813", "commenter_fname": "Emily", "commenter_lname": "Zadvorny", "comment_length": 1231}, {"text": "See attached file(s)", "comment_id": "DEA-2020-0031-0048", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0031-0048", "comment_date": "2021-01-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-23813", "commenter_fname": "Deepti", "commenter_lname": "Loharikar", "comment_length": 20}, {"text": "11 / 02 / 2020

COMMENTS: I have practiced medicine for 37 years and currently, I am the Chief Medical Officer at Urgent Point in Los Angeles, CA. I have been a DATA 2000 provider since 2001 and I have successfully treated thousands of patients over 20 years who suffer with chronic pain disorders and opioid use disorder. Over 20 years, my perspective on the treatment of opioid use disorder utilizing MAT has become more realistic because I have observed a dysfunctional medical system misunderstand the general approach to the treatment of opioid addiction.

There is no doubt that we do not have enough providers to treat opioid addiction. However, the problem is more complex and just allowing more providers to treat more patients will not necessarily reduce our countries epidemic of opioid use disorder. Currently 4% of the world's populations in the United States consumes 80% of the opioids produced by our world. Unfortunately, many of the providers who undergo training on the use of MAT do not fully understand that opioid use disorder is a condition that requires at minimum 6 months treatment and often requires a longer period of time.

Unfortunately, opioid addiction treatment has been treated as though opioid addicts are similar to alcoholics and residency training and AA oriented treatment programs in the United States have resulted in the emphasis being that addicts must approach their opioid addiction from an AA behavioral emphasis and this has caused many opioid addicted individuals to be undertreated because providers insisted on rapid tapering off BUPRENORPHINE early in treatment or forced patients to use lower doses of BUPRENORPHINE early in therapy. It is this emphasis that has resulted in opioid addicts early relapse and re-addiction to opioid drugs.

MAT should be offered as chronic therapy, like we treat all other chronic disorders ie. Diabetes, hypertension, heart disease, headaches, etc. The average treated individual is on 16 mg daily of BUPRENORPHINE to reduce 90% or more of opioid craving. It is only while opioid craving is extinguished that addicts are able to change behavior over time. The danger in the DEA changes is that more providers will be created and it will be easier to provide therapy but, if attitudes remain the same, we may say increased misuse and diversion. Our system of addiction treatment spends more money on keeping patients in residential treatment than to just treat people and monitor them as outpatients.
In Europe, providers treat patients for years and rigidly control the use of prescriptions with the primary care physician in control. In the U.S. the only drug that needs to be dispensed from the office is SUBLOCADE. In residential treatment, physicians can prescribe SUBOXONE for dispensing under rigid prescription controls. At discharge, the pharmacy should be the dispensing entity, not the physician provider.

I am glad that the DEA is changing the dynamics of access to treatment but, the overall approach to treatment must undergo a coordinated management approach that includes provider education and a focus that emphasizes necessary therapeutic approaches rather than to add cost to treatment by forcing unneeded "cookie cutter" AA management requirements. It is important to remember that Methadone is a form of MAT and the only requirement is to present to the clinic daily. AA management is not required. Buprenorphine is a better alternative because it is one of the safest medications ever produced. The insistence on AA philosophy over medication therapy has resulted in rigid treatment. Patients on an average of 16 mg daily will have opioid craving blocked and can change behavior without having to fight the opioid craving that drives addictive behavior. Providers should focus on monitoring of care and maintaining sobriety over forcing AA attendance.

The primary point is that BUPRENORPHINE dispensing really doesn't require inpatient or residential treatment for the most part. As Methadone treatment has proven, it is the blocking of opioid craving that is the primary effect of MAT. I hope that my comments are helpful and provide a rationale observation regarding how opioid use disorder treatment should be viewed. Opioid addiction treated from the primary care office, like we treat most chronic disease is how we will successfully address our current epidemic of opioid addiction. It will be much less costly and more effective if we focus on how MAT should be instituted. The Residential treatment and addiction treatment center political lobby are focused on the most-costly therapies and will only perpetuate the current ineffectual opioid treatment approaches. Any changes in the prescribing of MAT must include an aggressive education program for providers that is uniquely mandated for the treatment of opioid use disorder.

Thank you and I am happy to continue this in-depth discussion in the future.

Sincerely,
Rick Chavez, M.D.

", "comment_id": "DEA-2020-0031-0002", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0031-0002", "comment_date": "2020-11-10T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-23813", "commenter_fname": "Rick", "commenter_lname": "Chavez", "comment_length": 5094}, {"text": "See attached file(s)", "comment_id": "DEA-2020-0031-0017", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0031-0017", "comment_date": "2020-12-01T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-23813", "commenter_fname": "Emily", "commenter_lname": "Laufer", "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "DEA-2020-0031-0022", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0031-0022", "comment_date": "2020-12-10T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-23813", "commenter_fname": "Ted", "commenter_lname": "Buckley", "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "DEA-2020-0031-0014", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0031-0014", "comment_date": "2020-11-27T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-23813", "commenter_fname": "Christina", "commenter_lname": "Harley", "comment_length": 20}, {"text": "As the only pharmacist in the North Carolina General Assembly I believe North Carolina is on the frontline of the opioid crisis. One proven solution is the use of long acting injectable formulations of buprenorphine. It is vital that all individuals diagnosed with opioid use disorder have the necessary access to important forms of medication for treatment. The interim final rule currently contains unnecessary restrictions that would hinder patient access.
First, the fourteen-day rule does not take into account that it may take longer than 14 days to arrange for a patient to visit a clinic to receive the injection or that currently medications obtained via buy-and-bill options are permitted to be stored for periods far exceeding 14 days. In order to ensure proper access, the ability to store injectable medications should be extended to at least 60-days.
Secondly, in many instances, data 2000 waived practitioners, while able to prescribe injectable buprenorphine, may not have a facility to administer the injections. To accommodate this, non-data waived practitioners should be permitted to administer injections ordered by a data waived provider. This should include pharmacists who may administer injections ordered by data waived providers. This can ensure that patients in rural areas, residential care facilities, and those receiving regular treatment via telemedicine can receive life-saving medication to treat their opioid use disorder.
", "comment_id": "DEA-2020-0031-0031", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0031-0031", "comment_date": "2020-12-22T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-23813", "commenter_fname": "Representative Wayne", "commenter_lname": "Sasser", "comment_length": 1471}]}, {"id": "CMS-2020-0060", "title": "Value in Opioid Use Disorder Treatment Demonstration (CMS-10728)", "context": "2021-04-04T01:05:32Z", "purpose": "Nonrulemaking", "keywords": null, "comments": [{"text": "See attached file(s)", "comment_id": "CMS-2020-0060-0009", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2020-0060-0009", "comment_date": "2020-07-29T04:00:00Z", "comment_title": "Comment on CMS-2020-0064-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "How do an FQHC sign up to participate. Please advise.

Thanks,

", "comment_id": "CMS-2020-0060-0002", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2020-0060-0002", "comment_date": "2020-07-14T04:00:00Z", "comment_title": "Comment on CMS-2020-0060-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 80}, {"text": "Please see attached comments from the American Association of Nurse Practitioners on CMS-10728 Value in Opioid Use Disorder Treatment Demonstration. ", "comment_id": "CMS-2020-0060-0007", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2020-0060-0007", "comment_date": "2020-07-29T04:00:00Z", "comment_title": "Comment on CMS-2020-0064-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 149}, {"text": "See attachment re CMS-10728 Value in Opioid Use Disorder Treatment Demonstration", "comment_id": "CMS-2020-0060-0006", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2020-0060-0006", "comment_date": "2020-07-29T04:00:00Z", "comment_title": "Comment on CMS-2020-0063-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 80}, {"text": "Please see the attached letter from the American Society of Addiction Medicine (ASAM).", "comment_id": "CMS-2020-0060-0003", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2020-0060-0003", "comment_date": "2020-07-28T04:00:00Z", "comment_title": "Comment on CMS-2020-0060-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 86}, {"text": "See attached file.", "comment_id": "CMS-2020-0060-0008", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2020-0060-0008", "comment_date": "2020-07-29T04:00:00Z", "comment_title": "Comment on CMS-2020-0064-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 18}, {"text": "Please see attached. ", "comment_id": "CMS-2020-0060-0004", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2020-0060-0004", "comment_date": "2020-07-29T04:00:00Z", "comment_title": "Comment on CMS-2020-0060-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 21}, {"text": "Please see the attached letter from axialHealthcare.", "comment_id": "CMS-2020-0060-0005", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2020-0060-0005", "comment_date": "2020-07-29T04:00:00Z", "comment_title": "Comment on CMS-2020-0060-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 52}]}, {"id": "CMS-2019-0090", "title": "Secure Electronic Prior Authorization for Part D Drugs\nCMS-4189-P", "context": "2021-06-11T13:26:49Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "See attached file(s)", "comment_id": "CMS-2019-0090-0053", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0090-0053", "comment_date": "2019-08-21T04:00:00Z", "comment_title": "Abarcahealth", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "On behalf of McKesson, I am pleased to submit comments on the proposed rule "Medicare Program: Secure Electronic Prior Authorization for Medicare Part D (CMS-4189-P)."", "comment_id": "CMS-2019-0090-0042", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0090-0042", "comment_date": "2019-08-20T04:00:00Z", "comment_title": "McKesson Corporation", "commenter_fname": null, "commenter_lname": null, "comment_length": 177}, {"text": "Please see attached comments from the American Association of Nurse Practitioners. ", "comment_id": "CMS-2019-0090-0012", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0090-0012", "comment_date": "2019-08-20T04:00:00Z", "comment_title": "AANP", "commenter_fname": null, "commenter_lname": null, "comment_length": 83}, {"text": "See attached file(s)", "comment_id": "CMS-2019-0090-0011", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0090-0011", "comment_date": "2019-08-20T04:00:00Z", "comment_title": "Senior Care Pharmacy Coalition", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Please find attached comments from the American Medical Association. ", "comment_id": "CMS-2019-0090-0031", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0090-0031", "comment_date": "2019-08-20T04:00:00Z", "comment_title": "American Medical Association", "commenter_fname": null, "commenter_lname": null, "comment_length": 69}, {"text": "Prior authorizations (PAs) were implemented as cost saving measure, to ensure that expensive medications were truly needed and that no less costly alternative was an option. Currently, prescribers and their staff spend an inordinate amount of time on PAs, sometimes nearly two workdays cumulatively (Robeznieks, 2018), putting the cost saving benefit into question. As electronic prescribing and electronic health records become the rule rather than the exception, it makes sense to tie the acts of prescribing and authorizing together.
It is difficult to justify the upfront costs without looking at the bigger picture, because the entities subject to the upfront costs of converting to an electronic PA platform may not be the same entities benefiting from the cost saving. As both a healthcare consumer and a registered nurse, I can see clear benefit to this proposed change. From the provider standpoint, I have personally seen the snowball effect that the hassle associated with PA leads to. Patients can be deterred by the PA process, causing decreased medication compliance which ultimately causes larger health problems and increased cost. Research by CoverMyMeds, a company that produces electronic PA software, discovered that nearly 30 percent of these prescriptions are abandoned by patients(Beaton, 2018). As a person prescribed a medication that required a PA, it was frustrating to learn that often the prescriber was unaware of the PA requirement, since they can vary with insurance providers or the indication for the prescription. Having built-in alerts that inform the provider of the requirement, while prompting for the PA in real time simply makes good sense.

Beaton, T. (2018). 96% of payers are committed to electronic prior authorization. Health Payer Intelligence. Retrieved from https://healthpayerintelligence.com/news/96-of-payers-are-committed-to-electronic-prior-authorization.

Robeznieks, A. (2018). Cut prior authorization hassles through automation, EHR integration. American Medical Association. Retrieved from https://www.ama-assn.org/practice-management/sustainability/cut-prior-authorization-hassles-through-automation-ehr
", "comment_id": "CMS-2019-0090-0002", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0090-0002", "comment_date": "2019-07-23T04:00:00Z", "comment_title": "Sheva Serhofer", "commenter_fname": null, "commenter_lname": null, "comment_length": 2189}, {"text": "THIS PROPOSED RULE IS YET ANOTHER DEMAND ON NONREIMBURSED PHYSICIAN TIME. IF PASSED, IT MUST INCLUDE A FEE SCHEDULE, SUCH AS A $25 FLAT REIMBURSEMENT PER GENERATED PAR.", "comment_id": "CMS-2019-0090-0004", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0090-0004", "comment_date": "2019-07-23T04:00:00Z", "comment_title": "Ninon Germain", "commenter_fname": null, "commenter_lname": null, "comment_length": 171}, {"text": "See attached file(s)", "comment_id": "CMS-2019-0090-0005", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0090-0005", "comment_date": "2019-07-23T04:00:00Z", "comment_title": "Comment on CMS-2019-0090-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Point-of-Care Partners (POCP) is pleased to provide the Centers for Medicare and Medicare Services (CMS) with comments on CMS 4189, Medicare Program; Secure Electronic Prior Authorization for Medicare Part D.

As conveyed in our comments, POCP is uniquely positioned to comment on this proposed requirement. We are a nationally recognized consulting firm in the areas of electronic prescribing (ePrescribing); standards to support payers, prescribers and pharmacies; specialty pharmacy automation; electronic exchange of health and administrative data; interoperability of electronic health records (EHRs); and electronic medication management. POCP also provides related management and strategic consulting services in those areas to a wide range of stakeholders.

POCP applauds CMS in taking another step forward to stimulate adoption of ePA for drugs covered under the Medicare Part D patients pharmacy benefit. Thank you for the opportunity to provide feedback.

Please see attached file for our full comments.", "comment_id": "CMS-2019-0090-0052", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0090-0052", "comment_date": "2019-08-21T04:00:00Z", "comment_title": "Point-of-Care Partners", "commenter_fname": null, "commenter_lname": null, "comment_length": 1040}, {"text": "Please see the attached for comments from the American Academy of Neurology.", "comment_id": "CMS-2019-0090-0007", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0090-0007", "comment_date": "2019-08-13T04:00:00Z", "comment_title": "Comment on CMS-2019-0090-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 76}]}, {"id": "FDA-2021-N-0275", "title": "Morphine Milligram Equivalents: Current Applications and Knowledge Gaps, Research Opportunities, and Future Directions; Public Workshop; Request for Comments", "context": "2021-09-02T12:14:28Z", "purpose": "Nonrulemaking", "keywords": ["2020-846", "CDER", "Notice", "Morphine Milligram Equivalents:", "Current Applications and Knowledge Gaps,", "Research Opportunities, and Future Directions;", "Public Workshop;", "Request for Comments", "Open"], "comments": [{"text": "Please remove MME's. Its based on flawed information. Everyone metabolizes medicines differently. Everyone also does better or worse on different medicines. Pain is NOT the same for everyone. There are SO many different types/kinds of pain. As there are many different levels of pain for different people. Expecting everyone to do well on the same medicine or same amount of medicine is insane. The government should NOT be putting restriction on doctors(so then it harms us American people in pain). The doctor knows his patients the best. And we(the people) know our bodies & pain the best.(& what works best for us).
The "opioid epidemic" is 90 some percent because of illegal street drugs. NOT safe & effective prescription pain medicines. Please STOP harming us(the American people in pain) more then we're already hurting. Its insane that we are now forced to live in excruciating pain & can't get out of bed or out of our homes because of being in SO much pain because of being cut off or cut SO low from the medicines that once gave us quality of life. Which means now we can't work or take care of our families. No wonder there are more & more committing suicides. Or just as bad, turning to illegal street drugs.
Since the 2016 CDC guidelines & mme caps were made, over doses & deaths from illegal street drugs have shot up drastically(way way more then even before 2016). Because the gov't is just pushing more & more right to illegal street drugs since they can't get quality or care or treated humanely because they can't get their pain treated accurately any more. This HAS to STOP!!! PLEASE! Millions of us people in pain are begging you! PLEASE!!! Thank you!
Prescription pain medicines(opioids) are not harming or killing us. You have it ALL wrong & are harming us more & even killing us!!! Its illegal street drugs(opioids) that are causing the over doses & deaths. Please, Please, PLEASE stop the torture on people in pain who are trying to get their pain treated accurately, legally & humanely. & hopefully with a little compassion. Which you've taken away, since the doctors are SO restricted now.
The opium plant was given to us since the beginning of time to help us with our pain. Problems didn't start to occur until illegal street drugs came into the picture. Because illegal street drugs aren't controlled & you never know what they will contain or how much. Plus then people use other drugs or alcohol & that's what causes them to overdose or die. Speaking of alcohol, people die of alcohol thousands of times more then prescription pain medicines(& illegal street drugs) but yet alcohol is legal??? Go figure!!! Please stop torturing people in pain who just want to get relief(legally) & be able to live a half normal life. Please get rid of mme's and the cap on prescription medicines.
One day you might find yourself in constant, ongoing pain, day after day, that nothing else helps but prescription pain medicines. But then 'YOU" won't be able to get relief then either. How would you like to live your life like that? I'm sure you wouldn't. Well, we don't want to either. Prescription pain medicines are approved to help pain. & they work for many many people(who take them responsibly). We the people should have the freedom to be able to get medicines that help us so we can move around(work, take care of family, etc.). We should NOT be restricted & pain medicines should NOT be held from us when they greatly help us & give us a much better quality of life. We should have a say in what our medical care consists of. We should NOT be restricted. Nor should things that help us be held back from us. Nor should we be forced into something we're not comfortable with(or that isn't approved like injections).
Please help stop the torture people in pain are having to go through now. Please stop mme's & cap's on them.
Thank you very much!", "comment_id": "FDA-2021-N-0275-0127", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0275-0127", "comment_date": "2021-06-28T04:00:00Z", "comment_title": "Comment from Candi Petelli", "commenter_fname": null, "commenter_lname": null, "comment_length": 4137}, {"text": "Imagine living with a rare genetic bone disease that has no cure and causes excruciating pain. Then imagine the medication that effectively alleviated that pain for 29 years is abruptly tapered and you are forced to take only half the dosage your body has become dependent on.
Not only is the pain unbearable, but the resulting stress placed on the body prevents you from exercising or participating in physical therapy, which is vital to someone with Ochronosis/Alkaptonuria (AKU) to prevent chronic joint pain and inflammation.
AKU is known as “Black Bone Disease” because it turns bones black and brittle. It is the oldest metabolic disease on earth and has even been found in Egyptian mummies!
After being diagnosed with AKU, I was placed on a very high dosage of morphine to stop my body from producing Homogentisic Acid (HGA). People like me born with AKU are missing an enzyme that prevents them from fully breaking down HGA. At high levels, HGA devours my bones, turning them black and stripping the cartilage and cushions between them.
My former physician of 32 years identified morphine as a pain medication that helped without causing side effects. I was able to function again and live a decent life, in spite of having a debilitating disease.
But in 2017, the CDC opioid guideline was adopted in Hawaii as state law, and my doctor was driven out of practice. I cannot find a doctor to replace him. They all see my need for morphine, but they do not want to risk their livelihoods by taking me on as a patient. I am being harmed by the state and no one will do anything to help me! Due to the morphine being reduced to half of my original dosage, the HGA accumulation has eaten two holes into my heart valves, resulting in a life-threatening heart condition. HGA has also spread to my upper cervical spine, my lower cervical spine, along with my liver and kidneys.
I have endured irreparable damage by being forced off my old dosage of medication in such an inhumane manner. Every doctor I have been referred to has refused to accept me as a patient once they look over my medical records and see I have a rare genetic bone disease that requires opioids.
Only when I was forced on a lower dosage did AKU start to spread. I have had four failed surgeries on a non-operative disease, and no doctor wants to put their livelihood on the line to help keep this disease from hurting me more!
I have never abused drugs or alcohol in any form. I have comprehensive medical records, including MRIs and x-rays documenting my illness and treatment history. It will also show that for 29 years on the original morphine dose, my liver stayed strong and clean, compared to a patient who has been on a toxic medicine like Suboxone that is just as addictive.
Please help me obtain the help I need before this disease spreads even more than it has. I am totally bedridden and need help to regain my quality of life.
I pray that a revision of CDC guideline will allow doctors to do their jobs again without being persecuted, and will give me back my life so that I can grow old with dignity. Legitimate pain patients who had never abused drugs are getting treated like addicts, demonized for taking prescribed medicines from licensed doctors.
Please watch this video if you have any questions about my disease: https://www.youtube.com/watch?v=7PpQU3wrdlM&t=30s
Gigi Brandford lives in Hawaii.
\u2028
", "comment_id": "FDA-2021-N-0275-0132", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0275-0132", "comment_date": "2021-06-28T04:00:00Z", "comment_title": "Comment from Virginia Brandford", "commenter_fname": null, "commenter_lname": null, "comment_length": 3469}, {"text": "As with the entirety of the CDC guidelines and their implementation and cross reference allegedly unintended amongst agencies, private and public, medical facilities, practices, and other clinical locations and policies, the MME standards are not backed by high quality science of the 3,4 or even 2nd level.

This is significant because while people who are clinically addicted as indicated by medical manuals have access to MAT including various buprenorphine products which has no defined MME equivalent and is very dangerous when considering the abuse and overdose context, medications more frequently used from chronic pain in the four decades ending through 2010 (many of which are used today but overall opioid prescribing(s) have dived off a cliff declining by roughly 70% since 2011) it makes no sense that narcotics such as hydrocodone, oxycodone, meperidine, hydromorphone, etc have become considered more dangerous and in the context of addiction and overdose, no more than 1% experience these adverse events (refer to BMJ); further, as a chronic pain patient, I can tell you doctors know what they are doing usually and are disgusted with the extreme interference by DOJ (including state DOJs) DEA, BOPs, Med Boards, etc as they seek to cast the addiction spell on all patients experiencing chronic pain from varying sources and diseases (endometriosis, sickle cell, myalgic encephalitis/chronic fatigue syndrome, CANCER) Most doctors already understand the pain medication hierarchy (for example: oxycodone is orally stronger than codeine mg for mg)
Most doctors try everything else before narcotics, and most patients are literally scared to death of narcotics.

The MME, based on little to zero science, has done nothing but to limit doctors in their individualized treatment. MME use in clinical settings has caused doctors of all shapes, types, and sizes to become scared of these millennia old opium medications and their century plus old derivatives (for example: hydrocodone & oxycodone synthesized around 1918 most likely for war vets which btw whose suicide rates have doubled in the middle of the cutting off of their decades old utilized narcotic pain meds)

To conclude, MMEs are not useful, do not make sense, do not prevent the patient that wants to down a bottle of ANY AVAILABLE pills for suicide(s), and are NOT scientifically backed by any source that has zero COI.

Oxycodone is stronger than hydrocodone but as a result of MME use and CDC guidelines, myself as a patient who experiences better analgesia and less side effects with hydrocodone, am unable to get an effective dose of a hydrocodone product (60-90 mg/mme/day) and instead I am left to deal with 45 mg of oxycodone per day because according to MME/CDC guidelines, this equals 67.5 MME (yes, chronic pain patients have careers, can do math, and are also intelligent humans).

So in effect, MME has forced me to be on a medicine that I don't feel is as effective. I should not have to feel that I "am lucky to get treated at all" as I have been made to feel based on all government policy.

One more thing: doctors and pharmacists are scared of the number of pills as well as the dosage: Vicodin HP 1 every 4 hours or 180/mo makes sense based on my pain level and represents no increase for five to seven years in my clinical treatment but because of MME, 180 tablets per month is considered "too many" even though it equals in MME what I receive in oxycodone.

I hope this reaches someone sane, intelligent, and not bought off by big pharma like Vanila Singh. Ms Singh will go down in history as the worst USA CMO because she now has a board position at BioDelivery Sciences, Inc and makes a wonderful $450,000 per annum for promoting buprenorphine products as the sole opioid to be used for chronic pain.

My final note is that before the 2016 CDC guidelines became implemented into various laws, forced into clinical practice, etc., I was very stable as a patient 6'2" 170 6-10% body fat, exercised 1-2 hours a day 3-4 days a week, could withstand 12 hour work days & my pain was effectively managed because with some diseases SYMPTOM MANAGEMENT IS ALL YOU CAN DO.

Preventive measures like food cannot fix genetics, and we are not nazis practicing eugenics. I appreciate my heritage with blonde hair and blue eyes BUT EUGENICS is NOT what America is about.

I wish the worst on anyone who doesn't get it, doesn't understand ultra metabolizers, and doesn't have a friend/family member experiencing a disease with pain as a symptom. Based on stats tens of millions of people experience debilitating chronic pain to the point they are disabled. That's not cool, fun, funny, exciting, or interesting to deal with.

Best wishes-", "comment_id": "FDA-2021-N-0275-0138", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0275-0138", "comment_date": "2021-06-28T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 4879}, {"text": "Docket No. FDA-2021-N-0275 Please see attached comments about both the flawed MME guidelines and the resulting CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016, which are based on the MME guidelines.", "comment_id": "FDA-2021-N-0275-0136", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0275-0136", "comment_date": "2021-06-28T04:00:00Z", "comment_title": "Comment from Lisa Amos", "commenter_fname": null, "commenter_lname": null, "comment_length": 233}, {"text": "1. Observe Goodhart's Law

Simplifying the complexity of prescription decisions into a framework of guidelines transfer the focus away from the care of the patient and towards the guidelines themselves.

The quality of care then becomes defined by how well the guidelines approximate patient care. But pain is fundamentally subjective - both a symptom and a disease - manifesting in unique ways per patient.

Accurate guidelines should reflect the complexity in pain presentation, not attempt to standardize decision-making.

For in simplifying, we inevitably oversimplify, and impose an unfair standardization on prescribing decisions that adversely affect patients.

Ensure that the revise guidelines do not hurt patient care by constraining provider decision-making.

2. Focus on Maimonidean Uncertainty

The physicians of lore upon which we conduct oaths to patients - Hippocrates and Maimonides - were empiricists and focused on treating patients by minimizing the uncertainty in presenting symptoms.

Healthcare is unavoidably litigious, and much of the policies enacted are as much legal as medical. We must find a balance between the rubrics of law, which favor standardization and simplification, and the complexity of medicine, which favor direct experience and uncertainty.

This balance can be found in structuring the guidelines in a manner that encourages a specific perception relative to a decision. For example, instead of relying on a guideline recommending initial dose of opioids to be prescribed, create a guideline that emphasizes a line of thinking, a perception, to enhance the decision-making process.

3. Guidelines as Nudges

The guidelines effectively become nudges - not prompting a decision, but prompting a thought process. Providers must justify their decisions through appropriate, clinically-sound rationale, utilizing a clinically accepted perception-driven guidelines.

In this manner we standardize how providers should think, but allow the thinking to cater to each patient's unique needs.

Healthcare is as much behavioral economics as it is a science. The former recognizes that decisions are often irrational, but by creating guidelines that emphasize rational thinking, clinically sound frameworks of patient care, we place the onus on providers to think through their clinical decisions - and utilize that thinking as the legal justification.

Instead, we have abrupt discontinuations or forced tapering schedules, attempting to approximate the guidelines with irrationally oversimplified decisions. We should revise the guidelines to encourage patient-centric thinking, allowing providers to customize patient care by adhering to one of multiple guidelines that structures how providers should think through the decision to prescribe opioids.

Examples of such guidelines that emphasize clinically appropriate thinking focus on the relationship of the patient to the medication, and the benefit gleaned relative to the acceptable risks of the medication.

4. Additional documents

Please see the attached documents. They highlight my efforts to expound upon frameworks of medical jurisprudence. Please note that I have both medical and legal experience with the opioid epidemic, and I hope my experience can help identify meaningful solutions for the opioid epidemic.

I am willing to volunteer my time to help your efforts.

Please email me at jjoshi45@gmail.com or call me at 630-430-8024.", "comment_id": "FDA-2021-N-0275-0139", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0275-0139", "comment_date": "2021-06-28T04:00:00Z", "comment_title": "Comment from Daily Remedy", "commenter_fname": null, "commenter_lname": null, "comment_length": 3595}, {"text": "You cannot set a limit for opioids or any other medications. Everyone is different & processes medication differently, just as they do different medications. We are not robots that can all take the same medicine at the same doses & have the same outcomes. We as people, our bodies are different & don't work like that.
Between the 2016 CDC guidelines & the mme's, people in pain are being tortured. The government is playing doctor & knows nothing about our bodies & our pain(nor does it know our tolerances & how our bodies process pain meds or at what doses helps our pain). Everyone's pain is different & should not be treated the same. Some people do well with lower doses. But some people need higher doses & do very well with them.
The government needs to quit playing "All mighty" or "All knowing" & stop restricting our doctors which in turn stops people in pain from receiving compassionate care & held from medicines that can greatly help them.
Restricting doctors from prescribing prescription pain medicines are torturing people in pain & are just forcing then to go to the streets for illegal street drugs(which is the main culprit of the opioid epidemic) or they are committing suicide.
Since doctors were forced to cut or drop people's prescription pain medicines, over doses & deaths(& also suicides) have sky rocketed. Again, its just pushing more & more right to the cause(illegal street drugs).
Most people want to do the right thing(legally) & go to a doctor to have their pain treated so they can live a half decent life. So they can continue to work & take care of their families, etc. But since the falsified & misleading 2016 CDC guidelines & mme's, its just pushing more & more to illegal street drugs & therefore more & more over doses & deaths, as well as suicides(since we just can't live every day in SO much pain).
You have to burn the CDC guidelines & quit using them as law to prosecute our doctors(who are just trying to help us). Do not make any more "guidelines' since they'll just be used as law again. & rescind the mme's too.
Most of us know our bodies best & what helps us or works best for us. We should be able to be a part of what our medical care consists of. We should have a say in what we feel would help us(not forced into or away from something).
I thought this was America??? Then why do we not have a choice in our own medical care/prescription care & why are medicines that greatly help us being taken away from us(when we've taken them as prescribed & stored correctly & when they have helped us for many many years)?
Stop punishing & torturing people in pain because of illegal street drugs!!!
That is not fair at all!!! People in pain who take prescription pain medicines are being majorly tortured. We are looked down on & treated like a druggie. When we're nothing like that. We are given a hard time to get our prescriptions filled(if we can even get a prescription any more). Our doctors are SO restricted that they don't know what to do so they make things up & make it seem like we are "drug seeking" or called other things, when its been proven time & time again, how well prescription pain medicines work. But because the doctors hands are tied, they push us away & can't help us now. Or are to afraid to.
This has to STOP NOW!!!! It should have never started.
The CDC nor PROP(who where the one's who created the "guidelines") do NOT have the expertise to be making rules or laws. & again we(American people) know our bodies best & should have a say in our medical treatment. Not be pushed away or sent for another surgery or injection when those were proven before not to work.
Stop this insanity!!! & give us back the meds that once gave us a quality of life!
PLEASE!!! Millions & millions of us are begging you!!! Stop the insanity on safe & effective prescription pain medicines! & stop ruining our lives & torturing us!!!", "comment_id": "FDA-2021-N-0275-0140", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0275-0140", "comment_date": "2021-06-28T04:00:00Z", "comment_title": "Comment from Mare Petrelli", "commenter_fname": null, "commenter_lname": null, "comment_length": 4237}, {"text": "Docket No. FDA-2021-N-0275 for Morphine Milligram Equivalents: Current Applications and Knowledge Gaps, Research Opportunities, and Future Directions; Public Workshop; Request for Comments.

The workshop had many informative presenters but I wanted to highly endorse Jeffrey Fudin, PharmD & Nabarun Dasgupta, MPH, PhD. As well as Toska Cooper, Liz Jonia-Grant & others in his study. Both Fudin & Dasgupta both stressed NO MME limits & pointed out the numerous flaws in the calculations/conversions themselves. The recommendations must remove current MME limits whether in the guidelines or state laws.  It seems daily new federal/ state legislation is proposed to limit prescribing & it's literally killing pain patients & Veterans. We have a critical patient care crisis that requires emergent actions.  We need help now.

Misinformation is rampant & being spread by a group of "addiction experts" w/o pain mgt experience. For one they're highlighting common pain/disease signs & symptoms to pain med side effects & calling for forced tapering. This is unacceptable. Many are part of the disease process & are present whether on meds or not. This Propaganda/ opioidhysteria is hurting more people than its "saving."

Take a look at the current tapering recommendations/scenarios-

Patient not functioning by atleast 30% - Taper. (Not every disabled person can reach this goal. Plus ALS, quadriplegics & other compromised pts are being forced tapered. It should NOT matter if they can get out of bed.

Patient functioning well- Taper
Pt NOT functioning well - Taper
Pain adequately controlled- Taper
Pain NOT well controlled - Taper
Pt expresses pain mgt working very well - consider OUD, taper.
Pt expresses need for higher pain medication - consider OUD , taper.

No pt can succeed with these types of parameters designed to taper in just about every situation.  

Brain fog/confusion - Taper
Insomnia - Taper
Constipation- Taper. Look how many other med cause constipation, insomnia, brain fog & they don't call for immediate discontinuation.  Plus many of these signs/symptoms continue after discontinuation of meds. It's their disaese/pain causing them.  I have these with or without medication but they are extremely worse without adequate pain control. Suicidal ideations are common in both untreated & undertreated pain. A Misconception is pain pts want to end their life. No, we want the unbearable pain 24/7 to lesson- huge difference.  Once our pain levels are  controlled - the majority stop having these thoughts. It’s really that simple. It's about STOPPING THE PAIN.

Listed as a "potential for "harm" -  >65yo, anxiety/depression or >50MME.  BUT Above 65yo is the lowest population of overdoses.  Anxiety/depression is often a requirement for SSI/SSDI Disability approval because it is an expected outcome of disability. Chronic pain can be very depressing especially when it's uncontrolled.  I personally (& many others) didn't develop anxiety until the CDC guidelines were developed. This living in constant fear of losing one's meds returning to that agony is very disconcerting & real. But there are "addiction experts" now trying to add a new diagnosis that would make this fear similar to OUD. For a condition that they themselves created. Diabetics fear not having enough insulin- no difference. This is literally insane!

I am bedbound w/o higher doses of pain medications along with associated meds. I am non functioning & dependent.  At 90MME I am stable with much improvec function ability & my quality of life is much much mproved. No suicidal thoughts. I could still benefit from an even higher dose but that is no longer an option with the CDC GL & false narrative that pain meds are causing the opioid crisis.  In 2019, per the CDC, out of the 70,000 OD deaths- 12,000 were from pain meds. Unfortunately they don't track how many were from suicides due to forced tapering.

Liz Jonia-Grant wrote- "It is disheartening, but unfortunately not surprising. Far too often we are the victims of good intentions of those "wanting to do something" About the opioid overdose epidemic but the something that is done over simplifies the problem & pushes cookbook medicine upon those of us with complicated medical conditions. And while everyone debates whether the MNE limit was the right thing to do,we are forced to live by it, because Medical personnel & others treat guidelines as mandates. So we wait. And we suffer. And we hope it will all get sorted so we can get the care we need."

We need individualized care. NO MME limits & help pain pts access to opioid pain medications. In 2019 the 70,000 were mostly illicit made Fentanyl & heroin- street drugs. Yet pain pts & their doctors are the target. This isn’t helping. Illegal drug deaths have exploded - that's the problem.  Protect the patient.   Thank you for your time", "comment_id": "FDA-2021-N-0275-0142", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0275-0142", "comment_date": "2021-06-28T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 5276}, {"text": "Placing chronic pain patients on the same dosage of opiate pain medication is not scientifically proven effective. Individual aspects have been ignored. People who have been stable and functional on higher doses are now disabled and suffering. The pendulum has gone too far in the wrong direction. Just because they are an easier population to target than illegal drug traders does not make it right. Government needs to remove itself from the physician/patient relationship and let doctors be doctors again.", "comment_id": "FDA-2021-N-0275-0108", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0275-0108", "comment_date": "2021-06-21T04:00:00Z", "comment_title": "Comment from Cheryl Gilbreath", "commenter_fname": null, "commenter_lname": null, "comment_length": 508}, {"text": "Stop The Insanity. Remember that commercial? We’ll here we are. As a nurse (RN, BSN, DON) of over 37 years, haven’t we learned anything? You are punishing people in chronic, severe pain. We need the 90 MME lifted entirely. Physicians are trained to determine the best dosage, and closely monitor patients. This dosage doesn't even cover daily opioid therapy for most people on one medication, and now they've been told they can only have one. The cuts have been extreme for chronic patients and they are getting sicker, avoiding hospitals and surgeries, and dying either to their illness or suicide. Some have resorted to street drugs with fatal consequences. It’s gone as far as to limit dying hospice patient’s pain relief! We need this workshop to influence the CDC and actually save us all. NOW. My grandmother died in the 70’s, screaming in pain. The doctor refused to give her any more morphine because “she’ll become addicted.” She died two days later. True story. You must LEARN and stop this ignorant cycle of patient abuse. Opioids ARE effective in long term, chronic pain. Doctors prescribe any and everything before using them. Let them do the job they are trained and educated to do. Study after study has shown that prescribed opioids are not the culprit with drug overdoses. Wake up and stop this cruel interference now.", "comment_id": "FDA-2021-N-0275-0112", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0275-0112", "comment_date": "2021-06-21T04:00:00Z", "comment_title": "Comment from Cynthia Hughes", "commenter_fname": null, "commenter_lname": null, "comment_length": 1391}, {"text": "These “CDC Guidelines” have become de facto law across the country & they have NO basis in science. It makes no sense that a pain patient might die if given 1mg over, but an addict *starts* MAT at 13 TIMES the MME amount. The guidelines do not take into account personal pharmacology, allergies, nor any other concerns. It’s a one-size-fits-none sham of a guide. Also it doesn’t matter if the guidelines say “exceptions can be made!” if the DEA/medical boards are using it as a hard-and-fast rule by which doctors lives are destroyed. Additionally, LTOT has proven to be safe and effective, not creating addiction at all, whereas the addiction reaction is known to happen with the first exposure. Plus, diversion among chronic pain patients is rare, and we know the “opioid epidemic” is actually an opioid overdose death epidemic, fueled by illicit fentanyl and fentalogues coming from the illegal drug trade, not prescriptions. The under-treatment and non-treatment of pain has led to countless suicides (as noted by the VA) and with post-COVID pain creating even more pain patients, this needs to be fixed RAPIDLY. The Guidelines have even created an international crisis, with one woman in Ontario asking to be euthanized rather than live with her untreated chronic pain. This is a genocide. It has to stop. ", "comment_id": "FDA-2021-N-0275-0120", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2021-N-0275-0120", "comment_date": "2021-06-21T04:00:00Z", "comment_title": "Comment from Pamela Curtis", "commenter_fname": null, "commenter_lname": null, "comment_length": 1364}]}, {"id": "DEA-2014-0005", "title": "Schedules of Controlled Substances: Rescheduling of Hydrocodone Combination Products from Schedule III to Schedule II", "context": "2022-03-22T11:18:07Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "The proposed rescheduling of hydrocodone will place a large time-consuming burden on physicians and will result in a larger number of pills available for diversion. I am a Plastic,Reconstructive, & Hand surgeon in Lufkin, a small city in rural Deep East Texas. I am very busy, working at least 70 hours each week. Burns and hand & arm surgery particularly, with crush injuries from the heavy steel manufacturing and logging industry, are associated with signficant pain. It is my general policy to initially prescribe a small number of pain pills (30) following surgery. It is also my belief that one doesn't get any extra points for suffering, so if a patient has pain then I certainly wish to alleviate his suffering. I am presently president of the medical staff at Woodland Heights Hospital, recent president of the County Medical Society, former president of the medical staff at Memorial Medical Center, and I sit on the bylaws committees of both hospitals. I have been a delegate to the Texas Medical Association twenty times in my 25 year career in this same location. That is mentioned only to emphasize that I am not a crack-pot, I am a well respected member of the medical community. If a patient requires a refill, I can currently pick up the phone and speak to the pharmacists I know by name and quickly provide a refill. If hydrocodone is made schedule II, then I must instead write a prescription, make it accessible to the patient to pick up and carry to the pharmacist, or I must carry it to the pharmacy and drop it off. Forty percent of my patients live farther away from Lufkin than forty miles. Given the increased difficulty for me to refill the prescriptions I promise you that I will make my initial prescription in all cases at least 60 tablets. Not all of them need a re-fill, I assure you of that; but, a significant number do, and it would be such a hassle trying to get patients from Jasper, Newton, Onalaska, Cleveland, Shepherd, Livingston, Crockett, Grapeland, etc their prescription refills, therefore I promise you I will provide larger numbers up front. Unused pills sitting around are likely to be diverted. Please do not make my life more complicated, my patients truly in pain suffer more, and especially do not create your unintended consequence of MORE pills being diverted. Houston is not the same as Lufkin, and Washington DC is not the same as Williston, North Dakota. Please, while sitting in your ivory tower in Washington, DC, try to imagine how it is in rural areas of East and West Texas, Wyoming, or Western North Dakota. Enclosed is a photo of a map in my office. I have had at least one patient come from each dot on the map. Some of them have come for elective surgery, many in East Texas and Louisiana because they were injured. How in the world do you expect me to get their schedule II scripts to them at 8:00 pm at night? ", "comment_id": "DEA-2014-0005-0102", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2014-0005-0102", "comment_date": "2014-03-13T04:00:00Z", "comment_title": "Comment on FR Doc # 2014-04333", "commenter_fname": "William", "commenter_lname": "Strinden MD", "comment_length": 2937}, {"text": "See attached file(s)", "comment_id": "DEA-2014-0005-0295", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2014-0005-0295", "comment_date": "2014-04-25T04:00:00Z", "comment_title": "Comment on FR Doc # 2014-04333", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 20}, {"text": "On first thought, I support changing to schedule 11 as hydrocodone by itself is schedule 11. However does this also apply to the cough syrups that have a small quantity of hydrocodone? Just which combinations would be involved?", "comment_id": "DEA-2014-0005-0019", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2014-0005-0019", "comment_date": "2014-02-28T05:00:00Z", "comment_title": "Comment on FR Doc # 2014-04333", "commenter_fname": "anonymous", "commenter_lname": "Anonymous", "comment_length": 229}, {"text": "Re: Docket No. DEA-389

I am asking you to reconsider making hydrocodone a CII drug. I have arthritis in my cervical spine and this medication offers some relief from the terrible pain. I have been taking this drug for 2 years and don't believe that I am a public or personal threat to myself or to others. I am prescribed 90 tables per month, but typically don't take them all. I take them only as needed. I feel that me and other patients like myself who are not abusing hydrocodone and are taking it as prescribed, are being singled out and punished just because others are abusing this drug. People will abuse any drug, if they are so inclined.

If you make this drug a CII, I will have to get a new prescription each time, meaning that I will have to see my doctor each time and pay for an office visit each time. I am have very limited income and a high insurance deductible, so this will very difficult for me to do. Please, consider the patients that truly need this drug and who are not abusing or diverting it to others before making this decision that will impact my medical bills.

Thank you. ", "comment_id": "DEA-2014-0005-0043", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2014-0005-0043", "comment_date": "2014-03-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2014-04333", "commenter_fname": "Jennifer", "commenter_lname": "Williams", "comment_length": 1150}, {"text": "I believe that hydrocodone products should be moved to C2 medications because too many people are abusing it because it is more available ,also it has big potential for abuse", "comment_id": "DEA-2014-0005-0039", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2014-0005-0039", "comment_date": "2014-03-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2014-04333", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 174}, {"text": "As a community pharmacist for 16 years and now a faculty member in a college of pharmacy teaching pharmacy law, I see several unintended consequences of moving hydrocodone combination products from CIII to CII status. These include the following:

1. Drug of choice prescribed will change from hydrocodone combination products to some other CIII medications like codeine codeine combination products, Suboxone and Subutex (which have off-label uses for pain) and other CIII pain medications. This really isn't solving the abuse problem -- it is just shifting the problem to another drug.

2. This change will put increased hurdles on patients and pharmacists for those with legitimate pain and have a legitimate reason for using the medication.

3. There are already drug shortages for other CII medications because of stop orders that wholesalers are putting on community pharmacies that are impeding those pharmacies and pharmacists abilities to take care of patients with legitimate needs. Moving hydrocodone combination products to CII status will make this situation worse if there is no corresponding changes to this process.

4. We are already seeing an increase in heroin and other CI substance abuse as a result of the decreased availability of oxycontin and other oxycodone containing products. Not sure which is the lesser of the two evils.

I realize that the DEA is an enforcement agency -- I would like to know when the legitimate patient was lost in the big picture. Instead of having health care providers and pharmacists taking care of patients as our primary roles, it seems that the DEA would rather health care providers and pharmacists have our primary role be the "drug police". That is not what I went to pharmacy school for nor do I believe this is what most health care providers went to school for.

In conclusion, I realize why the DEA and FDA think that rescheduling hydrocodone combination products is a good idea. I believe the unintended consequences of the move would actually make the situation worse. Therefore, I respectfully ask that the DEA not reschedule hydrocodone combination products to CII.

Sincerely,

Mary Gurney", "comment_id": "DEA-2014-0005-0038", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2014-0005-0038", "comment_date": "2014-03-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2014-04333", "commenter_fname": "Mary", "commenter_lname": "Gurney", "comment_length": 2257}, {"text": "I am a nurse practitioner in a state that does NOT allow us to write class II narcotics. For many patients we are their only healthcare provider.

This change will severely affect our patient’s ability to obtain their pain medications. Our practice is in a very rural area where the nearest pain management provider is approximately 1 hour away making it unobtainable for many patients. Many patients cannot make the drive due to cost of gas, cars in poor shape, or lack of family support to take them.

We also have a problem with the pain management providers not accepting all insurances, especially the Medicaid patients.

I do not want to see this rule changed. It will impact the poor, underserved patients the most.
", "comment_id": "DEA-2014-0005-0018", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2014-0005-0018", "comment_date": "2014-02-28T05:00:00Z", "comment_title": "Comment on FR Doc # 2014-04333", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 768}, {"text": "My name is Deborah. I am 42 years old and live in Alabama. I have a lower spinal birth defect, DDD, spinal stenosis & other painful health issues. For the past 6 years I have been under the care of a neurologist. In order to function I rely on Norco 10/325's, 2 pills per dose, 4 doses per day. I have been on this amount for 3 years & have worked hard to not increase this dosage. I am uninsured. Alabama is a state that refused the medicaid expansion funding allowed via the new National Healthcare Law. What this means to me is that I am in the gap, not enough income to buy a health plan but too much income to qualify for help through my state. I had a hearing to determine if I will be allowed my SSDI benefits 12/18/13 and am still waiting for the decision, If approved there will still be a large gap between approval & when Medicare will cover my medical expenses. I woke this morning to find that the rescheduling of my pain medicine is one step closer to becoming a reality. The impact this will have in my life is enormous so I am writing to give you a glimpse into how this will affect my family. My doctor of 6 years, due to a sanction placed by the state medical board cannot currently write any prescriptions stronger than a schedule lll. At this point I see my doctor 4x a year for appointments. Beginning last December the visits were reduced to $100 but until that point I had paid $175/visit for 3 years and then $250/visit from that point until the recent reduction. The $250 price range is the norm for visits to comparable doctors in my area. I have also done disc decompression that I raised 3/4 of the funding for via a fundraiser. I am making payments on the balance & will be for quite some time. I also pay out of pocket for all of my medications at the cost of $200/month. If this rescheduling goes into effect I will either have to stop treatments completely or switch my care to a new doctor & pay even more for my care. New patient doctor visits cost about $300 & follow up visits are in the $200-250 range. I am aware that the cost involved with obtaining a new prescription each month could run $75 for a urine screen or pick up fee to full visit cost every month. There is no way I can possibly absorb these costs & it may not even be an option to continue my care. When I first heard of these potential new regulations I made a few calls to doctors in my area and each time I mentioned that I am uninsured & require narcotics to maintain my quality of life the roadblock came up. Doctors do not want to take on an uninsured patient, apparently we are a risk whether it be fear of our diverting our medications or the potential that we may need therapy or care that we are unable to afford. I beg of you to consider the impact this rescheduling will have on myself & my family. Being unable to work I rely on family to help with these expenses and it has created a circle where they break their backs only to keep us barely above water. My children will have to watch mom suffer in agonizing pain. Now I am able to walk for short distances & leave the wheelchair for times that the walking is just more than my back & hips can tolerate. As a chronic pain patient I am very aware that some misuse this type of medication. Narcotics were not my first choice nor one I wanted but the only other medication that somewhat helped is a medication called Ultram. I tried it but it made me drunken, loopy & unable to function, I fell several times while taking it. I am at risk for having seizures if I ever take it again. I take my medication as directed & humbly give urine screens & pill counts when asked, I keep my medication under lock & key & don't even let people know I am on this medicine for fear of my safety if those who are addicted find out I am prescribed this. I can't even "rally the troops" so to speak via social media to encourage others to speak out for fear of those addicted knowing I have access to this narcotic & additionally, my pain contract forbids my sharing that I take this medication. It may be hard to imagine having no health insurance, if you are reading this letter you probably have it; but please try to imagine how drastically this will impact my life if it does go into effect. PLEASE, I beg of you, don't take my quality of life away. I have so much to offer to my family and children and society but I can't if I am in such pain that I can't function. My pain without intervention is so bad that I am unable to even think coherently & become severely depressed. I have cried buckets wondering how I can help myself maintain what little quality of life I have. PLEASE don't punish me and my family for actions of those who acquire these drugs illicitly & harm themselves. I've done everything required to show I do not misuse/divert my medicine. Abusers don't care about the law & will just find another substance to abuse. I have my pride, I have never begged for anything but I BEG you. If not for me, please, for my children.", "comment_id": "DEA-2014-0005-0022", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2014-0005-0022", "comment_date": "2014-03-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2014-04333", "commenter_fname": "Deborah", "commenter_lname": "Anonymous", "comment_length": 5126}, {"text": "I think this is a great idea. I work with addicted adults and teenagers, and think this move will help put these drugs more out of their reach. You will always get people who are addicted to any opioids, but the harder you make it to get them, the better.", "comment_id": "DEA-2014-0005-0033", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2014-0005-0033", "comment_date": "2014-03-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2014-04333", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 257}, {"text": "As a practicing physician, pain medications are a powerful (yet potentially dangerous) tool to assist my patients. Unfortunately those choosing to divert medications to unintended uses dilute my ability to provide safe and effective treatment to patients.

I am IN FAVOR of moving hydrocodone-containing medications into Schedule II drug category to: 1) allow me to continue providing safe and effective therapy where appropriate; 2) improve surveillance on appropriate prescribing, dispensing, and utilization of these medications; 3) improve law enforcement and judiciary support to licensed prescribing physicians; 4) providing law enforcement and judiciary with enhanced mechanisms to stiffle illegal prescribing, use, and diversion of hydrocodone-containing substances.

Hydrocodone medications have been Schedule III drugs and despite that level of oversight, drug diversion has demonstrably and consistently increased. Drug diversion is a HUGE public safety issue and the Federal Government is tasked with provision of measures to protect US citizens; albeit sometimes from their own misadventures.

In dispatching its Public Safety mandate, the US DEA must move hydrocodone into Schedule II.
", "comment_id": "DEA-2014-0005-0028", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2014-0005-0028", "comment_date": "2014-03-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2014-04333", "commenter_fname": "Michael", "commenter_lname": "Elston", "comment_length": 1228}]}, {"id": "HHS-OCR-2022-0018", "title": "Confidentiality of Substance Use Disorder (SUD) Patient Records", "context": "2024-02-05T14:21:26Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "See attached file", "comment_id": "HHS-OCR-2022-0018-0207", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OCR-2022-0018-0207", "comment_date": "2023-03-07T05:00:00Z", "comment_title": "Comment from UnityPoint Health, HHS-OCR-2022-0018, HHS-OCR-2022-0018-0001, 2022-25784", "commenter_fname": null, "commenter_lname": null, "comment_length": 17}, {"text": "*", "comment_id": "HHS-OCR-2022-0018-0005", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OCR-2022-0018-0005", "comment_date": "2023-03-07T05:00:00Z", "comment_title": "Comment from DeFraia, Matthew, HHS-OCR-2022-0018, HHS-OCR-2022-0018-0001, 2022-25784", "commenter_fname": "Matthew", "commenter_lname": "DeFraia", "comment_length": 1}, {"text": "See attached file(s)", "comment_id": "HHS-OCR-2022-0018-0083", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OCR-2022-0018-0083", "comment_date": "2023-02-10T05:00:00Z", "comment_title": "Comment from atai Life Sciences, HHS-OCR-2022-0018, HHS-OCR-2022-0018-0001, 2022-25784", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "HHS-OCR-2022-0018-0204", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OCR-2022-0018-0204", "comment_date": "2023-02-10T05:00:00Z", "comment_title": "Comment from Northwest Portland Area Indian Health Board, HHS-OCR-2022-0018, HHS-OCR-2022-0018-0001, 2022-25784", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Please see the attached comment letter on behalf of the Ohio Hospital Association.", "comment_id": "HHS-OCR-2022-0018-0088", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OCR-2022-0018-0088", "comment_date": "2023-02-10T05:00:00Z", "comment_title": "Comment from Ohio Hospital Association, HHS-OCR-2022-0018, HHS-OCR-2022-0018-0001, 2022-25784", "commenter_fname": null, "commenter_lname": null, "comment_length": 82}, {"text": "The Pharmaceutical Care Management Association (PCMA) appreciates the opportunity to comment on the notice of proposed rulemaking issued by the U.S. Department of Health and Human Services, Office of Civil Rights and the Substance Abuse and Mental Health Services Administration entitled: “Confidentiality of Substance Use Disorder (SUD) Patient Records” as published in the Federal Register on December 2, 2022.

See attached.", "comment_id": "HHS-OCR-2022-0018-0098", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OCR-2022-0018-0098", "comment_date": "2023-02-10T05:00:00Z", "comment_title": "Comment from Dube, Tim, HHS-OCR-2022-0018, HHS-OCR-2022-0018-0001, 2022-25784", "commenter_fname": "Tim", "commenter_lname": "Dube", "comment_length": 448}, {"text": "See attached file(s)", "comment_id": "HHS-OCR-2022-0018-0159", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OCR-2022-0018-0159", "comment_date": "2023-02-10T05:00:00Z", "comment_title": "Comment from Recovery Alliance of Austin DBA RecoveryATX, HHS-OCR-2022-0018, HHS-OCR-2022-0018-0001, 2022-25784", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "
The Honorable Xavier Becerra
Secretary
Department of Health and Human Services
Washington, DC 20201


Dear Secretary Becerra:

On behalf of the Healthcare Information and Management Systems Society (HIMSS), we are pleased to provide written comments to the Notice of Proposed Rule Making (NPRM) regarding RIN 0945-AA16 Confidentiality of Substance Use Disorder (SUD) Patient Records. HIMSS appreciates the opportunity to leverage our members’ expertise to share feedback on the movement to align privacy compliance requirements for health information. We look forward to continued dialogue with the Department of Health and Human Services (HHS) and the HHS Office for Civil Rights (OCR) on these topics.

HIMSS is a global advisor and thought leader and member-based society committed to reforming the global health ecosystem through the power of information and technology. As a mission-driven non-profit, HIMSS offers a unique depth and breadth of expertise in health innovation, public policy, workforce development, research, and analytics to advise global leaders, stakeholders, and influencers on best practices in health information and technology driven by health equity. Through our innovation engine, HIMSS delivers key insights, education and engaging events to healthcare providers, governments, and market suppliers, ensuring they have the right information at the point of decision. Headquartered in Chicago, Illinois, HIMSS serves the global health information and technology communities with focused operations across North America, Europe, the United Kingdom, the Middle East, and Asia Pacific. Our members include more than 120,000 individuals, 480 provider organizations, 470 non-profit partners, and 650 health services organizations.

As we see attention shift to a consumer-based approach regarding integrated care, with greater incorporation of technology into the healthcare setting, we are witnessing more information becoming readily available and its access a critical dependency. As result, there are two competing truths that need to be reconciled: patient information must be treated respectfully and unequivocally needs to be protected, for both privacy and security purposes; and healthcare delivery and coordination of care cannot be achieved without reliable information shared in an interoperable manner across various, sometimes competing, systems. Thus, a careful balance must be made between the need to keep the information private and secure, while remaining shareable across various environments to help ensure that patient health and care is not impeded.

HIMSS supports the proposed changes to 42 CFR Part 2 (“Part 2”) to allow, subject to patient consent, Part 2 records to be exchanged using privacy protections aligned with the way HIPAA protects patient records. HIMSS strongly encourages HHS to continue the necessary work to further align personal health information, including Part 2 records. As a matter of principle, HIMSS firmly believes that seamless, secure, ubiquitous, and nationwide data access and interoperable health information exchange should ensure the right people have the right access to the right health information in a usable format at the right time to provide the optimal level of care. The reduction of barriers to the appropriate exchange of health information through harmonizing privacy and security laws, regulations, directives, and industry-led guidelines is paramount to transforming the health ecosystem, modernizing care delivery, driving health innovation at the institutional and personal level, and enabling health research.

While HIMSS supports the pathway indicated in the proposed rule, we offer observations on several provisions that could create barriers to the seamless and appropriate exchange of health information. For our public comments, HIMSS submits the attached thoughts and recommendations on opportunities to revise the proposed rule.

Thank you,

Harold F. Wolf III, FHIMSS
President & CEO

", "comment_id": "HHS-OCR-2022-0018-0090", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OCR-2022-0018-0090", "comment_date": "2023-02-10T05:00:00Z", "comment_title": "Comment from HIMSS, HHS-OCR-2022-0018, HHS-OCR-2022-0018-0001, 2022-25784", "commenter_fname": null, "commenter_lname": null, "comment_length": 4141}, {"text": "See attached file(s)", "comment_id": "HHS-OCR-2022-0018-0167", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OCR-2022-0018-0167", "comment_date": "2023-02-10T05:00:00Z", "comment_title": "Comment from SisterReach, HHS-OCR-2022-0018, HHS-OCR-2022-0018-0001, 2022-25784", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Please see the attached document. ", "comment_id": "HHS-OCR-2022-0018-0183", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OCR-2022-0018-0183", "comment_date": "2023-02-10T05:00:00Z", "comment_title": "Comment from UW Health, HHS-OCR-2022-0018, HHS-OCR-2022-0018-0001, 2022-25784", "commenter_fname": null, "commenter_lname": null, "comment_length": 34}]}, {"id": "FDA-2018-P-3355", "title": "Requests that the FDA recategorize Naloxone 4mg Nasal Spray from Legend (prescription only) to over-the-counter status.", "context": "2022-11-17T14:40:09Z", "purpose": "Nonrulemaking", "keywords": ["Citizen Petition", "CDER", "recategorize Naloxone 4mg Nasal Spray from", "Legend (prescription only) to over-the-counter", "status", "Oregon Pain Guidance"], "comments": [{"text": "See attached file(s)", "comment_id": "FDA-2018-P-3355-0018", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-3355-0018", "comment_date": "2019-03-06T05:00:00Z", "comment_title": "Comment from NYC Department of Health & Mental Hygiene", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "As an infectious diseases specialist who was a pioneer in HIV/AIDS research, I have seen first-hand the impact of an epidemic has on affected individuals, their families and loved ones, and on the public health of a community. I am now working at the intersection of infectious diseases and the injection opioid epidemic and on developing harm reduction services in rural West Virginia. West Virginia leads the country in opioid overdose fatalities, with the highest rate per 100,000 by a wide margin. Widespread access to naloxone is key to curbing the overdose fatality rate.

Not only does naloxone meet the medical criteria for OTC designation, but the continued difficulties that both people who inject drugs (as well as their families and friends) encounter in obtaining this life-saving medication-- despite state laws meant to facilitate access-- has been well-documented in published studies, including here in West Virginia which is at the epicenter of this devastating epidemic.

OTC access-- as long as the naloxone is affordable-- will go a long way to solving the problem of getting naloxone into the hands of the people who actually need it, especially in rural areas where 911 help can be a 20-minute ride away. This loss of primarily young lives is a public health emergency, and there is no more important mission in healthcare than saving lives. Readily accessible naloxone is essential to that mission.
", "comment_id": "FDA-2018-P-3355-0012", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-3355-0012", "comment_date": "2018-11-28T05:00:00Z", "comment_title": "Comment from Judith Feinberg", "commenter_fname": null, "commenter_lname": null, "comment_length": 1446}, {"text": "Increasing the accessibility and availability of Naloxone will save lives. I was a pharmacy technician at the time condoms were moved from behind the pharmacy counter out to the shelves in the Health and Beauty section of a local Target store, and since I stocked those shelves I saw at first hand the increase in sales of these products. There was no prescription requirement on these products, it was simply removing one step (asking the pharmacist or technician for the product). Eliminating the need to ask for a prescription, present the prescription to the pharmacist, and then be offered counselling on the product will reduce stigma and possible embarrassment; this will lead to more instances of Naloxone in the possession of those that could benefit. The only downsides I can see are whether insurances will continue to pay for this product once it is OTC, and what the cost of the product would be (i.e., above the copay amounts the patient would have paid had the product been filled as a prescription).", "comment_id": "FDA-2018-P-3355-0015", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-3355-0015", "comment_date": "2018-11-28T05:00:00Z", "comment_title": "Comment from Rob Reinhardt", "commenter_fname": null, "commenter_lname": null, "comment_length": 1019}, {"text": "There are too many people dying from lack of availability. Also the cost remains too high but should be reduced as an over the counter item.", "comment_id": "FDA-2018-P-3355-0007", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-3355-0007", "comment_date": "2018-11-05T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 141}, {"text": "See attached document. ", "comment_id": "FDA-2018-P-3355-0019", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-3355-0019", "comment_date": "2019-12-12T05:00:00Z", "comment_title": "Comment from Adapt Pharma Operations Limited", "commenter_fname": null, "commenter_lname": null, "comment_length": 24}, {"text": "An effective health intervention is one which is sound in and of itself and which is well-timed. Making naloxone widely available is sound in itself and it would be desperately well timed.

In the past 3 years I've trained about 200 people to use naloxone. They include frightened parents, stressed counselors, and nurses, lab techs, patients and prescribers. Laypeople readily understand how to use nasal naloxone. I've seen the light go on in someone's eyes because they have one more thing now that could save their child or a client they are meeting in the home. The range of health literacy among these has been great. No one has been mystified by the training. What upsets people is the idea of meeting an overdose without it.

Fentanyl is like a runaway train in the switch yard of the opioid epidemic. It's the steepest graph among the 3 describing opioid overdose death. Because the onset of overdose is so quick our best chance to save lives is to have naloxone widely available in our communities. Making naloxone over the counter is a strong step in that direction. While it does not in itself bring the price down, over the counter status is likely to help by expanding the number of people who would access it. If the projected number of deaths, let alone total number of overdose events, for the next decade is approximately 500,000 (AJPH Oct 2018 Humphreys et al) that is a market, unfortunately.

The risk profile for naloxone is nearly zero. Its benefit immense. It is actually a deterrent to abuse: in order to breath the victim must also suffer withdrawal.

As one of the 70 signers of this petition to FDA to make naloxone over the counter I hope FDA will find that it is sound, compassionate and timely to agree with our request.", "comment_id": "FDA-2018-P-3355-0009", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-3355-0009", "comment_date": "2018-11-28T05:00:00Z", "comment_title": "Comment from Sara Smith", "commenter_fname": null, "commenter_lname": null, "comment_length": 1812}, {"text": "I submitted a comment about 10 days ago but have not either seen it posted or gotten a rejection. Is there a better way to submit? Others have asked about how to comment. Thanks!", "comment_id": "FDA-2018-P-3355-0010", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-3355-0010", "comment_date": "2018-11-28T05:00:00Z", "comment_title": "Comment from Sara Smith", "commenter_fname": null, "commenter_lname": null, "comment_length": 181}, {"text": "Why should an addict who purchases illegal drugs on the street in order to get high (not for legitimate pain relief) be able to get over the counter help, while mllions of americans with painful medical conditions are forced to suffer because medication that helps them has been forcibly reduced to a level where it does not work, or worse, completely removed? US taxpayers and honest Americans should not be paying the price in pain or tax dollars to fix someone elses medical problem. If people in pain cannot get their medication over the counter (and we do not me nsaids which destroy kidneys, liver, cause blood condition problems), OR by prescription, than there is absolutley no reason why someone with an addiction disorder should be able to get their meds OTC.

Figures Lie and Liars Figure Why the Demographics of the So-Called Prescription Opioid Crisis Dont Work, Richard A, Lawhern, NPR 11/16/17
http://nationalpainreport.com/figures-lie-and-liars-figure-why-the-demographics-of-the-so-called-prescription-opioid-crisis-dont-work-8834839.html

The Opioid Epidemic In 6 Charts Designed To Deceive You, ACSH, Josh Bloom, 10/12/17
https://www.acsh.org/news/2017/10/12/opioid-epidemic-6-charts-designed-deceive-you-11935

The truth about the US opioid crisis prescriptions arent the problem
Marc Lewis is a neuroscientist and author on addiction, The Guardian
https://www.theguardian.com/commentisfree/2017/nov/07/truth-us-opioid-crisis-too-easy-blame-doctors-not-prescriptions

CDC Researchers State Overdose Death Rates From Prescription Opioids Are Inaccurately High, CATO INSTITUTE, J Singer, 3/22/18
https://www.cato.org/blog/cdc-researchers-state-overdose-death-rates-prescription-opioids-are-inaccurately-high

Are Prescription Opioids Driving the Opioid Crisis? Assumptions vs Facts. Rose ME1.
Pain Med. 2018 Apr 1;19(4):793-807. doi: 10.1093/pm/pnx048.
https://www.ncbi.nlm.nih.gov/pubmed/28402482

Message to CDC: Tear Down Your Walls of Silence!, 8/20/18,Richard Lawhern, PhD
https://www.painnewsnetwork.org/stories/2018/8/19/message-to-cdc-tear-down-your-walls-of-silence

CDC: Most Overdoses Involve Illicit Opioids, 8/31/18 Pat Anson
https://www.painnewsnetwork.org/stories/2018/8/31/cdc-most-overdoses-involve-illicit-opioids

One in 10 Suicides Linked to Chronic Pain, 9/12/18, Pat Anson
https://www.painnewsnetwork.org/stories/2018/9/12/one-in-10-suicides-linked-to-chronic-pain

Chronic Pain Among Suicide Decedents, 2003 to 2014: Findings From the National Violent Death Reporting System, Annals of Internal Medicine 9/11/18
http://annals.org/aim/fullarticle/2702061/chronic-pain-among-suicide-decedents-2003-2014-findings-from-national

CDC: 50 Million Americans Have Chronic Pain, 9/13/18, Pat Anson
https://www.painnewsnetwork.org/stories/2018/9/13/cdc-50-million-americans-have-chronic-pain

CDC Prevalence of Chronic Pain and High-Impact Chronic Pain Among AdultsUS, 2016, Weekly / 9/14/18 / 67(36);10011006, MORBIDITY & MORTALITY
https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.htm

Stop Calling it an Opioid CrisisIts a Heroin and Fentanyl Crisis, JEFFREY SINGER, 1/9/18
https://www.cato.org/blog/stop-calling-it-opioid-crisis-its-heroin-fentanyl-crisis

Diversion of Blame and the Opioid Crisis, 9/4/18, Richard Dobson, MD
https://www.painnewsnetwork.org/stories/2018/9/4/diversion-of-blame-and-the-opioid-crisis

B.C. doctors cant limit opioids or discriminate against pain patients: college
CAMILLE BAINS, VANCOUVER THE CANADIAN PRESS, 6/6/18
https://www.theglobeandmail.com/canada/article-bc-doctors-cant-limit-opioids-or-discriminate-against-pain-patients-2/

Fentanyl & Heroin Deaths Lead Soaring Overdose Rate, 12/21/17
https://www.painnewsnetwork.org/stories/2017/12/21/fentanyl-heroin-deaths-exceed-overdoses-from-pain-meds

Why Untreated Chronic Pain is a Medical Emergency 1/28/18
http://www.pharmaciststeve.com/?p=23988

Untreated Chronic Pain can Kill! 6/20/17 Suzanne Stewart
http://nationalpainreport.com/untreated-chronic-pain-can-kill-8833859.html

J Geurin, Staff sgt US Air Force (Honorably Medically Discharged)
Served 1997-2008 https://www.regulations.gov/document?D=FDA-2018-N-1621-1264

Why Living In Pain Will Eventually Kill You, By Kristin Hayes, RN, 7/27/17
https://www.verywell.com/why-living-in-pain-will-eventually-kill-you-3972227

Response Opioid Policy Steering Committee Stefan G. Kertesz, MD, MSc and Ajay Manhapra, MD
University of Alabama at Birmingham School of Medicine & Yale School of Medicine
https://www.regulations.gov/contentStreamer?documentId=FDA-2017-N-5608-0938&attachmentNumber=1&contentType=pdf

Time: Report: Chronic, Undertreated Pain Affects 116 Million Americans, Maia Szalavitz 6/29/11
http://healthland.time.com/2011/06/29/report-chronic-undertreated-pain-affects-116-million-americans/

War On Opioids Punishes Desperate Pain Patients, The Peoples Pharmacy
https://www.peoplespharmacy.com/2017/03/13/war-on-opioids-punishes-desperate-pain-patients/comment-page-3/#comments", "comment_id": "FDA-2018-P-3355-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-3355-0006", "comment_date": "2018-09-27T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 5271}, {"text": "Thank you for receiving our petition. This is a much needed step in the right direction to keeping our community and families safe from accidental overdose.
", "comment_id": "FDA-2018-P-3355-0011", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-3355-0011", "comment_date": "2018-11-28T05:00:00Z", "comment_title": "Comment from Kristie Klavinger", "commenter_fname": null, "commenter_lname": null, "comment_length": 162}, {"text": "I am writing to support making naloxone available as an OTC medication.
As a practicing physician it is clear that this increased availability will save many lives and produce minimal harm or risk. ", "comment_id": "FDA-2018-P-3355-0014", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-3355-0014", "comment_date": "2018-11-28T05:00:00Z", "comment_title": "Comment from Martin Albert", "commenter_fname": null, "commenter_lname": null, "comment_length": 203}]}, {"id": "FDA-2019-N-2514", "title": "Standards for Future Opioid Analgesic Approvals and Incentives for New Therapeutics to Treat Pain and Addiction; Public Hearing", "context": "2019-11-22T12:45:40Z", "purpose": "Nonrulemaking", "keywords": ["2019-368", "CDER", "Standards for Future", "Opioid Analgesic Approvals and Incentives", "New Therapeutics to Treat Pain and Addiction", "Public Hearing", "Open"], "comments": [{"text": "I am a chronic pain patient. Opioid restrictions have hurt me and many of my friends, and killed some we know. Doctors are cutting their patients off cold turkey, or forcefully tapering them against their will extremely quickly. They are citing the CDC's 2016 Guidelines, which are for ACUTE cases, not chronic cases. The DEA is actively prosecuting doctors for treating chronic pain patients at appropriate levels, to the point that so few providers remain that we have a pain epidemic in our country. We have 25 million americans with high impact pain, pain that debilitates them. Another 40 million with chronic pain. Pain is the NUMBER ONE reason people go to the doctors. And you can't even get it treated anymore. At least 1 in 10 suicides are associated with chronic pain. Pain kills. Pain ruins lives. And we so highly prize preventing addictions that aren't even occuring from prescriptions - a long term study of chronic pain patients found .56% became addicted after 6 months of use. Less than 1% - and acute patients rarely get pain medication outside of surgery and often not even then, now. Our government is publishing LAWS about the amount of MME that a drug can have - are our politicians doctors, then? How is this their job?

Statistically speaking this is an illicit FENTANYL and HEROIN crisis, not an opioid crisis. Restricting prescription pain medications this heavily, when the prescription pain pill problem has been solved and over-solved for years, only hurts pain patients and doesn't help addicts. We need to address illicit heroin and illicit fentanyl. We need people to understand that illicit fentanyl isn't the same as fentanyl in a hospital, and that illicit drugs are extremely unsafe and contain pollutants. We need to address the problems underlying drug addiction and decrease access to street drugs, not conveniently slap on a band-aid that sounds good by restricting pain pills even more. Many individuals can't even get their medication, thanks to federal opioid budget cuts of up to 80% in the case of some opioids this year alone. Pharmacies run out. Individuals are left in terrible, life threatening withdrawals or in agony for days. Insurance companies no longer feel compelled to pay for opioids since physicians are uninclined to prescribe them and no one is likely to enforce punishment on a doctor for NOT giving pain medication. In fact, when I was with a chronic pain friend during her hospitalization for severe, hard to treat pain, she asked for a lidocaine IV. This is non-opioid, non habit forming. They told her that they couldn't do her IV, and then they cut her pain medication in HALF. She was in so much pain she wanted to die already, and now her pain tripled and she was going through withdrawals. They left her like this for over a day. They did not care. They cared only that their asses were covered and they weren't prescribing more than 60 MME.

This is essentially a genocide against pain patients and chronic illness patients, who are dying by the thousands of heart attacks from pain and suicide. Did you know the number one condition putting someone on disability is chronic pain, most often back pain? I wish our country luck when the economic impacts of this many additional disabled individuals, unable to work, hits. Pain meds help maintain functionality, the ability to work, and quality of life.

Please include pain patients properly using medication in your panels, so our voice is heard. Our need for these medications should not be threatened due to others actions, and it has been, unintentionally or intentionally. Impact is greater than intent. Please make EXPLICITLY clear in any future legislation that these bills do NOT apply to chronic, intractible pain patients.

I have a genetic disease. There is no cure. There is no treatment. My joints dislocate multiple times a day, my brain pressure rises causes agonizing headaches. My bones ache due to inflammatory conditions and autoimmune conditions. I spend every waking moment in pain, and I am 22. Pain medication gives me the ability to go to school and have some quality of life. Without it, I would be home bound. And it is constantly in threat. We live in fear. Help us. ", "comment_id": "FDA-2019-N-2514-0057", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-2514-0057", "comment_date": "2019-09-12T04:00:00Z", "comment_title": "Comment from Claire Jeske", "commenter_fname": null, "commenter_lname": null, "comment_length": 4284}, {"text": "I can agree that there needs to be new methods of pain management researched to help combat the terrible opioid crises that this country is going through. I do wonder though what potential ingredients would be used in this analgesic, and if though the FDA says there is no risk of addiction, there could be a dependence on the analgesic as well. I also question how available this type of pain management will be since opioids are more readily available, thus the reason we have the crisis we do. In the risk-benefit analysis are we also taking those who are already addicted to opioids into consideration and are we also considering that addiction is a disease and the possibility that even with the treatment of pain will the dependency on the opioids be combated?



I can appreciate that the FDA is having this meeting to discuss different options, but are the voices of those addicted or their families voice going to be heard or will it be overshadowed by the opinions of those in the medical field or in pharma sales. I do hope that there can be a real resolution to this crisis and perhaps the suggestion of a "non-addictive" analgesic is the right answer. I also hope that in finding a solution to the opioid crisis, we can then work on the treatment of those on other addictive drugs without the use of suboxone.



Living in an area where the opioid crisis is very prevalent I would like to see more ways to help combat this, and I would like to see more people be open to the discussion of different treatments for those in pain. I think too many times we overlook the reasons why people become addicted in the first place. The pharma company, yes I do know it was one particular family, that created oxycontin and hydrocodone that is the substances that are at the very heart of this crisis, should be held responsible for the crisis that was created, and hopefully have no part in creating new ways to combat pain.



I also have the hope that this forum will be able to show that not all persons are receptive to the same type of pain management and can in some way look at individuals when coming up with solutions. Yes, the analgesic is a great start but there are some who may not be receptive to topical treatments. The FDA needs to research how to take what non-addictive properties are in the analgesic that they are trying to develop and apply those to an oral type of medicine.



"2. Should sponsors of new opioid analgesics be required to demonstrate some comparative advantage relative to existing analgesics? If so, what new authorities would be necessary to impose a comparative advantage requirement for opioid analgesics?

3. If so, how should that comparative advantage be defined?

a. Can it be quantified?

b. Should the assessment encompass any potential comparative advantage, including, e.g., safety advantages that reduce the prevalence or consequences of abuse or misuse by non-patient populations?

c. For any given application, to which existing products should the proposed new product be required to demonstrate comparative advantage? Any other opioid approved for the same analgesic indication(s) for which approval is sought? What are the implications if the new product only offers a comparative advantage over some of the other opioid products approved for the same indication(s)?"......

These questions that are being asked are going in the right direction, and I agree that the advantages of the analgesic should be defined. I do also like that the patients are actually being thought of, though it does still seem like they see patients as just a number and not actually as a person.



Human beings are at the core of this problem and there is a need to make sure that we look at the patients, addicts, and those who will need pain management in the future as such. We have to look at them as humans not just as some numbers or as some statistics. ", "comment_id": "FDA-2019-N-2514-0090", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-2514-0090", "comment_date": "2019-10-30T04:00:00Z", "comment_title": "Comment from Rebecca Haynes", "commenter_fname": null, "commenter_lname": null, "comment_length": 4045}, {"text": "I'm a CHRONIC PAIN PATIENTS WHO SUFFERING in UNBEARABLE PAIN BECAUSE of BEING DENIED PAIN MEDICATIONS that work to make my life bearable. Why take a way what has worked FOR so MANY years for so many ..if you had CHRONIC PAIN you would know what I'm talking about. But you don't. How can anyone live with them SELVES knowing what you ARE doing to US. Letting us SUFFER UNTIL WE CAN'T HANDLE ANYMORE pain and are forced to COMMIT SUICIDE
You know it's not PRESCRIPTION DRUGS that is the problem IT'S ILLEGAL DRUGS that ARE KILLING PEOPLE..And you continue to let us SUFFER UNTIL Death. Someone's going to be RESPONSIBLE FOR our DEATHS and SUFFERING. This is the WORST CRIME in HISTORY AGAINST CHRONIC PAIN PATIENTS AND VETERANS WHO ARE SUFFERING in UNBEARABLE PAIN BECAUSE WE'RE DENIED the LIFE SAVING PAIN MEDICATIONS AND MORE SUICIDE DEATHS BECAUSE WE CAN'T HANDLE the PAIN ", "comment_id": "FDA-2019-N-2514-0060", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-2514-0060", "comment_date": "2019-09-16T04:00:00Z", "comment_title": "Comment from Kim Buchholtz", "commenter_fname": null, "commenter_lname": null, "comment_length": 915}, {"text": "These comments are submitted in response to the Federal Register notice Standards for Future Opioid Analgesic Approvals and Incentives for New Therapeutics to Treat Pain and Addiction, Docket FDA-2019-N-2514. This is a written version of comments made orally at the September 17, 2019, Food and Drug Administration (FDA) public hearing on this topic.", "comment_id": "FDA-2019-N-2514-0095", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-2514-0095", "comment_date": "2019-11-05T05:00:00Z", "comment_title": "Comment from PinneyAssociates", "commenter_fname": null, "commenter_lname": null, "comment_length": 351}, {"text": "See attached file(s)", "comment_id": "FDA-2019-N-2514-0087", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-2514-0087", "comment_date": "2019-10-24T04:00:00Z", "comment_title": "Comment from Recro Pharma", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "This is an anonymous post.
I have read many of the comments for this issue. I have lived with chronic pain for many years. I have seen the damage that the CDC requirements have done to pain patients. It has decimated entire medical clinics, pharmacies and families all across the United States.
I ask the reader this; if you took this issue and superimposed it to say, car accidents, would the results be the same? Would there be as passionate a response?Car accidents kill many more people a year then overdoses.People purposely abuse their privilege, not right, to drive. People completely control their texting or drinking or using drugs or being tired that affects their driving capabilities that end both theirs and innocent peoples lives.
Why hasnt the public demanded that individuals cars be taken away? That cars become illegal? Demand stricter regulations on cars? You dont even hear people complaining about it in the same fashion.
Look at gun rights. After a severe shooting, activists demand the restriction of gun laws, etc.The NRA states its the people but not the guns. And the fact is, taking away a persons ability to own a weapon, a person who follows ALL the laws makes little sense when the bulk of criminals could care less about gun laws and acquire their weapons illegally. Hurting law abiding citizens by punishing them for merely following the law makes little sense. Unless its about the STATEMENT and not the actual action.
The SAME can be said for what is happening all across America now. The fact is, if all of these governmental agencies and nurses and the CDC and everyone who is calling for and achieving the taking away of pain medicine from legitimate pain patients and pain clinics and pharmacies were truly interested in fightingTHE WAR ON DRUGS, wouldnt they want their efforts to yield results? Attacking legitimate pain patients or even considering prescriptions legally acquired to be in any way related to the elicit fentanyl and heroin overdose deaths and current opioid crisis would be like comparing drunk driving deaths to heart attacks . They are COMPLETELY DIFFERENT issues and the current culture would be like attacking heart surgeons ability to perform to correct and curb drunk driving. It makes little sense other then as a political statement in a political environment.
Just because legitimate pain medication can be be used to overdose on and the fact that opioid medication is technically related to heroin or fentanyl, does not mean destroying pain patients ability to get medicine will stop fentanyl or heroin from being brought in and abused. In fact, it makes it WORSE!
To compare the two is like saying that heart attacks and drunk driving deaths both deal with people dying and trying to cut off the head to cure the head ache .
Because what is happening in the United States right now is madness and is ONLY helping the entities making the statements.
Its not helping people in pain for legitimately documented injuries and conditions that have NEVER abused their medication ever.
Its not helping people that are being denied pain relief during surgeries. Its madness.
Its not helping doctors offices just trying to help people compassionately.
I talked to a doctor that told me he was bringing the ENTIRE medical office down to a 60 MG morphine equivalent. Not for any medical purpose but only a legal one. So every single patient is considered the same. All addicts. ALL being accused of being just like the heroin and fentanyl dealers and junkies. All being lumped together.
It would be like saying a murderer and a war hero that has taken lives are both the same. Technically the actions are related, but the INTENTIONS are light years apart.
So unless we are going to start putting war heros in prison for life, we need to STOP THIS MADNESS NOW.
There are so many other ways to look at this situation. The point is that punishing people for treating pain with medication that is merely scientifically related to the drugs being sold illegally and causing the MAJORITY of the deaths is not rational, or appropriate. We are never going to eliminate pain. We are not going to stop the headache by cutting off the head.
By what is happening now accusing people of selling their prescriptions without any proof or reasoning at all. It MAKES NO SENSE.
Even if we made pain medication illegal it would not stop the drug crisis. AT ALL. It will make it WORSE.
The rationale that taking legitimate prescriptions off the street simply because someone following the rules could be lying or diverting their medication is like saying that we should eliminate cars because someone could get drunk and kill someone.
Many more people are driving without killing someone. Many more people are using their medication because they NEED it.
And lets say we take all the cars away? We would not be able to go to work, to live to eat to survive. THE EXACT same thing happening to legitimate pain patients out there.
", "comment_id": "FDA-2019-N-2514-0084", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-2514-0084", "comment_date": "2019-10-24T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 5072}, {"text": "Why should people with chronic pain or cancer be denied pain relief because a segment of the population has no will power or self-control? People need to be held accountable for their choices. The government loves to enable people so that they do not have to face the consequences of their actions. I have rarely taken an opioid because I dont like how they make me feel, but I dont want to be denied access to them, if I ever do need them for pain management.", "comment_id": "FDA-2019-N-2514-0086", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-2514-0086", "comment_date": "2019-10-24T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 460}, {"text": "Gabapentin prescription renewal now requires me to visit my prescribing doctor every Three (3) months. This is a difficult requirement for we senior citizens who have spinal stenosis. I spent 2 hours in my doctors office today filling our paper work and will be required to return to my prescribing doctor in 3 months to get a refill prescriptions. The FDA should be more aware of the administrative burden they place on drugs like Gabapentin which can not possibly be a candidate for drug abuse.", "comment_id": "FDA-2019-N-2514-0023", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-2514-0023", "comment_date": "2019-08-07T04:00:00Z", "comment_title": "Comment from Thomas Kirchgessner", "commenter_fname": null, "commenter_lname": null, "comment_length": 496}, {"text": "Looking for new treatments or releasing new meds is a good thing to do. Ignoring what the CDC, FDA, DEA HHS and more did to Chronic and intractable pain patients needs to be fixed. You need to do more then release a clarification that no one paid attention to. What happened was the opposite of what you intended to happened. A new more aggressive and intimidating campaign against the chronic pain community to force new tapers and doctors to stop the pain medication and abandon their patients.
What will you do to fix this or help the over 50 million chronic pain patients you caused and destroyed the lives of these patients. Like an addict its not about the person its about the friend, family and anyone who knows this person. There are millions of us some say as much as 50 million to 100 million of people living in chronic intractable pain.
In 2016 CDC in section on how to continue treatment of a patient on LTO. They were asked if they wanted to taper and if the answer is no keep the patient on the same does. The CDC guidelines said to offer a slow taper and go over the risks. This did not happen did it?
What else happened? Suicides and driving patients to the street for relief. A huge amount of death because no one read the guidelines.
Go back and fix this before you attempt new treatments and pain medication. The guidelines were written to help primary care physician to start a chronic pain treatment for new patients. It was never meant for patients taking LTO.
Go back and let the doctors treat their patients with the same pain medication for years. Give us back our doctors, let them out of jail, give us back our medication and stop the DEA.
Most of all admit what you did. Admit in 2015 you were warned what would happen if the guidelines were released as is and you did it anyway. Admit you inflated the number of overdose deaths related to prescription pain medication. Admit you released the correct numbers 1 year after reviewing the death certificates. Admit it took you 4 years to release clarification to the 2016 guidelines and you have known it for 4 years and you are causing more problems and hurt to pain patients. Admit to the propaganda released and you set back on your asses and let it happen. Go before congress and admit what you did to us.

My story

I was with my pain doctor for 20 years at the same clinic and on the same dosage when on 4-23-17 the medication that controlled my pain were stopped. I arrived for routine follow-up when a new doctor I have never seen walked in to tell me he is stopping all pain medication for each person within one month. It took me six months to find clinic to accept me as a patient and he treated me like a new patient.

My worst pain is from 4 different migraines including chronic cluster migraines, several ruptured disks from a back injury and severe disk degeneration. Spinal Bifida, Scoliosis, Fibromyalgia , chronic kidney stones and more.

8-23-2018 I had one of the worst cluster migraines on its 5th day, the pain, a flair up from my disk rupture was acute and my chronic kidney stones started dropping. This was my 4th kidney stone episode this year. I was in horrific pain.

I have a pain contract so my son called the clinkic to let them know he was taking me to the ER. He was told he could take me but under no circumstances could they give me any pain medication. My son called 3 more times; on the 3rd call was told we needed permision from the doctor and he already left for the day. No one told him about me. The next day he was told the same and the next appointment we were told the same.

No one should suffer horrific pain. Our doctors abandon us pharmacists profile us and refuse to fill our prescriptions even for cancer. A family pet would never be allowed to live in pain. The family would show mercy and let the pet go to sleep.

Before April 2017 I was happy, able to work, involved in many craft projects and saw my daughter and grandchildren often and they live 40 miles away. Because of the migraines my husband created a dark room and I spend most of my time in there. My back and other causes make me change positions every hour. I do not get much sleep. After months of appointments I said to that doctor I think about suicide every day sometimes every hour because of the pain. He did not evan look at me and walked out the door.

Help me before I become a statistic.

As chronic pain patients (CPP) most of us live in terror, horrific pain, anxious, depression, torture, sick, dark, isolation, anger, sad, cry, worthless, alone, jobless, misunderstood, fear, insomnia, helpless, broke, scared, scared of surgery, hopeless and at times hopeful.

We have a disability and because of that disability we suffer discrimination just like every group of people. Our doctors abandoned us pharmacist profile us and the public treats us as addicts. No pharmacist wants to fill a prescription fo pain medication even for cancer.

", "comment_id": "FDA-2019-N-2514-0037", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-2514-0037", "comment_date": "2019-09-12T04:00:00Z", "comment_title": "Comment from Chris Jolley", "commenter_fname": null, "commenter_lname": null, "comment_length": 5095}, {"text": " I am having irreparable damage being done to my health after being forced off a medicine dosage, I have been prescribed safely for over twenty-six years. I need to be tapered off this drug SAFELY so as to cause NO HARM to the genetic bone disease, Alkaptonuria/Ochronosis, rare genetic disease which causes bones to go black and brittle hence why its also called black bone disease.AKU is caused by a missing enzyme which means patients cannot fully breakdown a toxic acid called homogentisic acid (HGA). HGA attacks bones and cartilage, causing severe pain and disability as life progresses. The way I have been forced off a medicine I had taken for so long is hurting my heart along with causing the HGA levels to attack my bones even more than they already have, causing this disease to spread even more through my body. OCHRONOSIS causes bones to grind against each other cutting off nerve endings it's a severely painful disease, only treatment that is listed, for this disease is taking pain medicine- there is NO other treatment listed for this disease, except a medicine that has just came out but is not attainable as of yet, which does not take away the pain of the disease, but, helps with the cause. I am on a list to get it one day- I am trying very hard to stay healthy enough. Ochronosis is perhaps the oldest known metabolic diseases on the planet- found in Female Egyptian Mummies, yet there is no cure. I am TIRED of being treated like a criminal -because I was born with a genetic disease! I have been abandoned by my doctor, and he did not refer to to another doctor, as he had always promised me. I have been treated like a criminal at my pharmacy, that I had gone to for over thirty years, one day they are my loyal store and the next, they were treating me like a crook. I was forced off my medicine dosage and NOW the rare incurable bone disease OCHRONOSIS/Alkaptonuria, is getting worse and worse everyday! I do not want to become totally bed ridden suffering a life with the pain of this disease that turns your bones black after it eats away all the cartilage between the bones causing them to grind and scrape against each other , it has attacked the valves to my heart, my kidneys and liver. And, now my entire cervical spine has been totally damaged. The doctor I had for 32 years was able- thru having me change my diet, do chiropractic help and cortisone shots, was able to keep this disease from spreading, it had stayed in my neck and hip for over twenty-six years, but, now it is spreading down my spine. By being denied my pain medicine dosage without being able to ween off of it at required 10% at a time , and made to live in total pain day and night. I can no longer get the exercise I need that kept this disease from building up in my joints, it is now eating away all the cartilage-turning my bones black, causing my urine to turn black. I am praying I can find doctor who will help me lower my need for the opioid medicine, that I was put on for twenty-six years in a SAFE way, the harm being done to me now, there is no cure from, which makes me desperate! I do not wish to become dependent and more sickly, when I was so independent for so many years. I have no where or one to turn to. PLEASE I NEED HELP! I bought my own home in my early thirties, I was the first female camera operator doing ENG field work in Los Angeles, I have a FCC 1st Class Radiotelephone License that entitled me to run and operate any television or Radio station in America. Yet, after I bought my land and home, I found out after five botched surgeries that I had a rare genetic bone disease that was non operative and has no cure. I still was able to stay independent, Until, the misapplied CDC Guidelines forced me off a medicine I had been taking responsibly and safely for over twenty-six years- This has caused this disease to now, start attacking my heart and rest of my cervical spine. I pray that revision of CDC Guidelines and allowing doctors to do their jobs without being persecuted will give me back my life and I can grow old with dignity. Please contact me and let me know if you can help. - its means everything to me. Please watch this video if you have any questions about my disease : https://www.youtube.com/watch?v=7PpQU3wrdlM&t=30s
CDC and the FDA has put out warnings to never force a patient off a medicine they have taken for as long as I have been made to take this medicine. The irreparable injury being done to me, I am scared, I will end up totally cripple. I ask you to please help me to live the decent life I WAS LIVING without the pain of this disease. I have MRI's and X-Rays and any other records you are welcome to view, I thank you for your time and help in this matter. = Mahalo Nui Loa, ", "comment_id": "FDA-2019-N-2514-0034", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-2514-0034", "comment_date": "2019-08-28T04:00:00Z", "comment_title": "Comment from GiGi Brandford", "commenter_fname": null, "commenter_lname": null, "comment_length": 4769}]}, {"id": "FDA-2016-P-1090", "title": "Requests that the FDA take action to implement two initiatives for the co-prescribing of naloxone as part of FDA\u2019s comprehensive action plan to respond to growing epidemic of opioid abuse, dependence, and overdose.", "context": "2020-07-23T17:18:03Z", "purpose": "Nonrulemaking", "keywords": ["Citizen Petition", "CDER", "OPEN", "2016-1889", "Lachman Consultant Services, Inc.", "naloxone", "epidemic", "opioid", "abuse", "dependence", "overdose", "implement two initiatives", "co-prescribing", "Medically Assisted Therapy (MAT)", "Risk Evaluation and Mitigation Strategies", "REMS", "Elements to Assure Safe Use", "ETASU", "high-dose", "benzodiazepine", "Adapt Pharma Ltd."], "comments": [{"text": "July 15, 2016

Division of Dockets Management (HFA305)
Food and Drug Administration
Department of Health and Human Services
5630 Fishers Lane, Room 1061
Rockville, MD 20552

Dear Sir or Madam,

On behalf of the Partnership for Drug-Free Kids, a national non-profit organization that provides support and guidance to families struggling with their son or daughter's substance use and advocates for greater understanding and more effective programs to treat the disease of addiction, I write to offer our position on the Citizen's Petition requesting that the Food and Drug Administration (FDA) require naloxone co-prescribing with high dose opioid prescriptions, all products prescribed for medication assisted treatment of opioid disorders and simultaneous opioid and benzodiazepine prescriptions. The Citizens Petition also asks the FDA to update specific Risk Evaluation and Mitigation Strategies (REMS).

Currently there are 129 overdose deaths in the United States each day, most of which are caused by an opioid. Co-prescribing naloxone to reverse potential opiate overdoses is a common-sense step to help address this crisis. Despite the fact that the Centers for Disease Control and Prevention (CDC) has called on prescribers to consider co-prescribing in certain circumstances and the fact that three states (Maryland, Delaware and Massachusetts) have issued similar state-level recommendations, not enough physicians are acting. IMS data shows that in the year that ended February 2015 there were 247 million opioid painkillers prescribed but only 40,000 prescriptions for naloxone. We need to make sure that physicians are getting naloxone in the hands of more patients and families.

We urge the FDA to require naloxone co-prescribing under the conditions laid out in the Citizen's Petition. We also urge FDA to update the REMS to require that medication guides include information about opioid overdose and treatment and to update the Elements to Assure Safe use to require that naloxone be prescribed and distributed alongside all medicines to treat opioid use disorders, high-does opiates and opiates prescribed alongside benzodiazepines unless providers opt out on documented grounds.

At the Partnership we work with far too many families who have lost a child to an overdose and countless more moms and dads who are terrified that their child will be the next overdose statistic. Co-prescribing naloxone will dramatically increase access to this medication and will give families a fighting chance to save their loved ones life in the event of an overdose.

I thank you for your attention to this important matter and look forward to continuing to work with the FDA to reduce opiate misuse and abuse in our country.

Sincerely,

Marcia Lee Taylor
President and CEO
", "comment_id": "FDA-2016-P-1090-0012", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-P-1090-0012", "comment_date": "2016-07-20T04:00:00Z", "comment_title": "Comment from Partnership for Drug-Free Kids", "commenter_fname": null, "commenter_lname": null, "comment_length": 2913}, {"text": "see attached ", "comment_id": "FDA-2016-P-1090-0013", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-P-1090-0013", "comment_date": "2016-07-20T04:00:00Z", "comment_title": "Comment from Young People in Recovery", "commenter_fname": null, "commenter_lname": null, "comment_length": 13}, {"text": "I am submitting AATOD's comments in support of the Adapt Pharma Citizen's Petition. Please see attached. ", "comment_id": "FDA-2016-P-1090-0018", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-P-1090-0018", "comment_date": "2016-09-21T04:00:00Z", "comment_title": "Comment from American Association for the Treatment of Opioid Dependence", "commenter_fname": null, "commenter_lname": null, "comment_length": 113}, {"text": "The attached document contains the American Society of Addiction Medicine's (ASAM) comments on the citizen petition filed on behalf of Adapt Pharma Ltd. ", "comment_id": "FDA-2016-P-1090-0007", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-P-1090-0007", "comment_date": "2016-06-24T04:00:00Z", "comment_title": "Comment from American Society of Addiction Medicine (ASAM)", "commenter_fname": null, "commenter_lname": null, "comment_length": 157}, {"text": "I am a writing on behalf of the American Association for the Treatment of Opioid Dependence in support of the Adapt Pharma Citizen's Petition.

With best regards,

Mark Parrino ", "comment_id": "FDA-2016-P-1090-0019", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-P-1090-0019", "comment_date": "2016-09-21T04:00:00Z", "comment_title": "Comment from American Association for the Treatment of Opioid Dependence", "commenter_fname": null, "commenter_lname": null, "comment_length": 199}, {"text": "The attached document expresses the opinion of the Academy of Integrative Pain Management (AIPM; formerly the American Academy of Pain Management) that a prescription for naloxone should be offered to each patient when an opioid analgesic is prescribed to that patient. In taking that position, the AIPM is in congruence with this citizen petition, and asks FDA to rule favorably on that petition.

The AIPM's opinion considers what is known, and not known, at this time regarding risk of overdose for patients using opioid analgesics, and takes the view that offering a naloxone prescription should be part of a thorough patient counseling session that is appropriate for any patient using opioid analgesics. This practice also preserves patient autonomy, allowing the patient, after being properly informed about the risks of opioid analgesics, to make an autonomous decision about filling the naloxone prescription.

The AIPM views universal naloxone co-prescribing as an important practice that is one part of a larger risk mitigation plan for patients using opioid analgesics. ", "comment_id": "FDA-2016-P-1090-0011", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-P-1090-0011", "comment_date": "2016-07-06T04:00:00Z", "comment_title": "Comment from Academy of Integrative Pain Management", "commenter_fname": null, "commenter_lname": null, "comment_length": 1103}, {"text": "Caregiver Action Network (CAN) supports the Citizen Petition submitted by Adapt Pharma. CAN is the nation's leading non-profit organization advocating for the 90 million family caregivers across the country.

We are aware and alarmed that the majority of opioid overuse and heroin deaths in the U.S. actually occur in the home. We believe, as do many experts, that co-prescribing naloxone, the opioid overdose antidote, is an effective way to combat the epidemic of opioid overuse deaths.

Therefore, we support the recommendation that providers prescribe naloxone with all high-dose opioid products, all Medically Assisted Therapy (MAT) products, and all opioid drug products when combined with a benzodiazepine prescription.

We further support adding the new Elements to Assure Safe Use (ETASU) requiring that naloxone be prescribed and distributed alongside all MATs, high-dose opioids, and all opioid dosages when combined with benzodiazepine, unless providers opt-out on documented grounds.

We believe that these recommendations will help address the major implementation barriers to co-prescribing under the current guidance, including stigma and awareness and education levels. Requiring the offer of a prescription for naloxone as an ETASU within the REMS framework will raise the level of patient awareness and education both of naloxone and its use in an opioid overdose emergency. It will help create a more robust dialogue between a physician and patient around opioid risks, including the opportunity for physicians to discuss risk in the context of the benefit of naloxone as part of risk mitigation.
", "comment_id": "FDA-2016-P-1090-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-P-1090-0005", "comment_date": "2016-06-24T04:00:00Z", "comment_title": "Comment from John Schall", "commenter_fname": null, "commenter_lname": null, "comment_length": 1660}, {"text": "I have been a Family Physician for 30 years. I am now a federal government physician working in Baltimore, MD -- and we are one of the epicenters for the heroin epidemic. All of our patients prescribed narcotics, to include methadone, need to be offered intranasal naloxone. Period. They and their families need to also be educated on the correct use of the intranasal form of this drug. It is safe, it is effective, and it is saving lives. What is the down-side?", "comment_id": "FDA-2016-P-1090-0021", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-P-1090-0021", "comment_date": "2016-10-07T04:00:00Z", "comment_title": "Comment from J G Jolissaint", "commenter_fname": null, "commenter_lname": null, "comment_length": 463}, {"text": "August 5, 2016

Comment on Docket ID: FDA - 2016-P-1090-0004

Dear FDA reviewers,

The US Pain Foundation supports the Citizens Petition submitted by Adapt Pharma. The mission of the US Pain Foundation is to educate, connect, inform and empower those living with pain while also advocating on behalf of the entire pain community. As a 501(c) ]3 non-profit dedicated to serving those who live with pain condition and their care providers, US Pain Foundation helps individuals find resources and inspiration.

We are gravely concerned about the on-going opioid overdose epidemic in the United States, now resulting in an average 129 deaths daily according to Addiction Policy Forum. More than 75% of these take place outside medical settings, with the majority of these (54%) taking place in homes. The pain community is one of the most impacted by these unnecessary deaths. Not only are these loses unnecessary, there are enormous direct and indirect costs to families, healthcare systems, employers and society that may be greatly mitigated through existing channels.
We acknowledge that co-prescribing naloxone, the opioid overdose antidote, has increasingly gained support across a broad range of stakeholders, including federal agencies, medical professional associations and patient advocates, as an effective way of increasing access to naloxone and tackling the crisis.
Both the American Medical Association and the Centers for Disease Control and Prevention issued guidelines which call for physicians to offer naloxone when factors that increase risk for opioid overdose, such as a history of overdose, substance use disorder, high-dose opioids, or opioids prescribed concurrently with benzodiazepines, are present.
However, in spite of a growing consensus to co-prescribe naloxone, IMS data shows little uptake of naloxone by prescription under the current "opt-in" approach. In the year ended February 2015 there were 247 million opioid painkiller prescriptions, but only 40,000 prescriptions for naloxone, which indicates that support for co-prescribing is not translating into every day practice.
We therefore support the recommendation that providers prescribe naloxone with all high-dose opioid products, Medically Assisted Therapy (MAT) products and all opioid drug products when combined with benzodiazepine, unless providers opt-out on documented grounds.

Moreover, we support adding the new Elements to Assure Safe Use (ETASU) requiring that naloxone be prescribed and distributed alongside all MATs, high-dose opioids and all opioid doses when combined with benzodiazepine, unless providers opt-out on documented grounds.

These recommendations will help to systemize the existing broad support for co-prescribing. These will also drive greater awareness and education, and help to address stigma by enabling more discussion between physician and patient on opioid risks and the beneficial use of naloxone in emergency overdose situations. We support the Citizens Petition and encourage FDA to exercise its authority in order to help stem this crisis which is taking many of our best and brightest away from us.

Paul Gileno
President
US Pain Foundation
670 Newfield Street, Suite B
Middletown CT 06457
www.uspainfoundation.org
", "comment_id": "FDA-2016-P-1090-0016", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-P-1090-0016", "comment_date": "2016-08-11T04:00:00Z", "comment_title": "Comment from US Pain Foundation", "commenter_fname": null, "commenter_lname": null, "comment_length": 3359}, {"text": "See attached file(s)", "comment_id": "FDA-2016-P-1090-0017", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-P-1090-0017", "comment_date": "2016-08-23T04:00:00Z", "comment_title": "Comment from American Student Medical Association (AMSA)", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}]}, {"id": "FDA-2018-P-2851", "title": "Requests that the FDA refrain from approving any pending or future application for an opioid product submitted pursuant to section 505(b) or 505(j) of the FD&C Act, including NDA No. 22324 submitted by Pain Therapeutics, Inc., with a proposed indication or any other labeling that suggests that the product is appropriate for chronic use.", "context": "2019-04-25T21:54:28Z", "purpose": "Nonrulemaking", "keywords": ["Citizen Petition", "CDER", "refrain from approving any pending or", "Pharmaceutical Manufacturing Research Services,", "Inc", "future application for an opioid product", "submitted pursuant to section 505(b) or 505(j)", "of the FD&C Act,", "including NDA No. 22324 submitted by", "Pain Therapeutics, Inc., with a proposed", "indication or any other labeling that suggests", "that the product is appropriate for chronic use", "OPEN"], "comments": [{"text": "Just so you know. After 7 surgeons 4 neuro, 3 ortho medical science cannot fix me. I like so many people and conditions are left with a small glimpse of what our lives used to be. All that can be done for me now is to control the pain. Now so many of you irresponsible people want to take away the only thing I have left? Limited mobility? I have been taking opiates for my pain for 5 years. Never built a tolerance, never od'd, never been to a hospital for complications with the medicine. You have (you should have by now, studies have shown it, why don't you read?) My brain does not associate a reward with medicine. My pain eats it all up. It would be equal to you taking a Tylenol. To me is all it is " a glorified Tylenol" but after months of suffering and trying everything under the sun the opiate was the only one that could take it. The irresponsible actions of the CDC (which may very well be illegal, irresponsible at best) have already killed scores of innocent patients when at your command there Dr turned their back on them and their pain. That blood is already on your hands, how much more do you need to soak in the blood of innocent Americans. They are dying as I write you. The mind and body can only take so much. I hope you never have to experience it. If you do it may already be too late for you as you will get no reprieve from your pain because of your recent actions. The thing about pain is, it comes for everyone, no one is immune. Don't matter how much money, how important, how great you feel today. You may very well be next. That's when you will understand that America's Dr's and health system turned their back on you or maybe your mother,father,son,daughter. It's coming, maybe not today, not tomorrow but it will affect someone close to you. When they cry in agony you need to tell them you did that. You had to re-brand the heroin epidemic by telling people that Dr's did it. You have to suffer too protect someone that will find a way anyway and any drug to abuse. Don't believe me? What was common at the beginning of the 20th century? Idiots were shooting up peanut butter oil.

way.", "comment_id": "FDA-2018-P-2851-0030", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-2851-0030", "comment_date": "2018-12-13T05:00:00Z", "comment_title": "Comment from Michael Petro", "commenter_fname": null, "commenter_lname": null, "comment_length": 2181}, {"text": "I would like to comment on the citizen's petition : "Refrain from approving any pending or future application for an opioid product
submitted pursuant to section 505(b) or 505(j) of the FD&C Act, including NDA No.
22324 submitted by Pain Therapeutics, Inc., with the proposed indication of
management of pain severe enough to require daily, around-the-clock, long-term
opioid treatment and for which alternative treatment options are inadequate".

There are enough pain medications available to the public without it being necessary for the FDA to approve any other opioid for pain control. It has been noted that every day, more than 115 people in the United States die from overdosing on opioids, and last year 72,000 Americans died last year due to overdosing on drugs (National Institute of Health, 2018, p.1). The total number of overdoses in annually exceeds deaths from HIV, guns, and car accidents. Moreover, 21 to 29 % of those who are prescribed opioids abuse them, and 12% will develop an opioid disorder, while 6% who use opioid will eventually transition to heroine. Statistics show that 80% who abuse heroine first abused opioids. It has been further noted that the Midwestern region saw opioid overdoses increase 70 percent from July 2016 through September 2017, and opioid overdoses in large cities increase by 54 percent in 16 states in 2017 (National Institute of Health, 2018, p.1). Despite these facts, the Food and Drug Administration approved an especially powerful opioid painkiller despite criticism that the medicine could be a danger to public health. The drug Dsuvia, is an opioid that is 10 times stronger than fentanyl, and has been used in the military for soldiers in severe distress, as it can be dissolved for quick pain relief under the tongue (silverman, 2018, p.1).. This is certainly not necessary, especially with the nationwide opoiod epidemic and continued deaths from this terrible disease. Many children are born to parents who are addicted to opioids and face a long journey ahead of them ranging from withdraws to in and out of foster homes. This needs to be stopped immediately and refraining from approving any future opioids is a start.

References:
The Opioid Crisis. (2018). The National Institute of Health
Silverman, E. (2018). Despite criticism and concerns, FDA approves a new opioid 10 times more powerful than fentanyl", "comment_id": "FDA-2018-P-2851-0031", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-2851-0031", "comment_date": "2018-12-13T05:00:00Z", "comment_title": "Comment from Heather W", "commenter_fname": null, "commenter_lname": null, "comment_length": 2440}, {"text": "I am writing in strong support of the section of the petition that reads that the FDA should "refrain from approving any pending or future application for an opioid product submitted pursuant to section 505(b) or 505(j) of the FD&C Act, with the proposed indication of management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.
As stated in the CDC Guideline, Although opioids can reduce pain during short-term use, the clinical evidence review found insufficient evidence to determine whether pain relief is sustained and whether function or quality of life improves with long-term opioid therapy. While benefits for pain relief, function, and quality of life with long-term opioid use for chronic pain are uncertain, risks associated with long-term opioid use are clearer and significant.1
The CDC Guideline noted the real lack of longer-term trials of opioids for chronic pain. The recent year-long SPACE Trial at the Minnesota VA Hospital2 meets the criteria that the CDC was looking for in determining longer-term efficacy. Nonopioid treatment was associated with significantly better pain intensity than opioid treatment. While the result was probably not clinically significant, it certainly did not provide support for efficacy of opioid treatment.
It is time for the FDA to reconsider this indication (management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate) for existing drugs.
The standard of safe and effective is simply not met.

References:
1.Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep. 2016 Mar 18;65(1):1-49. doi: 10.15585/mmwr.rr6501e1.
2.Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018;319(9):872882. doi:10.1001/jama.2018.0899
", "comment_id": "FDA-2018-P-2851-0035", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-2851-0035", "comment_date": "2019-02-07T05:00:00Z", "comment_title": "Comment from Daniel Busch", "commenter_fname": null, "commenter_lname": null, "comment_length": 2233}, {"text": "See attached file(s)
My comment is in regard to length of chronic pain or regard to chroinic pain and/or disbelief and/or hesitancy to acknowledge chronic pain by petitioner. Round the clock administration of said medication has not been adequately described in terms of dosage by petitioner. Personal observation is one of disregard to a populace that does exsist. A more empathetic and acknowledged terminology could and should be used. Conclusion: chronic pain exists, physically, everyday for so many patients. Those patients did not cause this unfair and unjustified assault. There is a better way instead of this which is unrelenting in making human beings feel so much worse. Physically and emotionally. ", "comment_id": "FDA-2018-P-2851-0028", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-2851-0028", "comment_date": "2018-09-25T04:00:00Z", "comment_title": "Comment from Sue", "commenter_fname": null, "commenter_lname": null, "comment_length": 715}, {"text": "I fully agree with and support this petition. I do not believe it goes far enough as further opioid, manmade or organic,
should not be licensed for manufacture, distribution or prescribed, but, until such time as that occurs this petition is a
reasonable step in a logical direction leading to the removal of opioids and derivatives from circulation.", "comment_id": "FDA-2018-P-2851-0034", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-2851-0034", "comment_date": "2019-02-07T05:00:00Z", "comment_title": "Comment from Alfred Brock", "commenter_fname": null, "commenter_lname": null, "comment_length": 360}, {"text": "Are all yall just evil idiots? First of all its a proven fact pain is pain, cancer has nothing to do with it. Pain is all relative to the person and disease or injury. Im a professional with a broken back who functions fine on an opioid. Why arent hypocrites like yall trying to stop the soring alcoholism problem by banning scotch. You cant govern morality and governing something you dont personally suffer with is just immoral and ideological wrong. You understand that some patients have been using opioids for 20 plus years without any issue whatsoever. That includes children with horrific diseases such a spina bifida, grandma with arthritis the veterans with bullet holes and missing limbs from Vietnam. All use an opioid for many years to take away enough pain to manage their days, without addiction or incidents. Its time the cdc came clean on lying to the public with there false information along with the FDA! We have an illegal illicit heroin and illicit Fentanyl and illicit drug crisis, we have never, until the manufactured one had a prescription drug crisis!
Marijuana a class 1narcotic is now legal, and patients under the care of a physician are told to think through your pain or use hypnosis or some sudo bs! I say my body my choice! The rest of yall can go F yourself!
I hope the very people pushing this no opioid nonsense is in a horrible car accident or their children get cancer, we will see how you think about pain control then you hypocritically stupidity morons!
If you read this, Ive usec an opioid for years, I work I function because I have relief , take it away Im done.
Any physician would fall for this crap should have their license removed! Your oath said do no harm meaning treat me that includes pain!
", "comment_id": "FDA-2018-P-2851-0029", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-2851-0029", "comment_date": "2018-11-28T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 1769}, {"text": "FDA:
I have been following FDA approvals and activities concerning opioids since the loss of my son and have researched oxymorphone extensively. This citizens petition sums up many of the failures that have led to this horrific epidemic. I am unclear as to why the FDA will not take action. I do not understand why the FDA will not protect public health and ensure drug safety!
1)Enriched Enrollment was an industry driven decision for profit (not based of efficacy or safety)
2)The original approvals were not proven to be effective with the indications allowed
3)ADF Is nothing but a marketing scam and proven to NOT be a valid label
4)Oxymorphone should have NEVER been put back on the market! Clinical trials were manipulated, and the effects have been devastating.
5)Opioids have been marketed and distributed inappropriately and NOTHING has been done!

Many years from now looking back at this what will be said about this Federal Agency in history books? No one stopped it, no one cared enough to protect the citizens of the United States of America from greed and despair. Lives have been lost that could have been saved if only those who were put in positions at the FDA had integrity and morals to do the right thing.
What will it take? How many have to die?

", "comment_id": "FDA-2018-P-2851-0032", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-2851-0032", "comment_date": "2018-12-13T05:00:00Z", "comment_title": "Comment from Emily Walden", "commenter_fname": null, "commenter_lname": null, "comment_length": 1531}]}, {"id": "DEA-2012-0008", "title": "Disposal of Controlled Substances", "context": "2021-12-02T01:00:56Z", "purpose": "Rulemaking", "keywords": ["Disposal"], "comments": [{"text": "See attached.", "comment_id": "DEA-2012-0008-0184", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2012-0008-0184", "comment_date": "2013-03-18T04:00:00Z", "comment_title": "Comment on FR Doc # 2012-30699", "commenter_fname": "Larry", "commenter_lname": "Wagenknecht", "comment_length": 13}, {"text": "See attached.", "comment_id": "DEA-2012-0008-0180", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2012-0008-0180", "comment_date": "2013-03-18T04:00:00Z", "comment_title": "Comment on FR Doc # 2012-30699", "commenter_fname": "Nick", "commenter_lname": "Sylvia", "comment_length": 13}, {"text": "Drug Enforcement Agency:
Since 2007, the Rock County Health Department in Wisconsin, in collaboration with many, many community partners, has collected 13,279 pounds of unwanted prescription and nonprescription medication through our drug collection program. This is 13,279 pounds of drugs that have been kept out of our groundwater and out of the hands of our children.
We are proud of the collaboration that has successfully and safely collected and disposed of such a large amount of medication. If these new regulations are put in place, it will very likely result in the end of this successful program due to the additional costs and logistical challenges.
In Rock County, law enforcement retains the controlled substances and the Health Department stores non-controlled substances in a secure facility. Local pharmacists separate the controlled medications from the non-controlled medications, but this will not be allowed under the new regulations. Last year, the Health Department stored approximately 3600 pounds of non-controlled medications. Some law enforcement offices do not have the capacity to store this quantity of medications.
The medication that is going to be destroyed is removed from the packaging; the medication is stored in containers and the packaging is discarded. Requiring medications to be stored in the packaging, in which it was received, will result in 7 to 10 times the number of containers needed to be destroyed. This is going to add a significant cost for disposal.
Our local law enforcement agencies are already stretched due to budget cuts and placing this additional cost and responsibility on them will mostly like end our successful drug collection program. Please reconsider these changes so we can continue to get these medications out of our community.
", "comment_id": "DEA-2012-0008-0137", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2012-0008-0137", "comment_date": "2013-02-28T05:00:00Z", "comment_title": "Comment on FR Doc # 2012-30699", "commenter_fname": "Chris", "commenter_lname": "Ramos", "comment_length": 1832}, {"text": "I own an independent pharmacy and it never made sense to me that we were trusted to dispense controlled medications to patients but not dispose of them if needed. Prescription drug abuse is a huge problem and I hope this helps!", "comment_id": "DEA-2012-0008-0024", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2012-0008-0024", "comment_date": "2013-01-31T05:00:00Z", "comment_title": "Comment on FR Doc # 2012-30699", "commenter_fname": "Elizabeth", "commenter_lname": "Thrush", "comment_length": 228}, {"text": "It is unfair to restrict medications to cancer patients only. Myalgic Encephalomyelitis (ME) is an extremely painful condition which has been rated to have more serious and more severe pain than that suffered by a cancer patient. ME also can result in death. Currently the condition is known in the states as fibromyalgia/CFS.

Please do not restrict pain medication to those only with cancer when there are far worse conditions. I beg you. I have been disabled with this condition for years and it is not painful when undergoing treatment, but always painful, 24x7x365xLIFE.

If you start restricting one medication, others will also follow suit and it will not be possible for many to tolerate their conditions. Assisted physician suicide is not an option to patients that believe in God.", "comment_id": "DEA-2012-0008-0030", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2012-0008-0030", "comment_date": "2013-02-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2012-30699", "commenter_fname": "Stephanie", "commenter_lname": "McGrath", "comment_length": 812}, {"text": "Hospitals have many challenges in today's changing healthcare environment. Disposing of waste should not be one of them.

The DEA should be providing guidance and support with controlled substance disposal. We need to have guidlines. The DEA tells us that flushing a controlled substance, putting it into kitty liter, and putting it into hazardous waste containers for haulers to remove is not making the CS non-retrievable, therefore is unacceptable disposal. Since all of those are not correct the DEA should be providing us an answer.

I think we can agree that hospitals want to do the right thing. They do not want to see controlled substances leave a negative effect on our environment and certainly do not want to see them abused. It's time that our government agencies (DEA, EPA) work together and provide us with the tools we need to get a very important job accomplished.", "comment_id": "DEA-2012-0008-0060", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2012-0008-0060", "comment_date": "2013-02-15T05:00:00Z", "comment_title": "Comment on FR Doc # 2012-30699", "commenter_fname": "Mary", "commenter_lname": "Reissman", "comment_length": 911}, {"text": "I am the Founding Dean of the School of Pharmacy at Husson University. I am writing this letter in strong opposition to one of the stipulations of the proposed rule:

“…the substances contained in the inner liners and mail-back packages may not be individually handled, counted, inventoried, or otherwise discerned.”

For the past few years I have been volunteering to assist the University of Maine’s Center on Aging in their “Safe Medicine Disposal for ME Program.” The data collected in this mail back program was one of a kind, since it was the only mail back program that could legally accept controlled substances.

Much important information was gathered through the project. Knowing which medications are being wasted allows for targeted educational programs to medication prescribers and/or patients. It also helps payers get a handle on the huge amount of waste in the system and may incentivize them to implement programs to help reduce it.

By preventing the cataloging of what is being collected throughout the country is a tremendous waste of extremely valuable information resources regarding our society’s medication-taking behavior. Patient non-adherence to prescribers’ direction is a significant health care problem that costs our society billions. Besides the cost of the unused medication, other related expenditures include the extra health care costs for treating patients who become sicker from a lack of appropriate therapy, subsequent lost days of work, and the loss of other contributions to society. More importantly there is much pain, suffering and early deaths that could be prevented. The information gathered in take-back programs could help greatly in alleviating this problem.

I urge the DEA to reconsider this portion of the rule. A very simple solution to the DEA’s concern for security is to have any cataloging or counting be conducted under the supervision of law enforcement agents.", "comment_id": "DEA-2012-0008-0067", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2012-0008-0067", "comment_date": "2013-02-20T05:00:00Z", "comment_title": "Comment on FR Doc # 2012-30699", "commenter_fname": "Rodney", "commenter_lname": "Larson", "comment_length": 2033}, {"text": "Thank you for the opportunity to comment on Docket No. DEA - 316.

The proposed rules are a common sense solution to the management of unwanted drugs. It is critical that these drugs are diverted from disposal in landfills and wastewater treatment plants.

The following suggestions would lower the cost to manage this waste while at the same time provide the necessary level of security when dealing with controlled substances.

1. There are requirements for 2 authorized employees to witness the removal of the inner liner ((1317.50). Some small retail pharmacies may not have 2 employees working at the same time. It is important to have 2 people witness the removal, but one of the two could be the reverse distributor employee. The way to insure that there are 2 witnesses is to have a drop box that the user places the drugs into. The box could have 2 separate locks that would require both the pharmacist and the reverse distriibutor to be present when the box is unlocked.

2. There is a requirement that the waste be destroyed within 14 calendar days. (1317.15) Currently the San Luis Obispo County Integrated Waste Management Authority, through our hazardous waste contractor, collects sharps from 45 local pharmacies. The collected sharps are stored at our household hazardous waste facility. To reduce costs we have our medical waste contractor pick up the sharps from the household hazardous waste facility on a monthly basis. If we offer a similar service for the collection of drugs, we would also like to hold the drugs for a monthly pickup. An alternative could be that the waste be destroyed within 30 days or when more than 200 pounds are stored, whichever occurs first.
", "comment_id": "DEA-2012-0008-0095", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2012-0008-0095", "comment_date": "2013-02-27T05:00:00Z", "comment_title": "Comment on FR Doc # 2012-30699", "commenter_fname": "William", "commenter_lname": "Worrell", "comment_length": 1757}, {"text": "The City of Fort Collins would like to thank the DEA for publishing these proposed rules for safe medication disposal. Overall, we are supportive of these rules and understand that DEA’s primary concern is preventing illegal diversion of controlled substances.

The proposed regulatory language reads:
"Controlled substances collected by collectors may not be individually counted or inventoried."
The meaning of this rule is not clear. The use of the word “may" leaves it open to interpretation. If what was meant is, "Controlled substances collected by collectors do not have to be individually counted or inventoried." we are very supportive.
•Suggestion: Clarify the wording.
", "comment_id": "DEA-2012-0008-0098", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2012-0008-0098", "comment_date": "2013-02-27T05:00:00Z", "comment_title": "Comment on FR Doc # 2012-30699", "commenter_fname": "Errin", "commenter_lname": "Henggeler", "comment_length": 798}, {"text": "On behalf of Community Anti-Drug Coalitions of America (CADCA), which represents more than 5,000 community coalitions nationwide, please see the attached comments on the notice of proposed rulemaking for the Drug Enforcement Administration (DEA), Department of Justice, published in the Federal Register, Volume 77, Number 246, Friday, December 21, 2012. ", "comment_id": "DEA-2012-0008-0028", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2012-0008-0028", "comment_date": "2013-02-01T05:00:00Z", "comment_title": "Comment on FR Doc # 2012-30699", "commenter_fname": "General Arthur", "commenter_lname": "Dean", "comment_length": 355}]}, {"id": "FTA-2006-24592", "title": "Controlled Substances and Alcohol Misused Testing", "context": "2022-11-04T01:08:35Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": null, "comment_id": "FTA-2006-24592-0006", "comment_url": "https://api.regulations.gov/v4/comments/FTA-2006-24592-0006", "comment_date": "2006-08-04T04:00:00Z", "comment_title": "Substance Abuse Program Administrators", "commenter_fname": "Jeff", "commenter_lname": "Sims", "comment_length": 0}, {"text": null, "comment_id": "FTA-2006-24592-0004", "comment_url": "https://api.regulations.gov/v4/comments/FTA-2006-24592-0004", "comment_date": "2006-08-03T04:00:00Z", "comment_title": "American Public Transportation Association - Comments", "commenter_fname": "William", "commenter_lname": "Millar", "comment_length": 0}, {"text": null, "comment_id": "FTA-2006-24592-0003", "comment_url": "https://api.regulations.gov/v4/comments/FTA-2006-24592-0003", "comment_date": "2006-08-02T04:00:00Z", "comment_title": "Drug & Alcohol Testing Industry Association (DATIA) - Comments", "commenter_fname": "Jeff", "commenter_lname": "Smith", "comment_length": 0}, {"text": "There are three areas where the Ohio Department of Transportation, Office of Transit requests clarification on the June 5, NPRM, Docket Number FTA-2006-24592 on Controlled Substances and Alcohol Misuse Testing.

The first clarification needed is what entities are covered by the NPRM. Is this regulation for private and/or nonprofit carriers who are contract providers? Are direct recipients, subrecipients, or designated recipients such as community action organizations that receive Section 5311 funding directly from the state exempt from this NPRM? Should the direct recipients, subrecipients, or designated recipients still be covered the same as they have always been under the Federal Transit Administration drug and alcohol regulations (drug and alcohol testing based on the percentage of work performed per employee, FTA vs FMCSA)?

We would also like clarification on how national contractors, such as First Transit, Laidlaw, MV, determine which type of DOT test is conducted. If this is determined based on the overall type of operation at the national level, these entities could end up testing all of their employees under FMCSA instead of FTA. Ohio suggests using a location by location basis. For example, if MV is the Section 5311 contract provider at a specific location, all of the employees at that location be tested under FTA, regardless of category of testing (FTA or FMCSA) that the company falls under when looking at the number of employees at the national level.

The third area where we would like clarification concerns full time employees versus part time employees. Ohio suggests the type of test (FTA or FMCSA) should be determined based on full time equivalent employees versus total number of employees at either the national or specific local location. For example, if Laidlaw has 100 employees and 30 drive full time, year round for a Section 5311 subgrantee and the other 70 drive a school bus 4 hours a day during a school year, the type of test should be based on the full time equivalent number of employees and not the total number of employees.

Thank you for the opportunity to comment on the NPRM.

", "comment_id": "FTA-2006-24592-0002", "comment_url": "https://api.regulations.gov/v4/comments/FTA-2006-24592-0002", "comment_date": "2006-07-14T04:00:00Z", "comment_title": "Ohio Department of Transportation - Comments", "commenter_fname": "Marianne", "commenter_lname": "Freed", "comment_length": 2200}, {"text": null, "comment_id": "FTA-2006-24592-0005-0002", "comment_url": "https://api.regulations.gov/v4/comments/FTA-2006-24592-0005-0002", "comment_date": "2006-08-03T04:00:00Z", "comment_title": "Pipeline Testing Consortium, Inc., and American Medical Review Officers, LLC - Comments", "commenter_fname": "David", "commenter_lname": "Paine", "comment_length": 0}, {"text": null, "comment_id": "FTA-2006-24592-0005-0001", "comment_url": "https://api.regulations.gov/v4/comments/FTA-2006-24592-0005-0001", "comment_date": "2006-08-03T04:00:00Z", "comment_title": "Pipeline Testing Consortium, Inc., and American Medical Review Officers, LLC - Comments", "commenter_fname": "Mike", "commenter_lname": "Neuway", "comment_length": 0}]}, {"id": "CDC-2017-0043", "title": "Evaluation of Medication-Assisted Treatment (MAT) for Opioid Dependence ", "context": "2017-08-21T08:52:53Z", "purpose": "Nonrulemaking", "keywords": null, "comments": [{"text": "Ibogaine should be considered for descheduling or rescheduling, as it holds immense therapeutic promise for the treatment of addiction, and it is already being used with great success in other countries, and the U.S. if falling behind. Ibogaine's illegality is part of why overdoses are a problem. ", "comment_id": "CDC-2017-0043-0003", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2017-0043-0003", "comment_date": "2017-07-12T04:00:00Z", "comment_title": "Comment from (Anonymous Anonymous)", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 302}, {"text": "See attached file(s)", "comment_id": "CDC-2017-0043-0004", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2017-0043-0004", "comment_date": "2017-08-21T04:00:00Z", "comment_title": "Comment from (Anonymous Anonymous)", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "CDC-2017-0043-0002", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2017-0043-0002", "comment_date": "2017-07-06T04:00:00Z", "comment_title": "Comment from (David Julien)", "commenter_fname": "David", "commenter_lname": "Julien", "comment_length": 20}]}, {"id": "CMS-2008-0073", "title": "Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2009; and Revisions to the Amendment of the E Prescribing Exemption for Computer Generated Facsimile Transmissions", "context": "2022-01-09T19:05:38Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "OTHER ISSUES-SLEEP TEST
Consumers are provided a listing of CPAP providers to meet the Patient Choice
requirement. By taking the listing and allowing non-afilliated healthcare systems
that have both the sleep lab and a DME is restricting access. The physician
ordering the test should not provide the CPAP because an accredited DME
provider should provide the equipment. Physicians diagnose, suppliers provide the
education on the use and monitor compliance, this is written in the supplier
standards that is distributed.

The population is growing and the diagnosis is not simple. There are many criteria
which must be met prior to the decision to treat with a CPAP. This is scientific
protocal and not based on a "biased" opinion.
Maybe this proposed regulation is just that-a biased opinion to keep the most
qualified locally based health care systems who also have a sleep lab and a DME
from providing the much needed services to the Medicare beneficiary. This is
restrictive care.

I oppose this proposed regulation.", "comment_id": "CMS-2008-0073-0321", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2008-0073-0321", "comment_date": "2008-08-22T04:00:00Z", "comment_title": "Anonymous--CPAP", "commenter_fname": null, "commenter_lname": null, "comment_length": 1115}, {"text": "I vote for option #2 of the "Proposed Changes to Enrollment and Billing Rights"
change.
", "comment_id": "CMS-2008-0073-0327", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2008-0073-0327", "comment_date": "2008-08-25T04:00:00Z", "comment_title": "Haiken, Jeffrey--PHYS/NPP ENROLLMENT", "commenter_fname": null, "commenter_lname": null, "comment_length": 107}, {"text": "INDEPENDENT DIAGNOSTIC TESTING FACILITIES
Please refer to file code CMS-1403-P.

I am writing to comment on the proposed rule change regarding diagnostic imaging
facilities referenced above. Although I am not opposed to applying standards to
ensure patient safety and improve quality of care, I feel that there are several
implications of the proposed rule that are unnecessary and will instead decrease
access to care by Medicare beneficiaries and increase costs. Here are my concerns:

1. IDTF designation is not appropriate or necessary for office-based imaging.
As an orthopaedic surgeon, diagnostic imaging is essential to my medical
decision-making process for my patients. If I am restricted from obtaining
x-rays, MRI studies, or other studies by the new regulations, then it will
negatively impact my ability to provide care to Medicare patients by delaying
access to these studies. Furthermore, it will increase costs by requiring
multiple office visits to order and then review studies. Finally, I am likely
to choose to see fewer Medicare patients if obtaining the studies I need for
their treatment requires cutting through red-tape and jumping over hurdles. The
end result is less access to care for Medicare beneficiaries.

2. Supervision of diagnostic imaging facilities should not be limited to
radiologists. As an orthopaedic surgeon, I am trained and able to interpret the
diagnostic studies that I order. Any attempt to limit the physicians who can
supervise diagnostic imaging must include a mechanism for non-radiologists to
obtain certification to perform the imaging that they need. Limiting
supervision to radiologists will increase the cost of studies by decreasing
competition between imaging providers. It is also unnecessary as a
non-radiologist physician can be just as proficient at interpreting imaging
studies as a radiologist.

3. Requiring general supervision by a radiologist can also decrease the quality
of studies performed. In my practice, we choose to have our studies interpreted
by remote radiologists who have subspecialty training in reading musculoskeletal
imaging. Radiologists with these qualifications are not readily available in
our local market. If we were required to have supervision of our imaging by a
local radiologist, the quality of interpretation could decrease.

4. Direct supervision of contrast administration by a radiologist is
unnecessary. As a surgeon with clinical experience dealing with contrast
extravasation and reactions, I am at least as qualified, if not more qualified,
as a radiologist to supervise the administration of contrast for imaging
studies. Limiting these studies to direct supervision by a radiologist will
increase the cost of these studies by decreasing competition, and will not
improve the safety or quality of these procedures for Medicare beneficiaries.

In summary, I urge you not to adopt the proposed rule change without making
changes to ensure available access to quality imaging and interpretation for
Medicare beneficiaries.

Thank you.", "comment_id": "CMS-2008-0073-0339", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2008-0073-0339", "comment_date": "2008-08-25T04:00:00Z", "comment_title": "McGehee, James--IDTFs", "commenter_fname": null, "commenter_lname": null, "comment_length": 3249}, {"text": "RE: CMS-1403-P

I am writing to comment on the propsed changes to the ENROLLMENT RULES.
Currently, a physician is enrolled retroactively to the first date of service. The
propsoed rules would delay the enrollment to the date Medicare approves the
application or either the date of filing or the date an enrolled supplier started
rendering services. Either of these approaches would be difficult for anesthesia.
As you are aware, there is a serious shortage of anesthesiologists and recruiting
a new physician can be very difficult and time consuming. A delay in
credentialing a physician for Medicare would be a serious problem for our group
because Medicare comprises 25% of our patient population. Our physicians
choose to not look at a patient's insurance when providing care in order to be
totally objective. If one of these changes is implemented we might be forced to
look at insurance and delay a surgery until a Medicare credentialed physician was
available. This does not provide quality care for the patient, surgeon or hospital.
We do not want to begin looking at insurance before providing service. And we
certainly do not want to be placed in the position of delaying surgery simply
because the Medicare credentialing is not complete. We do not have the luxury
of starting a physician after all insurance credentialing is completed.

The second approach would be the preferred approach if a change is inevitable. If
the change is implemented, I would suggest part of the change be that Medicare
carriers be required to process applications in a timely manner, with a resonable
time frame spelled out, and penalties imposed if they cannot meet the time
frame. It is unfair for physicians to be penalized for the delayed action of the
carriers.", "comment_id": "CMS-2008-0073-0358", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2008-0073-0358", "comment_date": "2008-08-25T04:00:00Z", "comment_title": "Kreps, Linda--PHYS/NPP ENROLLMENT", "commenter_fname": null, "commenter_lname": null, "comment_length": 1894}, {"text": "The burden of hiring a supervising radiologist for in-office x-rays would only add
another layer of cost and oversight, negatively impacting patient care.", "comment_id": "CMS-2008-0073-0373", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2008-0073-0373", "comment_date": "2008-08-25T04:00:00Z", "comment_title": "Peterson, James--IDTFs", "commenter_fname": null, "commenter_lname": null, "comment_length": 159}, {"text": "WEST COUNTY HEART ALLIANCE
2335 DOUGHERTY FERRY RD.
ST. LOUIS, MO 63122

August 25, 2008

Kerry N. Weems, Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attention: CMS-1403-P
Mail Stop: C4-26-05
7500 Security Boulevard
Baltimore, MD 21244-1850

Re:Revisions to Payment Policies Under the Physicians Fee Schedule
and Other Revisions to Part B for CY 2009; Proposed Rule

Dear Mr. Weems:
On behalf of the West County Heart Alliance and our 18 individual practicing
cardiologists and 15 staff, we appreciate the opportunity to submit comments to
the Centers for Medicare & Medicaid Services (“CMS”) regarding the “Resource-
Based PE RVU’s” section of the above referenced July 7, 2008 Proposed Rule.
We are specifically concerned with the 2009-2010 PE RVU’s established for non-
facility outpatient cardiac catheterization procedure codes and the significant
negative impact that could result for our practice and our Medicare patients if
these values are finalized for the 2009 Physicians Fee Schedule.
The West County Heart Alliance is a Physician owned outpatient cardiac
catheterization lab servicing 2000 cardiac patient annually with a service area
covering East Central and Southern Missouri.
The West County Heart Alliance is a member of the Cardiovascular Outpatient
Center Alliance (COCA) and as such we have actively been involved in the effort
that COCA made in 2007-2008 to collect and submit direct and indirect cost data
to the CMS Center for Medicare Management in response to their specific
November 2007 request. Unfortunately, the Center senior staff chose not to share
the results of their analysis with COCA or the Congressional offices that requested
this information and instead returned the issue to the AMA PERC/RUC for
reconsideration. The AMA PERC/RUC declined to reconsider their 2007
recommendations without contacting COCA for any information or comments. As
a result, CMS states in the July 7, 2008 Federal Register, page 38512: “We are in
agreement with RUC recommendations, (including the recommendation that no
change be made to the direct inputs for CPT 93510, a cardiac cath code)”.

We are disheartened that CMS chose not to use or even share its own analysis of
COCA’s complete cost data; once again resulting in PE RVU recommendations
that severely undervalue the direct and indirect costs associated with providing
these procedures to our patients. The PE RVU values published in the July 7,
2008 Proposed Rule would result in additional draconian cuts in reimbursement for
cardiac catheterizations performed in physician practice or IDTF locations. For
example, the 2008 reimbursement for the technical components of the primary
three CPT codes for a Left Heart Cath (93510TC, 93555TC, and 93556TC) were cut
by 23.33% in 2008, would be cut by an additional 14.38% in 2009, and cut another
18.29% in 2010 for a total reduction of 46.36% from 2007 levels. At the same
time, the outpatient hospital APC payments for the exact same procedure were
increased by 8.56% in 2008 and are proposed to increase by another 4.84% in
2009. Since the APC reimbursement was already 6.35% higher than the PFS
rates in 2007, this means that as of January 1, 2009 the reimbursement for this
procedure in a non-hospital outpatient cath lab (OPCL) will have dropped from
93.65% of the APC rate to 54.02%.

These severe and unsupported reductions have already resulted in the closing (or
sale to hospitals) of several OPCLs and if not reversed will more than likely result
in the closure of the majority of OPCLs in the country. This result would force
thousands of Medicare patients who now benefit from improved access and lower
costs into more acute hospital settings where their copayments will cost each of
them several hundred dollars more than the same procedure in an OPCL. Even
comparing the original 2007 Physician Fee Schedule payment with the proposed
2009 APC rate, the increased cost to the Medicare Trust Fund and Medicare
beneficiaries from this shift would conservatively add up to $28.5 million. If the
current 2008 PFS payment is compared to the 2009 APC rate, the additional cost
to the Medicare program increases to $59.5 million.

COCA is on record in their April 30, 2008 meeting with Dr. Jeffery Rich requesting
that CMS reconsider the complete cost data provided to them by COCA in
December 2007 and establish PE RVU’s for non-facility outpatient cardiac
catheterization procedures that more reasonably reflect the direct and indirect
costs of providing these procedures. In addition, the American College of
Cardiology is on record in their June 11, 2008 letter to Dr. Rich requesting that
CMS at least freeze the 2009 reimbursement at 2008 levels until an additional
review of OPCL indirect costs can be conducted.

We request that CMS listen to the recommendations of COCA and ACC and
develop fair and reasonable reimbursement for non-facility outpatient cardiac cath
procedures for 2009 before it is too late and we are forced to close or sell our
OPCL to a local hospital. The ultimate severe negative impact on the Medicare
program, our Medicare patients, and our practice is unnecessary if CMS would
only utilize the data that they have already analyzed.

Thank you for the opportunity to comment on this critical issue. Please contact
me at 314-570-3312 if you are interested in the specific details of our request.

Sincerely,
Scott W. Hylton R.N.
Manager
West County Heart Alliance
", "comment_id": "CMS-2008-0073-0384", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2008-0073-0384", "comment_date": "2008-08-26T04:00:00Z", "comment_title": "Hylton, Scott--PE", "commenter_fname": null, "commenter_lname": null, "comment_length": 6282}, {"text": "I am writing to comment on proposed changes to ENROLLMENT RULES for
providers.

Starting a new Anesthesiologist in a new practice typically takes 3-6 months from
interviews to Hospital privileges. Quite often privileges are obtained mere hours
before starting to work in the OR. Only then can a new provider apply for
enrollment as a Medicare provider. Current rules allow retroactive enrollment to day
of application. Proposed changes would delay our ability to bill for the new
Anesthesiologist's services for up to a couple of months.

Our choices are then all bad: do we try to have the new physician avoid Medicare
cases, nearly impossible when call is taken into account. Or are we put in a
position of providing his/her uncompensated services for a time? We simply do not
have the luxury of waiting for an Anesthesiologist to have all enrollments in hand to
start work in a new practice.

Enrollment works as is, do not change it.", "comment_id": "CMS-2008-0073-0378", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2008-0073-0378", "comment_date": "2008-08-26T04:00:00Z", "comment_title": "Forest, Robert--PHYS/NPP ENROLLMENT", "commenter_fname": null, "commenter_lname": null, "comment_length": 1016}, {"text": "CMS 1403-P once again illustrates the lack of understanding and lack of
awareness present with CMS officials today, as demonstrated in the Competitive
Bidding Debacle. The definition and rule change that will not allow an individual or
a company to own a Sleep Lab and a seperate Medical Equipment company
entity not only infringes once again upon free enterprise, but quite frankly misses
the mark if the target idea is to curb abuse.
These DME entities still must receive referrals and orders from physicians; the
Sleep lab cannot order a CPAP, nor can the DME company initiate the therpay
without the physician's order. There is no danger of "self gratification" because the
ordering physician decides where the referral will go. The Sleep Lab performs the
sleep study, the study is interpreted by a doctor, the final report is then sent to
the ordering physician, who them refers the CPAP to a qualified provider.
It should also be noted that many DME companies that are seperate entities and
owned by the same owenr as a Sleep Lab arer also accrediited companies.
The real targets should be Labs and DME operations jointly owned by physicians
or Labs and DME operations owned by hospitals. In those cases, the entities can
benefit from "self referral". The fact that that has occurred for years has created an
unstable playing field for many honest privately owned companies.
As written, this change will only hurt small companies, while directing more
business to larger national companies, once again limiting patient choice and free
enterprise.
as i have stated before, the real target should be limiting physician and hospital
ownership in such realted entities, not private ownership that cannot and do not
write the ordrs necessary for self referral.", "comment_id": "CMS-2008-0073-0016", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2008-0073-0016", "comment_date": "2008-07-17T04:00:00Z", "comment_title": "Metcalfe, Harley--CPAP", "commenter_fname": null, "commenter_lname": null, "comment_length": 1895}, {"text": "CMS should be applauded for recognizing the need for inpatient telemedicine
subsequent visit codes for consults provdided via telemedicine. Further, they
should be applauded for recognizing the value of this service and the injustice of
seeking to avoid compensating physicians for this service, now being provided for
free via telemedicine, when it is a billable service in person. There are not too
many things that I have been involved with that I can honestly say everyone is
happy with but telemedicine is one of them. Referring physicians are happy,
patients are happy and consulting physicians are happy. Not to mention that it is
far better care than that provided by the telephone which is likely to be inadequate,
leave no one particularly happy and end up costing more in the long run. Thank
you for acting on this important and pressing issue!!!", "comment_id": "CMS-2008-0073-0019", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2008-0073-0019", "comment_date": "2008-07-18T04:00:00Z", "comment_title": "Assimacopoulos, Aristides--TELEHEALTH", "commenter_fname": null, "commenter_lname": null, "comment_length": 911}, {"text": "I agree with the proposed regulations which would not allow any entity to provide a
sleep test and to also provide any equipment to a patient who has been tested by
that that same entity.
As physicians and physician groups are being bought by hospitals, the physician
is coming under more pressure by hospital administrations to administer more
test and to prescribe more services and equipment to patients being tested. There
can also be a bias in the interpretation of sleep studies by a physician who is
employed by a hospital. This could be especially possible when his salary and/or
bonus is directly related to the income generated by the test and prescription of
equipment which will also be supplied by a hospital owned medical equipment
company. We have also seen in the Charlotte community, the monopolization of
referrals for equipment by hospital owned sleep labs. Patients are not always
offered a choice of providers. The result is that there is no competition and thus no
reason for a hospital owned company to offer quality service or competitive pricing.
Physicians who are employed by a hospital should not be allowed to refer patients
to a hospital owned medical equipment company!
Another respondent has suggested that a company not owned by the sleep lab
may not provide the same mask as used in the sleep test. This is doubtful as
most homecare companies carry a wide variety of mask for existing customers. It
is in the best interest of the company and the patient to provide the patient with a
mask that will best ensure compliance by the patient. Homecare companies also
have more time to spend with the patient in the home environment fitting the most
appropriate mask for the patient to use in his own sleeping environment. The sleep
environment of a diagnostic lab and that of the patients' home are completely
different. Also not all sleep labs send the mask home used in the test.
Additonally, private physicians who own sleep labs are currently not allowed to
refer Medicare or Medicaid patients to medical equipment companies in which
they have ownership. Thus, there is no incentive to prescribe equipment that the
patient may not need.
I strongly urge the adoption of this regulation. It will surely result in more choice of
providers to Medicare patients. It will also result in a higher quality of service to
the Medicare patient and can help to keep competitve pricing in the marketplace.

My final argument for this regulation is the positive effect it will have on the tax
payer in general. No longer will tax paying private companies have to unfairly
compete with not for profit hospitals. This will allow private companies to continue
in business, grow as they provide quality service and continue to pay taxes to
local governments. As not for profit hospitals gobble up the business, the "profits"
they generate are used to buy more and more property which becomes
nontaxable. This is not good for the community and places an additional burden
on local taxpayers.
Respectfully,
H. Edward Eubanks
23 Washington Lane
Concord, NC 28025
", "comment_id": "CMS-2008-0073-0020", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2008-0073-0020", "comment_date": "2008-07-18T04:00:00Z", "comment_title": "Eubanks, H Edward--CPAP", "commenter_fname": null, "commenter_lname": null, "comment_length": 3304}]}, {"id": "CMS-2019-0111", "title": "Revisions to Payment Policies under the Medicare Physician Fee Schedule, Quality Payment Program and Other Revisions to Part B for CY 2020 (CMS-1715-P)", "context": "2020-10-16T21:14:52Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "Sept 12, 2019

Centers for Medicare &amp; Medicaid Services
Department of Health and Human Services
Attention: CMS1715P
P.O. Box 8016
Baltimore, MD 212448016

RE: Medicare Program; CY 2020 Revisions to Payment Policies under the Physician Fee Schedule and
Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicaid
Promoting Interoperability Program Requirements for Eligible Professionals; Establishment of an
Ambulance Data Collection System; Updates to the Quality Payment Program; Medicare Enrollment of
Opioid Treatment Programs and Enhancements to Provider Enrollment Regulations Concerning Improper
Prescribing and Patient Harm; and Amendments to Physician Self-Referral Law Advisory Opinion
Regulations [CMS-1715-P]

Dear Administrator Verma:

I am writing in response to the request for comments on the Centers for Medicare and Medicaid Services
(CMS) Calendar Year (CY) 2020 Revisions to Payment Policies under the Physician Fee Schedule (PFS)
and Other Revisions to Medicare Part B proposed rule.

I am a physical therapist assistant and am concerned about this potential regulation change. Physical therapy and occupational therapy services are critically important for improving patient function in order to return home or maintain their highest level of independence and quality of life.

I appreciate the opportunity to provide feedback to CMS on the proposed rule. Specifically, I am writing
in response to CMS proposed application of the CQ/CO modifier when outpatient physical therapy and
occupational therapy services are furnished in whole or in part by a physical therapist assistant (PTA) or
occupational therapy assistant (OTA).

I understand that Section 53107 of the Bipartisan Budget Act of 2018 (BBA), enacted on February 9,
2018, included the assistant adjustment as a pay-for provision related to the repeal of the Medicare Part B
payment cap for therapy services. However, if finalized as proposed, this policy will negatively affect
Medicare beneficiary access and add administrative burden. Further, if the application of the modifiers is
finalized as proposed, the access to and safety of vital outpatient physical and occupational therapy
services for the most vulnerable physically impaired beneficiaries will be compromised.

I ask the Secretary to not finalize these policies as proposed. Instead, I am requesting that CMS, in
finalizing the therapy assistant adjustment provisions of Section 1834 of the BBA, implement the
following policy:

1. When a therapist and assistant are jointly furnishing services to a patient at the same time as a
team, and the therapist is fully engaged in the service during that time, the service during that
time period should be identified as a therapists services and be allocated to the therapist.
2. That CMS define in whole or in part to mean skilled therapy service furnished by a PTA or an
OTA that is furnished under the supervision of a therapist, but independent of any time the
therapist is furnishing the service.
3. That only those units of services provided in whole or in part by the assistant should be subject
to the 10% de minimis standard, the CQ/CO modifier, and subsequently the 15% payment
adjustment, not all units of the entire therapy service.
4. That no new burdensome documentation requirements be added. At a maximum, sub regulatory
guidance could revised to include a statement such as The provider should have a mechanism in
place to provide evidence whether a specific service was furnished independently by a therapist
or an assistant, or was furnished in part by an assistant in sufficient detail to permit the
determination of whether the de minimis threshold was met.

Thank you for the opportunity to comment on the CY 2020 Medicare Physician Fee Schedule and
proposed rule.

Sincerely,

Alvin Fall
PTA", "comment_id": "CMS-2019-0111-6442", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0111-6442", "comment_date": "2019-09-17T04:00:00Z", "comment_title": "Comment on CMS-2019-0111-0092", "commenter_fname": null, "commenter_lname": null, "comment_length": 4096}, {"text": "I am writing in strong support of CMS' efforts to eliminate unnecessary administrative barriers by simplifying current documentation requirements for evaluation and management (E/M) services. Currently, CMS only allows E/M documentation provided by medical students to be verified, rather than re-performed, by teaching physicians for billing purposes. This places a significant burden on physician, PA, and NP preceptors of PA and NP students and restricts the ability of preceptors to train the future health workforce. I therefore applaud CMS' recognition of this issue and its proposed changes, which would allow all preceptors to verify the documentation provided by medical, PA, and NP students. This will allow preceptors more time to train students and provide patient care.

The proposed rule clearly intends to allow NPs, PAs, and other preceptors to verify, rather than re-perform, documentation provided by students in the medical record. Therefore, I urge CMS to specifically name PAs and NPs as clinicians eligible to verify documentation, rather than including them as "other members of the medical team," which may lead to unnecessary confusion. Rather than stating that the documentation of "students" can be verified, the term "medical, PA, and NP students" should be utilized. By explicitly naming the types of clinicians and students for which documentation can be reviewed and verified, misinterpretation on the part of health systems, providers, and educators can be eliminated - thus improving both clinical training opportunities and, ultimately, patient care.

I further encourage CMS to reexamine the current physical presence requirement that results in significant burden for preceptors when students are participating in patient care. While physical presence in the clinic is critical for safe patient care, presence in the examination room during documentation is onerous and unnecessary."

", "comment_id": "CMS-2019-0111-6412", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0111-6412", "comment_date": "2019-09-17T04:00:00Z", "comment_title": "Comment on CMS-2019-0111-0092", "commenter_fname": null, "commenter_lname": null, "comment_length": 1988}, {"text": "I am writing in strong support of CMS' efforts to eliminate unnecessary administrative barriers by simplifying current documentation requirements for evaluation and management (E/M) services. Currently, CMS only allows E/M documentation provided by medical students to be verified, rather than re-performed, by teaching physicians for billing purposes. This places a significant burden on physician, PA, and NP preceptors of PA and NP students and restricts the ability of preceptors to train the future health workforce. I therefore applaud CMS' recognition of this issue and its proposed changes, which would allow all preceptors to verify the documentation provided by medical, PA, and NP students. This will allow preceptors more time to train students and provide patient care.

The proposed rule clearly intends to allow NPs, PAs, and other preceptors to verify, rather than re-perform, documentation provided by students in the medical record. Therefore, I urge CMS to specifically name PAs and NPs as clinicians eligible to verify documentation, rather than including them as "other members of the medical team," which may lead to unnecessary confusion. Rather than stating that the documentation of "students" can be verified, the term "medical, PA, and NP students" should be utilized. By explicitly naming the types of clinicians and students for which documentation can be reviewed and verified, misinterpretation on the part of health systems, providers, and educators can be eliminated - thus improving both clinical training opportunities and, ultimately, patient care.

I further encourage CMS to reexamine the current physical presence requirement that results in significant burden for preceptors when students are participating in patient care. While physical presence in the clinic is critical for safe patient care, presence in the examination room during documentation is onerous and unnecessary.", "comment_id": "CMS-2019-0111-6590", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0111-6590", "comment_date": "2019-09-17T04:00:00Z", "comment_title": "Comment on CMS-2019-0111-0092", "commenter_fname": null, "commenter_lname": null, "comment_length": 1972}, {"text": "Thank you for recognizing and addressing the disparity between student documentation requirements for teaching physicians and their students and those for advanced practice nurses (APRNs) and physician assistants (PAs) preceptors and their students. Currently, CMS allows teaching physicians to review and verify any student documentation of the components of E/M services in the medical record, rather than re-document the work. However, this burden reduction policy was not applied to APRN/PA preceptors and their students. Excluding APRN/PA preceptors and their students from this policy had the unintended effect of heightening the challenge of securing preceptors for APRN/PA students when teaching clinicians are in short supply. The revision contained in the Medicare Physician Fee Schedule proposed rule will authorize all APRNs /PAs and physicians to review and verify rather than re-document work for all E/M services by all members of the medical care team (including APRN/PA students). This will remove the disparity and lead to parity among providers and burden reduction for all clinicians. Therefore, we support the inclusion of APRN/PAs in the proposed rule.

For additional information, please contact the AANP Government Affairs Office at 703/740-2529 or governmentaffairs@aanp.org.", "comment_id": "CMS-2019-0111-6713", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0111-6713", "comment_date": "2019-09-17T04:00:00Z", "comment_title": "Comment on CMS-2019-0111-0092", "commenter_fname": null, "commenter_lname": null, "comment_length": 1348}, {"text": "As a physical therapist and employer of 5 Physical Therapists assistants, I urge the payment policy be reviewed and deemed not beneficial for patient care. The use of physical therapists assistants in the healthcare world is vital for efficiency and quality. The proposed decrease in reimbursement will negatively impact employment and likely lead to additional shortages of rehab professionals through the country. I fully understand the need for cost containment however strongly disagree with this methodology. I urge your committee or group to reconsider the payment reduction.
Sincerely, Joe Walters PT
Owner, Physical Therapy One
Portage, MI 49024 ", "comment_id": "CMS-2019-0111-6706", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0111-6706", "comment_date": "2019-09-17T04:00:00Z", "comment_title": "Comment on CMS-2019-0111-0092", "commenter_fname": null, "commenter_lname": null, "comment_length": 671}, {"text": "I am writing in strong support of CMS' efforts to eliminate unnecessary administrative barriers by simplifying current documentation requirements for evaluation and management (E/M) services. Currently, CMS only allows E/M documentation provided by medical students to be verified, rather than re-performed, by teaching physicians for billing purposes. This places a significant burden on physician, PA, and NP preceptors of PA and NP students and restricts the ability of preceptors to train the future health workforce. I therefore applaud CMS' recognition of this issue and its proposed changes, which would allow all preceptors to verify the documentation provided by medical, PA, and NP students. This will allow preceptors more time to train students and provide patient care.

The proposed rule clearly intends to allow NPs, PAs, and other preceptors to verify, rather than re-perform, documentation provided by students in the medical record. Therefore, I urge CMS to specifically name PAs and NPs as clinicians eligible to verify documentation, rather than including them as "other members of the medical team," which may lead to unnecessary confusion. Rather than stating that the documentation of "students" can be verified, the term "medical, PA, and NP students" should be utilized. By explicitly naming the types of clinicians and students for which documentation can be reviewed and verified, misinterpretation on the part of health systems, providers, and educators can be eliminated - thus improving both clinical training opportunities and, ultimately, patient care.

I further encourage CMS to reexamine the current physical presence requirement that results in significant burden for preceptors when students are participating in patient care. While physical presence in the clinic is critical for safe patient care, presence in the examination room during documentation is onerous and unnecessary.", "comment_id": "CMS-2019-0111-6705", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0111-6705", "comment_date": "2019-09-17T04:00:00Z", "comment_title": "Comment on CMS-2019-0111-0092", "commenter_fname": null, "commenter_lname": null, "comment_length": 1972}, {"text": "CMS,
I strongly disagree with the CY 2020 Medicare Physician Fee Schedule Proposed Rule update to certain CPT codes for cardiac PET Imaging (CPT codes 78491, 78492, 78x31, 78x32). I disagree with this policy as it is based off of incorrect data and observation. It appears that inaccurate overhead data, a lack of thorough survey inputs and non-"real world" assumptions have caused Medicare and the RUC to recommend changes to the work inputs associated with Direct Expense and Practice Expense values, that combined with an inaccurate utilization rate resulted in a proposed reimbursement decline that is significant enough to make it impossible for facilities to continue to offer cardiac PET services after January 1, 2020.

The RUC and Medicare relied on market survey data to provide inputs for calculating the technical component (TC) reimbursement. These flawed surveys provided incorrect data or incomplete data regarding equipment direct expense, utilization rate, and practice expense inputs. In addition, the surveys failed to assess the true cost of starting, operating, and maintaining a cardiac PET lab, omitting input allowances for numerous high cost requirements. Therefore, based on this flawed survey data, both the RUC and Medicare recommended a reimbursement value well below what is necessary for the technical operation of a cardiac PET laboratory. I request that CMS NOT commence with the proposed reimbursement in 2020 and instead allow reimbursement to continue at current levels.

", "comment_id": "CMS-2019-0111-6759", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0111-6759", "comment_date": "2019-09-17T04:00:00Z", "comment_title": "Comment on CMS-2019-0111-0092", "commenter_fname": null, "commenter_lname": null, "comment_length": 1543}, {"text": "Dear Administrator Verma,

RE: CMS-2019-0111-0092

I am writing today to comment on the CY 2020 Revisions to Payment Policies under the Physician Fee Schedule (CMS-1715-P). Specifically, I strongly support the proposal to allow Certified Registered Nurse Anesthetists (CRNAs) to provide the pre-anesthetic assessment in Ambulatory Surgical Centers (ASCs) as part of the Conditions for Coverage (CfC).

This change would relieve ASC regulatory burden associated with operating the Medicare program, reduce healthcare costs, and ensure patient safety. CRNAs are highly educated anesthesia experts who are fully qualified to provide the pre-anesthesia assessment. In fact, performing the pre-anesthetic assessment and evaluation of the risk of anesthesia is within the scope of practice of a CRNA.

This proposal would align the anesthetic risk and pre-surgery evaluation standard with the post-anesthetic evaluation standard and would promote continuity of care for the patient by allowing "the patient's anesthesia professional to have familiarity with the patient's health characteristics and medical history."

In many facilities, CRNAs may be the only anesthesia providers, and, therefore, the only healthcare professionals possessing the expertise and training to perform the pre-anesthetic evaluation. Modification of this requirement would promote efficiency and flexibility in ASCs and will reduce administrative burden.

This is the right proposal for patients and for the healthcare system, and I urge you to ensure that it is included in the final rule. Thank you for taking the time to review these comments.

Sincerely,
Pamela Thurman
726 Marina Village Dr

Grand Rivers, KY 42045-9010
", "comment_id": "CMS-2019-0111-6644", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0111-6644", "comment_date": "2019-09-17T04:00:00Z", "comment_title": "Comment on CMS-2019-0111-0092", "commenter_fname": null, "commenter_lname": null, "comment_length": 1838}, {"text": "Dear Administrator Verma,

RE: CMS-2019-0111-0092

I am writing today to comment on the CY 2020 Revisions to Payment Policies under the Physician Fee Schedule (CMS-1715-P). Specifically, I strongly support the proposal to allow Certified Registered Nurse Anesthetists (CRNAs) to provide the pre-anesthetic assessment in Ambulatory Surgical Centers (ASCs) as part of the Conditions for Coverage (CfC).

This change would relieve ASC regulatory burden associated with operating the Medicare program, reduce healthcare costs, and ensure patient safety. CRNAs are highly educated anesthesia experts who are fully qualified to provide the pre-anesthesia assessment. In fact, performing the pre-anesthetic assessment and evaluation of the risk of anesthesia is within the scope of practice of a CRNA.

This proposal would align the anesthetic risk and pre-surgery evaluation standard with the post-anesthetic evaluation standard and would promote continuity of care for the patient by allowing "the patient's anesthesia professional to have familiarity with the patient's health characteristics and medical history."

In many facilities, CRNAs may be the only anesthesia providers, and, therefore, the only healthcare professionals possessing the expertise and training to perform the pre-anesthetic evaluation. Modification of this requirement would promote efficiency and flexibility in ASCs and will reduce administrative burden.

This is the right proposal for patients and for the healthcare system, and I urge you to ensure that it is included in the final rule.

Sincerely,
Ursula Waller
128 Marshall Rd

Buckhead, GA 30625-2906
", "comment_id": "CMS-2019-0111-6631", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0111-6631", "comment_date": "2019-09-17T04:00:00Z", "comment_title": "Comment on CMS-2019-0111-0092", "commenter_fname": null, "commenter_lname": null, "comment_length": 1770}, {"text": "Dear Administrator Verma,

RE: CMS-2019-0111-0092

I am writing today to comment on the CY 2020 Revisions to Payment Policies under the Physician Fee Schedule (CMS-1715-P). Specifically, I strongly support the proposal to allow Certified Registered Nurse Anesthetists (CRNAs) to provide the pre-anesthetic assessment in Ambulatory Surgical Centers (ASCs) as part of the Conditions for Coverage (CfC).

This change would relieve ASC regulatory burden associated with operating the Medicare program, reduce healthcare costs, and ensure patient safety. CRNAs are highly educated anesthesia experts who are fully qualified to provide the pre-anesthesia assessment. In fact, performing the pre-anesthetic assessment and evaluation of the risk of anesthesia is within the scope of practice of a CRNA.

This proposal would align the anesthetic risk and pre-surgery evaluation standard with the post-anesthetic evaluation standard and would promote continuity of care for the patient by allowing "the patient's anesthesia professional to have familiarity with the patient's health characteristics and medical history."

In many facilities, CRNAs may be the only anesthesia providers, and, therefore, the only healthcare professionals possessing the expertise and training to perform the pre-anesthetic evaluation. Modification of this requirement would promote efficiency and flexibility in ASCs and will reduce administrative burden.

This is the right proposal for patients and for the healthcare system, and I urge you to ensure that it is included in the final rule.

Sincerely,
Jaclyn Taylor
108 S Elmhurst Ave

Mount Prospect, IL 60056-3125
", "comment_id": "CMS-2019-0111-6629", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2019-0111-6629", "comment_date": "2019-09-17T04:00:00Z", "comment_title": "Comment on CMS-2019-0111-0092", "commenter_fname": null, "commenter_lname": null, "comment_length": 1779}]}, {"id": "HHS-OS-2009-0007", "title": "Proposed Rule on Buprenorpine Dispensing In Opioid Treatment Programs", "context": "2019-01-11T01:04:12Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "Comment 4", "comment_id": "HHS-OS-2009-0007-0006", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2009-0007-0006", "comment_date": "2009-08-17T04:00:00Z", "comment_title": "Comment on FR Doc # fr_doc_num", "commenter_fname": "Ronald", "commenter_lname": "Pike", "comment_length": 9}, {"text": "see attatched file", "comment_id": "HHS-OS-2009-0007-0008", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2009-0007-0008", "comment_date": "2009-08-17T04:00:00Z", "comment_title": "Comment on FR Doc # E9-14286", "commenter_fname": "Elizabeth", "commenter_lname": "Stanton MD", "comment_length": 18}, {"text": "please see attached comments from the Cleveland Clinic", "comment_id": "HHS-OS-2009-0007-0003", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2009-0007-0003", "comment_date": "2009-07-20T04:00:00Z", "comment_title": "Comment on FR Doc # E9-14286", "commenter_fname": "blair", "commenter_lname": "barnhart", "comment_length": 54}, {"text": "Comment from Robert Newman, M.D.", "comment_id": "HHS-OS-2009-0007-0010", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2009-0007-0010", "comment_date": "2009-08-17T04:00:00Z", "comment_title": "Comment on FR Doc # E9-14286", "commenter_fname": "Robert", "commenter_lname": "Newman", "comment_length": 32}, {"text": "Please see the attached PDF file", "comment_id": "HHS-OS-2009-0007-0014", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2009-0007-0014", "comment_date": "2009-08-18T04:00:00Z", "comment_title": "Comment on FR Doc # E9-14286", "commenter_fname": "Thomas", "commenter_lname": "Merrill", "comment_length": 32}, {"text": "See attached.", "comment_id": "HHS-OS-2009-0007-0012", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2009-0007-0012", "comment_date": "2009-08-18T04:00:00Z", "comment_title": "Comment on FR Doc # E9-14286", "commenter_fname": "Elinore", "commenter_lname": "Mccance-Katz, M.D.", "comment_length": 13}, {"text": "August 17, 2009

Re: Dockett No. CSAT 001, Proposed Rule Change for Buprenorphine Take Homes for Opioid Treatment Programs (OTPs)

At Texas Clinic, we started utilizing buprenorphine, specifically Suboxone, soon after it was approved for usage in our OTP. We have had great success with this medication, as it seems to have reached a new population of individuals addicted to opiates.

Our main problem from the very beginning in giving buprenorphine to our patients has been the cumbersome take home restrictions identical to those placed on methadone dispensing. We are constantly having to get exception requests for take homes while our colleagues in private practice were simply able to prescribe or dispense Suboxone with no such restrictions.

The take home restrictions have definitely been a deterrent to successful treatment. Over the years, we have had patients drop out of treatment while waiting for their take homes to be processed for approval or simply switch to a private practice (which actually cost them more) because they had freedom to work, go to school, or manage their household more easily.

We would strongly be in favor of lifting any take home restrictions on buprenorphine in OTPs and, therefore, amending the Federal OTP regulations as soon as possible. In this vain, we would further propose that an emergency order be issued, lifting such restrictions immediately, to avoid the possibility of any other patients leaving treatment, relapsing, and going back to a life of abusing opioids.

Thank you for allowing us to comment on this proposed rule change.

Sincerely,
Farrukh Shamsi, MBA
Executive Director
Texas Clinic Fulton
6311 Fulton St.
Houston, TX 77022
(713) 694-8100", "comment_id": "HHS-OS-2009-0007-0009", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2009-0007-0009", "comment_date": "2009-08-17T04:00:00Z", "comment_title": "Comment on FR Doc # E9-14286", "commenter_fname": "Farrouk", "commenter_lname": "Shamsi", "comment_length": 1798}, {"text": "Please find comments by the American Society of Addiction Medicine, regarding the approval of take-home buprenorphine within OTPs, attached. (Docket No. CSAT 001) Thank you.", "comment_id": "HHS-OS-2009-0007-0007", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2009-0007-0007", "comment_date": "2009-08-17T04:00:00Z", "comment_title": "Comment on FR Doc # E9-14286", "commenter_fname": "Alexis", "commenter_lname": "Geier-Horan", "comment_length": 175}, {"text": "See Attached", "comment_id": "HHS-OS-2009-0007-0011", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2009-0007-0011", "comment_date": "2009-08-18T04:00:00Z", "comment_title": "Comment on FR Doc # E9-14286", "commenter_fname": "Charles", "commenter_lname": "O'Keefe", "comment_length": 12}, {"text": "See Attached.", "comment_id": "HHS-OS-2009-0007-0013", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2009-0007-0013", "comment_date": "2009-08-18T04:00:00Z", "comment_title": "Comment on FR Doc # E9-14286", "commenter_fname": "Doug", "commenter_lname": "Kramer", "comment_length": 13}]}, {"id": "DOT-OST-2006-24112", "title": "Procedures for Transportation Workplace Drug and Alcohol Testing Programs: Revision of Substance Abuse Professional Credential Requirement", "context": "2015-05-26T10:25:30Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": null, "comment_id": "DOT-OST-2006-24112-0014-0002", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2006-24112-0014-0002", "comment_date": "2006-04-10T04:00:00Z", "comment_title": "Air Transport Association of America, Inc., Regional Airline Association, National Air Carrier Association, and Air Carrier Association of America", "commenter_fname": "Ronald", "commenter_lname": "Priddy", "comment_length": 0}, {"text": null, "comment_id": "DOT-OST-2006-24112-0007-0002", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2006-24112-0007-0002", "comment_date": "2006-03-27T05:00:00Z", "comment_title": "National SAP Network", "commenter_fname": "Kathleen", "commenter_lname": "Bruner, Ph.D, CEAP", "comment_length": 0}, {"text": null, "comment_id": "DOT-OST-2006-24112-0014-0004", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2006-24112-0014-0004", "comment_date": "2006-04-10T04:00:00Z", "comment_title": "Air Transport Association of America, Inc., Regional Airline Association, National Air Carrier Association, and Air Carrier Association of America", "commenter_fname": "Edward", "commenter_lname": "Faberman", "comment_length": 0}, {"text": "I would like to say that I find it unfair that every other licensing board has had to
have approval from all 50 states before being approved to do SAP work and there
are concessions being made for MFT's. I think if the DOT is serious about having
SAP's truly be the gatekeeper for public safety then they need to keep a high and
consistent standard for every licensing board and not take shortcuts because of
political expediency.

", "comment_id": "DOT-OST-2006-24112-0003", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2006-24112-0003", "comment_date": "2006-03-13T05:00:00Z", "comment_title": "Rob Sullivan", "commenter_fname": "Rob", "commenter_lname": "Sullivan", "comment_length": 476}, {"text": null, "comment_id": "DOT-OST-2006-24112-0014-0003", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2006-24112-0014-0003", "comment_date": "2006-04-10T04:00:00Z", "comment_title": "Air Transport Association of America, Inc., Regional Airline Association, National Air Carrier Association, and Air Carrier Association of America", "commenter_fname": "Sophy", "commenter_lname": "Chen, Esq.", "comment_length": 0}, {"text": null, "comment_id": "DOT-OST-2006-24112-0018", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2006-24112-0018", "comment_date": "2006-04-14T04:00:00Z", "comment_title": "NJ Transit", "commenter_fname": "D.", "commenter_lname": "McGrawel", "comment_length": 0}, {"text": null, "comment_id": "DOT-OST-2006-24112-0021-0002", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2006-24112-0021-0002", "comment_date": "2006-04-24T04:00:00Z", "comment_title": "First Advantage", "commenter_fname": "Josephine", "commenter_lname": "Kenney, J.D.", "comment_length": 0}, {"text": null, "comment_id": "DOT-OST-2006-24112-0013-0001", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2006-24112-0013-0001", "comment_date": "2006-04-10T04:00:00Z", "comment_title": "PharmaTox Institute of Addiction Studies", "commenter_fname": "Star", "commenter_lname": "Cannon", "comment_length": 0}, {"text": null, "comment_id": "DOT-OST-2006-24112-0012", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2006-24112-0012", "comment_date": "2006-04-07T04:00:00Z", "comment_title": "International Certification & Reciprocity Consortium of Alcohol and Other Drug Abuse (ICRC/AODA)", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "DOT-OST-2006-24112-0009-0001", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2006-24112-0009-0001", "comment_date": "2006-04-03T04:00:00Z", "comment_title": "Substance Abuse Program Administrators", "commenter_fname": "Elizabeth", "commenter_lname": "Emerson", "comment_length": 0}]}, {"id": "FDA-2017-P-1359", "title": "Request that the FDA the following actions: Revoke approval of OxyContin's indication for the management of pain, approval of all extended-release opioids indicated for the management of pain and approval of all immediate-release opioid drug product labeling supporting use for the treatment of chronic pain", "context": "2017-08-31T16:42:01Z", "purpose": "Nonrulemaking", "keywords": ["Citizen Petition", "CDER", "Pharmaceutical Manufacturing Research Services", "PMRS", "Revoke approval of OxyContin", "approval of all extended-release opioids", "approval of all immediate-release opioid", "management of pain", "chronic pain", "2017-1067"], "comments": [{"text": "I look at the reports on how the "opioid epidemic", has got to be stopped and addressed. I am, along with millions of other Americans, are on the other end of opioids.
I am on the end of the chronic pain disease epidemic. As the CDC, DEA and Medicaid and medicare, and numerous other government associates, are blaming Doctors for the over prescribing of medication, NOBODY, is looking at or reading the statistics from chronic pain disease patients. How about not addressing these drugs as dangerous and addictive. Let's look at them as lifesaving and medically necessary for the million of Americans in chronic pain. Chronic pain is a disease. It is now becoming an epidemic.
No other disease medication is scrutinized. Chronic pain is a disease. We as patients are being denied, dismissed and overlooked by our drs due to all the scrutiny associated with treating chronic pain disease. Our doctors are afraid to treat us adequately. We have a disease that medication is readily accessible to us and we are being denied. We pain patients are truly being discriminated against, due to people who use heroin, illegal fentanyl, and placed a blame on anyone but themselves. This is a witch hunt for drs who prescribe life saving medication and pain disease patients who benefit from this medication.
We have a chronic disease. We want to be able to take care of our homes, our children, our selves, as much as possible, but without access to our, potentially, life saving medications, we are unable to do so. We want to live not just exist in pain 24/7.
We need the government agencies to look at the real statistics, not the hand picked.
We need help. With all the headlines, topics and stories on how opioids are bad, let's look at what good they do for our disease of chronic pain and the million of Americans they help.
", "comment_id": "FDA-2017-P-1359-0025", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-1359-0025", "comment_date": "2017-08-07T04:00:00Z", "comment_title": "Comment from Candi Simonis", "commenter_fname": null, "commenter_lname": null, "comment_length": 1901}, {"text": "See attached file(s)", "comment_id": "FDA-2017-P-1359-0027", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-1359-0027", "comment_date": "2017-08-31T04:00:00Z", "comment_title": "Comment from Veronica Griffin", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}]}, {"id": "FDA-2012-P-0260", "title": "Request that the (\"Commissioner\") investigate actions taken by the Center for Devices and Radiological Health (\"CDRH\") related to the August 8, 2011 proposed rule", "context": "2019-12-20T12:32:25Z", "purpose": "Nonrulemaking", "keywords": ["cdrh", "cranial electrotherapy stimolator", "August 8, 2011", "76 FR 48062", "CES", "February 10, 2012", "insomnia", "chronic pain", "open"], "comments": [{"text": "As a PhD psychotherapist who supervised clinicians in a WTC mental health program for five years, I experienced a severe case of PTSD after leaving the program, with accompanying depression. That lasted for almost two years. When the Fisher Wallace stimulator was recommended to me, I had never heard of it, but obtained the device within a week. Using it for 20 minutes per day on the lowest level level I had no side effects from it, and my symptoms were almost totally alleviated within 10 days. For myself, I need to use the machine at least three days per week to remain symptom free. The machine is not expensive, I can use it while drinking my morning coffee and reading the paper, and it has been easier than playing around with psychotropic medications to try to find one that would work, and it has nine of the side effects of meds!!!", "comment_id": "FDA-2012-P-0260-0014", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0260-0014", "comment_date": "2013-04-22T04:00:00Z", "comment_title": "Anonymous - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 849}, {"text": "The Fisher Wallace device is excellent. I have recieved much praise from my patients who have used for pain, anxiety and depression. I highly recommend it.", "comment_id": "FDA-2012-P-0260-0015", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0260-0015", "comment_date": "2013-04-22T04:00:00Z", "comment_title": "Robert Alexander Florian, Ed.S. - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 155}, {"text": "I am a board certified psychiatrist in practice for 34 years. I have founded several mutispecialty centers and maintain a private practice. I served as Assistant Clinical Professor of Psychiatry at UCLA from 1979--2001. I am author of Contagious Emotions: Staying Well When Your Loved One is Depressed, a Simon and Schuster hardcover and trade paperback.

I have direct clinical experience using the FW Cranial Stimulator on patients with insomnia, GAD, Major Depressive Disorder and Bipolar Disorder, Depressed. I have prescribed the FW device to approximately 30 patients. The device has been well tolerated by every patient and not one patient has ever returned their device within the 60 days period that is given for refunds. I most commonly use the device in combination with other therapies but have used it as a stand alone device for insomnia.

The device should be classified no higher than Class Two. It has less adverse events than patients I have sent for rTMS therapy--in fact every patient has complained about some adverse effects from TMS. Its efficacy has been greater and it is a far less invasive treatment in terms of delivery.

I have no financial interest in the Fisherwallace company nor do I receive remuneration from the company. I am voluntarily contributing this information to correct a mistake that does a disservice to patients. ", "comment_id": "FDA-2012-P-0260-0012", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0260-0012", "comment_date": "2013-04-22T04:00:00Z", "comment_title": "Ronald Mark Podell - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1397}, {"text": "I have used a version of the Fischer Wallace Stimulator on both myself and patients for more then 20 years. More recently I have specifically used the Fischer Wallace Stimulator, also on patients as well as myself. Indications I have used it for include pain and menopausal symptoms including fatigue due to poor sleep at night. I have NEVER had a serious side effect from the unit. Once in a while a patient may complain of feeling slightly dizzy after using the unit but nothing else. It works well on orthopedic type pain such as low back or cervical pain. It works great for calming headaches. I strongly endorse the use of this unit. Bonnie OConnell, Physical Therapist", "comment_id": "FDA-2012-P-0260-0011", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0260-0011", "comment_date": "2013-04-22T04:00:00Z", "comment_title": "Bonnie Lynn OConnell P.T. - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 680}, {"text": "Cranial electrostimulation (CES) is a safe, effective, economic treatment for the symptoms of anxiety, depression, and sleep disturbance that commonly occur in soldiers and veterans suffering with posttraumatic stress. The device and therapy offer another option in addition to psychotropic medications and verbal therapy for the treatment of these conditions. In the past 10 years, over 2.5 million men and women have served in the combat theaters of Iraq and Afghanistan. Estimates of those suffering with posttraumatic stress range from 20 to 40%, or 500,000 to 1,000,000.

CES devices offer significant, clinically meaningful advantages over existing approved alternative treatments, especially over those anti-depressant medications that are ineffective in treating soldiers with PTSD. Cranial Electrotherapy Stimulation devices, including the Fisher Wallace Stimulator, are intended to treat life-threatening or irreversibly debilitating psychiatric conditions in soldiers suffering from depression, anxiety and insomnia in association with Post Traumatic Stress and substance abuse.

The availability of the device is in the best interest of patients – especially our soldiers. With the return of hundreds of thousands of soldiers from Iraq and Afghanistan, subjecting CES manufacturers to the PMA process will interfere with the availability of these devices precisely when access to them is most needed.
", "comment_id": "FDA-2012-P-0260-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0260-0004", "comment_date": "2012-04-19T04:00:00Z", "comment_title": "Stephen N. Xenakis - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1443}, {"text": "Because I have chronic pain and most nights cannot sleep through the night, I decided to try the CES unit to see if it would help me sleep and might relieve some of my fibromyalgia and arthritis pain. I was amazed at the first night's relief. By the end of the week I was sleeping without break for the entire night. I was in absolute disbelief. Awaking pain-free with the ability to move and walk was truly wonderful. I have recommended the CES unit to my military clients and I am appalled that this valuable noninvasive technology is in peril of not being available.", "comment_id": "FDA-2012-P-0260-0019", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0260-0019", "comment_date": "2013-05-20T04:00:00Z", "comment_title": "Randi Jean Jensen - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 575}, {"text": "The Fisher-Wallace device has been extremely effective with many patients with whom I have used it to improve depression, anxiety, and sleep issues. I am finding it more effective than other similar devices.", "comment_id": "FDA-2012-P-0260-0010", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0260-0010", "comment_date": "2013-04-22T04:00:00Z", "comment_title": "Dr. Robin Schaeffer - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 208}, {"text": "I am a mind/body psychotherapist and dance/movement therapist, in private practice and teaching here and in Europe, in and out of academic settings.

I have had several severe repetitive impact injuries resulting from working with seriously psychotic patients with dance/movement therapy in hospital and clinic settings for over 30 years. I have had 3 major surgeries as a result of these injuries: one for a large calcified tumor in my right metatarsil, a 3 level lamenectomy and micro-discectomy on my lumbar spine, and a shoulder surgery with 12 elements, including repairing a full rotator cuff tear, and repositioning my biceps tendon.

Because I also have severe cervical stenosis, as well as lumbar stenosis, and have been having severe radiculating pain down my right arm, I was told I likely would need neck surgery in the future to address this problem.

The pain made it difficult for me to sleep and lack of sleep made the pain worse. My osteopath suggested the Fisher Wallace Stimulator to deal with the pain and associated difficulty sleeping. I have been using it for several months and find it extremely helpful. I find it also helps with the emotional side of dealing with severe pain. My pain is more manageable, my sleep better in general, and I feel more resilient in dealing with it.

I have also recommended this device for two of my psychotherapy clients; one dealing with the severe pain of RA, and related insomnia, anxiety and depression, and one with PTSD with associated bio-emotional symptoms.

I highly recommend this device and its FDA approval.", "comment_id": "FDA-2012-P-0260-0013", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0260-0013", "comment_date": "2013-04-22T04:00:00Z", "comment_title": "Johanna Climenko - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1620}, {"text": "It is another expansive scam. Product does not do any thing", "comment_id": "FDA-2012-P-0260-0007", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0260-0007", "comment_date": "2013-04-22T04:00:00Z", "comment_title": "Dr. Muhammad Z Qureshi - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 60}, {"text": "The Fisher wallace device is no different than any other depression treatment. it works for a while, then stops. This suggests to me it is a placebo effect - a very expensive one since insurance doesn't cover it and it costs $700. Worse are the sponges that the company charges a ridiculous amount for.

Frankly, I think it's an overpriced rip off that should not be approved.", "comment_id": "FDA-2012-P-0260-0008", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-0260-0008", "comment_date": "2013-04-22T04:00:00Z", "comment_title": "j s - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 392}]}, {"id": "FDA-2019-N-1845", "title": "Fixed-Quantity Unit-of-Use Blister Packaging for Certain Immediate-Release Opioid Analgesics for Treatment of Acute Pain; Establishment of a Public Docket; Request for Comments", "context": "2021-02-18T11:37:44Z", "purpose": "Nonrulemaking", "keywords": ["2019-208", "CDER", "Notice", "Fixed-Quantity Unit-of-Use", "Blister Packaging for Certain Immediate-Release", "Opioid Analgesics for Treatment of Acute Pain", "Request for Comments", "OPEN"], "comments": [{"text": "

January 07, 2021
Stephen Hahn, MD
Commissioner
Food and Drug Administration
C/O Dockets Management Staff (HFA-305)
5630 Fishers Lane, Rm. 1061
Rockville, MD 20852
RE: Docket No. FDA-2019-N-1845, “Fixed-Quantity Unit-of-Use Blister Packaging for Certain Immediate-Release Opioid Analgesics for Treatment of Acute Pain; Establishment of a Public Docket; Request for Comments"
Dear Commissioner Hahn:
On behalf of Adam and Marybeth Gillan, and their daughter, Maisie Lucienne Gillan, we urge you to take action in packaging safety and technology advancements to mandate blister packaging for any medication lethal to an infant or child. These medications, known as “one pill kills,” are over-prescribed in high quantities. The packaging is intended as safe, but the functional use of the prescription and its traditional pill bottle container creates untold opportunities for mishandling, miscounting, and access to children.
The Gillan's daughter, at a neighbor’s home, came across a methadone pill no one even knew was missing. Hours later she was dead, and it took an autopsy to understand why. From the criminal justice system to the current regulatory environment around opioids and patient safety, Maisie was failed at every turn, cast off as an unforeseeable tragedy.
Between 1999 and 2017, more than 9,000 children and teenagers died from opioid poisoning in the United States, including 650 children under 5 years old, according to the Centers for Disease Control and Prevention. These are tragedies that left 9,000 parents to bury their children.
We can do better and we must do better. Layers of protection are available to protect patients from harming themselves or others. Blister packaging alone may not have saved Maisie's life, but that layer of protection would have clearly identified a pill as missing, or it may never have been lost in the first place. Lives are at stake, and too many, including Maisie’s, have already been lost.
Sincerely,
A concerned parent", "comment_id": "FDA-2019-N-1845-0152", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-1845-0152", "comment_date": "2021-01-08T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 2087}, {"text": "Opioids should be in blister packs. These “one kill pills” have taken babies from too many families simply from poor packaging. Please consider the safety of the youngest members of our society. ", "comment_id": "FDA-2019-N-1845-0149", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-1845-0149", "comment_date": "2021-01-06T05:00:00Z", "comment_title": "Comment from Kristen Seymore", "commenter_fname": null, "commenter_lname": null, "comment_length": 207}, {"text": "Please see attached comment letter.", "comment_id": "FDA-2019-N-1845-0108", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-1845-0108", "comment_date": "2019-07-29T04:00:00Z", "comment_title": "Comment from OptumRx", "commenter_fname": null, "commenter_lname": null, "comment_length": 35}, {"text": "Rhodes Pharmaceuticals L.P. respectfully submits the attached comments to docket FDA-2019-N-1845.", "comment_id": "FDA-2019-N-1845-0120", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-1845-0120", "comment_date": "2019-07-31T04:00:00Z", "comment_title": "Comment from Rhode Pharmaceuticals L.P.", "commenter_fname": null, "commenter_lname": null, "comment_length": 97}, {"text": "Please see attached.", "comment_id": "FDA-2019-N-1845-0119", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-1845-0119", "comment_date": "2019-07-31T04:00:00Z", "comment_title": "Comment from National Community Pharmacists Association", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Please see attached comment letter.", "comment_id": "FDA-2019-N-1845-0118", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-1845-0118", "comment_date": "2019-07-31T04:00:00Z", "comment_title": "Comment from Upsher-Smith Laboratories, LLC", "commenter_fname": null, "commenter_lname": null, "comment_length": 35}, {"text": "See attached file(s)", "comment_id": "FDA-2019-N-1845-0109", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-1845-0109", "comment_date": "2019-07-29T04:00:00Z", "comment_title": "Comment from Healthcare Compliance Packaging Council", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Your request says active pain but if you launch this it will be done across the board and those of us that have chronic pain will then be negatively impacted again! There is no need for this and please stop trying to force new rules to an already convoluted process. We dont need any more rules or changes or additions added to the reason why we wont be able to get our pain medication. We are responsible adults and we are not the problem! Its illegal drugs, please focus on that. ", "comment_id": "FDA-2019-N-1845-0073", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-1845-0073", "comment_date": "2019-06-28T04:00:00Z", "comment_title": "Comment from Melissa Quackenbush", "commenter_fname": null, "commenter_lname": null, "comment_length": 482}, {"text": "I am a registered recovery room nurse from MA and I welcomed the idea of unit-dose blister packs for distribution. Currently, surgeons always order 30 plus tabs of opioid analgesics for procedures that might just need a days supply. Patient's go home all of this extra medication which might lead to misuse. I welcome the idea of the blister packs but most importantly I like the discussion on how to dispose of these medications. Either education on the back of the packaging on how to dispose of these medications properly or mail pouches for easy return are both good options.", "comment_id": "FDA-2019-N-1845-0031", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-1845-0031", "comment_date": "2019-06-10T04:00:00Z", "comment_title": "Comment from Kimberly Kopp", "commenter_fname": null, "commenter_lname": null, "comment_length": 583}, {"text": "Blister packages are difficult to open for seniors and others with compromised dexterity. They are not child proof and may expose children to a higher risk of ingestion. I applaud efforts to address opioid misuse and accidental exposure. The proposed blister packaging requirement is costly with limited to no benefit. Prescribing smaller quantities and allowing partial fills of CII medications will better address opioid concerns. ", "comment_id": "FDA-2019-N-1845-0016", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-N-1845-0016", "comment_date": "2019-06-10T04:00:00Z", "comment_title": "Comment from Margaret Lydon", "commenter_fname": null, "commenter_lname": null, "comment_length": 433}]}, {"id": "FDA-2017-N-1094", "title": "Training for Opioid Analgesic Prescribers--Exploring the Path Forward", "context": "2017-08-25T16:17:17Z", "purpose": "Nonrulemaking", "keywords": ["2017-76", "Training for Opioid Analgesic Prescribers"], "comments": [{"text": "Please see the attached file with personal testimony from a mother about her son which addresses the real needs of a chronic pain patient who suffers verifiable, substantiated, persistent chronic pain due to a genetic condition that results in daily subluxations and dislocations of joints. It discusses the necessary use of opioid medications in a controlled environment with doctor supervision, and how important reasonable access to opioids is in the treatment of his particular medical problem.", "comment_id": "FDA-2017-N-1094-0160", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-1094-0160", "comment_date": "2017-06-23T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 499}, {"text": "Dear Dr. Throckmorton,
Let's go back in time for a minute and recognize that FDA's ineffective warning, regarding the dangers of corticosteroids used to treat back pain, continues to result in unsustainable numbers of catastrophic injuries throughout the country - and the legitimate need for opioids for adhesive arachnoiditis patients (including misdiagnosed cases of Fibromyalgia).

As we both know, the topic of pain is complex (and not what it appears) as underlying profit motives have skewed accurate statistics.

On the National debate:

Federal OWCP is willing to authorize reimbursement for repeated, high risk epidural steroid injections. Ron Angel was offered ESI treatment indefinitely for his low back pain (approx. $2000 per injection). Ron also suffered an OTJ cervical spine injury, now a retired wildland fire fighter:

https://www.painnewsnetwork.org/stories/2015/10/21/jumping-from-fire-into-federal-work-comp-nightmare

For the record (again), the most commonly used corticosteroid used for back pain is Pfizer's Depo-medrol. Below is the link to Pfizer/New Zealand Depo-medrol datasheet:

http://www.medsafe.govt.nz/Profs/Datasheet/d/Depomedrolinj.pdf

Please note top of page 7: "Depo-Medrol may be used by any of the following routes: intramuscular, intra-articular, periarticular, intrabursal, intralesional and into the tendon sheath. It MUST NOT be used by the intrathecal, epidural or intravenous routes (see CONTRAINDICATIONS, WARNINGS AND PRECAUTIONS and ADVERSE EFFECTS)."

And bottom of page 18: "ADVERSE EFFECTS
Administration by other than indicated routes has been associated with reports of serious medical events including: arachnoiditis, meningitis, paraparesis/paraplegia, sensory disturbances, headache, functional gastrointestinal disorder/bladder dysfunction, seizures, visual impairment including blindness, ocular and periocular inflammation, and residue or slough at injection site."

FDA's warning has not changed the harmful standard of care for back pain, or the problem of injured worker coercion to undergo high risk, high cost injections: https://www.fda.gov/Drugs/DrugSafety/ucm394280.htm

We have reason to believe that FDA sold out to the interests of professional medical societies and large corporations (Pfizer). Arachnoiditis is grossly misdiagnosed for fear of legal liability; adverse events are under-reported/not reported to FDA for same reason.

Check out the comment written by Dr. Laxmaiah Manchikanti, Chairman of the American Society of Interventional Pain Physicians in Pain News Network blog:

https://www.painnewsnetwork.org/stories/2015/8/19/experts-say-epidural-injections-overused

Laxmaiah Manchikanti, MD 2 years ago Pending Awaiting Moderation 1 like
This is a very interesting perspective; however, there appears to be significant misinformation. All in all arachnoiditis is a significant problem which has been missed by multiple governmental agencies as well as physician organizations. It will not go away by ignoring it. All parties have responsibility. It can be avoided by utilizing alternate techniques, alternate drugs, and finally patients must also share responsibility. In the United States, no one can force anyone to have a procedure. Further, each and every patient should be educated about and understand the risks and benefits of any and all procedures and physicians should explain to them that steroids are an off-label use.

When you add up the error rates and multiply the estimated numbers of ESIs administered annually, you start to realize the magnitude of the problem. This cumulative trauma impacting the American public is not sustainable -- and little is being done to address medical malpractice taking place across the country. Both FDA and CDC are disregarding this public health crisis.

Let's face it: these agencies are run by politically appointed administrators. Dr. Tennant should be leading discussions on long term intractable pain conditions at FDA. Instead, the view is lop-sided, thanks to the likes of PROP, Ballantyne, and Sullivan:

https://www.painnewsnetwork.org/stories/2015/12/10/controversy-grows-over-journal-article-on-pain-treatment


On the Montana Front - please familiarize yourself with these egregious cases:

https://www.painnewsnetwork.org/stories/2017/5/26/patient-suicide-blamed-on-montana-pain-clinic

https://www.painnewsnetwork.org/stories/2017/5/18/patients-allege-mistreatment-at-montana-pain-clinic

https://www.painnewsnetwork.org/stories/2017/5/19/montana-urine-tests-sent-to-bankrupt-drug-lab

http://mtpr.org/post/pain-helped-him-pull-trigger

Unsuspecting back pain patients are pushed into harmful procedures then end up with permanent injuries and chronic pain for the remainder of their lives. Corporate decision makers deny these injuries and abandon them in their time of need.

We've been here done this.

Submitted on behalf of Arachnoiditis Awareness and Prevention A.S.A.P.
", "comment_id": "FDA-2017-N-1094-0251", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-1094-0251", "comment_date": "2017-07-12T04:00:00Z", "comment_title": "Comment from Terri Anderson", "commenter_fname": null, "commenter_lname": null, "comment_length": 5323}, {"text": "I've had moderate-to-severe rheumatoid arthritis for 9 years now. It is a very painful condition that is quite a challenge! I had to go on Disability, because I cannot depend on my body's ability to do just normal day-to-day activities consistently.
I started taking Percocet, which is an opioid, with my first flare-up in 2008. Flare-ups affect multiple joints all over my body with burning, throbbing, aching, stiff & swelling joints that usually last between 3-6 months. When the disease finally calms down to moderate status, my joints have a dull ache that causes extreme fatigue, so I still need pain relievers when I do projects that require more strength in my joints or when the pain is too uncomfortable to sleep. Unfortunately, with this disease, there has never been a day without pain. I have continued taking opiates for almost a decade, because getting some relief is worth the risk. Since there are some days when I can go without pain relievers, I have never considered myself to be an addict. I take my opiate medications responsibly. I have used many alternative ways to help relieve the pain, everything from acupuncture to tapping. I am not addicted, but I am dependent on opiates, as another tool to make my life productive, worth living, & less painful.
A few years ago, many obstacles were set in place to make it extremely difficult to obtain prescriptions for pain relief. The federal government, in deciding to stop people from becoming addicted to opioids, made it extremely difficult for people like me, with a chronic pain condition, to continue getting the very medications that make our lives tolerable & worth living. The CDC, DEA, FDA, NIH, & members of local & federal government have made our lives painful and unproductive. Our Quality of Life is being taken away from us! It is influencing our physicians, because now they are refusing to continue to prescribe opiates to control long-term chronic pain. They fear for their careers instead of caring for their patients.
My prescriptions have been reduced to half the dosage needed to lessen the pain, and this has totally altered the way I live my life, significantly reducing my capabilities. Extreme limitations & inconvenience along with increased office visits & costs are just a few of the many roadblocks we face in getting our prescriptions for pain relief now.
It's not fair to punish those of us who legitimately need opiates due to a disease or injury, in an effort to curtail another group that chooses to abuse the medications we need to live our lives in a productive way. Our lives literally depend on these medications to function. My disease has become much worse as a result of not being able to access the opioid medications that are necessary to lessen my pain, allow me to function, and be productive; whether it is to enable me to still work for a living or just be able to do things as simple as opening a door, cooking, doing housework, or just getting ready for the day.
In my experience, Pain Management Specialists are not needed. Mine does not understand my disease at all, & I am treated like an addict. He is a spine specialist which has nothing to do with rheumatology. Per his suggestions, I have tried various pain relievers, even one that caused me tremendous harm. He doesn't understand my pain or the cause, but I now have to pay for 2 doctor visits, 1 for the disease & 1 for pain. It is very expensive, stressful, & time-consuming just to be able to lessen the pain associated with my disease now. Healthcare was better & more efficient when my rheumatologist was able to treat both the disease & the pain.
CDC Guidelines were created in a sneaky, underhanded way without any expertise. (Attached)
The DEA has scared physicians out of treating pain. The FDA has required pharmaceuticals to reformulate opioids, which is a complete fail. The reason I know this is because when a Pain Management Specialist prescribed Oxycontin ER, my first month was the old formulation which lessened the pain adequately. However, the next month I received a new formulation which did not work at all for me.
Most people do not understand that the "opioid problem" is a substance abuse problem, not a chronic pain problem. As Dr. Kolodny & CDC continue to propagandize the false narrative that our medications are the problem and lump them in the same category as heroin, cocaine, & illegal fentanyl, we cannot live our lives productively & suicides will continue to happen more often. (Attached)
My suggestions are:
1.Immediate withdrawal of CDC guidelines for rewriting by a much better qualified stakeholder group including both pain management specialists & chronic pain patients.
2.DEA should be forced by Congress to cease prosecution of doctors whose only "crime" is an attempt to serve the medical needs of their patients.
3.Specialists like Rheumatologists should prescribe pain medications, because they understand both the disease & the pain associated with it.", "comment_id": "FDA-2017-N-1094-0112", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-1094-0112", "comment_date": "2017-05-22T04:00:00Z", "comment_title": "Comment from Pam Hawthorne", "commenter_fname": null, "commenter_lname": null, "comment_length": 5262}, {"text": "Attached please find comments submitted by the National Community Pharmacists Association (NCPA). ", "comment_id": "FDA-2017-N-1094-0272", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-1094-0272", "comment_date": "2017-07-12T04:00:00Z", "comment_title": "Comment from National Community Pharmacists Association", "commenter_fname": null, "commenter_lname": null, "comment_length": 98}, {"text": "Please start over with appropriate CDC guidelines.
Doctors need reassurance that it is safe to help chronic pain patients,
Preventing suicides in opiate refugees.
We must help patients who have become dependent on opiates over the last two decades.
Some cannot wean off opiates.
In my home state of Montana, there is a hostile regulatory environment for doctors who help pain patients. ", "comment_id": "FDA-2017-N-1094-0018", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-1094-0018", "comment_date": "2017-05-05T04:00:00Z", "comment_title": "Comment from Mark Ibsen", "commenter_fname": null, "commenter_lname": null, "comment_length": 411}, {"text": "This is crony capitalism! Why are we attacking law abiding citizens using narcotic pain killers with government intervention? If the pain patients don't get their treatment from a doctor they will get it from a dealer. Heroin use will go up if we restrict pain medication for patients. Great for big government jobs for all the law enforcement involved in the war on drugs but terrible for the patient. This is just like gun control where overzealous idiots try to take guns from law abiding citizens to reduce gun ownership by criminals and it NEVER WORKS! Get big government out of the doctors office; these people went to school for YEARS and they know better than government agencies what their patients need. If you support restrictions on patients pain medications I hope you die a slow and painful death yourself so that you become a victim of your own legislature. Doctors and patients don't need the government counting their pills.", "comment_id": "FDA-2017-N-1094-0050", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-1094-0050", "comment_date": "2017-05-12T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 957}, {"text": "See attached file(s)", "comment_id": "FDA-2017-N-1094-0137", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-1094-0137", "comment_date": "2017-05-30T04:00:00Z", "comment_title": "Comment from Effie Tetteh", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Hi again. The past few months I have been slowly buying things to make artisan soaps. I have been on SSI for years with my autistic daughter. I want to DO THINGS! BE PRODUCTIVE and give back! If I have to sit in a chair and cry all the time, how could I possibly live? No human wants to do nothing and be in constant pain. This kind of pain never goes away. No, I would never kill anyone, but this kind of pain is relentless.
Broderick's neighbors told the Review Journal that he was a husband and father of two, who mostly kept to himself but had a friendly wave. One neighbor called Broderick a "really nice gentleman" who complained of back pain.
"He used to talk about taking pain pills," said Welborn Williams. "He couldn't get any sleep at night."
Broderick's Facebook page reveals a man who loved fishing and was a gun enthusiast. Ironically, in 2012 Broderick recommended without comment on his page a story about an employee at a Las Vegas medical clinic who was shot during an armed robbery.
The Review Journal reported that Broderick had a concealed weapons permit and five firearms. Williams said Broderick had offered to teach him about firearms.
"I hate to see anyone in pain like that," Williams said. "But there should have been another way for him."
https://www.painnewsnetwork.org/stories/2017/6/30/patient-shoots-two-at-las-vegas-pain-clinic
http://www.pharmaciststeve.com/
An email received this week from a chronic pain activist: "We just lost another intractable member of our support group two nights ago. She committed suicide because her medications were taken away for interstitial cystitis (a horribly painful bladder condition) and pudendal neuralgia, both of which she had battled for years. The nerve pain is equivalent to end-stage cancer pain, but the CDC and doctors in Colorado were merciless. She just couldn't hang on any longer without hope." She was just 30 years old.
http://globalnews.ca/news/3571142/commentary-a-deeply-disturbing-email-begins-to-tell-the-opioid-story-for-chronic-pain-patients/

"There's a difference between the people (who) need them and the people who are abusing them," Kain said.

The CDCin 2016 released new guidelines that discourage primary care doctors from prescribing opioids for chronic pain. The guidelines were meant to curb the rampant over-prescribing practices of the past but may have also created unintended consequences. "I don't walk with a cane. I don't have an open wound. I'm not in a wheelchair," Kain said, adding that looks can be deceiving. Most of the time, she's stuck in her Pleasant Hill home trying to get through the day with excruciating back pain.
http://www.kcci.com/article/has-opioid-epidemic-vilified-chronic-pain-patients/9970531", "comment_id": "FDA-2017-N-1094-0183", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-1094-0183", "comment_date": "2017-07-07T04:00:00Z", "comment_title": "Comment from Bambi Tuckey", "commenter_fname": null, "commenter_lname": null, "comment_length": 2910}, {"text": "I am a chronic pain patient and it took over 8 months to officially diagnosis me. I agree with training those prescribing pain medication both on pain and addiction signs. I also agree with go slow and low but not making it LAW because think about my situation I have Complex Regional Pain Syndrome CRPS and if you make limits on pain medication a law by state I have to go every week to the doctor to get a new prescription, pay co pays every week, go to the pharmacy every week until officially diagnosed with chronic pain. This puts burdens on the doctors time and the patients time and money. Most chronic pain patients take medication responsibly to ease the pain. We aren't taking it to "feel good". There must be some subjectivity when dealing with pain. The 30 day to now 3-7 days has been rectified, urine screens happen monthly, we go every month to the doctor as implemented. The focus needs to be on illicit drugs on the street. Evidence has proved that prescriptions have declined while overdoses have increased. Some insurances don't cover investigational treatments so your options are limited by insurance. You can't put real pain patients into one box and you can't scare doctors so much they abandon patients because of too much oversight. They are trained and if they aren't get them to take an online course and if a patient needs to be in pain management get them to a specialist. We must find a way to stop hurting real pain patients because we deserve care just like someone with cancer does and we also need to find a place for those suffering side effects of taking pain medication and get them help. Stop hurting and start helping. I'd love for CDC and politicians making black and white rules to live just one day in my shoes. Talk to the different chronic pain support groups, rare disease groups. You must hear both sides and bring the pendulum back that has swung way to far in err of hurting pain patients. ", "comment_id": "FDA-2017-N-1094-0086", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-1094-0086", "comment_date": "2017-05-18T04:00:00Z", "comment_title": "Comment from Amy V", "commenter_fname": null, "commenter_lname": null, "comment_length": 1987}, {"text": "Note I have RA, OA, fibromyalgia, degenerative & herniated disk (lumbar & cevical). Been on opioid 20 yrs this yr. I want to increase my meds from 4 to 5 a day. Instead I was given a stronger med 4 's
a day. Stronger is not as effective as the one I was taking. I've protested but Dr's say can't prescribe more than 4 a day, so I suffer in silence. Afraid to upset the apple cart.", "comment_id": "FDA-2017-N-1094-0095", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-1094-0095", "comment_date": "2017-05-18T04:00:00Z", "comment_title": "Comment from Michelle Harford", "commenter_fname": null, "commenter_lname": null, "comment_length": 408}]}, {"id": "SAMHSA-2016-0001", "title": "Medication Assisted Treatment for Opioid Use Disorders", "context": "2020-12-09T01:15:23Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "I am a physician who has run an outpatient buprenorphine-naloxone treatment program for 5 years now, limited to a maximum of 100 patients at a time, so welcome the increased access proposed. Since you are seeking comments primarily related to the reporting requirements for those that choose to treat up to 275 patients, one comment I have is that the "burden" of reporting has less to do with the questions being asked than with the reporting method. If there is a 15 page paper form to complete each month, that would be burdensome. I would not consider it burdensome, though to complete a one page on-line form with blanks to fill in for: 1) Numbers of patients seen per month; 2) Number who are currently in or have completed outpatient drug counseling; 3) Number who have left the program and reason.
Other comments:
1)Part of your proposed rule is unmanageably vague:
"b. Percentage of active buprenorphine patients (patients in treatment as of reporting date) that received psychosocial or case management services (either by direct provision or by referral) in the past year due to:
1. Treatment initiation
2. Change in clinical status"

--What does 'psychosocial or case management service' include? If you mean group outpatient drug treatment or individual counseling, it should say that.
--What does 'change in clinical status' mean?
--When you are looking for percentages, is there a certain "benchmark" we are being required to meet?
2)Another part of your proposed rule is also vague and burdensome the way it is worded:
"c. Percentage of patients who had a prescription drug monitoring program query in the past month"
--We query the PDMP for every single controlled substance prescription, so I am not sure how writing "100%" every month is going to help you. If we were to accidentally miss someone, I am not sure how we would know it. It would seem to me the PDMP for each state would have a better handle on that information.
3)There should be some oversight of HOW patients are being treated with buprenorphine and none of this data gathering includes that. The makers of Suboxone, for instance, recommend no more than two 8-2mg films daily as the usual maintenance dose, and that up to three a day can be given for extenuating circumstances, yet many doctors in New York City are well known for prescribing three a day consistently, for months, if not years, and giving 30 days of medication at a time. Most opioid addicts know they do not need three a day, so the extra medication is just a source of income to them. Where is the oversight on that?
4)One of the biggest burdens likely to keep some providers from wanting to see more than 100 patients is the prior authorizations required by most insurance companies (particularly all versions of Medicaid) prior to starting buprenorphine and, for some companies, quarterly. Some will only pay for the generic buprenorphine pill, which is difficult to split in order to taper someone down over time, and will not pay for Suboxone or its competitors. Others will stop paying for buprenorphine altogether if someone tests positive on a urine drug screen for marijuana (which is not even treated with buprenorphine). Yet others have a 3 to 5 day wait for approval for a new patient we have just seen who has stopped the heroin and wants their buprenorphine that first day. What are they supposed to do for 3-5 days, continue heroin? The insurance companies need oversight as wellor at least we providers should have a 24 hour hotline phone number to call to have SAMHSA intervene with the insurance company.
", "comment_id": "SAMHSA-2016-0001-0511", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0511", "comment_date": "2016-07-26T04:00:00Z", "comment_title": "Comment on FR Doc # 2016-16069", "commenter_fname": "G", "commenter_lname": "Thibault", "comment_length": 3872}, {"text": "This is a good start but it does not go far enough. As an Addiction Specialist I am capable of providing significant services to a large number of patients. When I was a Family Practitioner I use to manage more than 5000 patients. There is no limit on the number of patients that any other type of specialist can treat. Endocrinologists are not limited in the amount of insulin dependent patients that they can treat.

Addiction is a medical disease and it needs to be treated by medical specialists. I can treat more people and provide fantastic care. I can provide full time counseling services, 24 hour phone coverage, evening, weekend, and holiday coverage, integrated electronic medical records with real time following of prescriptions that patients are filling, etc. However, I cannot expand to provide these services if my ability to see patients is limited to only 200. Please allow me to practice to my full potential and to be able to provide the services that patients need and are entitled to at a reasonable cost. I can only do this if I have the ability to increase the volume of my practice thus dispersing the cost of services across more patients. I would urge you to consider eliminating a treatment limit all together for appropriately certified physicians, or at the very least increasing to number permitted to be treated to a more significant 500 or 1000 patients. Note that Senate bill S.1455 (TREAT Act) was recently amended to allow a 500 patient limit. Perhaps this rule could be changed to be consistent with that initiative. ", "comment_id": "SAMHSA-2016-0001-0012", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0012", "comment_date": "2016-04-17T04:00:00Z", "comment_title": "Comment on FR Doc # 2016-07128", "commenter_fname": "Lee", "commenter_lname": "Tannenbaum, M.D.", "comment_length": 1566}, {"text": "Persons suffering from Opioid Use Disorder have a difficult time finding treatment in the current system. Not only are Medication Assisted Treatment locations few and far between, they also have enormous waiting lists leaving those who want treatment, unable to secure it. The current limit of 100 patients per prescriber is not enough to handle the amount of persons affected. Please support increasing this limit to 200 and also continue to look into other ways we can make treatment easily accessible.", "comment_id": "SAMHSA-2016-0001-0015", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0015", "comment_date": "2016-04-17T04:00:00Z", "comment_title": "Comment on FR Doc # 2016-07128", "commenter_fname": "Angie", "commenter_lname": "Geren", "comment_length": 504}, {"text": "Thanks so much for sending this out and furthering efforts to increase access to medication assisted treatment. I was a Suboxone prescriber for over seven years, though I currently work as a medical administrator for a multi-site mental health and substance abuse agency in CT. We do offer Suboxone in one of our outpatient clinics; this is a part of a program that includes Intensive Outpatient, relapse prevention, and much co-occurring behavioral health treatment.

I am in total support of raising the limit from 100 to 200. I also think the added requirements for prescribers are reasonable, though I would want a crisp definition of what constitutes an acceptable setting. I am board certified but have never pursued additional certification from ASAM or in addiction medicine or psychiatry. I have however always prescribed in a clinic setting where counseling, at various levels of intensity, are provided. This also includes diversion strategies, lots of urine collection, and focus on treating co-occurring mental health problems, which are rampant in this population.

As a final comment, where the need is greatest, is among the Medicaid population. I'm hopeful that this increase in the limit will allow those few clinics that take Medicaid reimbursement, help meet this tremendous unmet need.", "comment_id": "SAMHSA-2016-0001-0022", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0022", "comment_date": "2016-04-17T04:00:00Z", "comment_title": "Comment on FR Doc # 2016-07128", "commenter_fname": "Charles", "commenter_lname": "Atkins", "comment_length": 1326}, {"text": "With the shortage of prescribing physicians and the overwhelming opioid crisis, this would seem to be a rule change that is long overdue.", "comment_id": "SAMHSA-2016-0001-0024", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0024", "comment_date": "2016-04-17T04:00:00Z", "comment_title": "Comment on FR Doc # 2016-07128", "commenter_fname": "Thomas", "commenter_lname": "Grinley", "comment_length": 137}, {"text": "I support the rule to change to the highest patient limit from 100 to 200 patients per qualified doctor.

I am employed as a chemical health intake coordinator, a common call from an opiate user seeking help is frustration of trying to find an outpatient provider of bupronorphine thiat is accepting new patients. There is not enough providers to meet the needs of this community. Increasing the volume of allowed patients per provider will assist with opening more doors for this population to get they initial help they need so they can begin a recovery process. ", "comment_id": "SAMHSA-2016-0001-0035", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0035", "comment_date": "2016-04-17T04:00:00Z", "comment_title": "Comment on FR Doc # 2016-07128", "commenter_fname": "James", "commenter_lname": "Murray", "comment_length": 574}, {"text": "I am a Board Certified Addiction Specialist and this bill is essential to helping the large numbers of opioid addicted patients who do not have access to MAT. Every patient who calls my office to get in my Suboxone program is asking for help and to save their lives. When I have to refuse treatment w Suboxone because of the current patient limit, I am depriving a life saving medication to a patient who may return to the street and overdose on heroin. PLEASE AT A MINIMUM RAISE THE CAP to 500 patients.

Dr. Rick Campana
Diplomate ABAM, FASAM", "comment_id": "SAMHSA-2016-0001-0098", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0098", "comment_date": "2016-04-22T04:00:00Z", "comment_title": "Comment on FR Doc # 2016-07128", "commenter_fname": "Rick", "commenter_lname": "Campana", "comment_length": 556}, {"text": "See attached file(s)", "comment_id": "SAMHSA-2016-0001-0227", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0227", "comment_date": "2016-05-23T04:00:00Z", "comment_title": "Comment on FR Doc # 2016-07128", "commenter_fname": "Kent", "commenter_lname": "Seitz", "comment_length": 20}, {"text": "I am a physician, Board Certified in Addiction Medicine, practicing in the field for over 20 years. I work for the VA, providing buprenorphine services across the entire state of Montana using TeleHealth technology, as well as serving as Medical Director for 3 Opioid Treatment Programs (OTPs) and on the staff at Pathways Treatment Center, a psychiatric and addiction treatment facility. I have treated all kinds of addictions, both inpatient and outpatient, and am familiar with the state of the art in Addiction Medicine and the scientific literature.

Please see the attached file for my comments.
", "comment_id": "SAMHSA-2016-0001-0101", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0101", "comment_date": "2016-04-25T04:00:00Z", "comment_title": "Comment on FR Doc # 2016-07128", "commenter_fname": "Robert", "commenter_lname": "Sherrick", "comment_length": 616}, {"text": "I am a board certified psychiatrist with added Qualifications in Addiction Medicine. I have treated patients suffering from addiction for over 25 years and have trained many future clinicians in this field. Currently I treat United States veterans exclusively in a VA substance abuse program in the tri-state area of Kentucky, Ohio and West Virginia. This VA is one of two VA hospitals with highest percentage of prescription drug abuse. We are trying to correct the poor prescribing practices of our predecessors. Also the tri-state area tops the nation in drug overdoses. Unlike the private sector we cannot close admissions to our opiate treatment program to veterans suffering from opiate dependence when I reach my 100 limit. We also cannot hire physicians willing to prescribe Suboxone to our veterans since they have lucrative private practices where they charge an average of $300 monthly just for their service (does not include cost of medication and $25 toxicology screen.) We cannot outsource these veterans to the private community because the government pays Medicare rates which are much lower than the $300/month. The private doctors can easily fill their 100 slots with folks willing to pay $300/month in cash.

I have not been able to convince my administration to apply for SAMSHA official OTP program with institutional license which would allow us to expand services. The same lack of knowledge in this area which lead to the problem seems to be impeding the solution. So I am chronically frustrated and worry about welfare of our veteran population. Some of the pressure has been alleviated by outsourcing of patients to local methadone programs.

I applaud President Obama's push to expand training of pain management in medical schools. I would favor increasing the limit to 200 for clinicians board certified in addiction and for VA hospital programs. I do have some concerns about private clinicians with little experience in treating addiction profiting from those addicted to pain medications without providing appropriate care. ", "comment_id": "SAMHSA-2016-0001-0009", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0001-0009", "comment_date": "2016-04-17T04:00:00Z", "comment_title": "Comment on FR Doc # 2016-07128", "commenter_fname": "Nancy", "commenter_lname": "Rubio", "comment_length": 2090}]}, {"id": "FDA-2007-P-0415", "title": "Enact Stricter Guidelines in Prescribing Methadone for any Reason (CLOSED)", "context": "2021-09-01T01:01:09Z", "purpose": "Nonrulemaking", "keywords": ["Victims", "METHADONE", "Enact", "stricter guidelines ", "CDER"], "comments": [{"text": "HELLO, DUE TO THE RELAXED LAWS IN REGARD TO METHADONE
DISTRIBUTION, MY SISTER WAS ALLOWED ACCESS TO THE DRUG OFF
THE STREET AS A WAY TO HELP HER SLEEP BETTER. SHE OVERDOSED
ON METHADONE ON JAN. 1ST 2007. I AM ASKING ON HER BEHALF,( AND
ON THE BEHALF OF ANY POTENTIAL FUTURE VICTIMS OF THIS DRUG )
THAT METHADONE NOT BE GIVEN TO ADDICTS IN DOSES EXCEEDING
THEIR DAILY AMOUNT, THUS NOT ALLOWING FOR ITS EASY ACCESS ON
THE STREET. MAY YOU LET YOUR CONSCIENCE GUIDE YOU IN ANY
DECISION MAKING PROCESS REGARDING THE EASE OF AVAILABILITY OF
THIS DEADLY/DANGEROUS DRUG. BEST REGARDS, DUSTIN RHODES", "comment_id": "FDA-2007-P-0415-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2007-P-0415-0004", "comment_date": "2008-07-23T04:00:00Z", "comment_title": "Dustin Rhodes - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 635}, {"text": "I Lost my husband due to methadone Overdose In December 2007, I was left with
3 children to raise. I am a resisdent of the Eastern KY, West Virginia area One of
the biggest areas in the comtry for methadone distribution. Here ANYONE as long
as you are 18 and have cash can go into 1 of any number of methadone clinics
and walk out with a cocktail of things. Methadone syrup, wafers, pills and in some
cases if you have enough money all of it and in large quantities (up to 240 pills). I
dont think its right that these people just walk in there and get it sell it that night
and keep claiming lives and go on like they did nothing. Its just the families of the
deceased that has to deal with the loss because I assure you the person who sold
my husband methadone is still selling and still causing deaths. He dont care that
he befriended my husband and contributed to his death. He tried to sell to my 13
year old child after her father was buried. But its not just one its 1 of hundreds or
thousands of people who go to these doctors and they arent monitered or
anything. They are given their weapons (120 to 240)and they go kill with it. They
kill our friends and our family and Not one soul, not one of you can say it hasnt
touched in your family because if it hasnt it will, Its hitting everyone. Everyone
thinks it wont until you face the day you have to put someone you love
underground forever. Please help stop the sensless distribution of Methadone
before it claims your husband ,wife,child or parent. Whatever the case may be its
not safe to be given to people not under close watch. Knowing alot of people really
need it, it can still be a good idea to give it inpatient and if its not an inpatient case
there is other methods other less dangerous drugs to use without sending this
deadly stuff out on the streets for our loved ones to get, killing and forever throwing
grief upon the innocent families of those it kills. I know i am one voice but i hope
and pray to GOD I am a loud voice because someone needs to get us help to get
this off the street, off the pharmacy shelf and in hospitals only. Thank you and
GOD BLESS", "comment_id": "FDA-2007-P-0415-0009", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2007-P-0415-0009", "comment_date": "2008-11-10T05:00:00Z", "comment_title": "Florence Ann Kilgore - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 2269}, {"text": "Methadone has left many families without their loved ones. The clinics that
dispense this drug must be under scrutiny by the Federal Government.
My grand daughters father died from a so-called overdose given by a clinic for pain
and I do not want anyone to lose their father like she did.", "comment_id": "FDA-2007-P-0415-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2007-P-0415-0006", "comment_date": "2008-07-23T04:00:00Z", "comment_title": "Barbara Phillips - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 305}, {"text": "Methadone is killing our children. It is in our communities, school systems and in
the home. Much of it is obtained by doctors or clinics who are out to make
money
and worse than drug dealers. A former student has died recently because of
obtaining Methadone from the EAST INDIANA TREATMENT CENTER. A doctor
by the name of Dr. Nabil Babar is prescribing Methadone to many individuals here
in the Maysville, Ky. area. This doctor should by stripped of his occupation and
these clinics should be closely monitored. I have reported this particular clinic to
to DEA and have spoken to our congressmen.

PLEASE SAVE OUR CHILDREN!!!!

Julie Fern
St. Patrick School
Maysville, Ky. 41056", "comment_id": "FDA-2007-P-0415-0008", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2007-P-0415-0008", "comment_date": "2008-08-14T04:00:00Z", "comment_title": "Julie Fern [St. Patrick School Wellness Committee] [- Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 750}, {"text": "Please consider the strictest possible regulations for the drug methadone.
Personally, I feel this drug should be taken off the market. It is much too
dangerous and unstable to be given for any reason. My son died after being given
this drug to help him recover from a prescription drug addiction. His life was never
the same once he was in the methadone program. He had numerous car
accidents, physical problems, and depression and anxiety. These all occured after
entering the methadone clinic. Another problem is doctors continue to treat these
patients , in methadone clinics, with painkillers, muscle relaxants. The
combination is deadly. It compromises the respiratory system and many times
results in death while sleeping. I told my son's doctor he was a drug addict on
methadone and he still walked out of his office that day with large prescriptions for
painkillers and muscle relaxants. Something must be done, either take it off the
market or start educating doctors on how to prescribe such a dangerous drug.
Thank You,
Linda Tyler
", "comment_id": "FDA-2007-P-0415-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2007-P-0415-0005", "comment_date": "2008-07-23T04:00:00Z", "comment_title": "Linda Tyler - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1200}, {"text": null, "comment_id": "FDA-2007-P-0415-0007", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2007-P-0415-0007", "comment_date": "2008-07-23T04:00:00Z", "comment_title": "GSSAC Prevention Center - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}]}, {"id": "HHS-OS-2018-0027", "title": "Pain Management Task Force Draft Report", "context": "2019-04-02T01:29:04Z", "purpose": "Nonrulemaking", "keywords": null, "comments": [{"text": "Chiropractic needs to be included rather than dismissed as a modality as this report indicates", "comment_id": "HHS-OS-2018-0027-0415", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0027-0415", "comment_date": "2019-02-01T05:00:00Z", "comment_title": "Comment on FR Doc # 2018-28403", "commenter_fname": "Norri", "commenter_lname": "Collier, DC", "comment_length": 94}, {"text": "I have chronic pain due to nerves damaged in a surgery for 5 years now. I tried every conceivable alternative treatment, yoga, meditation, acupuncture, CBD, and THC, and on and on. They did not work Then I tried Tylenol and after 3 days it made me sick. Then I tried Ibuprofen, which helped a bit but it injured my stomach and I had to stop taking it. I tried some other NSAID's, but they did not help much.

Finally I was prescribed hydrocodone. 7.5 mgs twice a day and it works. Nothing else does. I have had 3 surgeries trying to fix the nerve, nothing is fixed yet and thank God for hydrocodone. I read where some "study" found tylenol and or advil was found to work as well as opioids for post operative pain. I have never heard anything so ridiculous in my life.

You should know, my brother's Doctor is scared to death to prescribe any type of opioid. He thinks the guidelines are the law.
I am sure by now you have gotten enough data to see the guidelines have not reduced opioid deaths but just increased fentanyl deaths.

This lady in our community due to the guidelines had her pain pills discontinued. She killed herself...https://www.pressdemocrat.com/news/8639079-181/charge-dismissed-against-petaluma-man.

I don't know how you can fix this mess you have made, but it has caused way too much suffering.", "comment_id": "HHS-OS-2018-0027-0357", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0027-0357", "comment_date": "2019-01-24T05:00:00Z", "comment_title": "Comment on FR Doc # 2018-28403", "commenter_fname": "Timothy", "commenter_lname": "Fitzpatrick", "comment_length": 1390}, {"text": "I am a 64 year old female chronic pain patient suffering from Spondylolisthesis (having had a failed back surgery), Fibromyalgia and Osteoarthritis. I was forced to leave my lucrative professional career and go on SS Disability about 10 years ago.

My initial pain management physician, treated me with many epidural steroid shots and pain medication until I was suddenly unable to reach him and his staff after countless calls for an appointment and to renew my medication. I was forced to go to the ER because of my intolerable pain, after which I went to his office in person. He burst out of his office and screamed out loud to a packed waiting room that I was a desperate drug addict seeking drugs. I was stunned and mortified.

I found another pain management specialist under which I endured more epidural steroids. As a type 1 diabetic these raised my blood sugar levels to extremely high levels and had me in danger of hyperglycemic coma. They also caused severe epidural headaches. He then had me try innumerable medications including Gabapentin, muscle relaxers, low dose Naltrexone, and others. These provided zero pain relief or gave me intolerable side effects to include severe dizziness.
He then coerced me in to having a spinal cord stimulator implanted in my body. This failed to relieve my pain and it was removed. I then had a stimulator from another manufacturer implanted. This did help with my pain but did not eliminate the need for further relief in order to function, so he continued to provide some pain medication.

He then tapered my pain medication to half of what it had been. He told me it was because the government was cracking down on Doctors, and that several of his colleagues had lost their licenses. He was afraid to prescribe. His pain management group now became a spine care center. He suggested I get a second spinal cord stimulator implanted in another area of my back.

He now tells me the practice no longer prescribes pain medication - even for cancer patients.

I now receive a fraction of the pain medication which allowed me to live a tolerable life. I can no longer do any housework. The time I can spend on my feet or walking is very limited. I cannot have a normal social life or participate in many activities.

My life has been forever altered by pain which could easily be controlled by a safe, inexpensive pain medication solution that I am now being denied. The opioid deaths in this country are happening to drug addicts deciding to take illegal, deadly street drugs - not patients like myself in a controlled physician environment. The millions like me in this country, have been thrust
in to a life of severe suffering. Some so bad, that suicides from intolerable pain are skyrocketing.

We ask that legitimate pain patients not be punished for the actions of drug addicts, and that our Doctors be allowed, without fear, to treat us.

Thank you for your attention to this urgent human crisis.
", "comment_id": "HHS-OS-2018-0027-0312", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0027-0312", "comment_date": "2019-01-23T05:00:00Z", "comment_title": "Comment on FR Doc # 2018-28403", "commenter_fname": "Stephanie", "commenter_lname": "Lobignat", "comment_length": 3037}, {"text": "Incurable Chronic Pain Condition. Treated over many years, started with medication therapies, invasive procedures, Brain Surgery, Gamma- knife Radiation and eventual disability 10 years before retirement age.
I worked through all the complications of every medicine, every procedure, surgery, but the Gamma-knife was my Achilles heel.
I have tried everything recommended and suggested in the Trigeminal Neuralgia treatment handbooks for patients which are acknowledged by the leading specialists in the field. Patient Advocacy included.
It's been long, hard and painful.
I just want to be able to have some kind of life which even with OPIOIDS is limited.
My latest attempt is a small portable ultrasound device I had to petition my doctor for over two years to be able to try. Oh! Yes! And on my own dime as any alternative therapy I tried was out of pocket as well.
This is the shame of it all. Pain medications work to alleviate pain. All the alternative treatments cost exorbitant amounts of money that have no coverage.
Until the Insurance Industry opens it's pockets and that includes Medicaid and Medicare I'm afraid alternative medicine will remain out of reach for most Chronic Pain Patients.
I even read in these comments a plug for massage therapy? Who's kidding who? Massage therapy may assist some pain patients but many of us can't get out of our house to get there....... Or have the assistance we need to participate in the recommended alternative therapies. What I see happening is now the one item OPIOIDS is now being trashed or being set up as a non-viable payment reimbursement classification.
I myself just changed my insurance provider and it created nothing but problems for my doctor, pharmacy and especially me!
I left one pharmacy I tried due to the insurance company I had, yes Atena and CVS.
Aetna was sold and CVS bought. CVS pharmacy in Chicago made up their own rules as to how they would dole out prescription narcotics outside of the law. I called and emailed the CVS corporate in Rhode Island. I did receive a call back from a corporate pharmacist telling me the CVS pharmacy was not following the law. I couldn't run away fast enough!
My doctor who I respect who I discuss my interactions with has shared that pharmacists are totally ignoring prescriptions.
I myself had a pharmacist of course from the same CVS write a belligerent note on my prescription bottle highlighted with bright pink highlighter. I thought the note was from my doctor, after speaking with her and her office, found out it was placed on my script bottle from the pharmacist?
Who does that? Get in the middle of a 20 year relationship with a patient and a doctor?
It's important you know I want to be out of pain, I've had enough, I didn't ask for it and I've tried everything experts have recommended and had to save up money for the privilege of doing it.
So after you tackle laws on OPIOIDS. You could tackle payment reimbursement parameters for payment related to alternative treatment.
All I see happening is the government does not want to pay for legal prescription therapy that is reimbursed.
How about the study committee for ethical insurance reimbursement for all the marvelous alternative treatments that we are supposed to take advantage of and have access to use?
If they work as well why aren't they paid at 80/20 long term with no time limits applied?
All you are doing is setting up a stampede to the nation's emergency rooms for people in pain.
Or the black market for lethal doses of drugs to stop the pain.
Do you not understand most of us live on the edge as it is!", "comment_id": "HHS-OS-2018-0027-0313", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0027-0313", "comment_date": "2019-01-23T05:00:00Z", "comment_title": "Comment on FR Doc # 2018-28403", "commenter_fname": "Christine", "commenter_lname": "M", "comment_length": 3731}, {"text": "Acupuncture is an effective and safe on the pain management. Hopefully it will be covered by Medicare.", "comment_id": "HHS-OS-2018-0027-0321", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0027-0321", "comment_date": "2019-01-23T05:00:00Z", "comment_title": "Comment on FR Doc # 2018-28403", "commenter_fname": "Ling", "commenter_lname": "Zheng", "comment_length": 102}, {"text": "Dear Dr. Singh,

RE: Docket ID# HHS-OS-2018-0027

As a Certified Registered Nurse Anesthetist (CRNA), I'm writing today to express my concerns with the Department of Health and Human Services' Pain Management Best Practices Inter-Agency Task force draft report titled "Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations."

I am supportive of recommendation 1c under section 3.3.3 (Workforce), which recommends expanding the availability of non-physician pain specialists. However, this recommendation is contradicted by another recommendation in the report for credentialing and training requirements that limit the pathways available for non-physician practitioners, such as CRNAs, to be able to provide interventional pain procedures. CRNAs are qualified pain practitioners who have the training and experience to provide high-quality treatments to patients suffering from a wide range of acute and chronic pain conditions, in a variety of practice settings. CRNAs who provide pain management do so in accordance with our professional scope of practice, federal and state law, and facility policy.

As part of our educational preparation, CRNAs are required to learn and demonstrate competence in the management of pain. And, the standards issued by the Council on Accreditation mandate that nurse anesthesia programs provide content in, but not limited to, anatomy, physiology, pathophysiology, pharmacology, and acute and chronic pain management. These standards also require that student nurse anesthetists obtain clinical experiences in regional anesthetic techniques (i.e., spinal, epidural, and peripheral nerve blocks). As such, CRNAs possess the necessary knowledge and skills to employ therapeutic, physiological, pharmacological, interventional, and psychological modalities in the management and treatment of acute and chronic pain.

Additionally, the Centers for Medicare and Medicaid Services (CMS) recognizes the ability of CRNAs to perform and bill for acute and chronic pain management services. The U.S. House of Representatives also recognizes the ability of CRNAs to perform pain management services and urged the Department of Defense to make funds available for CRNAs to pursue existing pain management fellowships. CRNAs and other non-physician providers play an integral role in providing these services, which positively impact several areas, including patient safety, reducing prescription drug abuse, and cost savings; and should be recognized in the report.

I strongly urge HHS and the Task Force not to adopt these recommendations as drafted and request that the credentialing and training requirements be amended to be inclusive of all types of practitioners and their educational pathways.


Sincerely,
Jennifer Andrews
1240 Golf Crest Ct

Springfield, IL 62707-7601

", "comment_id": "HHS-OS-2018-0027-1725", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0027-1725", "comment_date": "2019-03-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2018-28403", "commenter_fname": "Jennifer", "commenter_lname": "Andrews", "comment_length": 2981}, {"text": "Dear Dr. Singh,

RE: Docket ID# HHS-OS-2018-0027

As a Certified Registered Nurse Anesthetist (CRNA), I'm writing today to express my concerns with the Department of Health and Human Services' Pain Management Best Practices Inter-Agency Task force draft report titled "Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations."

I am supportive of recommendation 1c under section 3.3.3 (Workforce), which recommends expanding the availability of non-physician pain specialists. However, this recommendation is contradicted by another recommendation in the report for credentialing and training requirements that limit the pathways available for non-physician practitioners, such as CRNAs, to be able to provide interventional pain procedures. CRNAs are qualified pain practitioners who have the training and experience to provide high-quality treatments to patients suffering from a wide range of acute and chronic pain conditions, in a variety of practice settings. CRNAs who provide pain management do so in accordance with our professional scope of practice, federal and state law, and facility policy.

As part of our educational preparation, CRNAs are required to learn and demonstrate competence in the management of pain. And, the standards issued by the Council on Accreditation mandate that nurse anesthesia programs provide content in, but not limited to, anatomy, physiology, pathophysiology, pharmacology, and acute and chronic pain management. These standards also require that student nurse anesthetists obtain clinical experiences in regional anesthetic techniques (i.e., spinal, epidural, and peripheral nerve blocks). As such, CRNAs possess the necessary knowledge and skills to employ therapeutic, physiological, pharmacological, interventional, and psychological modalities in the management and treatment of acute and chronic pain.

Additionally, the Centers for Medicare and Medicaid Services (CMS) recognizes the ability of CRNAs to perform and bill for acute and chronic pain management services. The U.S. House of Representatives also recognizes the ability of CRNAs to perform pain management services and urged the Department of Defense to make funds available for CRNAs to pursue existing pain management fellowships. CRNAs and other non-physician providers play an integral role in providing these services, which positively impact several areas, including patient safety, reducing prescription drug abuse, and cost savings; and should be recognized in the report.

I strongly urge HHS and the Task Force not to adopt these recommendations as drafted and request that the credentialing and training requirements be amended to be inclusive of all types of practitioners and their educational pathways.


Sincerely,
R Haynes
1919 Dunraven Rd

Bloomington, IL 61704-9705
", "comment_id": "HHS-OS-2018-0027-1738", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0027-1738", "comment_date": "2019-03-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2018-28403", "commenter_fname": "R", "commenter_lname": "Haynes", "comment_length": 2966}, {"text": "Hi- I am a psychologist, and I have RLS, and I work in substance use treatment and fully understand the importance of addressing the opioid crisis. I nightly take Requip and Gabapentin which make me too drowsy to function, even at a low dose, during the day. I am embarrassed that I occasionally need to take Tramadol for long afternoon meetings. I probably take two pills a month, or less, yet it is important that I be able to continue to do. It is the only medication that does not make me drowsy and yet helps me to sit and function at work during meetings. It is important that legislation not be too strict that it overrides medically necessary treatment.
thank you!", "comment_id": "HHS-OS-2018-0027-1751", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0027-1751", "comment_date": "2019-03-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2018-28403", "commenter_fname": "SUE", "commenter_lname": "NELSON", "comment_length": 676}, {"text": "I have had hip dysplasia, spinal deterioration, 3 left hip replacements, two right knee revisions, RSD/CRPS, pineal brain tumor and seizures from a year old until today (age 541/2.. ) I've been forced to taper off benzodiazepines (after 23 years) which has caused deafening tinnitus. My pain medication was cut from oxycodone 15mg TID (7 years without incident or abuse) to 10mg Hydrocodone. My pain management doctor refuses to increase medication to help with my excruciating pain. I have only left my bed, in 8 months, to go to multiple specialists that are a 3 hr rpund trip from my home. The doctors have taken away my quality of life. I have broken no laws EVER, don't use alcohol/marijuana or illegal drugs, jumped through every "hoop" but I am still treated like a drug addict!! I haven't been able to be the wife, to my husband of 32 years, that he deserves and I've missed almost a year of being able to visit my four children and 5 grandchildren ( and another grandbaby is due late May 2019). I have been treated horribly by pharmacists every time I have to pick up my low dose medications. I'm afraid of being completely cut off of all opioids due to false narrative of "opioid crisis", doctors fears and pharmacists/insurance company refusing to fill doctors orders! The guidelines were never meant to effect current pain patients but we're the ones being effected the most while illicit drug use increases. My disability, constitutional and human rights are being violated. Please stop this before more chronic pain patients commit suicide after being forced to stop all opioids! Lawmakers should never get between a patient and their doctor! ", "comment_id": "HHS-OS-2018-0027-1693", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0027-1693", "comment_date": "2019-03-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2018-28403", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 1705}, {"text": "End the Drug War.

In a decriminalized environment absolutely none of this draft report would be necessary. Government created a problem, now government is pretending to want a solution, but in fact until the Drug War is completely and permanently ended no solution will ever be anything other than substantially sub-optimal.

In a decriminalized environment opioid addiction is 100% benign, except for those individuals who knowingly and intentionally pursue risky behavior. These people are already pursuing their risky behavior choices in the current Drug War environment, so there will be absolutely no negative impact of decriminalizing opioids, and the elimination of negative Drug War externalities will be overwhelmingly positive for society.

Providers need to quit being paranoid about opiates.

Government needs to grow up.", "comment_id": "HHS-OS-2018-0027-1699", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0027-1699", "comment_date": "2019-03-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2018-28403", "commenter_fname": "Richard", "commenter_lname": "Stewart", "comment_length": 867}]}, {"id": "FDA-2018-P-4338", "title": "Request that the FDA refrain from approving any pending or future application for an opioid product submitted pursuant to section 505(b) or 505(j) of the FD&C Act, including NDA No. 209774 submitted by SpecGx LLC (\u201cMNK-812\u201d), with an indication or any other labeling that suggests that the product is appropriate for chronic use.", "context": "2019-04-18T15:28:24Z", "purpose": "Nonrulemaking", "keywords": ["CITIZEN PETITION", "PHARMACEUTICAL MANUFACTURING RESEARCH SERVICES,", "INC.", "PMRS", "opioid product", "SpecGx LLC (\u201cMNK-812\u201d)", "abuse-deterrent labeling", "NDA No. 209774", "Roxicodone", "Reference Listed Drug (RLD)", "chronic pain", "opioid addiction", "Citizen Petition (FDA-2017-P-1359)", "OxyContin 10 mg, 20 mg, and 40 mg tablets", "(NDA 20-553)", "CDER"], "comments": [{"text": "Im 46 years old & 12 years ago my life changed forever. That was the year I had my 1st (up to 7 & my neurosurgeon says about every 5 years I will need another) Spinal Fusion which was a disaster & left me with permanent Nerve damage & in Chronic Pain. After so many surgeries & so much trauma involving my spinal Nerves I also ended up w a disease called CRPS. My pain is horrendous & I fight everyday just to get out of bed & to shower these days. A year ago I wasnt this bad, I could actually go w my mom to a store & maybe lunch that day but now w the CDC laws my meds have been cut in half. So now its been 2 times in my life where I have lost everything & the most important part that was just taken away now was my quality of life. For 12 years Ive been on these opioid medications & Ive never had a medication emergency, never ran out earlier than I should, never changed pharmacies, etc. I followed every rule & now Im getting punished because of the addicts!! Its not fair...without meds or even life as it is now, Im only 46 years old, I cant live the rest of my life this way. Please dont throw the disabled & the chronic pain patients away. Our lives matter ", "comment_id": "FDA-2018-P-4338-0021", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-4338-0021", "comment_date": "2019-03-26T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 1220}, {"text": "Shameful request ! This kind of rhetoric is forcing millions of pain patients to suffer needlessly. After 20 years of Pain it was OxyContin that helped
more than any other pain reliever. Stop this madness now.", "comment_id": "FDA-2018-P-4338-0020", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-4338-0020", "comment_date": "2019-03-04T05:00:00Z", "comment_title": "Comment from John Sandherr", "commenter_fname": null, "commenter_lname": null, "comment_length": 213}, {"text": "This commentary is in response to the citizen petition posted by Pharmaceutical Manufacturing Research Services, Inc. pertaining to pending and future approvals of opioid products. This commentary will be in response to two of the major requests posed in this petition; to no longer approve any opioid medication with an indication of chronic pain and to refrain from approving any opioid with abuse-deterrent labeling. It should be noted that the petition is certainly aiming to solve a major public health crisis; the abuse and misuse of opioid continues to rise in the United States and has resulted in an unprecedented amount of opioid overdose deaths. It has been a major goal of the current administration, the FDA and many public health organizations to have a greater control on opioid distribution and use and this commentary should not discount the continued efforts that are needed to combat the opioid epidemic. Instead, this commentary should be used to evaluate and strengthen the current arguments of this petition.
As noted in the petition, chronic pain is defined as pain persisting for longer than 1 month beyond resolution of the underlying insult, or pain persisting beyond 3 months. While the petition calls to refrain from approving and other opioid medications for chronic pain, we should question if this medication could benefit end-of-life palliative care or severe chronic pain from serious illness such as cancer. An article in the AMA Journal of Ethics discusses the goals of a physician in end-of-life care and the use of opioids1. The article notes that a physician should aim to benefit the patient and minimize the burden of doing so, strive to preserve life and provide comfort in dying, and meeting individual needs and those of society. It could easily be argued that a new opioid, with immediate release technology, could provide comfort in dying to the patient and meet the needs of society, better than current opioids, by employing abuse deterrent technology. While it is important that we are cognizant of opioid addiction, it is also important to remember the intended use of these medications and ensure that individuals with chronic pain have fair access to all prescriptions available
The second point of commentary is on the petitions request to refrain from approving any opioid product with abuse-deterrent labeling. Its important to properly label prescriptions and if advanced technology has been used it an effort to curb abuse it is proper to note that on the bottle. Its possible that another name should be used in place of abuse-deterrent, such as diversion technology, but manufacturers should be rightfully credited with this technology and there should be some notation on the bottle of the new formulation. Also, in rebuttal of the petition, there are current articles that note that abuse-deterrent technology is effective is reducing the possibility of both intranasal and intravenous use2. Immediate release tablets are designed to transform from a pill into gel when an abuser attempts to crush or inhale the pill. The gel will also cause a burning sensation if its attempted to be snorted intranasal in a greater attempt to deter this abuse.
There are many thorough and well thought facts included in this petition and it should be thoughtfully considered by the FDA. Its clear that as a country, we need to be more conscious and considerate of the prescriptions that we approve and think about long-term implications before approving and NDA. Opioid use needs to be monitored more closely to deter abuse but it needs to be ensured that individuals with chronic pain have access to new medications and technology. We cannot deny patients in pain from their right to fair and just treatment and pain reduction.
Sources:
1. https://journalofethics.ama-assn.org/article/common-misconceptions-about-opioid-use-pain-management-end-life/2013-05
2. https://www.ncbi.nlm.nih.gov/pubmed/29308593

", "comment_id": "FDA-2018-P-4338-0019", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-4338-0019", "comment_date": "2018-11-28T05:00:00Z", "comment_title": "Comment from Kaitlin Perrine", "commenter_fname": null, "commenter_lname": null, "comment_length": 3988}, {"text": "I am a citizen of the USA I am 64 year old and am disabled since 2008 Before that i worked two jobs and never did drugs never smokes and on occasion drink a glass of wine or beer on a holiday or birthday.I am frustrated with the way I have recently been
treated by my doctors and medical staff because of our government ! I for many years have had Cronic pain with my fibromyalgia and arthritis with generative disc desease and other issues like depresion cronic anxiety .Thats enough as of now.I have been taken of my pain meds because of my anxiety medication mind you It has taken me many years to find the right combinations of medications and I have had no problem till now my phyciatrest has worked with me and other primary doctors to find something that works and that are in the so called guidelines now They have not been successful .I have also never misused My medicines I am not an addict just a person in pain. My life has totally been turned upside down I am not able to watch my grand children or go to family functions because of all this I am not able to live the life I once lived It was not perfect but it was liveable I of coarse am not alone in this there are many more .They cry in pain and they feel alone because our government has failed them .We know there is a drug epidemic those that abuse and misuse even sell horrible drugs to innocent people even children But we should not be the ones targeted. 90 percent of senior citizens do not misuse or over dose on theres or someone else's medications .I AM LIKE I SAID SPEAKING FOR ME AND OTHERS LIKE ME THIS IS WRONG AND SOMETHING NEEDS TO BE DONE PLEASE HEAR OUR VOICES CALLING FOR HELP WE DO NOT DESERVE THIS IS UNCONSTITUTIONAL!
", "comment_id": "FDA-2018-P-4338-0023", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-4338-0023", "comment_date": "2019-04-05T04:00:00Z", "comment_title": "Comment from Linda Melton", "commenter_fname": null, "commenter_lname": null, "comment_length": 1724}, {"text": "I am just one person that represents the chronic illness community. I feel like something that isnt mentioned in this discussion is that this is a last resort treatment for many of us. We dont abuse this medication and use it as directed as one pice of a multifaceted treatment plan that includes things like yoga and meditation. I feel like if you truly want to address this issue the answer lies in finding better treatment for chronic illnesses. I dont understand the logic behind saying its appropriate for people not to deal with pain for a few days after surgery or an injury but not for chronic illness. Pain is very distressing to the body which is the whole reason we use it as a treatment and long term distress causes more health conditions. I cant speak for everyone but through the last 15 plus years Ive been dealing with chronic pain and illness I have gone off of opiates to try different medications and while opiates arent ideal no treatment is and for most of us they play a pivotal role in our ability to function everyday. Chemo isnt an ideal treatment neither is insulin, but when you are ill you only have the options available to you. Like anything there are people who exploit things to their benefit. I dont see how taking treatment that isnt being abused from an already vulnerable population. I agree these meds were being over prescribed but if there is any appropriate use for these meds it would be for chronic and terminally ill people who have to be on supervised treatment the rest of their lives. Many people start abusing these drugs due to the lack of info and oversight that has already transpired and cutting them off with no medical guidance. Taking treatment from those who have been using it appropriately would make an already vulnerable population absolutely desperate. We are not being represented or advocated for and would hope that we are not neglected and the decision will be left to the Dr and patient. This treatment is a big responsibility and should be treated as such. I see the top Dr in my state for my condition and he has been absolutely phenomenal in the guidance and treatment I have received from him and I feel grateful he wasnt a dr feel good and knows how to properly prescribe the lowest doses for as long as possible. I had been to drs prior to him that were totally over prescribing and I advocated that to the dr I see now. My point is with chronic illness every moment of every day is a major task to overcome there are days I can barely get from my bed to the bathroom . Thats managing my illness with several meds and yoga and meditation when we finally get our regimens to a point where we can atleast take care of the bare minimum to survive its a huge blessing and throwing a wrench in someones treatment plan throws their lives in absolute upheaval for weeks months maybe years. We all have people that count on us too. Nothing is going to magically fix the damage the lack of oversight has caused and taking the only treatment options we have when there is nothing to replace it with is just as irresponsible. So I dont know how you measure or quantify if something truly gives relief to someone that is ill but I can tell you this if they didnt give me relief from my illness I wouldnt take them as part of my treatment many antidepressants and neurological meds for chronic pain and illness like Lyrica have just as violent and as many side effects and you have to ween off of them because the body becomes physically dependent or addicted to them. Ive had to do this several times from several so called treatments. Not every treatment works for everyone so please lets leave this to the patients and their drs who have exhausted all the options and would love for new treatments to be available and are anxiously hoping they do but until that time I still have to be a functioning member of society. Thank you for your time", "comment_id": "FDA-2018-P-4338-0022", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-4338-0022", "comment_date": "2019-04-01T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 3909}, {"text": "I agree that those that abuse opioids and any other narcotic is making it next to impossible to get any narcotics prescribed if you have chronic pain or acute stress such as PTSD. I am 100% service connected total and permanent disabled and any narcotics that I was receiving and were helping me are being discontinued with no replacements of meds that do anything to help control my symptoms. Then when I was sent through the program to see a civilian doctor, they did two surgeries on me but would not prescribe any pain control because they said the VA wont let them and my VA doctors refused to prescribe any pain medication to me either because of the opioid crises. They consider every narcotic off limits if its an opioid or not and my urine is checked for any drugs every three months or more often. I am at the mercy of the VA and the doctors have obviously been told to take everyone off narcotics and not to prescribe any. If a civilian doctor does write a prescription for me I have to get it rewritten by a VA doctor before I can get it filled and they wont rewrite them. Medical marijuana is legal in my state but they wont discuss its use or the use of CBD which is totally legal to use. Having to go civilian for care will make this problem even worse because of what I have stated. Also I received this email to comment on the changes to the VA on April 10th but it states that all comments had to be received by sometime in March. This seems like it will be a bad deal for us veterans just by the way I was contacted about it over a month after comments were being considered. I would appreciate a response to my statement and would like to include that I was a registered nurse in the USAF and civilian.", "comment_id": "FDA-2018-P-4338-0024", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-P-4338-0024", "comment_date": "2019-04-11T04:00:00Z", "comment_title": "Comment from Julie Shapiro", "commenter_fname": null, "commenter_lname": null, "comment_length": 1723}]}, {"id": "DOD-2011-HA-0085", "title": "TRICARE; Removal of the Prohibition to Use Addictive Drugs in the Maintenance Treatment of Substance Dependence in TRICARE Beneficiaries", "context": "2020-10-22T01:28:06Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "See attached", "comment_id": "DOD-2011-HA-0085-0035", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2011-HA-0085-0035", "comment_date": "2012-03-01T05:00:00Z", "comment_title": "NAABT Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}, {"text": "Dear Sir/Ma'am,
Please note my strong support FOR the proposed rule change.
The exclusion of maintenance therapies for addiction treatment because they are "addictive" ignores best practices in the medical treatment of substance use disorders, ties the hands of service providers, and makes recovery from chemical dependence harder for patients to achieve.
The proposed rule change would increase the effectiveness of treatment for this life-threatening and widespread illness.
Thank you,
William Aprill
LCSW-BACS, LAC, CCGC", "comment_id": "DOD-2011-HA-0085-0002", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2011-HA-0085-0002", "comment_date": "2012-01-03T05:00:00Z", "comment_title": "Comment on DOD_FRDOC_0001-3051", "commenter_fname": null, "commenter_lname": null, "comment_length": 565}, {"text": "Patients enrolled in a methadone clinic accept a high level of supervision and demonstrate a commitment to their recovery.", "comment_id": "DOD-2011-HA-0085-0017", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2011-HA-0085-0017", "comment_date": "2012-02-14T05:00:00Z", "comment_title": "Comment on DOD-2011-HA-0085-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 122}, {"text": "I have submitted the comment below on letterhead using the file upload function. Here is the text.

As a researcher and clinician in the addiction field, I am writing to express my strong support for the proposed inclusion in TRICARE of coverage for methadone and buprenorphine maintenance for drug dependent individuals. Extensive research – much of it conducted with former military personnel receiving care in the Veterans Health Administration – indicates that opiate substitution therapies sharply reduce illicit drug use and risk of fatal overdose. These therapies have also been proven highly cost-effective.

At a time when a growing number of U.S. military personnel are reporting problems with prescription and non-prescription opioids, the addition of this benefit to TRICARE is critically important. For the regulatory change to be maximally beneficial to the health of our military personnel and their families, it should be coupled with extensive outreach to TRICARE providers to make them aware of the new insurance benefit.

Thank you for proposing this major step forward for the TRICARE program.

", "comment_id": "DOD-2011-HA-0085-0003", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2011-HA-0085-0003", "comment_date": "2012-01-03T05:00:00Z", "comment_title": "Comment on DOD_FRDOC_0001-3051", "commenter_fname": null, "commenter_lname": null, "comment_length": 1284}, {"text": "The use of opioid maintenance therapy on a long term basis has not been proven to improve functionality or reduce mortality or relapse. Most tests of the efficacy of opioid treatment therapy have been conducted on a short term basis. Research has shown that on a short term basis, those given methadone or buprenorphine reduce their use of other opioids, but only for as long as they are on the drugs. Many continue to use other substances such as alcohol, and continue to be at risk of overdose. Methadone overdoses have increased 400% from 2004-2008. Harm reduction philosophy (upon which use of an addictive substance is sanctioned to treat dependence on another substance) is an enabling philosophy that continues addiction, rather than treat it. As long as the person remains dependent on an abusable substance, he or she can never realize his/her potential as a whole, infinite spiritual being. It is a disrespectful and demeaning approach to the plight of the addict and keeps him/her shackled to the progression of this dangerous mental disorder and foreshortens his/her life. The use of chronic opioid therapy for chronic noncancer pain has created this epidemic of opioid dependent persons and yet so little is being done to stop the production of opioid dependent persons and much is being propagated about the "evidence-based" need for the use of more opioids to treat the problem. This is insane!", "comment_id": "DOD-2011-HA-0085-0004", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2011-HA-0085-0004", "comment_date": "2012-01-03T05:00:00Z", "comment_title": "Comment on DOD_FRDOC_0001-3051", "commenter_fname": null, "commenter_lname": null, "comment_length": 1419}, {"text": "The proposed change reflects the best evidence-based practice in the treatment of opioid dependence. I fully support this change in the applicable regulation.

I speak from the experience of prescribing buprenorphine (Suboxone/Subutex) since 2004 in the treatment of opioid dependence in the context of a comprehensive treatment program by our agency of which I am the medical director. I also support Opioid Treatment Programs that prescribe methadone in the treatment of opioid dependence along with counseling.

I am Board-certified in Internal Medicine and Addiction Medicine and have been working in the field of addiction medicine since 1989.", "comment_id": "DOD-2011-HA-0085-0007", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2011-HA-0085-0007", "comment_date": "2012-01-10T05:00:00Z", "comment_title": "Comment on DOD-2011-HA-0085-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 666}, {"text": "Dear Sir or Madam,

On behalf of the Ohio Department of Alcohol and Drug Addiction Services (ODADAS) Clinical Roundtable Committee, I am pleased to submit the following comments on the proposed rule related to TRICARE benefits, “Removal of the Prohibition to Use Addictive Drugs in the Maintenance Treatment of Substance Dependence in TRICARE Beneficiaries (Document ID DOD-2011-HA-0085-0001).”

The Clinical Roundtable -- comprised of six senior clinicians and supervisors with established expertise in the clinical treatment of addictive disorders, drawn from ODADAS-certified treatment agencies from across the state -- strongly supports extending the benefit so that maintenance regimens of Medicated-Assisted Treatment (MAT) will be covered by TriCare. Scientific literature supports provision of MAT on an ongoing basis as being far more efficacious than alternative approaches, including detoxification-only or short-term utilization of MAT. Furthermore, several Roundtable members are familiar with the use of opioid replacement therapies (MAT) on an ongoing basis in their own agencies and have found it to be effective and practical.

The Clinical Roundtable also recommends addressing barriers that limit access to other clinical services (counseling, case management) within the TRICARE system. MAT is considerably more likely to be effective when combined with counseling and case management services; however, community agencies with the highest level of expertise in providing such services have found that they cannot receive reimbursement through TRICARE. While the Clinical Roundtable fully supports and recommends immediate action on the MAT proposal, there is a strong consensus that further access to addiction-related services needs to be addressed as well.

Thank you for this opportunity to provide comment. Please do not hesitate to call or email if I can be of additional assistance.

Sincerely,

Orman Hall, Director
ODADAS
", "comment_id": "DOD-2011-HA-0085-0026", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2011-HA-0085-0026", "comment_date": "2012-02-27T05:00:00Z", "comment_title": "Comment on DOD-2011-HA-0085-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 2019}, {"text": "See attached file(s)", "comment_id": "DOD-2011-HA-0085-0020", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2011-HA-0085-0020", "comment_date": "2012-02-23T05:00:00Z", "comment_title": "Comment on DOD-2011-HA-0085-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached.", "comment_id": "DOD-2011-HA-0085-0033", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2011-HA-0085-0033", "comment_date": "2012-02-28T05:00:00Z", "comment_title": "CSAC Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 13}, {"text": "On behalf of NAADAC, the Association for Addiction Professionals, which represents the professional interests of more than 75,000 addiction counselors, educators and other addiction-focused health care professionals in the United States, Canada and abroad, we thank you for this opportunity to submit comments to the Department of Defense regarding the TRICARE: Removal of the Prohibition to Use Addictive Drugs in the Maintenance Treatment of Substance Dependence in TRICARE Beneficiaries (RIN 0720–AB54).

NAADAC applauds the proposed change in TRICARE policy regarding the use of therapeutic drugs in maintenance treatments for substance dependence. There is a wealth of medical evidence available that supports the belief that medication-assisted treatments are safe and highly effective. The extension of benefits to include these treatments increases the quality of treatment options available to TRICARE beneficiaries.

The use of medication-assisted treatments is not for everyone. Thus, we would recommend that included in the rule is a requirement that all individuals undergo an assessment prior to starting any medication-assisted treatment to ensure that they are receiving the appropriate care. We also recommend that there be a requirement that anyone receiving medication-assisted treatments also take part in a comprehensive psychosocial treatment program to be administered concurrently. We believe these added components will serve to prevent further dependence by assisting counselors in obtaining an ongoing assessment of the treatment.

While NAADAC does not have an official written statement outlining support for medicated assisted treatment for individuals with addiction problems, since 2005 we have been active in the development of training experiences surrounding this topic for addiction treatment professionals. Through a training program entitled “NAADAC’s Life Long Learning Series” five different training experiences have been developed and trained to ", "comment_id": "DOD-2011-HA-0085-0015", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2011-HA-0085-0015", "comment_date": "2012-02-14T05:00:00Z", "comment_title": "Comment on DOD-2011-HA-0085-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 2048}]}, {"id": "FDA-2022-N-0165", "title": "Providing Mail-Back Envelopes and Education on Safe Disposal With Opioid Analgesics Dispensed in an Outpatient Setting; Establishment of a Public Docket; Request for Comments", "context": "2022-06-30T13:57:24Z", "purpose": "Nonrulemaking", "keywords": ["OPEN", "Request for Comments", "Establishment of a Public Docket", "Dispensed in an Outpatient Setting", "on Safe Disposal With Opioid Analgesics", "Providing Mail-Back Envelopes and Education", "CDER", "2021-715"], "comments": [{"text": "Comment regarding: Providing Mail-Back Envelopes and Education on Safe Disposal With Opioid Analgesics Dispensed in an Outpatient Setting

I think that regulation requiring a Mail-Back Envelope to be provided with every opioid analgesic will create a lot of waste and burden on the retail pharmacy. I think regulation should look at making every retail pharmacy be able to take back unused narcotics for destruction. Certainly having prepaid envelopes offered to each patient is fine but requiring them to be given even if not desired is wasteful.", "comment_id": "FDA-2022-N-0165-0045", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-0165-0045", "comment_date": "2022-04-22T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 557}, {"text": "Whether there are specific opioid analgesic drug products for which requiring mail-back envelopes is more important from a public health perspective and, if so, which products.
Although some opioids are more abused than others, all opioids have the potential to be abused or misused. Having exceptions will add confusion and inefficiencies. A pharmacist can provide a first-time education which can include the general purpose of the envelope, general information about unsafe disposal, etc. If there are exceptions, patients will come asking for help to sort or select the appropriate medications to place in the envelope. Patients will not retain after 6 months such details. It will be simple to have pharmacies stick a label stating: “Must be safely disposed of according to the law”. It is a single step that can be easily introduced into a pharmacy workflow.
Patients will respond to a general call of disposing of by mail if there is a continuous message, not a bi-annual campaign. It is more likely that a well-developed program that provides clear communication of the multiple alternatives to dispose of unused opioid have an impact. Repetition and reach are key to any public health effort.

How pharmacies could develop and implement algorithms to determine when to provide a mail-back envelope, including how feasible or practical it would be for pharmacies to do so.
How pharmacies could identify those patients who are most likely to have unused opioids to optimize the provision of mail-back envelopes to these patients and potentially positively impact the share of mail-back envelopes that are utilized to safely dispose of opioid analgesics.

It can be difficult for a pharmacy to identify patients who potentially will have unused medicine. Therefore, pharmacies can have the envelope available and can target, based on past prescriptions, patients with possible unused opioids. As a one-time effort is great but not as an ongoing effort. Pharmacists promote in a general manner to dispose of all unused medicine and individually when providing medication therapy management (MTM). But not all patients have the benefit of an MTM service.

Whether requiring the provision of mail-back envelopes under the OA REMS should also include a requirement for patient counseling and/or provision of take-home materials on safe disposal at the point of dispensing.

Having an envelope is a novel approach that will add cost to the manufacturer and to the dispensing of an opioid prescription. A pharmacist can provide a first-time education which can include the general purpose of the envelope, general information about unsafe disposal, etc. We need to look further into what causes residues or unused medications. An additional first-step strategy is to minimize risk and the possibility of having home residuals is educating doctors to prescribe fewer quantities for post-surgeries. A patient with a tooth extraction does not need a 7-day supply of therapy. A patient with shoulder surgery will visit the surgeon in a week, why give the patient 21-days of therapy? The burden always falls outside the doctor’s realm. What pharmacists need is the capability of deciding approaches to avoid getting into the hands and homes of patients an amount of drug that, to start, is suspected and probable of converting to “unused”.
", "comment_id": "FDA-2022-N-0165-0053", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-0165-0053", "comment_date": "2022-04-22T04:00:00Z", "comment_title": "Comment from Nelly Conte", "commenter_fname": null, "commenter_lname": null, "comment_length": 3421}, {"text": "While I appreciate the intent of this proposed program, I don't think the implementation would work. People may lose or misplace the envelope and many people may never use them. This creates a lot of waste and doesn't address the issue.

Instead, I think that it makes more sense to have drop boxes for all unused medication in every pharmacy and those can be incinerated. For patients who are unable to get to a pharmacy, having an envelope as described available on request would help them. ", "comment_id": "FDA-2022-N-0165-0042", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-0165-0042", "comment_date": "2022-04-22T04:00:00Z", "comment_title": "Comment from Ellen Simes", "commenter_fname": null, "commenter_lname": null, "comment_length": 511}, {"text": "Do you really think that it is easier to store an envolope until needed, find the envelope when it is needed, place the contents in the envelope, and take it to the post office/mail box than it is to flush a few tablets down the toilet? It sounds like a gimmick to get more money for the post office.", "comment_id": "FDA-2022-N-0165-0057", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-0165-0057", "comment_date": "2022-04-27T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 301}, {"text": "What you have done to the most needy population is criminal, chronically Ill people need their pain relief and because others use street drugs I have to lay in bed and cry in pain. I’m in pain 24/7 because you have interfered with with my doctors ability to treat my pain properly your proposal doesn’t go far enough to help the chronically Ill. I have considered suicide and considered street drugs I just haven’t gotten to the point that I’ve made those moves. I don’t want to leave my wife and daughters but I’m not sure I can handle this pain much longer but you people don’t care . Fuck You", "comment_id": "FDA-2022-N-0165-0063", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-0165-0063", "comment_date": "2022-04-29T04:00:00Z", "comment_title": "Comment from Mike Gilligan", "commenter_fname": null, "commenter_lname": null, "comment_length": 637}, {"text": "The idea of providing mail-back envelopes with opioid analgesics is a great idea to minimize opioid medications from lingering in our communities. I would desire to see the mailers be recyclable to minimize waste and unintentional negative impact on the environment. I also would recommend making acceptance of the mailer voluntary for the patient for similar reasons since the majority of chronic opioid prescriptions dispensed to individual patients will be consumed.", "comment_id": "FDA-2022-N-0165-0065", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-0165-0065", "comment_date": "2022-04-29T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 471}, {"text": "Most pharmacies have drop boxes for returning unused medications. Because of the CDC guidelines and concerted effort to avoid prescribing pain medication to patients, there is little opportunity for diversion but much greater harm to patients as prescription opioids are now being overly policed by the DEA. Micromanaging every single pill dispensed to patients is a wasteful diversion from the true threat to public health from the manufacturing and trafficking of illicit deadly drugs, and it also interferes with the practice of medicine. If a pharmacy doesn't have a drop box, then mail back envelopes can be available at the pharmacy if asked for. Does the DEA now plan to start tracking how many prescribed pills that a patient takes? Will that become a new red flag for prosecution or justification for the DEA to make dosing recommendations which become de facto law?", "comment_id": "FDA-2022-N-0165-0062", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-0165-0062", "comment_date": "2022-04-29T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 879}, {"text": "This is an absurd, unreasonable, and wasteful effort.

People can obtain methods to destroy unwanted medications from their pharmacies. This is unnecessary, a huge strain on pharmacies, and provides dubious benefit.

Studies show the majority of diverted medications are from health care facilities, not consumers.

This is an unreasonable attempt to mitigate a problem that doesn’t exist.
", "comment_id": "FDA-2022-N-0165-0064", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-0165-0064", "comment_date": "2022-04-29T04:00:00Z", "comment_title": "Comment from Andrea Anderson", "commenter_fname": null, "commenter_lname": null, "comment_length": 428}, {"text": "This is absurd. If you must send something to the patient then is should be an envelope or container that automatically renders drug unusable once place in envelope. Putting opioids into the mail in an envelope just increases risk of diversion. ", "comment_id": "FDA-2022-N-0165-0066", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-0165-0066", "comment_date": "2022-04-29T04:00:00Z", "comment_title": "Comment from Janice Garland", "commenter_fname": null, "commenter_lname": null, "comment_length": 245}, {"text": "Waste of money and pharmacist time as a valuable resource. Also, this creates more opportunities for theft of opioids as they are circulated through the mail system with SO many chances for them to be taken. NOT a good idea for SO many reasons. We have safe disposal options already.", "comment_id": "FDA-2022-N-0165-0068", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-0165-0068", "comment_date": "2022-05-02T04:00:00Z", "comment_title": "Comment from Amy D", "commenter_fname": null, "commenter_lname": null, "comment_length": 286}]}, {"id": "CMS-2022-0191", "title": "Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Program for Contract Year 2024", "context": "2023-08-09T10:02:19Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "I am writing as a concerned Independent Agent, who cares about my clients and the means to which I can help them find the best Medicare Supplement option for their specific needs. Adding more and more regulations to agents AS A WHOLE will only be to the detriment of my clients and potential clients. Independent Agents are not the same categorically, as those at a large call center who are simply badgering Medicare Beneficiaries. They certainly don't care about the individuals they are calling. They just want to convince them to sign up for their product. These are the agencies you need to be regulating. NOT the Independent Agencies who actually HELP their clients. Adding more regulations, such as recording phone calls (2023 regulation) and 48 hour Scope of Appointments (proposed for 2024) will only hinder our ability to help our current clients and potential clients. We actually know our clients in most cases. We knew them when they were our clients for the Marketplace or an employee for one of our group clients. We know their health history and we take the time to go over what medications they take, to be sure they get the best supplements for their specific needs. We will no longer be able to do that with our hands tied! Please take these concerns into consideration for the current and proposed regulations. Please consider separating the regulations imposed on Independent Agencies vs the Large Call Centers who are cold calling beneficiaries without consent. They are the big bad wolf you are looking to tie up, not me!", "comment_id": "CMS-2022-0191-0253", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2022-0191-0253", "comment_date": "2023-02-13T05:00:00Z", "comment_title": "Comment on CMS-2022-0191-0001", "commenter_fname": "Sara", "commenter_lname": "Dean", "comment_length": 1550}, {"text": "•Prior authorization policies should only be used to confirm the presence of diagnoses. They should not be used to predetermine the necessary length of stay or for preadmission coding. ", "comment_id": "CMS-2022-0191-0301", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2022-0191-0301", "comment_date": "2023-02-13T05:00:00Z", "comment_title": "Comment on CMS-2022-0191-0001", "commenter_fname": "Cindy", "commenter_lname": "Thomas", "comment_length": 230}, {"text": "MTM Eligibility - We oppose lowering the cost threshold to the average annual cost of 5 generic drugs. Decreasing the cost threshold to one fifth of what the 2023 threshold is, will greatly increase the number of MTM eligible members, which again, is a significant financial impact to plans. The increased administrative cost will result in increased member premiums, copays and deductibles and will not result in more robust plan benefits to offer members.
We request some additional clarification and details on the proposed updated annual cost threshold methodology to fully understand the impact of this change. Will the methodology utilize the top 5 utilized generic drugs by prescription volume? Or the top 5 generic drugs by cost (i.e., plan paid amount)? Will this include/exclude generic specialty medications, that may be outliers in terms of cost compared to other non-specialty generic medications? Will there be a process to detect outlier NDC's to ensure they are not included in the average AWP calculation? Is the cost per 30-day supply of medication? ", "comment_id": "CMS-2022-0191-0287", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2022-0191-0287", "comment_date": "2023-02-13T05:00:00Z", "comment_title": "Comment on CMS-2022-0191-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 1076}, {"text": "Below is an example of a Medicare Advantage plan clearly stating in the denial rationale that the 2MN rule does not apply to Medicare members. I have also attached a redacted determination letter from a different Medicare Advantage plan and another attachment of my supportive statements for the necessity of CMS-420-1.

Clinical: 75 yo woman presented to the ED with bloody stools and leg swelling. Positive signs of heart failure. Anemia with a hemoglobin of 7.5 and dropped to 6.8 and heme positive stools. Found to have acute diverticulitis and new cardiomyopathy with congestive heart failure; ejection fraction of 30%. Required four night stay for stabilization and treatment of acute diverticulitis, GI bleed and congestive heart failure.

MA plan determination: The member was hospitalized from 04/09/22 to 04/12/22 (discharged 04/13/22) at a DRG facility. Does the admission meet InterQual criteria (Severity of Illness and Intensity of Service) for acute inpatient level of care, OR could the services have been provided in an observation level of care? The two-midnight rule does not apply. InterQual criteria is used for both Commercial and Medicare members.

Determination: Upheld.

The member does not meet defined InterQual criteria for inpatient admission for GI bleed or diverticulitis. The admission dated 04/09/22 to 04/12/22 (discharged 04/13/22) does not meet InterQual criteria (Severity of Illness and Intensity of Service) for acute inpatient level of care. The services could have been provided in an observation level of care.
", "comment_id": "CMS-2022-0191-0295", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2022-0191-0295", "comment_date": "2023-02-13T05:00:00Z", "comment_title": "Comment on CMS-2022-0191-0001", "commenter_fname": "Florian", "commenter_lname": "Moger", "comment_length": 1591}, {"text": "We would like clarification on how the adherence measures will be excluded from the CAI adjustment. Our understanding is that the CAI adjustment looks at the total population of the plan and calculates the percentage of low income, dual eligible, and disabled members. It is unclear how excluding the adherence measures would be applied to the calculation. Furthermore, we are concerned with the impact of implementing risk adjustment to the adherence measures. For the diabetes adherence measures, the change had an adverse effect on the rating.", "comment_id": "CMS-2022-0191-0280", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2022-0191-0280", "comment_date": "2023-02-13T05:00:00Z", "comment_title": "Comment on CMS-2022-0191-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 546}, {"text": "I support you efforts to make MA plans more closely align their coverage decisions with traditional Medicare. ", "comment_id": "CMS-2022-0191-0327", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2022-0191-0327", "comment_date": "2023-02-13T05:00:00Z", "comment_title": "Comment on CMS-2022-0191-0001", "commenter_fname": "RUSSELL", "commenter_lname": "JACKSON", "comment_length": 111}, {"text": "Regarding Guardrails - We feel that removing the guardrails will lead to unpredictability which will hurt plan's ability to budget and plan. While we understand that Tukey is meant to remove outliers and limit large swings, we feel keeping the guardrails in place will act as a guarantee.", "comment_id": "CMS-2022-0191-0282", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2022-0191-0282", "comment_date": "2023-02-13T05:00:00Z", "comment_title": "Comment on CMS-2022-0191-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 292}, {"text": "Page 58, Section H. Review of Medical Necessity Decisions by a Physician or Other Health Care Professional With Expertise in the Field of Medicine Appropriate to the Requested Service and Technical Correction to Effectuation Requirements for Standard Payment Reconsiderations (§§ 422.566, 422.590, and 422.629)

•Adverse Decision – appropriate expertise to deny – Is there more objective direction that can be provided to define this as it feels slightly subjective?
", "comment_id": "CMS-2022-0191-0319", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2022-0191-0319", "comment_date": "2023-02-13T05:00:00Z", "comment_title": "Comment on CMS-2022-0191-0001", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 547}, {"text": "If you think direct mail during an election year is bad, you should see the volume of mail during Medicare Open Enrollment. Just like a political campaign, it can be difficult at times for knowledgeable professionals to figure out the best health insurance product let alone a single, 85 year-old, childless widow with chronic health conditions. Our hospital, Neosho Memorial, sponsored an unbiased educational program this year using SHICK counselors through the Area Agency on Aging. The attendees stories were desprate and heartbreaking. CMS's policy and technical changes to Medicare Advantage Program is good for our elderly and their healthcare providers. Please continue, you cannot underestimate the difference they will make in helping our patients simply make better choices AND receive the health services they "believe" they are paying for.
", "comment_id": "CMS-2022-0191-0240", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2022-0191-0240", "comment_date": "2023-02-13T05:00:00Z", "comment_title": "Comment on CMS-2022-0191-0001", "commenter_fname": "Patricia", "commenter_lname": "Morris", "comment_length": 878}, {"text": "I am an agent and mentor I teach agents how to own their own Medicare business. I read the deceptive marketing practices flourish in Medicare advantage Report by the finance committee. If you really look at the organizations that have the majority of complaints to CMS. You will find it is the robocallers, telemarketing, Television Advertising, radio advertising, and direct mail campaigns. These are the Third party organizations (TPMO), the problem is CMS and Ron Wyden Committee has lumped the above with Field agents and brokers. They are not the same and agents and Agency's do not advertise nor act to deceive consumers.
You need to separate these bad actors from independent agents and Agency's. Independent agents are helping consumers understand Medicare and are local in their area helping consumers understand Medical Group Networks, Formularies, and how the plan works. We do not call without a permission to call or SOA. Independent agents should not be lumped into these bad actors that you talk about in your deceptive marketing report, you know who is to blame yet you are punishing agents and agency owners who are not part of these deceptive practices. Agents and Agency owners follow the rules set forth by CMS. We only help those who we meet in person who request our help. Agents and Agencies would be good with getting rid of TV advertising, radio, direct mail campaigns, telemarketing bait and switch. Please do not get rid of educational Events, permission to call and SOA we are out here helping not hurting our seniors. We want you to get rid of these people who blow up our customers phone promising the unrealistic freebies that don't exist. But please know it is not the independent agent or agencies. Your problem is people who don't even hold a license in the insurance industry the robocallers, telemarketers, TV ads and deceptive direct mail. Stop those and your complaints will end.
Remember agents were the good guys!", "comment_id": "CMS-2022-0191-0248", "comment_url": "https://api.regulations.gov/v4/comments/CMS-2022-0191-0248", "comment_date": "2023-02-13T05:00:00Z", "comment_title": "Comment on CMS-2022-0191-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 1979}]}, {"id": "EPA-HQ-OPPT-2017-0327", "title": "Scopes of the Risk Evaluations to be Conducted for the First Ten Chemical Substances under the Toxic Substances Control Act; Notice of Availability", "context": "2022-04-09T01:06:04Z", "purpose": "Nonrulemaking", "keywords": null, "comments": [{"text": "Please see the attached comments filed on behalf of Sappi North America.", "comment_id": "EPA-HQ-OPPT-2017-0327-0003", "comment_url": "https://api.regulations.gov/v4/comments/EPA-HQ-OPPT-2017-0327-0003", "comment_date": "2017-11-16T05:00:00Z", "comment_title": "Comment submitted by Kenneth F. Gray, Pierce Atwood LLP on behalf of Sappi North America (Sappi)", "commenter_fname": null, "commenter_lname": null, "comment_length": 72}, {"text": "Please see the attached comments filed on behalf of Sappi North America.", "comment_id": "EPA-HQ-OPPT-2017-0327-0002", "comment_url": "https://api.regulations.gov/v4/comments/EPA-HQ-OPPT-2017-0327-0002", "comment_date": "2017-09-21T04:00:00Z", "comment_title": "Comment submitted by Kenneth F. Gray, Pierce Atwood LLP on behalf of Sappi North America (Sappi)", "commenter_fname": null, "commenter_lname": null, "comment_length": 72}]}, {"id": "DEA-2021-0003", "title": "Suspicious Orders of Controlled Substances", "context": "2024-02-17T01:00:31Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "See attached file(s)", "comment_id": "DEA-2021-0003-0008", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2021-0003-0008", "comment_date": "2020-12-02T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-21302", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "DEA-2021-0003-0018", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2021-0003-0018", "comment_date": "2021-01-05T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-21302", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "DEA-2021-0003-0013", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2021-0003-0013", "comment_date": "2021-01-06T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-21302", "commenter_fname": "Scott", "commenter_lname": "Collier", "comment_length": 20}, {"text": "Please see the attached comment letter.", "comment_id": "DEA-2021-0003-0015", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2021-0003-0015", "comment_date": "2020-12-28T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-21302", "commenter_fname": "Kevin", "commenter_lname": "Nicholson", "comment_length": 39}, {"text": "
Thank you for all
Best Regards
Mr.Rungsun Gunkoom", "comment_id": "DEA-2021-0003-0021", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2021-0003-0021", "comment_date": "2020-12-02T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-21302", "commenter_fname": "Rungsun", "commenter_lname": "Gunkoom", "comment_length": 62}, {"text": "I am writing to express my support for the DEAs implementation of 21 CFR Section 1300-1301. As is the PDDA already requires that distributors of controlled substances make an effort to investigate, report and maintain record of any suspicious orders. The addition of the two-option system of reporting in 21 CFR 1301.78 would make the procedure for dealing with suspicious orders much clearer registrants while leaving them with leeway to deal with orders they are able to clear of suspicious circumstances as long as they maintain records on the due diligence that cleared the order. Additionally, according to the DEAs own findings this regulation would eliminate a grey area in reporting which has allowed registrants to neglect maintaining proper records of due diligence, and in some cases report suspicious orders after they have already been filled.

While there might be some concern that this regulation would impose additional costs upon registrant firms the proposed rule complies with the RFA and will actually end up saving registrants an estimated total of $2,931,000 via the use of the ARCOS Distributor Tool which was developed to ease the cost of due diligence on registrants as well as the use of the DEAs central database for reporting suspicious orders. Overall, there is little reason to not pass what is functionally a standardization of reporting procedures in a wider legislative effort to stem the abuse of controlled substances.

", "comment_id": "DEA-2021-0003-0035", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2021-0003-0035", "comment_date": "2021-03-31T04:00:00Z", "comment_title": "Comment on FR Doc # 2021-03361", "commenter_fname": "Andres", "commenter_lname": "Oliver", "comment_length": 1474}, {"text": "The abuse of controlled substances has been an issue for decades. President Nixon first signed the Controlled Substances Act in 1970, over 50 years ago, yet the abuse of prescription drugs remains a prevalent issue. It has taken the lives of celebrities like Prince and Michael Jackson and the media has extensively covered its danger.
On the other side of the coin, the media has promoted the younger generation into growing attached to these drugs. Many artists and influencers expose their audience to their lifestyles and promote the recreational use of drugs like xanax, codeine, or cannabis, causing their fans to try them out and potentially get addicted.
Speaking from personal experience, kids in my high school who, whether it be prescribed or not, had access to adderall and were distributing it to their friends or just taking it recreationally. Even though its side effects may not be as harmful as other drugs, it still inevitably causes addiction.
Although it will not end substance abuse altogether, this proposition takes the right step towards a good cause, and I support it.
", "comment_id": "DEA-2021-0003-0037", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2021-0003-0037", "comment_date": "2021-03-31T04:00:00Z", "comment_title": "Comment on FR Doc # 2021-03361", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 1270}, {"text": "Pharma Logistics agrees with and supports excluding reverse distributors from the proposed rule. However, based on review of regulatory text in §1301.74(b)(3), we believe that the following statement may be written incorrectly:
orders placed by registrants to DEA registered reverse distributors requesting the return or
destruction of controlled substances, are not distributions subject to the provisions of this part.

Pharma Logistics formally requests the DEA to reword this statement to read as follows:
orders placed by DEA registered reverse distributors to registrants
", "comment_id": "DEA-2021-0003-0038", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2021-0003-0038", "comment_date": "2021-03-31T04:00:00Z", "comment_title": "Comment on FR Doc # 2021-03361", "commenter_fname": null, "commenter_lname": null, "comment_length": 607}, {"text": "See attached file(s)", "comment_id": "DEA-2021-0003-0003", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2021-0003-0003", "comment_date": "2020-12-02T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-21302", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "DEA-2021-0003-0020", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2021-0003-0020", "comment_date": "2020-12-02T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-21302", "commenter_fname": "Omar", "commenter_lname": "Pirzada", "comment_length": 20}]}, {"id": "DEA-2009-0013", "title": "Schedules of Controlled Substances:\r\nPlacement of 5-Methoxy-N,NDimethyltryptamine\r\nInto Schedule I of\r\nthe Controlled Substances Act", "context": "2021-12-02T01:00:49Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "I object to the splitting of this Docket's components between Docket ID: DEA 2009-0008 and Docket ID: DEA 2009-0013. This makes it confusing, more difficult to view all the components and extremely difficult to communicate to others where and how to locate, view or comment on Docket No. DEA-331. This also seems to have created a situation that evaded Regulations.gov's email notification for monitoring Docket No. DEA-331 because it was monitoring Docket ID: DEA 2009-0008.

Additionally, this splitting of Docket No. DEA-331 components into two Docket IDs (one of which is closed for comment) failed to effectively remedy the defect that DEA states is the reason for reopening the comment period.

I further object to starting the 30 day comment period for Docket ID: DEA 2009-0013 on 10/28/09 but not posting some of the supporting documents there until 11/03/09. This effectively reduces the comment period to less than 30 days.

I request all documents, notices of removed documents and comments be consolidated in one Docket ID with proper notice in each existing Docket ID of the new Docket ID and its URL. I further request the comment and request for hearing period be restarted from the time the new Docket ID is posted and that the comment period be increased to no less than 180 days for reasons which were stated in the comment posted 9/22/09 and the gravity of objections which have been made in initial form; most specifically, but not exclusively, First Amendment objections, Tenth Amendment objections, dispute of DEA's Federalism implications finding and inadequacy of 30 days to provide opportunity for religious minority and other aggrieved members of the general public to learn of this NPRM and comment or request hearing.

Full comment in attached file.", "comment_id": "DEA-2009-0013-0007", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2009-0013-0007", "comment_date": "2009-11-09T05:00:00Z", "comment_title": "Comment on FR Doc # 55502", "commenter_fname": "Gerrard", "commenter_lname": "Winstanley", "comment_length": 1821}, {"text": "Objection to Scheduling 5-MeO-DMT addressing barrier to scientific research and other matters.", "comment_id": "DEA-2009-0013-0020", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2009-0013-0020", "comment_date": "2009-11-30T05:00:00Z", "comment_title": "Comment on FR Doc # 55502", "commenter_fname": "Gerrard", "commenter_lname": "Winstanley", "comment_length": 94}, {"text": "Assuming something is bad without actually researching the subject has proven itself throughout history to later be a mistake. A classic example was the Vatican's fight against Galileo Galilei. They feared him bringing new knowledge to the people that the church could not itself provide.

If we were to move this chemical to a schedule 1 substance, we would be agreeing that knowledge is unimportant. This is because the chemical would no longer be allowed to be researched.

Further research could prove this chemical important to the US in future situations. If we were to ban it however, we could potentially miss out on a scientific opportunity.

I hope you will not allow the US to be held back in its pursuit of knowledge.

Stephen Tanner", "comment_id": "DEA-2009-0013-0005", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2009-0013-0005", "comment_date": "2009-11-09T05:00:00Z", "comment_title": "Comment on FR Doc # 55502", "commenter_fname": "Stephen", "commenter_lname": "Tanner", "comment_length": 784}, {"text": "Six hospitalizations and one reported death over the span of a decade? This is a serious threat to public safety?

The reported death was an instance of poly-drug ingestion including MAOIs. MAOIs in high concentrations are dangerous and can make taking relatively safe drugs such as Benadryl potentially deadly. How is the DEA able to determine that the death was from 5-MeO-DMT and not the other drugs in the user's concoction?

The DEA also claims that 5-MeO-DMT is being sold as or as an adulterant to ecstasy/MDMA. While I have no reason to dispute the authenticity of the drug seizure, it is a fact that 5-MeO-DMT is not orally active. Putting 5-MeO-DMT into a pressed pill for human ingestion is pointless. It is not clear why this seizure was referenced, but it should be made clear that 5-MeO-DMT is not active orally and is not at all related to ecstasy except in this bizarre seizure.

In the reports the DEA has provided, 5-MeO-DMT is repeatedly likened to LSD and mescaline despite sharing few similarities. 5-MeO-DMT has a brief duration of effect in humans, and most recreational-minded users would find it entirely unpleasant.

It has been hypothesized that 5-MeO-DMT could be used in the treatment of alcoholism and depression.", "comment_id": "DEA-2009-0013-0016", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2009-0013-0016", "comment_date": "2009-11-30T05:00:00Z", "comment_title": "Comment on FR Doc # 55502", "commenter_fname": null, "commenter_lname": null, "comment_length": 1288}, {"text": "The current comment period does not allow sufficient time to develop a meaningful or thoughtful response to the notice. Regulation of Tobacco Products FDA-2009-N-0294 had a 90 day comment period which was extended by 90 days to allow sufficient time to develop meaningful, thoughtful responses. Please extend the comment period for DEA-2009-0013-0001 to
180 days.
A 30 day period is so short it seems futile to comment.", "comment_id": "DEA-2009-0013-0011", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2009-0013-0011", "comment_date": "2009-11-30T05:00:00Z", "comment_title": "Comment on FR Doc # 55502", "commenter_fname": null, "commenter_lname": null, "comment_length": 430}, {"text": "Docket # DEA-331

5-MeO-DMT should not be placed in Schedule I and the period for public comment should be extended by 24 months so people can do the kind of research FDA should have done. We want scientists, not sockpuppets.

Soma is being recommended for schedule IV and much more evidence of harm has been shown for that than 5-MeO-DMT. Schedule V would allow age restrictions and purity regulation. It would also allow research into psychiatric and other use. Doctors could prescriibe it for terminally ill patients if it would help people prepare for the transitition from this life to whatever follows.", "comment_id": "DEA-2009-0013-0012", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2009-0013-0012", "comment_date": "2009-11-30T05:00:00Z", "comment_title": "Comment on FR Doc # 55502", "commenter_fname": "Bob", "commenter_lname": null, "comment_length": 624}, {"text": "Appendix to Comment Tracking Number: 80a5e5ed
Appendix C

Entheogens — Sacramentals or Sacrilege? by Thomas B. Roberts, Ph.D. Used by permission. Submitted as a separate file/comment but incorporated by reference. I couldn't find a way to paste this in with no change resulting. Renamed "Docket No. DEA–331 --- Apendix C to Gerrard Winstanley Comment draft 009--- Entheogens-Sacramentals-or-Sacrilege-draft-11e by Thomas B. Roberts.doc" to reference Docket No. DEA–331 without making any change in the file. Including the full file with no changes in it was a condition of the permission (see below).

---- Original Message ----
From: "Thomas Roberts" <troberts@niu.edu>
To: <REDACTED EMAIL ADDRESS >
Cc: < REDACTED EMAIL ADDRESS >
Sent: Thursday, November 19, 2009 9:16 PM
Subject: Re: Copyright permission request

> Dear Mr. Winstanley,
>
> You have my permission to use this file as you propose provided you
> include the full file and make no changes in it.
>
> Thomas B. Roberts
>
>
> Tom Roberts
>
> ===============
> We are all prisoners of our minds. This realization is the first step
> on the journey to freedom.
>
> --- Ram Dass
>>>> "Gerrard Winstanley" < REDACTED EMAIL ADDRESS > 11/16/09 1:51
>>>> AM >>>
> Thomas B. Roberts, Ph.D., Professor Emeritus
> Dept. of Leadership, Educational Psychology and Foundations
> Northern Illinois University
> DeKalb, IL. 60115
>
> I request permission to include Entheogens -- Sacramentals or
> Sacrilege?: Design for a course syllabus found at
> http://www.cedu.niu.edu/lepf/edpsych/faculty/roberts/Entheogens-Sacramentals-or-Sacrilege-draft-11e.doc
> as an appendix to a public comment on the Notice of Proposed
> Rulemaking,
> Docket No. DEA-331.The deadline for comments is 11/27/2009. The
> comment
> I would prefer to append this to should be ready for submission
> within a
> few days although I can use this in a seperate comment as long as I
> get
> permission to use it in ti", "comment_id": "DEA-2009-0013-0019", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2009-0013-0019", "comment_date": "2009-11-30T05:00:00Z", "comment_title": "Comment on FR Doc # 55502", "commenter_fname": "Gerrard", "commenter_lname": "Winstanley", "comment_length": 2340}, {"text": "Docket No. DEA-331

5-MeO-DMT should not be scheduled. If the CSA doesn't allow wine to be prohibited but allows sacraments of nonmainstream religions to be prohibited it violates the First Amendment and is unconstitutional. If it's unconstitutional it's not a valid law so nothing should or can be scheduled under the CSA. That's easy to understand.

I also request a 24 month extension of the period for public comment.", "comment_id": "DEA-2009-0013-0014", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2009-0013-0014", "comment_date": "2009-11-30T05:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": "Lynne", "commenter_lname": null, "comment_length": 453}, {"text": "We are opposed to the rule based on the data and reports provided. The rulemaking would be improved by adding more scientific data on the effects of the drug. Instead of relying on blogs and websites that do not have proper accreditation, perhaps the DEA should wait for human statistics before rulemaking, given the very limited use of this drug. The DHHS report relied heavily in their recommendation on the drug’s lack of a “currently accepted medical use,” but that is not one of the 8 factors that the DEA and DHHS use for determining drug scheduling. Further, the DHHS did not mention this until the very end of the recommendation report, yet it was a pivotal point in their final recommendation. There should be consistency in the standards used by collaborating agencies. In addition, since they have not done testing on humans yet, what is their basis for asserting there is no accepted medical use? Until these issues are addressed we would not support any rulemaking on this drug.", "comment_id": "DEA-2009-0013-0009", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2009-0013-0009", "comment_date": "2009-11-16T05:00:00Z", "comment_title": "Comment on FR Doc # 55502", "commenter_fname": "Zachary", "commenter_lname": "Barrett", "comment_length": 1013}, {"text": "The controlled substance 5-MeO-DMT or 5-Methoxy-N,N-Dimethyltryptamine is a very serious psychedelic and powerful psychedelic. The Drug Enforcement Agency is right in proposing that this should be moved up on the Controlled Substance List into the Schedule 1 which is the most serious of categories in this act and warrants the most intense of punishments if found using, possessing, or selling these substances. This drug is similar to DMT another hallucinogen and is considered extremely dangerous. The government should place this higher up on the list along with other psychedelics due to its severity and dangerous reactions that users experience. As they explain that the government has repeatedly seized various amounts of this substance and has done numerous studies proving that there is no therapeutic or medicinal purpose of this drug. This drug is commonly used for recreational use primarily by young adults and teenagers. The only use outside of recreational use is for shamanistic purposes in South American countries where they are used as an entheogen which is a substance which has psychoactive effects. The use of this substance in the United States is however not for religious purposes and can be controlled by the government. I believe that they are doing the right thing by attempting to make it a Schedule 1 drug because there is no good that can come from it and people have had many negative side effects from the use of it. Your judgment is impaired and your senses are distorted which is similar to LSD (Lysergic Acid) or Psilocybin Mushrooms which are also schedule 1 substances on the list. If the effects are similar to one another and the uses are too recreational and have no proven medicinal or therapeutic purposes than it definitely should be considered a highly illegal drug and not allowed to be bought offline from chemical supply companies. Few states so far have already declared this derivative of frog venom and tree bark as a Schedule 1 offense but the DEA has not yet made it mandatory for all states to place this drug that high up on the list. It is in the best interest of the government to make the use, possession, or distribution of 5-MeO-DMT illegal so that it is not out on the streets being used by people for the wrong purposes because there is not one scientific study that proves the use of this drug is beneficial in any way.", "comment_id": "DEA-2009-0013-0006", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2009-0013-0006", "comment_date": "2009-11-09T05:00:00Z", "comment_title": "Comment on FR Doc # 55502", "commenter_fname": null, "commenter_lname": null, "comment_length": 2384}]}, {"id": "EPA-HQ-OAR-2022-0707", "title": "Protection of Stratospheric Ozone: Updates Related to the Use of Ozone-Depleting Substances as Process Agents", "context": "2023-12-12T08:40:15Z", "purpose": "Rulemaking", "keywords": ["Controlled Substances", "ODS", "Ozone-Depleting-Substances", "Process Agents"], "comments": [{"text": "The Montreal Protocol is deemed one of the most successful international environmental treaties as it was the first treaty to achieve ratification by all countries in the world. It has created unprecedented results in reducing ozone-depleting substances (ODS) and greenhouse gases. According to the UN Environment Programme, the Parties have phased out 98% of ODS globally compared to 1990 levels. With a significant portion of ODS being greenhouse gases, the Protocol has also contributed to protecting the climate and recovering the ozone layer. With the United States leaving and re-entering the Paris Agreement, it is essential to demonstrate that the country is still committed to international cooperation and environmental protection. With more transparent reporting and recordkeeping, the US can demonstrate its commitment to improving climate protection globally and accurately documenting its contribution.
The EPA has put concerted efforts into replacing ODS with non-ozone-depleting substances, but there are still circumstances when using ODS is necessary. Decision X/14 of the Protocol permits the use of ODS as process agents. All parties must submit an annual report detailing process agent emissions, containment technology, and production and importation of controlled substances for use as process agents to the Secretariat. The proposed rule by EPA defines precise recordkeeping and reporting requirements for US entities.
EPA has compared the difference between applying TRI and GHGRP approaches. The TRI approach does not require the entity to report the source of its information or the emission factors used. With EPA suspecting only six entities will be impacted by this proposed rule, none of which are small entities, the GHGRP approach is more reasonable. Because this approach would require the entity to use specific methodology and report more detailed information, the data is more consistent and manageable for EPA to validate.
In EPA’s draft memo for emission reporting for process agents, the methods described for different processes are often engineering calculations, chemical engineering principles, or engineering assessments, which allow estimates to be created for various process components based on specific assumptions and knowledge. These methods are more likely to produce more reliable emissions data than the mass balance approach. A mass balance approach requires the quantification of the process inputs and outputs. When calculating ODS emissions from process agents, the accuracy of the inputs and outputs of the process is a concern, so the emission factors produced from a mass balance method may be more unreliable. Subsequently, setting one testing method for different processes instead of allowing multiple is reasonable. Although permitting multiple methods would enable the entities to use the form best suited to their available resources and expertise, there are few entities that this rule impacts. Consistent, validated information is better for evaluating process agent emissions in the United States and provides more reliable information to the Secretariat.
Based on this review, EPA should finalize the rule as proposed. The rule will provide more consistent, reliable, validated data to be reported to the Secretariat. With the United States making up the most consumption of ODS for process agents and creating the most emissions out of any country under the Montreal Protocol, improving recordkeeping and reporting is vital to accurately representing emissions in the United States and understanding the global impact of those emissions.
", "comment_id": "EPA-HQ-OAR-2022-0707-0017", "comment_url": "https://api.regulations.gov/v4/comments/EPA-HQ-OAR-2022-0707-0017", "comment_date": "2023-11-14T05:00:00Z", "comment_title": "Anonymous public comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 3639}, {"text": "See Attached", "comment_id": "EPA-HQ-OAR-2022-0707-0020", "comment_url": "https://api.regulations.gov/v4/comments/EPA-HQ-OAR-2022-0707-0020", "comment_date": "2023-12-12T05:00:00Z", "comment_title": "Comment submitted by Honeywell International, Inc. \u2013 Colonial Heights", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}, {"text": "See attached file(s)", "comment_id": "EPA-HQ-OAR-2022-0707-0016", "comment_url": "https://api.regulations.gov/v4/comments/EPA-HQ-OAR-2022-0707-0016", "comment_date": "2023-11-14T05:00:00Z", "comment_title": "Comment submitted by Michael Ravnitzky", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "EPA-HQ-OAR-2022-0707-0018", "comment_url": "https://api.regulations.gov/v4/comments/EPA-HQ-OAR-2022-0707-0018", "comment_date": "2023-12-12T05:00:00Z", "comment_title": "Comment submitted by Environmental Investigation Agency (EIA)", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Comments provided in the uploaded file. ", "comment_id": "EPA-HQ-OAR-2022-0707-0019", "comment_url": "https://api.regulations.gov/v4/comments/EPA-HQ-OAR-2022-0707-0019", "comment_date": "2023-12-12T05:00:00Z", "comment_title": "Comment submitted by Occidental Chemical Corporation", "commenter_fname": null, "commenter_lname": null, "comment_length": 41}]}, {"id": "CDC-2022-0024", "title": "Proposed 2022 CDC Clinical Practice Guideline for Prescribing Opioids", "context": "2022-11-29T11:59:11Z", "purpose": "Nonrulemaking", "keywords": null, "comments": [{"text": "I am begging you to change these guidelines. Thanks to a NY Times article on 3/13/22, “The Other Victims of the Opioid Crisis,” I finally had the information I needed to ask the right questions about why I cannot get the relief from chronic pain that would enable me to live my life. I do not remember the date but have a clear memory of the day my pain management doctor said he could not give me the level of medication I needed because of this guideline. He said the government apparently only understood black and white. And, yes, this was a period of time that it was scandalous that there were doctors who opened offices just to hand out opioid prescriptions. Just a few months before my husband were in my hospital room talking to my spine surgeon after my 7th spinal fusion about the problem. None of us foresaw the horrible swing of the pendulum. I hope you caught that it was the 7th fusion. Except for vertebrae C3, which is filled with stenosis, my entire spine has been surgically or auto-fused. I assume that whoever reading this knows what these means in terms of pressure on nerves and blood vessels coming from the spine.
I was in my early 30’s (now 75) when told I had arthritis in my lower spine. For years doctors tested me for rheumatoid arthritis because my osteoarthritis is so extensive and bilateral. My first orthopedic surgery was my carpal tunnels in my early 40’s. In my 50’s, the surgeries alternated between my knees (4 replacements) and my spine. When my spine has been opened, if the surgery was near a previous one where bone material had filled in, the earlier hardware was removed to prevent a possible infection site. One of those was attacked again by arthritis and was done again.

About a year ago I would sometimes get shooting pains in my feet. At my next appointment with my spine surgeon (every 3 months), I was told that when I bent my back L3 and L4 were sliding over the nerves to my feet. Fortunately my surgeon is not only highly skilled but very conservative, so there was no immediate scheduling of a surgery that would have involved removing the hardware from the last fusion at T10 through L2, replacing it and continuing the fusion down through my pelvis (both sides of my sacrum are eroded by arthritis; after years of steroid shots, it became too painful to get in position for the shots). Within 6 months L3 & 4 self- fused. Good. The good news was that there would be no surgery. The bad news is that the nerve is under constant pressure which means constant pain. Unfortunately I do not tolerate the medications used for nerve pain. From what I have read on the web from NIH, Mayo, and Cleveland, the treatment that remains is opioids.

For the last 3-4 years, I have been taking a generic hydrocodone 10mg-acetaminophen 325 and used a Fentanyl 25 mcg duragesic patch. I don’t think the patch does much of anything except for maybe the middle 24 hrs. I also take one 100mg of Celebrex per day.

The pain in my feet is most intense when I try to sleep. Before I try to sleep I take a Tizanidine tablet and a Zolpidem tablet. At most I sleep for 2 hrs. before pain awakens me; sometimes I can fall asleep for another hour or two. Pain takes away any desire to eat; I make myself do it to keep glucose levels even (insulin resistant). As often as not I am in tears which is not the person I am. I haven’t seen my family in months because I don’t want my beloved grandchildren to see me in this condition. I don’t go anywhere and I don’t do anything because it means more movement and more pain. Books have been a mainstay of my life, but pain even keeps me from reading. I want my life back.

My pain management doctor will not increase my dosage. I don’t know if this is really his choice or the policy of the much-vaunted health service for which he works.

While you change this guideline, I am also begging you to change who is allowed to do the prescribing. It is beyond belief that anyone would think that an anesthesiologist should prescribe these medications rather than a primary care physician who would know the patient best or even a specialist such as an endocrinologist, rheumatologist who the patient sees regularly.

Unlike the man in The NY Times article, suicide is not an option for my beliefs about life, but that doesn’t mean I haven’t thought about the relief it might bring.
I am begging you to give me and the thousand like me our lives back.", "comment_id": "CDC-2022-0024-5098", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2022-0024-5098", "comment_date": "2022-04-13T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 4595}, {"text": "As a patient and advocate for adequate analgesia for the chronic disease and disability communities, I have witnessed and experienced the barriers to pain management and healthcare caused by CDC 2016 Guidelines. The harms patients suffer include experiencing severely increased high impact pain, forced tapers, patient abandonment, mental health crises, and suicide. Patients have lost access to adequate and appropriate pain care. CDC Guidelines also facilitate patient loss of access to the general healthcare system including primary care and mental healthcare. Healthcare providers now make decisions not based on their best clinical judgement, but through a lens of liability, fear, and stigmatization.
This expanded clinical guideline will significantly increase the harms to all patients in all clinical settings in need of appropriate pain management. As evidenced by the harmful outcomes of the 2016 Guidelines and lack of any action to reverse these harms, terms such as “unintended consequences” and “wide misapplication” are now moot. Patients and providers are aware any issuance of federal guidance will be interpreted as standard of care, mandate, policy, and law, as federal guidance is designed to accomplish. This underscores the lack of forethought and understanding CDC demonstrates in its guidance issuance effects on providers and patient populations.
CDC Injury Prevention Center does not have the professional experience, expertise, or stakeholder input necessary to develop guidance on the appropriate treatment of pain in all clinical settings. The influence of special interest groups is obvious in the failure to address serious conflicts of interest of authors and blatant violations of the Federal Advisory Committee Act. The updated guidelines make painfully evident CDC Injury Prevention Center is insufficient and unqualified to provide guidance on treatment of acute, subacute, or chronic pain through the exclusion of new relevant evidence, data, and research, continued use of the scientifically invalidated metric of Morphine Milligram Equivalent (MME), as well as exclusion of input from stakeholders who possess the expertise and experience to contribute to best practice guidance for pain treatment including the crucial tool of appropriate opioid prescribing.
The harms to patients caused by the 2016 Guidelines are still occurring in vast numbers of patients. The 2022 updated Guidelines do not address reversal of these harms and will further cause increased harms to expanded patient populations without any viable plan to track patient outcomes from implementation. As a patient with lived experience, a disabled person, and an advocate for pro-patient care, to prevent continued and increased patient harms, it is imperative CDC withdrawal and rescind both the 2016 Guidelines and the 2022 updated Guidelines immediately.
Thank you for your time,
[name redacted], Ambassador, Chronic Disease Coalition
", "comment_id": "CDC-2022-0024-5101", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2022-0024-5101", "comment_date": "2022-04-13T04:00:00Z", "comment_title": "Comment from Kai, Koa", "commenter_fname": "Koa", "commenter_lname": "Kai", "comment_length": 3002}, {"text": "You need to let doctors prescribe medicine as they see fit. If someone has an injury, there is often no way of knowing whether pain will be acute or chronic. I used to have chronic pain. At the time, my hospital was discouraging opioid use. That led to me not getting the proper pain treatment. My primary doctor kept trying to get me to stop taking Percocet even though I was in constant pain. Evevtually the Percocet didn't work as well. And you know what? My doctor refused to up my dose. She was worried that I would become a junkie in 10 years. I promised her that I would commit suicide long before that happened. I had to double my dose of Percocet and take it once every other day just to get four hours of relief in a 48 hour period.

I researched pain treatments to try. Massage therapy? Tried it. It didn't fix my pain. Trigger point therapy? I tried both the pressure kind (worked a little at first, but eventually not) and the injection kind. An anesthesiologist injected a steroid and lidocaine near one of my nerves. The 20 minutes of relief was amazing! I thought I found a fix. But the steroid irritated the nerve. I have never been in so much pain in my life! Percocet did nothing for that pain. I spent a day and night crying and wishing I was dead. I wanted to go to a hospital for help, but was afraid that I would be accused of doctor shopping and would no longer be allowed to have any Percocet. You would think that by the way my doctor acted, that I was on a lot of Percocet. Nope. I got 10 mg/day. Other women with a similar issue were on 3 times that amount. To get further help with pain management, I wanted to try physical therapy. I made an appointment. The therapist told me I wouldn't get drugs from her. Who hoes to a physical therapist for drugs? Then she wanted to know about pain and drug use in my family members. Crazy right? I was there to find out if there was something I could physically try to get rid of my pain, but here this therapist was trying to see if I'm doctor shopping and if I've got drug addicts in my family. She didn't recommended no physical therapy. Instead, I was told to do enjoyable things like spend time with friends. I told her I was in too much pain to enjoy friends plus the shear act of pretending to not be in pain when with friends was mentally and emotionally exhausting. I was told to relax with a hot bath or learn meditation. That's when I knew something was was wrong in this hospital. I could tell the hospital had given directives to discourage pain medicine use. I was right. About a year later. I found an article about Group Health that stated the insurance carrier/hospital told doctors to encourage their patients to stop taking prescription pain medicine.

I tried meditation for pain management. Hated it. I found that the hospital had an online group meeting to help with chronic illness. Listening to people worried about losing their jobs or marriages made my depression sooooo much worse. Plus, the class gave the same crappy advice that the physical therapist gave. I dropped the class. At some point I tried a salve I bought on the internet. Didn't work. I bought a tens unit. Didn't work. I was pissed. I tried so hard to find non opioid ways to deal with my pain, but there was no help. The one thing that did help, I couldn't get a higher dose of. At the time, I had a coworker who had a bad fall. She got strong meds, physical therapy, AND water therapy. I couldn't wait to switch insurance companies. I finally understood why people called Group Health "Group Death".

My situation was made worse because I was the one trying to find alternative treatments. My doctors insisted nothing could be done without more medicine which they would give me. I was suicidal. I mean neither my gynecologist or primary doctor recommended that I seek treatment elsewhere. In fact, I was told that if I doctor shopped, my pain management treatment would end.

Once I switched insurance, what a difference! I was in so much pain that I couldn't wait to see my new doctor. I went to an urgent clinic to see if I could get muscle relaxers to help. I told the doctor everything that I had tried. I even told him how badly the trigger point injection was. I forgot to mention in my previous stated here that, on top of the excruciating pain. I urinated like a horse for days which caused severe leg cramps for weeks. You wouldn't think trying to stop pain would cause me to be in even more pain. That doctor got me on a non opioid and my new doctor added a different non opioid to that. He also told me Group Health didn't have a pain specialist, so they were limited in what they could prescribe. I should have been sent to a specialist!

My new doctor recommended physical therapy. My new physical therapist was very familiar with my problem and gave me exercises that were very helpful. My pain decreased significantly. Still, it took over two years before I wasn't in pain 24/7.

", "comment_id": "CDC-2022-0024-5109", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2022-0024-5109", "comment_date": "2022-04-13T04:00:00Z", "comment_title": "Comment from Turner, Monica", "commenter_fname": "Monica", "commenter_lname": "Turner", "comment_length": 5087}, {"text": "The CDC guidelines are based on noble motives-to improve health care, protect doctors from malicious prosecution, and patients from side effects of opioid prescriptions.

Unfortunately, they fail at all three, because the goals are impossible in our current legal and social environment.

The great hollowing out of the middle class, driven by federal tax policy, has increased deaths of despair starting at least in 1979. Physician prescribing certainly hasn’t increased deaths from alcohol or suicide. Neither was it the cause of increased use of drugs of all sorts.

The Epidemic of Despair Among White Americans: Trends in the Leading Causes of Premature Death, 1999–2015 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5607670/

Why Deaths of Despair Are Increasing in the US and Not Other Industrial Nations Deaths of Despair Rise Steeply in the US vs Western Europe, Canada, Australia, and Japan https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2788767#ysc210003f1

Deaths of Despair article w graphs How Working-Class Life Is Killing Americans, in Charts https://www.nytimes.com/interactive/2020/03/06/opinion/working-class-death-rate.html

Opioid/Overdose Crisis as a Dialectics of Pain, Despair, and One-Sided Struggle - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7676222/

America's 1% Has Taken $50 Trillion From the Bottom 90%
https://time.com/5888024/50-trillion-income-inequality-america/

Deaths from overdoses of all sorts have been increasing smoothly since 1979.
https://science.sciencemag.org/content/361/6408/eaau1184/tab-figures-data

Actions based on misunderstanding the problem cannot solve the problem.

In fact, the physician’s task is simply impossible. Prescribing opioids comes with a high risk of felony prosecution; even if the prescribing is perfect, that is irrelevant if prosecutors show anomalies in the business or operations side of the practice. And we know that no one prescribes perfectly 100% of the time. When the price for this is 20 years in prison, doctors simply refuse to prescribe.

The problem is the 1970 CSA that criminalizes use and possession of medications. The US prohibited use and sale of alcohol for 13 years, then wisely decided this was bad policy. We’ve had drug prohibition for 50 years, and all that’s done is waste money, kill Americans and put minority men in jail.

The best CDC could do would be to recognize the epidemic of deaths of despair its causes, and advocate social policy to reverse them.
The least CDC could do would be to not make the situation worse by prescribing bleeding and purging. ", "comment_id": "CDC-2022-0024-5106", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2022-0024-5106", "comment_date": "2022-04-13T04:00:00Z", "comment_title": "Comment from Liepmann MD FAAFP, Peter", "commenter_fname": "Peter", "commenter_lname": "Liepmann MD FAAFP", "comment_length": 2734}, {"text": "Thank you for the opportunity to comment on the proposed CDC Guideline for Prescribing Opioids for Chronic Pain. While the proposed guidelines are an improvement from the 2016 guidelines, they do not represent a significant enough change to allow patients with legitimate chronic pain disorders who depend on opioid therapy to reduce their pain and improve their quality of life. It is understandable that the CDC is hoping to reduce drug overdose deaths. However, while opioid prescriptions have decreased by over 40% in the last decade (likely caused in part by the 2016 guidelines), annual drug overdose deaths in the U.S. have increased. The problem is clearly not with the prescribing of opioids—illicit street drugs are primarily driving the increase. There is therefore no reason to unfairly target chronic pain patients who are trying to treat their pain with the medical recommendations of their doctors. We do know that as legal prescriptions have decreased, suffering, disability, and suicide among those who suffer with chronic pain have risen steadily.
The CDC's 2016 guidelines have unfortunately led to extremely harmful unintended consequences for patients with chronic pain. Many states adopted laws and regulations that limited opioid prescribing. Similarly, many health insurances based policies on those guidelines. Many doctors have stopped prescribing opioids at all or minimize what they will prescribe, despite patients’ documented needs, because it is seen as such a huge risk to their license. Some doctors will not take on new patients who have been prescribed opioids. Many pharmacies will not fill patients' prescriptions due to the increasing regulatory burden. As a result of this, patients with chronic pain who have legitimately and safely taken opioids to control their pain for years now have to jump through herculean obstacles to obtain their prescriptions.
The proposed guidelines do not balance discussing the known risks of opioids with the benefits of continuing opioids for chronic pain when a patient has failed other treatment options. The guidelines also do not take into account the incredible harms of poorly managed chronic pain, which include physical distress, mental agony, inability to hold a steady job, disability, and suicide. The guidelines must include strong language discouraging physicians from abandoning patients who depend on opioids for their pain. Additionally, citing specific doses can be interpreted (as it was in the 2016 guidelines) as giving a hard ceiling. Physicians need to be trusted to use their judgement to decide which medications are safe and beneficial for their patients, and at what doses.
These guidelines matter deeply to me because I have a close friend in her early 40s who suffers from chronic pain and who currently spends the majority of her productive hours simply trying to obtain the medications that her doctor feels are most beneficial and safe for her. She has tried multiple other treatment methods to manage her pain, such as numerous non-opioid medications, procedures, injections, implanted spinal stimulators, complementary/ alternative medication modalities, mind-body strategies, etc. Her doctor agrees with her current treatment plan and has been prescribing opioids to her safely for many years. She is at low risk for overdose and would never dream of selling or giving away her medications. She does not get "high" from her medications—she simply has a reduction in pain that allows her to function on a daily basis. Most months out of the year, the red tape is so incredibly obstructive that she ends up running out of her needed medication, leading to dangerous sudden tapering, extreme pain, and inability to function. If her current doctor were to retire, it would be virtually impossible for her to find another doctor willing to take her on as a new patient and continue the medications that she has safely used to attain a minimum quality of life.
My friend, like thousands of other chronic pain patients around the country, is depending on the CDC to take back much of the harmful language from the 2016 guidance. The CDC needs to replace the prior language with more appropriate statements that respect the benefits that many chronic pain patients receive from taking opioids and that acknowledges the incredible harms that come from limiting dosing, suggesting medically unnecessary tapers and making it incredibly difficult for patients to obtain the medication that their doctor has decided is best for them. One set of proposed changes that takes the needs of chronic pain patients into account was written by [name redacted], PhD and [name redacted], MD (https://www.practicalpainmanagement.com/treatments/pharmacological/opioids/commentary-how-fill-holes-cdc-opioid-prescribing-guideline-revisi). These proposed revisions should be strongly considered by the CDC.", "comment_id": "CDC-2022-0024-5107", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2022-0024-5107", "comment_date": "2022-04-13T04:00:00Z", "comment_title": "Comment from Harford, Marisa", "commenter_fname": "Marisa", "commenter_lname": "Harford", "comment_length": 4941}, {"text": "6 years ago CDC issued Guidelines for opiod prescription and use. They have been a foreseeable disaster. Illegal fentanyl heroin cocaine meth are killing more Americans then ever. People with injuries surgery child birth are denied or get limited safe pain relief medication. ChronicPainPatients have their opiod prescription canceled or severely limited. Some seek Illegal drugs which have unknown ingredients, quality & amounts.

The CDC Guidelines should be totally rescinded. If not, then substantially limited.", "comment_id": "CDC-2022-0024-5132", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2022-0024-5132", "comment_date": "2022-04-13T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 527}, {"text": "I have MS, congential spinal stenosis, degenerative disc disease, and need a knee replacement I can't get until next year. Because of all my issues I developed drop foot. The drop foot causes me to fall a lot. I never get pain meds even though I fractured my knee and footand had had bulging discs from my many falls. I basically sit on the couch most of the day because trying to do things or stand longer than 15 min I feel like my back is going to break. I have never abused my medication so I should not be treated like I have. These guidelines have poisoned the entire healthcare industry. Doctors and nurses are not treating pain even while patients lie in hospital. Pharmacists are making decisions about whether you deserve to fill the prescription or decide not to give you the full prescription. It's absolutely Ridiculous.

My brother had multiple surgeries in a short period of time to clean out staph infection that has spread to bone throughout his body including 2 operations on his spine. He spent weeks lying in bed in agony. They were stingy with the morphine and oxy. They didn't try other options finally at week 5 he got Dilaudid which helped so much. He was actually able to carry a conversation and not be groaning in pain. He should have been given more medication. He should have gotten other medications tried. Instead he was in agony for weeks. Not only are these measures not a step in the right direction the intention behind these guidelines is positioning all aspects of healthcare. ", "comment_id": "CDC-2022-0024-5129", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2022-0024-5129", "comment_date": "2022-04-13T04:00:00Z", "comment_title": "Comment from Galicia-Pigg , Elizabeth", "commenter_fname": "Elizabeth", "commenter_lname": "Galicia-Pigg", "comment_length": 1535}, {"text": "I have been a chronic pain patient for 12 years. My pain was being controlled by pain medication up until 2018 when I was force cutoff of 385 MME with no taper. I went from working full time to not being able to get out of bed. My quality of life is next to nothing now compared to when I was properly medicated. Please help me and millions of others in ridding the 2016 opioid prescribing guidelines. Please do not put a MME cap on our medications. This will only continue to dissuade Drs. from being comfortable enough to prescribe the medication I need to survive and work as a functional member of society. I deserve a quality of life which has been taken from me and my family.
Thank you.", "comment_id": "CDC-2022-0024-5265", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2022-0024-5265", "comment_date": "2022-04-13T04:00:00Z", "comment_title": "Comment from M., Nika", "commenter_fname": "Nika", "commenter_lname": "M.", "comment_length": 698}, {"text": "DON'T FORGET THE CURSE!!!!!!!", "comment_id": "CDC-2022-0024-5263", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2022-0024-5263", "comment_date": "2022-04-13T04:00:00Z", "comment_title": "Comment from Brown, Keith", "commenter_fname": "Keith", "commenter_lname": "Brown", "comment_length": 33}, {"text": "I have been living with severe chronic pain for decades. This pain has negatively impacted every facet of my life. I have tried countless treatments for pain, including: OTC medication, prescription medication (non-pain medications, non-opioid pain medications, and opioids), injections, physical therapy, minimally invasive procedures, and major surgeries. The ONLY treatment that has given me relief and afforded me an acceptable quality of life is a combination of one long-acting and one short-acting opioid.
Now, my insurance company, FEP BC BS, is taking me off opioids completely. This is against my will and over the strong objections of my long-time physicians. FEP BC BS is using the CDC’s strict 2016 opioid guidelines to justify their decision. The CDC’s follow-up clarification statement on these guidelines has been ignored. This has caused great harm to me and to many others. The CDC must issue new, flexible guidelines that INCLUDE the clarifications, thereby making it more difficult for insurance companies to cherry-pick the official advice.
I am physically dependent on, NOT addicted to or abusing, opioids. I have been on these two opioids for at least five years. I am a responsible and compliant pain management patient. I adhere to the strict terms of my patient contract and I have never given my physicians cause for concern.
My condition has not changed. My behavior has not changed. What has changed is FEP BC BS opioid policy. This new policy is based on the CDC 2016 opioid guidelines and it completely dismisses the CDC, FDA, and HHS clarification statements that were issued later, in response to serious concerns over misapplication of the guidelines. FEP BC BS is misapplying the guidelines in the exact ways they have been explicitly told not to. For example:
-FEP BC BS has instituted a rigid MME/day allotment and refuses to consider a prescriber’s informed opinion or a patient’s individual situation. The CDC’s clarification paper states “POLICIES THAT MANDATE HARD LIMITS CONFLICT WITH THE GUIDELINE’S EMPHASIS ON INDIVIDUALIZED ASSESSMENT OF THE BENEFITS AND RISKS OF OPIOIDS GIVEN THE SPECIFIC CIRCUMSTANCES AND UNIQUE NEEDS OF EACH PATIENT.”
-FEP BC BS has rejected explicit safety warnings from the CDC, such as, “…SERIOUS HARM IN PATIENTS WHO ARE PHYSICALLY DEPENDENT ON OPIOID PAIN MEDICINES SUDDENLY HAVING THESE MEDICINES DISCONTINUED OR THE DOSE RAPIDLY DECREASED. THESE INCLUDE SERIOUS WITHDRAWAL SYMPTOMS, UNCONTROLLED PAIN, PSYCHOLOGICAL DISTRESS, AND SUICIDE.” The FDA agrees, stating, “…SHOULD NOT ABRUPTLY DISCONTINUE OPIOIDS IN A PATIENT WHO IS PHYSICALLY DEPENDENT.”
-FEP BC BS ignores the CDC’s assertion that, “THE RECOMMENDATION STATEMENT DOES NOT SUGGEST DISCONTINUATION OF OPIOIDS ALREADY PRESCRIBED AT HIGHER DOSAGES.”
This insurance company has inappropriately seized total control of my treatment. They have taken on the role of doctor and regulator. They have imposed hard limits. They have not considered my specific situation. They have not listened to my physicians. They have not listened to me. They have not listened to the CDC, FDA, or HHS. They have rapidly decreased my medications by a weekly 50% (a far cry from HHS advice to, WHEN tapering or discontinuation is appropriate, decrease opioids by no more than 10% per month). FEP has done this though I am physically dependent on these medications and have been for years, and despite the extreme physical and psychological effects I have and will continue to experience.
Since their drastic cuts, I have been unable to sleep and have suffered with intense anxiety and panic attacks (at one point, I thought I was having a heart attack). I have headaches, joint and muscle pain, nausea, diarrhea, exhaustion, irritability, and more. I cannot complete necessary tasks. I feel worthless. And I know none of this is going to get better. It is only going to get worse. I have no more appeals and my only recourse is to take my insurance company to court. This will cost $30,000. I feel powerless, desperate, and hopeless. The life that awaits me is one of agonizing, daily pain and scant functionality. It is not a life worth living and I don’t know what I’m going to do.
The CDC MUST incorporate these clarifications into the new guidelines, otherwise their sound, patient-centered advice will continue to be ignored and people with pain will continue to suffer. While the 2016 guidelines were created with good intent, they led to dramatic overcorrections and knee-jerk reactions that have resulted in serious negative repercussions. Pain is not being adequately treated and is often completely ignored. Doctors, nurses, pharmacists, and insurance companies feel free to openly engage in patient-profiling and discrimination. People in pain are resorting to desperate measures as their options for relief dwindle to nothing. Please take steps to fix these and other unintended consequences. ", "comment_id": "CDC-2022-0024-5274", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2022-0024-5274", "comment_date": "2022-04-13T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 5075}]}, {"id": "FDA-2014-P-0205", "title": "Impose Safety Labeling Changes on Immediate-Release Opioid Analgesics That Parallel the Final Safety Labeling Changes Resulting From Completion of the 505(o) Procedures Initiated on September 10, 2013 for Extended-Release and Long-Acting Opioid Analgesics", "context": "2016-03-22T12:16:54Z", "purpose": "Nonrulemaking", "keywords": ["cder", "citizen petition", "open", "2014-1298", "oxycontin", "oral solution", "NDA #021306, #019892, #019034", "opioid analgesics", "extended-release and long-acting", "ER/LA"], "comments": [{"text": "See attached file(s)", "comment_id": "FDA-2014-P-0205-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-P-0205-0003", "comment_date": "2015-07-24T04:00:00Z", "comment_title": "Comment from The Center for Lawful Access and Abuse Deterrence (CLAAD)", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "I am writing to provide data that may be relevant to this petition. We conducted a retrospective, population-based, descriptive study of medication histories of overdose decedents using data from North Carolina medical examiners and matched data from the state's prescription monitoring program, in 2010. We looked at which opioids had been prescribed to decedents in the 60 days prior to overdose death. The results have undergone peer review and published (early) in Pain Medicine. The paper is attached. The findings suggest IR opioids are more likely to have been prescribed to overdose decedents, compared to ER opioids. For IR oxycodone and ER fentanyl, we observed a dose-dependent relationship between dose strength and overdose death rates standardized by the number of prescriptions.

-----

Data analysis: Death certificate data, prescription records, and toxicology results for each decedent were assigned a unique identification number, which was used to link the three data sources. The linked data were used to determine the number of deaths to which each drug contributed, as well as how many of those decedents filled a prescription for the drug that contributed to their death. To understand possible relative contribution of the dosage unit, we performed a subset analysis of the number of prescriptions dispensed to overdose decedents in the two months prior to death, for the four opioid analgesics that were available as both immediate-release and extended-release formulations for outpatient use in 2010: fentanyl, morphine, oxycodone, and oxymorphone. We chose a lookback period of 60 days prior to the date of death as a reasonable timeframe for exposure.

Results: Among the 824 (92%) of overdose victims with available toxicology results, 625 (76%) died from prescription drugs only, 97 (12%) died from illicit drugs only, 88 (11%) died from both prescription and illicit drugs, and 14 (2%) died from other (e.g., over-the-counter) drugs. For 359 (44%) of overdose victims, only one drug contributed to death, while 263 (32%) of victims died from two drugs (in a primary or additive role), 124 (15%) died from three drugs, and 78 (10%) died from four or more drugs.

On an absolute population level, immediate-release formulations of oxycodone were more often dispensed to overdose decedents in the two months prior to death than extended-release oxycodone, likely a function of availability (Table 4). Immediate-release oxycodone products showed a strong increasing linear trend (rho=1.00, p<0.01) between the dose strength and the proportion of prescriptions dispensed to overdose decedents. The most common strengths prescribed to a decedent who died of an oxycodone overdose were 10mg (72 prescriptions) and 5mg (61 prescriptions) for immediate-release, and 20mg for extended-release (12 prescriptions). The higher dose oxycodone extended-release formulations (40mg, 60mg, and 80mg) combined had 10 prescriptions.

However, the higher dose and extended-release oxycodone prescriptions had higher rates of prescriptions to overdose decedents than lower dose oxycodone products. Most oxymorphone prescriptions dispensed to those who died of an oxymorphone overdose were for the extended-release formulation (24 prescriptions) compared to the immediate-release formulations (6 prescriptions). The highest dose oxymorphone (40 mg extended-release) had the highest proportion of prescriptions prescribed to overdose decedents (103 per 100,000) for all the opioids tested. Most morphine-related overdose deaths involved the extended-release products (35 prescriptions versus 14 prescriptions). Despite their considerable potency and ease of administration, no transmucosal immediate-release fentanyl prescriptions were noted in the 60 days prior to death among those who died of a fentanyl overdose, however the two highest doses of the transdermal fentanyl patch (75 ug/hr and 100 ug/hr) combined accounted for 65% of the prescriptions written to these decedents. There was a strong linear trend for dose strength observed with fentanyl patches dispensed to fentanyl overdose decedents, ranging from 8.57 per 100,000 prescriptions (95% CI: 8.32, 8.83) for 25 mcg/hr to 82.19 per 100,000 prescriptions (95% CI: 81.80, 82.57) for 100 mcg/hr. ", "comment_id": "FDA-2014-P-0205-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-P-0205-0004", "comment_date": "2015-07-24T04:00:00Z", "comment_title": "Comment from Nabarun Dasgupta", "commenter_fname": null, "commenter_lname": null, "comment_length": 4314}]}, {"id": "FDA-2019-D-1917", "title": "Drug Abuse and Dependence Section of Labeling for Human Prescription Drug and Biological Products -- Content and Format; Draft Guidance for Industry; Availability", "context": "2019-12-03T10:11:59Z", "purpose": "Nonrulemaking", "keywords": ["2015-14", "CDER", "Guidance for Industry", "Drug Abuse and Dependence Section", "Labeling for Human Prescription Drug", "Biological Products", "Content and Format", "OPEN"], "comments": [{"text": "Drug addiction and abuse is on the rise in the United States and over 19 million Americans battled a substance abuse disorder in 2017. The over-prescription of opioid-based pain relievers has led to a dramatic increase in the occurrence of opioid addiction, overdoses, and heroin usage. There is a strong correlation between prescription opioid use and heroin use, with 4 out of 5 heroin addicts reporting their abuse started with prescribed opioids. Hydrocodone and oxycodone consumption doubled and increased by 500%, respectively, from 1999 to 2011. The opioid-related overdose death rate nearly quadrupled during this time frame and the United States Centers for Disease Control and Prevention (CDC) listed opioid overdose prevention as one of the top five public health challenges in 2014. Heroin overdose deaths among whites between 18 44 increased by 171% since 2001, and from 1999 2017, almost 400,000 Americans died from overdosing on prescription and illicit opioids.

In 2006, the Food and Drug Administration (FDA) amended the requirements on the content and format of labeling for Human Prescription Drug and Biological Products. It was recognized that health care practitioners had difficulty accessing, reading, and using the information provided to them when prescribing medications, and this led to errors. The amendment of part 201 (21 CFR part 201) included a new Highlights of Prescribing Information section, which offers a brief introduction on the prescription medication and a Boxed Warning to apprise the practitioners of the dangers associated with that medication. This did nothing to lessen the frequency with which opioid-based pain relievers are abused and we are facing a widespread epidemic that is destroying the lives of U.S. citizens and their families. We need to revisit the required labeling and the verbiage used to inform our citizens of the dangers associated with these drugs.

Given the urgency of the crisis at hand, the need to properly inform patients regarding a drugs potential for abuse is more pressing than ever and studies have shown that physicians have often been found to inadequately perform their duties when conveying instructions for medications. Moreover, physicians and pharmacists frequently fail to provide information using language that can be understood by patients. Thus, the problem is two-fold. Therefore, the last remaining opportunity for advising is the accompanying print materials given to patients such as the container label, patient package inserts, consumer medication information, medication guides, etc. Unfortunately, however, many of these valuable documents have been shown to be too complicated, and written at a level too difficult for most patients to comprehend and use. Professional guidance regarding a given drugs potential for abuse is inadequate and while FDA-2019-D-1917 addresses the need for attention on this issue, it in no way requires manufacturers or pharmacies to adhere to any standard.

Variability in medication labeling has been shown to impact patient interpretation of instructions, and the effect is most significant in patients with limited health literacy. In a 2007 study that included 4 large US cities, Shrank et al. found considerable variability in medication labeling, especially in the content of instructions and warnings. In the most extreme cases, some pharmacies failed to include warning stickers or medication guides. In 2015, patients in Chicago and Atlanta were shown to have limited knowledge of the active ingredients in their acetaminophen-containing analgesics. Again, high variability was found in labeling and warning information on the patients medications. A lack of consistency in medicinal labeling is enabled by the absence of standard labeling enforcement. While recommendations are useful, there is evidence that labeling guidelines as a stand-alone strategy may not be adequate to prevent the misuse of medications.

Ultimately, while the authors recommend changes to the scope and strength of FDA-2019-D-1917, we also recognize that many of the most urgent changes to labeling must have the force of law behind them. We would recommend that the Senate HELP committee and the Ways and Means Subcommittee on Health draft new laws that would require labels to be uniform in structure and language, with standards developed by the agency. Clarity and uniformity will allow physicians and patients alike to make informed decisions. We would also recommend that this legislation require lay language to be included to describe dependence risks and symptoms, so that patients could better understand both risks and dependence itself. It is our duty to use our knowledge regarding the science to require language on prescription drug labeling to be more informative, direct, and administered to patients in a manner that makes them more aware of the dangers associated with opioid-based prescription medications.

Full Comment Attached as PDF.", "comment_id": "FDA-2019-D-1917-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-D-1917-0006", "comment_date": "2019-09-05T04:00:00Z", "comment_title": "Comment from The Penn State Science Policy Society", "commenter_fname": null, "commenter_lname": null, "comment_length": 5021}, {"text": "Please see attached Janssen comments.", "comment_id": "FDA-2019-D-1917-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-D-1917-0005", "comment_date": "2019-09-05T04:00:00Z", "comment_title": "Comment from Janssen Research & Development, L.L.C.", "commenter_fname": null, "commenter_lname": null, "comment_length": 37}, {"text": "See Attached", "comment_id": "FDA-2019-D-1917-0009", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-D-1917-0009", "comment_date": "2019-09-05T04:00:00Z", "comment_title": "Comment from Benzodiazepine Information Coalition", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}, {"text": "See attached file.", "comment_id": "FDA-2019-D-1917-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-D-1917-0003", "comment_date": "2019-08-30T04:00:00Z", "comment_title": "Comment from GlaxoSmithKline (GSK)", "commenter_fname": null, "commenter_lname": null, "comment_length": 18}, {"text": "See attached file(s)", "comment_id": "FDA-2019-D-1917-0007", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-D-1917-0007", "comment_date": "2019-09-05T04:00:00Z", "comment_title": "Comment from PinneyAssociates, Inc.", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Please see attached Pfizer comments.", "comment_id": "FDA-2019-D-1917-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-D-1917-0004", "comment_date": "2019-09-05T04:00:00Z", "comment_title": "Comment from Pfizer, Inc.", "commenter_fname": null, "commenter_lname": null, "comment_length": 36}, {"text": "See attached file(s)", "comment_id": "FDA-2019-D-1917-0008", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-D-1917-0008", "comment_date": "2019-09-05T04:00:00Z", "comment_title": "Comment from Pharmaceutical Printed Literature Association", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See Attached", "comment_id": "FDA-2019-D-1917-0010", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-D-1917-0010", "comment_date": "2019-12-03T05:00:00Z", "comment_title": "Comment from MERCK", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}]}, {"id": "FDA-2014-N-0374", "title": "Postmarketing Requirements for the Class-Wide Extended-Release/Long-Acting Opioid Analgesics; Public Meeting; Request for Comments", "context": "2017-03-24T11:37:47Z", "purpose": "Nonrulemaking", "keywords": ["cder", "cder201424"], "comments": [{"text": "See attached file(s)", "comment_id": "FDA-2014-N-0374-0008", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-0374-0008", "comment_date": "2017-03-20T04:00:00Z", "comment_title": "Comment from Teva Pharmaceuticals", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "I want to thank the FDA for inviting me to this important stakeholders meeting. My 2 cents in no particular order:

1. I commend the FDA and the industry partners for tackling this issue. We all recognize the critical issues we are discussed. I'd like to acknowledge the tremendous amount of work already done and left to do.

2. If I ask myself the fundamental question, do I believe these studies will move the field forward? The answer is an emphatic YES!.

3. Do I believe these studies will provide the definitive answers to all the questions in this area? The answer is a resounding NO! However, this gives us researchers and funders reason to continue to address the questions raised.

4. My concerns were articulated beautifully by other stakeholders/meeting participants. The philosophical bent of these studies was an almost exclusive focus on the harms of these medications. And very limited attention to the potential benefits. While this leaning towards harms really addresses important questions, there is the wonderful opportunity to address more questions. In the current framing, the answers will likely help the FDA from a regulatory standpoint and industry to meet the postmarketing requirements. But have limited influence on clinical decision making and possibly unintended consequences by focusing exclusively on harms. I worry that the current environment were become even more "opioiphobic" among prescribers and lead to restricted access to opioids for pain sufferers that benefit from them.

5. question: I may have missed it, but I did not hear the rationale for the ambitious timelines to conduct the studies.

6. An opportunity to triagulate data sources and incorporate qualitative data might be considered especially for the doctor/pharmacy shopping study. A better understanding of "drug seeking" could benefit from talking with patients (qualitative data collection). What is the patient's view of this concept? ", "comment_id": "FDA-2014-N-0374-0009", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-0374-0009", "comment_date": "2017-03-24T04:00:00Z", "comment_title": "Comment from Matt Bair", "commenter_fname": null, "commenter_lname": null, "comment_length": 2043}, {"text": "See attached file(s)", "comment_id": "FDA-2014-N-0374-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-0374-0006", "comment_date": "2017-03-20T04:00:00Z", "comment_title": "Comment from Daniel Wang", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "FDA-2014-N-0374-0007", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-0374-0007", "comment_date": "2017-03-20T04:00:00Z", "comment_title": "Comment from American Society of Anesthesiologists", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Subject: Marketing and discussion of home-brew (i.e., non-approved) urine testing on FDA property without any discussion of severe limitations.

I watched the public meeting via the webcast feature. Dr. Passik – an employee of a urine lab – touted the use of expensive mass spectrometry-based urine testing without revealing its severe limitations. Others, perhaps ignorant of these limitations, made statements that cannot be supported with evidence. In order to protect FDA’s reputation as an evidence-based institution, I provide the information that follows. While I could provide an exhaustive and lengthy summary of the medical literature, the federal court case noted below is succinct and accurate.

In a case called Millennium Laboratories, Inc. v. Ameritox, Ltd., 924 F. Supp. 2d 594 (D. Md. 2013), between two of the largest laboratories in the United States performing urine drug testing, Millennium Laboratories, Inc. and Ameritox, Ltd., the Court noted that:

By processing patients’ urine samples through sophisticated laboratory equipment, Millennium and Ameritox can provide doctors with considerable information. Their tests can determine the presence (and, by necessary implication, absence) of the prescribed pain mediation and a wide variety of other drugs, whether prescription, non-prescription, legal, or illegal. The test can also quantify the amount of pain medication or its metabolite present in the urine.

Even using this advanced technology, however, UDT [urine drug testing] has its limitations. First, it provides only a snapshot of current drug use; drugs and their metabolites remain in a person’s urine only for so long. Additionally, because individuals metabolize drugs at different rates, UDT cannot determine the dosage taken by the patient or when he took the dosage. During the litigation, Millennium and Ameritox agreed that UDT can determine whether certain drugs are present or absent, but it cannot determine prescription compliance.

Id. at 597-598.", "comment_id": "FDA-2014-N-0374-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-0374-0005", "comment_date": "2017-03-20T04:00:00Z", "comment_title": "Comment from James Harris", "commenter_fname": null, "commenter_lname": null, "comment_length": 2071}, {"text": "Postmarketing requirements for ER/LA opioid analgesics;

It's difficult to do much postmarketing. An adaptive learning program where a lesson is taught, and questions asked, and later answers given to check on the answers wherein an appropriate number of "lesson-answer-correction" would constitute a test given, possibly by the DEA before granting a DEA license.

A major problem is confusion by the patient on distinguishing between a LA and short acting medication. The medications should be such that recognition is possible in the dark. Actiq, for example, is like a sucker. Easy to distinguish. Short acting opiates could have a hole in the center. They could be packaged differently. Taking a LA medication thinking to be short acting, taking it every 4 hours, is lethal! Analgesic patches are relatively safe.

Patients suffering with chronic pain syndrome (338) have impaired cognition. Treating their syndrome adequately improves cognition making it less likely that they will make an error. First of all, this disease needs recognition. I have attached an article I wrote for the California Department of Rehabilitation when serving as medical consultant.", "comment_id": "FDA-2014-N-0374-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-0374-0004", "comment_date": "2017-03-20T04:00:00Z", "comment_title": "Comment from Edward Manougian", "commenter_fname": null, "commenter_lname": null, "comment_length": 1205}]}, {"id": "HHSIG-2014-0002", "title": "Medicare and State Health Care Programs: Fraud and Abuse; Revisions to the Office of Inspector General's Exclusion Authorities", "context": "2021-10-16T01:00:53Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "See attached file(s)", "comment_id": "HHSIG-2014-0002-0006", "comment_url": "https://api.regulations.gov/v4/comments/HHSIG-2014-0002-0006", "comment_date": "2014-07-08T04:00:00Z", "comment_title": "Comment on FR Doc # 2014-10390", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 20}, {"text": "PhRMA Comments - See attached file(s)", "comment_id": "HHSIG-2014-0002-0020", "comment_url": "https://api.regulations.gov/v4/comments/HHSIG-2014-0002-0020", "comment_date": "2014-07-09T04:00:00Z", "comment_title": "Comment on FR Doc # 2014-10390", "commenter_fname": "Lauren", "commenter_lname": "Roth", "comment_length": 37}, {"text": "See attached file(s)", "comment_id": "HHSIG-2014-0002-0018", "comment_url": "https://api.regulations.gov/v4/comments/HHSIG-2014-0002-0018", "comment_date": "2014-07-09T04:00:00Z", "comment_title": "Comment on FR Doc # 2014-10390", "commenter_fname": "Sam", "commenter_lname": "Ennis", "comment_length": 20}, {"text": "Please see uploaded file for Greater New York Hospital Association comments to OIG-403-P2: Medicare and State Health Care Programs: Fraud and Abuse; Revisions to the Office of Inspector General’s Exclusions Authorities. Thank you for conisdering our comments. ", "comment_id": "HHSIG-2014-0002-0014", "comment_url": "https://api.regulations.gov/v4/comments/HHSIG-2014-0002-0014", "comment_date": "2014-07-09T04:00:00Z", "comment_title": "Comment on FR Doc # 2014-10390", "commenter_fname": "Brittany", "commenter_lname": "Allison", "comment_length": 267}, {"text": "Please see the attached letter from the American Hospital Association.", "comment_id": "HHSIG-2014-0002-0007", "comment_url": "https://api.regulations.gov/v4/comments/HHSIG-2014-0002-0007", "comment_date": "2014-07-08T04:00:00Z", "comment_title": "Comment on FR Doc # 2014-10390", "commenter_fname": "Melinda", "commenter_lname": "Hatton", "comment_length": 70}, {"text": "On behalf of New Jersey Hospital Association, attached please find our comment letter with regards to OIG-403-P2.

Thank you. ", "comment_id": "HHSIG-2014-0002-0009", "comment_url": "https://api.regulations.gov/v4/comments/HHSIG-2014-0002-0009", "comment_date": "2014-07-09T04:00:00Z", "comment_title": "Comment on FR Doc # 2014-10390", "commenter_fname": "Elizabeth", "commenter_lname": "Ryan", "comment_length": 134}, {"text": "See attached letter.", "comment_id": "HHSIG-2014-0002-0002", "comment_url": "https://api.regulations.gov/v4/comments/HHSIG-2014-0002-0002", "comment_date": "2014-07-08T04:00:00Z", "comment_title": "Comment on FR Doc # 2014-10390", "commenter_fname": "Dianne", "commenter_lname": "De La Mare", "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "HHSIG-2014-0002-0010", "comment_url": "https://api.regulations.gov/v4/comments/HHSIG-2014-0002-0010", "comment_date": "2014-07-09T04:00:00Z", "comment_title": "Comment on FR Doc # 2014-10390", "commenter_fname": "Cybil", "commenter_lname": "Roehrenbeck", "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "HHSIG-2014-0002-0012", "comment_url": "https://api.regulations.gov/v4/comments/HHSIG-2014-0002-0012", "comment_date": "2014-07-09T04:00:00Z", "comment_title": "Comment on FR Doc # 2014-10390", "commenter_fname": "Scott", "commenter_lname": "Amrhein", "comment_length": 20}, {"text": "PhRMA Comments ", "comment_id": "HHSIG-2014-0002-0019", "comment_url": "https://api.regulations.gov/v4/comments/HHSIG-2014-0002-0019", "comment_date": "2014-07-09T04:00:00Z", "comment_title": "Comment on FR Doc # 2014-10390", "commenter_fname": "Lauren", "commenter_lname": "Roth", "comment_length": 15}]}, {"id": "SAMHSA-2016-0004", "title": "Protecting Our Infants Act Report to Congress ", "context": "2021-05-04T01:00:35Z", "purpose": "Nonrulemaking", "keywords": ["Protecting Our Infants Act", "Neonatal Abstinence Syndrome", "Noenatal Opioid Withdrawal", "Opioid Use Disorder", "Pregnancy", "Prenatal Opioid Exposure"], "comments": [{"text": "See attached file(s)", "comment_id": "SAMHSA-2016-0004-0023", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0004-0023", "comment_date": "2017-02-21T05:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": "Rebecca", "commenter_lname": "Abbott", "comment_length": 20}, {"text": "Stop infant circumcision. ", "comment_id": "SAMHSA-2016-0004-0007", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0004-0007", "comment_date": "2017-01-27T05:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 26}, {"text": "See attached letter from the American Society of Addiction Medicine", "comment_id": "SAMHSA-2016-0004-0016", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0004-0016", "comment_date": "2017-02-17T05:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": "Susan", "commenter_lname": "Awad", "comment_length": 67}, {"text": "See attached letter from Alkermes.", "comment_id": "SAMHSA-2016-0004-0018", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0004-0018", "comment_date": "2017-02-21T05:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": "Sarah", "commenter_lname": "Akerman", "comment_length": 34}, {"text": "Please see attached comment letter.", "comment_id": "SAMHSA-2016-0004-0020", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0004-0020", "comment_date": "2017-02-21T05:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": "Seamus", "commenter_lname": "Dolan", "comment_length": 35}, {"text": "Women need supports in addition to services, while pregnant and after their child is born. Babies exposed to drugs in utero are often fussy, difficult to soothe infants and children. It would be wonderful if the administration could find a way to tap into the compassionate individuals who are Pro-Life to volunteer their services to these families in need. Perhaps hospitals, clinics and treatment programs could be funded to advertise for volunteers and pay for child abuse and other appropriate clearances and provide training to the volunteers. Magee-Womens Hospital in Pittsburgh, PA has a program in their neonatal unit for volunteers to hold and rock babies. The waiting list is so long they no longer take names for volunteers. Programs like this across the country would be wonderful.", "comment_id": "SAMHSA-2016-0004-0009", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0004-0009", "comment_date": "2017-01-31T05:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": "Janice", "commenter_lname": "Meinert", "comment_length": 799}, {"text": "See attached file(s)", "comment_id": "SAMHSA-2016-0004-0011", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0004-0011", "comment_date": "2017-02-14T05:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": "Victoria", "commenter_lname": "Coleman-Cowger", "comment_length": 20}, {"text": "Please see Drug Policy Alliance's comment on Docket Number SAMSHA 2016-0004 attached.", "comment_id": "SAMHSA-2016-0004-0022", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0004-0022", "comment_date": "2017-02-21T05:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": "Grant", "commenter_lname": "Smith", "comment_length": 89}, {"text": "As a former methadone patient who gave birth to 3 children while in treatment, I would like to see national standards advocating the use of split dosing upon confirmation of pregnancy. Maintaining an even level of medication in the system is essential to avoid learned withdrawal response in infants and can reduce symptom severity or prevent neonatal abstinence syndrome. There was no document or public study available concerning pregnancy while in methadone treatment. I had to do the research myself and present the studies to the clinic doctor in order to Split dose for the duration of my pregnancy and while breastfeeding. None of my children experienced NAS due to my diligence and willingness to fight for the healthiest outcome for them. Not all clinics are willing to allow for split dose. In my time as an advocate for patients, there were multiple occasions where despite the research, the clinic refused the patient split dose simply due to inconvenience, which is not a proper response in an evidence-based setting. Setting national standards, giving a clinic the proper method for administering medication during pregnancy, would benefit both mother and child and would reduce the severity of NAS in this population.

Additionally, having a website where patients could easily read the potential complications and outcomes of opioid use in pregnancy is necessary. There is no one place where these women could read the studies, learn the potential for NAS symptoms in babies, and educate themselves on the effect of use and ways to lessen the potential for these effects on their children. Knowledge is instrumental in assisting these women.

", "comment_id": "SAMHSA-2016-0004-0010", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0004-0010", "comment_date": "2017-02-06T05:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": "Ericka", "commenter_lname": "Lear", "comment_length": 1683}, {"text": "RE: Docket Number SAMHSA-2016-0004

The Association of State and Territorial Health Officials (ASTHO) is pleased to offer the attached comment letter regarding the
Protecting Our Infants Act Report to Congress, "Part 4: Strategy to Protect Our Infants" (Section 2(b) of the Act) to the
Substance Abuse and Mental Health Service Administration (SAMHSA), US Department of Health and Human Services.

", "comment_id": "SAMHSA-2016-0004-0012", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2016-0004-0012", "comment_date": "2017-02-14T05:00:00Z", "comment_title": "Comment on FR Doc # N/A", "commenter_fname": "Lynn", "commenter_lname": "Chaiken", "comment_length": 435}]}, {"id": "DEA-2008-0009", "title": "Electronic Prescriptions for Controlled Substances", "context": "2015-11-17T12:28:19Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "I think e-prescribing is wonderful and would eliminate forgeries. Pharmacies could
email practices instead of calling them if there were any questions about the Rx or
its authenticity as well. It would move toward a paperless practice, and save
money for everyone.

If banks can move money this way, then we can do prescribing this way!", "comment_id": "DEA-2008-0009-0081", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2008-0009-0081", "comment_date": "2008-09-23T04:00:00Z", "comment_title": "Comment on DEA-218 by Jonathan Daitch", "commenter_fname": "Jonathan", "commenter_lname": "Daitch", "comment_length": 362}, {"text": null, "comment_id": "DEA-2008-0009-0027", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2008-0009-0027", "comment_date": "2008-07-31T04:00:00Z", "comment_title": "Comment on DEA 218 by Stephen Strockbine (RPh)", "commenter_fname": "Stephen", "commenter_lname": "Strockbine (RPh)", "comment_length": 0}, {"text": null, "comment_id": "DEA-2008-0009-0025", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2008-0009-0025", "comment_date": "2008-07-31T04:00:00Z", "comment_title": "Comment on DEA-218by Grace Ward", "commenter_fname": "Grace", "commenter_lname": "Ward", "comment_length": 0}, {"text": null, "comment_id": "DEA-2008-0009-0235", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2008-0009-0235", "comment_date": "2008-10-06T04:00:00Z", "comment_title": "BJC Healthcare - Christian Hospital - Schultz - DEA-218 comments", "commenter_fname": "Donna", "commenter_lname": "Schultz", "comment_length": 0}, {"text": "NCPDP is submitting the following 2 documents as response to DEA-218P
Electronic Prescriptions for Controlled Substances.", "comment_id": "DEA-2008-0009-0065", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2008-0009-0065", "comment_date": "2008-09-18T04:00:00Z", "comment_title": "Nat'l Council for Prescription Drug Prog. - Lee Ann Stember - Comment on FR Doc # E8-14405", "commenter_fname": "Lynne", "commenter_lname": "Gilbertson", "comment_length": 126}, {"text": "Please see comments attached.", "comment_id": "DEA-2008-0009-0146", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2008-0009-0146", "comment_date": "2008-09-26T04:00:00Z", "comment_title": "Tennessee Pharmacists Association - Baeteena Black - Comment on DEA-218", "commenter_fname": "Baeteena", "commenter_lname": "Black", "comment_length": 29}, {"text": "Please see attached file. ", "comment_id": "DEA-2008-0009-0135", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2008-0009-0135", "comment_date": "2008-09-26T04:00:00Z", "comment_title": "Texas Medical Assoc. - Joseph Schneider - Comment on DEA 218", "commenter_fname": "Joseph", "commenter_lname": "Schneider", "comment_length": 27}, {"text": null, "comment_id": "DEA-2008-0009-0132", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2008-0009-0132", "comment_date": "2008-09-25T04:00:00Z", "comment_title": "Illinois State Medical Society - Julie Powers - Comment on DEA-218", "commenter_fname": "Julie", "commenter_lname": "Powers", "comment_length": 0}, {"text": null, "comment_id": "DEA-2008-0009-0204", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2008-0009-0204", "comment_date": "2008-09-30T04:00:00Z", "comment_title": "Dean Health System - Mooney - DEA-218 Comments", "commenter_fname": "Allison", "commenter_lname": "Mooney", "comment_length": 0}, {"text": "Re: Docket No. DEA-218P: Electronic Prescriptions for Controlled Substances

The Pain & Policy Studies Group (PPSG) respectfully submits a series of
comments to the United States Drug Enforcement Administration (DEA). These
comments are in response to the DEA’s anticipated modification of the Code of
Federal Regulations (CFR), which is outlined in the proposed rule for “Electronic
Prescriptions for Controlled Substances” and the corresponding Solicitation of
Comments of June 27, 2008 (Docket No. DEA-218P).

We recognize the obligation of healthcare professionals to provide effective
treatment for legitimate medical purposes while also avoiding knowingly
contributing to diversion of prescription controlled substances. Alternatively, law
enforcement and regulatory officials should prevent prescription medications from
becoming a source of harm or abuse while ensuring that they are available for
patient care. It is this principle that underlies the proposed rule; the DEA states
that the planned electronic prescribing system is designed to reduce diversion
through prescription forgeries and maintain a sufficient supply of controlled
substances for legitimate purposes (p. 36722).

Although the proposed rule is considered an addition to, rather than a replacement
for, the existing rules for prescribing, and practitioners’ use of electronic
prescribing is voluntary at this time, the DEA anticipates that all practitioners will
eventually transition to electronic prescribing of controlled substances (p. 36761).
As a result, it is essential that the authority be adequate, and that the technical
and procedural characteristics of an electronic prescribing system be carefully
and thoroughly vetted not only by practitioners, regulators, and law enforcement
officials, but also by healthcare facility and insurance administrators and, perhaps
most importantly given the nature of this electronic system, computer security
experts. We do not have enough information or expertise to comment on the
calculated fiscal impact or the technological appropriateness of the proposed
electronic prescribing system. However, it remains unclear whether increases in
registration fees will be used to cover the costs of the new system. In addition, it
seems that the DEA is placing much of the responsibility for system security on
practitioners and pharmacies, but does the DEA have sufficient statutory authority
to do so? Does such authority to require this new responsibility lie within the
Controlled Substances Act (CSA) authority to register practitioners? Further, with
today’s technology, would it not be more appropriate and efficient for this
responsibility instead to be accomplished centrally and electronically? We
appreciate the DEA’s requests throughout the proposed rule for multidisciplinary
feedback on various aspects of the prescribing system. Such feedback will help
achieve a final electronic controlled substances prescribing system that is feasible
and effective while sufficiently satisfying the DEA’s objectives and concerns.

We applaud the DEA for attempting to offer an electronic controlled substances
prescribing system that is designed to minimize the risk of diversion of these
prescription medications while ensuring their adequate supply for legitimate
medical and scientific purposes. However, there are a number of procedures and
requirements within the proposed CFR regulations that demand further
consideration, so that the ultimate implementation of an electronic prescribing
system does not foster unintended practitioner concerns about potential federal,
state, or local law enforcement oversight.

The question of balance. Despite the statement that the proposed regulations are
designed to “ensure an adequate supply of controlled substances for legitimate
medical, scientific, research, and industrial purposes” (p. 36722) the new rule
does not seem to establish responsibility for monitoring and reporting of cases
where legitimate electronic prescriptions cannot be filled in a reasonable period.
The DEA should consider what system safeguards are needed to ensure an
adequate supply of medications to patients with legitimate prescriptions. The
obligation to ensure adequate medication availability and access should be
reflected throughout the regulation, as it is in the CSA.

§ 1311.100(c) – Eligibility to issue electronic prescriptions. Under this provision,
practitioners are given the broad responsibility to confirm whether an electronically-
issued prescription for a controlled substance does not conform to “all essential
respects to the law and regulations” (p. 36775). This requirement clearly
establishes an obligation for the practitioner to be responsible for the effectiveness
of the security system established by this regulation, and for verifying third-party
audit reports (as in § 1311.155(f)). Of course, practitioners must remain
responsible for issuing electronic prescriptions only for a legitimate medical
purpose and in the usual course of professional practice, as they are with paper or
oral prescriptions. However, the technological complexity of the electronic
prescription system, and corresponding services, could establish for practitioners
an onerous burden of oversight over a system for which they ultimately have little
control. Responsibility for the efficacy and accuracy of the electronic prescribing
system and security services should reasonably fall to the hardware/software
manufacturers and the computer security technicians.

§ 1311.105(b)(2 & 3) – Electronic prescription system requirements: Identify
proofing. Among other requirements, practitioners who wish to prescribe
controlled substances electronically must submit to in-person identify proofing
conducted either by the state professional or licensing board, state controlled
substances authority, or a state or local law enforcement agency. This is a
practice requirement that has few if any precedents with other, non-law
enforcement, professionals, and the healthcare community likely will perceive this
as a criminalization of medical practice. Research and published reports
demonstrate that healthcare practitioners historically have avoided engaging in
prescribing practices associated with greater law enforcement scrutiny, such as
with state triplicate prescription monitoring programs. The prospect of
practitioners acquiring identify proofing through local law enforcement agencies
could significantly impede the widespread adoption of electronic prescribing.
Given these considerations, we recommend that the requirement of in-person
identity proofing, if maintained, be satisfied solely through the use of non-law
enforcement organizations.

§ 1311.140(b) – Electronic prescription system requirements: Providing log of
prescriptions to practitioner. A practitioner using an electronic prescription
system seems required to review, and indicate review of, monthly logs of all
electronic prescriptions issued by the practitioner during the previous month using
that system. When describing this provision in the Section-By-Section
Discussion of the Proposed Rule (p. 36754), the DEA does not detail the
practitioner’s ultimate responsibility to review and approve the information in the
logs, the manner and timeframe in which the review must be completed, or the
practitioner’s liability for failing to review the log. This obligation, as well as the
other requirements detailed above, seems to create a new practice standard that
places more responsibility, and thus increased liability, for proper implementation
of the law on practitioners. In addition, there is a need to specify the
confidentiality of all such records, including who has access and under what
circumstances.

§ 1311.165(a) – Pharmacy system requirements: Prescription processing.
Pharmacists have a corresponding responsibility for the proper prescribing and
dispensing of controlled substances (§ 1306.04(a)). This proposed provision
requires the pharmacy, or “the prescribing practitioner’s service provider or one of
the intermediaries” to verify the validity of a practitioner’s DEA registration prior to
dispensing; if the prescription is not determined to be valid for any reason, the
pharmacy must reject the prescription – “A pharmacy that fails to check the
validity of controlled substance prescription before dispensing is legally
responsible if the prescription is invalid” (p. 36740). Under current federal law,
pharmacists are not required to verify a practitioner’s DEA registration before every
controlled substance prescription, paper or oral, is dispensed, but are given
guidance about how to verify practitioner registration, when there is a reason to do
so, in the DEA’s Pharmacist Manual (April, 2004). Although this new requirement
could be considered simply an extension of the “corresponding responsibility”
requirement of § 1306.04(a), the language could be viewed as creating an
additional legal and practice standard which may an additional compliance burden
for pharmacies and may even become part of state pharmacy boards’
requirements .

Again, we agree with the DEA’s objective of proposing an electronic controlled
substances prescribing system that reduces medication harm and risk of
diversion while maintaining availability for legitimate medical and scientific
purposes; given this objective, the new regulation should require the DEA to
submit an annual report concerning various aspects of the system operation,
including the prevalence of system errors that reduce patient access and how
these are corrected. However, the proposed system of checks and balances
seems likely to create a cumbersome and overly strict system that, if
implemented as currently designed, would result in an enormous burden of
oversight for practitioners and pharmacies. We anticipate that concern about law
enforcement actions resulting from failure to comply with the complex regulatory
requirements will be a substantial reason for practitioners and pharmacies
deciding against voluntarily engaging in these procedures. Since practitioners
currently have the option of issuing electronic prescriptions, such profound
disincentives would argue against electronic prescribing becoming a feasible
practice, thereby undermining the program intent. We urge the DEA to consider
the issues above, as well as those involving sufficiency of authority, fiscal impact,
and system and security technology, when modifying the proposed rule before
issuing the final regulations.

Sincerely,

Aaron M. Gilson, MS, MSSW, PhD
Director of U.S. Program, Senior Scientist

David E. Joranson, MSSW
Founder, Distinguished Scientist", "comment_id": "DEA-2008-0009-0117", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2008-0009-0117", "comment_date": "2008-09-25T04:00:00Z", "comment_title": "University of Wisconsin Pain & Policy Studies Group - Aaron M. Gilson - Comment on DEA -218", "commenter_fname": "Aaron", "commenter_lname": "Gilson", "comment_length": 11677}]}, {"id": "DEA-2011-0015", "title": "Classification of Two Steroids, Prostanozol and Methasterone, as Schedule III Anabolic Steroids Under the Controlled Substances Act", "context": "2021-12-02T01:00:55Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "I find it very upsetting that you can just point a finger and do whatever you want. I don't do any illicet drugs or buy from black market sources. However, I do enjoy taking dietary supplements . When you can go to any store and buy alcohol and destroy your body, life and those around you it makes banning these supplements seem kind of silly. Basically you are forcing people like me who don't want to break any laws want to go to black market sources and buy things that are not regulated or safe. Why is it that women can buy hormonal products all day long which allows them to have sex unresponsibly but yet , a guy like me who is older can't help his body be healthy. Don't use teenagers as an excuse to help your ban. just regulate it and I.D. them. I shouldn't have my freedoms taken away because some people are ignorant and irresponsible with how they use certain products. Kids are getting high on nutmeg for god's sake and you can overdose on it and die. ...just saying.
please consider the freedoms we the people love and hold dear before waving your big magic wand .
Warmest Regards,
A concerned Taxpayer", "comment_id": "DEA-2011-0015-0003", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2011-0015-0003", "comment_date": "2011-12-02T05:00:00Z", "comment_title": "Comment on FR Doc # 2011-30081", "commenter_fname": "J", "commenter_lname": "Sanders", "comment_length": 1156}, {"text": "I support the Drug Enforcement Administration’s proposed rule that would classify two steroids, rostanozol and methasterone, as anabolic steroids under Schedule III of the Controlled Substances Act (CSA). If these two drugs became classified as Schedule III controlled substances they would be added to the list of anabolic steroids that must have regulated provisions of control according to the CSA. Tests have been done to show that these two drugs fit the four criteria that classifies a steroid as an anabolic steroid as defined by the Anabolic Steroid Control Act of 2004. Adding rostanozol and methasterone to this list would make these drugs illegal to use or possess for anyone who is not following the regulation provisions of the Controlled Substance Act. This could prevent the use, sell, and trafficking of these drugs to people who are not using them correctly and do not really need them. Anabolic steroids are very dangerous when not used correctly. They cause both physical and emotional problems, such as severe mood swings. They are also very addictive and if anything can be done to keep these drugs out of the hands of people who will be negatively affected by them, it should be done. This regulation would provide that help. Therefore, I support this rule. ", "comment_id": "DEA-2011-0015-0004", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2011-0015-0004", "comment_date": "2011-12-02T05:00:00Z", "comment_title": "Comment on FR Doc # 2011-30081", "commenter_fname": null, "commenter_lname": null, "comment_length": 1294}, {"text": "The classification of these two substances as Schedule III Anabolic Steroids Under the Controlled Substances Act should be a no brainer. No opposition should be in place or have any merit. The damage these two types of steroids can ,and have done while not under proper supervision is great. One person has already lost their live and I hope we don't lose anymore. The longtime affects of misusing steroids is clearly known, but with no harsh penalties in place people will continue to abuse them. The immediate removal of all supplements containing these two drugs should become top priority once the law allows. I look forward to reading in the future about how this proposed rule has been passed.", "comment_id": "DEA-2011-0015-0005", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2011-0015-0005", "comment_date": "2012-01-19T05:00:00Z", "comment_title": "Comment on FR Doc # 2011-30081", "commenter_fname": "mike", "commenter_lname": "Beato", "comment_length": 704}]}, {"id": "FDA-2012-N-0548", "title": "Drug Safety and Risk Management Advisory Committee; Notice of Meeting", "context": "2013-06-17T15:42:17Z", "purpose": "Nonrulemaking", "keywords": ["oc", "oc2012142", "drug safety management", "October 29-30, 2012", "hydrocodone", "analgesics", "antitussive"], "comments": [{"text": "I am opposed to moving Hydrocodone substances to a Schedule 2 status. This will impact the patients access to this medication in a timely fashion for proper pain contro as more restrictions to get proper prescription in hand of pharmacist from physician will take place. Going about this in a different light by giving further education of physicians, better and further use of PDMP's and access, better controls and abilities for proper disposal of product with help and input of pharmacy all lend to better solutions to hinder the abuse issues surrounding the medication. Tighter restrictions lend to higher abuse as noted by just looking at what has taken place with Oxycodone.

I oppose the move to Schedule 2 status. Believe their are better resolutions and solutions.

Thank you", "comment_id": "FDA-2012-N-0548-0445", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0548-0445", "comment_date": "2013-02-12T05:00:00Z", "comment_title": "Tim Lee Weippert - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 808}, {"text": "Dear Dr. Throckmorton:

I am a community pharmacist and would like to present my views on the implications for pharmacies and impact on patients surrounding the rescheduling of hydrocodone containing products.

While pharmacists share concerns regarding the abuse, misuse and diversion of these prescription drugs, these concerns must be balanced with the impact on patients who legitimately need access to them.

Rather than reschedule hydrocodone containing products, it is important for you to consider the following:

• States Can Reschedule Controlled Substances: Under Federal law, states can act on their
own to place tougher restrictions on the prescribing and dispensing of controlled substances. As a result, any state may classify these products as Schedule II without a change in Federal law, based upon the public health needs and experience of their citizens.

• Products Will Be Harder to Obtain to Treat Pain: Hydrocodone in combination is one of the last non-Schedule II drugs available to treat moderate to severe pain. If these products are reclassified into Schedule II, prescribers will no longer be able to phone in prescriptions to pharmacies for their patients. Schedule II drugs can only be filled after a pharmacy receives a hard copy prescription signed by the prescriber except in an emergency. The process of calling in an emergency supply of a Schedule II medication does not allow for timely and continued access to needed medications. In most instances there is a significant lag time that will often pass before the physician can be reached to provide the required written order. This means delays in properly caring for the patient’s needs.

• Rescheduling Would Likely Increase the Value of Illicit Hydrocodone Products and This May Lead to Increased Crimes in Pharmacies: As you are aware, the issue of pharmacy crime is very serious and unfortunately on the rise. I have serious concerns that pharmacies may become even larger targets than we ", "comment_id": "FDA-2012-N-0548-0129", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0548-0129", "comment_date": "2013-02-01T05:00:00Z", "comment_title": "HUGH PATRICK MACK - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 2060}, {"text": "Regarding the change of hydrocodone to a class II drug: I believe we are chasing our tails in trying to regulate "abuse" out of out system. It cleary has not worked in the past and will not work in the future. However, Oxycontin tablets were reformulated several years ago so that the tablets could not be crushed. This change in the tablet reduced the abuse potential of Oxycontin by 99%.
My suggestion is to work in conjuction with manufactures to develope doseage forms that CAN NOT be abused.... ie smart tablets that check levels of medication and will not release any more medication after a certain level is reached. I know that this is a complicated issue but so were transdermal patches and insulin pumps 30 years ago...
Lets get to work!
Mike Cionci", "comment_id": "FDA-2012-N-0548-0131", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0548-0131", "comment_date": "2013-02-01T05:00:00Z", "comment_title": "Michael D Cionci - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 783}, {"text": "Re-scheduling Oxycodone will only make it more difficult for patients in need. More dollars should be allocated to the DEA to enforce laws and regulations already in place. Physicians (where the Rx starts) must be better educated and overseen as their writing habits are already accessible to the DEA. Heavy writers of narcotics should be visited and educated. Placing the burden on wholesalers and distributors is not working because there are no guidelines and these wholesalers and distributors are being asked to come up with formulas that are skewed and not working.
A persons health and needs cannot be placed in a formula. A Pharmacist is not a detective - They are already working behind bullet proof glass or have an armed guard ($$$) on hand in their facility.
Set up sensible and understandable rules and guidelines. When I have talked to the local DEA office, they admitted they do not have the personnel, nor do they have guidelines. They are just an enforcement arm, again without any rules or guidelines.
It's a big problem - Handle it properly, not making healthcare more difficult.", "comment_id": "FDA-2012-N-0548-0135", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0548-0135", "comment_date": "2013-02-01T05:00:00Z", "comment_title": "Mel Brodsky R.Ph. - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1123}, {"text": "February 1, 2013
Douglas C. Throckmorton, M.D.
Deputy Director for Regulatory Programs
Center for Drug Evaluation and Research
Food and Drug Administration
10903 New Hampshire Ave., Bldg. 31, rm. 2417
Silver Spring, MD 20993-0002

Dear Dr. Throckmorton:
I am a community pharmacist and would like to present my views on the implications for pharmacies and impact on patients surrounding the rescheduling of hydrocodone containing products.
While pharmacists share concerns regarding the abuse, misuse and diversion of these prescription drugs, these concerns must be balanced with the impact on patients who legitimately need access to them.
Please consider:
• States Can Reschedule Controlled Substances: Under Federal law, states can act on their
own to place tougher restrictions on the prescribing and dispensing of controlled substances based upon the public health needs and experience of their citizens.
• Products Will Be Harder to Obtain to Treat Pain: Hydrocodone in combination is one of the last non-Schedule II drugs available to treat moderate to severe pain. If these products are reclassified into Schedule II, prescribers will no longer be able to phone in prescriptions to pharmacies for their patients. Schedule II drugs can only be filled after a pharmacy receives a hard copy prescription signed by the prescriber except in an emergency. The process of calling in an emergency supply of a Schedule II medication does not allow for timely and continued access to needed medications. This means delays in properly caring for the patient’s needs.
• Rescheduling Would Likely Increase the Value of Illicit Hydrocodone Products and this May lead to increased crimes in Pharmacies.
I understand the concerns about diversion and abuse of these products and I share these concerns. Nevertheless, moving all of these hydrocodone products to Schedule II will result in significant barriers for patients who have a legitimate need for these products. Sincerely, Maureen Gallagher, RPh.", "comment_id": "FDA-2012-N-0548-0144", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0548-0144", "comment_date": "2013-02-01T05:00:00Z", "comment_title": "Maureen Gallagher - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 2081}, {"text": "Dear Dr. Throckmorton:

I am a community pharmacist and would like to present my views on the implications for pharmacies and impact on patients surrounding the rescheduling of hydrocodone containing products.

While pharmacists share concerns regarding the abuse, misuse and diversion of these prescription drugs, these concerns must be balanced with the impact on patients who legitimately need access to them.

Rather than reschedule hydrocodone containing products, it is important for you to consider the following:

• States Can Reschedule Controlled Substances: Under Federal law, states can act on their
own to place tougher restrictions on the prescribing and dispensing of controlled substances. As a result, any state may classify these products as Schedule II without a change in Federal law, based upon the public health needs and experience of their citizens.

• Products Will Be Harder to Obtain to Treat Pain: Hydrocodone in combination is one of the last non-Schedule II drugs available to treat moderate to severe pain. If these products are reclassified into Schedule II, prescribers will no longer be able to phone in prescriptions to pharmacies for their patients. Schedule II drugs can only be filled after a pharmacy receives a hard copy prescription signed by the prescriber except in an emergency. The process of calling in an emergency supply of a Schedule II medication does not allow for timely and continued access to needed medications. In most instances there is a significant lag time that will often pass before the physician can be reached to provide the required written order. This means delays in properly caring for the patient’s needs.

• Rescheduling Would Likely Increase the Value of Illicit Hydrocodone Products and This May Lead to Increased Crimes in Pharmacies: As you are aware, the issue of pharmacy crime is very serious and unfortunately on the rise. I have serious concerns that pharmacies may become even larger targets than we ", "comment_id": "FDA-2012-N-0548-0197", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0548-0197", "comment_date": "2013-02-06T05:00:00Z", "comment_title": "Sam I Marshall - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 2060}, {"text": "I would like for you to consider the implications of CII scheduling of hydrocodone products for all cancer and home hospice patients. We are in a very rural area with a high percentage of elderly patients. Unfortunately some of these will develop cancer, it is always easier on them to be treated at home, but if the Dr. from their oncology clinic (who is usually in a distant and larger town) cannot call these medicines in, then the patient either does without or has to travel 100 miles just to get a presciption. This just isn't feasible for most families and usually leads to putting the patient in the hospital or nursing home (a much more expensive alternative). Thank you for your consideration. Ronny Hefner, P.D., S&H Pharmacy, McCrory, AR 72101", "comment_id": "FDA-2012-N-0548-0206", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0548-0206", "comment_date": "2013-02-06T05:00:00Z", "comment_title": "ronny hefner - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 764}, {"text": "The moving Hydrocodone products to Schedule C-II will deny many pts with acute as well as chronic pain access to this medication.. especially outside of normal doc's office hours.. which will either increase the work load on ER's, increase medical expenses, or cause the acute pain pt to remain in pain or the chronic pain pt to be thrown into withdrawal.
Who is going to accept responsibility for adding these unnecessary cost to a system that is already out of control.. or allowing pts to be left in pain/withdrawal... which is a form of torture. Maybe our country only finds it unacceptable to torture terrorists who wants to kill us., but not those in our society.
Schedule C-II has not worked all that well to prevent diversion of Oxycodone, Opana and other C-II drugs.. Who believes that putting Hydrocodone in that schedule will alter much diversion?", "comment_id": "FDA-2012-N-0548-0209", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0548-0209", "comment_date": "2013-02-06T05:00:00Z", "comment_title": "Steven R Ariens - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 875}, {"text": "My name is Joshua Favre, and I am a student pharmacist in Mississippi. I have worked in the pharmacy for a little over 5 years now. I do not believe drugs containing hydrocodone should be moved to a class II. I understand the need to control the distribution of the medication, but I do not think this is the way to go about it. Hydrocodone products are given to patients whom just come out of the dentist, the hospital, or for chronic pain. It would be much simpler for the dentist or doctor to be able to call in the prescription for these patients. The chronic users would then have a limited prescription for monthly periods. I have had many elderly patients who come in once every three months to get their three month supply because it ails them to get around on a day to day basis. If the drug was moved to a Class II, I believe the problem would still persist just as it is. ", "comment_id": "FDA-2012-N-0548-0211", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0548-0211", "comment_date": "2013-02-06T05:00:00Z", "comment_title": "Joshua Brian Favre - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 883}, {"text": "January 30, 2013
Douglas C. Throckmorton, M.D.
Deputy Director for Regulatory Programs
Re: FDA-2012-N-0548; Drug Safety and Risk Management Advisory Committee; Notice of
Meeting; Community pharmacy perspective regarding the public health benefits and risks of
drugs containing hydrocodone either combined with other analgesics or as an antitussive.
Dear Dr. Throckmorton:
I am a community pharmacist and would like to present my views on the implications for
pharmacies and impact on patients surrounding the rescheduling of hydrocodone containing
products. While pharmacists share concerns regarding the abuse, misuse and diversion of these
prescription drugs, these concerns must be balanced with the impact on patients who
legitimately need access to them.Rather than reschedule hydrocodone containing products, it is important for you to consider the following:
States Can Reschedule Controlled Substances: Under Federal law, states can act on their
own to place tougher restrictions on the prescribing and dispensing of controlled substances.
As a result, any state may classify these products as Schedule II without a change in Federal law, based upon the public health needs and experience of their citizens. I prectice in the state of Florida which has had the ledgon drug carisoprodol in a higher classification for many years. Products Will Be Harder to Obtain to Treat Pain: Hydrocodone in combination is one of the last non-Schedule II drugs available to treat moderate to severe pain. If these products are reclassified into Schedule II, prescribers will no longer be able to phone inprescriptions to pharmacies for their patients. Schedule II drugs can only be filled after a
pharmacy receives a hard copy prescription signed by the prescriber except in an emergency. Rescheduling Would Likely I ncrease the V alue of I llicit Hydrocodone Products and This May Lead to Increased Crimes in Pharmacies: As you are aware, the issue of pharmacy crime is very serious and unfortunate.", "comment_id": "FDA-2012-N-0548-0212", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0548-0212", "comment_date": "2013-02-06T05:00:00Z", "comment_title": "Roland R Medeiros - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 2053}]}, {"id": "DOD-2015-HA-0062", "title": "Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)/\nTRICARE: Refills of Maintenance Medications Through Military Treatment Facility Pharmacies or Nation Mail Order Pharmacy Program", "context": "2020-10-22T01:30:45Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "Attached are the comment of the National Association of Chain Drug Stores", "comment_id": "DOD-2015-HA-0062-0006", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2015-HA-0062-0006", "comment_date": "2015-10-07T04:00:00Z", "comment_title": "Comment on DOD-2015-HA-0062-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 73}, {"text": "Attached please find comments submitted by the National Community Pharmacists Association (NCPA). ", "comment_id": "DOD-2015-HA-0062-0007", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2015-HA-0062-0007", "comment_date": "2015-10-07T04:00:00Z", "comment_title": "Comment on DOD-2015-HA-0062-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 99}, {"text": "These people who have worked so hard to ensure our freedom should not have to worry about their medications. This rule is intended to save a few bucks but at what expense? If our retired military are on maintenance medications they can't afford to miss a day of medications due to any sort of delays ie. snail mail. ", "comment_id": "DOD-2015-HA-0062-0008", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2015-HA-0062-0008", "comment_date": "2015-10-07T04:00:00Z", "comment_title": "Comment on DOD-2015-HA-0062-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 323}, {"text": "Recommend adding the following paragraph under paragraph 5 of Part 199.21 as sub paragraph viii. "All medications not provably known to be chemically stable at temperatures above 150 degrees Fahrenheit will be shipped in climate controlled containers during the months of May through September. All medications not provably known to be chemically stable below the freezing point of water will be shipped in climate controlled containers during the months of November through March. Climate control for these medications will be maintained until in the hands of the customer."

The FDA only certifies medications to be chemically stable between the temperatures of 59 degrees Fahrenheit and 86 degrees Fahrenheit. While some pharmaceutical manufacturers have tested their medications and found the climate control is absolutely necessary, many others have not. UPS trucks and other delivery vehicles in the Southeast U.S. often have on-truck temperatures near the brown sides of their trucks that exceed the boiling point of water. In the winter, particularly in the North, temperatures well below zero are similarly found in these vehicles. Medications exposed to these temperatures can change chemical composition and pose grave risk to the consumer, to include the risk of death. Anecdotal information on mail order pharmacy use in central Alabama has resulted in emergency room visits having been required for some patients as a result of these chemical changes in the heat of summer. The FDA has the necessary reports on file. If mail-order pharmacy use is to be directed, precautions should be taken to ensure the medicines shipped in this matter are kept in proper storage from the door of Express Scripts to the door of the customer.

Those who have served our military and receive these benefits deserve to know their medications are safe. Safeguards should be in place to ensure that all medications are kept within or near the FDA recommended temperature range of 59-86 degrees, unless it is absolutely proven that a particular medication can withstand a greater temperature range. "Best Commercial Practices" do not do this. "Best Commercial Practices" maximize profits, not safety. Those who have served this country deserve to have their safety put first.

As such, I recommend that the proposed insertion of a sub-paragraph viii (8) with the verbiage above, be inserted into the proposed change to the regulations.
", "comment_id": "DOD-2015-HA-0062-0002", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2015-HA-0062-0002", "comment_date": "2015-08-18T04:00:00Z", "comment_title": "Comment on DOD-2015-HA-0062-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 2505}, {"text": "I have concerns that this change while offering some savings to Tricare is only targeting retirees. why aren't active duty being targeted as well? This question has to be asked. Just as there is discussion of hardship waivers, why not blanket waivers for say remote duty stations that have no or limited pharmacy access. Active duty has more readily access the the military pharmacies than most retirees as a good portion of active duty reside on the same military installations the pharmacies. Also will additional staffing be provided at the military pharmacies to accommodate the influx of retirees who will be forced to use the base pharmacy because of this rule? i don't see anything posted about this issue.", "comment_id": "DOD-2015-HA-0062-0005", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2015-HA-0062-0005", "comment_date": "2015-10-05T04:00:00Z", "comment_title": "Comment on DOD-2015-HA-0062-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 721}, {"text": "I have concerns that this change while offering some savings to Tricare is only targeting retirees. The question has to be asked why aren't active duty being targeted as well? Just as there is discussion of hardship waivers, why not blanket waivers for say remote duty stations that have no or limited pharmacy access. Active duty has more readily access the the military pharmacies than most retirees as a good portion of active duty reside on the same military installations the pharmacies. Also will additional staffing be provided at the military pharmacies to accommodate the influx of retirees who will be forced to use the base pharmacy because of this rule? I see nothing posted about augmenting staffing for the certain influx of retirees.", "comment_id": "DOD-2015-HA-0062-0003", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2015-HA-0062-0003", "comment_date": "2015-08-18T04:00:00Z", "comment_title": "Comment on DOD-2015-HA-0062-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 752}, {"text": "I would like to make the following comments to the interim final rule revisions paragraph (r) to 32 CFR 199.21:

(2) Medications covered

(iii) It will be cost effective to dispense the medication from the mail order pharmacy.

"A concerted effort on the part of the mail order pharmacy shall be made to refill all prescriptions, for a patient, at the same time. All the filled prescriptions shall be combined and shipped in a single container ". I take 10 prescribed meds by mouth each day; Express Scripts cannot seem to fill all orders at the same time, rather they ship each med on a staggered basis (even when all scripts are submitted at the same time) thereby charging TRICARE more for shipping and handling. My local pharmacy has no trouble filling all the scripts in a single visit for pick up.

(5) Procedures.

(ii) An effective communication plan that includes efforts to educate beneficiaries in order to optimize participation and satisfaction will be implemented.

There must be an administrative channel for feedback as to the service received. My mail order pharmacy issues many conflicting communications to me and there is no one person to talk to. One representative says something that is conflicted by the follow up representative; notification of shipment status is nearly always wrong in that the med does not get shipped as promised and is weeks behind. I do not know that until I call, then I am informed they have not shipped it yet due to some lame excuse. My satisfaction and health therefore suffer. Prior approvals for brand name meds seem to disappear from the system. My doctors spend a great deal of time writing justification of brand name meds and it appears they are routinely denied. Denials of prescription medically necessary medications are not signed by a medical doctor or anyone, there must be personal accountability! Personally, my experience with the mail order pharmacy is that they basically Deceive, Delay, and Deny prescribed meds for military retirees.

", "comment_id": "DOD-2015-HA-0062-0004", "comment_url": "https://api.regulations.gov/v4/comments/DOD-2015-HA-0062-0004", "comment_date": "2015-09-22T04:00:00Z", "comment_title": "Comment on DOD-2015-HA-0062-0001", "commenter_fname": null, "commenter_lname": null, "comment_length": 2085}]}, {"id": "FDA-2017-P-5396", "title": "Request that the FDA immediately seek removal of oral and transmucosal UHDU opioid analgesics from the market", "context": "2022-02-11T16:25:25Z", "purpose": "Nonrulemaking", "keywords": ["Citizen Petition", "Changes in Opioid Prescribing in the US", "American College of Medical Toxicology", "National Safety Council", "Assoc of State and Territorial Health Officals", "Centers for Disease Control and Prevention", "American Academy of Pain Medicine", "American Pain Society", "UHDU Opioid Analgesics", "OxyContin 80 milligram tablet", "oxycodone", "UHDU opioids", "CDC Guideline", "fatal overdose", "50\u2013100MME", "20 MME", "opioid use disorder"], "comments": [{"text": "I am writing for my husband who is in too much pain to form sentences. He has been removed from his pain medication after 8 years with the same doctor. It is inhumane for the government to decide who is in pain and how much medication they need. Pain patients are committing suicide because they see no way out of the pain they have from failed surgeries AS, cancer,other diseases, end of life pain.
Please think, if this was your family member, how would you feel if they were in excruciating intractable pain every day. The pain medication was working, they had a life, now they don't. They can't work any more or participate in life. Not only are they in pain but they are going through severe withdrawals. Is this what the govt intended when it began to blame long term pain patients for the opioid crises? What about the fake fentanyl being manufactured in China? In Nebraska this week enough of this manufactured or fake fentanyl was found to kill 5M people. Is this the goal Please, have compassion for those who are dying, in agony and can't take a pill.
I have seen that prescriptions for narcotics are down by 70% while death from fentanyl has risen 110% Can't anyone see what is happening? This chart is from MD but I have read other states are the same.", "comment_id": "FDA-2017-P-5396-0138", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-5396-0138", "comment_date": "2017-10-18T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 1291}, {"text": "I do understand the misuse of opiates but I have been on IR Oxycodone as a Chronic Pain Patient there are risk of over taking
medication but as your report says this has been in the ages of 13 to 25 mainly and those ages are very low and the over doses very high. I could understand not wanting anyone in hose age groups not being on that many MME but the Older people that have had Chronic Pain for many years knows the risk to look for and when not to take the medication during those times. Our Government has going why to far trying to stop a street drug problem that has been going on for years in one year and forgetting about Chronic Pain that can not be fixed with surgery or therapy. Some of use had surgery and came out worse than when we had it from no fault of our own and now have no one who will take s own as patients because of the damage done from our first surgery where does that leave us? i even understand wanting to stop the 30 mg oxycodone but this is going to cause more pills to be dispensed at 20 mg. I feel 120 mme would be more realistic than 90 mme at the lower dose per 4 to 6 hours.", "comment_id": "FDA-2017-P-5396-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-5396-0006", "comment_date": "2017-09-07T04:00:00Z", "comment_title": "Comment from Cathy Reiner", "commenter_fname": null, "commenter_lname": null, "comment_length": 1117}, {"text": "Studies are showing that under treating pain is already contributing to the increase of over dose on heroin and fentanyl. The CDC ignored warnings that this would happen. Further restriction will have dire consequences for millions and society as a whole", "comment_id": "FDA-2017-P-5396-0326", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-5396-0326", "comment_date": "2017-11-17T05:00:00Z", "comment_title": "Comment from Kenneth Adams", "commenter_fname": null, "commenter_lname": null, "comment_length": 254}, {"text": "Too many rare disorders we know so little about because of limited research funding. Many cause chronic pain which leads to total disability if not properly treated. Keep chronic pain people working & thriving in life instead of in bed on heating pad unable to concentrate. Pain causes accidents: i ran a red light because while driving, i couldnt concentrate & almost hit a car with kids in it. I did what dr told me - i got up & started moving, but pain will cause more deaths than drug addictions anyday of the week. Untreated pain kills in more ways than acknowledged by anyone.", "comment_id": "FDA-2017-P-5396-0341", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-5396-0341", "comment_date": "2017-11-17T05:00:00Z", "comment_title": "Comment from Mary Kotuba", "commenter_fname": null, "commenter_lname": null, "comment_length": 595}, {"text": "It is irresponsible and cruel to leave those in chronic pain without opioid medication. They are the most effective medications for chronic pain.", "comment_id": "FDA-2017-P-5396-0405", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-5396-0405", "comment_date": "2017-11-24T05:00:00Z", "comment_title": "Comment from Morag Moores", "commenter_fname": null, "commenter_lname": null, "comment_length": 145}, {"text": "See attached file for comments from the American Academy of Pain Medicine.", "comment_id": "FDA-2017-P-5396-0312", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-5396-0312", "comment_date": "2017-11-17T05:00:00Z", "comment_title": "Comment from American Academy of Pain Medicine", "commenter_fname": null, "commenter_lname": null, "comment_length": 74}, {"text": "Vote no on HR 6 so it will protect the chronic pain patients", "comment_id": "FDA-2017-P-5396-1631", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-5396-1631", "comment_date": "2018-09-12T04:00:00Z", "comment_title": "Comment from Kenneth Atwood", "commenter_fname": null, "commenter_lname": null, "comment_length": 60}, {"text": "People suffer from multitude of diseases which can cause intractable pain/ chronic pain and their doctors do tests to arrive at a diagnosis so they can treat them. It's unconscionable that an organization whose name reveals their bias which was arrived at sadly because one of their children had addiction disease and died from overdose would repeatedly attempt to interfere in doctor patient relationship. Furthermore it's absolutely incomprehensible that an org armed with the power of federal government would rather see disabled people suffer pain than admit their efforts are harming thousands if not millions of people. If you have a rodent in your yard are you going to blame your house cat? Statistics are proving the overdose increases are due to illegal street drugs, not prescriptions. This org would beat the house cat because the rodents in the yard are multiplying. If you do not identify the problem correctly all efforts to solve it will fail. I've seen multiple accounts of surgeries, including hip replacements, being done but patients are not receiving pain rx. Has this county lost its mind? There is an old saying 'you can lead a horse to water but you can't make him drink'. You can talk to an addict til you're blue in the face but if they. are not willing, you can't make them stop unless you lock them up. It took years for me to get a diagnosis of my autoimmune disease. It has affected all my bones and now my organs. My pain never ends and at times is comparable to child birth. If I was unable to have pain rx I would not be able to participate in daily activities. I can't even hold a phone because of pan and numbness in my hands, and this is the least of my challenges. Don't discount my life because someone else decided to try drugs and misuse them due to addiction receptor disease. I may be disabled but should not be discounted. Don't ban these meds and please stop harassing doctors who are trying to help people have some semblance of a normal life.", "comment_id": "FDA-2017-P-5396-0569", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-5396-0569", "comment_date": "2018-01-02T05:00:00Z", "comment_title": "Comment from P K", "commenter_fname": null, "commenter_lname": null, "comment_length": 2032}, {"text": "You Really Need to stop reducing opioid meds because you Know as well as Anyone with Internet that it's NOT prescribed opioid meds causing this! It's the Street Drugs including illicit and illegal drugs period!", "comment_id": "FDA-2017-P-5396-1636", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-5396-1636", "comment_date": "2018-09-12T04:00:00Z", "comment_title": "Comment from Glen Frink", "commenter_fname": null, "commenter_lname": null, "comment_length": 218}, {"text": "Ive dealt with degenerative disc disease, CRPS, fibromyalgia, raynauds disease and tachycardia. Because if all my health issues Ive had to search for medication and treatments that worked best for me. These health issues will never go away completely so I search for the best quality of life. Ive found the best combination for me is watch my diet, physical therapy, chiropractic care, stretching, pain medication and other treatments like stem cell injections. This combination is what works. Pain medication is essential in this combination so that I can get up daily and be productive running my internet talk show.
Ive advocated for the chronic pain committed for over 2 years. What PROP is suggesting will not change the overdose numbers in the way you would think. It will cause overdose rates to go up, more suicides and people will develop other major health issues due to the effects one has in high levels of pain. Im an example of this. My doctor tapered me below the 90mme for over a year and I developed tachycardia due to thigher blood pressure and constant out of control pain.
FDA please let doctors make the decision as to what each patient should have for medications and treatments. ", "comment_id": "FDA-2017-P-5396-1633", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-5396-1633", "comment_date": "2018-09-12T04:00:00Z", "comment_title": "Comment from Jonelle E", "commenter_fname": null, "commenter_lname": null, "comment_length": 1212}]}, {"id": "DEA-2009-0008", "title": "Schedules of Controlled Substances:\r\nPlacement of 5-Methoxy-N,NDimethyltryptamine\r\nInto Schedule I of\r\nthe Controlled Substances Act", "context": "2021-12-02T01:00:54Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "Please do not add 5-Methoxy-N,NDimethyltryptamine , or 5-MeO-DMT (5-methoxy-dimethyltryptamine) into Schedule I of
the Controlled Substances Act.

Thank you.
Aneitra Batteast", "comment_id": "DEA-2009-0008-0005", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2009-0008-0005", "comment_date": "2009-09-10T04:00:00Z", "comment_title": "Aneitra Batteast comment on DEA 331", "commenter_fname": "Aneitra", "commenter_lname": "Batteast", "comment_length": 190}, {"text": null, "comment_id": "DEA-2009-0008-0003", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2009-0008-0003", "comment_date": "2009-09-01T04:00:00Z", "comment_title": "Steve Lefevre Comment on DEA-331", "commenter_fname": "Steve", "commenter_lname": "Lefevre", "comment_length": 0}, {"text": null, "comment_id": "DEA-2009-0008-0006", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2009-0008-0006", "comment_date": "2009-09-17T04:00:00Z", "comment_title": "Jonathan comment DEA-331", "commenter_fname": "Jonathan", "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "DEA-2009-0008-0002", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2009-0008-0002", "comment_date": "2009-09-01T04:00:00Z", "comment_title": "Michael Winthrop Commnet on DEA-331", "commenter_fname": "Michael", "commenter_lname": "Winthrop", "comment_length": 0}, {"text": null, "comment_id": "DEA-2009-0008-0004", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2009-0008-0004", "comment_date": "2009-09-09T00:00:00Z", "comment_title": "Jonathan comment on DEA-331", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": "File ", "comment_id": "DEA-2009-0008-0007", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2009-0008-0007", "comment_date": "2009-09-22T04:00:00Z", "comment_title": "Comment on DEA 331", "commenter_fname": null, "commenter_lname": null, "comment_length": 5}]}, {"id": "FDA-2019-P-1679", "title": "Requests that the FDA revoke orphan drug designation for Sublocade (buprenorphine extended-release) injection for treatment of opiate addiction in opiate users, currently referred to as opioid use disorder", "context": "2019-11-07T16:23:01Z", "purpose": "Nonrulemaking", "keywords": ["revoke orphan drug designation for Sublocade", "(buprenorphine extended-release) injection for", "treatment of opiate addiction in opiate users,", "currently referred to as opioid use disorder", "OPEN", "Goodwin Procter LLP", "Braeburn, Inc.", "Citizen Petition", "CDER"], "comments": [{"text": "Andrea G. Barthwell, M.D. D.F.A.S.A.M.", "comment_id": "FDA-2019-P-1679-0046", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1679-0046", "comment_date": "2019-05-09T04:00:00Z", "comment_title": "Comment from Andrea Barthwell", "commenter_fname": null, "commenter_lname": null, "comment_length": 39}, {"text": "See attached file(s)", "comment_id": "FDA-2019-P-1679-0072", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1679-0072", "comment_date": "2019-07-25T04:00:00Z", "comment_title": "Comment from Edward Nunes", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "I know firsthand the devastation of the Opioid Addiction crisis. My husband and son have struggled with addiction for many years. My nonprofit organization Maryland Heroin Awareness Advocates (MHAA) is requesting the FDA to please strip the orphan designation granted to Sublocade.

Every individual is different and no single treatment will work for all of them. The more available treatment options we have will save lives, and are necessary to curb the massive deaths from opioid intoxication. This is definitely not a rare disease, and too many people who suffer don't have access to quality, long term treatment. We need to bring more medically assisted treatments to market not keeping treatments that have been found to be safe and effective off the market. The FDA needs to be on the side of patients and bring more treatments to the market.

The FDA should strip Sublocade of its orphan designation and ensure that more needed treatments are available to help stem this crisis.", "comment_id": "FDA-2019-P-1679-0048", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1679-0048", "comment_date": "2019-05-14T04:00:00Z", "comment_title": "Comment from Maryland Heroin Awareness Advocates", "commenter_fname": null, "commenter_lname": null, "comment_length": 1009}, {"text": "Medication assisted therapy is proven to be effective for patients in abstaining from use and remaining in treatment programs as well as reducing their risk of overdose. Our options are currently limited and restrictive, as they dont provide many opportunities for patients with less than perfect adherence. Just as we have seen with injectable antipsychotic medication, removing the variable of adherence for such an important disease state keeps people healthy longer. Compared to schizophrenia, this often means saving lives for patients with opioid use disorder. The classic definition of an orphan drug does not apply to this product and we need access to as many tools as possible to help these patients. Allowing another medication option will only give us more versatility to treat all patients in a way that works best for them. ", "comment_id": "FDA-2019-P-1679-0040", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1679-0040", "comment_date": "2019-05-03T04:00:00Z", "comment_title": "Comment from Haley Pals", "commenter_fname": null, "commenter_lname": null, "comment_length": 838}, {"text": "A medication such as buprenorphine cannot he considered an orphan drug when it is being used as the principle medication to treat a disease that has been declared a public health crisis. The FDA has stated that they are invested in making it easier for new treatments to be made available for the treatment of opioid use disorder however their actions show otherwise. As a treatment provider who sees the damage this disease causes to individuals and their families, I see the urgent need to have every life saving treatment made available today and not in 7 years from now.", "comment_id": "FDA-2019-P-1679-0028", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1679-0028", "comment_date": "2019-04-15T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 575}, {"text": "I write in my capacity as Professor of Psychiatry at NYU School of Medicine and as a NIDA-funded researcher focused on clinical trials for OUD. In the midst of an opioid crisis that affects several million people directly, plus family, friends, communities, there is a compelling need for a broad range of treatment options, and there seems to be no justification for orphan drug status, nor orphan disease exclusivity, neither on the basis of the size of the population, nor on the size of the market, nor exclusivity on the basis of "similarity." People need all of the pharmacotherapy options available, including various formulations (and durations of action) of buprenorphine, extended release naltrexone, methadone, etc. CAM2038, an alternative long-acting form of buprenorphine, differs substantially from Sublocade insofar as it can be initiated without a 7-day sublingual run-in period, making it the only long-acting opioid treatment that can be initiated directly in emergency departments (critical settings in which to intervene and save lives), and it does not contain NMP which precludes Sublocade use in pregnancy. ", "comment_id": "FDA-2019-P-1679-0031", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1679-0031", "comment_date": "2019-04-17T04:00:00Z", "comment_title": "Comment from John Rotrosen", "commenter_fname": null, "commenter_lname": null, "comment_length": 1144}, {"text": "The opioid epidemic is taking lives in my community and impacting many people that I love. Granting orphan drug exclusivity will limit the treatments available to those who need them most. This makes no sense whatsoever. Right now, we need MORE treatments on the market, NOT less. Please reverse this terrible decision immediately.", "comment_id": "FDA-2019-P-1679-0030", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1679-0030", "comment_date": "2019-04-16T04:00:00Z", "comment_title": "Comment from Matthew Harmon", "commenter_fname": null, "commenter_lname": null, "comment_length": 331}, {"text": "I am the Director and Founder of No More ODs, Inc. a Savannah Harm Reduction Coalition. We train and equip first responders, schools, restaurant staff, individuals or anyone that may come into contact with someone at risk of an opiate overdose, on how to identify an opiate overdose and how to reverse it.

After a life is saved, it is imperative to have resources available in order for the person to be able to live a healthy life of recovery. We need to be able to give options and choices to find the right fit for their Opioid Use Disorder.

I lost my son, Austin, to an opiate overdose 14 years ago. He didnt have the options available for a medically treated recovery. Granting orphan exclusivity to Sublocade would block other, needed treatments from being available to patients who need more options. Please do not grant orphan exclusivity to Sublocade, and please revoke its orphan drug designation. We need to ensure that patients can access to all safe and effective medications.
", "comment_id": "FDA-2019-P-1679-0043", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1679-0043", "comment_date": "2019-05-09T04:00:00Z", "comment_title": "Comment from Lesli Messinger", "commenter_fname": null, "commenter_lname": null, "comment_length": 1020}, {"text": "Hello. I am writing in reference to the petition being filed by Goodwin Procter against the FDAs decision to grant Sublocade orphan drug status. As a dual board certified Addiction Specialist and Family Medicine Physician, I work as a Regional Medical Director for CleanSlate Centers. We provide treatment to 13,000 patients in 11 states with OUD every day. I have personally had more than 15 years prescribing buprenorphine products.

On 1/10/18, Governor Wolf rightly declared the opioid epidemic an official statewide disaster in my home state of Pennsylvania following President Trump's declaration in October of 2017. Pennsylvania had 5559 opioid overdose related deaths in 2017. This is an all hands on deck disaster that demands every tool in the shed to be available for our patients.

I very much appreciate the benefit that buprenorphine related medications have brought to the table in treating this epidemic. I strongly believe that buprenorphine is directly accountable for countless lives saved during this crisis. I regularly see patients go from hopelessness to holding down a job and resurrecting their families in a matter of months or even weeks when they go through our program.

However, I firmly believe that as Alan Leshner, the former director of NIDA declared "All treatment works for some patients. No one treatment works for all patients". On the frontlines treating this epidemic, it is vital that we are given as many tools as possible. Indivior's product is a good product; however, it falls short in many instances. Having a product that is only injected once a week and indicated for induction in addition to maintenance in the treatment of OUD is invaluable.

I strongly urge you to please revoke the orphan drug status for Sublocade and allow other innovative people to continue to supply the medical world with much needed tools. ", "comment_id": "FDA-2019-P-1679-0047", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1679-0047", "comment_date": "2019-05-09T04:00:00Z", "comment_title": "Comment from Todd Fausnaught", "commenter_fname": null, "commenter_lname": null, "comment_length": 1931}, {"text": "I write this comment in my capacity as a former Governor of New Jersey and as the Chairman of President Trump's Commission on Drug Addiction and the Opioid Crisis.

During my time as Governor I declared the opioid crisis a public health emergency and passed package of bills that expanded access to treatment and reduced opioid prescriptions by over 26% in its first year. I know that one of the keys to dealing with the crisis of losing 72,000 Americans a year is to make more medication assisted treatment available to more people in the throes of addiction.

The FDA's decision to deny access to a buprenorphine depot injection treatment is against public policy and contrary to one of the specific recommendations of President Trump's Commission which I chaired. As an aside, the President himself has adopted that recommendation and 64 others from his Commission.

The reason for the decision is even more wrong headed--an illogical application of the Orphan Drug designation and resulting exclusivity. This is a decision that must be revisited to further add to the medical community's arsenal to deal with this deadly addiction crisis.

The Orphan Drug Act was enacted to encourage research and development of treatments that may otherwise go undiscovered. Buprenorphine is in no way, shape or form an orphan drug. There are millions of American suffering from addiction who could benefit from additional therapies to deal with their disease. This action by the FDA is contrary to that laudable and necessary goal of the Commission and, just as importantly, contrary to the intent of the law as enacted. The exclusivity decision was meant to compensate for an otherwise unprofitable drug. Quite to the contrary, Sublocade is projected to be extremely profitable.

This 1994 decision is no longer consistent with public health needs of 2019. The FDA must look at the needs of millions of Americans and make more treatments, not fewer, available to those in need. The FDA actions are not consistent with Administration policy. The FDA actions are contrary to implementing effective public health policy for this country. The FDA designation of Sublocade as an orphan drug is contrary to the law as passed and injurious to the public it is supposed to serve.

I urge the FDA to rescind this decision and to make more treatments available to those who suffer from the disease of addiction. As a former Governor and Chairman of the President's Commission on this very topic, I have spent a great deal of time studying this issue in detail. I am convinced that rescinding this will save lives. Isn't that one of the key missions of the FDA? I hope that is true on behalf of millions of families from New Jersey and across America who are suffering today and frantically searching for hope.

Respectfully,

Chris Christie
55th Governor of New Jersey
Chairman, President's Commission on Drug Addiction and the Opioid Crisis ", "comment_id": "FDA-2019-P-1679-0054", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1679-0054", "comment_date": "2019-05-30T04:00:00Z", "comment_title": "Comment from Chris Christie", "commenter_fname": null, "commenter_lname": null, "comment_length": 3023}]}, {"id": "FDA-1998-N-0155", "title": "Treatment of Narcotic Dependence", "context": "2021-09-01T18:03:27Z", "purpose": "Rulemaking", "keywords": ["DETOXIFICATION TREATMENT", "NARCOTIC DEPENDENCE", "MAINTENANCE", "NARCOTIC DRUGS", "cder"], "comments": [{"text": null, "comment_id": "FDA-1998-N-0155-0117", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1998-N-0155-0117", "comment_date": "2009-05-22T04:00:00Z", "comment_title": "Commonwealth of PA, Dept of Health - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-1998-N-0155-0119", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1998-N-0155-0119", "comment_date": "2009-05-22T04:00:00Z", "comment_title": "Bazelon Center for Mental Health Law etc - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-1998-N-0155-0034", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1998-N-0155-0034", "comment_date": "2009-05-03T04:00:00Z", "comment_title": "NIDA - IRP, Clinical Trials Section - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-1998-N-0155-0041", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1998-N-0155-0041", "comment_date": "2009-05-04T04:00:00Z", "comment_title": "Essex Substance Abuse Treatment Center I - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-1998-N-0155-0040", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1998-N-0155-0040", "comment_date": "2009-05-04T04:00:00Z", "comment_title": "Oregon Dept of Human Resources - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-1998-N-0155-0054", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1998-N-0155-0054", "comment_date": "2009-05-07T04:00:00Z", "comment_title": "Springfield Medical Clinic - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-1998-N-0155-0048", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1998-N-0155-0048", "comment_date": "2009-05-07T04:00:00Z", "comment_title": "Discovery House - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-1998-N-0155-0039", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1998-N-0155-0039", "comment_date": "2009-05-04T04:00:00Z", "comment_title": "New Horizons Health Services Inc - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-1998-N-0155-0035", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1998-N-0155-0035", "comment_date": "2009-05-04T04:00:00Z", "comment_title": "Texas National Alliance of Methadone - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-1998-N-0155-0036", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1998-N-0155-0036", "comment_date": "2009-05-04T04:00:00Z", "comment_title": "Tennessee Methadone Advocates Coalition - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}]}, {"id": "FDA-2005-P-0055", "title": "requesting that the Commissioner of Food and Drugs recommend scheduling of tramadol under the Controlled Substances Act.", "context": "2021-09-01T01:01:13Z", "purpose": "Nonrulemaking", "keywords": ["chronic pain", "alcohol dependence", "drug users", "methadone", "Rosei Rocha-Judd", "Controlled Substances Act", "tramadol", "CDER"], "comments": [{"text": "See attached", "comment_id": "FDA-2005-P-0055-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2005-P-0055-0004", "comment_date": "2016-03-22T04:00:00Z", "comment_title": "Comment from Ortho-McNeil, Inc. (Hyman, Phelps & McNamara)", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}]}, {"id": "VA-2017-VHA-0004", "title": "AP94 - Interim Final Rule - Fertility Counseling and Treatment for Certain Veterans and Spouses", "context": "2019-03-07T08:26:27Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "Given that thousands of veterans suffer from the inability to reproduce naturally after combat or training and could benefit from the IVF treatments, it is important to note that each attempt costs $12,000, not including the medications that can cost up to $5,000, which is a lot for anyone to pay out of pocket. I do feel that for veterans with service-connected disabilities the costs should be handled, ultimately costing the veteran and their spouse nothing. I also agree with the combination of the previous comments from Morgan Rector and Julianna Duncan saying that if it was not a full service-connected injury causing them to be incapable of naturally reproducing, then the cost should be dealt with to an extent, but not fully by The Department of Veterans Affairs. I also think Steven Ham's question over coverage of fertility treatments for veterans with PTSD should be examined within the regulation. ", "comment_id": "VA-2017-VHA-0004-0010", "comment_url": "https://api.regulations.gov/v4/comments/VA-2017-VHA-0004-0010", "comment_date": "2017-03-08T05:00:00Z", "comment_title": "Comment on AP94 - Interim Final Rule - Gomel, Trisha", "commenter_fname": "Trisha", "commenter_lname": "Gomel", "comment_length": 918}, {"text": "I have attended the past few Veterans' Affairs hearings and this issue continuously arose. All references to this topic have been completely positive and there are many wishes to continue the support for FY 18. I am in accordance to these views. I believe veterans held up their promise to serve this country and the least congress can do is make sure they are served to the best of this nations ability. I agree with Trisha Gomel's comment when she stated her feelings in regards to veterans with service-connected disabilities. Their costs should be covered, ultimately costing the veteran and their spouse nothing. I am also in accordance to Steven Ham's question over coverage for veterans with PTSD. I think there should be evaluations for all IVF patients and spouses, as well as further evaluations for those who may be borderline on mental health issues. ", "comment_id": "VA-2017-VHA-0004-0012", "comment_url": "https://api.regulations.gov/v4/comments/VA-2017-VHA-0004-0012", "comment_date": "2017-03-15T04:00:00Z", "comment_title": "Comment on AP94 - Interim Final Rule - Bustos, Alysse", "commenter_fname": "Alysse", "commenter_lname": "Bustos", "comment_length": 875}, {"text": "Given the information and statistics on genitourinary injuries it should be a top priority to add fertility counseling and treatments for certain veterans to the Veteran's Health Care Act. It is unfair for veterans not to have the ability to procreate because of injuries sustained at work. Also this will take stress away from current active duty, because there will no longer be a need to have children as soon as possible. With so much medical advancement for IVF the costs for treatment are no longer as high as they once were. Steven Ham's comments on fertility treatment for individuals with PTSD should also be further looked at. Treatments such as IVF may not be necessary for mental situations but fertility counseling maybe a cheaper solution for these situations. ", "comment_id": "VA-2017-VHA-0004-0015", "comment_url": "https://api.regulations.gov/v4/comments/VA-2017-VHA-0004-0015", "comment_date": "2017-03-21T04:00:00Z", "comment_title": "Comment on AP94 - Interim Final Rule -Gullan, Steven", "commenter_fname": "Steven", "commenter_lname": "Gullan", "comment_length": 783}, {"text": "I would like to know why my son Collin Nesbitt had to pay for IVF when he got cancer while he was in the military and lost his ability to have kids do I have to contact President Trump to get this taken care of he should be re embersed for have to pay for this.
John Nesbitt
Father of Collin Nesbitt", "comment_id": "VA-2017-VHA-0004-0004", "comment_url": "https://api.regulations.gov/v4/comments/VA-2017-VHA-0004-0004", "comment_date": "2017-02-14T05:00:00Z", "comment_title": "Comment on AP94 - Interim Final Rule - Nesbitt, John", "commenter_fname": "John", "commenter_lname": "Nesbitt", "comment_length": 307}, {"text": "I believe that The Department of Veteran Affairs should cover all In Vitro Fertilization costs for any veterans that were injured in service which resulted in the inability to naturally reproduce and their spouses. These people were selflessly serving our country and they deserve the opportunity to start a family of their own and build a life for themselves. It is the least we can do for them since they give up so much and risk their lives for the United States. Plus, In Vitro Fertilization can be very expensive and not many people can afford to do such a thing, especially veterans coming out of the service who may not have a concrete career to pay for it. I support this proposal and these new regulations and hope that this proposal is passed and that our veterans are given the choice to start their own family. ", "comment_id": "VA-2017-VHA-0004-0008", "comment_url": "https://api.regulations.gov/v4/comments/VA-2017-VHA-0004-0008", "comment_date": "2017-02-21T05:00:00Z", "comment_title": "Comment on AP94-Interim Final Rule-Duncan, Julianna", "commenter_fname": "Julianna", "commenter_lname": "Duncan", "comment_length": 823}, {"text": "my name is Tobi, am 28.
I have always aspire to be a military personnel since I was little which i later change my mind. this is basically because of an uncle (US Army) that turned impotent after a severe injury during war. he is 54years old and he has no child (contrary to his wish). now he can not afford to pay for IVF likewise his insurance. implementing this rule will not only give hope to these kind of veteran but could also encourage more military aspirants.", "comment_id": "VA-2017-VHA-0004-0011", "comment_url": "https://api.regulations.gov/v4/comments/VA-2017-VHA-0004-0011", "comment_date": "2017-03-09T05:00:00Z", "comment_title": "Comment on AP94 - Interim Final Rule - Olu, Tobi", "commenter_fname": "tobi", "commenter_lname": "olu", "comment_length": 473}, {"text": "See attached file(s)", "comment_id": "VA-2017-VHA-0004-0013", "comment_url": "https://api.regulations.gov/v4/comments/VA-2017-VHA-0004-0013", "comment_date": "2017-03-21T04:00:00Z", "comment_title": "Comment on AP94 - Interim Final Rule - Byers, Michael", "commenter_fname": "Michael", "commenter_lname": "Byers", "comment_length": 20}, {"text": "My husband is service connected for testicular cancer and can no longer have children we recently paid out of pocket 17,000 and when we called champva and went to billing at Local VA hospital no one knew anything about this at all. Luckily my husband spoke infront of the senate committee of veterans affairs about PTSD in Sacramento at the capital building and has some of the senates personal numbers. I think he should call them about this.", "comment_id": "VA-2017-VHA-0004-0005", "comment_url": "https://api.regulations.gov/v4/comments/VA-2017-VHA-0004-0005", "comment_date": "2017-02-14T05:00:00Z", "comment_title": "Comment on AP94 - Interim Final Rule - Nesbitt, Alena", "commenter_fname": "Alena", "commenter_lname": "Nesbitt", "comment_length": 443}, {"text": "Submitted in response to RIN 2900AP94Fertility Counseling and Treatment for Certain Veterans and Spouses

The American Society for Reproductive Medicine appreciates the opportunity to comment on the amendments made by the Department of Veterans Affairs to its regulations allowing fertility counseling and treatment to be made available to certain veterans and their spouses.

ASRM is a multidisciplinary organization of nearly 8,000 professionals dedicated to the advancement of the art, science, and practice of reproductive medicine. Distinguished members of ASRM include obstetricians and gynecologists, urologists, reproductive endocrinologists, embryologists, mental health professionals and others.

Members of this country's armed services, injured in active duty in a way that results in their inability to have children without the use of medical treatment, deserve to receive the treatments they need to build their families regardless of whether they seek this treatment while still serving or after separation from service. Therefore, we are in support of the work the Veterans Administration is doing to develop policy and clinical guidelines, consistent with those of the Department of Defense, for providing fertility care and IVF treatment to our veterans.

With 2.8 to 5% of combat injuries to US troops involving genitourinary trauma and the great majority of the injured under the age of 35, there is a definite need for fertility care for this population. While the VA has been able to provide certain fertility treatments, the agency has until now been prohibited by law from offering in vitro fertilization, preventing it from providing precisely the care needed by some of those who have been most severely injured.

We remain very concerned, however, that the legislation that allows expanded assisted reproductive services, i.e., IVF, through the VA is temporary. The need for IVF among injured veterans and their spouses is not going to disappear when the benefit included in the appropriations bill expires on September 30, 2018. The amendment made to VA regulations operates to bring the fertility treatments provided in the Veterans' medical benefits package into line with the fertility treatments available through the DoD to active duty personnel, which is exactly where they need to be and where they need to stay.

ASRM, working with veterans' organizations and infertility patients' organizations, will continue to advocate for repeal of the ban on VA's provision of IVF and to make IVF a permanent part of the Veterans' medical benefits. We hope to be able to achieve this by the time the amendment expires.
", "comment_id": "VA-2017-VHA-0004-0016", "comment_url": "https://api.regulations.gov/v4/comments/VA-2017-VHA-0004-0016", "comment_date": "2017-03-21T04:00:00Z", "comment_title": "Comment on AP94 - Interim Final Rule - Nicoll, Eleanor", "commenter_fname": "Eleanor", "commenter_lname": "Nicoll", "comment_length": 2725}, {"text": "I applaud the Department of Veteran Affairs for establishing the amendment to the services that are currently provided to veterans. I am glad to read (and agree) with the various comments in support of the VA offering fertility treatments to veterans suffering from the inability to procreate due to a service related injury. I believe that veterans should be able to obtain various medical care for them to live a healthy and fulfilling life. ", "comment_id": "VA-2017-VHA-0004-0014", "comment_url": "https://api.regulations.gov/v4/comments/VA-2017-VHA-0004-0014", "comment_date": "2017-03-21T04:00:00Z", "comment_title": "Comment on AP94 - Interim Final Rule - H., Kayleigh", "commenter_fname": "Kayleigh", "commenter_lname": "H", "comment_length": 444}]}, {"id": "FDA-2017-N-5608", "title": "Opioid Policy Steering Committee", "context": "2018-03-08T11:28:23Z", "purpose": "Nonrulemaking", "keywords": ["2017-818"], "comments": [{"text": "Please stop this witch hunt!!! I hope and pray none of you ever have to live like I do!!! If these "guidelines" were put out just to family practice Dr's then why has no one stepped up to tell these pain specialists to continue treating their pain pts... it's heroin killing people!!! You are taking away someone's only ability to function, without my meds I can't be a good wife and/or mother, I've done back and neck injections and they don't help with my chronic everyday pain, I did physical therapy until it stopped working, these meds weren't my first choice but they gave me my life back and now you're literally killing people because they see no hope anymore and they kill themselves because the pain is too much to handle, I'm curled up in the fetal position when my pain isn't under control and not able to take care of my family and bawling my eyes out!!! The state and/or government shouldn't be this involved in a Dr caring for their patient and no two patients are the same either, it's not a one size fits all ", "comment_id": "FDA-2017-N-5608-0155", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-5608-0155", "comment_date": "2017-11-13T05:00:00Z", "comment_title": "Comment from Tera Dabb", "commenter_fname": null, "commenter_lname": null, "comment_length": 1085}, {"text": "Hello, I am a medical professional, chronic pain sufferer and concerned citizen. It is well-known that the current crisis is fueled by heroin and illicit fentanyl more than pain medications and that we are repeating history. When we shut the pill mills down without offering any help to the patients who used them, we created a heroin epidemic that is the main source of overdoses today. Now, we are cutting off legitimate pain patients in the same manner without seeing the harm that does. After being abruptly cut off, these patients are in immense, unbearable pain and either commit suicide or buy fentanyl-laced prescription medications from street dealers, which causes them to overdose. Again, we are contributing to the opioid epidemic with short-sighted and overreaching policies.

Doctors are no longer prescribing these medications like they did in the past and are stopping entirely in some cases due to fear. We do not put the blame on a doctor if their diabetic patient goes against medical advice and is harmed due to noncompliance, yet we continue to prosecute pain management doctors when their patients harm themselves by going against medical advice. Why?

When we do actually get treatment for chronic pain patients who have been cut off, we put them on opioid maintenance medications like Suboxone. So, we essentially take them off of their opioid maintenance program just to put them on a new, more expensive one and treat them like criminals. Again, why?

The only way that we are going to solve this crisis is by focusing on the real problem: Addiction. Until we overhaul our addiction treatment and make it more affordable, less confusing and more effective, we will always have a problem with opioids. We need to stop focusing so much on legitimate patients who require these medications to be productive members of society and instead focus on helping those who are addicted.

It does not matter how many guidelines or policies or laws you make regarding pain medications, none of them will do any good. So far, in fact, they have really only made things worse. Please, for the sake of Americans across this country, begin focusing your efforts and money on addiction treatment that actually works. Only then will anything change.

Thank you. ", "comment_id": "FDA-2017-N-5608-0156", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-5608-0156", "comment_date": "2017-11-17T05:00:00Z", "comment_title": "Comment from Hillary B.", "commenter_fname": null, "commenter_lname": null, "comment_length": 2314}, {"text": "After numerous surgeries over the years for severe endometriosis, I was left with chronic pelvic pain due to scar tissue (that is aggravated by prolonged standing) and a condition called Pudendal Neuralgia (nerve damage that causes severe pain in the groin, vaginal and anal area with any amount of sitting) making it unbearable for me to sit for longer than 20 minutes. In fact, I had to give up a good government job because of the pain and was largely bed-ridden until I got into a comprehensive pain management program. For the past twelve years my pain has become manageable, and my life restored to some level of normalcy, with a number of pain medications that include opioids. The dosage is low (from 10mg to 30mg of Oxycodone per day) and I am permitted to take them "as needed", up to the aforementioned maximum dose, since my pain level varies from day to day depending on the nature and extent of my activity. I would like to point out, however, that my dosage has not changed in the entire twelve years I have been on this treatment regimen. Like so many other chronic pain sufferers, I do not...or should say dare not...abuse these medications as they mean the difference between a life worth living or wishing to die due to severe daily pain and activity restrictions. While illegal drug abuse and addiction is certainly a situation that needs to be addressed, please DO NOT punish those of us who depend on these medications for chronic pain relief by imposing unreasonable regulations that tie the hands of the responsible and ethical medical professionals running comprehensive programs of carefully monitored pain management...such as the one I attended until the new burdensome regulations made it impossible for them to continue their practice and they were forced to close down. ", "comment_id": "FDA-2017-N-5608-0247", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-5608-0247", "comment_date": "2017-11-28T05:00:00Z", "comment_title": "Comment from Janice H.", "commenter_fname": null, "commenter_lname": null, "comment_length": 1817}, {"text": "Is it necessary, is it safe, to include acetaminophen to every hydrocodone pill? Why can't you release an acetaminophen-free drug to reduce liver damage?", "comment_id": "FDA-2017-N-5608-0251", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-5608-0251", "comment_date": "2017-11-28T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 158}, {"text": "I have have four back surgeries and have been on and off opiates for over 30 years. I all that time I have stayed around the same dose of my opiate medication for the past 10 years even though my back has gotten much worse. As you can image I have have had many non-FDA approved epidural (which none worked) NSAID's that gave me 3 bleeding ulcers and 3 nights in ICU, PT, acupuncture,biofeedback and all other types of treatment, creams and braces. What I have found that allows me to get out of bed so I can live on my own is my opiate medication. My medication also helps me get to the store, helps me stand to fix my meals, exercise to keep my weight down and then to have enough relief to sleep when it is time too. The result that have been used have been faulse and we all know this is about money. Meanwhile you should ask you this question since these medications are so hard for people who really need them to get them prescribed to them why is more people dying each year from opiate overdoses? Basically the more the government gets involved in taking pain medication away from chronic pain patient and punsihing doctors who are treating us the more people who have died and will continue to do so. Get rid of the CDC requirement for chronic pain patients.
Below is what I deal wih every day", "comment_id": "FDA-2017-N-5608-0357", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-5608-0357", "comment_date": "2017-12-12T05:00:00Z", "comment_title": "Comment from Jenifer Markoe", "commenter_fname": null, "commenter_lname": null, "comment_length": 1310}, {"text": "The Abuse Deterrent Coalition has attached it's comment to this submission.", "comment_id": "FDA-2017-N-5608-0557", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-5608-0557", "comment_date": "2017-12-27T05:00:00Z", "comment_title": "Comment from Abuse Deterrent Coalition", "commenter_fname": null, "commenter_lname": null, "comment_length": 79}, {"text": "Please work on making more medication like Ultram and Nucynta, which are less likely to cause addiction, but still help chronic pain patients to function. Don't just turn your back on chronic pain patients without offering a solution. Please keep in mind that chronic pain patients are not the enemy, are not all abusers, misusers. Please keep chronic pain patients and their daily agony in mind when trying to solve this issue. Denying people relief who are in extreme pain is probably why a lot of people turn to obtaining them illegally. Yet, many doctor's offices are doing just that, and offering no other solutions. That seems like it will just make the problem even worse, not better. And forcing people to suffer to an extreme because of someone else's actions seems cruel.", "comment_id": "FDA-2017-N-5608-0394", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-5608-0394", "comment_date": "2017-12-19T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 793}, {"text": "People that are suffering from chronic pain such as Complex Regional Pain Syndrome which there is no cure for and is rated the highest pain level on the McGill Pain Scale are suddenly being told by their pain management doctor's that their dose of pain meds will be lowered or are being cut off cold turkey. People with this disease are not abusing their meds, they are urine tested. These meds make it able for them just to get out if bed. It's not fair that the doctor's have to be afraid of losing their licence's. They should not be told how to treat their patients.This disease Complex Regional Pain Syndrome is known as the Suicide Disease because people can't take the pain anymore. It affects all the limbs, internal organs and much more. You have no idea how many have taken their lives already. People in their 20's, mother's and father's, and many more. If the FDA and the Center for Disease Control keep dictating these rules to pain management doctor's there is going to be a lot more suicides. We should not have to be punished for the real drug addicts. We do not choose to have this disease and should not have our pain meds be taken away. I know of hundreds already going through this. The pain management doctor's should be able to treat their patients as they seem fit. Thank you", "comment_id": "FDA-2017-N-5608-0461", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-5608-0461", "comment_date": "2017-12-21T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 1338}, {"text": ""A one size fits all" dosing limit on opioids cannot be established. It fails to take into account the variations in individuals such as their condition, level of pain, genetic drug metabolism differences, and differences in ability to absorb in the GI tract. What suits one will never suit all. This needs to be left between the doctor and the patient to establish what is safe and effective for that individual and their needs.

I am a multiple rare disease patient, who suffers from severe intractable pain caused by my conditions. I have Adhesive Arachnoiditis, Ehlers-Danlos Syndrome, Chiari Malformation 1.5, cerebellar slumping, CRPS, and chronic spontaneous cerebrospinal fluid leaks.
A year and a half ago, my own pain management group forceable tapered all patients down to 90 mme. This took my own dosage, which I had been stable at for 8 years, down by 2/3rd. My pain became so severe that I could no longer function; I could not sleep, and when I did I had nightmares because of my pain. I could not even think; the pain was like a roar, and it drowned out even my own thoughts. It was not only terrible mentally; suffering that level of pain 24 hours a day had serious consequences for my physical health. The stress on my body caused my conditions to progress must faster, which meant losing the use of my arm and hand. I eventually finally left that pain practice when I reached a breaking point, and was very lucky to find a doctor willing to treat me as an individual. At that point, the constant stress of high pain had caused me to go into adrenal fatigue, and my cortisol level was close to 0. I had literally burnt out my adrenals, trying to withstand an inhuman level of suffering. Had I not gotten proper treatment for my pain at that time, I may have died.

I tell you my story as an example of why arbitrary dosage limits are harmful. Access to effective pain treatment must be preserved for chronic patients.
", "comment_id": "FDA-2017-N-5608-0490", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-5608-0490", "comment_date": "2017-12-22T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 1973}, {"text": "The majority of chronic pain patients use their meds as prescribed. We deserve to be treated with respect. Please stop taking our meds away from us. This will only cause more suicides and more people to turn to street drugs for help. ", "comment_id": "FDA-2017-N-5608-0555", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-5608-0555", "comment_date": "2017-12-27T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 234}]}, {"id": "DEA-2013-0010", "title": "Schedules of Controlled Substances: Placement of Tramadol into Schedule IV", "context": "2021-12-02T01:01:29Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "See attached file(s)", "comment_id": "DEA-2013-0010-0021", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2013-0010-0021", "comment_date": "2014-01-06T05:00:00Z", "comment_title": "Comment on FR Doc # 2013-25933", "commenter_fname": "Caroline", "commenter_lname": "Juran", "comment_length": 20}, {"text": "The reason this drug is being prescribed more is because the doctors don't fear the DEA breathing down their neck with a non scheduled prescription. I suffer chronic pain and this drug works for me. I can't imagine it having any abuse potential as you don't get High on it as you would taking the traditional schedule II and III narcotics. It doesn't even compare to pentazocine (Talwin) Sch IV. There is too much regulation of useful drugs in this country. I don't need my doctors scared to prescribe tramadol for me. I have been on it in excess of 7 years. My dose has remained the same for those seven years, 2 50mg tabs tid. It's not like the other narcotics and I've been on them all in the past at one time or another. If people want to try to get high off something they will. Something else will just fill in that gap. There seems to be a never ending story of scheduling drugs to what end. I live in Washington State, legal pot is available to me if I want it. I can't use marijuana as it makes me sick and I don't think it would help anyhow. Tramadol does help though, I do not want to see any scheduling decisions that scare my doctors off from prescribing a perfectly safe, effective, non escalating dose, necessary drug that I need to function . I have AIDS and severe peripheral neuropathy I have been on every drug from hydrocodone, morphine, and fentanyl and more not to mention all the amitrytylines and neurontins that don't work and cause bad side effects such as ticks, metallic taste, etc. This is the first one I have landed on that did not carry any of those drugs problems. All of those in Schedule II and III caused problems and the doses had to be escalated to keep my pain under control not to mention the addiction from them. I have finally found a non scheduled opiod where I don't have to escalate the dose that works for my pain (I've been on it over 7 years). Tramadol needs to remain unscheduled. This is not the first time this has been proposed and it needs to be overturned again. ", "comment_id": "DEA-2013-0010-0012", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2013-0010-0012", "comment_date": "2013-12-02T05:00:00Z", "comment_title": "Comment on FR Doc # 2013-25933", "commenter_fname": "Daniel", "commenter_lname": "Anonymous", "comment_length": 2067}, {"text": " “Docket No. DEA-351”

The Drug Enforcement Administration (DEA) proposes to place the substance 2-((dimethylamino)methyl)-1-(3-methoxyphenyl)cyclohexanol, its salts, isomers, salts of isomers, and all isomeric configurations of possible forms including tramadol (the term “isomers” includes the optical and geometric isomers) into Schedule IV of the Controlled Substances Act (CSA).

Ok, for the United States of America to meet or help meet the standards of "Our" treaty obligations under The Psychotropic Substances Act of 1978 as amended by the Controlled Substances Act proper regulation of the substance 2-((dimethylamino)methyl)-1-(3-methoxyphenyl)cyclohexanol, its salts, isomers, salts of isomers, and all isomeric configurations of possible forms including Tramadol (the term “isomers” includes the optical and geometric isomers) must be placed into Schedule IV of the Controlled Substances Act (CSA) or subjected to certain defined uses only. Current research shows the above named substance aka Tramadol to affect Public Health in the United States; the substance Tramadol has from research caused "Death", "Sickness" along with affecting "Commerce" by not being regulated enough to prevent "Serotonin syndrome" along with other symptoms.

I find it troubling that proper action has not already reflected a change in the regulation of "Tramadol", however now is the time. So the question proposed is to place "Tramadol" into either Schedule IV or III of the CSA. If "Tramadol" was to be placed into Schedule III of the CSA then what could occur is non use of the substance, now since there are reports of the drug working for some for "Restless leg syndrome" placement into Schedule IV should be considered. Further it would also be unethical not to a placement into the CSA. This substance is nothing compared to substances listed in Schedule III of the CSA so I believe action to place the substance into Schedule IV or V is warranted. I must note that there are similar substances that can be used that are much safer than "Tramadol" and those other substances have listings in Schedule IV and Schedules III along with Schedule II of the CSA.

Tramadol and its similar substances of this listings remind myself of "Libby Zion". I believe that to prevent "Death" along with "illness" caused by "Tramadol" we must accept previous similar occurrences and only allow combinations of Tramadol so in effect Schedule III placement could occur. Further notation should be noted that "Death" and "Illnesses" from using Tramadol are very different than substances listed in Schedule III of the CSA. We cannot compare Tramadol to Hydrocodone. Hydrocodone is an Opioid and Tramadol is Psychotropic in nature and very similar if not the same as a SNRI.

Codification

Section was enacted as a part of the Psychotropic Substances Act of 1978, and not as a part of the Controlled Substances Act which comprises this subchapter.
Change of Name

“Secretary of Health and Human Services” substituted for “Secretary of Health, Education, and Welfare” in par. (3) pursuant to section 509(b) ofPub. L. 96–88, which is classified to section 3508 (b) of Title 20, Education.
Effective Date

Section 112 of title I of Pub. L. 95–633provided that: “This title [enacting this section and section 852 of this title, amending sections 352, 802, 811, 812, 823, 827, 872, 952, and 953 of this title and section 242a of Title 42, The Public Health and Welfare, and enacting provisions set out as notes under sections 801 and 812 of this title] and the amendments made by this title shall take effect on the date the Convention on Psychotropic Substances, signed at Vienna, Austria on February 21, 1971, enters into force in respect to the United States.” [The Convention entered into force in respect to the United States on July 15, 1980.]

", "comment_id": "DEA-2013-0010-0020", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2013-0010-0020", "comment_date": "2013-12-12T05:00:00Z", "comment_title": "Comment on FR Doc # 2013-25933", "commenter_fname": "Thomas", "commenter_lname": "Thompson", "comment_length": 4155}, {"text": "Please find attached comments by the Healthcare Distribution Management Association (HDMA). ", "comment_id": "DEA-2013-0010-0028", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2013-0010-0028", "comment_date": "2014-01-06T05:00:00Z", "comment_title": "Comment on FR Doc # 2013-25933", "commenter_fname": "Anita", "commenter_lname": "Ducca", "comment_length": 92}, {"text": "Please see the attached document submitted on behalf of the American Veterinary Medical Association.

Thank you!", "comment_id": "DEA-2013-0010-0027", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2013-0010-0027", "comment_date": "2014-01-06T05:00:00Z", "comment_title": "Comment on FR Doc # 2013-25933", "commenter_fname": "W. Ron", "commenter_lname": "DeHaven", "comment_length": 121}, {"text": "Speaking and acting within ALL, ALL INCLUSIVE, his capacities, ALL INCLUSIVE, INCLUDING AND ESPECIALLY as the respective SOLE, PRO BONO Estate Administrator (abbreviated as "SOLE Est. Adm.") of the Delois Albert Brassell Estate (D-U-N-S Number 831823948 and active CAGE Code 5PAZ8) AND Robert James Brassell Estate (D-U-N-S Number 962019514 and active CAGE Code 64WJ9), ALL INCLUSIVE: I WANT MY OFFICIAL, FULLY-UPDATED, FULLY-AUTHENTICATED, FULLY-AUTHORIZED, FULLY-EMPOWERED ET AL., ALL INCLUSIVE, U.S. ET AL., ALL INCLUSIVE, DOD, USCG, NOAA (i.e., National Oceanic and Atmospheric Administration), CIA (i.e., United States Central Intelligence Agency), USDOJ (i.e., United States Department of Justice), HHS (i.e., United States Department of Health and Human Services), ODNI (i.e., Office of the United States Director of National Intelligence) ET AL., ALL INCLUSIVE, COMMON ACCESS CARDS (respectively one set for the aforementioned Delois Albert Brassell Estate and the other set for the aforementioned Robert James Brassell Estate, for now, for more sets WILL BE TIMELY AND CORRECTLY forthcoming) NOW, INCLUSIVE. Ever since I acquired the respective EINs (between Winter 2002 and Winter/Spring 2004) for the respective Delois Albert Brassell Estate (D-U-N-S Number 831823948 and active CAGE Code 5PAZ8) and Robert James Brassell Estate (D-U-N-S Number 962019514 and active CAGE Code 64WJ9), INCLUSIVE, among many various other Estates, INCLUSIVE, I was LEGALLY REQUIRED AND ENTITLED to be FORMALLY, CORRECTLY, TIMELY AND OTHERWISE ON-THE-RECORD informed of the precursors to ALL, ALL INCLUSIVE, such all-in-one smart cards, INCLUSIVE, so as to continue the work et al., ALL INCLUSIVE, said respective decedents were conducting, had established et al., ALL INCLUSIVE, among many various other affirmative-to-and-for-me matters, concerns et al., ALL INCLUSIVE. These, ALONG WITH MANY VARIOUS OTHER MATTERS, CONCERNS ET AL., ALL INCLUSIVE, WERE NOT FORTHCOMING, INCLUSIVE, i.e., IT DID NOT OCCUR, ALL INCLUSIVE. Said all-in-one smart cards, i.e., Common Access Cards, were, upon my additionally and correctly acquiring the respective New York State Surrogate Court (Suffolk County)-issued Certificates of Letters of Administration (a/k/a Certificates of Appointment) respectively for said Delois Albert Brassell Estate (Court Index Number 176A2004 (original court certificate number 17268), respective Certificate of Letters of Administration granted on and permanently valid from (i.e., respective date of estate administration appointment on) Friday, March 26, 2004 onward) and said Robert James Brassell Estate (Court Index Number 177A2004 (original court certificate number 17269), respective Certificate of Letters of Administration granted on and permanently valid from (i.e., respective date of estate administration appointment on) Thursday, March 18, 2004 onward), acquiring the respective D-U-N-S Numbers for each said and respective Estate AND FINALLY THE RESPECTIVE AND LONG-OVERDUE CAGE CODES (said Delois Albert Brassell Estate's respective CAGE Code actively issued on Tuesday, September 8, 2009 and said Robert James Brassell Estate's respective CAGE Code actively issued on Tuesday, September 10, 2010), ALL INCLUSIVE, REQUIRED TO BE TIMELY, OFFICIALLY, CORRECTLY, ON-THE-RECORD ET AL., ALL INCLUSIVE, TURNED OVER TO ME FIRST AND FOREMOST AS THE SOLE EST. ADM. OF THE RESPECTIVE REGISTERED ENTITIES SAID ESTATES, ALL INCLUSIVE. SAID COMMON ACCESS CARDS AND THEIR RESPECTIVE PRIVILEGES ET AL., ALL INCLUSIVE, WERE ILLEGALLY AND WITHOUT ANY OFFICIAL NOTICE-MAILED-TO-ME-AT-MY-OFFICIAL-BUSINESS-MAILING-ADDRESS-AT-THE-UNITED-STATES-POSTAL-SERVICE-JAMES-A.-FARLEY-BUILDING WITHHELD FROM ME WITHOUT ANY CAUSE ET AL., ALL INCLUSIVE, FROM THE HIGHEST LEVELS, ESPECIALLY FROM WITHOUT DOD, CIA, NOAA AND THE REST OF USDOC (i.e., United States Department of Commerce), USCG AND THE REST OF USDHS, ODNI ET AL., ALL INCLUSIVE, resulting in me, among numerous various other actions, INCLUSIVE, manually (via the USPS First-Class Mail) using my authority to purge virtually all independent contractors and subcontractors (including Charles Ellis Schumer (New York State Office of Court Administration currently-registered Attorney Registration Number 1923804 (since 1976) and William Gerard Asher (New York State Office of Court Administration currently-registered Attorney Registration Number 1209329 (since 1966))) associated with and within said respective Estates except for several respective independent contractors and subcontractors. The purge is OVERDUE AND NECESSARY, ALL INCLUSIVE, despite the metaphorical ET AL., ALL INCLUSIVE, foot dragging ET AL., ALL INCLUSIVE, from the President (i.e., POTUS), the rest of the White House Office/EOP, the United States National Security Council ("U.S. NSC"), the United States Homeland Security Council ("U.S. HSC") ET AL., ALL INCLUSIVE. I WANT ALL, ALL INCLUSIVE, MY COMMON ACCESS CARDS NOW, ALL INCLUSIVE. Thank you.", "comment_id": "DEA-2013-0010-0007", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2013-0010-0007", "comment_date": "2013-11-22T05:00:00Z", "comment_title": "Comment on FR Doc # 2013-25933", "commenter_fname": "Robert", "commenter_lname": "Brassell Jr (C07673494)", "comment_length": 5012}, {"text": "On behalf of the Prescription Drug Abuse Medical Task force of San Diego, California we would like to strongly support
the proposed Docket No. DEA regulation 351 to move Tramadol to a schedule IV medication.

Tramadol is currently a "loop hole" drug which is addictive, abused, and diverted, yet many patient and prescriber do not realize this because it is not a controlled substance. Tramadol cannot currently be tracked in our state Prescription Drug Monitoring Program because it is not a scheduled medication.The morphine equivalents of the typical Tramadol dose of 50 mg contains 10 morphine equivalents compared to Hydrocodone 5mg which contains 5 Morphine equivalents and Oxycodone 5 mg which contain 7.5 morphine equivalents.

This regulation is an important step in combating the prescription drug abuse epidemic.

Roneet Lev, MD FACEP
Chair, Prescription Drug Abuse Medical Task Force
San Diego, California", "comment_id": "DEA-2013-0010-0006", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2013-0010-0006", "comment_date": "2013-11-18T05:00:00Z", "comment_title": "Comment on FR Doc # 2013-25933", "commenter_fname": "Roneet", "commenter_lname": "Lev", "comment_length": 965}, {"text": "Society might not be as inept as believed to be
by those in power. Leave the people alone.
Let us decide what we ingest for pain or anxiety.
Many of us elderly persons know by now
That too many doctors turn away From pain treatment even though we
Patients have read about our "right to pain relief".
IGNORE THE STIGMA
SOMEONE HAS BEEN CRYING AND WRITHING AT
HOME, BED-RIDDEN FOR 3 WEEKS... RECLUSE..
IN PAIN.. TRULY WISHING FOR DEATH, when
Just a block away, medicine sits guarded by our laws..
Nurses and pharmacy assistants laugh us off
And the whole of society sits judging without pity
Or empathy. Control, control, and kill. Just wait until it
Happens to your loved one. It's coming for you, and you are
Not fighting hard enough for our liberty.

Stop badgering Doctors. They want to help, but dare they?

BUT THE DOCTOR SAYS I'M FINE
FINE? I'D BE BETTER OFF DEAD.

It's disgusting to witness someone hopeless, in pain ", "comment_id": "DEA-2013-0010-0024", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2013-0010-0024", "comment_date": "2014-01-06T05:00:00Z", "comment_title": "Comment on FR Doc # 2013-25933", "commenter_fname": "Deborah", "commenter_lname": "Anonymous", "comment_length": 1084}, {"text": "My girlfriend was in horrible pain for along time barely able to get off the couch. She had surgery her stomach muscle was torn from hip bone. Ins paid for half. Now both sides are torn and she has no insurance, being able to take the tramadol does not take all of her pain away but it helps to lead a some what normal life. It brakes my heart to think of her going back to that miserable women on the couch. Before the injury she was a work horse even worked side by side with her husband to build their own house. I realize there are addicts that abuse things but they always find some thing to get high on, Robatussin spray paint cans or whatever sick thing they find. The people that really need it and don't abuse it are the ones that will suffer. There not going to stop selling Robatussen or spray paint are they?", "comment_id": "DEA-2013-0010-0010", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2013-0010-0010", "comment_date": "2013-11-26T05:00:00Z", "comment_title": "Comment on FR Doc # 2013-25933", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 827}, {"text": "I support the proposed Docket No. DEA-351, Schedules of Controlled Substances: Placement of Tramadol into Schedule IV. As a Certified Pharmacy Technician I see on a daily basis the abuse that Tramadol gets from patients. It is a controlled substance in Mississippi and the stricter laws have seemed to lessen the abuse. Since it is a controlled substance in this state, patients are only allowed to get this prescription at the max, two days early and a max of five refills per prescription.
Mississippi is one of the more stricter states when it comes to controlled substances and medications in general. We are one of two states that has made pseudoephedrine a scheduled drug and we are also a state in which controlled medications cannot be transferred, even within the same state or even to the same chain pharmacy. Tramadol’s opioid like actions makes it just as addicting as other opioid’s. The known abuse of its pharmacology is a potential harm to patients and society. Since becoming a controlled substance in Mississippi it has cut down on many issues that comes with dispensing addictive but non-controlled medications. Instead of just refusing to fill it we can now go back to the state laws and their regulations regarding controlled substances. This proposed docket would also make the penalties for illegal manufacturing, dispensing, distribution, export, import or any other illegal activity harsher in punishment.
", "comment_id": "DEA-2013-0010-0008", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2013-0010-0008", "comment_date": "2013-11-25T05:00:00Z", "comment_title": "Comment on FR Doc # 2013-25933", "commenter_fname": "M", "commenter_lname": "Williams", "comment_length": 1504}]}, {"id": "FDA-1993-N-0363", "title": "Levo-Alpha-Acetyl-Methadol Revise Conditions for Use", "context": "2021-09-01T18:00:53Z", "purpose": "Nonrulemaking", "keywords": ["Methadone", "Dosage Form", "Detoxification", "Physiologically Dependent", "Levo-Alpha-Acetyl Methadol", "CDER", "OPEN", "Narcotic Addicition"], "comments": [{"text": "see attached", "comment_id": "FDA-1993-N-0363-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1993-N-0363-0006", "comment_date": "2017-04-17T04:00:00Z", "comment_title": "Comment from COMPA", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}, {"text": "see attached", "comment_id": "FDA-1993-N-0363-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1993-N-0363-0004", "comment_date": "2017-04-17T04:00:00Z", "comment_title": "Comment from James L. Sorensen", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}, {"text": null, "comment_id": "FDA-1993-N-0363-0009", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1993-N-0363-0009", "comment_date": "2017-04-17T00:00:00Z", "comment_title": "Comment from American Psychiatric Association", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-1993-N-0363-0010", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1993-N-0363-0010", "comment_date": "2017-04-17T00:00:00Z", "comment_title": "Comment from State of California Department of Alcohol and Drug Programs", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-1993-N-0363-0013", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1993-N-0363-0013", "comment_date": "2017-04-17T00:00:00Z", "comment_title": "Comment from Sidney H. Schnoll", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": "see attached", "comment_id": "FDA-1993-N-0363-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1993-N-0363-0005", "comment_date": "2017-04-17T04:00:00Z", "comment_title": "Comment from BAART", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}, {"text": "see attached", "comment_id": "FDA-1993-N-0363-0002", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1993-N-0363-0002", "comment_date": "2017-04-17T04:00:00Z", "comment_title": "Comment from Beth Israel Medical Center", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}, {"text": "see attached", "comment_id": "FDA-1993-N-0363-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1993-N-0363-0003", "comment_date": "2017-04-17T04:00:00Z", "comment_title": "Comment from Forest Tennant", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}, {"text": null, "comment_id": "FDA-1993-N-0363-0007", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1993-N-0363-0007", "comment_date": "2017-04-17T00:00:00Z", "comment_title": "Comment from California Organization of Methadone Provide (COMP)", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}]}, {"id": "DEA-2021-0004", "title": "Schedules of Controlled Substances: Removal of Samidorphan from Control", "context": "2021-12-02T01:00:43Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "Please see uploaded file for comments.

Daniel Gruener, MD", "comment_id": "DEA-2021-0004-0004", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2021-0004-0004", "comment_date": "2021-01-13T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-26812", "commenter_fname": "Daniel", "commenter_lname": "Gruener", "comment_length": 66}, {"text": "See attached file(s)", "comment_id": "DEA-2021-0004-0005", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2021-0004-0005", "comment_date": "2021-01-13T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-26812", "commenter_fname": "Ann", "commenter_lname": "Kurowski", "comment_length": 20}]}, {"id": "CDC-2018-0085", "title": "Partnership Opportunity to Identify Products for Fentanyl Exposure in Personal Protective Equipment Information Database", "context": "2019-04-01T10:19:41Z", "purpose": "Nonrulemaking", "keywords": null, "comments": [{"text": "For this partnership to be most successful, we need manufacturers who are willing to participate and commit to helping end users find appropriate personal protective products that align with current guidance around fentanyl exposure. The current guidance is unclear, and a small working group of manufactures and stakeholders should convene to provide clarity, especially around dermal protection (gowns and coveralls). The CDC has provided guidance around PPE, however in areas such as respiratory, dermal (gowns and coveralls) and eye/face protection, it is not clear as to which PPE would be most effective related to relevant identified PPE standards. I have heard input from manufactures indicating that there is confusion around risk layering (e.g., multiple layers of risk for each identified user group) and that it would be difficult to translate into a guidance tool. More work needs to be done to simplify the PPE selection and risk identification guidance process. ", "comment_id": "CDC-2018-0085-0012", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2018-0085-0012", "comment_date": "2019-02-27T05:00:00Z", "comment_title": "Comment from Jonathan Bihl", "commenter_fname": "Jonathan", "commenter_lname": "Bihl", "comment_length": 978}, {"text": "W.L. Gore & Associates is interested to participate in this effort. Gore is the manufacturer of CHEMPAK brand PPE laminates which are used in CBRN and Hazmat situations. Laminates and ensembles made from CHEMPAK laminates are certified to all classes of NFPA 1994 as well as NFPA 1999 and NFPA 1992.

It is important to take an ensemble approach to both Fentanyl and Ebola, as laminate performance enough is not sufficient to fully protect the first responder. The NFPA standards listed above provide excellent protection hierarchy based on hazard level. This is further discussed in the Interagency Board (IAB) October 2017 Recommended Best Practices to Minimize Emergency Responder Exposures to Synthetic Opioids, Including Fentanyl and Fentanyl Analogs. It is attached for reference. ", "comment_id": "CDC-2018-0085-0020", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2018-0085-0020", "comment_date": "2019-03-28T04:00:00Z", "comment_title": "Comment from Jason Horowitz", "commenter_fname": "Jason", "commenter_lname": "Horowitz", "comment_length": 807}, {"text": "Blauer Manufacturing Co. is interested in participating in this partnership opportunity. Blauer is a producer of PPE certified to the NFPA 1994 standard for Classes 3, 3R, and 4. Consistent with the Interagency Board's (IAB) guidance on fentanyl response, our suits are used by drug interdiction teams that target fentanyl production and milling operations.", "comment_id": "CDC-2018-0085-0019", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2018-0085-0019", "comment_date": "2019-03-28T04:00:00Z", "comment_title": "Comment from Tom Ames", "commenter_fname": "Tom", "commenter_lname": "Ames", "comment_length": 363}, {"text": "RPB Safety would be happy to participate from a respiratory protection perspective.", "comment_id": "CDC-2018-0085-0016", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2018-0085-0016", "comment_date": "2019-03-28T04:00:00Z", "comment_title": "Comment from Christopher Hughes", "commenter_fname": "Christopher", "commenter_lname": "Hughes", "comment_length": 83}, {"text": "Modeling of a reference should be similar to that for hazardous drugs and PPE with regards to testing standards for gloves, gowns and respiratory protection; which to date we have no registry for PPE for hazardous drugs. Noted standards for hazardous drug related PPE:

-ASTM D6978 permeation standard used for gloves for the safe handling of hazardous drugs

-ASTM F739 for materials use for garb while handling hazardous drugs (understanding a new standard is soon to be released)

A document should be created to assimilate the NIOSH Alert "Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Settings" DHHS (NIOSH) Publication Number 2004165

Understanding the spectrum of the document will go beyond 'Health Care Settings'; it MUST include healthcare in all settings (clinics, hospitals, home infusion, home care settings, etc.)

Scope should include: manufacturing, transportation, receiving, storage, compounding, administration, disposal, investigation, detection, laboratory assessment, patient/victim handling, ultimate destruction

The PPE document should include a simplistic pictographic on the proper donning and doffing sequence to protect individuals.
Example: CDC Ebola PPE posters, attached.

", "comment_id": "CDC-2018-0085-0014", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2018-0085-0014", "comment_date": "2019-03-26T04:00:00Z", "comment_title": "Comment from Fred Massoomi", "commenter_fname": "Fred", "commenter_lname": "Massoomi", "comment_length": 1333}, {"text": "CDC-2018-0085; NIOSH-319

SAS Safety Corp. is willing to participate", "comment_id": "CDC-2018-0085-0002", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2018-0085-0002", "comment_date": "2018-10-19T04:00:00Z", "comment_title": "Comment from Todd Zuella", "commenter_fname": "Todd", "commenter_lname": "Zuella", "comment_length": 76}, {"text": "Hello,

I am submitting on behalf of Draeger as we would like to participate.

Regards,

Jimmy Vo", "comment_id": "CDC-2018-0085-0004", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2018-0085-0004", "comment_date": "2018-11-09T05:00:00Z", "comment_title": "Comment from Jimmy Vo", "commenter_fname": "Jimmy", "commenter_lname": "Vo", "comment_length": 121}, {"text": "3M Personal Safety Division would like to participate.", "comment_id": "CDC-2018-0085-0021", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2018-0085-0021", "comment_date": "2019-04-01T04:00:00Z", "comment_title": "Comment from Donald Rust", "commenter_fname": "Donald", "commenter_lname": "Rust", "comment_length": 54}, {"text": "CDC-2018-0085; NIOSH-319 National Institute for Occupational Safety and Health of the Centers for Disease Control and Prevention
Bolle Safety is willing to participate in this program for PPE for Fentanyl Exposure. ", "comment_id": "CDC-2018-0085-0005", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2018-0085-0005", "comment_date": "2018-11-14T05:00:00Z", "comment_title": "Comment from Bill Godfrey", "commenter_fname": "Bill", "commenter_lname": "Godfrey", "comment_length": 224}, {"text": "this certainly brings about corruption. if fentanyl is that dangerous, why is it allowed to be used in america. why isnt it simply banned. i think this invites corruption when govt allows private industry to make money off references set for those using fentanyl.

better to just ban this pollution toxic chemicals from any use at any time in america. this is an invitation to corruption.
shut it down.", "comment_id": "CDC-2018-0085-0003", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2018-0085-0003", "comment_date": "2018-10-19T04:00:00Z", "comment_title": "Comment from Jean Ublieee", "commenter_fname": "jean", "commenter_lname": "ublieee", "comment_length": 415}]}, {"id": "FDA-2015-P-0059", "title": "Requests that the FDA ban the retail distribution of pure and highly concentrated caffeine as a dietary supplement. CSPI also requests that FDA limit the form in which caffeine is sold to prevent unreasonable risks to adolescents and others from overdoses of caffeine.", "context": "2018-04-19T14:29:20Z", "purpose": "Nonrulemaking", "keywords": ["2015-51", "Caffeine", "Powdered Caffeine", "Dietary Supplement", "Overdose", "Ban"], "comments": [{"text": "See attached letter urging the Agency to issue new enforcement letters on additional related products and to formalize a ban on highly concentrated caffeine supplements. ", "comment_id": "FDA-2015-P-0059-0010", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2015-P-0059-0010", "comment_date": "2015-12-10T05:00:00Z", "comment_title": "Comment from Center for Science in the Public Interest (CSPI)", "commenter_fname": null, "commenter_lname": null, "comment_length": 170}, {"text": "Please find attached a collection of news stories indicating the hazards of the caffeine in concentrated form in dietary supplements. It includes news coverage relating that a physician was able to order bulk, pure caffeine powder over the Internet using Amazon despite FDA's enforcement actions. ", "comment_id": "FDA-2015-P-0059-0012", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2015-P-0059-0012", "comment_date": "2016-06-13T04:00:00Z", "comment_title": "Comment from Center for Science in the Public Interest (CSPI)", "commenter_fname": null, "commenter_lname": null, "comment_length": 302}, {"text": "Dear Commissioner:

We write to provide additional materials in support of our Citizen Petition, Docket No. FDA-2015-P-0059, seeking a ban on the retail sale and distribution of pure powder caffeine as a dietary supplement. Since we submitted the petition in December 2014, six U.S. Senators, led by Senator Sherrod Brown of Ohio and Senator Richard Blumenthal of Connecticut, wrote a letter to the Commissioner in support of the petition and urging the agency to take action. In addition, only this week, the Ohio State Legislature passed a measure banning the sale of pure powder caffeine. The Senators' letter and news coverage of the Ohio legislation are attached for submission to the docket.

We thank FDA for its consideration of the Citizen Petition and of these materials.

Sincerely,

Laura MacCleery
Chief Regulatory Affairs Attorney
Center for Science in the Public Interest
1220 L St. NW Suite 300
Washington, DC 2000
", "comment_id": "FDA-2015-P-0059-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2015-P-0059-0005", "comment_date": "2015-07-21T04:00:00Z", "comment_title": "Comment from Center for Science in the Public Interest (CSPI)", "commenter_fname": null, "commenter_lname": null, "comment_length": 990}, {"text": "
October 6, 2015

Dr. Stephen Ostroff, M.D., Acting Commissioner
Food and Drug Administration (FDA)
10903 New Hampshire Avenue
Silver Spring, MD 20993

Re: Petition to Ban the Retail Distribution of Pure and Highly Concentrated Caffeine Sold in Powder Form as a Dietary Supplement, FDA-2015-P-0059-0003

Dear Acting Commissioner:

We applaud FDA for issuing warning letters to five companies distributing pure powdered caffeine. On September 1, 2015, FDA found that the products presented a significant or unreasonable risk of illness or injury to consumers, and directed recipients of the letters to cease distribution of these products

FDA indicated that a reason powdered caffeine is dangerous is the concentration of the product, making the difference between a safe amount and a toxic dose exceedingly small. The agency also wrote that safe quantities are "nearly impossible to measure accurately with common kitchen measuring tools." FDA stated that it will continue to aggressively monitor the marketplace for pure powdered caffeine products and take action as appropriate. We appreciate these preliminary efforts and FDA's clear commitment to ongoing oversight and action on this issue.

However, we urge FDA to press forward on a ban on the sale of caffeine powder in bulk for the reasons presented below. We also write to alert FDA that one company that did not receive an enforcement letter is still selling powdered caffeine in the United States, that a company that did receive a letter is still selling a related and risky product, and to raise concerns about related products that remain unaddressed by the agency's actions.

", "comment_id": "FDA-2015-P-0059-0009", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2015-P-0059-0009", "comment_date": "2015-12-10T05:00:00Z", "comment_title": "Comment from Center for Science in the Public Interest (CSPI)", "commenter_fname": null, "commenter_lname": null, "comment_length": 1747}]}, {"id": "FDA-2017-N-2903", "title": "Data and Methods for Evaluating the Impact of Opioid Formulations with Properties Designed to Deter Abuse in the Postmarket Setting: A Scientific Discussion of Present and Future Capabilities; Public Workshop; Issues Paper; Request for Comments", "context": "2017-09-15T11:56:53Z", "purpose": "Nonrulemaking", "keywords": ["CDER", "2017-77", "Data and Methods for Evaluating the Impact of", "Opioid Formulations with Properties Designed", "to Deter Abuse in the Postmarket Setting", "A Scientific Discussion of Present and Future", "Capabilities", "Public Workshop", "Issues Paper", "Request for Comments", "OPEN"], "comments": [{"text": "See Attached", "comment_id": "FDA-2017-N-2903-0018", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-2903-0018", "comment_date": "2017-09-15T04:00:00Z", "comment_title": "Comment from John Burke", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}, {"text": "1) Nomenclature
To call tamper-resistant opioids Abuse Deterrent Formulations (ADFs) substantially misstates what these technologies can accomplish even if and when they work as intended. The Food and Drug Administration (FDA) is a scientific agency that should subscribe to maintain standards of accuracy, especially when communicating with the public and with stakeholders on issue of such grave importance. Accordingly, the term ADFs should be abandoned in favor of a more accurate terminology.
2) Vaccines & Measurement
As was discussed during the public meeting, the appropriate analogy to draw when discussing the effort to elevate all licit opioid-prescribing is to vaccination, which must prove safe and effective for the recipient, and must also provide a herd immunity or substantial public health benefits in outcomes of interest. In order to judge tamper-resistant technology, two separate scales should be considered.
3) Scale 1
Considering the denominator all prescription pain pill users (adherent patients as well as misusing patients and recreational misuse), the FDA should itself sponsor prospective studies of tamper-resistant technologies based on categories of type (not a particular brand). Particular brands should then be asked to match or outperform those results. Entirely new innovations should be judged against similar products with proven results. Any brand that agrees to place its product in the bucket study should be rewarded, if the technology is proven effective, with increased market penetration. The outcome of interest here is: in this community of users, does the technology thwart attempts to manipulate it without incurring new or exacerbating existing hazards?
4) Scale 2
The denominators of interest here are all adverse outcomes: overdose death totals; overdose totals; Hep C or HIV infection rates; etc. The buckets of technology-types and/or individual brands supply the numerator. If these technologies successfully deter manipulation but do not meaningfully affect outcomes vital to abatement of the opioid crisis, then there is a limit to the kinds of "vaccination" or public health claims that can be made on their behalf. On the other hand, if they can be shown as effective, it is important to seize on that knowledge and advance their market penetration.
Kathleen J. Frydl", "comment_id": "FDA-2017-N-2903-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-2903-0004", "comment_date": "2017-07-13T04:00:00Z", "comment_title": "Comment from Kathleen Frydl", "commenter_fname": null, "commenter_lname": null, "comment_length": 2383}, {"text": "Inflexxion, Inc. - Comments re: Data and Methods for Evaluating the Impact of Abuse-Deterrent Opioid Formulations", "comment_id": "FDA-2017-N-2903-0014", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-2903-0014", "comment_date": "2017-09-12T04:00:00Z", "comment_title": "Comment from Inflexxion, Inc.", "commenter_fname": null, "commenter_lname": null, "comment_length": 113}, {"text": "On behalf of McKesson, I am pleased to submit comments on FDA's notice, "Data and Methods for Evaluating the Impact of Opioid Formulations With Properties Designed To Deter Abuse in the Postmarket Setting: A Scientific Discussion of Present and Future Capabilities; Public Workshop; Issues Paper; Request for Comments."", "comment_id": "FDA-2017-N-2903-0013", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-2903-0013", "comment_date": "2017-09-12T04:00:00Z", "comment_title": "Comment from McKesson", "commenter_fname": null, "commenter_lname": null, "comment_length": 333}, {"text": "See attached file(s)", "comment_id": "FDA-2017-N-2903-0010", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-2903-0010", "comment_date": "2017-09-12T04:00:00Z", "comment_title": "Comment from Jack Henningfield", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "We must not leave any room for inference or interpretation with the choice of nomenclature and the words "abuse deterrent" in the context of opioids. Read the attached document to obtain a thorough understanding and rationale for modifying the current language for these formulations.", "comment_id": "FDA-2017-N-2903-0012", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-2903-0012", "comment_date": "2017-09-12T04:00:00Z", "comment_title": "Comment from Melissa Tasse", "commenter_fname": null, "commenter_lname": null, "comment_length": 295}, {"text": "Preventing Prescription Opioid Addiction Reduces Reliance on Abuse Deterrent Formulations while Treating Chronic Pain

While the focus of this initiative is to evaluate opioid formulations that are identified as abuse deterrent, the fact is that the recreational abuse of opioids is proceeded by addiction to the opioids. It is just common sense: As with most diseases, preventing opioid addiction is a lot better than needing to treat it or, for that matter, trying to avoid ways those addicted can administer it to achieve a greater high .

In May, Dr. Scott Gottlieb, the new FDA Commissioner, declared that addressing the opioid epidemic is his first and highest priority. In his FDA VOICE blog, he cites data unequivocally establishing prescription opioids as the major cause of opioid addiction. These medications are also gateway drugs: Some 75 percent of heroin users in treatment began their addiction with prescription opioids.

Prescription opioids are responsible for the majority of opioid-overdose deaths, responsible for about 22,000 of the 33,091 fatalities in 2015. The Agency for Healthcare Research and Quality reported 1.27-million emergency-room visits or inpatient stays for opioid-related issues in 2014 (the most recent year for which data is available).

The public debates over legal and regulatory policies to combat this epidemic are ongoing, with opinions continuing to evolve. Yet discussions mainly fail to consider another vital concern: the medically legitimate needs of people who require prescription opioids to help live with chronic pain. The inconvenient truth is that moderate-to-severe chronic pain typically cannot be adequately controlled with non-opioids.

One highly promising solution to this dilemma focuses on an underutilized treatment for chronic pain called buprenorphine ("bu-pren-or-fin"). It is the only opioid in the CIII schedule of drugs, a category recognized by the FDA as representing a reduced risk of addiction. All other opioids for pain are grouped in the riskier CII class.

Until recently, buprenorphine was only available as a once-a-week transdermal (skin) patch, which limited its efficacy and caused some doctors to eschew it. Early last year, however, the FDA approved a twice-daily formulation of buprenorphine that provides significant pain relief: a small, transparent film resembling a Listerine breath strip that dissolves against the inside of the cheek.

In this new form, buprenorphine may play a key role in fighting the prescription-opioid epidemic. It is the least addicting of all the opioids. It typically does not lead to withdrawal symptoms when stopped. Importantly, it reduces the risk of death due to overdose because it doesn't shut down respiration the way other opioids can.

Buprenorphine is not immune to abuse, especially by people who've never before taken prescription-opioid medicationthe so-called opioid-nave. But it poses much less risk than CII opioids because it doesn't produce the same kind of potentially addictive euphoria. People living with chronic pain can get relief from buprenorphine but addicts looking for a high don't like the drug very much, according to studies.

The FDA has approved high-dose buprenorphine (generally, over ten times the amount approved for pain management) as a treatment for opioid addiction. The advantage of buprenorphine is that it can eliminate withdrawal symptoms without triggering euphoria. This is in stark contrast to the use of methadone to treat heroin addiction. The dual ability of buprenorphine to both manage pain and also addiction underscores its uniqueness.

The danger posed by CII opioids is real and immediate. In an analysis by the Centers for Disease Control and Prevention, the longer the exposure of opioid-nave patients to CII opioids, the greater the risk of becoming a chronic user. A one-day supply is associated with a 6 percent risk of continuing the opioid for at least a year; a 30-day supply is associated with about a 35-percent risk of becoming a chronic user.

There are common-sense conclusions to be drawn here. For chronic-pain patients who are not getting adequate relief from non-opioids, prescribers should be required to offer buprenorphine as a first-line therapy before resorting to a CII opioid. For patients who have been on a CII-opioid long-term, the mandate should be to gradually replace the medication with buprenorphine.

The quickest and most effective way to encourage this change is for pharmacy benefit-management companies to adopt these requirements nationally. In addition, the FDA should mandate labelling changes for all CII opioids, requiring that prescribers try buprenorphine first as a treatment for chronic pain.
", "comment_id": "FDA-2017-N-2903-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-2903-0003", "comment_date": "2017-07-13T04:00:00Z", "comment_title": "Comment from Frank O'Donnell, Jr MD", "commenter_fname": null, "commenter_lname": null, "comment_length": 4856}, {"text": "I look at the reports on how the "opioid epidemic", has got to be stopped and addressed. I am, along with millions of other Americans, are on the other end of opioids.
I am on the end of the chronic pain disease epidemic. As the CDC, DEA and Medicaid and medicare, and numerous other government associates, are blaming Doctors for the over prescribing of medication, NOBODY, is looking at or reading the statistics from chronic pain disease patients. How about not addressing these drugs as dangerous and addictive. Let's look at them as lifesaving and medically necessary for the million of Americans in chronic pain. Chronic pain is a disease. It is now becoming an epidemic.
No other disease medication is scrutinized. Chronic pain is a disease. We as patients are being denied, dismissed and overlooked by our drs due to all the scrutiny associated with treating chronic pain disease. Our doctors are afraid to treat us adequately. We have a disease that medication is readily accessible to us and we are being denied. We pain patients are truly being discriminated against, due to people who use heroin, illegal fentanyl, and placed a blame on anyone but themselves. This is a witch hunt for drs who prescribe life saving medication and pain disease patients who benefit from this medication.
We have a chronic disease. We want to be able to take care of our homes, our children, our selves, as much as possible, but without access to our, potentially, life saving medications, we are unable to do so. We want to live not just exist in pain 24/7.
We need the government agencies to look at the real statistics, not the hand picked.
We need help. With all the headlines, topics and stories on how opioids are bad, let's look at what good they do for our disease of chronic pain and the million of Americans they help.
", "comment_id": "FDA-2017-N-2903-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-2903-0006", "comment_date": "2017-08-07T04:00:00Z", "comment_title": "Comment from Candi Simonis", "commenter_fname": null, "commenter_lname": null, "comment_length": 1901}, {"text": "See attached file(s)", "comment_id": "FDA-2017-N-2903-0009", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-2903-0009", "comment_date": "2017-09-12T04:00:00Z", "comment_title": "Comment from Sid Schnoll", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Comments provided by RADARS System", "comment_id": "FDA-2017-N-2903-0015", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-2903-0015", "comment_date": "2017-09-12T04:00:00Z", "comment_title": "Comment from RADARS System", "commenter_fname": null, "commenter_lname": null, "comment_length": 34}]}, {"id": "DEA-2020-0005", "title": "Registration Requirements for Narcotic Treatment Programs with Mobile Components", "context": "2021-12-13T15:33:40Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "As a current staff member of Mental Health America helping those with mental illness, substance abuse and addiction, I firmly support this proposed rule. To create an environment easier for those battling addiction and exerting efforts to get help, it's essential to eliminate the tedious repetitive steps that could be avoided. To best support those overcoming addiction, national, state and local ratings, and accredited narcotic treatment programs (NTPs), it is important to factor waiving separate registration. By creating multiple steps of repetitive registration, some addicts and those in need may be deterred from completing the NTP. It's important to consider the advantages of modern technology to create alternate strategies. I firmly agree that this proposed rule and regulation change would support detoxification treatments and have far greater benefits than deficits on the American people. While creating more widely available services with less tedious steps of registration, in return, it will reduce the likelihood of relapse. As stated in Part II "Scope of the Proposed Rule", as long as requirements of this rule honor HIPAA and protect patients through security, record-keeping and reporting, this would be a step in the right direction to combat the opioid crisis in the U.S. ", "comment_id": "DEA-2020-0005-0024", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0005-0024", "comment_date": "2020-04-15T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-03627", "commenter_fname": "Stephanie", "commenter_lname": "Garrison", "comment_length": 1318}, {"text": "Comments from the National Council for Behavioral Health are attached.", "comment_id": "DEA-2020-0005-0026", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0005-0026", "comment_date": "2020-04-16T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-03627", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 70}, {"text": "
I would like to support the Drug Enforcement Administration (DEA) proposed revision to the existing regulations for narcotic treatment programs (NTPs) to allow a mobile component associated with the registered program to be considered a coincident activity. This revision could eliminate a potential barrier to programs that are reaching to areas that are underserved. It coincides with the Center for Disease Controls overarching goal of achieving health equity, eliminate disparities, and improve the health of all groups while decreasing premature death. People in rural areas have a complex mix for lack of access to care. In addition to being rurally located often times 200 miles from a provider, they tend to live below the poverty level. These compounded barriers reduce the chance of patients obtaining treatment that is greatly needed. Opening opportunities to reach the communities at need can potentially decreasing the triple fold opioid overdose death rate that has occurred over the years. This proposal is consistent with public health and safety in providing a much-needed service to an otherwise unreachable area that can satellite to multiple areas but stay within the confined of the state. Mobile units can be a safe, budget friendly approach to brick and mortar building that involve costly expenses and overhead. Research has proven that patients receiving medication assisted therapy are more likely to remain in treatment and less likely to partake in illicit opioid use. Something more has to be done. We are losing this battle at the cost of over 70,000 American lives.
", "comment_id": "DEA-2020-0005-0027", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0005-0027", "comment_date": "2020-04-17T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-03627", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 1647}, {"text": "As a social worker and a professor I
write in support of this change. I am deeply concerned about peoples access to treatment during this pandemic and feel that this change could help save
Lives. ", "comment_id": "DEA-2020-0005-0053", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0005-0053", "comment_date": "2020-04-27T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-03627", "commenter_fname": "Casey", "commenter_lname": "Bohrman", "comment_length": 204}, {"text": "I support this proposal to revise DEA regulations for narcotic treatment programs to allow a mobile component associated with the registered program to be considered a coincident activity. Increasing access to life saving opioid use disorder treatment is paramount in mitigating the consequences of our Country's opioid epidemic. Going forward, we should continue to increase access to medications for opioid use disorder, rather than re-implement archaic polices that restrict access to care and cause additional harms and restrictions to and on people who use opioids. We must continue to use science to guide our decisions, while reflecting on how our bias and subjective experiences impact how we react to these deviant and negative health behaviors. ", "comment_id": "DEA-2020-0005-0078", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0005-0078", "comment_date": "2020-04-28T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-03627", "commenter_fname": "Thomas", "commenter_lname": "Cole", "comment_length": 761}, {"text": "I am primary care physician, addiction medicine specialist and instructor at Yale School of Medicine. My research aims to improve the health of people with opioid use disorder. Myself and colleagues have previous demonstrated there exists a substantial urban-rural disparity in geographic access to methadone for opioid used disorder (https://doi:10.1001/jama.2019.12562 and https://doi.org/10.1016/j.drugalcdep.2020.107968) which creates a large mismatch in demand for methadone treatment services and supply of such services within the Unites States. I support the proposed change by the DEA to again allow mobile NTP within the United States to begin to address this disparity in geographic access to methadone.

Resistance to expanding access to methadone for opioid use disorder is often grounded in concerns about diversion and overdose due to greater methadone use. However, these concerns continue to overstate (or fail to define) the actual risk of harm due to these concerns. The likely harm from diversion of methadone is small compared to the risk of overdose and death from continued use of heroin or fentanyl. Therefore, even if small levels diversion and methadone overdose are associated with actions which expand methadone access, these harms are likely to be easily overshadowed by the overdose deaths prevented by allowing people with opioid use disorder to switch from using heroin or fentanyl to methadone treatment. It should be noted that while suboxone is an alternative medication for this population it also faces shortages in access and does not meet all patients needs make methadone access essential.

This change in policy is long overdue and it is worth stating that these changes alone will not address the disparities in methadone access our team has previously described, but it is a small step in the write direction. Additional regulatory and systems changes will be need to ensure universal access to methadone.

Sincerely,
Paul J Joudrey, MD, MPH
Program in Addiction Medicine
Yale School of Medicine
paul.joudrey@yale.edu", "comment_id": "DEA-2020-0005-0080", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0005-0080", "comment_date": "2020-04-28T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-03627", "commenter_fname": "Paul", "commenter_lname": "Joudrey", "comment_length": 2106}, {"text": "April 14, 2020

Uttam Dhillon
Acting Administrator
Drug Enforcement Agency
United States Department of Justice
8701 Morrissette Drive
Springfield, VA 22152

Dear Acting Administrator Dhillon:

I am writing on behalf of the City of Philadelphia's Department of Behavioral Health and Intellectual disAbility Services (DBHIDS) to communicate support for the Drug Enforcement Agency's (DEA) proposed rule regarding registration requirements for narcotic treatment programs (NTPs) with mobile components, as published in the Federal Register on February 26, 2020. DEA proposes to revise the existing regulations for NTPs to allow a mobile component associated with the registered program to be considered a coincident activity that does not need a separate registration.

DBHIDS supports a range of services for children, adults, and families, including mental health services, substance use treatment services, early intervention services, and intellectual disAbility services. Our mission is to strengthen and serve individuals and communities so that all Philadelphians can thrive.

DBHIDS unreservedly supports the proposed rule as a measure to make effective and appropriate substance use treatment services available to those people who most need them. The families and communities of Philadelphia have struggled greatly with the current opioid crisis, and despite the diligent and creative work of dedicated public servants across various City agencies the toll in morbidity, mortality and human suffering of opioid use disorders is still mounting. While our City continues to work on addressing this crisis in innovative and flexible ways, more is clearly needed.

In the course of our work serving people who have opioid use disorders, we have become convinced of the value of medication assisted treatment (MAT) in promoting recovery and limiting the harms caused by the disease of addiction. MAT, which entails the administration of opiate agonists such as methadone or buprenorphine, has been shown to improve outcomes when delivered as part of a comprehensive behavioral health treatment program, or when delivered alone. Accordingly, we support measures such as this proposed rule which will tend to increase the availability of MAT to people who could benefit from it.

Many of the individuals we serve experience disadvantages in multiple intersecting respects. They are far more likely to be impacted by the social determinants of health. They may suffer the impact of systemic racism. They may live in impoverished communities, or lack reliable access to transportation resources. They may experience insecurity in their access to food or housing. A recent study of the New Jersey Medication Assisted Treatment Initiative (NJ-MATI) indicated that people facing these challenges were most effectively served by mobile medication units (MMUs), which were more accessible and therefore better able to meet the needs of these individuals, as well as individuals who presented with more severe symptoms of opioid use disorders.

For these reasons, DBHIDS believes that the proposed NTP mobile component rule will be an aid to us in our mission to promote the thriving of all Philadelphians. We applaud the efforts of the DEA in this regard and look forward hopefully to the promulgation and implementation of this rule.

Sincerely,

David T. Jones
Commissioner
Department of Behavioral Health and Intellectual disAbility Services
", "comment_id": "DEA-2020-0005-0076", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0005-0076", "comment_date": "2020-04-28T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-03627", "commenter_fname": "Benjamin", "commenter_lname": "Locklair", "comment_length": 3558}, {"text": "I support the proposal to allow mobile Narcotic Treatment Programs to operate without separate registration. The proposal would make maintenance and detoxification treatment more available while requiring safeguards to minimize the risk of methadone and other controlled substance diversion.", "comment_id": "DEA-2020-0005-0077", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0005-0077", "comment_date": "2020-04-28T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-03627", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 292}, {"text": "I support the DEA's proposal to revise regulations for narcotic treatment programs to allow a mobile component alongside the brick and mortar building.

As someone who works at the intersection of those experiencing homelessness, leaving incarceration and OUD, this is something we have long been championing and asking for. Being able to prescribe with fewer barriers and reach the client where they are, is the definition of evidence based treatment- which MAT is considered the gold star. This is something that is brought up regularly within provider meetings and I am very happy to see this being researched. ", "comment_id": "DEA-2020-0005-0081", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0005-0081", "comment_date": "2020-04-28T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-03627", "commenter_fname": "Amanda", "commenter_lname": "Cowan", "comment_length": 628}, {"text": "As a healthcare provider, I know that methadone is an important and effective intervention for opioid use disorder and helps prevent deaths from overdose. You must allow mobile delivery of this life-saving medication ", "comment_id": "DEA-2020-0005-0085", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0005-0085", "comment_date": "2020-04-28T04:00:00Z", "comment_title": "Comment on FR Doc # 2020-03627", "commenter_fname": "Victor", "commenter_lname": "Rodionoff", "comment_length": 218}]}, {"id": "DOT-OST-1996-1132", "title": "Notice of Proposed Rulemaking - Amendment to Definition of \"Substance Abuse Professsional\"", "context": "2015-05-26T10:31:44Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "Comments of Certification Examining Board of LASACT, Inc.", "comment_id": "DOT-OST-1996-1132-0028", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-1996-1132-0028", "comment_date": "1996-04-22T04:00:00Z", "comment_title": "Certification Examining Board of LASACT, Inc. - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 57}, {"text": "Comments of Council on Alcohol & Other Drug Abuse, Inc.", "comment_id": "DOT-OST-1996-1132-0012", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-1996-1132-0012", "comment_date": "1996-04-05T05:00:00Z", "comment_title": "Council on Alcohol & Other Drug Abuse, Inc. - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 59}, {"text": "Comments of IBSAC Iowa Board of Substance Abuse Certification, Ron Alexander, Marcia A. Matthews, Step Industries, Inc., New Hampshire Technical Institute

", "comment_id": "DOT-OST-1996-1132-0023", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-1996-1132-0023", "comment_date": "1996-04-11T04:00:00Z", "comment_title": "Various Parties - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 164}, {"text": "Comments of Olcott & Associates, Consultants.", "comment_id": "DOT-OST-1996-1132-0010", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-1996-1132-0010", "comment_date": "1996-04-05T05:00:00Z", "comment_title": "Olcott & Associates, Consultants - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 49}, {"text": "Comments of PCACB Pennsylvania Chemical Abuse Certification Board.", "comment_id": "DOT-OST-1996-1132-0002", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-1996-1132-0002", "comment_date": "1996-04-01T05:00:00Z", "comment_title": "PCACB - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 66}, {"text": "Comments of The Wisconsin Association of Alcohol and Drug Abuse Counselors, Inc. WAADAC.", "comment_id": "DOT-OST-1996-1132-0009", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-1996-1132-0009", "comment_date": "1996-04-05T05:00:00Z", "comment_title": "WAADAC - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 88}, {"text": "Comments of United Behavioral Health Services.", "comment_id": "DOT-OST-1996-1132-0016", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-1996-1132-0016", "comment_date": "1996-04-09T04:00:00Z", "comment_title": "United Behavioral Health Services - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 46}, {"text": "Comments of The Montgomery Area Court Referral Program, Inc.", "comment_id": "DOT-OST-1996-1132-0014", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-1996-1132-0014", "comment_date": "1996-04-08T04:00:00Z", "comment_title": "The Montgomery Area Court Referral Program, Inc. - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 60}, {"text": "Comments of Vermont Alcohol and Drug Abuse Counselors Association.", "comment_id": "DOT-OST-1996-1132-0029", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-1996-1132-0029", "comment_date": "1996-04-30T04:00:00Z", "comment_title": "Vermont Alcohol and Drug Abuse Counselors Association - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 66}, {"text": "Comments of the Arizona Board for Certification of Addiction Counselors.", "comment_id": "DOT-OST-1996-1132-0004", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-1996-1132-0004", "comment_date": "1996-04-04T05:00:00Z", "comment_title": "ABCAC - Comments", "commenter_fname": null, "commenter_lname": null, "comment_length": 72}]}, {"id": "VA-2020-VHA-0023", "title": "AQ31-Proposed Rule-Elimination of Copayment for Opioid Antagonists and Education on Use of Opioid Antagonists", "context": "2021-12-13T15:35:34Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "Please see attached Word document. ", "comment_id": "VA-2020-VHA-0023-0021", "comment_url": "https://api.regulations.gov/v4/comments/VA-2020-VHA-0023-0021", "comment_date": "2021-01-05T05:00:00Z", "comment_title": "Comment on AQ31-Proposed Rule-Evans, Joel", "commenter_fname": "Joel", "commenter_lname": "Evans", "comment_length": 35}, {"text": "Opioid addiction is an ever-present threat to individuals living in the United States of American and around the world. According to the National Institute on Drug Abuse, 128 Americans die each day from a drug overdose. The problem of opioid addiction and overdose has been an increasingly important issue in the United States over the past couple of decades. Public health professionals and governmental organizations have been working together to create initiatives and rulings that favor preventative and treatment services for individuals that are addicted to drugs. The problem of opioid dependence is one that was, in part, caused by the drug manufacturers and physicians of the 1990s. Addiction and overdose are problems that need to be addressed. The United States Department of Veterans Affairs is working to improve the health outcomes of veterans who are at risk for addiction and overdose due to opioids.

Many deaths related to opioid addiction are preventable with public health intervention. Drug addiction is a multifactorial health issue caused by a multitude of different situations. Individuals impacted by opioid addiction often lack sufficient social support systems, suffered previous serious injuries, and are victims of poor prescription practices. Without interventional activities, an addicted individual could end up dying from a drug overdose. There are currently several populations disproportionately impacted by opioid dependence and opioid overdose.

Several populations are more vulnerable to struggling with drug addiction. A specific population at an increased risk within the United States are veterans. The Department of Veterans Affairs has an entire unit dedicated to overcoming drug abuse in veterans. The organization states that veterans experience Post-Traumatic Stress Disorder (PTSD) as a result of their service to their country. These individuals are more susceptible to drug use. This increased use could pose threats to their lives. Additionally, as a person is exposed to more stressors, the more that negatively impacts their health outcome.

Opioids are powerful drugs. Many of them serve as integral aspects of pain-relieving treatment in the United States. However, there are drawbacks to these powerful compounds. According to the Centers for Disease Control and Prevention, in the 1990s, the number of prescriptions written out for opioids began to rise. A rise in prescriptive practices correlated with the increased mortality due to opioid overdose. Since the discovery of opioids as an effective treatment for pain management, there have been issues with abuse, addiction, and overdose. As a nation, the United States is currently trying to combat this public health crisis.

A rule recently proposed by the Department of Veterans Affairs dealt with opioid addiction in the veteran population. As previously noted, these individuals are at an increased risk of addiction and overdose with opioids. The proposed rule would eliminate copay requirements for veterans seeking help for opioid addiction. Additionally, copayments would not be required for the obtainment of opioid antagonists. Common opioid antagonists are Naltrexone and Naloxone. Drugs like Naltrexone and Naloxone act in opposition to opioids. Opioid antagonists allow for the reversal of the negative impacts of opioids. If using extended-release versions of these drugs, they can cost hundreds to thousands of dollars. Veterans are typically older Americans who are already on restricted incomes. Adding this expense could push their budgets to the max. Eliminating the copay for Naltrexone and Naloxone could not only reduce the cost burden for veterans but also save their lives.

The number one cause of opioid dependence is related to pain management. Veterans experience injuries that persist well after they return home. We must ensure they have access to all of the services that they need to live a happy and healthy life. These high-risk individuals should have adequate access to opioid antagonists. Veterans should also have access to counseling and educational information on the subject of opioid addiction. We must fight for those who fought for us!", "comment_id": "VA-2020-VHA-0023-0009", "comment_url": "https://api.regulations.gov/v4/comments/VA-2020-VHA-0023-0009", "comment_date": "2020-11-18T05:00:00Z", "comment_title": "Comment on AQ31-Proposed Rule-Eckley, Kaitlyn", "commenter_fname": "Kaitlyn", "commenter_lname": "Eckley", "comment_length": 4228}, {"text": "Opioid overdose death rates in the veteran population have increased over 65% since 20101 which is of particular concern after noting the already increased risk veterans are placed at for developing comorbid mental health conditions. The Department of Veteran Affairs has many initiatives in place for combatting this problem, but there remains the issue of opioid use specifically as research is continuing to show that current efforts (such as decreasing prescription provision) are not sufficient in reducing this phenomenon. This proposed rule would eliminate the copays needed for veterans covered under the VA to access potentially life-saving drugs such as naloxone, an opioid antagonist that could bring an individual out of an active overdose.

While available without prescription, naloxone can cost individuals hundreds of dollars without insurance in some locations, and even with insurance can be costly. Previous research in the veteran population has shown that increased copays can decrease not only medication adherence, but medication seeking2. If the goal is to protect our veterans from the harm of prescription drug misuse, the answer shouldn’t be making it more difficult to access ALL medications, but instead making those that are helpful and potentially life-saving more accessible. The military experience, as researchers have described it, puts veterans at a unique risk for developing mental health conditions that adversely affect their daily life and can drive other inhibiting factors such as homelessness or poverty3. The logical and data-based solution that exists to help prevent these factors from interfering with an individual’s ability to access necessary healthcare is to eliminate copays when capable3,4.

We see that the opioid epidemic is showing no signs of slowing down and we know that since 2017 there have been staggering trends in overdose fatalities even without considering veteran status. Adding this in, it seems only logical that this step, eliminating copays for opioid education resources and antagonist agents, be taken to protect those that spent their life protecting us. This proposed rule does, however, indicate that these waivers would be applicable to those indicated as “high risk” and does not have current definition about how those identifications would be made, which is where I think there should be further discussion. Previous research has discussed the different conditions that are unique to veterans regarding opioid use as well as how veterans are at a higher risk level than many for disabling conditions upon returning from service3. This prompts me to question the necessity of this inclusion for this proposed rule. Why must an already-established high-risk individual be re-classified into a second tier of high-risk to access resources that should be available to all? What separates risk level when you are involving an already high-risk group of people? Why do we need to sever the resources within this population? Aren’t all at a high enough risk to justify their deserving free resources to protect their health?

This proposition also includes leverage about “education.” I think this is an extremely valuable consideration and am so glad to see that the VA is wanting to educate those at risk of opioid misuse on ways to prevent overdose as well as how to respond in the event that those efforts aren’t successful. That said, why are these services not currently being provided, and if they are to be in the future, why is a copay even necessary? What message does that send our veterans? This proposed rule about eliminating copay requirements for opioid antagonists and educational services about their use is extremely encouraging and a giant leap forward in my view. What I want to focus on moving forward is why we are still considering only providing this accessibility to some, and not to all. Is it necessary to classify at-risk individuals by who has the most risk, when in reality they all are in need of help? Is it really that much of a stretch to provide this service to all veterans? Can we not work together for all and not just for some?

1.https://doi.org/10.1016/j.amepre.2019.01.016
2.https://doi.org/10.1161/circulationaha.108.783944
3.https://doi.org/10.3109/10826084.2013.796991
4.https://doi.org/10.1161/circulationaha.108.829655
", "comment_id": "VA-2020-VHA-0023-0008", "comment_url": "https://api.regulations.gov/v4/comments/VA-2020-VHA-0023-0008", "comment_date": "2020-11-17T05:00:00Z", "comment_title": "Comment on AQ31-Proposed Rule-Caldwell, Kyle", "commenter_fname": "Kyle", "commenter_lname": "Caldwell", "comment_length": 4602}, {"text": "The Opioid Crisis in the United State is getting worse every day. Studies show that individuals with mental health illnesses have a higher chance of developing comorbid conditions like substance use disorders. Risk factors for mental health illnesses consist of both stress and trauma (NIH Comorbidity: Substance Use Disorders and Other Mental Illnesses DrugFacts) that are commonly found in the Military experience. "The 2014 JAMA Psychiatry study found the rate of PTSD to be 15 times higher than civilians." (NAMI Veterans and Active Duty) Given this information, it is the duty of the Department of Veteran Affairs to eliminate copays for Opioid Antagonists and Education on Use of Opioid Antagonists free of cost", "comment_id": "VA-2020-VHA-0023-0006", "comment_url": "https://api.regulations.gov/v4/comments/VA-2020-VHA-0023-0006", "comment_date": "2020-11-12T05:00:00Z", "comment_title": "Comment on AQ31-Proposed Rule-Capstick, Casey", "commenter_fname": "Casey", "commenter_lname": "Capstick", "comment_length": 729}, {"text": "The elimination of copayment for opioid antagonist is critical for the progress in the United States. More specifically it is needed to prevent overdose among veterans and people affiliated with the Dept. of Veteran Affairs. Eliminating the copayment for opioid education will benefit people of all backgrounds but especially for people who may not have the funds to educate themselves on the dangers of opioid abuse. Proving the free education will prevent future overdoses and also spread awareness of the negative side effects of drug abuse. I would change the wording in the proposal from antagonist to something that is more relatable and not so demeaning to people who will interpret it the wrong way. Other than that, the proposed federal rule should be passed and will be very beneficial to society as a whole. ", "comment_id": "VA-2020-VHA-0023-0003", "comment_url": "https://api.regulations.gov/v4/comments/VA-2020-VHA-0023-0003", "comment_date": "2020-11-09T05:00:00Z", "comment_title": "Comment on AQ31-Proposed Rule-Anonymous", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 819}, {"text": "Medical protocols that govern copayments to correspond with current legislative requirements. VA would be eradicating the copayment prerequisite for opioid antagonists equipped to veterans. These veterans who are at abnormal risk of overdose of a explicit medication or substance in order to setback the result of such an overdose. VA would also explain that no copayment would be mandatory for providing of learning on the use of opioid antagonists. The recommended rule would be a crucial part of VA's challenges to help veterans at an extreme risk of overdose.", "comment_id": "VA-2020-VHA-0023-0004", "comment_url": "https://api.regulations.gov/v4/comments/VA-2020-VHA-0023-0004", "comment_date": "2020-11-09T05:00:00Z", "comment_title": "Comment on AQ31-Proposed Rule-Cabrera, Eugenia", "commenter_fname": "Eugenia", "commenter_lname": "Cabrera", "comment_length": 567}, {"text": "While Public Law 114-198, sec. 915 and Public Law 114-223, sec. 243 already have eliminated co-payments for Veterans regarding Opioid antagonists, and the education of utilizing those lifesaving antagonists this rule would make the law clear in the VA's co-payment regulations, 38 CFR 17.108 and 17.110. This measure is critical in creating cross-governmental cohesion in the fight against the opioid crisis in our Veteran populace. According to the Veteran's Administration, the use of Opioids by the VA has decreased sustainably in the past several years, which has led to a decline in Opioid use and addiction amongst our Veterans. The availability and education on the use of Opioid antagonists would only further this fight against addiction and potentially save the lives of those suffering from Substance Abuse Disorder. The amendment to Section 17.110 paragraph (c)(12) adding a clear definition to whom is characterized by "high risk" is also an essential step in ensuring that any Veteran needing these measures will have the availability of lifesaving opioid antagonists afforded to them.

This proposed rule to amend 38 CFR 17.108 and 17.110 only solidifies the message of a united front against the opioid crisis in our Veteran community, and it secures that the policies enacted by Public Law 114-198, sec. 915 and Public Law 114-223, sec. 243 remain intact. ", "comment_id": "VA-2020-VHA-0023-0005", "comment_url": "https://api.regulations.gov/v4/comments/VA-2020-VHA-0023-0005", "comment_date": "2020-11-09T05:00:00Z", "comment_title": "Comment on AQ31-Proposed Rule - Kleisch, Suzanne", "commenter_fname": "Suzanne", "commenter_lname": "Kleisch", "comment_length": 1400}, {"text": "To Whom it May Concern,
I am a graduate student of public policy currently studying the rulemaking process. Thank you for the opportunity to contribute to this process; I hope my comment is useful in your considerations. My comment provides further support of your removal of the copayment burden for “high risk” veterans, a suggestion to strengthen the impact of this rule in conjunction with other VA programs, and an inquiry into your impact analysis lack of explanation on the impact of the expected loss of revenue on other veteran services.

Firstly, I agree with your course of action in codifying into regulation the two statutes that prompted this proposed rule. Removing the copayment requirement for high-risk individuals for receiving education about their medication and antagonist usage as well as for receiving treatment for an overdose itself will incentivize high-risk veterans’ usage of these services. This will reduce the risk of death from overdose by increasing the rate of overdose intervention as demonstrated by the VA’s assessment of service usage for high-risk individuals from 2017 to present (1). Since the launch of the VA’s Opioid Safety Initiative in 2013, the number of veterans prescribed opioids and the rate of opioid overdoses from prescription opioids has been decreasing. This program has multiple layers such as education, alternative pain management, risk mitigation strategies, and addiction treatment (2) and proved to be successful in reducing the opioid crisis in the veteran population however, the program is simply a starting point. This new rule, along with the Public Law statutes referenced above, further the goals of the OSI program, and the Comprehensive Addiction and Recovery Act of 2016, and are aligned with current best practices for treating chronic pain, mediating mental health comorbidities, and reducing the risk of addiction and overdose in the veteran population (3,4). Experts in the field have identified the removal of financial barriers to be a key factor in a person’s recovery from opioid dependence (4). By addressing the burden and deterrence of a copayment, this rule eliminates a barrier to treatment and education opportunities for many high-risk veterans who would otherwise forgo these services.

Education and outreach can help reduce self-stigmatization from internalized public stigmatization which is a leading factor in treatment deterrence for high-risk individuals (5). I believe this rule should incorporate wording ensuring outreach to identify high-risk veterans, encourage educational outpatient visits, and follow-up before and/or after both outpatient and inpatient visits for treatment and education. Not only will this increase the number of veterans who receive antagonist prescriptions, but these efforts will also aid the VA in tracking the most at risk of the high-risk population, aid in the dissemination of pain management alternatives, and overall reduce the risk of opioid misuse and overdose events. Outreach has proven effective in several studies conducted all over the US for people suffering with Opioid Use Disorder and is a main factor is reducing repeat overdose events (6,7,8,9,10). These outreach practices are already occurring in the VA and should be folded into the regulation to ensure their continuation as outreach is an integral part of increasing the effectiveness of this rule’s stated goal.

One aspect of the impact analysis that I am concerned about is the projected loss of revenue of >$150,000 with increases for each year of this rule’s existence due to the copayment exemptions. The “impact” analysis did not state where this revenue stream would be diverted from internally and how this may impact other veteran services of equal or greater importance. Does the VA plan to apply for a grant under the Food, Drug, and Cosmetic Act for the emergency treatment of opioid overdose (11)? One of these grants can offset at least $200,000 of antagonist costs which is greater than the yearly projected loss of revenue from this rule.
Thank you for considering my public comment in your review of the proposed rule Elimination of Copayment for Opioid Antagonists and Education on Use of Opioid Antagonists.

Best regards,
Mina Puig
Master of Public Policy and Administration Candidate
University of Massachusetts Amherst

Please see attached for list of referenced material.", "comment_id": "VA-2020-VHA-0023-0017", "comment_url": "https://api.regulations.gov/v4/comments/VA-2020-VHA-0023-0017", "comment_date": "2020-12-03T05:00:00Z", "comment_title": "Comment on AQ31-Proposed Rule-Puig, Mina", "commenter_fname": "Mina", "commenter_lname": "Puig", "comment_length": 4521}, {"text": "The U.S. Department of Veterans Affairs’ (VA) proposal for this rule change is a great idea to remove the barriers to treatment faced by veterans. Removing copays and providing education are two strategies that could potentially improve the health outcomes of veterans battling opioid use disorder (OUD) which leads to opioid overdoses. We must combat the factors that may deter veterans from receiving treatment. This proposed rule to, provide education on the use of opioid antagonists and to exempt co-payments, showcases the VA understands the need for prevention intervention strategies to remove the burden on the veteran population and their families.

According to the Pain Management Opioid Safety VA Educational Guide (2014), veterans are more likely to die from accidental overdose than non-veterans.1 Research shows that veterans are prescribed higher doses of opioids and receive prescriptions for sedatives concurrently when suffering from Posttraumatic Stress Disorder (PTSD).1 This combination increases the likelihood for an accidental overdose.1 The National Institute on Drug Abuse found that barriers to opioid antagonist include stigma, lack of education, and lack of patient interest.2 Other research found that logistics, treatment experiences and beliefs, and knowledge of OUD medications also contribute to the lack of opioid antagonist use by patients and providers.3 The stigmas associated with OUD and high out-of-pocket cost were the most common barriers for patients.3

A common drug to reverse the effects of opioid intoxication is naloxone, commonly known as Narcan. In 2013, the Substance Abuse and Mental Health Services Administration started to recommend providers prescribe this drug to patients taking opioids.4 The cost of Naloxone product have been increasing since 2009. Currently the version manufactured by Kaleo has increased from $690.00 USD in 2014 to $4,500 USD in 2016.4 This life saving drug can cost a veteran hundreds of dollars with insurance and be even more costly without it. The goal should be to improve the health outcomes of all veterans. Making sure they can afford their medications is one way to do this. Removing the co-payments from inpatient hospital care, outpatient medical care, and for medications will remove the barrier veteran’s face when trying to receive care. A large majority of veterans deal with homelessness and poverty after service. It is understandable that these veterans will not have insurance that will cover these treatments.

The lack of knowledge about OUD medications contributes to the absence of opioid antagonist use by patients and providers. Research found that the lack of knowledge pertained to where/how to get treatment and negative views of OUD medications.3 Providing education will give veterans a sense of involvement and control over their treatment. Educating on the use of opioid antagonists to reverse the effects of overdoses of specific medications or substances will improve the health literacy of veterans.

With the epidemic on opioid overdose continuing to rise it is important that we create legislation to combat it for the most at risk populations. Veterans volunteer their lives and time to protect the United States and it is our duty to protect them when they return home. Many veterans suffer from injuries, both physical and mental, while in service to this country, that lead to their prescription and addiction to opioids. They come back from war and suffer from stress, anxiety, pain, trauma, which tarnishes their mental health. The proposed rule by the VA to eliminate co- payments for inpatient hospital care, outpatient medical care, and for medications and providing education on opioid antagonists gives us the opportunity to do just this. As a daughter to two veterans and a family member to multiple veterans from varies branches of the military I believe this proposed rule will be impactful to veterans battling OUD.

References
1.Pain Management Opioid Safety VA Educational Guide . U.S. Department of Veteran Affairs ; 2014.
2.NIDA. Substance Use and Military Life DrugFacts. National Institute on Drug Abuse website. https://www.drugabuse.gov/publications/drugfacts/substance-use-military-life. October 23, 2019 Accessed November 18, 2020.
3.Mackey K, Veazie S, Anderson J, Bourne D, Peterson K. Evidence Brief: Barriers and Facilitators to Use of Medications for Opioid Use Disorder. U.S. Department of Veterans Affairs ; 2019.
4.Gupta R, Shah ND, Ross JS. The Rising Price of Naloxone — Risks to Efforts to Stem Overdose Deaths. New England Journal of Medicine. 2016;375(23):2213-2215. doi:10.1056/nejmp1609578
", "comment_id": "VA-2020-VHA-0023-0013", "comment_url": "https://api.regulations.gov/v4/comments/VA-2020-VHA-0023-0013", "comment_date": "2020-11-18T05:00:00Z", "comment_title": "Comment on AQ31-Proposed Rule-Thomas, Patricia", "commenter_fname": "Patricia", "commenter_lname": "Thomas", "comment_length": 4895}, {"text": "See attached file(s)", "comment_id": "VA-2020-VHA-0023-0018", "comment_url": "https://api.regulations.gov/v4/comments/VA-2020-VHA-0023-0018", "comment_date": "2020-12-04T05:00:00Z", "comment_title": "Comment on AQ31-Proposed Rule-NAMI", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}]}, {"id": "FDA-2019-P-1364", "title": "Request that the FDA impose a moratorium on approval of all NDAs for new opioids or new opioid formulations-WITHDRAWN 4/5/19", "context": "2019-08-05T12:03:41Z", "purpose": "Nonrulemaking", "keywords": ["Public Citizen\u2019s Health Research Group", "Approval of New Drug Applications for New", "Opioids or New Opioid Formulations", "non-existent opioid regulatory framework", "opioid crisis in the U.S.", "National Academies of Sciences, Engineering,", "and Medicine (the National Academies),", "OPEN", "CDER"], "comments": [{"text": "The FDAs continued approval of new potent opioids, which are known to threaten the public health, without first significantly improving the review process by creating and finalizing an opioid regulatory framework recommended by the National Academies, represents a clear and present continuing danger to the health and safety of people in this country.", "comment_id": "FDA-2019-P-1364-0007", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1364-0007", "comment_date": "2019-08-02T04:00:00Z", "comment_title": "Comment from Jonathan Boyne", "commenter_fname": null, "commenter_lname": null, "comment_length": 352}, {"text": "The Nation's opioid epidemic / crisis is far from over. The time has long past that we try to deal with it using a band-aid approach. The pharmacutical companies are not evil, but they have apparently chosen to not address this epidemic which is well documented and keep manufacturing far more of the varous opioid drugs than this country needs. Responsible government and private sector management should dictate a focus on developing sound opertional strategies to solve the current epidemic before we should be approving additional new opioid drugs. If this were a contagious disease there would be a mandated containment effort. Why do we think this isn't the same type of problem?", "comment_id": "FDA-2019-P-1364-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1364-0006", "comment_date": "2019-08-01T04:00:00Z", "comment_title": "Comment from Robert Dorris", "commenter_fname": null, "commenter_lname": null, "comment_length": 693}, {"text": "I support the fight against addiction, overdose and the import of illicit drugs into the United States. While FED UP fights for these causes however, you leave in your wake millions of chronically ill patients who suffer with severe pain as they are being denied appropriate opioid pain management. These are people who were on a long term managed and monitored regimen of opioid pain medication while adhering to every clause in their physician/patient contract. Both the New England Journal of Medicine and the Substance Abuse and Mental Health Services Administration (SAMHSA) released studies showing that less than 1% of those prescribed opioids for the purpose of managing chronic pain became addicted. Likewise, the study below explains that prescription opioid use to manage acute pain almost never results in addiction.

Researchers note that despite a documented doubling of opioid analgesic use from 2000 to 2010, they cannot find evidence that prescribing opioids for chronic pain is the principal driver of rising addiction rates in adults. OUD develops in only a small percentage of adults who are prescribed opioids for acute pain. In a large study of 640,000 opioid-naive patients in which chronic opioid use was examined one year after surgery for 11 surgical conditions, the prevalence was found to range from 0.12% for cesarean section deliveries to 1.4% for total knee replacement surgeries. In another study in which chronic opioid use was examined in approximately 18 million people with acute pain who had not undergone surgery and had never taken opioids, only 0.14% of those who were prescribed opioids were found to still use the medications a year later.

I hold no ill will toward those fighting addiction. They were a community stigmatized by those who hold office, the news media and the public at large. This has and continues to change but the fight must continue. In their place however are now those who suffer with intractable, chronic illness and resulting pain. This is now a community stigmatized by the same people who are coming to realize that it is far more effective and far more humane to offer treatment to those fighting addiction. But now those who live with debilitating pain become the lepers, refused treatment by the very same people who once turned a blind eye to those addicted.

I would ask that those involved in creating the message FED UP uses to reach out to the masses PLEASE adjust your language to highlight that pain patients must not be made the new target. Please take this request into consideration. ", "comment_id": "FDA-2019-P-1364-0008", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2019-P-1364-0008", "comment_date": "2019-08-05T04:00:00Z", "comment_title": "Comment from Bill Murphy", "commenter_fname": null, "commenter_lname": null, "comment_length": 2592}]}, {"id": "FDA-2017-D-2497", "title": "FDA Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioids", "context": "2018-01-29T14:06:44Z", "purpose": "Nonrulemaking", "keywords": ["2017-313"], "comments": [{"text": "See attached file(s)", "comment_id": "FDA-2017-D-2497-0280", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-D-2497-0280", "comment_date": "2017-07-10T04:00:00Z", "comment_title": "Comment from American Medical Association", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "HiDear Sir and Madom

I am a acupuncturist work in Virginia. acupuncture is works. I help many patient out pain or chronic pain with acupuncture. They wrote the story for me before. I put it in attachment as follow, may help you make the decision

", "comment_id": "FDA-2017-D-2497-0293", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-D-2497-0293", "comment_date": "2017-07-10T04:00:00Z", "comment_title": "Comment from Yan Fan", "commenter_fname": null, "commenter_lname": null, "comment_length": 264}, {"text": "Please see uploaded file with comments", "comment_id": "FDA-2017-D-2497-0445", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-D-2497-0445", "comment_date": "2017-07-11T04:00:00Z", "comment_title": "Comment from Academy of Integrative Pain Management", "commenter_fname": null, "commenter_lname": null, "comment_length": 38}, {"text": "On behalf of the Acupuncture Society of Virginia, please see the attached document with our organization's formal comment on FDA Draft Revisions to the Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioids. ", "comment_id": "FDA-2017-D-2497-0321", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-D-2497-0321", "comment_date": "2017-07-11T04:00:00Z", "comment_title": "Comment from Acupuncture Society of Virginia", "commenter_fname": null, "commenter_lname": null, "comment_length": 237}, {"text": "See attached file(s)", "comment_id": "FDA-2017-D-2497-0525", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-D-2497-0525", "comment_date": "2017-07-12T04:00:00Z", "comment_title": "Comment from American Academy of Pain Medicine", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "A recent clinical trial comparing acupuncture to IV morphine in the Emergency Department* showed acupuncture providing comparable pain relief, with a faster onset time and fewer minor adverse events (4 versus 85). A large meta-analysis** definitively established acupuncture's efficacy over and above placebo for chronic pain -- while also showing that even the sham acupuncture (placebo) procedures used for these trials themselves had a clinical effect size of 0.33, comparable to that of NSAIDS but without their side effects (which kill over 10,000 patients per year in the United States).

Many well-meaning and otherwise expert physicians are simply not aware that acupuncture is a highly effective nonpharmaceutical alternative to opioids for acute as well as chronic pain, with an excellent safety profile.

*Grissa, M. H., Baccouche, H., Boubaker, H., Beltaief, K., Bzeouich, N., Fredj, N., ... & Nouira, S. (2016). Acupuncture vs intravenous morphine in the management of acute pain in the ED. The American journal of emergency medicine, 34(11), 2112-2116.

**Vickers, A. J., Cronin, A. M., Maschino, A. C., Lewith, G., MacPherson, H., Foster, N. E., ... & Acupuncture Trialists' Collaboration. (2012). Acupuncture for chronic pain: individual patient data meta-analysis. Archives of internal medicine, 172(19), 1444-1453.

", "comment_id": "FDA-2017-D-2497-0672", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-D-2497-0672", "comment_date": "2017-07-14T04:00:00Z", "comment_title": "Comment from Claudia Citkovitz", "commenter_fname": null, "commenter_lname": null, "comment_length": 1385}, {"text": "See attached file(s)", "comment_id": "FDA-2017-D-2497-0670", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-D-2497-0670", "comment_date": "2017-07-14T04:00:00Z", "comment_title": "Comment from Lynn Ashcraft", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "To: Food and Drug Administration, DHHS
Re: A Blueprint on Using Acupuncture as Adjunct Therapy to ER/LA Opioid Analgesics for Chronic Pain Management

My name is Casey H. Potetz. I am an acupuncture intern at the World Medicine Institute, in Honolulu, Hawaii. I have completed over 2,500 hours of educational and clinical training in the field of Acupuncture and Chinese Medicine. I am pursuing a Master of Science in Oriental Medicine and am on track to achieve Diplomate of Oriental Medicine status in January of 2018.

I want to thank you for opportunity to present comments regarding the management and support of chronic pain patients. I would also like to recognize the FDA's Risk Evaluation and Mitigation Strategy and it's efforts to combat opioid misuse.

Healthcare providers should be aware of available treatment options that may lead to decreased dependency on opioid medications. I have attached an outline of information on acupuncture therapy. This outline is intended to make acupuncture information available to healthcare providers. I am pleased to share this information and accept any questions or comments regarding this subject.

Regards,
Casey Potetz
CaseyPotetz@gmail.com", "comment_id": "FDA-2017-D-2497-0234", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-D-2497-0234", "comment_date": "2017-06-09T04:00:00Z", "comment_title": "Comment from Casey Potetz", "commenter_fname": null, "commenter_lname": null, "comment_length": 1251}, {"text": "See attached file(s) The FDA must not adopt the VA DoD or CDC guidelines, as there is abundant evidence to suggest that these guidelines are responsible for up to 40% of overdose deaths,which are suicides due to untreated chronic pain according to the Montana state suicide coordinator. Physicians must be educated about the very real, deadly consequences of leaving pain unrelieved, and the role that opioids has to play in alleviating many of these people's pain. ", "comment_id": "FDA-2017-D-2497-0640", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-D-2497-0640", "comment_date": "2017-07-13T04:00:00Z", "comment_title": "Comment from Maxx Lamb", "commenter_fname": null, "commenter_lname": null, "comment_length": 470}, {"text": "The Strengthening the Mid-Atlantic Region for Tomorrow (SMART) 501c4 supports the FDA revisions of the Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioids. Educating both prescribers and patients on the risks of opioid therapy is key to combating the opioid overdose epidemic in the long term. We also suggest that the FDA take further action to impact the epidemic through expanding access to naloxone, by implementing a co-prescribing naloxone requirement to patients who are at risk of overdose as part of the FDA REMS program.

See attached file(s)", "comment_id": "FDA-2017-D-2497-0625", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-D-2497-0625", "comment_date": "2017-07-13T04:00:00Z", "comment_title": "Comment from Strengthening the Mid-Atlantic Region for Tomorrow (SMART)", "commenter_fname": null, "commenter_lname": null, "comment_length": 590}]}, {"id": "FDA-1977-N-0411", "title": "Relationship of Methadone Treatment Programs", "context": "2021-09-01T18:06:33Z", "purpose": "Nonrulemaking", "keywords": ["PROGRAM", "TREATMENT", "METHADONE"], "comments": [{"text": "N/a", "comment_id": "FDA-1977-N-0411-0002", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1977-N-0411-0002", "comment_date": "2012-08-07T04:00:00Z", "comment_title": "The ADDICTION CTR", "commenter_fname": null, "commenter_lname": null, "comment_length": 3}, {"text": "N/a", "comment_id": "FDA-1977-N-0411-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-1977-N-0411-0003", "comment_date": "2012-08-07T04:00:00Z", "comment_title": "EXEC OFFICE OF PRESIDENT", "commenter_fname": null, "commenter_lname": null, "comment_length": 3}]}, {"id": "DEA-2020-0002", "title": "Schedules of Controlled Substances: Placement of cyclopentyl fentanyl, isobutyryl fentanyl, para-chloroisobutyryl fentanyl, para-methoxybutyryl fentanyl, and valeryl fentanyl into Schedule I", "context": "2021-12-02T01:00:58Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "In light of growing number of opioid overdose deaths in America (more than 70,000 people died of opioid overdose in 2017 according to the CDC), I support the permanent addition of cyclopentyl fentanyl, isobutyryl fentanyl, para-chloroisobutyryl fentanyl, para-methoxybutyryl fentanyl, and valeryl fentanyl to list of Schedule 1 drugs. These drugs are structurally similar to the opioid fentanyl but are not FDA-approved drug products. As a result, users of these drugs are not protected by the FDA's quality standards. According to the CDC, abusing unregulated opioids of unknown quality and potency represents a significant risk of opioid overdose to users. Opioid overdose has been estimated to cost the United States more than 400 billion dollars annually (according the White House Council of Economic Advisors). Additionally, I argue that the social and emotional damage done to American communities caused by the opioid overdose epidemic cannot be presented solely financial terms. In an effort to minimize the presence of unregulated opioid substances of unknown quality and potency in illicit drug markets, I support the listing of these subtances as Schedule 1 drugs, as they meet the DEA's requirements for Schedule 1 subtances. ", "comment_id": "DEA-2020-0002-0011", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0002-0011", "comment_date": "2020-03-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-01681", "commenter_fname": "Brian", "commenter_lname": "Rogers", "comment_length": 1287}, {"text": "Why don't you get a chemist to make a list of all the chemical pictures that cause drug addicts who are using fentanyl to feel satisfied so that we don't do this stupid add five chemicals and China imports four hundred variants. The solution is to list every fentanyl variant as schedule 1.", "comment_id": "DEA-2020-0002-0009", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0002-0009", "comment_date": "2020-03-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-01681", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 298}, {"text": "The proposal to reschedule fentanyl to schedule one under the Controlled Substances Act though honorable in intent, may potentially do more harm than good. A large portion of our population relies on controlled substances, such has fentanyl, to relieve their chronic pain. While these drugs were never meant to be a long-term solution, that has become the reality we must deal with. Rendering fentanyl illegal would leave many patients in a lurch, unable to access the care they were previously receiving. These patients would no doubt either receive a prescription for a different opioid or worse, obtain illicit substances to fill the void they are now left with. While prescription drugs make up a great portion of the opioid epidemic and I agree that alternative therapies need to be established, it would be foolish to forget the schedule one substances that are already contributing to this nation-wide crisis. The majority of fentanyl related deaths are due to its mixture with other substances that are already classified as schedule one. Creating more illegal substances will not solve the issue, rather add fuel to the fire that is the illegal drugs trade. ", "comment_id": "DEA-2020-0002-0006", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0002-0006", "comment_date": "2020-03-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-01681", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 1167}, {"text": "Here's a article reported by CNN's Madeline Holcombe which explains everything we need to know about the fentanyl crisis that we are dealing with here in central Ohio: "This Ohio county (Franklin) may need a second morgue to handle the number of fentanyl overdoses." [1]

In her article, Holcome discusses the opioid scourge that is heavily affecting my home state. The article stated that [Franklin] county has seen 23 overdose deaths from January 31 to February 7, Dr. Anahi Ortiz, the county's coroner, said in a statement on her Facebook page. The next day, the county had five more. Dr. Ortiz also stated that [fentanyl] is the deadliest drug in the US, according to the Centers for Disease Control. It is up to 100 times more powerful than morphine, and just .025 milligrams can be deadly.While Franklin County usually has one or two overdose deaths in a day, Ortiz said on Facebook, one 26-hour period in September 2019 saw 10 people dying of overdoses.That year, overdose deaths in the county were up 15% from the year before, and 90% were opiate related.

Fentanyl is a drug that affects everyone and is not limited to race, income, social class, age, education level, etc. It is a killer and can be fatal on someone's first dose because of its potency and the chemicals it is mixed with for the purpose of "cutting" it for sale on the street and larger profits for the dealers.

I have never had a friend or relative killed or had their lives destroyed by it, but I believe that I am in the minority. Almost everyone has been impacted by these drugs. We have all watched the news reports, watched documentaries, seen the impacts of the drugs in TV shows or movies... everyone knows it is a problem which needs a solution ASAP! We need to make it a schedule 1 narcotic and take every legal step to eliminate fentanyl from our streets, or neighborhoods, our schools, and our homes. Fortunately we are in the process of closing/controlling entry on our southern border where most of this lethal drug is being smuggled in from central and southern America. There is no simple, single solution to combating this fentanyl plague, all possible solutions need to be taken, and reclassifying fentanyl to a schedule 1 drug is a necessary step to take.

[1] Madeline Holcombe, This Ohio county may need a second morgue to handle the number of fentanyl overdoses, CNN, (February 13, 2020), https://www.cnn.com/2020/02/13/us/ohio-fentanyl-overdose-second-morgue/index.html.

Thank you for considering my comments and concerns.

Respectfully,

James E. Yerian

", "comment_id": "DEA-2020-0002-0008", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0002-0008", "comment_date": "2020-03-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-01681", "commenter_fname": "James", "commenter_lname": "Yerian", "comment_length": 2663}, {"text": "This is a drug I think is abused by people by age and it is terrible to see it get worse year by year. I am glad that people will be punished at a higher degree of law if they are using these drugs to ruins the lives of others by providing a source for this drug. I hope that this reclassification will prevent further deaths and addiction.", "comment_id": "DEA-2020-0002-0010", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0002-0010", "comment_date": "2020-03-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-01681", "commenter_fname": "Jose", "commenter_lname": "Vargas", "comment_length": 340}, {"text": "Yes, this is good because the drug dealers are the words and much worse than the users.", "comment_id": "DEA-2020-0002-0007", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2020-0002-0007", "comment_date": "2020-03-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2020-01681", "commenter_fname": "Lily", "commenter_lname": "Grant", "comment_length": 87}]}, {"id": "FDA-2005-N-0093", "title": "International Drug Scheduling; Convention on Psychotropic Substances; Single Convention on Narcotic Drugs; Butorphanol; Delta-9-tetrahydrocannabinol (Dronabinol); Gamma-Hydroxybutyric Acid; Ketamine; Khat; Tramadol; Zopiclone; Buprenorphine; Oripavine ", "context": "2021-09-01T01:01:14Z", "purpose": "Nonrulemaking", "keywords": ["Oripavine", "BUPRENORPHINE", "Zopiclone", "TRAMADOL", "Khat", "KETAMINE", "Gamma-Hydroxybutyric Acid", "DRONABINOL", "Delta-9-tetrahydrocannabinol ", "BUTORPHANOL", "NARCOTIC DRUGS", "Single Convention ", "Convention on Psychotropic Substances", "International Drug Scheduling"], "comments": [{"text": null, "comment_id": "FDA-2005-N-0093-0007", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2005-N-0093-0007", "comment_date": "2006-01-24T05:00:00Z", "comment_title": "Food and Drug Administration - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-2005-N-0093-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2005-N-0093-0004", "comment_date": "2006-01-24T05:00:00Z", "comment_title": "Food and Drug Administration - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-2005-N-0093-0010", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2005-N-0093-0010", "comment_date": "2006-01-24T05:00:00Z", "comment_title": "Food and Drug Administration - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-2005-N-0093-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2005-N-0093-0005", "comment_date": "2006-01-24T05:00:00Z", "comment_title": "Food and Drug Administration - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-2005-N-0093-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2005-N-0093-0003", "comment_date": "2006-01-24T05:00:00Z", "comment_title": "Food and Drug Administration - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-2005-N-0093-0011", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2005-N-0093-0011", "comment_date": "2006-01-24T05:00:00Z", "comment_title": "Food and Drug Administration - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-2005-N-0093-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2005-N-0093-0006", "comment_date": "2006-01-24T05:00:00Z", "comment_title": "Food and Drug Administration - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-2005-N-0093-0009", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2005-N-0093-0009", "comment_date": "2006-01-24T05:00:00Z", "comment_title": "Food and Drug Administration - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-2005-N-0093-0008", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2005-N-0093-0008", "comment_date": "2006-01-24T05:00:00Z", "comment_title": "Food and Drug Administration - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-2005-N-0093-0002", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2005-N-0093-0002", "comment_date": "2005-12-19T05:00:00Z", "comment_title": "'Ray of Light Cannabis Chrisitan Ministry ' - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}]}, {"id": "CDC-2020-0001", "title": "Developing a Workplace Supported Recovery Program: A Strategy for Assisting Workers and Employers with the Nation\u2019s Opioid and Substance Use Disorder Epidemics: Request for Information", "context": "2020-08-06T07:34:45Z", "purpose": "Nonrulemaking", "keywords": null, "comments": [{"text": "See attached file(s)", "comment_id": "CDC-2020-0001-0017", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0001-0017", "comment_date": "2020-06-26T04:00:00Z", "comment_title": "Comment from Martin Oviasogie", "commenter_fname": "Martin", "commenter_lname": "Oviasogie", "comment_length": 20}, {"text": "Please see the attached letter from the American Society of Addiction Medicine.", "comment_id": "CDC-2020-0001-0006", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0001-0006", "comment_date": "2020-04-14T04:00:00Z", "comment_title": "Comment from Paul Earley", "commenter_fname": "Susan", "commenter_lname": "Awad", "comment_length": 79}, {"text": "Inclusion in a Workplace Supported Recovery Program (WSRP) is pertinent to ending the opioid epidemic in the U.S. Resources, such as alternatives to opioids for pain relief, should be at the forefront of this initiative. It could be increasingly difficult for employees struggling with opioid use working in larger companies to get all of the resources they need, as they may need specialized attention that cannot be given in a large company. Employers should be fully aware of the recoveree's past and be able to recognize the signs of an eminent relapse. This will require some sort of training for employers or managers and their willingness to participate fully in being a part of a (WSRP). Although employers may be weary of the time-consumption this program could take, they may be more willing to partake if there is some sort of incentive to them to participate. However, the incentive should be regulated as to prevent employers from taking advantage of the incentives without fully holding up their end of the deal as well. ", "comment_id": "CDC-2020-0001-0007", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0001-0007", "comment_date": "2020-04-14T04:00:00Z", "comment_title": "Comment from Jessica Anonymous", "commenter_fname": "Jessica", "commenter_lname": "Anonymous", "comment_length": 1039}, {"text": "I am interested in researching this project in Hawaii.", "comment_id": "CDC-2020-0001-0020", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0001-0020", "comment_date": "2020-07-17T04:00:00Z", "comment_title": "Comment from Cari Craig", "commenter_fname": "Cari", "commenter_lname": "Craig", "comment_length": 54}, {"text": "Local communities of recovery have historically been the place for persons in early recovery to find and obtain a job. Any future workplace recovery program should be developed collaboratively with recovery community organizations who know of recovery supportive employers.
Any future workplace supported recovery program should
- provide potential employers information on the benefits of hiring persons in recovery
- be inclusive of and collaborative with grassroots recovery community organizations familiar with local and regional recovery friendly employers
- consider incentivizing the hiring or persons in recovery as a way to expand opportunities for persons in early recovery and improve recovery outcomes
- reduce barriers to employment for person in recovery who may have historic arrest records that would keep them out of productive employment.

Thank you for the opportunity to comment

William Stauffer LSW
The Pennsylvania Recovery Organizations - Alliance

", "comment_id": "CDC-2020-0001-0024", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0001-0024", "comment_date": "2020-07-24T04:00:00Z", "comment_title": "Comment from The Pennsylvania Recovery Organizations - Alliance", "commenter_fname": null, "commenter_lname": null, "comment_length": 1028}, {"text": "On behalf of our more than 100,000 member physical therapists, physical therapist assistants, and students of physical therapy, the American Physical Therapy Association appreciates the opportunity to submit comments in response to the Centers for Disease Control and Prevention's request for information on Developing a Workplace Supported Recovery Program: A Strategy for Assisting Workers and Employers with the Nation's Opioid and Substance Use Disorder Epidemics.

APTA thanks CDC for the opportunity to comment on this proposed rule. We look forward to working with the agency in the future to help promote access to nonpharmacological options to pain management, including physical therapy. Should you have any questions regarding our comments, please contact Steve Postal, Senior Specialist of Regulatory Affairs, at stevepostal@apta.org or 703/706-3391. Thank you for your consideration. ", "comment_id": "CDC-2020-0001-0021", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0001-0021", "comment_date": "2020-07-21T04:00:00Z", "comment_title": "Comment from American Physical Therapy Association", "commenter_fname": "Steve", "commenter_lname": "Postal", "comment_length": 913}, {"text": "RECON KY is submitting the attached comment regarding Workplace Supported Recovery Programs.", "comment_id": "CDC-2020-0001-0025", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0001-0025", "comment_date": "2020-07-24T04:00:00Z", "comment_title": "Comment from RECON KY", "commenter_fname": null, "commenter_lname": null, "comment_length": 92}, {"text": "General Questions
1. What elements, attributes, activities, and resources should be involved in a Workplace Supported Recovery program (WSRP)? Describe why inclusion would benefit a WSRP.--I think it would be helpful to have some kind of flowchart that would direct an employer on whether a person with a criminal history and SUD should proceed with hiring. This would require research into WSRP and outcomes so employers could understand which applicants would have the highest chance at success. It may need to be unique to certain industries or job types (e.g., manual labor, office work, etc). It should include modifiable factors that the person could change to increase their odds of success, not just demographics that the person could not alter.

2. How do the elements, attributes, activities, and resources that make up WSRPs vary by industry and establishment size?--I think further research would be needed on this. see #1.

3. What WSRPs or related approaches are you aware of? Do any of these programs have evaluation or other outcome measures available?--I am not familiar with WSRP approaches and the research behind them.

4. Are you aware of any programs that may help employers fund or otherwise develop WSRPs? If so, what are they?--No, I am not.

5. What information is available about possible benefits for employers in hiring and/or retaining workers who are in recovery from substance misuse or a substance use disorder?--Not sure

6. What are the biggest concerns, fears, or challenges around WSRPs? If available, please provide any data or information to support these concerns.--From what I've heard: fear of ongoing criminal activity, substance use at work or under the influence on the job, fear of worker injury

7. What training related to this effort would be of value to managers/supervisors? To workers?--SUD as a medical issue, not necessarily a legal issue.

Questions About Workplaces
8. Are you aware of policies that organizations (including yours) have in place to address substance misuse and substance use disorder and, if so, what are they? (e.g., pre-employment drug testing, hiring, dismissal, disability, medical leave, benefits, and compliance with or implementation of Fair Labor Standards Act provisions)--We have pre-employement drug testing and can be randomly drug tested, although I'm not sure random, ongoing drug testing is utilized much if at all.

9. Which parts of your organization are involved in issues related to substance misuse or substance use disorders among your workers? (e.g., employee bargaining units, occupational health, safety department, human resources department, Employee Assistance Program)--Employee health, HR, EAP

Questions About Workplaces With a Recovery Program in Place
10. What services are offered as part of the program? Are there any limits or restrictions on these resources (e.g., position in organization, duration, eligibility)? If so, what are they?--Not aware of any services

11. Are any of these services available to employees dealing with the substance use disorder of another person, such as a spouse/partner, child, parent, or close friend? If so, what are they?--EAP

12. What major challenges and successes has your program had?--No program, but there should be one in my opinion and adequate research for it to be evidence-based to provide employee an employer adequate confidence that both will remain safe while the employee works and continues to support their recovery.", "comment_id": "CDC-2020-0001-0004", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0001-0004", "comment_date": "2020-03-24T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 3587}, {"text": "Please see attached files. Thank you.", "comment_id": "CDC-2020-0001-0018", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0001-0018", "comment_date": "2020-07-01T04:00:00Z", "comment_title": "Comment from Barbara Goldstein", "commenter_fname": "Barbara", "commenter_lname": "Goldstein", "comment_length": 38}, {"text": "To the National Institute for Occupational Safety and Health (NIOSH), CDC:

Pilleve is a DC-based digital health company that has developed a device that safely stores opioids and monitors usage. We appreciate the opportunity to provide comments regarding Workplace Supported Recovery Programs (WSRPs). Pilleve particularly commends NIOSH's efforts to ensure the support of employees in the workplace who need additional support for recovery from substance use disorder. Based on Pilleve’s areas of expertise, we will focus on the following areas as identified by DEA:

Elements, Attributes, Activities and Resources to be involved in a WSRP
Possible benefits for employers in hiring and/or retaining workers who are in recovery from substance misuse or a substance use disorder

A summary of the key points made in each section is as follows:
We recommend that WSRPs provide coverage of certain outpatient recovery programs, similar to EAPs but more comprehensive in scope, as well as stronger cultural support for employees in recovery through firm policy and flexible services.
The costs associated with supporting addiction recovery in the workplace is far less than firing and acquiring new hires; additionally, supporting employees in recovery boosts morale, and leads to stronger productivity and returns.
WSRPs should be flexible in scope and be available to individuals outside of work or home environments, especially with the rise of remote work. Environments and personal freedom are intertwined with increased potential of misuse and abuse. Controlled drugs should also be safely prescribed and carefully tapered.

We believe that digital health devices and applications can help physicians make data-driven decisions to appropriately improve opioid prescribing practices and manage patients remotely, especially for those in the workforce. As previously stated, Pilleve has developed a device to safely store opioids and monitor usage. These tools may also alleviate current healthcare limitations such as minimal physician-patient face-to-face opportunities and clinical burden to promote better patient outcomes. We believe that digital health technologies can be used and supported by WSRPs so that employees have higher likelihoods of recovery. As technology advances, many of these tools are becoming much more cost effective and are allowing for more possibilities and program structures.

Please see the attached file for our full set of comments.", "comment_id": "CDC-2020-0001-0032", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0001-0032", "comment_date": "2020-07-28T04:00:00Z", "comment_title": "Comment from Pilleve Inc.", "commenter_fname": null, "commenter_lname": null, "comment_length": 2535}]}, {"id": "DEA-2019-0013", "title": "Management of Quotas for Controlled Substances and List I Chemicals", "context": "2023-08-31T08:33:18Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "The restrictions of opioids after the CDC guidelines have caused undue hardships on all people who experience pain, acute and chronic. Suicides are up in people with chronic pain as are the number of people who have turned to street drugs. I have seen comments from chronic pain patients that say in order to get relief maybe the best way is to claim addiction in order to get methadone. Methadone is not a drug to utilize with its side affects on heart rhythm. It can cause sudden death.
I probably wont survive if my dose is reduced anymore because of the severity of my injuries due to a car accident 37 years ago. I am wheelchair bound now.
I have seen ads for new rehab facilities opening everywhere near me at the same time pain clinics are closing. Soon there wont be places for people suffering to go. Please dont cut production on opioids. ", "comment_id": "DEA-2019-0013-0115", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2019-0013-0115", "comment_date": "2019-11-05T05:00:00Z", "comment_title": "Comment on FR Doc # 2019-21989", "commenter_fname": "Rue", "commenter_lname": "Anonymous", "comment_length": 907}, {"text": "All this is doing is controlling what doctors can and will give their patients. More Cruel and unnecessary suffering by CPP. More government over reach I dont need the DEA in my doctors office. We are not drug addicts and treating as such as caused cruel and unnecessary suffering and pain. Stop the genocide on CPP. ", "comment_id": "DEA-2019-0013-0011", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2019-0013-0011", "comment_date": "2019-10-24T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-21989", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 318}, {"text": "There must be a system in place to manage the effects of inaccurate quotas. No one with pain significant to warrant use of opioids should be left without access to these life saving pain medications. The effects of this include needless suffering, heart attacks, strokes, withdrawal, suicide, medical collapse and death. It is a significant hardship and sometimes impossible for intractable pain patients to "pharmacy shop", looking for a pharmacythat has the needed medicine. This practice also flags the patient detrimentally. This is a no win situation for the sickest and most vulnerable subset of the population. Intractable pain patients do not divert their pain medicine as they need them for their own use. This should be taken into consideration. The unsafe, inhumane practice of using other classes of medicines to manage postoperative pain in the absence of opiates, leads to unnecessary suffering and untenable side effects such as liver and kidney failure. There must be a back up system in place. Thank you. ", "comment_id": "DEA-2019-0013-0010", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2019-0013-0010", "comment_date": "2019-10-24T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-21989", "commenter_fname": "Concerned", "commenter_lname": "Citizen", "comment_length": 1036}, {"text": "Please take into consideration the people who have legitimate reasons to take opioids and do not abuse them! I have Ehlers Danlos Syndrome which is a very painful hereditary connective tissue disorder. In my group alone, I have heard horror stories about people who's Drs have lowered or discontinued their pain control. Many of these people have committed suicide because they can't take the pain.
Please listen to some of them and hear their stories before you make a decision. I am fortunate in a way because of my body's response to most meds, my Dr implanted a pain pump (intrathecaly) which has it's own issues itself and not for everyone.
Tank you so much!", "comment_id": "DEA-2019-0013-0124", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2019-0013-0124", "comment_date": "2019-11-06T05:00:00Z", "comment_title": "Comment on FR Doc # 2019-21989", "commenter_fname": "Lori", "commenter_lname": "Perez", "comment_length": 689}, {"text": "My life has been taken away by pain that was only controllable with opoids. I have since been taken off due to doctor fear and now I'm bedridden. ", "comment_id": "DEA-2019-0013-0237", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2019-0013-0237", "comment_date": "2019-12-23T05:00:00Z", "comment_title": "Comment on FR Doc # 2019-21989", "commenter_fname": "Christian", "commenter_lname": "Woodward", "comment_length": 152}, {"text": "Further reduction to opioid medication will only result in more suffering and suicide due to excruciating pain not being controlled. WHY must chronic pain patients continue to pay with their lives for street drug addicts behavior? This is inhumane and soul crushingly cruel. As DEA agents, you MUST know where the problem is and where it's not. Go after the street drugs and cartels, God speed. There needs to be separation of street drugs and prescription pain medication when it comes to research. There needs to be separation between addicts and chronic pain patients before anyone is truly helped and the suffering and suicide is addressed. Please consider this before YOUR actions become genocide. ", "comment_id": "DEA-2019-0013-0259", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2019-0013-0259", "comment_date": "2019-12-26T05:00:00Z", "comment_title": "Comment on FR Doc # 2019-21989", "commenter_fname": "Michelle", "commenter_lname": "Anonymous", "comment_length": 707}, {"text": "The war on street drugs will never be won, but that is where your war is. Please continue to fight the good fight without dragging suffering chronic pain patients into all of this. We are not the problem. Addicts and chronic pain patients MUST be separated before anyone is truly helped. This would be a great start if you really want to begin to walk back the insane mistake made by the CDC guidelines that started this whole mess. Weather they want to take responsibility or not, the blood of all CPP suicides is on them. Knowing this, why in the world wouldnt they admit their mistake and immediately retract and carefully (with the help of pain management physicians) In plain english make it right? This should have been done a long time ago before innocent families had to watch their loved ones suffer such inhumane torture. Some to the point of suicide. Never in my lifetime would I have ever believed that this great country would force such suffering on their own citizens. It physically sickens me. Please tell me that (WE) are better than this. Please tell me that all of this suffering and death wasnt the agenda. There are innocent physicians in prison. This left whole practices full of abandoned CPPs. I can tell you from experience, its near impossible to find another physician to accept a new CPP who is on opioids. Your organization has terrorized them to the point that they are abandoning pain patients altogether. There are still wonderful caring physicians who would like to properly treat their patients and end their suffering but their hands are tied by YOU! This insanity must end. It only makes sense that the addiction specialists head the addiction plan and the pain management physicians and experts head the chronic pain plan. Please do whatever it takes to get it done right away. There are so many suffering and so close to giving up. I beg you to get it done so theres not one more loved soul that couldnt wait any longer.", "comment_id": "DEA-2019-0013-0086", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2019-0013-0086", "comment_date": "2019-11-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2019-21989", "commenter_fname": "Michelle", "commenter_lname": "Bannasch", "comment_length": 1958}, {"text": "Dear Sirs,

I am a chronic pain pt. have been on opioids for 20 years. I have tried to see about rehab but was told by a top inpatient rehab facility I had a preconceived notion about opioids and pain. Nothing they could give me would work because I needed stronger meds to control my pain. No I was not addicted only dependent. I need the meds to survive and live, even walk and perform personal care. There is no one I know who have ever abused their meds or anyone elses.
Please dont decrease the number of opioids being produced. The reasons there were a few problems were drug companies pushing the use and saying they were less addictive and certain doctors overprescribing. If I am unable to obtain oxycodone or fentanyl patches I cant live. ", "comment_id": "DEA-2019-0013-0095", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2019-0013-0095", "comment_date": "2019-11-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2019-21989", "commenter_fname": "Michelle", "commenter_lname": "Anonymous", "comment_length": 805}, {"text": "Chronic Pain Patients are the Lepors of 2019. We are denied Human Rights, Civil Rights and HIPPA protection. I am a Chronic Pain Patient, and I have trouble every month getting my pain prescription filled. More often than not the pharmacy can't fill my prescription because they can't get any Percocet in. And yes I have done every pain treatment out there prior to using opioids for my severe, relentless, unbearable constant pain. This includes; otc medications, heat/cold therapy, physical therapy, massage therapy, acupuncture, tens-unit, multiple cortisone injections, multiple nerve blocks both freezing/burning, biofeedback, spinal cord stimulator, as well as multiple spinal surgeries prior to being put on opioids for chronic pain treatment. In attempts to treat my chronic pain without using opioids. I had no choice but to try all I have listed or I would not be prescribed opioids, which were the only effective pain treatment. While all nonopioid treatments were ineffective the surgeries did bring feeling some back where I had been numb however: some treatments did indeed hurt me with a spinal cord injury, so never will I be out of pain. Along with that I'm having more surgeries so I can have pain pump implant. The implant will not eliminate my pain however; I'm hoping to at least be able to get my pain reduced to the level it was before my pain meds were cut in half. Along with my diagnosis of chronic pain, which is easily seen on my NCS/EMG, MRIs, X-rays, I now have pain induced high blood pressure, which has me becoming a stroke risk due to under-treated pain. My blood pressure was 200/116 at my Dr. appointment I immediately took my pain meds, but earlier than I was supposed to, 20 minutes after my reading was 130/70. I don't have high blood pressure I do have pain.This attack on opioids are causing many pain patients other life long health problems. I know this can become a permanent problem and the constant high blood pressure can lead to heart disease for me and all because of the opioid hysteria and That's what it is. When are chronic pain patients going to be considered? None of us want to live in pain, many have already committed suicide, many have died from untreated and under-treated pain, many are forced to navigate the streets to obtain pain relief, where are our rights? Who will defend us?
Val Windsor ", "comment_id": "DEA-2019-0013-0094", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2019-0013-0094", "comment_date": "2019-11-04T05:00:00Z", "comment_title": "Comment on FR Doc # 2019-21989", "commenter_fname": "Valerie", "commenter_lname": "Windsor", "comment_length": 2386}, {"text": "PLEASE HELP US CHRONIC PAIN PATIENTS WHO ARE SUFFERING IN UNBEARABLE PAIN BECAUSE WE'RE DENIED THE LIFE SAVING PAIN MEDICATIONS THAT MAKE LIFE BEARABLE MORE SUICIDES DEATHS BECAUSE WE CAN'T HANDLE THE PAIN Buy letting there be a SHORTAGE of PAIN MEDICATION available FOR PAIN PATIENTS AND surgeries and bad ACCIDENTS,bad MEDICAL conditions AND pain that does not stop like it should and BECOMES CHRONIC. Pain MEDICATIONS ARE a small part in this war on ABUSE it's the ILLEGAL DRUGS that ARE KILLING PEOPLE AND ADDICTS. We are the American people WHO you are hurting and betraying and KILLING us .taking our PAIN MEDICATIONS away is so wrong. CHRONIC PAIN PATIENTS ARE SUFFERING from HEART attacks the pain is so intense. Why are you doing this to us ?? You think you or your FAMILY are safe from CHRONIC PAIN...YOUR DEAD WRONG..I WOULD OF NEVER BELIEVED THAT YOU COULD BE IN THIS MUCH HORRIFIC PAIN AND SUFFERING YEAR AFTER YEAR AND IT NEVER STOPS UNTIL IT HAPPENED TO ME WHEN YOU HAVE A BAD ACCIDENT OR MEDICAL CONDITION OR BAD SURGERY AND YOU END UP WITH CHRONIC PAIN YOU WILL SUFFER TO UNTIL YOUR DEATH ", "comment_id": "DEA-2019-0013-0107", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2019-0013-0107", "comment_date": "2019-11-05T05:00:00Z", "comment_title": "Comment on FR Doc # 2019-21989", "commenter_fname": "Kim", "commenter_lname": "Buchholtz", "comment_length": 1119}]}, {"id": "FDA-2018-N-0987", "title": "Patient-Focused Drug Development on Opioid Use Disorder; Public Meeting; Request for Comments", "context": "2021-03-26T01:01:57Z", "purpose": "Nonrulemaking", "keywords": ["2018-86"], "comments": [{"text": "The rules regarding opioid use are getting ridiculous. You are hurting chronic pain patients! Every month, we must see our Pain Management Doctor and pray that he isn't going to try to wean us off our medications. I take a 12 hour in the morning and at night, with two breakthrough pills inbetween. I am barely able to function with my pain but there is no way I can try to request my dosage to be upped during this current climate, and I have been on the same dose for 3 years following a very large tumor removed from my spinal canal that has now become arachnoiditis. Opioids are the ONLY thing that seems to let me have halfway of a life currently. If I did not have them, I would not be able to function AT ALL due to my pain and limited ability to move throughout my day. Please, when you start putting these restrictions on paid meds, you MUST think about the chronic pain community. We have NO OTHER OPTIONS for pain management, especially living in a State where marijuana and even kratom are illegal. If I had to live with this pain and no opioids at all, I would probably just kill myself. This is barely a life, but taking my meds allows me to make coffee for my family, shower, and do minimal cleaning. I wouldn't be able to do anything without my meds, and by making this so difficult, I am totally afraid to ask for something stronger even though my condition is even worse than it was three years ago. Why are we not exempt from any kind of restrictions if we have pain that is never going to go away and are permanently disabled? Don't we have a right to try to be as normal and pain free as other people? I'm tired of feeling ashamed every time I go to my appt and have to do demeaning things like drug tests, fill out pages of paperwork, etc. This is not right!!! If we go to pain management, we are obviously complying and will comply so don't make us suffer for those who are straight up drug users and od'ing on stuff that they don't legitimately need. The people who are seeing their doctors each month are complying so please...enough with the restrictions! And bring us MORE choices on pain pills! Or medical marijuana! Or both preferably! It's inhumane this current climate for me and fellow pain sufferers!!! It's our bodies and we are not children! I'd love to put my name on here but I don't need to be flagged!!! One day, you will all see why we are scared. If you get in a car accident or something and have pain like we do, you will understand why we need to be able to keep getting our medication.", "comment_id": "FDA-2018-N-0987-0025", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-0987-0025", "comment_date": "2018-05-18T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 2598}, {"text": "This whole meeting seems to be on the effects that opioids have on a person using these pain medicine. However, you are not taking into consideration the many people who take these for many years to have some quality of life. When a person is injured with permanent pain or has a medical condition where pain is constant, these opioids give them a little quality of life. To live with constant pain without these medications, life is not worth living. Yet, you expect those people to stop a drug cold turkey. That is impossible. These people are not drug addicts but depend on these drugs to survive through the pain. We were originally told that anyone on this medication before 01/2018. that they could continue their meds. Now, the dose has been cut and another drug has been ordered,which was tried in the past and did not relieve the pain.If you want to stop people from O.D.ing, go to the Police Departments and get a list of all the people who have been arrested for the use and selling of these drugs and deny them! Don't take away the only hope we elder people have of any quality of life. My understanding was if you do not increase the mgs or the dosage, you may be dependent but not addicted. Now you want us to go to a pain clinic, we have, did not work! It now takes 6 months to get an appointment and another 2 months for "shots", so in the meantime, are we going to have withdrawals? It looks to me like we may have to become alcoholics to numb the pain! Just consider what you are doing to the legitimate opioid users. Thank you.", "comment_id": "FDA-2018-N-0987-0052", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-0987-0052", "comment_date": "2018-06-20T04:00:00Z", "comment_title": "Comment from Pame Lemon", "commenter_fname": null, "commenter_lname": null, "comment_length": 1569}, {"text": "I am a father of a 37 year old son who has been diagnosed with a neurological disease called RSD/CRPS from a car accident he had when he was 17 in highschool. RSD/CRPS is rated on the McGill Pain Index as the highest known pain, above removal of a finger, or even childbirth. He describes it as having gasoline poured on his skin and set on fire when it is not in control. Over the last 20 years, we have tried everything we could find to stop the pain including hyperbaric oxygen treatment, anti-inflammatory drugs, tens units, hypnotic therapy, chiropractic therapy, physical therapy, too many to remember them all. For the first 10 years after the accident my son had absolutely no life, bed ridden or chair ridden in our living room. Getting out of the house to go to the doctor was the majority of his life.

About 10 years ago we found a pain management doctor who placed him on high dosages of long acting morphine and fast acting opioids. 1900MME daily plus 8mg daily of klonopin. After 4 months on the drug, he began regaining his life back. 6 years ago, even though he was legally disabled, he went to work full time for 4 years. In August 2016 the government arbitrarily imposed it's 90 MME rule, the "one treatment fits all" mentality. He no longer can work. It took my son 10 years to reduce his pain medications by 65%. In January of 2017 he was on 960MME daily. Since the government intervention beginning in February of 2017, he has been forced to reduce his pain medications by another 65%, and in the process he lost his pain management doctor he had for 10 years. He is now on 280MME and with this new pain management doctor will continue to be reduced on his pain medications. It took 6 months to find a new pain management doctor due to the 90MME regulation.

To complicate matters, 10 years ago (by the same pain management doctor) he was also placed on a long acting benzodiazepine (klonopin) to combat nerve pain and the anxiety related to it. Now there has also been a restriction made that patients are not supposed to have both morphine/opioids and benzodiazepines. It took my son 10 years to reduce 50% of his benzodiazepine. He was expected to remove himself completely off of the benzodiazepine (4mg daily) in 4 months or completely remove himself off of the morphine and opioids. He could not complete either task of complete removal of either drug and this is why he lost his pain management doctor of over 10 years,

He has been physically tortured for the last 22 months, and is losing his life due to crippling pain again. Due to these forced pain medication reductions, his heart rate has been exceeding 200 bpm and his blood pressure has gone as high as 230/140. Since the reductions he has been placed on (4) blood pressure medications to keep him from having a stroke. Being on that many blood pressure medications causes him to feel severely depressed, which prior to these reductions was not the case. The pain could actually kill him. His sleep cycle is all but non-existent. The forced reductions has also caused periodic states of mental instability, which he never had issues with before We're all worried that his depression will eventually take his life.

", "comment_id": "FDA-2018-N-0987-0062", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-0987-0062", "comment_date": "2018-06-20T04:00:00Z", "comment_title": "Comment from C. Ligon", "commenter_fname": null, "commenter_lname": null, "comment_length": 3272}, {"text": "Ibogaine (or 18-MC)
It's been ignored long enough to the point of willful negligence. ", "comment_id": "FDA-2018-N-0987-0016", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-0987-0016", "comment_date": "2018-04-25T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 94}, {"text": "What is being done at a local level to prevent judges and correctional facilities from discriminating against those seeking or receiving methadone treatment?
Methadone being withheld and refused to inmates precipitating withdrawal with INTENT to punish.
Judges mandating forced detoxification from methadone, or incarcerating those who refuse to, and/or fail to do so.
Judges sentences including mandated levels of care, as if they are licensed healthcare providers capable to determine best practices.
Judges including in probation guidelines that methadone/suboxone treatment programs will not satisfy the requirements for drug treatment to complete probation.
", "comment_id": "FDA-2018-N-0987-0008", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-0987-0008", "comment_date": "2018-04-18T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 684}, {"text": "Hello: Seems to me, maybe incorrectly... that [both big pharma' AND] the FDA do a good job of "shoving the Ibogaine topic to the background". Just 30-days ago, as of April 20th 2018, I was FREED from a literal 30-year dependence (OK, addiction) to prescription opioids! That freedom was gained within mere hours of a ONE-TIME TREATMENT with Ibogaine Hydrochloride at https://BajaIbobaineCenter.com in Rosarito, BC, Mexico.

Either the FDA and big pharma will [eventually] work together and explore via clinical trials the Ibogaine promise, or there WILL BE an uprising within the patient community, I'm sure!

Ibogaine, Ibogaine Hydrochloride, norIbogaine and the "root of it all", the Iboga plant needs immediate focus! -Stanley Poe / northwest, Ohio", "comment_id": "FDA-2018-N-0987-0010", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-0987-0010", "comment_date": "2018-04-18T04:00:00Z", "comment_title": "Comment from Stanley Poe", "commenter_fname": null, "commenter_lname": null, "comment_length": 800}, {"text": "Later I will forward a letter written on behalf of a patient who after 10 years had his buprenorphine discontinued by insurance and we wrote the letter to the insurance commission and they are in process of investigating.

In the midst of an opiate death epidemic why would anyone refuse an effective Sched III opioid, Buprenorphine for pain??
Most insurance cos. are doing this. Only a few medicaid committees will allow it for pain. Washington St. a positive example. Idaho and other NW states would rather have everyone take opiates. Hmmm, in view of the epidemic, why should this happen?? Talk about a no-brainer.

Well rub your fingers together, it is all about money. The drug insert that insists on the use of Suboxone, which is 3x subutex is a problem as well. Subutex is safe and generic. We have been using it off-label for years for pain. Still not cheap, but a lot cheaper than dying. By itself, and no CNS issues, no OD's reported, on buprenorphine. Even ins. companies are still forcing that, even though 30% GI intolerance is an issue due to the naloxone. Clearly the drug is safe, even when used IV. But, guess what, the drug's pharmacokinetics by itself (agonist/antagonist) give it a ceiling beyond which it blocks itself and can make you sick if you take too much. . This feature makes it unattractive to the majority of abusers. It ceases giving a high and being fun. That is one reason no OD's reported and it is such a great drug for addicts. Insurance co's keep reading the drug handout and refuse to make wise decisions, and even some certified MD's do too. It is abused and sold, but that is ok for the recipient. They need it to relieve their withdrawal, if they can find a certified doc to rx., which they can't. Docs can learn to do this without a course. They do so for opiates, which are a lot more dangerous to rx.

Finally what kind of pain med do you want for your family, a safe one or an opiate that can cause OD deaths, especially if available for theft in your med cabinet? IV drug was approved for pain years ago and my surgeon daughter who used it during residency in 2000 reports it works great and no issues for post op pain. Maybe fentanyl will be needed if you break a leg, especially if you already take it for anything else, including addiction. Recently 2 opiate use disorder pts had a headon and broke their legs. Ortho called for anesthesia and they used a general with ketamine, which can cause dissociative thinking in adults. A good trade, no? Good solution, docs. By the way, the vets are way ahead of us, finding it effective for their patients in an oral solution.

In a few years the medical community and general public will all realize the safety and effectiveness of buprenorphine, and it will become the go to drug for pain. Cost and insurances that want to cut down allowed doses are the only barriers now. ", "comment_id": "FDA-2018-N-0987-0038", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-0987-0038", "comment_date": "2018-06-20T04:00:00Z", "comment_title": "Comment from Robert Rust MD ABAM", "commenter_fname": null, "commenter_lname": null, "comment_length": 2934}, {"text": "I saw two patients in the hospital this evening with endocarditis, a life-threatening infection of the heart, due to intravenous injection of buprenorphine-naloxone. One is 29, and was just told today that his heart is inoperable and he should be put on hospice. I asked the other to put her thoughts on paper, and this is what she wrote:

I'm a mother of 3 beautiful, smart, wonderful children (whom I have lost custody of due to IV drug use). It all really took off 4 years ago when I was introduced to Suboxone. I had been sick, throwing up sick, for a week, with no relief in sight. I was in the bathtub feeling like I was dying when my brother came in and told me he had something to make me feel better instantly. And yes, I wanted relief! He fixed me up a rig full of Suboxone and injected it into my arm. Within 5 minutes I was setting at the kitchen talbe, eating cereal and feeling much better. From that day on I was an IV Suboxone user. Me or my brother neither one had it prescribed, so we bought it off the street.

I wish I had never ever ever met Suboxone. I didn't know none of the risks of using it the way I did (IV). It sets up infection in your blood, heart and possibly your brain. It can take a year to fully detox from. I have been in the hospital for 3 weeks and will be here for another three so they can run antibiotics continuously to rid my body of infection. I was on the verge of death when I first got here. but I'm grateful for this rock bottom I've finally hit. It's taken me almost dying to realize my worth and to open my eyes up to how bad drug use is everywhere. If my story can help just one person then I'll forever be happy. I'm still very sick but getting better, one day at a time!!", "comment_id": "FDA-2018-N-0987-0069", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-0987-0069", "comment_date": "2018-06-20T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 1770}, {"text": "Since before my force taper from 450MME for 11yrs I was able to care for myself, my family, my 83 yr old mother, 76 yr old mother inlaw. Since the beginning of my force taper I am bed bound and unable to care for myself. My husband has had to cut back on work to care for our whole family. We are being foreclosures on our home because of my lupus, fibromyalgia, severe DDD with 3 herniated disks, chronic fatigue and other autoimmune diseases. I dont no what we are going to do now! I am so scared and in chronic pain 24/7! Please help me help myself! My high dose narcotics were helping me live a life. Still in pain but nothing like this. I beg you to stop this CDC Guidelines, etc so I can get my life back if it not already too late.", "comment_id": "FDA-2018-N-0987-0060", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-0987-0060", "comment_date": "2018-06-20T04:00:00Z", "comment_title": "Comment from Cynthia Boyd", "commenter_fname": null, "commenter_lname": null, "comment_length": 746}, {"text": "Thank you for hearing our stories. It is my sincere prayer that you read them with open hearts and minds.
I am a 54 y/o woman with spinal stenosis, bulging and herniated disks, fusion and bone spurs in C 3-6 stemming from an accident in 1998. The initial pain was excruciating and I was given opioids for one month. My pain subsided in the weeks to follow and I spent the next 11 or so years in discomfort at times that I would treat with Tylenol or Ibuprofen. The only time I had a thought of opioids was when the subject came up in the news. I mention this to bring light to the fact that my exposure did not cause me to become an addict. I went on to enjoy a full life filled with physical activities that I loved such as running, hiking, spelunking, not to mention raising three kids and owning and operating a very demanding construction company.
Fast forward 11 years... My neck began to "give me trouble", it was hurting worse and more often. I found myself running less, hiking less and being thankful that the kids were older and no longer needing my role as "soccer mom". I began to see a wonderful chiropractor who was adamant about never "cracking" my spine. While I truly liked him as a person and respected his profession, he was not helping me. I asked him about surgery and was told I was not a good candidate. My neck was getting worse, and fast. In 2009 my sister was diagnosed with stage 4 colon cancer. With no husband or children to help her I took on the job of caregiver, a job I wouldn't have missed for the world. However, it was during this time that I sought a Dr's care once again for my neck pain. I was referred to a pain management specialist in her state of Ohio. He prescribed low-dose oxycontin which afforded me the opportunity to care for my sister without having "down time" due to my own pain. I saw that specialist for almost a year before I returned home, opioid dependant and had several days of discomfort and thought I would go back to otc medications, which I suffered through for the next couple months (Still not an addict) before seeing a specialist here to treat my pain once again. His treatment had allowed me to enjoy my life as any normal person would. I hiked, worked, enjoyed my grandchildren, etc., etc. I have been with this Dr. since 2011. Over the years my tolerance has risen to my highest dose of 180 MME per day. This was working for me. It was working well. Due to the CDC recommendations my doctor was bullied into going against best practice and I was tapered by 25%, then most recently, 33% of that for a total of a 50% reduction in medication and what my Primary Care Dr. refers to as a "cocktail" of other drugs in its place, which includes a 500% increase in Gabapentin (from 600mg per day to 3000mg per day), 150mg Voltaren, 75mg Soma and Tramidol as needed. This has led to a virtual collapse in my life. I can no longer do the small things that most people take for granted. Things such as my own grocery shopping (4 times out of 5), no thought of going on a hike or planning a day at the zoo with my grandchildren. We have a family reunion planned this summer, which I had to back out of, as the thought of traveling and participating in large functions for a week is a distant dream. I spend most days gingerly counting my steps, careful not to step too hard or try to navigate any uneven terrain - if I can manage to walk at all. I am increasingly isolated from family and friends, which I will admit, depresses me at times.
It is baffling to me how the CDC can scare good doctors into stopping treatment for pain patients that gives us quality of life! I implore you to take this power away from them. I have read that even they say their arbitrary recommendations were not researched, nor do they apply to chronic pain patients.
This is the short version of my story. Thank you for taking the time to consider it in your Drug Development Policy.
Sincerely,
Beckie

", "comment_id": "FDA-2018-N-0987-0059", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-0987-0059", "comment_date": "2018-06-20T04:00:00Z", "comment_title": "Comment from Beckie Bonnell", "commenter_fname": null, "commenter_lname": null, "comment_length": 4036}]}, {"id": "FDA-2016-D-0785", "title": "General Principles for Evaluating the Abuse Deterrence of Generic Solid Oral Opioid Drugs Products", "context": "2017-11-22T10:26:14Z", "purpose": "Nonrulemaking", "keywords": ["2015-181", "General Principles for Evaluating", "Abuse Deterrence of Generic Solid Oral", "Opioid Drugs Products", "2016-932"], "comments": [{"text": "
My name is Jennifer Ford, and I have fibromyalgia. Including chronic pain, chronic fatigue, depression, anxiety, degenerative disc disease, COPD, just to name a few. I am able to barely maintain some level of a normal life with pain levels of a 5-6 on a good day. This is with the use of three hydrocodone a day. No more, no less. I receive a prescription of 90 per month. That's 3 a day, for 30 days. Take that away from me, and I have no idea what I'll do. Please leave chronic pain patients alone. We are patients, not addicts.

13", "comment_id": "FDA-2016-D-0785-0008", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-D-0785-0008", "comment_date": "2016-05-09T04:00:00Z", "comment_title": "Comment from Jennifer Ford", "commenter_fname": null, "commenter_lname": null, "comment_length": 556}, {"text": "No more opioid guidelines that hurt the Chronic Pain community. My doctors are refusing medications they themselves put me on. We matter, the quality of our lives matter and our voices need to be listened to. Addiction within our community is very rare. ", "comment_id": "FDA-2016-D-0785-0016", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-D-0785-0016", "comment_date": "2016-05-26T04:00:00Z", "comment_title": "Comment from C, Hope For The Hopeless Chronic Pain Issue's and Awareness", "commenter_fname": null, "commenter_lname": null, "comment_length": 254}, {"text": "I have taken opioids on and off for 30 years responsibly and safely. I have adhesive arachnoiditis. Without these meds many chronic pain patients will have no quality of life. What the government is doing is outrageous. You can buy codeine over the counter in Canada. It is not a gateway drug to heroin. Although the money grubbing addiction industry would like you to think so. The problem is heroin coming into the country from Mexico and China. If you want to fix the drug problem fix that. A new study shows that opioid overdoses peaked in 2012. Even if you take opioids off the market you will still have addicts acquiring it on the streets. You are throwing the baby out with the bath water. Patients who suffer everyday with excruciating pain rely on these medications to bring the pain down to a tolerable level. We take our medications responsibly. Any physician who says to take oxycodone off the market has no compassion. There is a place for opioids in medicine when the are prescribed responsibly. Pain patients are just getting warmed up! If you think we're going to tolerate this treatment you are wrong! ", "comment_id": "FDA-2016-D-0785-0025", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-D-0785-0025", "comment_date": "2016-06-06T04:00:00Z", "comment_title": "Comment from Katherine Owen", "commenter_fname": null, "commenter_lname": null, "comment_length": 1124}, {"text": "I my name is James I have a chronic pain disease called rsd or crps. I use some of these drugs to control my pain and help me get through my day. There are many of us in the same position as I am. If you put uncentsable regulations on this we are going to be the ones that suffer from this for others stupidity pleases stop and think about the people that need this to get though our days and nights and to be able to spend time with our families. There are other ways to weed out the people that are abouseing theses drugs. I know we as the people of this country don't really matter to you people on any of these maters, but maybe just maybe for once in your time in office you will do the right thing and help the people that put you there. If you all had to spend one day in any of our shose you would understand where we are coming from. PLEASE PLEASE STOP AND THINK BEFORE YOU TAKE ANY ACTION ON THIS. If you were one of use you would be doing all you can't to take a different position on any of this.", "comment_id": "FDA-2016-D-0785-0043", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-D-0785-0043", "comment_date": "2016-06-08T04:00:00Z", "comment_title": "Comment from James Boles", "commenter_fname": null, "commenter_lname": null, "comment_length": 1016}, {"text": "Dr. Glapinski, I am a chronic pain sufferer and one who is DEPENDENT on oxycodone for a QUALITY OF LIFE. In reading your comment, you are aware that chronic pain pts depend on opiods and are in agreement, and then you turn around and say ban oxycodone. Just because you are against it for what ever reason, there are MANY LEGITIMATE chronic pain pts who retain a QUALITY OF LIFE by taking oxycodone. I have tried nearly all of them over the course of ten years. Opiods were my last resort, first came years of physical therapy, massage, chiro, accupuncture, epidurals, discographies, OTC AND NSAIDS that tore my stomach and liver up, facet injections, trigger point injections, nerve blocks, steriods, nerves burned, TENS, and two FAILED spinal fusions that left me with severe nerve damage. Oxycodone happens to be the one medication that agrees with me and takes my unbearable pain to a tolerable level, when I was on the right dose. Because of all these INHUMANE restrictions by the CDC, FDA, DEA and the government, Legitimate pain ots are having their once stable dose lowered to INEFFECTIVE DOSES or totally stripped of them, leaving many in agony and severe withdrawal. Shame on any of you doctors who abandon their patients. We are suffering from incurable conditions that cause severe pain, I beg God to take me daily. Would you do that to your Mom? Could you sit back and watch your loved one be at war with their body, stabbing, burning, crushing, piercing, pains, the emotional and mental toll it takes on a person, If your loved one got relief by taking opiods, would you want them to have some QUALITY OF LIFE and enjoy what they can or strip them of the only treatment they gave them some relief, force them to remain bedridden, shut off from society, many are turning to suicide to escape the pain. You doctors took an oath to do no harm. I get the DEA is targeting all our drs, there is way more harm being done to the chronically ill, we are being FORCED to suffer, to exist in hell, All the doctors thruout this country who believe in helping the suffering, especially when we've tried the alternative therapies OUR BODIES could take, it's physically, mentally and emotionally exhausting fighting this battle, then the stigma that is thrown on our backs, shame on all of you dra for not standing alongside the suffering. Perhaps if you treated each person as if you would your mom, maybe there would be compassion and empathy brought back into the dr/patient relationship. I see and hear nothing but NEGLECT, ABUSE, DEGRADING, DISCRIMINATION AGAINST LEGITIMATE PAIN PTS. Another fact is there is no opiod epidemic. The CDC used false data, even admitted to MISCLASSIFYING MANY heroin and fentanyl deaths, doubling and tripling one persons death, legit pain pts who committed suicide were listed an overdose, if alcohol or any other illicit drugs played a part the CDC looked the other way, they created mass hysteria that the media and government took off with, constantly demonizing a chronic pain pts LIFE SAVING MEDICATIONS. The CDC created FALSIFIED STATISTICS MADE TO FIT THE GOVERNMENTS ADDICTION DRIVEN AGENDA. Chronic pain pts are LAW ABIDING citizens who have DEBILITATING INCURABLE CONDITIONS, who have tried whatever was put in front of us by the medical community to get relief. We dont BREAK THE LAW, WE DONT ABUSE, SELL, SHARE, SNORT, OR ANYTHING ELSE TO OUR LIFE SAVING MEDS. WE ARE SICK FOR GOD SAKE. We are treated HORRIBLY by the medical community, treated like everyone is a pill seeking junkie, addict, and criminals. I am so fed up with paying the high price with my health and overall well being because of those who CHOOSE TO ABUSE, people who CHOOSE TO BREAK THE LAW, WHO CHOOSE TO POP DRUGS, OR GET DRUNK OFF ALCOHOL, PEOPLE WHO CHOOSE TO DESTROY THEIR BODIES, Addicts are given all kinds of opportunities to get help, all kinds of doors open for them, hell even the government passes out clean needles to shoot their drug of choice up with and safe houses to go get high and shoot up. When an addict, someone who CHOOSES TO ABUSE , fails a drug test during treatment they are given chance after chance, they aren't kicked out and turned away, A LEGITIMATE chronic intractable pain pts are turned away, judged and labeled as addicts, pts who have been with their drs for years and were on the same stable dose that worked for them are having meds reduced or taken away thru no fault of our own, for following the rules, getting drug tested monthly, shamed at the pharmacy, if you even find a pharmacy to fill your LEGAL lifesaving medication. Nearly all chronic pain pts have suffered for years and have years of medical records documenting their DEBILITATING INCURABLE conditions, usually has had many MRI's scans, tests, etc.These debilitating conditions only continue to worsen over time, so why are we decreasing legit pain pts meds when the doses really should be increased. How would it make you feel if your own mother were so poorly neglected!?", "comment_id": "FDA-2016-D-0785-0056", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-D-0785-0056", "comment_date": "2016-06-08T04:00:00Z", "comment_title": "Comment from Pam Molnar", "commenter_fname": null, "commenter_lname": null, "comment_length": 5013}, {"text": "1.Although the theme of the guidance seems, as expected, to proof that tested generic formulation (T) is not inferior to an approved AD reference formulation (R) and some studies were designed to test T against R directly, e.g. syringeability, introducing the control formulation (C) in some studies, e.g. extractability, created some confusion between qualifying an original brand name AD formulation (R) and a generic. We believe that, for generics, T should be tested directly against R, with no need for a third formulation (control), unless one route of abuse was not considered/listed on the R label.

2.There is no clarity if in-vitro testing need to be done or at least verified by a third party laboratory to avoid manufacturer's bias which we have noticed as a third party lab.

3.The draft guidance, as well as the previously approved AD guidance, focus on opioids but we believe that it should cover, also, non-opioids of potential abuse, e.g. amphetamines or molecules that can be precursor for recreational drugs, e.g. pseudoephedrine.

4.Smoking simulation study listed 233C as a definite temperature for heating but from our experience, this temp was not good to volatilize morphine or oxycodone and for which we needed to optimize the heating conditions. Not sure why the paper ignition temperature was used to set up this figure noting that different heating techniques including direct heating a drug on a piece of aluminum foil or putting a drug directly on ignited charcoal, e.g. "hookah", have been used. We believe that, smoking simulation studies should be optimized first using pure compounds and select the most effective heating condition/temp to test an AD formulation.

5.The guidance did not mention core separation as a part of physical manipulation for formulations with API is enclosed in a core within a hard shell.

6.The guidance did not mention saline solution for extractability or syringeability where it's a potential solvent that can be easily obtained by a drug abuser and safely injected. In this regard, for generics, we believe that all or representative solvents which were used to qualify an R should be used for T.

7.For particle size distribution following physical manipulation, 500 micron was used as a cut-off; does this mean no particle size characterization is needed below 500 micron?

8.Free base isolation; 233C for 2-15 minutes was listed to dry up a precipitated base without a rationale. From our experience, different temperatures and/or different heating times can be needed and noting that 233C was already suggested for smoking simulation, heating some compounds at this temp for 15 minutes may cause significant loss.

9.Liquid-liquid extraction was not listed but from our experience, after proper optimization, it was an efficient tool to isolate some opioids.

10.The guidance did not handle AD formulation which depend on conjugation of an active moiety to a pharmacologically inert side chain which needs to be cleaved inside the human body for slow release of the active molecule.

11.The guidance suggest 28 to 18 for syringeability and we suggest to consider either 28 or 27 as the latter is common and such small bore size should not make a difference compared to 28.
", "comment_id": "FDA-2016-D-0785-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-D-0785-0003", "comment_date": "2016-04-29T04:00:00Z", "comment_title": "Comment from Abdel Halim", "commenter_fname": null, "commenter_lname": null, "comment_length": 3791}, {"text": "I don't understand why you think that going after physicians & their patients, specifically chronic pain patients is going to somehow make this heroin epidemic lessen or disappear. I am a woman who was born with severe JRA at 15 months old, have had several surgeries, & other diagnoses along the way........Fibromyalgia, CFS, seemingly untreatable bi-lateral hip bursitis, constant back spasms, & the list goes on. I have for over 10 years been under the care of my wonderful rheumatologist & have ALWAYS listened to her, followed all directions, & more importantly NEVER, EVER given her reason to think I was doing anything otherwise. I am a perfect patient. My pain meds make my life liveable & when I say that....I mean my kind of liveable. I am permanently disabled so nothing is perfect, BUT being able to make dinner for my family at night & do some light housekeeping is only because of my pain meds. And now you want to make it harder? For what? Why? To eliminate what you think is the reason for heroin? Look around, do some more research. We have above pharmacy grade opiates coming across our borders & drug dealers are selling it to addicts. That's NOT us. Under 5% of the chronic pain community become addicts. Do we depend on our meds? Yes, but for living, for function, & so we are not bedridden. We aren't getting "high", we are getting some relief. There's a HUGE difference between physical dependence & psychological dependence. We are not in the latter group. Diabetics rely on their insulin, we rely on pain management. There is really no difference. Every medication comes with risks. You overdose on an over the counter medication too. It's called personal responsibility & because some don't practice that, you make ALL pay? You have already made getting our meds tougher with changing the scheduling class, breathing down the necks of our doctors, making them so scared to actually treat their patients now, pain contracts, random urine tests, pill counts, etc, etc...... What else do you want?? After all those things were implemented NOTHING changed with the addicts. In fact in one city next to me the drug use & overdoses have actually doubled since then! Seems like you are barking up the wrong tree. I get my meds, keep them in a fire safe locked box & practice good medication safety, but now I feel that at any moment my rheumatologist could pull the rug out from under me because of fear, or because you come up with some other crazy rule/regulation. She has already stated that it is out of her hands & she actually told me she will not longer prescribe pain meds to new patients, only the ones that are already on them. Really? Find another way to control this epidemic, because last I checked drug addicts don't hang out at rheumatologist, neurologist, or oncologists offices. Go after the drug dealers & the border. Please leave those of us that do nothing wrong alone. Will you release the suicide rates in the chronic pain community when they go off the charts? Because I have already read of SO many, & in many cases it happened because a physician got scared & just stopped their meds cold turkey, which is incredibly dangerous & in my opinion medically unethical. Those people end up in the ER & are treated like subhuman beings. Wow, that's really good medical care. Let the rheumatologists, neurologists, oncologists, & pain clinic physicians do their job. None of us want to be on these meds, but we have come to them because we have tried everything else. I have done physical therapy several times & got cortisone shots every 3 months for over 4 years. Give me a break! Until the scientists & researchers come out with some other medication and/or treatment that works as good as opiates, leave us alone. There are also so many of us that cannot take the conventional medications for our diseases because we have really horrible side effects, & opiates end up being our safest most effective treatment. Why punish the innocent people just trying to live a semi-normal life? When are you going to stop punishing the wrong group of people? Why should we pay for others bad decisions? I am disgusted & I don't deserve to be treated like this. The way pharmacists look at us, treat us, & even lie about how they "cannot" fill our prescriptions is beyond ridiculous. Thankfully I have a wonderful pharmacy. I ran a chronic pain support group on line for over 4 years & I heard the horror stories. They have been so bad I was forced to stop running the group.....between the stress & my own illness, well.....I just felt I had nothing left to give my members. Everything looks dim for them, & that's a sad state of affairs for people that have no choice, who were born with horribly painful diseases & illnesses. They aren't addicts, they are patients. Shame on the medical community, the government, the DEA, & the CDC. You aren't doing your job, you are just creating another problem. Looks good on paper maybe? Horrible!", "comment_id": "FDA-2016-D-0785-0023", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-D-0785-0023", "comment_date": "2016-06-06T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 5186}, {"text": "We are real chronic pain patients with real pain...........not drug addicts!", "comment_id": "FDA-2016-D-0785-0071", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-D-0785-0071", "comment_date": "2016-06-08T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 76}, {"text": "The regulations against opiate pain medicine has been devastating to my family, to people I care about and to myself personally. I am not a pain patient or user of opiates but my husband who has been disabled for 20 years is a chronic pain patient. These regulations put him through on-going trauma, and pain. Our basic human rights are violated. We are not allowed to live where we want to, or in the state we want to, because we are prisoners to proximity to a doctor who will prescribe the essential medicine. To get this medicine he must submit to urine tests which violate his 5th amendment rights. Law enforcement doesn't belong in doctor's offices and hospitals! Basic human rights are disregarded in this failed "War on Drugs" created by Nixon for racist and evil objectives. Stop restricting medicines! Stop your "war" against the American people! Leave pain patients alone. Stop blaming suicides on pain medicine and look at the patients in chronic pain who are told that their only source of relief has been outlawed! Stop criminalizing self-medication. You are not supposed to control other people's choices with their own bodies. Citizens of the United States are back to having to reclaim their rights to self ownership.", "comment_id": "FDA-2016-D-0785-0078", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-D-0785-0078", "comment_date": "2016-07-07T04:00:00Z", "comment_title": "Comment from Heather Martin", "commenter_fname": null, "commenter_lname": null, "comment_length": 1267}, {"text": "Why are you not going after other patients medications? Start taking medications for those suffering from all other conditions too! SMH!! ", "comment_id": "FDA-2016-D-0785-0033", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2016-D-0785-0033", "comment_date": "2016-06-08T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 141}]}, {"id": "FDA-2017-N-6502", "title": "Opioid Policy Steering Committee prescribing intervention \u2013 exploring a strategy for implementation; Public Hearing; Request for Comments", "context": "2018-03-27T16:22:09Z", "purpose": "Nonrulemaking", "keywords": null, "comments": [{"text": "Im disabled spinal chord injury + tbi, w/spinal chord degeneration since 1982. Im submitting info on behalf of chronic, terminally ill and intractible pain patients across my state. My daily regime faces a number of challenges, and thats fine. However the difference between being completely bed ridden with daily home health care for most basic needs or leading a productive life as a contributing citizen is adequate pain management. Ive been under the care of the best in nation.Most of us have been screened by no fewer than 4 specialists in pain management and abide by contracts &/or monitoring programs for safety. That's also fine. If you research, you'll learn intractible, chronic and terminally ill pain patients are not addicts, Addiction is a seperate disease. We and our doctors know you do not care to learn the difference, do not care if a percentage of disabled patients' are left to suffer and die in coming years, but we do! Most of us have battled years to regain mobility, and ability over disabilities in an ablist society. We have the same rights to be heard, be treated as most appropriate regardless of required opioid dosages or brands. We the disabled persons have fought for the right to equal access, and a level playing field, so we may partake in lifes work, play and liberties. Our requirement for daily medication is; and should be viewed no differently than, a diabetic requiring insulin. Our Doctors, not our government, are best trained to know the best treatment plan(s). I do not doubt heroin from Afghanistan may be plaguing the black market, or illicit fentanyl may be a problem, however to limit our access to needed medication is misguided and cruel. Our pain management clinics are already multi tiered top level trained professionals in thier field serving only candidates carefully screened, monitored and appropriately treated. You work for us. It took many of us years to reenter the workplace and to advocate for a level playing field for ourselves and others. You have a duty to see that not one single patient with documented pain loses their access to required medications. No one who has not attended Medical School and further specialized in pain management/anesthesia per our USA medical doctors licensing and specialization criteria should attempt to overreach in determining appropriate patient care without guidance from the same. Patients are suffering, and more will suffer with any further cut backs to an already austere program. Thank You for your time.", "comment_id": "FDA-2017-N-6502-0334", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-6502-0334", "comment_date": "2018-03-12T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 2532}, {"text": "See attached file", "comment_id": "FDA-2017-N-6502-0340", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-6502-0340", "comment_date": "2018-03-26T04:00:00Z", "comment_title": "Comment from EagleForce Health", "commenter_fname": null, "commenter_lname": null, "comment_length": 17}, {"text": "Both of my sons are diagnosed with Sickle Cell disease. Now my younger son is 17 years old and only in the last 2 years he was offered a pain relaxer which works so much better for his pain. Everywhere we go its an arguement. Doctors are deciding to push these drugs on us even if we dont want them. Here in Newark, NJ advocating has become so hard on us. It is life and slow death for us please. The Sickle cell community is only Allowed to have morphine, oxycodone, dilaudid or fentinyl. WhY? Please hear me. My oldest son is a sophmore at LIU Post. He seems mentally slower. Classwork takes everything he has to give physicalky and mentally. The hospitals act blind to other pain management options. I am so sad. All I want is my family to survive. And live and thrive our American dream. Now I run Lion Hearts the Michelle Reinoso Foundation. To benefit youth and famies fighting Sickle cell disease. My mother was a fantastic nurse, always put her full trusr in he4 practitioners. Medicine has not made significant progress in this field in many years. Transitioning medicayion should be offered but its not. With these being the only options patients suffering painful crisis are labeled as addicts for asking for the medication prescribed to them. These opiods cause nueral damage, joint damage, delayed comprehension and depression. The beain builds a tolerance to these opioids so always needing more for relief. This just sad at every turn. My organization is anti narcotic. We want to bring patient advocasy, get well badkets, healthy lifestyle and sincere understanding. PLEASE hear us!!! lionheartsofnj.org ", "comment_id": "FDA-2017-N-6502-0409", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-6502-0409", "comment_date": "2018-03-27T04:00:00Z", "comment_title": "Comment from Alisha Polanco", "commenter_fname": null, "commenter_lname": null, "comment_length": 1622}, {"text": "see attached.
", "comment_id": "FDA-2017-N-6502-0417", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-6502-0417", "comment_date": "2018-03-27T04:00:00Z", "comment_title": "Comment from Daniel Busch", "commenter_fname": null, "commenter_lname": null, "comment_length": 18}, {"text": "As a member of Families for Intractable Pain Relief (FIPR) and both a medical professional (PharmD) and a Severe Intractable Pain Patient myself, I strongly support the following FIPR response listed below regarding the Opioid Policy Steering Committee Prescribing Intervention

FIPR position: We have no problem with a policy that requires written justification above a set opioid prescription threshold, whether that be 90 MMED per CDC Guidelines or 80 MMED from another guideline. However, we oppose any attempt to further specify threshold amounts by "clinical indication", i.e. specific diagnosis or set of symptoms. Every patient is unique. An opioid dose that works well for one patient may be inadequate for another patient with the same clinical indication and may constitute over-medication for still a third patient. Determination of appropriate dose is best left to the judgment and discretion of qualified pain physicians in consultation with the patient and family members. Documentation should become part of the patient's medical chart to be retained by the physician. We should not impose additional requirements upon physicians to provide certain forms or documents to insurance payers. The physician's treatment plan should reflect his or her seasoned judgment and insurers should be required to pay for what is prescribed.ONE SIZE WILL NEVER FIT ALL. STOP TRYING TO ACHIEVE UNIFORM DOSING. IT WILL ONLY CAUSE HARM.

My further response is listed below in the files provided.

", "comment_id": "FDA-2017-N-6502-0501", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-6502-0501", "comment_date": "2018-03-27T04:00:00Z", "comment_title": "Comment from Daniel Holder Jr", "commenter_fname": null, "commenter_lname": null, "comment_length": 1551}, {"text": "Dear FDA Staff,

It is admirable that FDA is seeking to "improve the safe use of opioid analgesics by curbing overprescribing to decrease the occurrence of new addictions and limit misuse and abuse of opioid analgesics." However, overprescribing is NOT the cause of the opioid epidemic, despite what PROP and it's "doctors" keep promoting.

God help us if FDA wants to do more than has already been done through the CDC Guidelines for Opioid Prescribing from 2016. Because of these guidelines, patients who require opioid medicines for chronic, intractable pain are suffering terribly, throughout our nation. As we speak, a friend of mine in Florida is almost suicidal, not because she has mental illness (she doesn't), but because she has intractable pain that was once managed but isn't any longer, due to forced tapering.

The CDC guidelines, as you know, were intended to direct primary care doctors on how to safely prescribe opioids, and to know when they might need to refer a patient to a pain specialist.

Instead, the guidelines have become "law," not only for primary care doctors, but for pain specialists as well. Doctors that started out with the aspiration of helping suffering people have now decided "it's not worth it." Who can blame them, with DEA tracking doctors, comparing prescribing habits to see who the "top prescribers" are, raiding offices and stripping compassionate, care-driven doctors like Forrest Tennant of their pain specialty certification?

I am sure you are aware that 166 million Americans are affected by chronic pain each year (source NIH), and yet the "disease" of addiction has become front and center, with the WRONG PEOPLE being blamed. The "war on drugs" has become a "war on pain patients, their families and compassionate doctors."

Getting pain relief in this country has become a FIGHT, when it should be a fundamental HUMAN RIGHT. A person in pain who goes to the ER is labeled as drug-seeking. Primary care doctors are afraid to prescribe. Getting in to see a pain specialist is neither quick nor easy, nor does it guarantee the patient will be helped.

More and more restrictions and regulations are being put in place that ONLY AFFECT law-abiding citizens whose sole need is medical care, and some quality of life.

The hoops that a chronic pain patient has to jump through, month after month, if they can get treatment at all, are already extremely burdensome. I don't think the average person understands what is required of patients in pain even trying to get a second opinion from another doctor is practically impossible, lest they appear to be "doctor shopping.

Doctors and pharmacists have been turned into policemen (and not kind ones), instead of caring professionals on a mission to alleviate suffering, that they once aspired to be.

Myriad chronic pain patients are being turned away from care altogether and masses of the fortunate who ARE getting some pain management are being under-treated, or forced to taper down on medicine that they may have been stable on, with good pain relief, for years.

Despite prescriptions for controlled substances going down for the past five years, drug overdoses continue to rise.
Patients in pain are already suffering and dying (by suicide, not overdose) because of increased regulations. It is unfair to not distinguish between "opioid overdoses" resulting from illicit drugs and prescription drugs being mixed versus deaths from patients taking medicine exactly as prescribed, which are much rarer. The numbers are being conflated and it is very misleading. Decreasing prescriptions is clearly not the answer to this problem.

Almost all of the opioid hysteria seems to be coming from a small group, mainly based in Washington (PROP). Dr. Bruce Psaty, on the Science Board to the Food and Drug Administration "appears" to have a bit of compassion left for patients in intractable pain. However, he is getting advice on how to treat patients from none other than Jane Ballantyne (President of PROP) and then advising the FDA. Does FDA not see this as a conflict of interest? I sure do.

Please stop punishing patients in pain and the few compassionate doctors we have left, for the misdeeds of drug addicts. IT'S NOT THEIR FAULT!

PLEASE SEE ATTACHMENTS

", "comment_id": "FDA-2017-N-6502-0449", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-6502-0449", "comment_date": "2018-03-27T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 4532}, {"text": "See attached file provided by the American Nurses Association.", "comment_id": "FDA-2017-N-6502-0448", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-6502-0448", "comment_date": "2018-03-27T04:00:00Z", "comment_title": "Comment from American Nurses Association", "commenter_fname": null, "commenter_lname": null, "comment_length": 62}, {"text": "See attached file(s)", "comment_id": "FDA-2017-N-6502-0446", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-6502-0446", "comment_date": "2018-03-27T04:00:00Z", "comment_title": "Comment from Mallinckrodt Pharmaceuticals", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "United States Pharmacopeia request for extension on the commenting period", "comment_id": "FDA-2017-N-6502-0075", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-6502-0075", "comment_date": "2018-02-12T05:00:00Z", "comment_title": "Comment from United States Pharmacopeia", "commenter_fname": null, "commenter_lname": null, "comment_length": 73}, {"text": "See Attached", "comment_id": "FDA-2017-N-6502-0061", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-6502-0061", "comment_date": "2018-01-26T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}]}, {"id": "DOE-HQ-2021-0017", "title": "Workplace Substance Abuse Programs at Department of Energy Sites", "context": "2022-09-15T10:50:29Z", "purpose": "Nonrulemaking", "keywords": null, "comments": [{"text": "To Whom It May Concern:

The Department of Energy’s proposed rule “Workplace Substance Abuse Programs at Department of Energy Sites,” Code of Federal Regulations Citation 10 CFR Part 707 is a worthy attempt to better our surroundings. Department of Energy employees and contractors who have security clearances undoubtedly handle sensitive and important information that necessitates discretion and delicate handling. I believe that the inclusion of contractors to the list of individuals that would fall under this proposed rule is a well-intentioned understanding that although they may be employed by the government, and The Department of Energy more specifically, on an as need basis, their importance and handling of information may be the same as any regular employee. The Workplace Substance Abuse Programs proposed rule is significant for the sole fact that the employees and contractors here have the ability to affect the environment, public health and safety, or national security; testing these individuals to make sure that they are not in any way distracted or under another influence is imperative to continue The Department of Energy’s mission running unimpeded.

Because of the importance laid out here, I believe that the agency should take additional measures to reinforce the idea that there is a zero-tolerance policy for substance abuse and that the work being conducted should not be conducted by individuals that cannot abide by the rules. One such additional measure that I believe could benefit The Department of Energy is increasing the size of the annual sample rate from 30 percent. The current proposed rulemaking lists those individuals in testing designated positions be tested at an annual sample rate of 30 percent, which I believe is not at a percentage high enough to ensure the departments continued safety nor the safety of everything that the department affects. At what percentage would safety concerns be duly covered I am not sure of, but at a higher rate from which it currently stands is needed.

Moreover, as to § 707.14(e), the department must add additional stipulations to the return of a contractor who was removed from the site for the use of illegal drugs. At the moment, the only requirement is that such individual who was removed from duty for such use of illegal drugs needs to notify The Department of Energy of their intent to return to a testing designated position and that The Department of Energy approve their return to such a position. I believe that because such individuals in these positions have already proven to show they interact with illegal substances, stipulations be added return to their post. Their approval to return to testing designated positions (which necessitate security clearances) should be conditioned on increased testing on their return. This would increase the likelihood that if such person decides to use illegal drugs again then the increased testing would increase the possibility of the department knowing about their refusal to comply with the department’s policies.

The people that are in these testing designated positions are individuals who make important decisions. They are protective force personnel, people involved in the construction/maintenance/operation of nuclear reactors, and personnel that deal with hazardous materials. The decisions these people make, and the mistakes they make as well, impact the public at large. Should they use illegal drugs the chances that mistakes, issues, and a host of other unfortunate situations arise undoubtedly increases. That is why The Department of Energy needs to increase annual sample rate as well as add conditions to the return of offenders of the policy. Thank you.

Christian Ruano
", "comment_id": "DOE-HQ-2021-0017-0002", "comment_url": "https://api.regulations.gov/v4/comments/DOE-HQ-2021-0017-0002", "comment_date": "2021-11-04T04:00:00Z", "comment_title": "Comment on FR Doc # 2021-19231", "commenter_fname": "Christian", "commenter_lname": "Ruano", "comment_length": 3827}, {"text": "Implementing substance abuse programs at the Department of Energy Sites is a good idea. Monitoring employees through drug tests will keep the sites clean and prevent accidents from happening. I believe some drugs shouldn't be included in the test since some people use them for beneficial reasons. ", "comment_id": "DOE-HQ-2021-0017-0003", "comment_url": "https://api.regulations.gov/v4/comments/DOE-HQ-2021-0017-0003", "comment_date": "2021-11-04T04:00:00Z", "comment_title": "Comment on FR Doc # 2021-19231", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 302}]}, {"id": "FDA-2012-N-0067", "title": "Assessment of Analgesic Treatment of Chronic Pain; A Public Workshop", "context": "2013-08-30T00:31:02Z", "purpose": "Nonrulemaking", "keywords": ["cder2011204", "CDER", "Public Workshop", "Analgesic Treatment"], "comments": [{"text": "See attached file(s)", "comment_id": "FDA-2012-N-0067-0014", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0067-0014", "comment_date": "2012-08-09T04:00:00Z", "comment_title": "NYC Department of Health and Mental Hygiene - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "It is my understanding that the FDA is doing everything in its power to make it more difficult and complex for patients, who genuinely suffer from chronic, severe pain syndromes, to access opiod medications. Having undergone a catastrophic ureteroscopy procedure, seven years ago, which resulted in the loss of my left kidney, permanent paralysis of my left flank muscles, chronic, severe nerve damage pain, and Stage 4 right kidney failure, I object to these actions by the FDA. The abrupt onset of severe kidney failure, following my surgeon's decision to remove my healthy left kidney, rather than repair my left ureter, has left me forever on the brink of requiring kidney dialysis.

There are no pain medications, apart from major opiods, that can adequately control the intense nerve pain I will suffer from, the rest of my life. All other known pain medications (apart from Tylenol), will damage my already impaired right kidney, so are prohibited. The obstacles that are already in place, for me to obtain my doses of Fentanyl patches are extraordinary. They include: my MD cannot phone in nor fax my prescription to the pharmacy, my MD's DEA number must be on all Fentanyl prescription documents, I must physically sign for the patches if I order them from a mail order pharmacy, and I must hand-deliver the Fentanyl prescription to pharmacy staff during pharmacy business hours, rather than at a time that is convenient for me.

Having been a professional RN for more than two decades, I am keenly aware that I'm not the only legitimate patient whose sole option for pain control involves major opiods. I have taken care of hundreds of ill & injured persons whose kidneys and/or other medical conditions or medications, prevented them from using NSAIDS or minor narcotics for pain control, on a long-term basis. It is cruel & unethical to make our health burdens more difficult than they already are. I didn't ask to be in this situation, nor did any of my former patients!", "comment_id": "FDA-2012-N-0067-0009", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0067-0009", "comment_date": "2012-08-07T04:00:00Z", "comment_title": "Staton Retired RN, BSN - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 2034}, {"text": "I think it is wrong to change the rules of my pain medications. I am pusshing 50 years old. I have and still do work very hard manual labor. I am a state certified plumbing contractor. That was in a very bad car accident back in 1980. I have been on
Pain management successfully for the past three years. Before this i could no longer do my job properly. I now can suport my family and be a successfully bisiness professional. If you take away my pain medication i will loose everything. It is not right to hurt everyone for the actions of a few bad seeds. Please do not mess with my medcation anymore. I already havd a hard time filling my legal percriptions. Please stop this madness and let me and my family live the life we diserve", "comment_id": "FDA-2012-N-0067-0013", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0067-0013", "comment_date": "2012-08-09T04:00:00Z", "comment_title": "Michael Phillips - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 739}, {"text": "Opioid pain medications are an essential treatment option for acute and chronic pain. I know of many individuals with Ehler-Danlos Syndrome (EDS) who suffer daily from chronic pain and it would be of tremendous benefit to them if they could obtain these medications from their physician. ", "comment_id": "FDA-2012-N-0067-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0067-0006", "comment_date": "2012-07-19T04:00:00Z", "comment_title": "Anonymous - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 288}, {"text": "I respectfully request that any decisions to be be made limiting pain medication be decided by a jury of my peers meaning people who have chronic pain. I contracted MRSA in 2006 on top of Paget's disease and I worked in the concrete swimming pool industry for 25 years as a nozzleman doing shotcrete thus all my joints are destroyed by osteoarthritis with bone spurs thruout my body. Honestly I tell you that without pain medication I cannot get out of bed.It enables me to help care for my grandchildren so please please in the name of God leave the prescribing and care up to my doctor, he is an honorable man.My bone marrow is swollen inside my bones. You can imagine the pain this creates. Again please, please I don't have cancer but my pain is great. Thank you for considering me and my family.Sincerely, Roger K. Cummings 501 S. Mccall Rd. Englewood, Florida 34223 Phone 9416811747 God Bless You", "comment_id": "FDA-2012-N-0067-0012", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0067-0012", "comment_date": "2012-08-09T04:00:00Z", "comment_title": "Roger Keith Cummings - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 910}, {"text": "See attached file(s)
I want to share a story about a young man named Scott. He’s out-going, loves cars, playing drums and his job as a mechanic.

Scott now endures daily pain in his mid-back that feels like someone is repeatedly stabbing him with a knife and twisting it. Three vertebrae in Scott’s thoracic back were fractured in a crush injury while working under a vehicle. After the accident, his wife moved out and he lost his job. Drumming sessions and driving his Corvette were no longer possible. Doctors said the bone fractures had healed, yet Scott’s pain continued unabated. He felt hopeless and isolated.

Having the kind of disabling pain Scott lives with is not uncommon. I know, because my accident from a crush injury has led to similar, debilitating back
pain. Through the support group I founded 12 years ago, I met Scott and more than 200 chronic pain sufferers.

Having chronic pain is like being sentenced to a life in prison. You are a prisoner in your own body. But, it’s worse than that. You are a prisoner who is subjected to torture 24/7. Our country frequently debates the morality of torture for prisoners who have killed thousands. But, I ask, what kind of moral society do we live in when we are talking about removing or severely restricting a treatment option that we know lessens this torturous existence for hundreds, thousands and perhaps millions of Americans?

Opioid analgesics do not help everyone with chronic pain and when they do, they do not completely relieve the pain. Scott has been on a long acting opioid for 10 years. Other than limiting time spent upright, it is the only treatment that has helped him. While he is still unable to work or play his drums, the medication has allowed him to regain pursuits tha", "comment_id": "FDA-2012-N-0067-0002", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0067-0002", "comment_date": "2012-07-03T04:00:00Z", "comment_title": "Massachusetts Pain Initiative - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1831}, {"text": "See attached file(s)", "comment_id": "FDA-2012-N-0067-0008", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0067-0008", "comment_date": "2012-08-07T04:00:00Z", "comment_title": "Peace Health Southwest Washington Medical Center - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Please see attached comments on behalf of the American Association of Nurse Anesthetists (AANA). ", "comment_id": "FDA-2012-N-0067-0010", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0067-0010", "comment_date": "2012-08-07T04:00:00Z", "comment_title": "American Association of Nurse Anesthetists (AANA) - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 97}, {"text": "See attached file(s)

Two Sections: PLEASE READ! I watched the THREE DAYS OF TESTIOMNY, asking for a few moments, that is all.", "comment_id": "FDA-2012-N-0067-0011", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0067-0011", "comment_date": "2012-08-09T04:00:00Z", "comment_title": "Jennifer M Moore - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 134}, {"text": "I been on pain management since 2008,and finally was considered disabled in aug of 2011, and I currently take oxycodone since being on pm,I take 6 a day,was 7 but due to the 'problems in florida pharmacies wouldn't allow anymore,I've been without meds for a few days and i cant even get outta bed,but while taking my medications it allows me to somewhat function as a normal human,shower cook shop and such.. There isn't any other medication out there that will allow me to do those things as I've tried,I can't imagine life without these, If you take these away you be hurting me and hundreds and thousands of people that depend on them for a better quality of life,and to take that away,would be cruelty as in cruelty to animals, no one deserves to suffer....The dea has played a huge role in are problem in florida,were lucky now to get are legal scripts,but not with out a huge crawl to find them,all your gonna do is force us pain patients to the streets to find a dealer for relief,an as we already are being treated like criminals they mite as well arrest us now,my back has hernated disks,bulging disks one hip bone larger then the other and just gonna get worse, please don't take a away the quality of life we all deserve...", "comment_id": "FDA-2012-N-0067-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-0067-0005", "comment_date": "2012-07-03T04:00:00Z", "comment_title": "Jeffrey W Kight - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1262}]}, {"id": "FDA-2020-N-1561", "title": "Opioid Analgesics (OA) REMS Public Workshop", "context": "2022-01-26T09:39:19Z", "purpose": "Nonrulemaking", "keywords": ["CDER", "Opioid Analgesics (OA) REMS Public Workshop", "OPEN"], "comments": [{"text": "See attached file(s)", "comment_id": "FDA-2020-N-1561-0010", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2020-N-1561-0010", "comment_date": "2021-02-19T05:00:00Z", "comment_title": "Comment from National Council on Independent Living", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Please see attached for comments on behalf of the CME Coalition.", "comment_id": "FDA-2020-N-1561-0008", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2020-N-1561-0008", "comment_date": "2021-02-19T05:00:00Z", "comment_title": "Comment from Continuing Medical Education (CME) Coalition", "commenter_fname": null, "commenter_lname": null, "comment_length": 64}, {"text": "Please see AMTA's comments attached.", "comment_id": "FDA-2020-N-1561-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2020-N-1561-0005", "comment_date": "2021-02-19T05:00:00Z", "comment_title": "Comment from American Massage Therapy Association (AMTA)", "commenter_fname": null, "commenter_lname": null, "comment_length": 40}, {"text": "See attached file(s)", "comment_id": "FDA-2020-N-1561-0007", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2020-N-1561-0007", "comment_date": "2021-02-19T05:00:00Z", "comment_title": "Comment from Rockpointe", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "FDA-2020-N-1561-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2020-N-1561-0004", "comment_date": "2021-02-19T05:00:00Z", "comment_title": "Comment from Accreditation Council for Continuing Medical Education", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "FDA-2020-N-1561-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2020-N-1561-0006", "comment_date": "2021-02-19T05:00:00Z", "comment_title": "Comment from PinneyAssociates, Inc.", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "February 11, 2021

Re: Opioid Analgesics Risk Evaluation and Mitigation Strategy (OA REMS)

To members of the FDA:
We are a new alliance of scientists and clinicians, civil rights advocates and people with lived experience of pain. Our mission is to advance the health and human rights of people living with pain. We envision a world in which pain is treated equitably and effectively, so that all people in pain have the opportunity to live full and productive lives.

We appreciate the opportunity to provide these comments on methods for evaluation of the opioid analgesics REMS program, docket #FDA-2020-N-1561-0001. We write to voice our concern that pain patients are increasingly being left without access to necessary medication and, in some cases, without healthcare altogether. In light of this harm, we believe that any evaluation of the OA REMS must include meaningful measures to document patient outcomes. We would also urge the FDA to solicit the input of patients as part of its evaluative process.

Please see our comment attached below. [The option to file a comment is not working. I will quickly try to fedex it].
", "comment_id": "FDA-2020-N-1561-0009", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2020-N-1561-0009", "comment_date": "2021-02-19T05:00:00Z", "comment_title": "Comment from Kate Nicholson", "commenter_fname": null, "commenter_lname": null, "comment_length": 1182}, {"text": "See attached file(s)", "comment_id": "FDA-2020-N-1561-0011", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2020-N-1561-0011", "comment_date": "2021-02-19T05:00:00Z", "comment_title": "Comment from National Pain Advocacy Center", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s) ", "comment_id": "FDA-2020-N-1561-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2020-N-1561-0003", "comment_date": "2021-02-19T05:00:00Z", "comment_title": "Comment from American Society of Anesthesiologists (ASA)", "commenter_fname": null, "commenter_lname": null, "comment_length": 21}]}, {"id": "CDC-2015-0112", "title": "Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain", "context": "2016-03-23T08:54:58Z", "purpose": "Nonrulemaking", "keywords": null, "comments": [{"text": "My son died of a heroin overdose in 2014 that started with legitimate prescription use after an accident. He had a history of abusing drugs, yet the doctor was more than willing to prescribe him oxy until he was addicted, and then cut him off by yelling at him in the hallway of his offices that he was done with him. We are losing a huge part of a generation to this disease, and steps HAVE to be taken to stop the over prescription and careless prescription of these very dangerous drugs. This is a start. Please enact these very sensible guidelines. Thank you.", "comment_id": "CDC-2015-0112-0586", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2015-0112-0586", "comment_date": "2015-12-23T05:00:00Z", "comment_title": "Comment from Jeri Paull", "commenter_fname": "Jeri", "commenter_lname": "Paull", "comment_length": 563}, {"text": "
My son Luke was polite, popular, multi-sport, all-star athlete. He was raised in a typical middle class home, we were very involved in our kids lives. As a freshman catcher on his high school baseball team he was being scouted by colleges. He had a wide network of friends, good morals and values, and a great sense of humor. People would meet him and tell us what an exceptional youngman he was. Then at 16, he suffered a serious sports injury, which required a meniscal transplant and was prescribed painkillers. Seemingly overnight, he became one of the hundreds of thousands of teens in our country addicted to prescription (Rx) painkillers. His life CHANGED & SO DID OUR FAMILIES. He went from being the person I described above to a stranger, the addiction devoured him and our family. It has been heartbreaking . He is 28 years old and now sits in a prison cell with a 17 year sentence ( as a non violent , never had a weapon or hurt anyone but himself) all related to his addiction to the pain killers which then became heroin. Our son is a smart, kind person he should not be in prison, along with so many other addicts. It all started with the pain pills and how freely the RX was written over and over again . I have included a picture of my son, because I want to remind you these are real people with real families So many people are addicted to prescription painkillers that drug overdoses are now the leading cause of accidental death in America, surpassing car crashes. And Rx painkiller abuse has led to an increased use of an even more deadly, accessible, and cheaper opiate: heroin. Please do not allow the special interest groups to interfere with progress and saving lives. I beg you to listen and do the right thing

Respectfully

Stacy Y Watson

More folks effected by this epidemic can be contacted at

http://addictsmom.com/", "comment_id": "CDC-2015-0112-1247", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2015-0112-1247", "comment_date": "2015-12-29T05:00:00Z", "comment_title": "Comment from Stacy Watson", "commenter_fname": "Stacy", "commenter_lname": "Watson", "comment_length": 1900}, {"text": "See attached file(s)", "comment_id": "CDC-2015-0112-1058", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2015-0112-1058", "comment_date": "2015-12-29T05:00:00Z", "comment_title": "Comment from Ken Renwick", "commenter_fname": "Ken", "commenter_lname": "Renwick, MD, MPH", "comment_length": 20}, {"text": "I am Ron Ward a person in long term recovery from the disease of addiction. In 2014, approximately 47,000 lives lost across the United States due to opiates/heroin. A dentist offered my wife Vicodin for a teeth cleaning. There needs to be strict guidelines on these prescriptions drugs that are highly addictive. This heroin epidemic is due to prescription drug abuse. A young lady from Delaware was prescribed Oxycontin due to the removal of her wisdom teeth and when she could no longer get the oxycontin she switched to heroin... Now she is on our Angels Remembered Wall (Sarah Keturah Ketchum Marvel) as she was in recovery and did not relapse- she took a shot gun and blew her head off. I was the same way and can relate as I now longer wanted to go back to drugs so I decided on April 23, 2013, I overdosed on a bottle of antidepressants and was in a coma for thirteen days. Today, I am writing this to be a voice for the many lives lost to the diseases of addiction and I am pleading with the CDC to make a change so we can start saving lives! Today I am the founder of Celebrating Restoration.

I have attached my attempted suicide pics... ", "comment_id": "CDC-2015-0112-0744", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2015-0112-0744", "comment_date": "2015-12-24T05:00:00Z", "comment_title": "Comment from Ron Ward", "commenter_fname": "Ron", "commenter_lname": "Ward", "comment_length": 1158}, {"text": "Dear Ms. Greenspan or to whom it may concern,Docket No. CDC-2015-011212-14-2015

I am a 56 year old chronic pain sufferer due to multiple DVT's (2002-2013) and a near fatal pulmonary embolism (2010). I also subsequently developed Central Pain Syndrome (2011) due to a spinal cord lesion caused by an implanted medical device gone awry. I am permanently disabled, receiving Social Security benefits and am bedridden 20+ hours a day with an average of a level 8 out of 10 pain. I am also an active committee member of the Central Pain Syndrome Foundation.

While each individual is unique in how their body processes different medications, opioids as a class have been demonstrated to be one of the most effective choices available today to the doctor and the pain patient. Adequate pain relief is perhaps the most crucial component of enabling the chronic pain patient to begin on the road to recovering some degree of functional restoration and quality of life. Of course, it is essential that a trusting, responsible long term relationship be developed between the doctor and patient when prescribing opioids. More often than not, it is the family practice physician that fulfills this role for the chronic pain patient.

The news media is constantly reporting that there is an opioid-related epidemic in America. Undeniably, there has been an increase in the number of opioid-related deaths. However, it is not clear at all how many of those deaths are attributable to the chronic pain patient in the above described relationship and to those who are illegally using/abusing opioids. This leaves the CDC's apparent "rush to judgement" in the development of the proposed 2016 guidelines on a shaky foundation at best (See attachment 1 below).

Furthermore, there appears to have been flagrant violations of the Federal Advisory Committee Act with both the too brief initial window of public comment and well as the secretive nature shown in not revealing the names of the CDC's Core Expert Group. The views of all interested stakeholders, especially when it comes to chronic pain patients, were not represented. As a result, both the medical community and the consumer stand to be inadequately served.

I am in favor of discarding these proposed guidelines and rebooting the effort with one in which all stakeholders are properly represented. In addition, there needs to be a more transparent process where all potential conflicts of interests are identified.

In closing, I do want to express my gratitude that an additional opportunity for public comment has provided. Further, allow me to emphasize that addressing this problem deserves the adequate time and the involvement of all stakeholders to gain the best solution possible.

Sincerely, Tim Parrish
", "comment_id": "CDC-2015-0112-0284", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2015-0112-0284", "comment_date": "2015-12-17T05:00:00Z", "comment_title": "Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain Comment from Tim Parrish", "commenter_fname": "Tim", "commenter_lname": "Parrish", "comment_length": 2923}, {"text": "Dear Ma'am or Sir,
My name is Katerina Showalter and I am writing in response to Docket No. CDC-2015-0112 to ask for a change in the guidelines for how doctors can treat people in pain who need access to treatments including opioids.
I need your help. I need you to listen to pain patients. I need you to include language in the guidelines that recognize patients as individuals who need access to effective pain management options, including opioids, sometimes for long periods of time or at high doses. I have a life-limiting progressive disease called mitochondrial disease. It causes severe pain, getting worse as more and more organs and muscles are affected. Since the rapid progression of my disease, I have tried many pain management options and even go to pain Cognitive behavioral therapy, but I was only able to leave my house regularly once I started opiod therapy. This semester was my first time going to school in 2 years. I am finally able to live out my life outside my bed. I understand that many less severe chronic conditions don't benifit from opiod therapy, but when you write these regulations you are also hurting my life as well. I want to participate in the community and be out of my bed. In fact on opiod therapy ive been able to do intensive Physical therapy and improve my autonomic function. I'm now standing for the first time in years. Please don't send patients like me back to our beds. Our diseases are killing us, we don't need one more obstacle to enjoying our lives outside of the hospital. Our care is only supportive, please dont take away one of our only supports.

Thank you for your interest in my well being. Included are pictures of me in the hospital on TPN and 2 months later with opiod therapy out visiting a lake.

Sincerely,
Katerina Showalter", "comment_id": "CDC-2015-0112-0282", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2015-0112-0282", "comment_date": "2015-12-17T05:00:00Z", "comment_title": "Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain Comment from Katerina Showalter", "commenter_fname": "Katerina", "commenter_lname": "Showalter", "comment_length": 1845}, {"text": "National Center for Injury Prevention & Control
Centers for Disease Control and Prevention
4770 Buford Highway N.E., Mailstop F-63
Atlanta, GA, 30341
Attn: Docket CDC-2015-0112

I am Barby Ingle, a chronic pain advocate, author on pain issues, and a chronic pain patient. I have been battling chronic pain since 1997. First with endometriosis which resulted in a full hysterectomy and left oophorectomy. In 2002, I developed Reflex Sympathetic Dystrophy. I have tried at least 2 dozen types of treatment options from invasive surgeries, chiropractics, physical therapy, to less invasive like medications, infusion therapy, oral orthotics and posture apparel.

I know that if I lose access to the treatments that are currently keeping me out of a wheelchair I will need daily opioid pain medications again. I developed internal bleeding after taking NSAIDS for over a year trying to stay away from prescription pain meds, after being told they were harmful for me. Turns out the NSAIDS were even worse. I see multiple providers to assist me in my care (PCP, neurologist, cardiologist, neuro-dentist, dentist, general surgeon, pain management, urologist, gastroenterologist, and others as needed). I have been through counseling, physical therapy, occupational therapy, Calmare therapy, and more.

I found that a well-rounded approach works best for me (medication, oral orthotic, posture exercises and apparel, infusion therapy [IV-ketamine and stem cell], medications and specialized physical therapy. I have faced insurance company barriers such as step therapy and prior authorization stall tactics. The weaker I become, the more I will cost the system. Considering this happens to too many of the 130million+ Americans also living with a chronic disease this is costing our society hundreds of billions of dollars that could be avoided.

If I didn't come up with fundraising and family to help me out, most of the care I received, I wouldn't have had an opportunity to receive. My only choice then would be pain medications. Many of my pain friends are in this tough situation. They wish they had access to other treatment options, but due to other limitations financial and blocks by insurance companies and providers becoming more and more afraid to prescribe to us the lifesaving medications I have seen a horrible trend increase over the past 5 years. Since 2012, I have lost at least 2 friends each month due to suicide. Many of them did it through intentional overdose. Their numbers are included in your 'abusers' statistics. They were not abusers, they were making a conscious decision based on the difficulty in getting proper care. When they feel trapped, hopeless, and like they are not going to be able to get their medication due to barriers like the ones the CDC is proposing they give up. They are getting slammed off of their medications and decide death is a better option as they have no strength to fight the system to get what they need.

We are the 98% that are doing things right. We are following the directions of our providers, we are doing what is allowed through our insurance and government. These decisions should be between the provider and the patient and it should be individualized care. We are the majority. Unfortunately, these guidelines are causing the 'right' to go wrong, to give up, to take despite measures. It is very hard to lose so many friends when it could be prevented. You have the ability to help the 'right'. You have the ability to concentrate on getting access to the majority. You have the ability to focus policies that will provide proper and timely access to those of us who need it while addressing the abusers in a more targeted manner. To blanket this abuse issues of the minority and cater to those who decide to do it wrong you are making more abusers. Some of whom are not even true 'abusers' they chose to overdose because of bad policies that are preventing proper access to care.

We need policies that open access to multiple forms of treatment and get insurance to cover a better multi-disciplinary approach to care. A good start would be guidelines from the CDC to better integration of eastern, western, psychological, and naturopathic treatments so that we are able to lower medication doses. Taking away pain medication and making providers afraid to prescribe due to your guidelines is only going to make more abusers, increase suicides, and tear apart the lives of millions. Thank you for taking the time to read my comments and opening the door for chronic pain patients across the country to voice their stories. We need hope, we need help. We don't need to be punished for the few who are doing it wrong. Please don't help lower our life standards and abilities due to the actions that abusers choose for themselves.

Sincerely,
Barby Ingle, President
Power of Pain Foundation
480-882-1342
www.powerofpain.org
See full letter attached", "comment_id": "CDC-2015-0112-0291", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2015-0112-0291", "comment_date": "2015-12-17T05:00:00Z", "comment_title": "Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain Comment from Barby Ingle", "commenter_fname": "Barby", "commenter_lname": "Ingle", "comment_length": 5065}, {"text": "My "call to action" article was recently posted on RSDS.ORG website and a slightly shortened version also published on PainNewsNetwork.org. This is what I said, also how I truly feel about the upcoming possible changes to Opioid prescribing or lack of ability for Dr's to be able to prescribe Opioids for non malignant pain "guidelines"! This is what I've written : ( Here's one location of my article: http://rsds.org/war-against-chronic-pain-sufferers/ ). I have attached the article which portrays my feelings and comments in my own written words! I've attached it in its entirety.
I suffer daily with chronic, horrible, burning nerve pain of CRPS "full body". I need my voice to be heard and so do many other chronic pain sufferers or "warriors", depending on how you look at it! I prefer to be a warrior and fight back! Do something about it! Please help me & my fellow CRPS/ Chronic pain patients keep the medications that do still work for for many of us!
These changes could hurt or kill many people or leave them/us to live our lives in such pain that we are unable to enjoy doing anything with our families or have any kind of fulfilling life at all. People die from under treated and/or untreated pain! Some of us can't have SCS or pain pumps due to other health issues, immune deficiency diseases! Some of us have tried and done it all throughout our many years with ongoing pain: epidurals, nerve blocks, trigger point injections, Pain psychiatry and Psychology! I was told by the pain Psych's that "I do not have an addictive personality"! They told me to "trust them, take the opioids"! That's what finally has worked for me. We don't all fit into a nice neat box! It will be detrimental for our medications to be taken away! Don't scream "hyperalgesia" because if it's working, and Im not asking for more, then just don't even go there! It's the same as with gun control laws! The bad guys will always find a way to get the guns! Just as the "bad guys" will find ways to get whatever they need! Please help the " good guys" this time! Please don't take away our medications and lastly, Who are these agencies or persons who think there's such a difference between malignant and non-malignant pain? CRPS is # 43 on the McGill /National pain scale, right up there next to cancer, childbirth & amputation of a digit!!!! So please stop this from happening and end this torture before it gets even harder and worse than it already is! Thank you !
My article is attached below, thank you!!!", "comment_id": "CDC-2015-0112-0293", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2015-0112-0293", "comment_date": "2015-12-17T05:00:00Z", "comment_title": "Comment from Suzanne Stewart", "commenter_fname": "Suzanne", "commenter_lname": "Stewart", "comment_length": 2679}, {"text": "Society is really trained to deal with things that have a beginning and an end,Either you get better or you are supposed to die. You are not supposed to have something that goes on and on, like chronic pain.Patients report that their doctors often dismiss their pain and send them away without providing any other options.Pain is experienced individually and is more than just a physical symptom and is not always resolved by curing the underlying disease. A third of the nation experiences chronic pain. ... It's more than we pay as a nation on cardiovascular disease and cancer.An estimated 116 million adults experience chronic pain, much of it preventable.The nation's health care system has largely failed Americans in pain and calls for a "cultural transformation" of the way in which the United States approaches and manages patients with pain. Chronic pain also is the most common cause of work loss and disability.Why Not Prevent Chronic Pain?

While major efforts are underway to prevent heart disease and diabetes, preventing chronic pain remains an elusive goal.
Serious, chronic pain affects at least 116 million Americans each year, many of whom are inadequately treated by the health-care system, according to a new report by the Institute of Medicine (IOM). I'm shocked and surprised at the magnitude of [the problem].There is abuse that occurs when individuals are drug-seeking and abuse that occurs in that people who need pain medications may not have access because physicians won't prescribe or the state has regulatory barriers."Making matters worse is the media and political attention that has been devoted to painkiller abuse and addiction. Conversely, very little attention is given to chronic pain, which affects a far greater number of people. About 9.3% of the population has drug or alcohol problems serious enough to require treatment, while severe chronic pain affects at least one in three Americans. (And yet, two national institutes are devoted to the research of addiction: the National Institute on Alcoholism and Alcohol Abuse and the National Institute on Drug Abuse.Although prescribing of opioids has almost doubled going from 3.2% of the population in 1988-94 to 5.7% in 2005-08 it's not clear that this is out of line with the rise in pain in the population or that the drugs are going to the right people.It's extraordinary how many patients describe themselves as feeling like collateral damage in the war on drugs because of extraordinarily burdensome [requirements to get opioid medications].There Are Many patients who had been on a stable and effective low dose of medication for years were suddenly cut off by their doctors for no apparent reason.Many pain patients, in fact, are paying the price for a policy not designed for their benefit.Doctors said they prescribed less than they thought was appropriate because of fear that law enforcement was "looking over their shoulder."The majority of people with pain use their prescription drugs properly, are not a source of misuse, and should not be stigmatized or denied access because of the misdeeds or carelessness of others."Ironically, while many people with pain have difficulty obtaining opioid medications, nonmedical users appear to obtain them far too easily.But the barriers to appropriate care go beyond the issue of painkiller misuse. There are only about 3,000 to 4,000 pain specialists in the entire U.S., which means that primary-care physicians, whose numbers are also dwindling and who are not educated specifically about pain, are left to treat most pain with little specific guidance about effective care. In medical school, students receive only a few hours at most of education on pain treatment.Meanwhile public and medical misperceptions are widespread about the nature of pain, its causes and the way it affects individual patients. Misinformation is fueled by the fact that comprehensive research is lacking, even on basic questions like how many people suffer from disabling chronic pain and how well existing drugs like opioids treat long-term pain.The most important message to get out is the concept of pain itself as a disease. The majority of primary care physicians do not agree with this even though there is overwhelming research in both humans and animals [showing that] pain causes damage to the nervous system. It's dangerous not to treat pain."People can Die from Chronic Pain". Therefore we must not take away the rights from People who suffer from Chronic Pain Daily to receive the Medications they need to Better Their Quality of Life!!! I Stand for All the People who live in Chronic Pain and have to be worried Day in and Day out weather they'll be able to get their Medications. This is a Travasty to those who suffer from Debilitating Chronic Pain! Keep us out of Pain! It's our right as People World Wide whom Suffer from Chronic Pain! Again don't take away our Right to Live a Quality Life or the Best We Can!

Sincerely Yours,

Fred Alegre", "comment_id": "CDC-2015-0112-0089", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2015-0112-0089", "comment_date": "2015-12-16T05:00:00Z", "comment_title": "Comment from Fredric Alegre", "commenter_fname": "Fredric", "commenter_lname": "Alegre", "comment_length": 5097}, {"text": "Doctors and nurses and research scientists have no knowledge about what it is like to suffer from a chronic illness or to require opioid medication for chronic pain. Do you think we actually like to take these medications, with all their side effects? You want to limit the amounts our doctors can prescribe, and limit the amounts we can take because you worry we will become addicted and use the medications to get "high". But what you don't understand is that people with severe chronic pain never get high from these medications. The pain-numbing effect of the medication gets all used up fighting the pain, and there is nothing left over to actually make us high. I have fibromyalgia and chronic migraines, and I have taken hydrocodone for years, and never once have I experienced any kind of "high" from taking it. A little drowsiness, yes. A lot of constipation, yes. But a drug induced euphoria? Never.

Please, reconsider these so-called "guidelines." Don't make it harder than it already is for doctors to treat their chronic pain patients.", "comment_id": "CDC-2015-0112-0199", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2015-0112-0199", "comment_date": "2015-12-16T05:00:00Z", "comment_title": "Comment from Cyrynda Walker", "commenter_fname": "Cyrynda", "commenter_lname": "Walker", "comment_length": 1105}]}, {"id": "FDA-2018-N-1621", "title": "Patient-Focused Drug Development on Chronic Pain; Public Meeting; Request for Comments ", "context": "2018-10-10T15:22:16Z", "purpose": "Nonrulemaking", "keywords": ["Patient-Focused Drug Development on Chronic Pain", "Notice of public meeting", "request for comments", "Meghana Chalasani", "Chronic Pain", "CDER", "OPEN", "2018-247"], "comments": [{"text": "My mother had severe restless leg syndrome (RLS.) After years seeking help for her overwhelming need to move her legs at night and dealing with dismissive and nearly abusive physicians, we found an M.D. who said that he would not have believed her symptoms had he not had RLS himself! Her husband, of 50 years, had to move to a separate bedroom because of her constant need to move. Mother was finally treated with drugs that allowed her to sleep for longer periods without walking about. Those drugs, first Sinemet and then various dopamine agonists, worked for a few years, but with major side effects that led to severe augmentation. Her RLS then started earlier in the day and prevented going to a movie, listening to a lecture or traveling despite her determination to live her life fully. She was exhausted all day and would sometimes just fall asleep in the middle of a conversation because of the impact of the medical regimen. When she was dying, she was in agony with RLS because she could not get up and move about. Moving while lying in bed did not alleviate the symptoms or did so only while she continued movement. When her RLS medications no longer worked, her neurologists had nothing to offer. Fortunately, once she was in hospice, people actually cared about her comfort and she was provided with opioid pain control which, more importantly to her, helped control her RLS. It was so sad that mother had to be dying to receive appropriate care. Fortunately, more physicians now understand that RLS is actually not in ones head, but is a real, not manufactured condition to gain attention. ", "comment_id": "FDA-2018-N-1621-1507", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-1621-1507", "comment_date": "2018-08-07T04:00:00Z", "comment_title": "Comment from Ann Hallum", "commenter_fname": null, "commenter_lname": null, "comment_length": 1617}, {"text": ". . 25 . 21.. ... ", "comment_id": "FDA-2018-N-1621-1311", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-1621-1311", "comment_date": "2018-07-16T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 184}, {"text": "Multiple sclerosis, EDS, mcad..I can't have injections bc of EDS. Professionals should know that. My last resort is going to be learning to buy and do heroin.", "comment_id": "FDA-2018-N-1621-0663", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-1621-0663", "comment_date": "2018-07-10T04:00:00Z", "comment_title": "Comment from Becca Smith", "commenter_fname": null, "commenter_lname": null, "comment_length": 162}, {"text": "I have been frustrated by having to even go to pain management to get my pain pills. First I received dilaudid from my eye surgeon that removed my blind eye. Then he no longer wanted to prescribe the 8-10 pills I used monthly and said I had to instead use the time , energy and money to go to a pain clinic for these pills for my blind ennucleated eye neuropathy. Im allergic to codeine and need dilaudid for relief. First the pain clinic said I could come every 3 months and get these pills, then they said CDC guidelines indicated that if they gave me any opiates I had to be seen monthly. This is costly and I have to drive or be driven ( I have lots of vision issues in the other eye) to a clinic an hour away because the one here in town shut down. This is a racket that is inconveniencing and punishing legitimate patient's need for pain control. Also over the past year and a half Ive been to the ER with kidney stones twice. In past years before this opioid epidemic kidney stone patients were regularly sent home with opiates as trying to pass a kidney stone is excruciating. Now they will not give you anything to help. This is cruel! Full disclosure- I never had kidney stones before 16 months ago but my brother had suffered with them off and on for 20 years and was always given pain meds. Anyway, my point continues to be that this crackdown on doctors and pharmacists is causing financial stress, treatment stress and travel stress on patients and is causing Doctors and Pharmacists to be reluctant to provide needed interventions to control pain.
If I didnt have the medication for my neuropathy Id be bedridden for 2-5 days a month. The pain is like a knife stabbing me through my eye and into my brain. With this pain control Im only having to spend 1-2 days per month in the bed and nonfunctional to my family. I do use an ice pack during flares and I use OTC analgesics to manage pain as much as possible. ", "comment_id": "FDA-2018-N-1621-0671", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-1621-0671", "comment_date": "2018-07-10T04:00:00Z", "comment_title": "Comment from Lori Vickery", "commenter_fname": null, "commenter_lname": null, "comment_length": 1937}, {"text": "Topic 1: Symptoms and Daily Impacts of Chronic Pain That Matter Most to Patients
1. How would you describe your chronic pain? (Characteristics could include location, radiation, intensity, duration, constancy or intermittency, triggers etc.)

muscular, skeletal, neurological; both diffuse and highly localized. I have a condition called Ehlers-Danlos Syndrome.

2. What are the most significant symptoms that you experience resulting from your condition? (Examples may include restricted range of motion, muscle spasms, changes in sensation, etc.)

Tens of joint dislocations daily, muscle spasms, restricted range of motion, chronic fatigue, mobility problems, inability to lift over a few pounds.

3. Are there specific activities that are important to you but that you cannot do at all or as fully as you would like because of your chronic pain? (Examples of activities may include work or school activities, sleeping through the night, daily hygiene, participation in sports or social activities, intimacy with a spouse or partner, etc.)

Sleeping, feeding self, washing self, recreational outings, working fulltime, sex.

4. How has your chronic pain changed over time? (Considerations include severity and frequency of your chronic pain and the effects of chronic pain on your daily activities.)

Started when I was around 23. I am now 29. It's all day every day but highly variant.

Topic 2: Patients' Perspectives on Current Approaches to Treatment of Chronic Pain
1. What are you currently doing to help treat your chronic pain? (Examples may include prescription medicines, over-the-counter products, and non-drug therapies.)

Topicals, heat, PT, trigger point injections, nerve blocks, exercise as much as possible, non-opioids, opioids, mindfulness, therapy.

a. How has your treatment regimen changed over time, and why? (Examples may include change in your condition, change in dose, or treatment side effects.)

I've gone through virtually every option offered by any doctor I've encountered except for prolotherapy (insurance won't pay) and steroid injections (contraindicated for my condition).

b. What factors do you take into account when making decisions about selecting a course of treatment?

I read the existing literature and also am constrained by provider willingness.

2. How well does your current treatment regimen manage your chronic pain? (Considerations include severity and frequency of your chronic pain and the effects of chronic pain on your daily activities.)

I would say it's moderately controlled due to opioids.

3. What are the most significant downsides to your current treatments, and how do they affect your daily life?

Biggest issue is things not working well enough and fatigue and stigma from medication.

4. What challenges or barriers to accessing or using medical treatments for chronic pain have you or do you encounter?

This war on opioids is out of control. It's a terrifying climate. I have intractable pain according to my state laws, but it is still extremely intimidating to even admit I am seeking pain mgmt unless the provider is trusted. I have been diagnosed and in treatment for years, but the strongest thing I have ever gotten prescribed is Tramadol despite the failure of invasive procedures. I went from being a research mathematician with an active social life to fully disabled and no longer active in my field.

5. What specific things would you look for in an ideal treatment for your chronic pain?

OPIOID ACCESSIBILITY.", "comment_id": "FDA-2018-N-1621-0674", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-1621-0674", "comment_date": "2018-07-10T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 3700}, {"text": "I am a 77 year old male submitting these comments to support the availability of low-dose opioids for the treatment of refractory Restless Leg Syndrome (RLS). I have been taking 10 to 15 mg of methadone daily for the past nine years after other medications (dopaminergic agents, dopamine receptor agonists, anti-convulsants, alpha-2-delta ligands, and others) failed to provide long-term relief, often ending with augmentation that made my symptoms worse than before I started taking the medicine. Methadone has controlled my symptoms for the past 9 years without augmentation. I initially developed RLS symptoms at age 58 and have required constant treatment since age 61. Without treatment I am unable to sleep because my leg(s) (one or both) jerk violently the moment I fall asleep, waking me. I have had numerous lab tests over the years and am always in the normal range for things associated with RLS, such as low iron levels.

Please make some allowance in the rules so legitimate low-dose patients can get the drugs they require for normal life without over burdening the medical profession with paperwork.

Additional details in the requested format are provided in the attached file.", "comment_id": "FDA-2018-N-1621-2232", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-1621-2232", "comment_date": "2018-09-10T04:00:00Z", "comment_title": "Comment from Walter Rauser", "commenter_fname": null, "commenter_lname": null, "comment_length": 1214}, {"text": "My name is Hilary Greek, and I have lupus (sle), fibromyalgia, and narcolepsy. I am on the board of directors for the Richmond Fibromyalgia and Chronic Pain Association, as well as the Events Coordinator and support group leader. I am also on the ATIP mailing list as a patient. I have no monetary stake in this hearing.
My best day feels like the day after a very intense full body workout with heavy weights after being completely sedentary for a year. It feels like everything is sore and no matter how many times the muscles are stretched out, it just doesnt make it feel any better. That is my baseline. My pain seems to be mostly bilateral. My joints feel like they have been packed full of glass bits and shards, with an occasional stab of a large screwdriver. I have burning pain, like my skin is inside-out and all of the pain receptors are on the outside. Contact with anything feels like being stabbed with an icepick when that burning pain is going on, including bedsheets and even the softest of clothing. I get charley horse-like spasms several times a week. The ones on the bottoms of my feet are particularly horrible. My back usually feels like it has been flayed. Sometimes it feels like someone has used a rototiller up and down my spine. Sometimes I feel like I have been put through a meat grinder then mushed back into shape. I get painful ulcers in my nose and on my scalp.
I dont remember what its like to not hurt I remember when the pain was bad, so bad I was always on the verge of tears. Before any medication, I used to cry myself to sleep, and hope that I would never wake up. When I would wake up again, I would cry because I had to live through another day in pain. How can I tell you how it has changed when I cant remember last week or last month? I go to laughter yoga and wear silly headbands and sometimes put use very bright purple or blue hair color just to get a laugh or a smile from myself and other people. I think that helps my mental health quite a bit. I take opioid pain medication and I think that helps take the sharpness off of the pain. I get dry needling done once a week, and that helps for a day or two. I get cortisone shots directly into trigger points and joints on an as needed basis when I just cant stand it anymore. I try to get to the gym a couple of times a week, and I stretch several times daily. I do yoga when I can, and I think that helps with my pain. I get a massage now and then when I can afford it. Laughter yoga has been a wonderful addition to my list of non-drug therapies. I was surprised and quite pleased to feel energized and calm after my first class, and I have been back nearly every week since. I wish there were more non-drug alternatives that were available and affordable.
The gym membership has hydro-massage beds, and those sometimes help, especially when I have lifted too much weight. I am always on the lookout for something that will help, like the laughter yoga. What can it hurt? Nothing but my abs, right? So I tried it, and not only was it fun, but I do get an almost euphoric feeling that lasts for hours afterwards. I still have pain, but it gets kicked down a notch, if that makes any sense. It means that I only take one pain pill at bedtime that night instead of two.
For a new treatment, I try to find someone that has done it and ask them about their results - more than one person if at all possible. I ask my husband to help me figure out what he thinks about it in a sort of risk/gain analysis. If its free and sounds like fun like laughter yoga, Ill give it a shot. If it has side effects like risking children being born with the head of a golden retriever, then probably not.
Current regulations dictate that I have to drive to get a paper copy of my opioid prescription from my doctors office to then go to the pharmacy and wait for them to fill it. This is quite inconvenient and I cannot send my husband to do it for me. What if I am in a flare and Im in too much pain to drive? What if I cant get out of bed? Its a good thing I have cute pajamas. Its cumbersome, frustrating, and it adds to the full time position of being chronically ill. This policy makes me feel like a criminal, or like I am doing something wrong just by picking up medication.
Please see attached document for full answers. ", "comment_id": "FDA-2018-N-1621-2264", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-1621-2264", "comment_date": "2018-09-10T04:00:00Z", "comment_title": "Comment from Hilary Greek", "commenter_fname": null, "commenter_lname": null, "comment_length": 4365}, {"text": "At the age of 71 and being a retied public official I find my government jumping the gun on these decanoin rules recommending and justifying an opioid crisis. For years heroin and fentanyl have been corrupting our society from Mexican drug gangs and their local distributors. This is a known fact that has been by panic and misinformation by our own government that has fueled the so called opioid crisis. My story is a 6 year battle with spinal stenosis, degenerative disc disease and spinal cord damage, six major surgeries including a spinal fusion, spinal cord stimulator that has been removed do to no relief and a pain pump that offers very little help. Now for the facts the only medication and I have been prescribed everything known to man opiates offer the best pain relief when managed properly.
Yes we have those who have no control over their addictions who need the proper treatment for which lacking, so they are mixed in with us the legitimate people who need their pain medication on a routine basis and we have a so called crisis and the FDA, CDC and DEA swing into action with swiping us all and our doctors off the map. This whole political witch hunt needs to stop and be thought through and just maybe a common sense approach may come of it. To finish my story I am looking at another major surgery to decompress my spinal cord and fuse L-2 and L-3 vertebrae's to relief some of the severe pain I deal with, not to mention my pain meds have been cut back by almost half and my pain doctor gave up and quit pain management. Will someone please listen to us and give our God given right to proper medical care and keep political witch hunts out of our medical care. ", "comment_id": "FDA-2018-N-1621-1414", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-1621-1414", "comment_date": "2018-07-23T04:00:00Z", "comment_title": "Comment from G Guidry", "commenter_fname": null, "commenter_lname": null, "comment_length": 1696}, {"text": "See Attached", "comment_id": "FDA-2018-N-1621-2328", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-1621-2328", "comment_date": "2018-09-11T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 12}, {"text": "Hello,

When i heard i am being given the opportunity to speak on this matter it gave me pause, I want to speak up however, the complete demonization of chronic pain sufferers and their quest to get some relief to have a semi normal life made me fear coming forward. After reading some of the comments i decided i have to speak.

When did it become acceptable to punish all for the crimes or weakness of others? Example of the women who took 35 Vicodin a day! How is that my fault and why should i pay personally for her addiction ?

I have been on pain meds for many years, i even took myself off them for awhile to see how i felt and could i cope without. I was off of pain meds for 9 months and i can tell you it was not fun. I tried ibuprofen, it doesn't work and made my stomach ulcers worse, i tried stretching, exercise, diet change, hot baths, ice, aspirin,12 aday! antidepressants. i gave it my all. Finally after days in bed i made an appointment to see my doctor and was immediately put back on my pain meds.
I take 2 or 3 a day just enough to take the edge off my pain and be able to be a productive citizen and live a semi normal life.
I have spinal and cervical stenosis, I have had one full knee replacement and one that needs replaced, due to arthritis i was also diagnosed with fibromyalgia.

Now you want to limit my pain relief because their are people who have addiction problems ? You want me and others to suffer for the weakness of others ?
I have even had some doctors try to get me to take Marijuana so they do not have to wright a pain med prescription. ?? Now i am old enough to remember when Marijuana was evil and against the law, now it is like going to the 7/11 store here in Oregon, there is a pot shop on every corner! the world is upside down for me.

I have been passed around by my own doctors, who disagree strongly with these new RULES but are in fear, and i can only hope my new doctor stands by me. by the way what ever happen to the medical oath "Do No Harm" because the doctors are in fear due to the new Rules, in turn harming chronic pain sufferers to avoid reprecission from the FDA.

I understand that there are people with drug problems, i understand everyone is different and some cannot help themselves when it comes to misuse of drugs, They will find other drugs as they always have.
You will not solve the drug problem in america by restricting those who truly need relief! you will force many to become Illegal users, Suicides will increase and pain suffers will have their quality of life dissolve.

Please find another way, please don't take it out on true chronic pain sufferers.People's lives are at stake!! not just the over users and abusers but the real chronic pain sufferers who go by the book and are responsible.

Thank You

", "comment_id": "FDA-2018-N-1621-1409", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2018-N-1621-1409", "comment_date": "2018-07-23T04:00:00Z", "comment_title": "Comment from Laura Van Tassell", "commenter_fname": null, "commenter_lname": null, "comment_length": 2905}]}, {"id": "DOT-OST-1996-1533", "title": "Final Rule - Amendment to Definition of \"Substance Abuse Professional\"", "context": "2015-07-29T08:33:47Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "I am a licensed LPC and would like to see LPC's added to the list of eligible providers to conduct SAP assessments. MFT's have been added. Licensed professional counselors are licensed in all 50 states, have a minimum of a masters degree in psychology or counseling or a related field, and meet educational and experiential requirements. I conduct non-DOT assessments currently, and would like to be able to join the SAP provider pool.I have extensive experience treating clients with substance abuse issues.
", "comment_id": "DOT-OST-1996-1533-0002", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-1996-1533-0002", "comment_date": "2015-07-29T04:00:00Z", "comment_title": "Marion Hecht", "commenter_fname": "Marion", "commenter_lname": "Hecht", "comment_length": 522}]}, {"id": "FDA-2011-D-0771", "title": "Draft Blueprint for Prescriber Education for Long-Acting/Extended-Release Opioid Class-Wide Risk Evaluation and Mitigation Strategy; Availability; Request for Comments", "context": "2017-12-12T10:34:17Z", "purpose": "Nonrulemaking", "keywords": ["cder2011165", "CDER", "Blueprint", "Opioid"], "comments": [{"text": "See attached file(s)", "comment_id": "FDA-2011-D-0771-0017", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-D-0771-0017", "comment_date": "2011-11-30T05:00:00Z", "comment_title": "Advocates for the Reform of Prescription Opioids, Inc. - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "FDA-2011-D-0771-0049", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-D-0771-0049", "comment_date": "2011-12-14T05:00:00Z", "comment_title": "National Association of Medical Education Companies (NAMEC) - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Please see the attached comments from the Alliance for Continuing Education in the Health Professions (formerly, the Alliance for Continuing Medical Education) regarding Docket No. FDA-2011-D-0771: Draft Blueprint for Prescriber Education
for Long-Acting/Extended-Release Opioid Class-Wide Risk Evaluation and Mitigation Strategy.", "comment_id": "FDA-2011-D-0771-0031", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-D-0771-0031", "comment_date": "2011-12-14T05:00:00Z", "comment_title": "Alliance for Continuing Education in the Health Professions - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 334}, {"text": "Quest Diagnostics Incorporated appreciates the opportunity to assist the U.S. Food and Drug Administration in developing the Blueprint for Prescriber Continuing Education Program. Quest Diagnostics is the world’s leading provider of diagnostic testing, information and services that patients and doctors utilize to make better health care decisions. With over 25 years of experience in toxicology testing, we perform over nine million urine drug tests (UDTs) annually across our network of four certified laboratories. UDT is well-established and recommended as an effective tool in pain management and prescription drug monitoring by numerous provider and patient organizations as well as the Federation of State Medical Boards and the Department of Veterans Affairs. We agree that prescribers should be knowledgeable about the need for UDT as a valuable tool to enhance patient safety, ensure appropriate patient access to prescribed drugs, and to help curb the prescription drug abuse and misuse epidemic. Taking into consideration the increasing rate of unintentional drug overdose and death due to prescription drugs, the Blueprint should incorporate UDT four times a year or more as appropriate.

Please contact me to further discuss the issues raised in this letter with the goal of improving patient care: Faith Cristol, 202-263-6260, faith.a.cristol@questdiagnsotics.com.
", "comment_id": "FDA-2011-D-0771-0030", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-D-0771-0030", "comment_date": "2011-12-14T05:00:00Z", "comment_title": "Quest Diagnostics Incorporated - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1400}, {"text": "Attached please find comments submitted by the National Community Pharmacists Association (NCPA). ", "comment_id": "FDA-2011-D-0771-0058", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-D-0771-0058", "comment_date": "2011-12-14T05:00:00Z", "comment_title": "National Community Pharmacists Association (NCPA) - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 98}, {"text": "See attached file(s)
Attached is a sheet providing more information on CO*RE.", "comment_id": "FDA-2011-D-0771-0055", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-D-0771-0055", "comment_date": "2011-12-14T05:00:00Z", "comment_title": "CAFP and CO*RE - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 81}, {"text": "See attached file(s)", "comment_id": "FDA-2011-D-0771-0054", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-D-0771-0054", "comment_date": "2011-12-14T05:00:00Z", "comment_title": "SPHERE, a program of Health Imperatives - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "N/A", "comment_id": "FDA-2011-D-0771-0068", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-D-0771-0068", "comment_date": "2011-12-23T05:00:00Z", "comment_title": "The Accreditation Council for Continuing Medical Education (ACCME) - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 3}, {"text": "please see attached comments", "comment_id": "FDA-2011-D-0771-0063", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-D-0771-0063", "comment_date": "2011-12-14T05:00:00Z", "comment_title": "Bridget McCrate Protus - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 28}, {"text": "I am a pharmacist in Fredericksburg, VA and in the past 2-3 years have seen an explosion in inappropriate prescribing of controlled substances. I am wondering why this blueprint is focusing only on long acting narcotics and not all controlled substances? I was recently a witness for the Virginia Board of Medicine in a case where a doctor's license was revoked for inappropriate prescribing. As I speak with doctors on the phone when I am verifying controlled prescriptions, I realize many offices have no real procedures in place to prevent addiction and illicit distribution. First off, a signed pain contract must be in place for each patient and if they deviate, the doctor has every right to discharge the patient. Previous medical records must be verified! It is not difficult today to falsify or use someone else's records. Personally, I would only accept records from a previous physician directly after contacting them myself. I would not accept records handed to me by the patient. If records can not be attained for a valid reason, the prescriber must perform an exam and any testing needed to confirm a diagnosis. PMP reports are also essential and must be done on every office visit... but be aware... patients now know about PMP reporting and will do whatever necessary to make sure their report looks acceptable. They will travel to different states because right now state PMP websites are not linked and you can only view one state at a time. Also, healthcare professionals must register separately for each state. Another way to deceive PMP reporting is to use multiple false names and dates of birth by obtaining false state identification cards. Finally, urine testing and bloodwork should be done to confirm substance use and also detect any illicit substance use. Please contact me if I can offer any additional information because I deal with this issue on a daily basis... wesandlorimilton@comcast.net", "comment_id": "FDA-2011-D-0771-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2011-D-0771-0003", "comment_date": "2011-11-30T05:00:00Z", "comment_title": "Lori Anne Milton - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1980}]}, {"id": "FDA-2022-N-2393", "title": "Public Workshops - Diagnostic and Monitoring Medical Devices for Opioid Use and Risk Prediction Devices of Opioid Use and Opioid Use Disorder - Opportunities and Challenges", "context": "2022-12-08T14:48:59Z", "purpose": "Nonrulemaking", "keywords": ["CDRH", "Notice", "Public Workshops", "Diagnostic and Monitoring Medical Devices", "for Opioid Use and Risk Prediction Devices of", "Opioid Use and Opioid Use Disorder", "Opportunities and Challenges", "Open"], "comments": [{"text": "This is a hard no for me. Let Dr's do what they think is best, not some machine telling them. Anti-opoiod rhetoric and targeting has killed many. People are left with death as the only option to escape chronic pain. Stay out of our Dr's appointments..this machine will inadvertently cause even more deaths..", "comment_id": "FDA-2022-N-2393-0008", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2393-0008", "comment_date": "2022-12-08T05:00:00Z", "comment_title": "Comment from Paula Perry", "commenter_fname": null, "commenter_lname": null, "comment_length": 315}, {"text": "I was told in April of 2019 the pain management practice I was seeing that I was being cut off meds. I remembered very well the pain I will have until I die would be back. Said stimulator was only thing could help. I saw doctor I'd not seen before in the over 4 years of being there. They made sure I got the meds for that, and in Aug of 2019 I got the permanent one and they were cutting my meds off. It was a domino effect. I know need helpers. I don't see where a device that can tell what your pain is useless. When I gave birth to my 2nd son they used a device to keep track of contractions. Didn't work, kept telling them I was having closer pain and they looked at machine and said I was fine. Finally they looked and my son was on his way out. I believe only the patient can tell you how much pain you have. A new gadget that can tell is just another medical expense that isn't necessary. We are human and places have seem to forgot that. Insurance spent thousands on the stimulator, which I believe is a waste of money. Since so many doctors have turned to them, rate of success isn't as good. Any extra equipment to put us through that doctor's need to use is just another insurance waste like my stimulator was. Would be a lot better to go back to what works for us. And keeping our records private as well. It is fast become inhumane treatment as it is. I feel it's a waste of money for insurance companies have to pay. Are doctors allowed to listen to patient anymore. I know what my pain is. Please stop trying more fixer uppers and technology. Insurance paid to get stimulator out. Please no more trusting a machine to tell us about our pain. It's ridiculous.", "comment_id": "FDA-2022-N-2393-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2393-0006", "comment_date": "2022-12-08T05:00:00Z", "comment_title": "Comment from Cindy Jezek", "commenter_fname": null, "commenter_lname": null, "comment_length": 1706}, {"text": "Please see attachment 1 for full comments. The mere suggestion that patients already harmed by existing opioid deprescribing efforts should be bio monitored, genetically tested, and computed via machine learning algorithms to predict risk, is absolutely terrifying. No one has taken account for the deplorable state of pain patients clawing for the right to exist without pain, yet now, our government is concerned we need to be further monitored and assessed to access our medication? Again, no one has asked us if we would be willing to submit to such devices or risk prediction testing and algorithms. We have established relationships with our providers who have already deemed our medication is necessary, why would we want non contextual data to determine otherwise? We are tired and frustrated at everyone else determining we are at risk when most of us are not. We are tired of our providers being targeted which puts our well-being at risk. If devices that use noncontextual data to determine risk are implemented, our providers will have no other choice except to put that information into practice. They will feel accountable to deny our appropriate medication due to a hostile regulatory environment.
", "comment_id": "FDA-2022-N-2393-0011", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2393-0011", "comment_date": "2022-12-08T05:00:00Z", "comment_title": "Comment from Cyndi Hoenhous", "commenter_fname": null, "commenter_lname": null, "comment_length": 1225}, {"text": "So let me get this straight: you want to subject me to a surgical procedure to prove that my pain is real? Who pays for this device? Who monitors it? What happens if this device breaks or malfunctions? As a person who suffers from chronic pain on a daily basis all because someone at the insurance company didn't feel my fractured spine was important enough to do a spinal fusion, do you really think I would trust anyone else doing unnecessary procedures to my body? After three tries with the insurance company, I finally had my fusion and guess what? My spine was in 2 pieces and my nerves were exposed and flapping. This is not a life I would wish on anyone. To push CPPs to do monthly drug tests, pill counts, sign contracts, and be treated like criminals; only to now be pushed to get a medical devise just to prove Im in pain is never going to happen. This is just another get rich quick scam the medical community will push, but it won't work. We are not criminals. Enough is enough.", "comment_id": "FDA-2022-N-2393-0015", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2393-0015", "comment_date": "2022-12-08T05:00:00Z", "comment_title": "Comment from M M", "commenter_fname": null, "commenter_lname": null, "comment_length": 1001}, {"text": "I am appalled at the lack of diversity of pain patients that were used. Valuable time was wasted playing prerecorded statement. There was a significant amount of duplicity. I am even more disturbed that there was not more discussion about how patients on LTOT are profiled and denied opioids even in acute pain while in hospital from Narxcare. A score that is shielded by privacy under argument that it's a "proprietary' algorithm. Yet FDA is testing the water to add more computer driven apparatus without transparency. DEA shouldn't be able to troll PDMP's an then use parallel construction to create cases against Dr's. FDA needs to address the elephant in the room that opioids are FDA approved but not allowed under DEA scrutiny.
", "comment_id": "FDA-2022-N-2393-0010", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2393-0010", "comment_date": "2022-12-08T05:00:00Z", "comment_title": "Comment from Janice Garland", "commenter_fname": null, "commenter_lname": null, "comment_length": 766}, {"text": "We (experts in statistical and psychiatric genetics, including substance use disorders) wish to raise important issues related both to the general topic and to a specific test that was described during the workshop. We highlight the expert consensus on 2 general issues about genetics of psychiatric and substance use disorders most relevant to the workshop and to potential approval of devices for risk prediction.

First, while genetic variations contribute to the risk for psychiatric and substance use disorders (SUD), the genetic contribution accounts for only about half of the variation in risk, and that portion is distributed among hundreds to thousands of genes. The idea that a small set of genetic variants, however combined, can distinguish those at elevated risk for an SUD simply does not align with accepted scientific fact regarding the genetics of SUD and other psychiatric disorders.

Second, there needs to be control for the participant’s genetic ancestry in any test for a trait or disorder that is complex (i.e., due to the effects of many genes). Groups of people differ in the frequencies of many genetic variants, and differences often track with recent ancestry. If these differences are not accounted for, they result in spurious findings where genetic variants that are actually indicators of the ancestry of a group can show up as false positive associations with the trait (e.g. the chopstick gene, PMID: 10673763). This is a major risk, because if a medical test preferentially confounds ancestry with OUD risk, it can contribute to biased treatment.

During the workshop, one particular test that is being evaluated by the FDA was described: the AvertD(TM) genetic test for Opioid Use Disorder (OUD) risk, from SOLVD Health. We think that it is an example of a flawed test that could generate harm, and serves as an example of issues that should be considered in evaluating any such test.

The AvertD(TM) test purports to predict who is at risk for becoming opioid dependent if prescribed opioids. The company proposes that a practitioner could test patients to determine risk before prescribing opioids, and use the information to guide his/her prescribing. The test uses 15 variants (PMID: 34452883); a prior version (PMID: 28801372) used those plus one additional. Based on the largest genome-wide studies to date (samples range from approx. 80,000 to 400,000; e.g. PMID: 35879402; PMID: 36171425; PMID: 34728798), even a full genome’s worth of markers is not currently able to predict an individual’s risk for OUD in a clinically useful way.

One group evaluated how ignoring the scientific consensus noted above results in bias (PMID: 34710714), with examples using the exact genetic markers used previously by the creators of the test. The proposed SNPs differed significantly in allele frequency among different populations, a major problem. Although the company’s particular machine-learning algorithm is not public, the group tested 5 major types of machine learning algorithms with the SNPs the company chose, as well as with 8 random sets of SNPs that were matched to theirs on allele frequency. These SNPs and algorithms were tested in a large number of carefully evaluated and ethnically matched individuals: half of European American and half of African American genetic ancestry, and within each group half of the participants met criteria for strictly defined OUD (DSM-IV) and half did not. The paper showed there was no predictive utility for OUD attributable to these SNPs. When done incorrectly the prediction could appear to exceed 90% accuracy but also – alarmingly – the prediction by this set of variants was highly confounded by ancestry such that it predicted subpopulations of minorities rather than OUD. This is particularly problematic, because it could exacerbate current biases in pain treatment. That paper also tested simulated data and another complex phenotype, tobacco smoking, and our results generalized. These analyses serve as a cautionary note when evaluating any genetic test for an SUD.

We urge your panel to carefully review the consensus on the genetics of OUD and the published work on algorithmic bias in genetic prediction of opioid use disorder in any decisions on such a predictive test.

A bibliography is appended as a pdf, due to space limitations.", "comment_id": "FDA-2022-N-2393-0016", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2393-0016", "comment_date": "2022-12-08T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 4427}, {"text": "This device to tell doctors if a patient needs pain medication is asinine. It’s a horrible idea. I’ve been on long term opiate therapy for 30 years. Opiates have saved my life. Without them I was unable to get out of bed without great pain and difficulty. When I was forced off opiate therapy because of the anti opiate hysteria it almost killed me. I ended up in the ER and a stay in the hospital for a week to stabilize my heart. This should never happen to another patient. Ever and putting a device on someone to measure how much pain they are in instead of just listening to the patient is ridiculous. Same with spinal cord stimulator’s. Another piece of medical quackery ", "comment_id": "FDA-2022-N-2393-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2393-0004", "comment_date": "2022-11-23T05:00:00Z", "comment_title": "Comment from Verl McCown", "commenter_fname": null, "commenter_lname": null, "comment_length": 697}, {"text": "I am a data scientist with over 20 years of experience and have been affected by addiction.

The presentations of A. Haotum claiming there is scientific consensus that his approach is correct is demonstrably incorrect. I reviewed the entirety of his published work including the papers he referred two in his short presentation. None of the papers follow best practices in our space. All papers contain numerous flaws in study design that have been shown to lead to invalid modeling and incorrect results.

For example, the in the study he spent the most time discussing, the inter-rater Cohen kappa coefficients the study data for the survey instrument (Semi-Structured Assessment for Drug Dependence and Alcoholism) used to classify opioid dependency range from ~0.1 to 0.4. This is important, because in electronically derived predictive classification modeling, we need to understand the noise in our data. It is a reasonable assumption that the Cohen kappas contribute to the class noise and therefore set the minimal amount of class noise in opioid dependency of the dataset within this range (i.e. the minimal amount of class noise in opioid dependency in your study would be ~10-40%). Whereas the empirically defined ancestry classification he used would not have equal class noise levels (although as you know the use of the 1000 genome data to assign ancestry and the under-specification issues with the genetic attributes (MAFs) in this approach is concerning especially for the AA groups). Given that the approaches used will degrade with as little as 5% class noise, and that the differences in class noise of at least 10-40%, the comparative analysis using the unadjusted/uncleaned data with the differences in class noise between the two classes studied in invalid and uninterpretable.

Numerous independent studies have shown using uncleaned/unadjusted data across apparently large difference in class noise between classes (opioid dependency and ancestry in this case) makes the modeling, comparisons, and the conclusions unsupported. In addition, I also have a significant concern in the way the study is designed to test hypotheses within a dataset across classes and then generalized externally. A reasonable interpretation of the results is that this dataset is not adequate to use for modeling opioid dependency, but that all that would be needed for this interpretation is to look at the inter-rater kappas for the class (it took me literally 10 min). Trying to generalize the limitations of the dataset to attributes or studies outside this dataset is utter nonsense.", "comment_id": "FDA-2022-N-2393-0002", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2393-0002", "comment_date": "2022-11-10T05:00:00Z", "comment_title": "Comment from Brian H.", "commenter_fname": null, "commenter_lname": null, "comment_length": 2627}, {"text": "Please read the attachment from the Oregon Pain Action Group which contains our comment. Thank you. ", "comment_id": "FDA-2022-N-2393-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2393-0005", "comment_date": "2022-12-06T05:00:00Z", "comment_title": "Comment from The Oregon Pain Action Group", "commenter_fname": null, "commenter_lname": null, "comment_length": 100}, {"text": "I writing this today to voice my concerns about the manner chronic pain patients are treated nowadays. Since the DEA has been threatening our Doctors, we have been forced into pain clinics where the Doctors have really no knowledge of of our history or any condition that our PCP would know right off the top of his head! It’s criminal that they are allowed to over ride our Doctors and in some cases put them in jail for only prescribing medication to their patients! In fact they are using this so called opioid crisis to do this! If truth be told 87% of deaths are from fentanyl that flows In across our Southrren border. Something must be done to help my community of chronic pain patients and deal with the illegal drugs pooring in", "comment_id": "FDA-2022-N-2393-0009", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2393-0009", "comment_date": "2022-12-08T05:00:00Z", "comment_title": "Comment from Robert Marx", "commenter_fname": null, "commenter_lname": null, "comment_length": 742}]}, {"id": "FDA-2005-P-0325", "title": "Temporary Recall of Approval of OxyContin and Palladone Removal From Market and Label Changes Limiting Indications to Severe Chronic Pain From Documented Peripheral Tissue Disease Potential - CLOSED", "context": "2021-09-01T01:01:24Z", "purpose": "Nonrulemaking", "keywords": ["painkillers", "morphine", "oxycodone", "Barbara Van Rooyan", "Kirk Van Rooyan", "cancer", "back pain", "chronic pain", "palladone", "OxyContin", "CDER", "closed"], "comments": [{"text": null, "comment_id": "FDA-2005-P-0325-0013", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2005-P-0325-0013", "comment_date": "2008-12-22T05:00:00Z", "comment_title": "Stephen G. Gelfand - Reply Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-2005-P-0325-0012", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2005-P-0325-0012", "comment_date": "2008-12-22T05:00:00Z", "comment_title": "Kirk Van Rooyan, M.D. and Barbara Van Rooyan. - Reply Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}, {"text": null, "comment_id": "FDA-2005-P-0325-0011", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2005-P-0325-0011", "comment_date": "2008-12-22T05:00:00Z", "comment_title": "Purdue Pharma LP - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 0}]}, {"id": "FDA-2012-P-1028", "title": "Safety Concerns Regarding Buprenorphine for Opioid Dependence-CLOSED", "context": "2013-05-30T08:33:02Z", "purpose": "Nonrulemaking", "keywords": ["CDER", "buprenorphine", "opioid", "dependence", "reckitt benckiser", "pharmaceuticals", "rbp", "rld", "nda", "anda", "subutex", "suboxone", "hc1", "naloxone", "child-resistant", "pediatric", "radars", "riskmap", "rems", "2012-8052", "CLOSED"], "comments": [{"text": "See attached file(s)", "comment_id": "FDA-2012-P-1028-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-1028-0004", "comment_date": "2012-10-23T04:00:00Z", "comment_title": "Amneal Pharmaceuticals, LLC (Venable LLP) - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Please see attached file.", "comment_id": "FDA-2012-P-1028-0007", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-1028-0007", "comment_date": "2012-12-11T05:00:00Z", "comment_title": "Actavis Inc. - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 25}, {"text": "See attached file(s)", "comment_id": "FDA-2012-P-1028-0016", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-1028-0016", "comment_date": "2013-02-26T05:00:00Z", "comment_title": "Morgan Lewis & Bockius - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "FDA-2012-P-1028-0015", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-1028-0015", "comment_date": "2013-02-26T05:00:00Z", "comment_title": "Amneal Pharmaceuticals, LLC (Venable LLP) - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "Actavis Inc. Comments to Docket No. FDA-2012-P-1028 (1-31-2013)", "comment_id": "FDA-2012-P-1028-0014", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-1028-0014", "comment_date": "2013-02-26T05:00:00Z", "comment_title": "Actavis Inc. - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 63}, {"text": "See attached file(s)", "comment_id": "FDA-2012-P-1028-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-1028-0003", "comment_date": "2012-10-23T04:00:00Z", "comment_title": "American Society of Addiction Medicine - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "FDA-2012-P-1028-0012", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-1028-0012", "comment_date": "2013-02-26T05:00:00Z", "comment_title": "American Society of Addiction Medicine - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "FDA-2012-P-1028-0013", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-1028-0013", "comment_date": "2013-02-26T05:00:00Z", "comment_title": "American Society of Addiction Medicine - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "This memo is submitted to provide a correction to the Reckitt Benckiser Pharmaceuticals -- Response to Amneal Comment (Doc ID: FDA-2012-P-1028-0005)", "comment_id": "FDA-2012-P-1028-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-1028-0006", "comment_date": "2012-12-11T05:00:00Z", "comment_title": "Reckitt Benckiser Pharmaceuticals Inc. - Correction", "commenter_fname": null, "commenter_lname": null, "comment_length": 148}, {"text": "See attached file(s)", "comment_id": "FDA-2012-P-1028-0017", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-1028-0017", "comment_date": "2013-02-26T05:00:00Z", "comment_title": "Amneal Pharmaceuticals, LLC (Venable LLP) - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}]}, {"id": "FDA-2012-N-1172", "title": "Impact of Approved Drug Labeling on Chronic Opioid Therapy; Public Hearing; Request for Comments", "context": "2013-04-23T11:24:53Z", "purpose": "Nonrulemaking", "keywords": ["cder", "cder2012179", "labeling ", "opioid", "public hearing", "drugs", "chronic pain", "extended-release ", "long-acting ", "ER/LA opioid ", "REMS", "abuse"], "comments": [{"text": "n/a", "comment_id": "FDA-2012-N-1172-0018", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-1172-0018", "comment_date": "2013-03-20T04:00:00Z", "comment_title": "Edward Manougian MD - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 3}, {"text": "Created in 2009, the Chronic Pain Research Alliance (CPRA) – led by the National Vulvodynia Association, Chronic Fatigue and Immune Deficiency Syndrome Association of America, Endometriosis Association and The TMJ Association – has served as the first and only collaborative advocacy effort dedicated to advancing both disorder-specific and collective federal research efforts on eight prevalent, but longtime neglected disorders that frequently co-occur and disproportionately affect women. They include: vulvodynia, temporomandibular disorders (TMD), fibromyalgia, endometriosis, chronic fatigue syndrome (CFS), chronic headache, interstitial cystitis/painful bladder syndrome and irritable bowel syndrome.

As highlighted in the landmark 2011 Institute of Medicine Report, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research, millions of Americans suffer from one or more of these disorders at an enormous cost to both the U.S. economy and to the individual sufferer. Only a handful of treatments have been approved by the FDA for the treatment of five of these disorders, and despite their widespread prevalence, cost and life-altering impact, no FDA-approved therapies exist for vulvodynia, TMD and CFS. In addition, the federal government’s investment in researching these disorders is poor – averaging just a couple of dollars per affected individual, and only a handful of clinical trials are currently studying the effectiveness of treatments to manage these conditions. The result is that sufferers are routinely misdiagnosed and shuffled from office-to-office in search of a diagnosis and effective treatment; when a diagnosis is made, very little scientific evidence exists to inform treatment recommendations, and the afflicted are left to try to gain some semblance of quality of life by stumbling upon an effective treatment(s) through the only option available to them – many months (and often times years) of trial-and-error. An expanded", "comment_id": "FDA-2012-N-1172-0248", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-1172-0248", "comment_date": "2013-04-09T04:00:00Z", "comment_title": "Christin Veasley (CPRA) - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 2038}, {"text": "I have RSD. the only thing that allows me to live as normal a life, raise the last 2 of the 4 children I have, coach their teams, go to PTA, Hold down a full time critical Gov job and get thru the day without crying too much is because I have NORCO. would i choose to take this? NO. I would much prefer to live a normal life. Some days I take what is prescribed, some days i take 1 or none. It depends, but let me ask you something. If someone you loved, God forbid as I wouldnt wish RSD on The worst people in the world, your Mom, Dad, Wife, sister, brother or child had RSD and it felt, on a daily bases and even while sleeping, that their bones were being stabbed from the inside with a hot poker, their muscles were being eaten by fire ants while getting the worst indian burn ever, to the point their skin felt as if it would tear, would you want them to have relief from that? That is what I go through daily and some have it worse. But I'm guessing as Doctors or FDA employees, no one in your family would have to suffer needlesly that way. Please, Please don't let the A-Hole celebrities and recreational drug users put us back into dispare. There is a reason they call RSD the suicide disease. thank you for your time.....mary", "comment_id": "FDA-2012-N-1172-0210", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-1172-0210", "comment_date": "2013-04-01T04:00:00Z", "comment_title": "Mary Estalee Juarez - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1243}, {"text": "The NFMCPA understands reasonable and necessary safety measures, but we believe the recommendations for severely restricting opioids (hydrocodone & oxycodone): 1) to a maximum daily dose equivalent to 100 mg for non- cancer pain ans 2) a maximum durations of 90 days for continuous daily use are EXTREME MEASURES! I have been living with chronic, unrelenting pain for the past 20 years and will suffer severe consequences from such restrictions. No alternative treatments are being offered. I object to the FDA changes for more stricter hydrocodone product prescribing by changing them from Schedule III to Schedule II classification of drugs. My doctor prescribes medications to treat my chronic pain. He is the one who should decide what his patient needs, and not the government. Thank you.", "comment_id": "FDA-2012-N-1172-0189", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-1172-0189", "comment_date": "2013-03-29T04:00:00Z", "comment_title": "Debra Angel - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 801}, {"text": "I am a sufferer of Chronic severe pain due to Fibromyalgia. I have pain that on the 1-10 pain scale is a 25.I have been on the narcotic Oxycontin 80 mg twice a day for about 15 years.I take it as prescribed only.Even with this strong pain med.I still have to take Nucenta for breakthrough pain and I take Ibuprofen 600mg three times a day.I certainly did not ask for this horrid pain which is frequently worse than some cancers.I do work a part time job and have a small home business but if my dose is lowered or my pain med.taken away I will be non-functional and then need to be on government disability.Also,the pain would be so severe that either I would die from the pain or I would have to take my life.This I am sure goes for many pain sufferers that legitimately need pain control.We are not addicts.We need our legitimate pain controlled.I am sure you want me and other pain suffered to be productive members of society.Thank You for reading this. Jodi M.", "comment_id": "FDA-2012-N-1172-0195", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-1172-0195", "comment_date": "2013-03-29T04:00:00Z", "comment_title": "Jodi M. - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 965}, {"text": "I have RSD for 10 years now. 8 months ago my husband and I moved to Spokane WA. We moved from Nevada were I finally was starting to able to things like walking my dog. It took 2 long years changing my meds. I have RSD in my left shoulder all the way into my hand also have it is my left foot. Now I am worse than I first got it. I have been to 12 damn different doctors in Spokane. They just take me off all meds.It people like you that can live a normal life and don't care that people do have chronic pain. You will never go to bed at night crying yourself and people around get anger cause they can't help. Just because some parents are keep there an eye on their own kids. You will be leaving people like me no way out but suicide!!!!!! We are people that abuse these type of meds!!!!!
YOU PEOPLE SHOULD START THINKING ABOUT OTHER PEOPLE THAT DON'T KNOW IFTHEY CAN GO ON DAY WITH FOR THE REST THEIR LIVES WITH PAIN!!!!!!!!!!!!!!", "comment_id": "FDA-2012-N-1172-0207", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-1172-0207", "comment_date": "2013-04-01T04:00:00Z", "comment_title": "April Kathleen Whitmire - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 948}, {"text": "I am writing to comment on the FDA regulating use of opioid drugs. For people, including myself, who are in chronic pain, the use of opioid drugs is not an option. There are days when it might not be necessary but most days and especially a flare-up of the conditions I have the only way to function is with these drugs. If I had a choice, I would not take them or be in pain everyday of my life. I would not miss family gatherings, work, getting together with friends, lose friends who no longer can understand why I can't go anywhere. For some of us there is no option and whether or not we like it this is our reality. Opioid drugs make us feel somewhat normal and somewhat able to function. It does not make things go away just manageable for a while. If you or someone in your family suffered from a chronic, life-long pain condition, I wonder if this would be an issue. Please consider the millions of people this would affect. We are not drug addicts, we are drug users that go through our doctors to get the help we need. Thank you for your consideration. ", "comment_id": "FDA-2012-N-1172-0202", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-1172-0202", "comment_date": "2013-04-01T04:00:00Z", "comment_title": "Christine Rozenwaser - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1080}, {"text": "Impact of Approved Drug Labeling on Chronic Opioid Therapy. I would like to comment on this because I do have Fibromyalgia and if it were not for the Hydrocodone that I take, I would be in terrible, excruciating pain. My doctor has already told me that I am the worse case of Fibromyalgia that he has seen. The Hydrocodone doesn't even take away all of the pain, but it does take off the edge so it isn't so intense. This is why I do not believe in this new drug labeling. No, I am not an addict, I can go without the Hydrocodone, but it would be quite painful to do so.

Please do not approve this new drug labeling. I'm sure I am not the only one out here dealing with this problem. ", "comment_id": "FDA-2012-N-1172-0091", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-1172-0091", "comment_date": "2013-03-22T04:00:00Z", "comment_title": "Teresa Lynn Marin - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 707}, {"text": "Pain medications can be and in most cases is necessary for a person to have a nomal life. Every person's pain level and tolorence is different and WHO has the right to say what you should and should not take. If there is a medication that helps you control and frees you of pain (which if one has never had a cronic condition requiring this) then it should be allow for ANYONE to be able to get the medication when prescribed by a Physcian or Nurse.
Not all medications work the same way for everyone I was on a medication for years that helped me lead a normal life under controlled pain medication and now because of someone or a group of someone's I am in constant pain and have been since my Doctor can no longer prescribe the medication I need to live a semi normal life. My pain will never be totally gone but the difference between being completely bed ridden and living a semi normal life that allows a person to function should be a choice that my Doctor and myself make, Not a group of people who have never been in a situation where pain is a everyday problem to having a life that most people live. Contast pain causes severe depression and in my case not moving my body helps prevent the pain to a small degree compared to being on the pain medication which helped me and allowed me to move about more freely and enjoy life as much as possible. Until you are in a situation yourself where you experience this I don't believe that anyone should have the right to say whether a medication of any kind should be limited or not be allowed. Spend a day in the shoes of someone in chronic pain for just one day and experience the suffering and depression that it causes then think again about whether medication should be allowed to help make a major change in a persons life.
Thank you for the chance to express my opinion in hope of concideration and a chance to once again have a major life change, to start living again and to love again.
Sincerely
Mary Beams", "comment_id": "FDA-2012-N-1172-0130", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-1172-0130", "comment_date": "2013-03-25T04:00:00Z", "comment_title": "Mary Beams - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 2004}, {"text": "The PROPs recommendation of a maximum duration for continuous opioid treatment is a serious concern to those who legitimately suffer from chronic pain. I am a young adult living with Trigeminal Neuralgia (TN), also referred to as the Suicide Disease. Living the past 17 years with TN has stripped away my dreams and ruined my quality of life. I have been prescribed over 45 non-narcotic meds in attempt to manage my pain. These meds have resulted in the most awful side-effects.

I have found on-going treatment with narcotic pain meds to be a life-saver for me. I have been taking narcotic pain meds for 10 years with mild side effects and little negative impact on my life. I have never taken them at a different dose or method than my doctor has instructed. I only take them to treat my constant and debilitating nerve pain in order to achieve more out of life – including maintaining my career, my independence, some quality of life, and basic survival. TN is a disease that becomes progressively worse over time. The last time my treatment did not include pain medication, I was so disabled that I could not work, care for myself independently, or perform basic ADLs. I could not eat, talk, brush my teeth, smile, or withstand a summer breeze without excruciating pain. I fully believe that I would NOT BE ALIVE TODAY if it hadn’t been for the narcotic pain management treatment my doctor began a decade ago.

What is 90 days of pain relief out of a lifetime of constant, debilitating pain? How can the PROP be allowed to decide who must suffer to death and who can be relieved of their pain? Why make the chronic pain patient who has a chance to live, succeed, and participate in life again, suffer needlessly when there are reliable treatments that work? Setting a maximum duration for opioid treatment will prevent chronic pain sufferers from receiving the medical care they need to survive.
", "comment_id": "FDA-2012-N-1172-0145", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-N-1172-0145", "comment_date": "2013-03-25T04:00:00Z", "comment_title": "Ginger K Grigsby - Comment", "commenter_fname": null, "commenter_lname": null, "comment_length": 1936}]}, {"id": "HHS-OS-2019-0008", "title": "Pain Management Task Force Meeting with CMS", "context": "2019-07-08T14:31:42Z", "purpose": "Nonrulemaking", "keywords": null, "comments": [{"text": "Attached, Please find the comment letter from Fujifilm SonoSite, Inc. Thank you. ", "comment_id": "HHS-OS-2019-0008-0016", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0008-0016", "comment_date": "2019-07-08T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-11473", "commenter_fname": "Jill", "commenter_lname": "Rathbun", "comment_length": 82}, {"text": "See attached file(s)", "comment_id": "HHS-OS-2019-0008-0015", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0008-0015", "comment_date": "2019-07-08T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-11473", "commenter_fname": "Patricia", "commenter_lname": "Trifunov", "comment_length": 20}, {"text": "Dear Sirs and Madams,
I am a Thoracic surgeon in Manchester NH and want to share my experience with you regarding Cryo-analgesia nerve block application for post thoracotomy and VATS lung surgery pain. I have been utilizing the Atricure Cryo-sphere prob for the last six years on over 400 cases of both thoracotomy and Minimally invasive VATS and robotic cases. I have seen a dramatic reduction in post operative narcotic requirement post op in many cases No narcotics have been needed. A recent study published in the AATS journal has shown that 14% of post thoracotomy and 9% min invasive VATS lung surgery patients are at sig risk for opiod addiction. I have just submitted an abstract to the AATS for publication demonstrating that in a single institution case comparison review we document a overall five fold reduction in post op narcotic use in patients who received cryo-analgesia. This highly effective procedure is not reimbursed for as such the hospital has to absorb the cost for the technology. I believe it would be much more utilized across the US if hospitals could be appropriately reimbursed. This procedure has added a critical advantage in my post operative care with improved outcomes and significantly reduced need for narcotics.
Please feel free to contact me if you have further questions.
Thank you,
Sincerely
Curt Quinn", "comment_id": "HHS-OS-2019-0008-0027", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0008-0027", "comment_date": "2019-07-08T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-11473", "commenter_fname": "Curtis", "commenter_lname": "Quinn", "comment_length": 1365}, {"text": "Please see our comments attached. ", "comment_id": "HHS-OS-2019-0008-0012", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0008-0012", "comment_date": "2019-07-08T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-11473", "commenter_fname": "Mark", "commenter_lname": "Leahey", "comment_length": 34}, {"text": "Attached, please find a comment letter from Neuros Medical, Inc. Thank you. ", "comment_id": "HHS-OS-2019-0008-0014", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0008-0014", "comment_date": "2019-07-08T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-11473", "commenter_fname": "Jill", "commenter_lname": "Rathbun", "comment_length": 77}, {"text": "Hello,
I am a trauma surgeon working in two busy level one trauma centers in Florida, Delray Medical center and St. Marys medical center, Florida. As a trauma surgeon I encounter and treat the widest range of all conceivable causes of acute and chronic pain. From the cancer patient that in addition to the chronic pain due to cancer has suffered a traumatic event due to a motor vehicle crash. A gunshot victim that has acute pain due to the devastating injury Which then will be complicated by expected chronic pain. The child that was burned in a family barbecue in over 30% of her body, and many more.
We have great solutions to help manage acute pain but when it comes to chronic / prolonged pain especially in trauma we try to decrease over use of narcotics.
I would like to bring forth to the committee additional modality for pain control that has been overlooked and in my experience has decreased my narcotic outpatient prescription by more than 80%. This Remarkable decrease in the use of narcotics were specifically affective patients that suffered severe traumatic chest wall injury. Cryo-ablation, Nurolysis of intercostal (thoracic) nerves by means of freezing the nerves provides relief from pain from an approximate. 4 to 5 months. This new approach has reduced my dispensing narcotic practice by more than 80%. This is a remarkable amount.
The major impediment to allow even wider use of this technology is directly related to the lack of reimbursement. The side effects is numbness at the injured site for a period of 4 to 5 months followed by recovery of the sensation at the injured site long past the time that the injury required to heal. while obviating the need for narcotics to aid in pain management.
Please consider allowing reimbursements for this procedure that affords a remarkable alternative that proven to be safe.
Thank you,
Nir J. Hus, MD, PhD, FACS.
Trauma Surgery,
General Surgery,
Acute Care Surgery,
Trauma & Surgical Critical Care
Delray Medical Center, Delray FL.
Assistant Professor of Surgery School of Medicine, Florida Atlantic University, FL
DrNirHus@gmail.com", "comment_id": "HHS-OS-2019-0008-0025", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0008-0025", "comment_date": "2019-07-08T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-11473", "commenter_fname": "Nir", "commenter_lname": "Hus", "comment_length": 2191}, {"text": "Dear Dr. Singh:

RE: Docket ID# HHS-OS-2019-0008

Medtronic has been involved in the study and treatment of pain for more than 40 years, and we have a broad portfolio of device-delivered pain therapies, including targeted drug delivery, spinal cord stimulation, and balloon kyphoplasty, which have benefited hundreds of thousands of patients worldwide. These therapies enable healthcare providers to help their patients manage chronic pain and possibly lessen the overall use of oral opioids. Medtronic also leads in the development of technologies used in minimally invasive surgery (MIS), which have been shown to reduce post-surgical pain as well as readmissions, surgical site infections, and lengths of stay.

We commend the Task Force for concluding and publishing their final report of recommendations on Pain Management Best Practices. We appreciate the opportunity to comment on the Task Force recommendations to CMS regarding payment and coverage policies for chronic and acute pain, service delivery models, access to therapies and medical devices, and other issues outlined in section 6032 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act.

Attached letter includes our specific requests and commentary pertaining to Sections 2.1.1, 3.3.2, 3.4.2 and 4 of the Pain Management Best Practices Inter-Agency Task Force Final Report.

Thank you for the opportunity to comment on the Pain Management Task Force Draft Report. If you have questions or need additional information, please contact me.
", "comment_id": "HHS-OS-2019-0008-0008", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0008-0008", "comment_date": "2019-06-25T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-11473", "commenter_fname": "Peter", "commenter_lname": "Horwich", "comment_length": 1627}, {"text": "Please see attached for comments on behalf of Nevro Corp.", "comment_id": "HHS-OS-2019-0008-0011", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0008-0011", "comment_date": "2019-06-25T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-11473", "commenter_fname": "David", "commenter_lname": "Caraway, MD, PhD", "comment_length": 57}, {"text": "See attached file(s)
Medical Clinical Affairs
3M Center
Building 275-4W-02
St Paul, MN 55144
Via Electronic Mail Only

June 26, 2019

U.S. Department of Health and Human Services
Office of the Assistant Secretary for Health
200 Independence Ave., SW
Room 736E
Attn: Alicia Richmond Scott,
Pain Management Best Practices Inter-Agency Task Force Designated Federal Officer
Washington, DC 20201

Re: Meeting of the Pain Management Best Practices Inter-Agency Taskforce

Dear Ms. Scott:

On behalf of 3Ms Health Care Business Group (HCBG), we are writing to provide comments for consideration by the Inter-Agency Task Force as they deliberate and make recommendations related to section 6032 of the SUPPORT for Patients and Communities Act (SUPPORT Act).

3M appreciates the efforts of the Inter-Agency Task Force in hosting a meeting to discuss the issues outlined in section 6032 of the SUPPORT ACT. Section 6032 seeks to address various methods for preventing and addressing opioid addiction including a review of payment and coverage policies to determine whether they have resulted in incentives or disincentives that have contributed to the opioid crisis as well as a review of therapies that manage acute and chronic pain and minimize the risk of opioid misuse and abuse.

The Medical Solutions Division (MSD) of 3Ms HCBG manufactures medical devices and supplies which serve as non-drug, non-opioid topical treatment alternatives for open and damaged skin and wounds. 3M is devoted to assisting in alleviating the opioid epidemic and have recommendations. We would like to address the following issues that are included as part of section 6032 of the SUPPORT Act:

Review of payment and coverage policies that may incent or disincentive use of therapies that manage chronic and acute pain and that minimize opioid abuse and misuse
Other Task Force recommendations
Review of payment and coverage policies that may incent or disincentive use of therapies that manage chronic and acute pain and that minimize opioid abuse and misuse
Skin is one of the most pain-sensing organs. Functional skin integrity is essential to minimizing and preventing acute and chronic pain, which is addressed in all care settings acute, perioperative, post-operative, post-acute, and the community and home setting. Prevention and treatment of open or damaged skin, wounds, or surgical sites to control pain requires awareness and access to non-drug, non-opioid topical alternatives. For this type of alternative, present policies either do not adequately address coverage or payment or are not addressed in the post-acute or home arena.

We recommend that specific devices utilized in the Hospital, Wound Care Clinic or community setting be made readily accessible for take-home patient use when appropriate through Durable Medical Equipment and supply (DME) or other Non-Opioid coverage and payment avenues.
We ask for specific emphasis be placed on reviewing DME policies for consideration of topical non-drug, non-opioid alternatives for the treatment of open and damaged skin, acute and chronic wounds, and infection prevention.
We also recommend that access to these alternatives be considered when the patient is either not eligible for the Home Health benefit or when the benefit has expired.
We ask for consideration to explore a new benefit category for a class of products as an at home topical non-opioid alternative.

Other Task Force recommendations
3M has a long history of providing educational programs aimed at identifying and improving the management of acute and chronic medical conditions. In the area of skin and wounds these include but are not limited to pressure injury, medical-adhesive related skin injury, irritant and moisture - associated dermatitis, and venous and diabetic foot ulcers. In this era of value-based care, 3M is actively engaged in identifying and developing health-economic solutions that may be utilized in all phases of the patient journey.

Conclusion
3M appreciates the opportunity to provide these comments and asks that they be strongly considered by the Inter-Agency Task Force. We look forward to continuing to work with the Task Force and its member agencies on solutions that will help to alleviate and control the acute and chronic pain that is contributing to this nation-wide crisis. Please feel free to contact me should you have any questions at 651-737-8865 or fdhorin@mmm.com.

Respectfully submitted,

Franceen Horin, MBA
US Reimbursement Manager
Medical Clinical Affairs
3M Center
Building 270-4N-04
St. Paul, MN 55144-1000
", "comment_id": "HHS-OS-2019-0008-0019", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0008-0019", "comment_date": "2019-07-08T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-11473", "commenter_fname": "Franceen", "commenter_lname": "Horin", "comment_length": 5094}, {"text": "Please see attached for comments from the American Pharmacists Association. ", "comment_id": "HHS-OS-2019-0008-0004", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2019-0008-0004", "comment_date": "2019-06-24T04:00:00Z", "comment_title": "Comment on FR Doc # 2019-11473", "commenter_fname": "Jenna", "commenter_lname": "Ventresca", "comment_length": 76}]}, {"id": "CDC-2020-0029", "title": "Management of Acute and Chronic Pain: Request for Comment", "context": "2020-10-16T11:48:19Z", "purpose": "Nonrulemaking", "keywords": null, "comments": [{"text": "You absolutely cannot let legitimate pain suffers just continue to suffer in pain. As long as they are not abusing their medicines, they should be allowed to continue pain management for chronic medical condition such as peripheral diabetic neuropathy and other things that are incurable.", "comment_id": "CDC-2020-0029-1966", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0029-1966", "comment_date": "2020-05-12T04:00:00Z", "comment_title": "Comment from (name)", "commenter_fname": "S", "commenter_lname": "W", "comment_length": 289}, {"text": "Re: Centers for Disease Control and Prevention (CDC), Department of Health and Human Services (HHS)
Docket No. CDC-2020-0029

Salutations,

As a practicing pharmacist in the independent community setting, I've watched the country's opioid epidemic spawn and evolve over the last 10+ years. My state has learned to be very diligent about the documentation and cross-referencing of CII opioid prescriptions; no longer is it common to see patients looking to fill scripts for unusually-large monthly supplies of opioids from a prescriber practicing on the other side of the state. Rather, now the common occurrence is a significant number patients who are asked to jump through hoops in order to treat legitimate pain.

This sudden shift has proved detrimental for both patients dealing with chronic pain and patients dealing with addiction. Fentanyl has ravaged my state under the guise of heroin and it's extremely troubling to see the aftermath entailed. Prescriber's shouldn't have to deny care to patients because of a fear about what could happen to their license. The de-prescribing measures taken over the last few years are very effective and should remain in place to curb access of these drugs to individuals for whom they're not intended. However, a concerted effort must be made to ensure those who need them aren't suffering the collateral damage. Me must ensure that patients with qualifying past medical histories have access to these drugs and affordable addiction rehabilitation must be available for those who need it or would otherwise end up looking for street alternatives in the form of heroin.

Lastly, we need to spearhead robust research into potential alternatives for chronic pain management as well as that for treating those with opioid use disorders. Substances with well-known anecdotal evidence suggesting potential use for the treatment of patients with OUD, such as mitragyine or kratom, must be studied and understood. Prohibition has rarely proved to itself as an effective solution; addressing the lack of access to adequate mental healthcare should be a top priority in addition to providing healthcare professionals with the resources and the approval in order to provide their highest level of patient care. ", "comment_id": "CDC-2020-0029-1967", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0029-1967", "comment_date": "2020-05-12T04:00:00Z", "comment_title": "Comment from (name)", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 2312}, {"text": "As a natural healthcare doctor (chiropractor) I see many people with long term chronic pain issues. And, though my patients get significant relief with chiropractic care they need safe alternatives to turn to when pain strikes and chiropractic is not enough. One of those safe alternatives is Kratom. A plant based medicine that has been used for hundreds, possibly thousands of years. Considering millions of people have taken this medicine for many years with little to no bad side effects is a testament to its safety and effectiveness. Of course, the pharmaceutical industry would like to eliminate this safe alternative to deadly opiates because of the profit motive. People are more important than drug companies making profit at the expense of human lives. Do the right thing and consider the centuries of safe use of Kratom for pain relief. ", "comment_id": "CDC-2020-0029-1973", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0029-1973", "comment_date": "2020-05-12T04:00:00Z", "comment_title": "Comment from (name)", "commenter_fname": "Bruce", "commenter_lname": "King", "comment_length": 849}, {"text": " I am a retired 65 year old male. Due to several muscular/skeletal birth defects and long term wear I developed disabling spine and joint pain about 8 years ago. To date I have had 6 orthopedic surgeries. During these years I have used oxycodone acetaminophen for pain control. Oxycodone dosage has been up and down during these years. I have definitely felt the negative side effects of opiates such as irritability, increased tolerance, insomnia, and constipation. Until I retired 5 years ago, oxycodone was my only pain control medicine. After I retired, I was free from random drug testing by my employer and I started using marijuana in conjunction with oxycodone, eventually with my doctors knowledge. Upon having daily regular doses of marijuana I was able to substantially reduce the oxycodone dosage. There was a period were I stopped using oxycodone completely. Now, I use marijuana daily in conjunction with low 2.5mg doses (20mg/day) oxycodone. I realized the pain control was due to the combination of marijuana and opiate as soon as I began using marijuana regularly. Scientific publications have shown this effect. One in particular duplicated my 2.5mg oxycodone dose (1).
I am now a strong advocate for marijuana legalization and participate in state, local, and federal lobbying efforts. We need changes to federal marijuana laws and removal of marijuana from the Federal Controlled Substances List so that people like me can have access to safe, regulated, high quality marijuana to reduce or stop their opiate use.

(1) Cooper, Z.D., Bedi, G., Ramesh, D. et al. Impact of co-administration of oxycodone and smoked cannabis on analgesia and abuse liability. Neuropsychopharmacol 43, 2046-2055 (2018). https://doi.org/10.1038/s41386-018-0011-2", "comment_id": "CDC-2020-0029-1976", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0029-1976", "comment_date": "2020-05-12T04:00:00Z", "comment_title": "Comment from (name)", "commenter_fname": "Roger", "commenter_lname": "Sillmon", "comment_length": 1780}, {"text": "Today again I'm thinking about what's to come in heath care involving chronic pain control
At 70 years old my body's is becoming more crippled. Changes are needed, I fear that at my age I already cannot control pain levels, sleep is becoming a huge issue. I pray that these rules involving treatment will change very soon
.My doctor's are clearly not willing to treat this issue even knowing I need there help.In past year's they have prescribed narcotic pain medicines for flares or injurys from my condition. I cannot submit to any more back surgery, clearly there's nothing to be gained anymore. I do try everything else like a gym membership which I am using less now. Change is to slow in coming if at all to help me. Now with nerve pain setting into my feet its becoming hard to even walk. I'm confined to my bedroom most of the time,the less active I am the more disabled I become.", "comment_id": "CDC-2020-0029-1975", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0029-1975", "comment_date": "2020-05-12T04:00:00Z", "comment_title": "Comment from (name)", "commenter_fname": "Roger", "commenter_lname": "Holland", "comment_length": 927}, {"text": "As a firefighter and EMT for over 20 years Ive seen the worst of this epidemic. I have also seen a lot of people that are good people have to suffer due to regulations and blanket approaches. There are a lot of people that have died due to over prescribing and abuse of narcotics. The flip side is there are a lot of people dying due to suicide because they dont want to live with the chronic pain. There are also a lot of people dealing with injuries who are too afraid to see out surgery knowing the pain meds prescribed wont cope with the pain post operation. Please realize you dont have to blanket approach this. There are solutions to stop the epidemic but also allow those that need these meds to have access to them.

Thank you", "comment_id": "CDC-2020-0029-2029", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0029-2029", "comment_date": "2020-05-13T04:00:00Z", "comment_title": "Comment from (name)", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 744}, {"text": "Most of my pain,depression, and stress comes from Military service. While managed with medication, and consultation most frustrations comes from discrimination, and poor management. These factors increase suicidal thoughts and low interest in achieving daily tasks.

Its frustrating that mental health is not being addressed to a more legal and constitutional basis
", "comment_id": "CDC-2020-0029-2628", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0029-2628", "comment_date": "2020-06-02T04:00:00Z", "comment_title": "Comment from (name)", "commenter_fname": "Pablo", "commenter_lname": "Sanchez", "comment_length": 379}, {"text": "I have had diabetic neuropathy for over 13 years, to the point of tears. It is very uncomfortable to have a normal daily life. I was prescribed Cymbalta, when my symptoms were mild. Later another doctor prescribed Hydrocodone 5's, as my pain worsened. I was moved up to higher mg doses(10, 15,to 30. I was finally tested by a neurologist, and we decided methadone 10mg were the best option for me, because they ease my pain throughout the day. I feel like my life can have some sense of normalcy. Currently, I do not want surgery to kill the nerves, in my feet,so I am satisfied with taking medication. I wish I did not have to rely on these pills, but I do. I take them, as prescribed, proven by my tests each visit. I do not like people thinking everyone taking narcotic pain medication, is an addict, because I am not addicted", "comment_id": "CDC-2020-0029-2581", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0029-2581", "comment_date": "2020-06-02T04:00:00Z", "comment_title": "Comment from (name)", "commenter_fname": "lester", "commenter_lname": "wilson", "comment_length": 833}, {"text": "TO: CDC

I suffer from bad knees. I know this is not unusual as many have this problem. My situation is different as I have Multiple Myeloma which is bone marrow cancer. Surgery to correct my problem is very iffy as bone surgery and bone marrow cancer are incompatible and if done the bones take an extremely long time to heal if they heal at all.

I have tried Pain Management (PM) three times with no success. The FIRST time I tried PM they said they could not help. The SECOND time I tried PM they did a nerve block with no success. Since the block failed, I was told nothing else could be done. The THIRD time I tried PM, I was told they do not treat knee problems. I believe PM is only for a select few. They cannot treat pain if it is a bone on bone, but they do not inform you of this.

I took an Opioid based drug for a year. I could not take 3 a day as recommended as it would make me itch all over. I took only one in the morning to take the edge off my pain when I got out of bed. From what I can determine all narcotic drugs make me itch. However, while in rehab for orthoscopic surgery on my knee they would give patients 4 mg of Hydromorphone prior to physical therapy. This is when I realized I could take it if I limited it to one a day and occasionally two if necessary.

My Doctor claimed he could no longer give me a months supply. A months supply was 3 per day for 30 days. A month supply would last three months since I took only one per day. I do not know if a Maryland State law was passed or if Priva Health (a physician health management program) is the problem. I know Priva Health kicks back money to the Doctor, but I'm not sure under what circumstances. I imagine the less he provides, the more money he makes.

At any rate, I have to take over the counter pain medication that will destroy my kidneys and they are slowly failing. One of the problems with my particular cancer, it too destroys kidneys. The combination of the two will accelerate their demise.

RLR", "comment_id": "CDC-2020-0029-2588", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0029-2588", "comment_date": "2020-06-02T04:00:00Z", "comment_title": "Comment from (name)", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 2069}, {"text": "I’ve been dealing with chronic pain for over nine years with multiple congenital spine issues that led to a neurological pain disorder called, central pain syndrome, leaving me in 24/7 moderate to severe pain. It took me 2 1/2 years of pushing for help, seven specialists to get a dx and appropriate treatment. I wanted to go back to my career! I had to put up with abuse by healthcare workers being blown off, ignored, belittled, demeaned, actually physically abused by behaviors such as of pulling a tray table away when my arms are resting on them, yes but why I was still wearing a neck brace, (my surgeon prescribed it for 12 weeks). I was being told how I feel and not being listened to, being yelled at when I asked, after 2.5 years Of doing exactly as I was told to for something stronger because i was suffering in pain all the time, which often involved being curled up in a ball, Teeth chattering and having a hard time to breathe. Miss treatment also included seeing a pain psychologist who mocked me because I said it was too hard getting into his anti gravity recliner because it required putting all my weight into both arms to do so. He told me, “nobody else has ever complained about it”, among other demeaning comments. I had 2 cervical spine surgeries That led to cervical spine and nerve damage as well as later found damage to my spinal cord. Ever since the CDC recommendations I have petrified of having my medications taken away yes I was told that is now what is recommended. It didn’t matter all I went through to get the help I needed to be able to do basic things such as not being curled up in bed, breathing, being able to eat, stand, carry on a conversation, etc because of pain. If you were into Chronic pain groups on social media you would see the suffering. There are not many comments on this that you were asking for because chronic pain people are a group of people who struggle With no just Pain, we struggle with just doing simple daily activities and having to write something, if one even hears about it, is very hard to do. So I don’t just listen to those that have taken the time to write, go look in these pain groups and read about the suffering there’s thousands and thousands of them. I still put up with attitudes from medical assistance and nurses at my doctors office. I have them documented. I’m afraid to say anything because I’m afraid to lose my compassionate doctor. And if I lost him what I find another who would be willing to prescribe me what is now a 10th of what I was taking that was recommended by the University of Michigan for my diagnoses. I can’t write anymore now central nervous system becomes overstimulated and I get nauseous when I try to do too much.", "comment_id": "CDC-2020-0029-2592", "comment_url": "https://api.regulations.gov/v4/comments/CDC-2020-0029-2592", "comment_date": "2020-06-02T04:00:00Z", "comment_title": "Comment from Kay, Sheri", "commenter_fname": "Sheri", "commenter_lname": "Kay", "comment_length": 2778}]}, {"id": "DEA-2023-0028", "title": "Expansion of Induction of Buprenorphine via Telemedicine Encounter (DEA948)", "context": "2023-07-27T17:37:58Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "See attached file(s)", "comment_id": "DEA-2023-0028-2732", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2023-0028-2732", "comment_date": "2023-03-31T04:00:00Z", "comment_title": "Comment on FR Doc # 2023-04217", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "DEA-2023-0028-2708", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2023-0028-2708", "comment_date": "2023-03-31T04:00:00Z", "comment_title": "Comment on FR Doc # 2023-04217", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "DEA-2023-0028-2727", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2023-0028-2727", "comment_date": "2023-03-31T04:00:00Z", "comment_title": "Comment on FR Doc # 2023-04217", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "DEA-2023-0028-2703", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2023-0028-2703", "comment_date": "2023-03-31T04:00:00Z", "comment_title": "Comment on FR Doc # 2023-04217", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attached file(s)", "comment_id": "DEA-2023-0028-2731", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2023-0028-2731", "comment_date": "2023-03-31T04:00:00Z", "comment_title": "Comment on FR Doc # 2023-04217", "commenter_fname": "Caden", "commenter_lname": "Owens", "comment_length": 20}, {"text": "The Blue Cross Blue Shield Association (BCBSA) appreciates the opportunity to respond to the Drug Enforcement Administration’s (DEA) request for comments on its Notice of Proposed Rulemaking (NPRM) on Expansion of Induction of Buprenorphine via Telemedicine Encounter (88 FR 12890).
BCBSA is a national federation of 34 independent, community-based and locally operated Blue Cross and Blue Shield (BCBS) companies (Plans) that collectively provide health care coverage for one in three Americans. For more than 90 years, BCBS Plans have offered quality health care coverage in all markets across America – serving those who purchase coverage on their own as well as those who obtain coverage through an employer, Medicare and Medicaid.

BCBS companies are committed to addressing the opioid crisis and ensuring that everyone impacted by the opioid crisis receives the right care in the right setting and has access to evidenced-based treatment. BCBS companies continue to work with medical professionals, pharmacists, elected leaders and community organizations to reduce improper opioid use and provide resources, clinical expertise and other insights to address the crisis. These efforts are critical to building and maintaining a robust opioid use disorder (OUD) treatment system that ensures widespread access to treatment.
BCBSA continues to encourage wide promotion of medication-assisted treatment (MAT) as the standard of care for OUD, recognizing that the National Institutes of Health have indicated that MAT has the highest probability of providing effective treatment for OUD when prescribed and monitored safely. As the DEA notes, when prescribed and monitored safely, MAT medications are considered effective in treating OUD, and have been found to have no adverse effects on a patient’s mental capacity, physical functioning or employability. Yet, despite the overwhelming evidence of buprenorphine’s effectiveness for treating OUD, it remains highly underutilized. Only 18% of individuals with an OUD receive MAT, and many receive no treatment at all.

One driver of the somewhat limited uptake is the significant shortage of providers prescribing MAT in many communities, particularly in rural and other underserved areas. On top of the workforce issues challenging primary and mental health care, only a limited number of providers are trained in best practices for OUD treatment, including MAT, and are actively treating the condition. This is demonstrated by the reality that as of 2020, 40% of U.S. counties lacked a single provider that could prescribe buprenorphine for OUD in an office setting.

For individuals currently receiving MAT, this treatment is a key component to maintaining recovery and functioning. If they lose access to this treatment and their recovery is compromised, they may be at risk of losing a job or other serious consequences that could heavily impact their lives and their families.

We applaud the removal of the outdated federal rules that prevented health care providers from prescribing buprenorphine (known as the “X-waiver”), as part of the 2023 appropriations package. This change allows additional health care providers to prescribe MAT for OUD, and further expands patient access to OUD treatment. However, this NPRM undermines that progress by increasing barriers to MAT. We urge the DEA to build the work of Congress in supporting more robust access to MAT for patients with OUD. To that end, we have several recommended modifications to the DEA’s proposed rule, detailed in our attached comment letter.
", "comment_id": "DEA-2023-0028-2714", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2023-0028-2714", "comment_date": "2023-03-31T04:00:00Z", "comment_title": "Comment on FR Doc # 2023-04217", "commenter_fname": null, "commenter_lname": null, "comment_length": 3660}, {"text": "As a telemedicine OUD provider, I strongly oppose the DEA's proposal to require an in-person visit for buprenorphine prescription. This is a high-barrier imposition in an era when primary care is increasingly hard to find. There is a complete lack of evidence for in-person visits improving patient outcomes or preventing diversion. This rule will do an immense amount of harm for patients who are most vulnerable as those are the patients who are least able to complete this unneeded task. ", "comment_id": "DEA-2023-0028-2693", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2023-0028-2693", "comment_date": "2023-03-31T04:00:00Z", "comment_title": "Comment on FR Doc # 2023-04217", "commenter_fname": "J", "commenter_lname": "Craig", "comment_length": 495}, {"text": "Bicycle Health has changed my life. I abused pain pills since I was 16 yrs old due to a dysfunctional home environment. I am now 38 years old with a 6 yr old autistic son. During Covid and due to my sond behavior I couldn't take the stress and emotional pain anymore and had no where to turn. I started taking Norcos again to help me cope, well sooner than later I needed more and more and it was killing my budget. Mind you all of my immediate family has passed away except for my 67 yr old mother who is not equipped to take my son for me. I cried out to God what do I do!??? I don't want to be on pain pills and I have no way to rehab because no one can take my son (he is nonverbal and I'm a single mom) Bicycle Health Team saved my life. I was able to communicate and get help via video and get kind and compassionate help. Please do not enforce a rule or law that would cost so many their lives. ", "comment_id": "DEA-2023-0028-2696", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2023-0028-2696", "comment_date": "2023-03-31T04:00:00Z", "comment_title": "Comment on FR Doc # 2023-04217", "commenter_fname": "Rebecca", "commenter_lname": "Devilbiss", "comment_length": 914}, {"text": "With a medication like buprenorphine, access should be limited as little as possible. Because of the unprecedented rise in opioid related overdoses, drug users should have as much access to regulated safer options like buprenorphine at all times. One should not need a prescription to access this medication. Its not unreasonable for distribution to be monitored, however, especially when considering the ultra-potent opioids that currently keep the illicit market afloat, excessive purchasing of buprenorphine might not indicate illicit redistribution; but the necessary regimen for someone with OUD and an unreasonably high tolerance to live unimpaired. One might argue that increasing access to this extent would increase use among individuals who arent dealing with OUD, however, even in the case that someone who hasnt previously used opioids becomes dependent on buprenorphine, it is a far safer alternative to opioids available from the illicit market. That is ignoring the fact that in many areas, opioids are already available over the counter; like loperamide and tianeptine. Opioids are already readily available to people who dont have a prescription (or a reason to have one), thus more ready access to a reasonably potent opioid like buprenorphine would only serve as a means of harm reduction; allowing anybody who wishes to use an opioid for whatever reason, to do so with a safe, reliable product that is produced within legal regulations, it would slow down the production of novel synthetic opioids created to replace holes in the illicit market, due to a lower demand because of safer access. there are far more benefits to having a legal, easily obtainable substance than one that is prohibited. Looking at alcohol, the situation is almost entirely identical. During prohibition, the purchase of alcohol was made more dangerous because users had to participate in an unregulated market, alcohol that was available was often produced under poor/no regulations and often contained harmful substances like methanol which would result in a deadlier product for users. People can drink themselves to death; and will, whether alcohol is legal, or illegal. The same situation exists with a drug like heroin. People have used opioids for thousands of years, and according to statistics, will continue to do so despite prohibition. If heroin is illegal, the product on the market will be tainted and more dangerous; causing more deaths by overdose. If heroin is legal, the dea can regulate the production of the drug and make sure anyone who uses it is doing so in a far safer environment with a far safer product. legalize and regulate drugs. drug prohibition was created with racist intent and kills people. bye", "comment_id": "DEA-2023-0028-2697", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2023-0028-2697", "comment_date": "2023-03-31T04:00:00Z", "comment_title": "Comment on FR Doc # 2023-04217", "commenter_fname": "Patrick", "commenter_lname": "Blount", "comment_length": 2725}, {"text": "In reference to Docket No. DEA-948, please do not restrict access to treatment for opioid use disorder. Peoples lives depend on this assistance. Thank you!", "comment_id": "DEA-2023-0028-2701", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2023-0028-2701", "comment_date": "2023-03-31T04:00:00Z", "comment_title": "Comment on FR Doc # 2023-04217", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 155}]}, {"id": "FDA-2022-N-2673", "title": "Safety and effectiveness of certain naloxone hydrochloride drug products for nonprescription use; Request for Comments", "context": "2023-01-20T13:40:36Z", "purpose": "Nonrulemaking", "keywords": ["Safety and effectiveness of certain naloxone", "hydrochloride drug products for nonprescription", "Request for Comments", "CDER", "FRDTS 2022-446", "OPEN"], "comments": [{"text": "As a licensed HCP I support that all naloxone products should be moved from prescription to OCT status. The FDA choosing not to evaluate all products (even the 8 mg intranasal product KLOXDXADO and the 5 mg ZIMHI) to OTC is beyond perplexing.

Move naloxone to OTC NOW! ", "comment_id": "FDA-2022-N-2673-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2673-0003", "comment_date": "2022-11-17T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 279}, {"text": "Komen", "comment_id": "FDA-2022-N-2673-0002", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2673-0002", "comment_date": "2022-11-17T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 5}, {"text": "I am writing to submit my support for nonprescription/over-the-counter access to naloxone formulations across the United States. I am a PhD health researcher whose dissertation focus was on opioid use disorder and harm reduction. Naloxone saves lives, it is as simple as that. Increasing access to naloxone can help reduce overdoses and overdose deaths. Naloxone cannot be used recreationally, and there has been no scientific evidence of significant harm related to naloxone administration that outweighs the risks of opioid overdose. ", "comment_id": "FDA-2022-N-2673-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2673-0004", "comment_date": "2022-11-17T05:00:00Z", "comment_title": "Comment from Maria Bolshakova", "commenter_fname": null, "commenter_lname": null, "comment_length": 536}, {"text": "ZIMHI is an amazing product! ", "comment_id": "FDA-2022-N-2673-0071", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2673-0071", "comment_date": "2022-12-22T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 29}, {"text": "Please allow naloxone to be distributed over the counter! In fact, if there is a way to have it available OTC for free - that would be the best harm reduction our country could provide to our citizens. It is a public health mechanism to save lives. My clinical practice is treating substance use disorders and I get out all the narcan I have. It is the best way to reverse an overdose and it needs to be readily available to everyone.", "comment_id": "FDA-2022-N-2673-0066", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2673-0066", "comment_date": "2022-12-20T05:00:00Z", "comment_title": "Comment from Kathy Nevins", "commenter_fname": null, "commenter_lname": null, "comment_length": 434}, {"text": "See attached file(s)", "comment_id": "FDA-2022-N-2673-0070", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2673-0070", "comment_date": "2022-12-22T05:00:00Z", "comment_title": "Comment from American Society of Anesthesiologists", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "We have decades of experience showing that laypeople with minimal training can successfully use naloxone to save lives. FDA desperately needs to make naloxone available over-the-counter in order to eliminate the myriad bureaucratic barriers that stem from its current status as a prescription-only product. While recent efforts, like the clarification related to the DSCSA, have gone a long way toward making naloxone easier to procure by harm reduction programs, they do not get rid of all hurdles. Additionally, making naloxone OTC would help protect end users who are sometimes harassed by police for having a prescription-only medicine. While I welcome FDA’s initiative to encourage sponsors to apply for OTC status for certain formulations and dose strengths, FDA’s preliminary assessment unfortunately leaves out the products with the longest track record of community use – 0.4 mg/mL intramuscular naloxone. The evidence of success of community naloxone programs is largely built upon the long use of IM product by lay bystanders. These decades of experience show that it is appropriate and safe for community use – especially by people who use drugs who are most often the frontline responders. This product is truly the backbone of the harm reduction naloxone response. And importantly, it is much more affordable than intranasal and autoinjector products. FDA should go further than simply encouraging companies to apply for OTC status for certain IN and autoinjector products. The agency should itself initiate an OTC switch for the widely used IM formulation. Not doing so risks giving the appearance that this critically important formulation is a second-tier product, which will have real implications for the harm reduction programs that rely on it, and for the people who use it.", "comment_id": "FDA-2022-N-2673-0067", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2673-0067", "comment_date": "2022-12-20T05:00:00Z", "comment_title": "Comment from Roxanne Saucier", "commenter_fname": null, "commenter_lname": null, "comment_length": 1819}, {"text": "As a public health nurse, I strongly support the availability of over-the-counter naloxone. Naloxone is a life-saving medication that is safe and effective for the reversal of opioid overdose. In fact, naloxone is far safer than many currently available over-the-counter products. Many states allow widespread dispensing of naloxone, which has been shown to be a public health benefit.

With increased access, the public would also benefit from widespread education campaigns that explain the signs of opioid overdose, how to respond, and how to access effective treatments for opioid use disorder (of which the gold standard is opioid agonist medications).
OTC naloxone may have the added benefit of normalizing carrying naloxone and destigmatizing the use of opioids. While much more is needed to destigmatize drug use and addiction, OTC naloxone would be a small step in this direction.
", "comment_id": "FDA-2022-N-2673-0075", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2673-0075", "comment_date": "2022-12-29T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 907}, {"text": "With the increase of synthetic fentanyl and opioid-related deaths across the country, expanding access and eliminating barriers to Narcan is pertinent. I work in patient access in the pharmaceutical industry for an unaffiliated company. I have no ties to this legislation or companies involved other then I’m the daughter of a recovering addict. I found my dad cold and blue, from an opioid-overdose. I called 911 and when the paramedics used 4 cans of Naloxone to save his life that night. The paramedics said if they would’ve arrived 15 seconds later, he would’ve died. My dad has overdosed multiple times but this was the closest call and it was directly in front of me. Had I had access to Narcan OTC, I would’ve administered it myself waiting for the paramedics to arrive. A friend lost her boyfriend to an accidental overdose due to synthetic fentanyl being laced. She to found him cold and blue, administered CPR, the paramedics used multiple cans of Narcan and could not revive him. It was simply too late and the fentanyl was too strong. Another family member overdosed on thanksgiving, his friend had a prescription for Narcan, and administered narcan and saved him on the driveway. I then submitted documents to get him baker acted and on the road to recovery. Addicts do recover, they just need the opportunity to do so and having Naloxone OTC without a prescription provides that opportunity. The proposed switch will expand consumer access and save lives. Personally, I would always keep Narcan in my purse in case anyone needs me to administer it. Increased access to Naloxone is vital to the public. ", "comment_id": "FDA-2022-N-2673-0077", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2673-0077", "comment_date": "2023-01-04T05:00:00Z", "comment_title": "Comment from Savannah Simbulan", "commenter_fname": null, "commenter_lname": null, "comment_length": 1641}, {"text": "I support over-the-counter availability of naloxone due to the overwhelming likelihood that the people responding to an overdose will not have had the ability to obtain a prescription. A lifesaving, time-sensitive drug should not be gated behind a doctor’s prescription, particularly when the people most likely to use it will be recalcitrant to openly admit they are users of illegal drugs. ", "comment_id": "FDA-2022-N-2673-0100", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2022-N-2673-0100", "comment_date": "2023-01-13T05:00:00Z", "comment_title": "Comment from Sam Gross", "commenter_fname": null, "commenter_lname": null, "comment_length": 398}]}, {"id": "FDA-2017-P-1911", "title": "Request that the FDA ensure follow on products citing BUTRANS as the reference listed drug are as safe and effective as BUTRANS. CLOSED", "context": "2017-07-21T12:33:01Z", "purpose": "Nonrulemaking", "keywords": ["Citizen Petition", "CDER", "Kleinfeld Kaplan & Becker, LLP", "BUTRANS", "buprenorphine", "reference listed drug", "Purdue Pharma L. P.", "CLOSED"], "comments": [{"text": "This war on "opioids" is actually a war on chronic incurable diseases. A war on chronic pain disease patients who benefit from opioid medications. Medications that enable millions of Americans relief of chronic debilitating pain associated with these diseases.
The fiction, widespread hysteria and distorted truths about this "opioid epidemic", is killing legitimate chronic pain disease patients who use their medications responsibly. We are patients.
100 million Americans have one or more chronic incurable pain Diseases. As the CDC, DEA, FDA, Medicaid and Medicare, and numerous other government agencies, are blaming Doctors for the over prescribing of opioid medication. NOBODY, is looking at or reading the statistics from chronic pain disease patients. How about NOT addressing these drugs as dangerous and addictive. When all else fails: physical therapy, exercise, over the counter medications and numerous injections etc, we chronic pain disease patients, are left with one option to help us cope, opioid pain medication. Lets address this medication as lifesaving and medically necessary for the million of Americans with chronic diseases. Chronic pain is a disease. Chronic pain disease patients are now the epidemic. The addiction rate of chronic pain disease patients is .02-.6 %. We do not misuse or abuse our medications.
No other disease medication is scrutinized. We, as patients, are being denied, dismissed, overlooked and discriminated against, by our physicians, due to all the scrutiny associated with treating chronic pain disease with opioid medications. Our Dr's are afraid to treat us humanely, ethically and adequately. We have a disease that medication is readily accessible and beneficial to us and we are being denied. We, pain patients, are being discriminated against, due to people who abuse illegal heroin and illegal fentanyl. This is a direct hunt for Doctors who prescribe life saving medication, for pain disease patients, that benefit from them. We have our privacy invaded, we no longer are able to have doctor/patient confidentiality. We now have insurance agencies, pharmacists, and other government agencies in our physicians offices, monitoring, prosecuting and policing our physicians.
Though the statistics show a reduction in, opioid medications distributed, due to the CDC guidelines, death rates of overdoses from illegal opioids is rising.
The specific causes of deaths also needs to be closely investigated. The opioid in the person's system needs to be specified. Was it an illegal opioid, was it opioid medication specifically for that person, was there other drugs or alcohol involved? These statistics need to come out. These Government agencies do not want that information out, due to the fact that this "opioid epidemic", would then be debunked.
Let's put the shoe on the other foot. Restricting or taking away our medications is like FORCING people who do not want this medication to take it. One day those against these medications will need them but they will be denied.
We have a chronic disease. We want to be able to take care of our homes, our children, our selves, as much as possible. Without access to these life saving medications, we are unable to do so. We want to live, not just exist in pain 24/7.
We need the government agencies to look at the real statistics, not the hand picked. These agencies are not physicians. They are trying to doctor us, patients, without a medical license. They are also trying to police our physicians. This is a war on a disease, medications, physicians and patients.
We, chronic pain disease patients, need help. All the headlines, topics and stories on how opioids are bad and how people are abusing, misusing, overdosing, becoming addicted or dying from them. We need to look at the good they do and how they help our disease of chronic pain and the million of Americans who use them for some relief.
The government needs to put the focus on illegal drugs coming into, being manufactured and distributed in this country, illegal fentanyl, illegal heroin, methamphetamine, cocaine and all other ILLEGAL DRUGS. Not the legally prescribed and medically necessary medications we patients need. We chronic pain disease patients need help, but we are helpless due to the government and government agencies. There is stigma, scrutiny and discrimination against us due to a category of medications we desperately need and benefit from, opioid medications.
WE ARE PATIENTS NOT ADDICTS! !", "comment_id": "FDA-2017-P-1911-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-1911-0004", "comment_date": "2017-07-21T04:00:00Z", "comment_title": "Comment from Candi Simonis", "commenter_fname": null, "commenter_lname": null, "comment_length": 4632}]}, {"id": "FDA-2017-N-4515", "title": "International Drug Scheduling; Convention on Psychotropic Substances; Single Convention on Narcotic Drugs; Ocfentanil, Carfentanil, Pregabalin, Tramadol, Cannabidiol, Ketamine, and Eleven Other Substances; Request for Comments", "context": "2017-12-21T14:08:00Z", "purpose": "Nonrulemaking", "keywords": ["International Drug Scheduling", "Convention on Psychotropic Substances", "Single Convention on Narcotic Drugs", "Ocfentanil, Carfentanil, Pregabalin, Tramadol,", "Cannabidiol, Ketamine, and Eleven Other", "Substances", "Request for Comments", "OPEN"], "comments": [{"text": "Cannabidiol most definitely has medical value and does not belong in schedule I in relation to the Controlled Substances Act.
This should be already known by the Department of Health and Human Services, but I will list it here anyway.
The Department of Health and Human Services has held a patent on the medical value of cannabinoids since 2003
(patent number 6630507) for their value as neuroprotectants. I will attach the abstract of 6630507, but it states specifically
that CBD is beneficial because it avoids toxicity. CBD alone does help alieve a degree of inflammation and pain.
Cannabis in its entirety with its entourage effect involving all terpenes, all cannabinoids, and all other compounds working in
synergy are what would be most beneficial to patients suffering with conditions that are not presently treatable with modern
options in medicine. The modern world is recognizing the benefits of the cannabis plants and its components.
As a patient, I can testify to the fact that both cannabidiol on its own, and the cannabis plant in its many forms has helped to
relieve a great degree of my pain at times when I believed that I would no longer be able to survive, and when nothing else
would work. Allopathic medicine is not always the answer. I am thankful to the FDA for awakening to the benefits of CBD
and for acknowledging the scientific evidence that is being presented the world over.

CBD has also been shown to improve cognition in multiple studies of impairment. Dr. Mechoulam is a researcher in Israel who has
been conducting US research on cannabis since 1964. That is the year he began receiving $100,000 per year from the US
National Institutes of Health to begin researching the effects of cannabis and to determine medical benefits or effects.
He received $100k per annum until 2010, and concluded long ago that there were medical benefits.

In an interview that appeared in Newsweek, Mechoulam stated, "Having seen the clear medical benefits of cannabis over
more than 50 years of research, he is baffled that there's still reluctance to embrace marijuana as medicine. "We believe
modern science is going ahead, right?" he asks. "Well, it's not. When insulin was discovered in the 1920s, it became a
drug in months. Cortisone was discovered in the late 1940s, and it was made into a drug a year or two later.
Anandamide was discovered 23 years ago and has still never been administered to a human being.
I'm not sure that's progress." Anandamide is a different cannabinoid other than CBD, but he has also researched CBD.

CBDforDiabetes Mechoulam has been testing CBD on mice bred to have a version of type1 diabetes that manifests around
age 14 weeks. He and his co-workers treated these mice with CBD for their first 6-7 weeks of life, then tested them 6-7 weeks
later and found that only 30% had developed diabetes (compared to 90-100% given placebo). CBD did not just prevent
onset but blocked development of diabetes. In a follow-up experiment the mice weren't given a course of CBD until age
14 weeks, when they were developing diabetes. They were then tested at age 24 weeks, and again only 30% of the treated
mice were found to have diabetes. In other words, CBD did not just prevent onset but blocked development of diabetes.
Examination of the insulin-producing islets showed that only 8% were intact in the untreated diabetic mice, whereas 77%
were intact in the mice treated with CBD. "I believe that here we have something very promising," Mechoulam said.
"We plan to have a clinical trial starting next week treating patients, and hopefully at the next meeting I will tell you that all
of them are cured." "Let'shavesomemoreCBD" Cardiologists working with mice at Hebrew University have found that
CBD treatment at the time of a heart attack can reduce infarct size by about 66%.

I am not going to list all of the wonderful things that CBD and THC do. I will say that they act as balancing agents to one
another.

MY FINAL SUMMARY IS TO DESCHEDULE CBD AND KEEP IT DESCHEDULED FROM THE CSA. I BELIEVE THAT ALL
CANNABINOIDS SHOULD REMAIN DESCHEDULED (THE NATURALLY OCCURING CANNABINOIDS).

ALSO TRAMADOL, KETAMINE, AND PREGABLIN SHOULD NOT BE SCHEDULED SUBSTANCES.

SCHEDULING OF ANY OF THE SUBSTANCES I LISTED MAKE IT HARDER ON PATIENTS THAT ARE ALREADY SUFFERING
TO OBTAIN THE MEDICATIONS THEY MUCH NEED TO BE ABLE TO OBTAIN A BETTER QUALITY OF LIFE.

PLEASE READ THE ATTACHMENTS AS SUPPORTING DOCUMENTATION. PLEASE RELY ON SCIENTIFIC DATA. PLEASE
LISTEN TO THE PEOPLE. PLEASE RELY ON CURRENT DATA!!! THANK YOU FOR THE OPPORTUNITY TO PROVIDE
MY INPUT.
", "comment_id": "FDA-2017-N-4515-0436", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-4515-0436", "comment_date": "2017-08-18T04:00:00Z", "comment_title": "Comment from John Fouts", "commenter_fname": null, "commenter_lname": null, "comment_length": 4941}, {"text": "I am a board certified physician and have researched the endocannabinoid system extensively for the past 6 years. Even though there is a plethora of evidence in the literature supporting Cannabidiol (CBD) to be an effective treatment for certain medical conditions, I do not see any benefit of legalizing this particular compound alone, as it is only beneficial in the environment of of the other cannabinoids, yielding the so called "entourage effect". This basically means that the therapeutic effects of the whole plant are much greater than the sum of its parts. CBD requires other cannabinoids to be effective. Alone, marketed mostly in high doses, will cause a down regulation of CB2 receptors. We know that the Department of Health and Human Services owns patent 6630507, which explains how both, CBD AND THC are neuroprotective. Downregulation of CB2 hence is doing more harm than good. CBD has a very narrow therapeutic window. CBD is a weak agonist on CB2 receptors. THC is required for this. In order to understand the medicinal values of Cannabis, we need to start from the beginning.

1. Is the whole plant with THC really dangerous? Let's look at the science.
2. What does the National Institute of Drug abuse say?
3. Why is the federal government funding cannabis research in Israel?
4. Who is Dr. Nora Volkow really and what does she (as the head of NIDA) say about this?
5. What evidence does the federal government present about the dangers of THC?
6. What evidence is there from other institutions?

All of these questions will be answered. Please read the attached document.
You can also find it at http://drbogner.com/nih-blowing-smoke-medical-cannabis/.

Please examine the following carefully, and consider legalizing the whole plant.

Sincerely,

Dr. Christian Bogner, MD, FACOG
Advanced Microglial and Cannabinoid Signaling Research
Plant-Based Nutrition,
Cornell University
www.drbogner.com

", "comment_id": "FDA-2017-N-4515-1063", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-4515-1063", "comment_date": "2017-08-18T04:00:00Z", "comment_title": "Comment from Christian Bogner", "commenter_fname": null, "commenter_lname": null, "comment_length": 2024}, {"text": "Food and Drug Administration HHS,

Please consider my public comments with regard to the potential inclusion of cannabidiol (CBD) in the World Health Organizations international drug scheduling code.

I oppose the imposition of additional international restrictions limiting either its use or access. Cannabidiol lacks the sort of abuse potential and mood-altering activities to warrant such action by WHO. Seventeen US states explicitly recognize by state CBD as a therapeutic agent. Safety trials, such as those publicly available here: https://www.ncbi.nlm.nih.gov/pubmed/22716148 and here: https://www.ncbi.nlm.nih.gov/pubmed/22129319 here and here have determined the substance to be non-toxic and well-tolerated in human subjects. Even the head of the US National Institute on Drug Abuse, Dr. Nora Volkow, has publically acknowledged in an op-ed here: http://www.huffingtonpost.com/nora-volkow/cannabidiol_b_7834066.html that CBD is a safe drug with no addictive effects.

Recent clinical trials have reported that CBD administration can safely and effectively mitigate epileptic seizure frequency, reduce blood pressure, improve the quality of life in patients with Parkinsons disease, mitigate anxiety, and potentially reduce certain drug cravings. However, the substance is unlikely to reach its full therapeutic potential if WHO imposes unnecessary and arbitrary restrictions upon its access or use. For these reasons, I ask the FDA to not recommend that WHO take any further action to either schedule or restrict CBD under international codes. Cannabidiol is not presently scheduled under existing UN treaties and it should remain that way.

david wetterman
dalassabre@aol.com
1444 s old Bruceville Road
Bruceville, Texas 76630", "comment_id": "FDA-2017-N-4515-1643", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-4515-1643", "comment_date": "2017-08-29T04:00:00Z", "comment_title": "Comment from David Wetterman", "commenter_fname": null, "commenter_lname": null, "comment_length": 1782}, {"text": "Food and Drug Administration HHS,

Please consider my public comments with regard to the potential inclusion of cannabidiol (CBD) in the World Health Organizations international drug scheduling code.

I oppose the imposition of additional international restrictions limiting either its use or access. Cannabidiol lacks the sort of abuse potential and mood-altering activities to warrant such action by WHO. Seventeen US states explicitly recognize by state CBD as a therapeutic agent. Safety trials, such as those publicly available here: https://www.ncbi.nlm.nih.gov/pubmed/22716148 and here: https://www.ncbi.nlm.nih.gov/pubmed/22129319 here and here have determined the substance to be non-toxic and well-tolerated in human subjects. Even the head of the US National Institute on Drug Abuse, Dr. Nora Volkow, has publically acknowledged in an op-ed here: http://www.huffingtonpost.com/nora-volkow/cannabidiol_b_7834066.html that CBD is a safe drug with no addictive effects.

Recent clinical trials have reported that CBD administration can safely and effectively mitigate epileptic seizure frequency, reduce blood pressure, improve the quality of life in patients with Parkinsons disease, mitigate anxiety, and potentially reduce certain drug cravings. However, the substance is unlikely to reach its full therapeutic potential if WHO imposes unnecessary and arbitrary restrictions upon its access or use. For these reasons, I ask the FDA to not recommend that WHO take any further action to either schedule or restrict CBD under international codes. Cannabidiol is not presently scheduled under existing UN treaties and it should remain that way.

Colleen Graham
coll_rtz@hotmail.com
Home, 130 w 4th ave
San Manuel, Arizona 85631", "comment_id": "FDA-2017-N-4515-1651", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-4515-1651", "comment_date": "2017-08-29T04:00:00Z", "comment_title": "Comment from Colleen Graham", "commenter_fname": null, "commenter_lname": null, "comment_length": 1778}, {"text": "Food and Drug Administration HHS,

Please consider my public comments with regard to the potential inclusion of cannabidiol (CBD) in the World Health Organizations international drug scheduling code.

I've had six spinal surgeries I need a 7th from C2-C7 which has been done but needs reworked. I have ankylosing spondylitis, hep C and fibromyalgia. I've almost died and the only reason I'm breathing is from CBD oil. This government is destroying sick peoples ability to get help and you almost killed me. Have a conscience and start helping the Vets.. You are killing the men and women that would died for their country. This is a shame. Save our vets.

I oppose the imposition of additional international restrictions limiting either its use or access. Cannabidiol lacks the sort of abuse potential and mood-altering activities to warrant such action by WHO. Seventeen US states explicitly recognize by state CBD as a therapeutic agent. Safety trials, such as those publicly available here: https://www.ncbi.nlm.nih.gov/pubmed/22716148 and here: https://www.ncbi.nlm.nih.gov/pubmed/22129319 here and here have determined the substance to be non-toxic and well-tolerated in human subjects. Even the head of the US National Institute on Drug Abuse, Dr. Nora Volkow, has publically acknowledged in an op-ed here: http://www.huffingtonpost.com/nora-volkow/cannabidiol_b_7834066.html that CBD is a safe drug with no addictive effects.

Recent clinical trials have reported that CBD administration can safely and effectively mitigate epileptic seizure frequency, reduce blood pressure, improve the quality of life in patients with Parkinsons disease, mitigate anxiety, and potentially reduce certain drug cravings. However, the substance is unlikely to reach its full therapeutic potential if WHO imposes unnecessary and arbitrary restrictions upon its access or use. For these reasons, I ask ", "comment_id": "FDA-2017-N-4515-1813", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-4515-1813", "comment_date": "2017-08-30T04:00:00Z", "comment_title": "Comment from Bruce Pocorus", "commenter_fname": null, "commenter_lname": null, "comment_length": 1934}, {"text": "Food and Drug Administration HHS,

Please consider my public comments with regard to the potential inclusion of cannabidiol (CBD) in the World Health Organizations international drug scheduling code.

I oppose the imposition of additional international restrictions limiting either its use or access. Cannabidiol lacks the sort of abuse potential and mood-altering activities to warrant such action by WHO. Seventeen US states explicitly recognize by state CBD as a therapeutic agent. Safety trials, such as those publicly available here: https://www.ncbi.nlm.nih.gov/pubmed/22716148 and here: https://www.ncbi.nlm.nih.gov/pubmed/22129319 here and here have determined the substance to be non-toxic and well-tolerated in human subjects. Even the head of the US National Institute on Drug Abuse, Dr. Nora Volkow, has publically acknowledged in an op-ed here: http://www.huffingtonpost.com/nora-volkow/cannabidiol_b_7834066.html that CBD is a safe drug with no addictive effects.

Recent clinical trials have reported that CBD administration can safely and effectively mitigate epileptic seizure frequency, reduce blood pressure, improve the quality of life in patients with Parkinsons disease, mitigate anxiety, and potentially reduce certain drug cravings. However, the substance is unlikely to reach its full therapeutic potential if WHO imposes unnecessary and arbitrary restrictions upon its access or use. For these reasons, I ask the FDA to not recommend that WHO take any further action to either schedule or restrict CBD under international codes. Cannabidiol is not presently scheduled under existing UN treaties and it should remain that way.

Christopher Allaman
christopher.allaman@gmail.com
G26 Forest Hts
Butler, Pennsylvania 16001", "comment_id": "FDA-2017-N-4515-1821", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-4515-1821", "comment_date": "2017-08-30T04:00:00Z", "comment_title": "Comment from Christopher Allaman", "commenter_fname": null, "commenter_lname": null, "comment_length": 1788}, {"text": "Food and Drug Administration HHS,

Please consider my public comments with regard to the potential inclusion of cannabidiol (CBD) in the World Health Organizations international drug scheduling code.

I oppose the imposition of additional international restrictions limiting either its use or access. Cannabidiol lacks the sort of abuse potential and mood-altering activities to warrant such action by WHO. Seventeen US states explicitly recognize by state CBD as a therapeutic agent. Safety trials, such as those publicly available here: https://www.ncbi.nlm.nih.gov/pubmed/22716148 and here: https://www.ncbi.nlm.nih.gov/pubmed/22129319 here and here have determined the substance to be non-toxic and well-tolerated in human subjects. Even the head of the US National Institute on Drug Abuse, Dr. Nora Volkow, has publically acknowledged in an op-ed here: http://www.huffingtonpost.com/nora-volkow/cannabidiol_b_7834066.html that CBD is a safe drug with no addictive effects.

Recent clinical trials have reported that CBD administration can safely and effectively mitigate epileptic seizure frequency, reduce blood pressure, improve the quality of life in patients with Parkinsons disease, mitigate anxiety, and potentially reduce certain drug cravings. However, the substance is unlikely to reach its full therapeutic potential if WHO imposes unnecessary and arbitrary restrictions upon its access or use. For these reasons, I ask the FDA to not recommend that WHO take any further action to either schedule or restrict CBD under international codes. Cannabidiol is not presently scheduled under existing UN treaties and it should remain that way.

I am reformed opioid addict - drugs prescribed by licensed VA doctors to treat crippling arthritis. I would probably not be alive today, were it not for cannabis. Yet Federal drug policy prohibits doctors from using a wonderfully effec", "comment_id": "FDA-2017-N-4515-1852", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-4515-1852", "comment_date": "2017-08-31T04:00:00Z", "comment_title": "Comment from Paul Shaffer", "commenter_fname": null, "commenter_lname": null, "comment_length": 1922}, {"text": "Food and Drug Administration HHS,

Please consider my public comments with regard to the potential inclusion of cannabidiol (CBD) in the World Health Organizations international drug scheduling code.

I oppose the imposition of additional international restrictions limiting either its use or access. Cannabidiol lacks the sort of abuse potential and mood-altering activities to warrant such action by WHO. Seventeen US states explicitly recognize by state CBD as a therapeutic agent. Safety trials, such as those publicly available here: https://www.ncbi.nlm.nih.gov/pubmed/22716148 and here: https://www.ncbi.nlm.nih.gov/pubmed/22129319 here and here have determined the substance to be non-toxic and well-tolerated in human subjects. Even the head of the US National Institute on Drug Abuse, Dr. Nora Volkow, has publically acknowledged in an op-ed here: http://www.huffingtonpost.com/nora-volkow/cannabidiol_b_7834066.html that CBD is a safe drug with no addictive effects.

Recent clinical trials have reported that CBD administration can safely and effectively mitigate epileptic seizure frequency, reduce blood pressure, improve the quality of life in patients with Parkinsons disease, mitigate anxiety, and potentially reduce certain drug cravings. However, the substance is unlikely to reach its full therapeutic potential if WHO imposes unnecessary and arbitrary restrictions upon its access or use. For these reasons, I ask the FDA to not recommend that WHO take any further action to either schedule or restrict CBD under international codes. Cannabidiol is not presently scheduled under existing UN treaties and it should remain that way.

Jason McGrath
jsnmcgrath1977@yahoo.com
44 Foxwood Road
Bear Creek , Pennsylvania 18702", "comment_id": "FDA-2017-N-4515-1871", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-4515-1871", "comment_date": "2017-08-31T04:00:00Z", "comment_title": "Comment from Jason McGrath", "commenter_fname": null, "commenter_lname": null, "comment_length": 1784}, {"text": "Food and Drug Administration HHS,

Please consider my public comments with regard to the potential inclusion of cannabidiol (CBD) in the World Health Organizations international drug scheduling code.

I oppose the imposition of additional international restrictions limiting either its use or access. Cannabidiol lacks the sort of abuse potential and mood-altering activities to warrant such action by WHO. Seventeen US states explicitly recognize by state CBD as a therapeutic agent. Safety trials, such as those publicly available here: https://www.ncbi.nlm.nih.gov/pubmed/22716148 and here: https://www.ncbi.nlm.nih.gov/pubmed/22129319 here and here have determined the substance to be non-toxic and well-tolerated in human subjects. Even the head of the US National Institute on Drug Abuse, Dr. Nora Volkow, has publically acknowledged in an op-ed here: http://www.huffingtonpost.com/nora-volkow/cannabidiol_b_7834066.html that CBD is a safe drug with no addictive effects.

Recent clinical trials have reported that CBD administration can safely and effectively mitigate epileptic seizure frequency, reduce blood pressure, improve the quality of life in patients with Parkinsons disease, mitigate anxiety, and potentially reduce certain drug cravings. However, the substance is unlikely to reach its full therapeutic potential if WHO imposes unnecessary and arbitrary restrictions upon its access or use. For these reasons, I ask the FDA to not recommend that WHO take any further action to either schedule or restrict CBD under international codes. Cannabidiol is not presently scheduled under existing UN treaties and it should remain that way.

jacob haskins
haskins.jacob@gmail.com
32592 N cherry Creek RD
Queen Creek, Arizona 85142", "comment_id": "FDA-2017-N-4515-1857", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-4515-1857", "comment_date": "2017-08-31T04:00:00Z", "comment_title": "Comment from Jacob Haskins", "commenter_fname": null, "commenter_lname": null, "comment_length": 1785}, {"text": "Food and Drug Administration HHS,

Please consider my public comments with regard to the potential inclusion of cannabidiol (CBD) in the World Health Organizations international drug scheduling code.

I oppose the imposition of additional international restrictions limiting either its use or access. Cannabidiol lacks the sort of abuse potential and mood-altering activities to warrant such action by WHO. Seventeen US states explicitly recognize by state CBD as a therapeutic agent. Safety trials, such as those publicly available here: https://www.ncbi.nlm.nih.gov/pubmed/22716148 and here: https://www.ncbi.nlm.nih.gov/pubmed/22129319 here and here have determined the substance to be non-toxic and well-tolerated in human subjects. Even the head of the US National Institute on Drug Abuse, Dr. Nora Volkow, has publically acknowledged in an op-ed here: http://www.huffingtonpost.com/nora-volkow/cannabidiol_b_7834066.html that CBD is a safe drug with no addictive effects.

Recent clinical trials have reported that CBD administration can safely and effectively mitigate epileptic seizure frequency, reduce blood pressure, improve the quality of life in patients with Parkinsons disease, mitigate anxiety, and potentially reduce certain drug cravings. However, the substance is unlikely to reach its full therapeutic potential if WHO imposes unnecessary and arbitrary restrictions upon its access or use. For these reasons, I ask the FDA to not recommend that WHO take any further action to either schedule or restrict CBD under international codes. Cannabidiol is not presently scheduled under existing UN treaties and it should remain that way.

Arturo Valadez
xtremeaj25@gmail.com
613 Candleglo
Windcrest, Texas 78239", "comment_id": "FDA-2017-N-4515-1862", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-N-4515-1862", "comment_date": "2017-08-31T04:00:00Z", "comment_title": "Comment from Arturo Valadez", "commenter_fname": null, "commenter_lname": null, "comment_length": 1769}]}, {"id": "DOT-OST-2016-0189", "title": "Procedures for Transportation Workplace Drug and Alcohol Testing Programs: Synthetic Opiates and Minor Amendments", "context": "2018-01-10T08:47:39Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "See attached file(s)", "comment_id": "DOT-OST-2016-0189-0048", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2016-0189-0048", "comment_date": "2017-03-23T04:00:00Z", "comment_title": "Comment from Robert E. Willette", "commenter_fname": "Robert", "commenter_lname": "Willette, Ph.D.", "comment_length": 20}, {"text": "Comments from the Association of Flight Attendants-CWA, AFL-CIO", "comment_id": "DOT-OST-2016-0189-0037", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2016-0189-0037", "comment_date": "2017-03-17T04:00:00Z", "comment_title": "Comment from Association of Flight Attendants-CWA, AFL-CIO", "commenter_fname": "Heather", "commenter_lname": "Healy", "comment_length": 63}, {"text": " I Dajuan Leavell a previous employee under the federal Department Of Transportation in Toledo, Ohio will love to comment
on the 49 rule of shy bladder. I think that the MRO evaluation process under the shy bladder situation is not reasonable at all.
I understand that an individual could hold his or her urine in for 3 hours due to them knowing the results will be positive. Altho
ugh what about the ones that are negative without a medical history and documentations of urinating problems? They do not get to prove there
innocents and they could also loose there livelihood. This is very unfair! its almost like robbery of your career to a existing
medical condition that was currently discovered. There has got to be a better way to prove your innocents in this situation.
Its hard to believe the MRO will consider a highly probable condition without medical documentation. I even offered blood and a hair test. YOU LOOSE GOOD
RELIABLE EMPLOYEES this way. I had never failed a drug test in my life. It hurts so bad its like being convicted of a crime
you didn't do. I committed 5 years to my employer no call offs and worked when the needed me, no discipline nothing on
my file or record. And this shy bladder situation is a joke when you don't look further into the situation. It could be something
that an employee will find out when its too late and lost there job!! You guys have to do better than that!!
Thank You for taking the time out to here me out. Please feel free to give feedback. My email is dajuanleavell23@gmail.com
", "comment_id": "DOT-OST-2016-0189-0009", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2016-0189-0009", "comment_date": "2017-01-30T05:00:00Z", "comment_title": "Comment from Dajuan Leavell", "commenter_fname": "Dajuan", "commenter_lname": "Leavell", "comment_length": 1598}, {"text": "

March 24, 2017


VIA Federal eRulemaking Portal


Docket Management Facility
U.S. Department of Transportation
1200 New Jersey Ave., SE
West Building Ground Floor Room W12-140
Washington, DC 20590-0001

Subject: Docket No. DOT-OST-2016-0189

Dear Docket Clerk,

The San Francisco Municipal Transportation Agency (SFMTA) appreciates the opportunity to review the U.S. Department of Transportation's (DOT) proposal to revise its drug testing program regulations as follows:
Align DOT's regulated-industry drug testing with the Department of Health and Human Services (HHS) laboratory drug testing requirements;
Add clarification to certain existing drug-testing provisions;
Remove outdated information from DOT's current regulation; and,
Remove the requirement for employers and C/TPAs to submit blind specimens.
We are in agreement and support the proposed changes.

SFMTA would also like to take this opportunity to express its interest in commenting on other aspects of the DOT regulations that are not currently open as part of this proposed rulemaking, such as post-accident testing, definition of an accident, and when drug testing is deemed appropriate. For example, we believe that the current definition of "accident" may not be broad enough to encompass other situations for which testing may be appropriate, such as serious safety violations, e.g., signal violations.

Specifically, we would welcome an opportunity to comment formally on the following sections of the Code of Federal Regulations (CFR): 49 CFR 655.4: Definitions, "Accident"; 49 CFR 655.43: Reasonable Suspicion Testing; and, 49 CFR 655.44: Post-Accident Testing.

We strongly encourage DOT to initiate a formal discussion on these issues as soon as possible. If you have any questions or require additional information, please do not hesitate to contact me at 415.701.4720 or Ed.Reiskin@sfmta.com.

Sincerely,

Edward D. Reiskin
Director of Transportation



", "comment_id": "DOT-OST-2016-0189-0070", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2016-0189-0070", "comment_date": "2017-03-27T04:00:00Z", "comment_title": "Comment from San Francisco Municipal Transportation Agency", "commenter_fname": "Edward", "commenter_lname": "Reiskin", "comment_length": 2318}, {"text": "See attached file(s)", "comment_id": "DOT-OST-2016-0189-0060", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2016-0189-0060", "comment_date": "2017-03-24T04:00:00Z", "comment_title": "Comment from CONSOL Energy Inc.", "commenter_fname": "Steven", "commenter_lname": "Buffone", "comment_length": 20}, {"text": "See attached PDF", "comment_id": "DOT-OST-2016-0189-0063", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2016-0189-0063", "comment_date": "2017-03-24T04:00:00Z", "comment_title": "Comment from Transportation Trades Department, AFL-CIO", "commenter_fname": "Edward", "commenter_lname": "Wytkind", "comment_length": 16}, {"text": "Comment provided by: Lisa Bradley; Certified Training Solutions

RE: DOT-OST-2016-0189-0038

We would like to express a similar opinion regarding 40.33, commented by SAPAA.

The concern is the requirement for all collectors, BATs, STTs, SAPs, and MROs to subscribe to the free ODAPC list-serve. This is an excellent idea, and we stress to our trainees that they need to sign up for updates online and that it is their responsibility to keep up with Regulation changes. However, please consider allowing more time (beyond the October 1, 2017 effective date) for all of these service agents to subscribe to the email updates list. We intend to communicate to our clients that they must subscribe to the list; however, we believe there will be many service agents that may not be aware of the requirement in such a short time (and thereby, be out of compliance once the Rule takes effect). We believe that allowing a bit more time for more service agents to hear about the Rule will result in a higher compliance rate once it goes into effect.

Some of our clients in covered industries have also expressed concern, since they are responsible for ensuring they use only compliant service agents. A question to consider is: Who is responsible for ensuring that all of these BATs, Collectors, etc. actually are on the email updates list and how will it be enforced?

Example: A trucking company uses a collection site/clinic for their urine drug collections, and the DER initially checks to ensure that all currently-employed collectors and BATs are subscribed to ODAPC's list-serve. However, there is often a lot of turnover in these types of positions at clinics and collection facilities. If every DER at every covered-company has to call every service agent (and document) frequently -possibly even daily to truly ensure full compliance - this will create significant new costs and record-keeping burdens on covered employers that may not have been considered in the new language.

Thank you for the opportunity to comment.", "comment_id": "DOT-OST-2016-0189-0054", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2016-0189-0054", "comment_date": "2017-03-23T04:00:00Z", "comment_title": "Comment from Lisa Bradley", "commenter_fname": "LISA", "commenter_lname": "BRADLEY", "comment_length": 2085}, {"text": "I believe that all drivers, in any instance, need to be tested for any kind of drug in their system because it is very unsafe to drive, specially, commercial vehicles under the influence of drugs because these drugs do not let people react as the normally would.", "comment_id": "DOT-OST-2016-0189-0032", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2016-0189-0032", "comment_date": "2017-03-09T05:00:00Z", "comment_title": "Comment from Miguel Lopez", "commenter_fname": "Miguel", "commenter_lname": "Lopez", "comment_length": 262}, {"text": "Dear Regulators,
I've worked over 20 years in this industry as a marketing rep for a SAMHSA certified lab, a collector-trainer and for a TPA. In my job, I communicate with labs, collection sites, TPA's, BAT techs and employers on the DOT regulations and collection requirements. I agree in the addition of the synthetic opioids and believe this would greatly increase safety for the public and help provide intervention to those who suffer with drug addiction. I also agree with the minor changes mentioned. I do feel the collector training should include the following scenarios for mock collections as a minimum: 1. Standard mock collection (no errors) 2. Shy bladder A. The normal scenario where the donor eventually provides a full specimen within range B. The unusual scenario where the donor stays all 3 hours, is compliant, but does not provide a specimen. 3. A specimen offered where the specimen is either "temp out of range" or "appears to be tampered" and the donor agrees to the 2nd observed collection. #4 would be the 2nd observed collection, also talking about the other scenarios when an observed collection may be ordered and 5. A refusal to test (being disruptive, not follow collection instruction, etc.) and 5B: Items a donor can refuse to do (i.e. not initial bottles seals or sign the COC form or provide a full SS #, that does not cancel the test when the donor follows all other guidelines. I find when you cover all of these items with mock collections, there are less errors and better retention. I also have found some SAMHSA certified labs have found the ability to test beyond the limited description for substitute specimens in order to capture the use of synthetic urine, (which is a real problem, and needs to be addressed). I believe the actual DOT positive drug test rate is far higher than reported. Labs should be able to use proprietary methods without having to fully disclose what they are except to the MRO who views the test result and the SAMSHA certified labs who would do a secondary confirmation test to verify the same result. It's a little like computer viruses and hackers, labs are always trying to stay one step ahead of the bad guys who would tamper with a test, but under the current DOT regulations, they have to give out the formula on how to do it. This really is a 2nd subject that deserves it's own rulemaking. There are currently SAMSHA certified labs that have effectively shut down the majority of use of these kind of tampering agents with NON-DOT tests, the same should be true for DOT testing since the technology is available. I would not advise not adding this subject to the existing recommendations as this would only delay the opioid panels from being added.



The current DOT collector guidelines do not address electronic chain of custody forms in either training guidelines or in practice guidelines.
It's recommended that the collector must go through the DOT collector training using standard paper chain of custody forms, and that if the collector will be using electronic chain of custody forms, must have additional training from the vendor on how to properly process the electronic chain of custody form on-line. In addition, common errors include the collector dismissing the donor without providing a specimen without fully allowing for the 3 hour time frame because they are closing for lunch or for the day. This should be a collector error and fatal flaw. I also think unless the site can reliably provide male and female collectors, they should not be able to offer to do a DOT collection, since some observed collections will be initiated during the collection (i.e. specimen temp out of range) which cannot be predicted in advance. I think it's also a disservice to claim to offer DOT breath alcohol without having the confirmation(i.e. breath alcohol test) available at the site. The reason is while the clear majority of alcohol saliva tests are negative, when one is positive it most likely is for reasonable cause or post-accident scenario where the outcome is critical.

It would also be helpful to include in the observed collection procedure on how to handle a transgender collection. Most collectors agree that the "legal" sex that is registered on the donor's driver's license, however this is a thorny issue with many opinions, so would further recommend this subject have it's own rule-making period. I would also recommend that the opioid panel be flexible enough that the employer and/or MRO can order additional opioid testing not in the expanded panel (i.e. Fentanyl) as the drugs of abuse are constantly evolving and users will continue to change their drugs of abuse in order to avoid detection. ", "comment_id": "DOT-OST-2016-0189-0056", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2016-0189-0056", "comment_date": "2017-03-24T04:00:00Z", "comment_title": "Comment from Esther Miller", "commenter_fname": "Esther", "commenter_lname": "Miller", "comment_length": 4849}, {"text": "Timely submitted comments the Chamber of Shipping of America are attached here.

R/
Kathy J Metcalf
President and CEO
Chamber of Shipping of America", "comment_id": "DOT-OST-2016-0189-0041", "comment_url": "https://api.regulations.gov/v4/comments/DOT-OST-2016-0189-0041", "comment_date": "2017-03-21T04:00:00Z", "comment_title": "Comment from Chamber of Shipping of America", "commenter_fname": "Kathy", "commenter_lname": "Metcalf", "comment_length": 168}]}, {"id": "USN-2016-HQ-0002", "title": "Privacy Act of 1974; System of Records (alteration, N05350-1, Navy Drug and Alcohol Program System)", "context": "2020-10-22T01:11:55Z", "purpose": "Nonrulemaking", "keywords": null, "comments": [{"text": "It is always important to keep records of most things and above all a person's well being for
many reasons, principally if that person is involved in the US Navy. It is even more so essential to keep records if that person
has a history or present state of a drug or alcohol addiction. This is a very proficient on process that will undoubtedly help maintain records and authority according to their state of being. A very crucial part when it comes to taking control in certain
expertise in the US Navy; A total improvement success.", "comment_id": "USN-2016-HQ-0002-0002", "comment_url": "https://api.regulations.gov/v4/comments/USN-2016-HQ-0002-0002", "comment_date": "2016-02-26T05:00:00Z", "comment_title": "Comment on FR Doc # 2016-02946", "commenter_fname": null, "commenter_lname": null, "comment_length": 549}]}, {"id": "FDA-2012-P-1180", "title": "Determine That an Abbreviated New Drug Application (ANDA) Oxycodone Hydrochloride Extended-Release Capsules may be \r\nSubmitted and be Considered Bioequivalent to the Reference Listed Drug (RLD) Oxycontin\u00ae (Oxycodone Hydrochloride Controlled-Release) Tablets", "context": "2016-01-12T12:11:00Z", "purpose": "Nonrulemaking", "keywords": ["cder", "2012-9568", "ANDA", "oxycodone hydrochloride controlled-release", "Oxycontin", "tablets", "bioequivalent", "oral", "oxycodone", "RLD", "open"], "comments": [{"text": "Please see the attached comment submitted on behalf of Purdue Pharma L.P.", "comment_id": "FDA-2012-P-1180-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2012-P-1180-0005", "comment_date": "2016-01-12T05:00:00Z", "comment_title": "Comment from Purdue Pharma L.P.", "commenter_fname": null, "commenter_lname": null, "comment_length": 73}]}, {"id": "FDA-2017-P-6307", "title": "Request that the FDA designate Morphine Sulfate Extended Release Tablets, 100 mg from Rhodes pharmaceuticals LP (ANDA# A074769) as reference standard (RS) for the subject drug product to conduct in vivo bioequivalence studies.", "context": "2019-03-14T16:22:32Z", "purpose": "Nonrulemaking", "keywords": ["CITIZEN PETITION", "CDER", "Aurolife Pharma LLC", "Reference listed drug (MSCONTIN", "NDA # 019516)", "Purdue Pharma LP", "discontinued", "MS CONTIN", "Referencing Approved Drug Products in ANDA", "Morphine Sulfate Extended Release Tablets", "100 mg", "Rhodes Pharmaceuticals LP (ANDA# A074769)"], "comments": [{"text": "Goals for Chronic Pain Patients to receive adequate pain relief;
* For correct misinformation online and in Media about chronic pain patients and opioid therapy be amended and corrected!
* * institute a Chronic Pain Patients "Bill Of Rights".

-We all have a right to relief from our debilitating pain and discomfort.
* United Nations policy states PAIN MANAGEMENT IS A FUNDAMENTAL HUMAN RIGHT, under treatment or not treating is a crime against humanity and considered torture! That is what is being done to chronic pain patients all over this country right now! I being one of them as I am experiencing abandonment of care from my doctor. who has refused to treat me. Thus, I am in a very precarious state right now! I looking for a doctor. However, all pain management specialist are booked for at least a four month window! My pain is chronic 24/7, 365 days a year. I can't wait that four months. I do not want to end up as a statistic on the suicide list!

Since the narrative of the "opioid epidemic" has taken hold, some/ many doctors are refusing pain relief, in fear of retribution, imprisonment or loss of livelihood!
Many hospitals are implementing after surgery a spinal block and Tylenol, many patients are dying attributing it to cardiac arrest which is not the case!

#2 Collateral damage Because of the innumerable, severe, and long lasting effects of constant pain, I believe that treatment for chronic pain is a human right.

It impairs every part of a persons entire life, career, family, mind, body, spirit and soul. From financial hardships due to being unable to work and the family issues as we cannot be the parents, grandparents partners that we would have and should be.

Many chronic pain patients are hypo metabolizers or hyper-metabolizer ... I suffer with malabsorption I had a surgically inserted port in my chest.
I had tpn pumped into to my body for 12 to 24 hours a day for 8 + years.
I could not absorb the proteins in my food this is the way I sustained my life. It makes sense since food did not absorb either did my medication that is why I had to have higher doses For it to work.

We are not a one-size-fits-all society.

This creates, a lot of collateral damage to the family because we are not able to function in a fashion that our family needs us to ! It also starts to deteriorate our children's mindset as they are continually worried as to our health, expectancy of life/ longevity of life !

I know this first-hand has changed who my four children could have been ! It put too much weight on them while trying to go through school and life in general !
Because of all the family issues in addition to other health issues like brain and organ damage from lack of sleep, medications, and the rewiring of your brain from constant stress. Air condition, heating our sensory capabilities are all screwed up we need to help chronic pain patients get better treatment, education of the public on the complexities of chronic pain, lobby the government to make changes that will benefit chronic pain patients, and to foster a better understanding of chronic pain patients struggles day in Day Out with daily life.

After reading so many frustrating stories of chronic pain patients dealings with the healthcare industry, I decided to create a foundation that would serve the needs of chronic pain patients everywhere. By first educating the public on what chronic pain really is, how it affects us and our families, and what is missing in our treatment. Then I would like to focus on changing how government views chronic pain patients and writes guidelines and legislation that affects them.

For those of us who suffer day in and day out 24/7, 365 days a year Relentless, cruel, aching, affliction, agony, burn, catch, convulsive, cramping, crick, discomfort, distressing, fever, gripping, hurting, illness, injury, irritation, laceration, malady, misery, pang, paroxysm, prickling, sickness, smarting, soreness, spasm, stinging, stitching, straining, tenderness, thro, tingling , tormentous, torturous, troubling, twinging, wounding always present, horrendous, debilitating pain sharp, exacerbating,

There is a need in the chronic pain community and it is not being addressed, please we need to reduce the suffering as much as possible, of people suffering from chronic pain.
Suicidedue2pain

Malabsorbtion -TPN

Music therapy
Massage
Behavior therapy
Physical therapy
Biofeedback
Acupuncture etc
Three options - reform of opioid guidelines
3. Campaign/Organizational Goal and Key Objectives
Educating the public about chronic pain and how it affects chronic pain patients.

-Fight preconceived notions on pain medication and those who need it.
-What is missing from treatment of chronic pain?

-Changing governmental views
-Get new guidelines on pain medication created for chronic pain sufferers.

-Explain how the war on opioids is killing chronic pain sufferers!", "comment_id": "FDA-2017-P-6307-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-6307-0006", "comment_date": "2018-05-01T04:00:00Z", "comment_title": "Comment from CATHY KEAN", "commenter_fname": null, "commenter_lname": null, "comment_length": 5172}, {"text": "Dear Readers,

I am not certain how to write this letter, but I feel I must respond and comment on these regulations and have a voice in federal making of decisions.
I have been in chronic pain since 1984. In all these years since a respiratory infection ended with widespread body pain, I have not had one day without pain. The original disease has increased from musculoskeletal to inflammatory and degenerative arthritis throughout all my joints. Every X-ray is filled with arthritis and bone spurs, even bone in locations bone should not be. An MRI of my spine sent me to a neurosurgeon who said the only surgery that might work would never permit me to bend over again.

I take both diazepam and hydrocodone, in addition to medications you might not consider opioids or narcotics. These two are not high dosage, but they have worked and allowed me an active life. Daily I take care of horses, my own home, animals, and I work. I work as a writer and have had 16 books published while taking these medications. My main publisher has been WW Norton in NY. And for poetry, I have used a smaller, independent press. I also travel frequently to read my work, do workshops, and lecture on a variety of topics.

This is with my medications.

Without them, I am unable to get out of bed. I have had screams that are involuntary. I cannot bend or do any movement or work. My hands do not work, will not type, nor can I walk without severe pain. Without these medications, I will have no life, or
at least not one worth living.

The Dr. has changed. Even he has fear. He does not wish to prescribe medications like the ones I take, swears they would kill anyone else, all the exact same stories as the numerous other pain patients say they have heard. I feel sorry for those of us in pain, but I also feel sorry for those in the medical profession who are unable to really help their patients.

Many pain patients have been committing suicide rather than living a life suffering. These deaths are worse than the ones of addicts who are shooting up because they are created by the government's regulations and fear tactics. They are going after the wrong people.

Most of us are taking our meds at the right times, not asking for larger doses, and are responsible with our meds. We do not misuse our medicines. For us they are not addictive drugs, but healing agents that allow us to live full lives.

Please consider this in your Regulations. We do want to live. We do not overdose. We are not the criminals. We want to be free from pain, as anyone else also would.

Sincerely,
Linda Hogan
Professor Emerita
U of Colorado, Boulder
www.lindahoganwriter.com

", "comment_id": "FDA-2017-P-6307-0003", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-6307-0003", "comment_date": "2018-03-28T04:00:00Z", "comment_title": "Comment from Linda Hogan", "commenter_fname": null, "commenter_lname": null, "comment_length": 2763}, {"text": "I'd like to start out by saying I'm a 39 yr old mother of 6. And have had chronic pain for over half my life.
I was 11 yrs old when I first started having back pain and then went on to knee pain. I was cative throughout school I was involved in track n field, volleyball, cheerleading & basketball. I had to wear 2 knee braces and was on a very high does of anti-inflammatory prescription from my knee doctor at age 12. After giving birth to my 3rd child at age 20 I had my 1st knee surgery, every year after that 1st surgery i had knee surgery after another for 5 years... I had been sent to neurologist's and physical therapy chiropractor and differant doctor's ect.
Finally at age 28 i found my dr and he referred me to a spine specialist and he diagnosed me with Schumann's disease which is very painful my spine was 69% curved on top and 69% curved on the bottom. They did surgery October15th 2010 and it was a very long recovery.
I've been on Percocet for 7 yrs and don't abuse it. I can't even get out of bed, walk or do basic self care without it. I've seen what drug addiction has done to our community and people i love.
But dont punish us that need our medication to live our basic daily lives.", "comment_id": "FDA-2017-P-6307-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2017-P-6307-0005", "comment_date": "2018-04-17T04:00:00Z", "comment_title": "Comment from Miranda MuellerMcClure", "commenter_fname": null, "commenter_lname": null, "comment_length": 1261}]}, {"id": "USCG-2004-17455", "title": "Validation of Merchant Mariners' Vital Information and Issuance of Coast Guard Merchant Mariner's License and Certificates of Registry", "context": "2020-11-06T01:03:13Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "As President of the Great Lakes Passenger Boat Association I represent our twenty, Tour and Ferry operators. Our membership is extremely concerned about the impact and burden imposed by the recent rule requiring mariners to report to a REC for identification verification and fingerprinting.

GLPBA members employ over 130 USCG licensed personnel. Many of these employees live over a day\u0092s drive time from Toledo, OH or St. Louis, MO the closest RECs (licensed personnel from two members would have a 1600 mile round trip to Toldeo). The cost of mileage, lodging, meals and time away from work is an unacceptable burden on businesses and their employees.

In these rules there seems to be little if any consideration for efficiency. Does it make sense to have hundreds of people per year traveling hundreds of miles for a procedure that takes 20 minutes to perform. Is it possible for mariners to be ID\u0092d and electronically finger printed at a local MSU? or could a \u0093memorandum of agreement\u0094 be arranged with a partner agency within the Dept. of Homeland Security, allowing them to check ID\u0092s and electronically scan fingerprints for the REC? One size does not fit all and some creative problem solving could resolve this issue as a win-win for the USCG REC and the mariner.

Our members businesses and their licensed personnel would appreciate your serious consideration of this issue.

Sincerely,

Mike Radtke
President, Great Lakes Passenger Boat Association
Marine Operations Manager, USCG 100 ton Master
Madeline Island Ferry Line
LaPointe, WI 54850

", "comment_id": "USCG-2004-17455-0114", "comment_url": "https://api.regulations.gov/v4/comments/USCG-2004-17455-0114", "comment_date": "2006-03-09T05:00:00Z", "comment_title": "Michael G. Radtke", "commenter_fname": "Michael", "commenter_lname": "Radtke", "comment_length": 1629}, {"text": "Please hold up on rule making untill you get more input from the river people
", "comment_id": "USCG-2004-17455-0118", "comment_url": "https://api.regulations.gov/v4/comments/USCG-2004-17455-0118", "comment_date": "2006-03-10T05:00:00Z", "comment_title": "Don D. Weymiller", "commenter_fname": "Don", "commenter_lname": "Weymiller", "comment_length": 82}, {"text": "March 8, 2006

To whom it may concern,

I would like to express my concerns regarding the extra time and expense for mariners, such as myself to travel at least twice to my local R.E.C. for any future license renewals. The new rule proposed would require one trip for finger printing and a second to obtain documents in person. This rule will place a daunting burden on mariners that do not live close to their respective R.E.C.s Not all mariners are home for months at a time. Crew rotations vary from (day on / day off) to (two months on / one month off) in most limited tonnage fleets. Traveling 450 miles or more, one-way is next to impossible for some licensees without taking unscheduled absences from their rotations. Travel, lodging, food, pay loss and document expenses will burden some of these salaries.

It seems incomprehensible to me that a mariner can renew their United States Passport via the United States Postal Service but, the United States Coast Guard can not accept this procedure because of reasons that are unclear or overbearing. Our pictures and fingerprints are recorded in our files from the procurement of our first document. A quick look into our jacket could reveal whether the face in the picture, matched with the fingerprints are the applicants. The State Department can do this after ten years. Five years should not require more training. This would take minimal effort compared to two personal appearances by every mariner from G.V.A.s to Masters. Our R.E.C.s have not shown that they can handle the extra traffic! It takes two months to get your documents back for one appearance now. Will it take four or more for two?

In closing, our time home is being consumed more and more by regulatory procedures, training and employee shortfalls. Our younger generation coming into the workforce will not put up with all this bureaucracy and workload. Time home and pay are the only real attributes that keep this workforce in place now. This new rule will only drive the United States Merchant Mariner another step closer to extinction. The United States Coast Guard should be encouraging the renewal of documents and experienced labor not driving them away.

Thank you for the chance to express my concerns.

Regards,

Captain Kenneth C. Graybill III

", "comment_id": "USCG-2004-17455-0119", "comment_url": "https://api.regulations.gov/v4/comments/USCG-2004-17455-0119", "comment_date": "2006-03-10T05:00:00Z", "comment_title": "Kenneth C. Graybill III.", "commenter_fname": "Kenneth", "commenter_lname": "Graybill III.", "comment_length": 2356}, {"text": "Requiring mariners to travel to a REC for fingerprinting and ID check when renewing documents and licenses is an excessive burden to the mariner.
With recent changes to regulations and requirements to keep licenses current, it has become a significant burden just to keep a license at all.

I currently hold a Master Oceans to 1600/3000 and have been licensed for over 25 years. Due to the extreme expense and burden of recent changes, i.e. STCW, MMD's, I am only able to use my license to the 100 ton level. Now you are adding considerably more expense to retaining the license. At the current rate of increase in the burden of retaining and maintaining my license, I will have to seek an alternative career. As a merchant seaman for all my adult life, and too old to start over, I find this additional burden quite unacceptable.
", "comment_id": "USCG-2004-17455-0111", "comment_url": "https://api.regulations.gov/v4/comments/USCG-2004-17455-0111", "comment_date": "2006-03-09T05:00:00Z", "comment_title": "Charles Cross", "commenter_fname": "Charles", "commenter_lname": "Cross", "comment_length": 854}, {"text": "I am writing regarding the recent interim rule published on January 13, 2006 regarding new identification procedures required for mariners.

I am a recently qualified Coast Guard Masters applicant. As part of the application process, I submit two fingerprint identification cards along with my application. Unfortunately, I had no idea the rules were going to be changed and I mailed my application on January 13 and it was not received by the Toledo REC until two days later.

The finger prints with my application were taken at the Police Department in the city of Edina, MN. I am a resident of Edina and they would only do fingerprints for residents. They require proof of identification via a picture ID. Under the new interim rule, I am required to go to Toledo and present to them a valid picture identification and either a birth certificate or valid passport.

Requiring people to go to a regional examination center seems burdensome and a significant additional expense. I don\u0092t think I can fly to Toledo from Minneapolis and back in one day.

I understand the need for additional security requirements in the post 9/11 era but there are a lot of ways to achieve the same purpose without the additional burden. A few of those alternatives are as follows:

1.There are numerous federal law enforcement offices throughout the country, such as the FBI, US Marshall\u0092s Office, Immigration authorities, etc.
2.There are numerous Coast Guard offices that can be used instead of the REC\u0092s.
3.The fingerprinting entity could require the same identification as the Coast Guard, i.e. a valid picture driver\u0092s license and a valid passport or birth certificate.

Understanding the need for additional security, I would ask that you balance that need with the cost and burden of severely limiting where a person can be fingerprinted.

I should also point out that most, if not all, of the people in my testing group were lucky enough to get their applications in before the unknown date of January 13, 2006 and do not have the extra burden and cost of going to Toledo.

Thank you for your consideration.
", "comment_id": "USCG-2004-17455-0145", "comment_url": "https://api.regulations.gov/v4/comments/USCG-2004-17455-0145", "comment_date": "2006-03-15T05:00:00Z", "comment_title": "Mark J. Condon", "commenter_fname": "Mark", "commenter_lname": "Condon", "comment_length": 2302}, {"text": "To whom it may concern,
I am the Captain-in-Charge of the ferry boat the MV Sugar Islander II. She is a 24 car passenger vessel that shuttles between Sault Ste. Marie, MI and Sugar Island, MI. We have 10 men that hold their 100 Gross Ton PCV Masters ticket.
The matter of fingerprinting for every transaction regarding our licenses has been brought to my attention.
In these uncertain days I can certainly understand the need for due diligence regarding licensing procedures for anyone who has control of a vessel the size of the Sugar Islander II and the hundreds of souls it carries on a daily basis, 365 days a year.
On the other hand, this fingerprinting/ID mandate, I feel, could be handled in several simpler ways that would be much less costly to the licensee and at the same time be just as effective.
For us, here in Sault Ste. Marie, to travel all the way to Toledo for simple fingerprinting every time we wish to upgrade or even simply renew our licenses, would be costly and frankly just a plain old nuisance. It would involve two days of driving, loss of wages, motel expenses, etc.
In my instance, I earned my license in 1981. I understand the need for the Dept. of Homeland Security to keep a tight rein on people in our profession. However, after twenty seven (plus) years, I will not, suddenly, become a terrorist or any threat to Homeland Security. To make that kind of journey in question is simply a case of "overkill".
I have no problem having my fingerprints in your database, I just believe there are far simpler and less costly (to the mariner) ways to accomplish this. Whether it be by being printed by local law enforcement, the closest Michigan State Police post, or even the nearest U.S. Coast Guard base---all would be acceptable. But a 400+ mile trip to Toledo is, as I said, overkill.
Surely there is a FAR better solution to getting Mariners' fingerprints on file than this complicated, costly solution that has been proposed.

Thank you for your time and the opportunity to respond.
Sincerely,

Douglas M. Bisdorf
Captain-in-Charge
", "comment_id": "USCG-2004-17455-0159", "comment_url": "https://api.regulations.gov/v4/comments/USCG-2004-17455-0159", "comment_date": "2006-03-20T05:00:00Z", "comment_title": "Douglas M. Bisdorf - Comments", "commenter_fname": "Douglas", "commenter_lname": "Bisdorf", "comment_length": 2147}, {"text": "I am submitting comments in regard to docket ID USCG-2004-17455, Validation of Merchant Mariners\u0092 Vital Information. I have problems with your proposed rule change requiring a licensed mariner to appear in person at a USCG REC for license renewal or upgrades. I understand that heightened security measures are needed, especially post 9/11, but this new requirement of appearing in person at one of the limited REC locations after original license issuance is unnecessary and unreasonable. The region I am employed as a mariner is the Great Lakes and travel to and from REC Toledo can easily take more than one day. This new requirement is not just inconvenient, but can also be a costly burden placed on us mariners\u0092. Since the CG License is not used as a picture identification it is unclear what this new requirement is actually solving in the field. If you are trying to head in this direction for security purposes then look into a major regulatory change and marry up the documentation and licensing processes and streamline the whole bureaucracy. Actual compliance in the field under the current system is still working with a piece of paper as a license with just a name on it, no picture or other biometrics. In the field compliance is not there yet to tie this license to whoever is holding it in the field with whatever fake ID they may have if they are actually a terrorist trying to sail under a fraudulent license. At this time forcing us mariners to show up in person at the REC for renewal or upgrade doesn\u0092t really solve the field compliance issue. In closing, if this requirement goes forward and you feel the need to have an independent verification of the mariner\u0092s identification and fingerprint, after the original issuance, than leverage other local agencies or provide more locations for mariners\u0092 to get the process completed. Your plan to use just the 17 USCG REC\u0092s is unsatisfactory. Also, don\u0092t tie this identification and fingerprinting visit it into the rigid renewal and upgrade administrative process within the specific REC. Work in flexibility for this piece of the process and allow walk up service at any REC at the mariner\u0092s convenience. Also let them walk up at any time during the renewal period. You already have the original information in the computer system. The goal is to re-verify the mariner\u0092s identification and fingerprints for the action on the license. Let the rest of the REC administrative process to evaluate expertise, character, and fitness for duty stay in the established rigid cycle. I urge you to not place additional bureaucratic and costly blocks to a mariner\u0092s livelihood.
", "comment_id": "USCG-2004-17455-0165", "comment_url": "https://api.regulations.gov/v4/comments/USCG-2004-17455-0165", "comment_date": "2006-03-21T05:00:00Z", "comment_title": "Timothy A. Cherry", "commenter_fname": "Timothy", "commenter_lname": "Cherry", "comment_length": 2658}, {"text": "I am writing to voice my concern about the electronic fingerprinting requirement. If this requirement passes, it will cause considerable undo harm in the renewal process of my 100-ton great lakes master license this fall. The two closest REC are 2-1/2 days of wages plus expenses. There is an electronic device 200 miles away in Minneapolis at the US Marshall Service. That federal agency is located in a one-day's time for me and my 12 fellow daptains. I hope something reasonable can be worked out. Thank you. Joni Brooks
", "comment_id": "USCG-2004-17455-0171", "comment_url": "https://api.regulations.gov/v4/comments/USCG-2004-17455-0171", "comment_date": "2006-03-27T05:00:00Z", "comment_title": "Joni l. Brooks", "commenter_fname": "Joni", "commenter_lname": "Brooks", "comment_length": 540}, {"text": "Our four captains are characteristically present at each annual vessel inspection. For each of them in turn to travel to either St. Louis or Toledo amounts to two days of travel time, a hundred dollars for fuel, overnight accommodations. We knowo our USCG marine inspectors and vice versa. Wouldn't this waste of energy and resources be better served using personnel in place? The local MIO. It's far more cost-efficient to send electronic equipment to user sites than to send people.
", "comment_id": "USCG-2004-17455-0172", "comment_url": "https://api.regulations.gov/v4/comments/USCG-2004-17455-0172", "comment_date": "2006-03-27T05:00:00Z", "comment_title": "David F. Strzok", "commenter_fname": "David", "commenter_lname": "Strzok", "comment_length": 499}, {"text": "I do not believe there is a need for somebody to have to appear in person at a REC to check their ID and fingerprints. I think the Coast Guard should document how many cases they know of where they received incorrect fingerprints, or issued a license to someone other than the person who should have received it. I think the requirements they used in the past should be sufficient without putting an undue travel burden on applicants who live a long way from a regional exam center.
", "comment_id": "USCG-2004-17455-0023", "comment_url": "https://api.regulations.gov/v4/comments/USCG-2004-17455-0023", "comment_date": "2006-02-01T05:00:00Z", "comment_title": "Roy A. Beasley", "commenter_fname": "Roy", "commenter_lname": "Beasley", "comment_length": 489}]}, {"id": "DEA-2023-0058", "title": "Placement of Nine Specific Fentanyl Related Substances in Schedule I (DEA1036)", "context": "2023-12-07T08:20:24Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "When looking at the schedule requirements, and the eight different factors going into what places a drug into a schedule, I believe that fentanyl should be placed in schedule 1. The fact that marijuana is classified as a schedule 1 drug, but not fentanyl blows my mind. Marijuana deaths are extremely low and not as likely to happen, whereas fentanyl deaths are on the rise, and thousands have suffered from it. Loved ones have lost family members to this drug which is why it should be classified as a schedule 1 drug. The risk to the public health, the potential for abuse, and dependency alone should classify it as a schedule 1 drug. Instead of extending the rule to December 31, 2024, put fentanyl as a schedule 1 drug today.", "comment_id": "DEA-2023-0058-0005", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2023-0058-0005", "comment_date": "2023-04-18T04:00:00Z", "comment_title": "Comment on FR Doc # 2023-07576", "commenter_fname": "Dazi", "commenter_lname": "Psurny", "comment_length": 730}, {"text": "
The Drug Enforcement Administration (DEA proposes to permanently schedule the following nine controlled substances in schedule I of the Controlled Substances Act (CSA). The nine specific fentanyl-related substances are: (1) Meta-fluorofentanyl, (2) Meta-fluoroisobutyryl fentanyl, (3) Para-methoxyfuranyl fentanyl, (4) 3-furanyl fentanyl, (5) 2′,5′-dimethoxyfentanyl, (6) isovaleryl fentanyl, (7) ortho-fluorofuranyl fentanyl, (8) alpha′-methyl butyryl fentanyl, and (9) andpara-methylcyclopropyl fentanyl.
I agree that Drug Enforcement Administration should make the nine Fentanyl-related substance listed under the category of Schedule I drugs permanent instead of constantly extending the temporary order multiple times. First it started on February 6, 2018, then two years later February 6, 2020. Then the Congress extended until May 6, 2021, after it was extended on December 29, 2021, and now the order was extended until December 31, 2024. After the extended order expires on December 31, 2024, this order should be made permanent, honestly, it should’ve been made permanent already. By finalized this rule, the federal law can act against the people who are handling these nine specifics fentanyl substance. Over 150 people die every day from fentanyl-related drug overdoses. I think it is time to take action against this fatal drug.
", "comment_id": "DEA-2023-0058-0011", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2023-0058-0011", "comment_date": "2023-05-17T04:00:00Z", "comment_title": "Comment on FR Doc # 2023-07576", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 1422}, {"text": "The designation of Nine specific Fentanyl related substances to Schedule I of the Controlled Substance Act should be made permanent after the temporary scheduling order expires on December 31, 2024. Fentanyl-related drug overdoses have been increasing throughout the US according to the National Institute on Drug Abuse. The Proposed rule states in the background information that these substances pose an imminent hazard to public safety, as citizens we see this news daily about the effects of fentanyl in communities across the country. In section 1 (a) the criteria for the potential of abuse is described through evidence that taking the drug will create a hazard to their health or to the safety of others in the community, it is clearly a hazard because of all the deaths that have been occurring due to Fentanyl overdose and the destruction it is causing in communities. Fentanyl and the list of related substances listed in the Rule being in a category of Schedule I drugs would allow for regulation of the substances and improve the Public’s Health from the negative effects of this drug.", "comment_id": "DEA-2023-0058-0006", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2023-0058-0006", "comment_date": "2023-05-01T04:00:00Z", "comment_title": "Comment on FR Doc # 2023-07576", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 1104}, {"text": "Discussion
Nine drugs are being suggested to be added to Schedule I of the Controlled Substances Act by the Drug Enforcement Administration (DEA). These substances are stated in the suggested regulation. The nine drugs all fulfill the criteria for fentanyl-related compounds defined in the interim scheduling directive from February 6, 2018. The Temporary Reauthorization and Study of Emergency Scheduling of Fentanyl Analogues Act stretched the power until December 31, 2024, and the Consolidated Appropriations Act of 2023 expanded it. If adopted, the proposed measure would irrevocably limit the nine particular compounds and impose punishments on any person found in the ownership of, manufacturing, importing, exporting, engaging in academic study, conducting chemical examinations, importing, or managing them in any other manner.
Direct and indirect effects on federal-state healthcare would result from the policy as mentioned above. Directly stated, it would boost federal oversight of manufacturing and disseminating possibly harmful chemicals, limiting their availability and expected abuse (Pardo et al., 2023). Furthermore, it would keep these drugs off the black market, giving the federal level greater assurance to administer and utilize drugs. By demonstrating the federal government's commitment to ensuring the well-being and protection of its residents, the policy move would help significantly increase public confidence in the medical field.
I support the suggested regulation in its entirety. The federal level must have a role in reducing the consumption of such drugs in a society where opioids are putting an ever-increasing strain on medical care. Rigorous regulatory oversight and criminal penalties for perpetrators will guarantee that authorities can effectively administer the law. It is critical to restrict the utilization of fentanyl replicates to people who need them for serious medical needs. Establishing a regular schedule, I classification for these medicines aids in ensuring that they are applied prudence and remain accessible for recognized medical purposes. Furthermore, raising public knowledge of the risks of abusing these drugs benefits their prevention. The suggestion is in line with this requirement and ought to be accepted.

Reference
Pardo, B., Kilmer, B., & Taylor, J. (2023). Illegal Supply and Supply Control. AMERICA’S OPIOID ECOSYSTEM, 273. https://www.jcoinctc.org/wp-content/uploads/RAND_Americas-Opioid-Ecosystem_2023.pdf#page=295", "comment_id": "DEA-2023-0058-0008", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2023-0058-0008", "comment_date": "2023-05-17T04:00:00Z", "comment_title": "Comment on FR Doc # 2023-07576", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 2531}, {"text": "The proposed regulation by the Drug Enforcement Agency (DEA) would permanently classify nine fentanyl-related substances as schedule 1 drugs. These substances were placed on a temporary schedule since February 6, 2018, and since then has been extended multiple times by Congress. However, this temporary order will expire on December 31, 2024, but the DEA is hoping to classify it as schedule 1 permanently thereafter. This would keep in place all regulations and law pertaining to how schedule 1 substances are handled, distributed, manufactured, or sold by anyone who handles the drug whether for illegal purposes or not.
This will affect healthcare on a federal level because the ongoing opioid crisis has seen multiple agencies across the government trying to bring this public health crisis under control. “There were about 1,550 pediatric deaths from fentanyl in 2021 – over 30 times more than in 2013, when the wave of overdose deaths involving synthetic opioids started in the US. A surge that began in 2018 led to a nearly 3-fold increase in deaths among older adolescents and a nearly 6-fold increase among children younger than 5. In 2021, 40 infants and 93 children ages 1 to 4 died from a fentanyl overdose (McPhillips, 2023). There are no reasons that children or anyone should be exposed to this drug because even a small amount can be deadly.
I would have to agree with this proposed regulation of classifying fentanyl-related substances as a schedule 1 drug with the ongoing epidemic of the opioid crisis that has grip the nation. Fentanyl is highly addictive being 50 to 100 times more potent than morphine (Fentanyl Drugfacts, 2023). While prescription fentanyl is given to some patients who have chronic pain or have had major surgery other alternative medications should be prescribed first leaving fentanyl as a last resort. While there’s an understanding that we will probably never get rid of substances such as fentanyl at least people might think twice about distributing it to others because it is such a highly addictive drug.
Reference
McPhillips, D. (2023, May 8). Fentanyl-related deaths among children increased more than 30-fold between 2013 and 2021. CNN. https://www.cnn.com/2023/05/08/health/fentanyl-overdose-deaths-children/index.html
U.S. Department of Health and Human Services. (2023, March 3). Fentanyl drugfacts. National Institutes of Health. https://nida.nih.gov/publications/drugfacts/fentanyl

", "comment_id": "DEA-2023-0058-0009", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2023-0058-0009", "comment_date": "2023-05-17T04:00:00Z", "comment_title": "Comment on FR Doc # 2023-07576", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 2489}, {"text": "The topic being proposed is the placement of nine fentanyl-related substances into Schedule I of the Controlled Substances Act. This proposal aims to combat the growing opioid epidemic in the United States by making it more difficult to produce and distribute these dangerous substances.

According to a news article by NPR, these nine fentanyl-related substances are not currently classified as controlled substances, which makes it easier for manufacturers to produce and distribute them without facing legal consequences. However, the proposed ruling would add these substances to Schedule I, which is reserved for drugs with a high potential for abuse and no accepted medical use.

At the federal level, this proposal could have significant impacts on the healthcare industry. It could lead to increased regulation and oversight of fentanyl-related substances, which could help prevent the misuse and abuse of these drugs. However, it could also make it more difficult for medical professionals to access these substances for legitimate medical purposes, which could potentially harm patients in need of pain management.

Overall, I agree with the proposed ruling to add these nine fentanyl-related substances to Schedule I. The opioid epidemic in the United States has had devastating effects on communities across the country, and it is important to take strong measures to combat it. While there may be some challenges associated with increased regulation of these substances, I believe the potential benefits outweigh the potential drawbacks.

", "comment_id": "DEA-2023-0058-0007", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2023-0058-0007", "comment_date": "2023-05-17T04:00:00Z", "comment_title": "Comment on FR Doc # 2023-07576", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 1584}, {"text": "The Drug Enforcement Administration (DEA proposes to permanently schedule the following nine controlled substances in schedule I of the Controlled Substances Act (CSA). The nine specific fentanyl-related substances are: (1) Meta-fluorofentanyl, (2) Meta-fluoroisobutyryl fentanyl, (3) Para-methoxyfuranyl fentanyl, (4) 3-furanyl fentanyl, (5) 2′,5′-dimethoxyfentanyl, (6) isovaleryl fentanyl, (7) ortho-fluorofuranyl fentanyl, (8) alpha′-methyl butyryl fentanyl, and (9) andpara-methylcyclopropyl fentanyl.
I agree that Drug Enforcement Administration should make the nine Fentanyl-related substance listed under the category of Schedule I drugs permanent instead of constantly extending the temporary order multiple times. First it started on February 6, 2018, then two years later February 6, 2020. Then the Congress extended until May 6, 2021, after it was extended on December 29, 2021, and now the order was extended until December 31, 2024. After the extended order expires on December 31, 2024, this order should be made permanent, honestly, it should’ve been made permanent already. By finalized this rule, the federal law can act against the people who are handling these nine specifics fentanyl substance. Over 150 people die every day from fentanyl-related drug overdoses. I think it is time to take action against this fatal drug.

", "comment_id": "DEA-2023-0058-0010", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2023-0058-0010", "comment_date": "2023-05-17T04:00:00Z", "comment_title": "Comment on FR Doc # 2023-07576", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 1422}]}, {"id": "SAMHSA-2023-0001", "title": "Medications for the Treatment of Opioid Use Disorder", "context": "2023-05-08T13:37:08Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "I think it would benefit greatly if Telemed appointments were permanently available for inductions/first visits.", "comment_id": "SAMHSA-2023-0001-0007", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2023-0001-0007", "comment_date": "2023-05-05T04:00:00Z", "comment_title": "Comment from Powell, Kennedy, HHS_FRDOC_0001, HHS_FRDOC_0001-0876, 2022-27193", "commenter_fname": "Kennedy", "commenter_lname": "Powell", "comment_length": 112}, {"text": "As a public health professional, I strongly urge SAMSHA to adopt the proposed changes to medications for opioid use disorder (MOUD) regulations to increase access to these lifesaving medications and enable people with substance use disorder (SUD) to successfully discontinue illicit drug use and reclaim their lives. I currently serve as deputy director of Virginia Harm Reduction Coalition, a 501(c)(3) nonprofit providing harm reduction services to people who use drugs (PWUD) in Southwest Virginia. I have witnessed firsthand the struggles our clients face in accessing MOUD, including not being able to afford to take time off work for appointments and facing stigma at work when they do, difficulties with getting childcare to facilitate appointments, and difficulties obtaining transportation to access appointments. I have witnessed clients struggle mightily to remain in treatment only to finally succumb to the weight of these barriers and relapse. The closest Medicaid-accepting methadone clinic to Roanoke, Virginia, is located 50 miles away in Martinsville. Methadone is much more effective for many of our clients than buprenorphine (especially since Virginia law makes obtaining buprenorphine without a naloxone component impossible for most patients). The availability of telehealth appointments for methadone patients and the ability of patients to receive up to 4 weeks’ worth of medication enables many more of our clients to enter and remain compliant with treatment. It is an absolute game changer. ", "comment_id": "SAMHSA-2023-0001-0014", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2023-0001-0014", "comment_date": "2023-05-05T04:00:00Z", "comment_title": "Comment from Zabielski, Barbie, HHS_FRDOC_0001, HHS_FRDOC_0001-0876, 2022-27193", "commenter_fname": "Barbie", "commenter_lname": "Zabielski", "comment_length": 1526}, {"text": "While I absolutely believe addiction and addiction issues are a significant problem, I wanted to make sure that my understanding (and my doctor’s understanding is correct as it was told to me, a pain patient). The proposal’s wording leaves no choice for someone taking opioids to NOT be dependent either physically or mentally. Meaning, it is appropriate to code all patient’s claims who use opioids as at least “opioid dependence” diagnosis. They have no choice to do this even if their doctors have zero dependency concerns documented in the medical chart. Even if the patient has no dependency issues with the opioid(s) being taken. And I am assuming there will be some sort of protections for the patients to ensure that there will be no denial of organ transplants, should they ever be needed in the future because of this coding. Because again, the patient and doctor had no choice.", "comment_id": "SAMHSA-2023-0001-0017", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2023-0001-0017", "comment_date": "2023-05-05T04:00:00Z", "comment_title": "Comment on HHS_FRDOC_0001, HHS_FRDOC_0001-0876, 2022-27193", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 918}, {"text": "Anything to make buprenorphine more easily accessible. It is by far the safest opioid. It's use to treat pain and opioid overdose should be studied and encouraged. It is safe enough to be dispensed over the counter to competent adults.
H B Edwards, MD
Addiction Psychiatrist
BehaveNet, LLC", "comment_id": "SAMHSA-2023-0001-0019", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2023-0001-0019", "comment_date": "2023-05-05T04:00:00Z", "comment_title": "Comment on FR Doc # 2022-27193", "commenter_fname": "HOWARD", "commenter_lname": "EDWARDS", "comment_length": 306}, {"text": "I am an OTP methadone patient. I've watched as federal and state laws have provided easier access to treatment. However, this means nothing if the OTP or Methadone clinic does not adopt these rules. I have 14 years 100% compliant in my treatment but my clinic will not allow me to have more than 6 take home doses. According to Samhsa and my state law I should be getting up to 27 doses. People at other clinics with less time clean can get more takehomes than me. But because you make these changes and do not require these opioid treatment programs to follow, nothing will change. It's a shame. You just let people suffer and die and do nothing about it. I am told by the people who run the clinic that they get paid more when we have to show up in person more. So it's become about these companies money and bottom lines and not peoples lives and treatment. You all should be quite ashamed of yourselves.", "comment_id": "SAMHSA-2023-0001-0020", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2023-0001-0020", "comment_date": "2023-05-05T04:00:00Z", "comment_title": "Comment on FR Doc # 2022-27193", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 919}, {"text": "January 24th, 2023

Substance Abuse and Mental Health Services Administration,
Department of Health and Human Services

Re: Notice of Proposed Rulemaking on Medications for the Treatment of Opioid Use Disorder

Dear Sir or Madam,
I am submitting a comment in response to SAMHSA’s proposed rulemaking “Medications for the Treatment of Opioid Use Disorder” published in the Federal Register on December 16th, 2022.

I am a 4th year medical student with a little more than 3 months left before graduation. I recently completed my addiction psychiatry rotation and I hope to practice as a Family Medicine Physician with a strong MOUD patient panel. I strongly support the rulemaking regarding the removal of stigmatizing language and inclusion of principles of harm reduction and patient centered perspectives. However, I would like to draw your attention to a few areas where you can better realize those ideals.

While the proposed change to methadone provision rules is an improvement to the pre-COVID days, it leaves many harmful practices in place. I would like to draw from the attached article by Frank et. al. published in the Harm Reduction Journal. Here, the authors affirm the importance of take-home doses, but note that the take-home dosing guidelines are the ‘ceiling’, not the ‘floor’, as “individual clinics can adopt stricter policies if they choose”. These policies can take many different forms, many of which are not addressed by the proposed rulemaking. I have also attached the “Methadone Manifesto”, published in the American Journal of Public Health. While the whole article is worth reading, Box A details some recommended additions/changes to the rule. Notably, the elimination of negative drug tests as a requirement for take home dosing, elimination of burdensome bottle return or lock box requirements, and prohibition of accelerated tapering schedules/financial detox (often insufficient for adequate withdrawal).

It is my belief that federal policy truly rooted in patient centered perspectives and harm reduction would include these provisions. I recommend reading both attached articles to push the proposed rule to be as patient-centered as possible. The MOUD policies should be as empowering and non-stigmatizing as the proposed language changes suggest. Thank you for the opportunity to submit a comment.

Sincerely,
Jay Mainthia

", "comment_id": "SAMHSA-2023-0001-0034", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2023-0001-0034", "comment_date": "2023-05-05T04:00:00Z", "comment_title": "Comment on FR Doc # 2022-27193", "commenter_fname": "Jay", "commenter_lname": "Mainthia", "comment_length": 2510}, {"text": "My name is Jeffrey A. Singer, MD and I am a senior fellow at the Cato Institute, in the Department of Health Policy Studies. Please see my attached comment on the Proposed Rule.", "comment_id": "SAMHSA-2023-0001-0015", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2023-0001-0015", "comment_date": "2023-05-05T04:00:00Z", "comment_title": "Comment from Singer, Jeffrey, HHS_FRDOC_0001, HHS_FRDOC_0001-0876, 2022-27193", "commenter_fname": "Jeffrey", "commenter_lname": "Singer", "comment_length": 177}, {"text": "I am totally NOT in favor of SAMHSA adopting the Proposed Rule as is, in its entirety because it will create a huge financial hardship on the agencies that receive funding based on being CARF accredited if given one year or a non-accreditation outcome for more than a few recommendations that could be resolved within 60-90-days. Without a lot of details regarding why SAMHSA is moving into this direction, it is very difficult to really assess the pros and cons. However, one thing that I know is that agencies work hard to comply with CARF standards as well as overall service delivery to consumers and to put these stricter expectations as well as time restraints on these agencies appears to be a setup for failure. No agency is perfect and to say an agency can only have a hand full of recommendation is not reality because of the overall diversity within all agencies. It is not a one size fit all type of situation. The reason why agencies have chosen to comply with CARF standards as initially written is because we were want to provide a high level of care to our consumer based on surveyors' overall feedback within a reasonable amount of time to correct issues, etc. This is not a agency at large friendly proposal. ", "comment_id": "SAMHSA-2023-0001-0042", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2023-0001-0042", "comment_date": "2023-05-05T04:00:00Z", "comment_title": "Comment on FR Doc # 2022-27193", "commenter_fname": null, "commenter_lname": null, "comment_length": 1238}, {"text": "I wanted to say that I think this is a good thing for MH & addicted patients, also think that MH patient for some if not most should not be taken away our rights to certain anxiety and panic attacks meds such as benzodiazepines. When I came to South Carolina from California I had to quit on my own wt benzodiazepines because no doctor here would refill it.I would like to suggest for more groups & resources for MH patients as is almost non existent here in SC. I don’t think MH or addiction should be stigmatized anymore.!!! Thank you ", "comment_id": "SAMHSA-2023-0001-0027", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2023-0001-0027", "comment_date": "2023-05-05T04:00:00Z", "comment_title": "Comment on FR Doc # 2022-27193", "commenter_fname": "Rose", "commenter_lname": "Muniz", "comment_length": 551}, {"text": "To expect a treatment center to not have a singular standard (out of 1900) out of conformance seems like an unrealistic expectation. If a surveyor finds one treatment plan out of all the charts that they look at and that treatment plan was completed a week after its due date. Then that would be the one singular out of conformance that they are allowed to have for their entire survey (now they know they are only going to get a one year and they are stuck in compliance nightmares all year for every clinic they have). This regulation would force surveyors to decide if they should make any recommendations to the clinic to help them improve or decide that it is crucial for the clinic to stay open to treat patients so they must ignore any issues and just issue a perfect 100% survey at every location to ensure access to treatment for patients. It defeats the purpose of professional consultation and makes the survey process punitive.", "comment_id": "SAMHSA-2023-0001-0040", "comment_url": "https://api.regulations.gov/v4/comments/SAMHSA-2023-0001-0040", "comment_date": "2023-05-05T04:00:00Z", "comment_title": "Comment on FR Doc # 2022-27193", "commenter_fname": "Scott", "commenter_lname": "N", "comment_length": 943}]}, {"id": "DEA-2011-0007", "title": "Controlled Substances and List I Chemical Registration and Reregistration Fees", "context": "2021-12-02T01:00:46Z", "purpose": "Rulemaking", "keywords": null, "comments": [{"text": "I think the fee increase is not a great idea. Most practices have encountered losses in the past 2 years due to Medicare and Medicaid reimbursement cuts. In the area in which I work, we have a 75% Medicaid/Medicare population and we take care of patients most practitioners won't due to the insurance issues.

I think instead, every practice who cannot provide proof of a 15% medicaid and at least a 30% Medicare patient population (both), should have thier rates increased for the rest of us who provide care to those without private insurance.

With gas, food and everything else increasing, and reimbursements dwindling; this is not a good time to increase fees for somethin which is mandatory for practice.", "comment_id": "DEA-2011-0007-0007", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2011-0007-0007", "comment_date": "2011-08-02T04:00:00Z", "comment_title": "Comment on FR Doc # 2011-16847", "commenter_fname": "Kathleen", "commenter_lname": "Glass", "comment_length": 732}, {"text": "I work as an NP in a non-profit, hospital based practice, covering three subacute rehab/LTC facilities. I have received a cost-of-living increase or less increase annually because of the economy, not because of my performance. The prescriptions I write are for long term care residents, patients at the end-of-life and post-op patients. Neither I nor my practice have the financial where-withall to support increased DEA fees. I think fees should be based on practice setting along with license to prescribe. I do not make a six figure salary, nor do I anticipate making a six-figure salary in my lifetime. I suggest the DEA review its licensing fees and adjust by practice and specialty.", "comment_id": "DEA-2011-0007-0006", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2011-0007-0006", "comment_date": "2011-08-02T04:00:00Z", "comment_title": "Comment on FR Doc # 2011-16847", "commenter_fname": "Lee", "commenter_lname": "Holfelder", "comment_length": 694}, {"text": "I am opposed to raising the cost of DEA application fees. The cost is just another barrier to NP practice. It will keep some NPs from being able to provide patients with prescriptions for controlled substances. This will prevent patients from getting adequate relief of symptoms in many cases.", "comment_id": "DEA-2011-0007-0175", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2011-0007-0175", "comment_date": "2011-09-06T04:00:00Z", "comment_title": "Comment on FR Doc # 2011-16847", "commenter_fname": "Kerri", "commenter_lname": "Cook", "comment_length": 293}, {"text": "This proposal to raise fees for DEA number applications is a huge barrier to practice. I am a new NP and quite frankly cannot afford a $700 fee.
Please reconsider raising the fee. ", "comment_id": "DEA-2011-0007-0179", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2011-0007-0179", "comment_date": "2011-09-06T04:00:00Z", "comment_title": "Comment on FR Doc # 2011-16847", "commenter_fname": "Marion", "commenter_lname": "Alston", "comment_length": 184}, {"text": "This fee is the most expensive that I am required to pay. At present $550.00 every three years. An increase in this rate will cause hardship on myself and other mid-level providers that must meet the requirement. Please know that our salaries are not so large as to make this fee affordable. Thank you for the consideration of what the fee increase will mean for us.", "comment_id": "DEA-2011-0007-0167", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2011-0007-0167", "comment_date": "2011-09-06T04:00:00Z", "comment_title": "Comment on FR Doc # 2011-16847", "commenter_fname": "Anna", "commenter_lname": "Bovee", "comment_length": 370}, {"text": "I propose that the DEA application fee's DO NOT increase for Nurse Practitioners", "comment_id": "DEA-2011-0007-0174", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2011-0007-0174", "comment_date": "2011-09-06T04:00:00Z", "comment_title": "Comment on FR Doc # 2011-16847", "commenter_fname": "colette", "commenter_lname": "frena", "comment_length": 84}, {"text": "I don't agree that the application fee for a DEA number should be raised for midlevel providers", "comment_id": "DEA-2011-0007-0184", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2011-0007-0184", "comment_date": "2011-09-06T04:00:00Z", "comment_title": "Comment on FR Doc # 2011-16847", "commenter_fname": "Jeannine", "commenter_lname": "Hoshino", "comment_length": 99}, {"text": " I respectfully ask that you reconsider raising the rates for DEA licensure. To do so would place financial constraints and barriers to Nurse Practitioner practice. Nurse Practitioners fill vital gaps in underserved areas and populations. Many positions carry no provisions for reimbursement of necessary licensure and fees, leaving the Nurse Practitioners to absorb this cost on their own.

Even if the cost were paid by a supervising physician, there might be a reluctance or inability to absorb the additional cost.

Nurse Practitioners take their prescribing privileges very seriously. We are invested in our profession and the well being of our paitents. Please do not add unnecessary obstacles to providing care. This decision would have far-reaching implications.", "comment_id": "DEA-2011-0007-0162", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2011-0007-0162", "comment_date": "2011-09-06T04:00:00Z", "comment_title": "Comment on FR Doc # 2011-16847", "commenter_fname": "Kimberly", "commenter_lname": "Callahan", "comment_length": 787}, {"text": "I am a certified nurse midwife in Indianapolis. In order to practice full-scope care to my clients, I maintain an active DEA. I do not receive any reimbursement or funding from my hospital or employer for this registration. I believe this large of a fee increase is truly prohibitive to practice in the current environment of healthcare budget restrictions. ", "comment_id": "DEA-2011-0007-0160", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2011-0007-0160", "comment_date": "2011-09-06T04:00:00Z", "comment_title": "Comment on FR Doc # 2011-16847", "commenter_fname": null, "commenter_lname": null, "comment_length": 364}, {"text": "Increases in the cost of maintaining a DEA number were inevitable, however this increase in light of a decreasing cost of administration with electronic registration and the proliferation of EMRs with improved potential for monitoring, is excessive and unwarranted. At a time when our incomes are being cut from every angle, from reimbursement to administrative costs, this would seem ill advised. Please consider that in addition, there is a tremendous amount of wasteful spending in the unnecessary and burdonsome costs associated with prescriptive limitations placed on NPs and PAs. Eliminating some of this waste would decrease expenses for the DEA thereby providing moneys from the cost savings. Please consider your support of this measure carefully. Thank you for seeking feedback on this issue.", "comment_id": "DEA-2011-0007-0149", "comment_url": "https://api.regulations.gov/v4/comments/DEA-2011-0007-0149", "comment_date": "2011-08-29T04:00:00Z", "comment_title": "Comment on FR Doc # 2011-16847", "commenter_fname": "Victoria", "commenter_lname": "Tyra", "comment_length": 802}]}, {"id": "HHS-OS-2018-0009", "title": "Meeting of the Pain Management Best Practices Inter-Agency Task Force ", "context": "2019-01-11T01:03:34Z", "purpose": "Nonrulemaking", "keywords": null, "comments": [{"text": "I am a chronic pain person. I have for last 5 yrs taking 2 ophiod medication a day. This is the only medication that works. I have done over the counter pills, therapy, injections , chiropractor, surgeries, ect to no relief of my pain. I have had four shoulder surgeries for torn rotator cuff and now have a calisfied shoulder. CDC now says 90 mm is my limit. My doctor has tried about every medication to try but did not help. Herion is what is causing deaths and now doctors are being arrested for writing ophiod prescriptions and this is wrong. The data includes all ophiod related death. Why is there a break down of herion only death data? This is a witch hunt and attack on the innocent for chronic pain and their doctors. What we need is for law enforcement to do their job and stop the illegal herion,fentanyl from being sold in this country. These laws on ophiod criss has no barring herion use but harming chronic pain patients and their doctors. You are now forcing doctors to turn away the chronic patients to commit sucide because they have no way for quality of life from severe pain that none of you have ever experienced. It should be up to doctors not government to determine how to treat chronic pain. We have all been put on a list, tested, pill counts, ect which a conviced person is not made to do but yet more death have gone up from herion. Anytime government gets involved it does more harm than good. Please listen to the chronic pain patients and doctors and quit harming all of us as your laws and guidelines are harming us and not helping herion addictions. I now if go to hospital, I have to bring my medication or no help for pain from surgeries as hospitals will not give you medication ordered by surgereons. Putting doctors in jail is wrong and making decissions on how to treat is the doctors decision and not to be prosciuttoed for treating patients. DEA should not be arresting private pain management offices and making doctors to turn away patients for treatment. Why don't you pass laws on herion addicts for their use? These laws and forced guidelines have done more harm to the innocent chronic pain patients than the herion addict. PLEASE wake up and get data on death you have caused now on innocent people who did not have any addictions but to have a quality of life to have some relief of their pain. It has been documented that chronic pain patients do not develop addictions but only relief of pain. Limiting surgery patients for pain medication is wrong and should not be lumped into one group as every surgery, person have different levels of pain than government telling you your pain level should be. Please I beg your to stop passing laws and guidelines you have no business in. Only the health insurance companies are benefiting as they now will not pay for it. You need to stop and help turn back the guildelines that were in affect in 2012. Chronic pain patients are now being treated as criminal for suffering from diseases, bad surgeries, ect and now suffer from pain and ophiod prescriptions are only pain relief for a quality of life you have now taken away from them and prison doctors and clinics for trying to help chronic pain patients. So wrong and I can only hope you read this and do the right decisions and stop making bad laws and guidelines that have not stop herion addictions and herion from being sold in this country. Also CDC have admitted data are not correct.
", "comment_id": "HHS-OS-2018-0009-2014", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0009-2014", "comment_date": "2018-06-18T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-09379", "commenter_fname": "Kathleen", "commenter_lname": "Queen", "comment_length": 3479}, {"text": "

I am judged on my appearance, I have tattoos, but I have never failed a drug test, not ever. If a doctor is going to judge on appearance then they need to acknowledge LACK of signs of addiction, I dont slur my words, I dont lack hygiene, I dress appropriately for the weather, I dont ask for early refills, Im not impoverished, or living outside my means.

I am 54, started paying into social security when I was ELEVEN years old, on disability for an inoperable back since the late 90's (approved in 10 days time FROM APPLICATION-FACT) , I have vertebra L4 shattered in 4 pieces.I have been on Norcos since the 90's, never failed a drug test, never asked for early refills. I lost my pain doctor, I was abandoned actually, and now I am treated as a drug addict teenager. I am sick of being categorized alongside the dregs of society. All Ive ever done is help people, and Im tired of being treated like Im one of the problems with society.

I informed my PCP that I had witnessed drug sales IN THEIR LOBBY, to which they didnt even respond, but when I needed medications from that office I was shunned and lied to, and treated like I was a criminal.

Doctors need better guidance from you, as they seem too scared to act outside of what they PERCEIVE to be the parameters (what I interpret as lack of own self confidence).They too often discontinue meds, or refuse to continue meds, absent fact or finding of fault on the part of the patient . The denial of appropriate care is a violation of a basic human right, ESPECIALLY in a country that legislates healthcare !!!

I suspect my own PCP of illicit or abusive drug use, perhaps doctors should submit to testing as well, and be allowed to express that they are openly "clean" as well, and not addicted to any substances.How many doctors are actually hiding their own addictions, while cutting legit pain patients off their meds ?

Doctors need to be reminded to FIRST DO NO HARM , not all people prescribed pain meds are drug abusers.Even addicts need to be treated with compassion, not judgment , ostricisation , and lack of care.

Doctors need to acknowledge individuality in their patients, and not group all pain patients into one nefarious category,THAT is medical negligence. If we are not supposed to take other patients meds, then we should not be looked at in the same negative category as any other patients.

It isnt fair to my family, or anyone around me ,for me to be hurting and compromised , and be grumpy , because some doctor is on a power trip, so busy knowing it all, that they fail to acknowledge any facts.Its hard to trust any doctor after being treated this way. I have been abandoned by four doctors in a row, I have had medical records LOST by doctors.

The only thing Im guilty of is wrecking my body (once worked 9 days with a broken back, got harder by the day), working to take care of my family and pay my taxes like a real american , I didnt ask to be put on disability and I sure didnt ask to be put in the position I am in now, denied proper medical care because of someone elses actions. How can I have any quality of life if it is taken away from me ?

I am attaching a copy of parameters that was not compiled by me, but by my wife, and I wholeheartedly agree with all the points outlined in it. (I also use my wifes email address, please do not disregard my comments due to a shared email address.)


", "comment_id": "HHS-OS-2018-0009-1949", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0009-1949", "comment_date": "2018-06-18T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-09379", "commenter_fname": "Lawrence", "commenter_lname": "Garner", "comment_length": 3511}, {"text": "To whom it may concern, I am a 40yr old chronic pain patient, I'm legally disabled and have been treated by a pain management Dr for over 5yrs. When the CDC guidelines came out, nearly every Dr/specialist/dentist/etc..began taking meds from every patient, terminal, chronic, and acute pain patient's alike - all because of incorrect data and overreaction. Now millions of people, including myself, have been left suffering in pain, and what is that going to accomplish? Nothing!!! Chronic pain patient's are seeking a life with less pain, while addicts are seeking a high, taking anything they can find, which is more often than not, a drug that's been smuggled in or made by an at home "chemist", who's putting Lord knows what into them - Fentanyl, as we all know, is used very often. When research into the actual cause of listed opioid deaths is completed, 99% of the cases involved Fentanyl, Oxycontin, Morphine or Heroin, occasionally Xanax or Valium was also present. Nearly all were known drug addicts, taking too much while chasing a high, while pain mgmt patient's take the same amount every day, and don't take more than prescribed! For me, with my overactive thyroid, any medication I take to work only half as long as it's supposed too, from the very first dose, and now because of the CDC guidelines, my Dr cut my medicine amounts in half without warning or cause, purely based on the CDC 90 MME number, which does not take into account metabolism and genetics affecting the efficacy of meds for each person's body and metabolism. I agree that Dentists and primary care Dr's treating acute pain patient's should not be prescribing the strongest, more addictive meds, without at least consulting a specialist. I lost my younger brother to a heroin overdose in 2011, he switched after becoming addicted to Oxycontin, which his dentist gave him oxy for a toothache!!! It wasn't abscessed or severe, yet the dentist gave him one of the most abused/strongest meds on the market. He was an addict, stealing to support his habit, only wanting to get high, and after numerous times going through rehab, and even overdosing once already, nothing scared him enough to want to stop using. I believe he'd still be alive if that dentist hadn't prescribed it.
Treating every person as if we're addicts, and all built the same, absolutely will not work, and it will do nothing to stop the number of overdose deaths, if anything, they'll increase, as chronic pain patient's either commit suicide because they can't live with the pain anymore, or, they themselves turn to buying illegal drugs on the streets, just trying to get some relief, and die from some nasty concoction that isn't what they expected. The 2 meds I take, are not listed one single time as cause of death, and yet they're affected because they're categorized the same as the one's people are actually dying on. We need individualized health care, built to each person's body, genetics and metabolism - we're not one size fits all! Stop punishing millions of innocent people, keep in mind that if we can't walk, stand, sit, etc...we won't be able to vote either! Go after the true source of the problem, illegally manufactured and smuggled drug's - not chronic pain patient's just trying to live a semi-normal life with less pain. Thank you for your time, Jennifer V
", "comment_id": "HHS-OS-2018-0009-0004", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0009-0004", "comment_date": "2018-05-24T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-09379", "commenter_fname": "Jennifer", "commenter_lname": "Vinnard", "comment_length": 3470}, {"text": "I am 62 year old disabled woman. I have osteoporosis and I have suffered two major BURST fractures and have lost count of how many compression fracture I have suffered. I suffed at least 2 compression fractures that were between 25%-50%. I have suffered a dislocated fracture of my R wrist an external device was used to set that fracture. I have broken of my feet at least twice. I suffered 3 compression fractures at my neck when I was knocked out by a 40 lb block of ice that fell off an M1Tank while I was working at APG, MD. I have at least 2 buldging discs and a pinched nerve at my T12 vertebra. I have Fibromyalgia, arthritis thru out my back, DDD and migraines.
In an effort to deal with my chronic pain issues I have spent, out of pocket, over $10,000 on epidurals, acupuncture, Thi chi classes, maggage, chair yoga classes, vitamins, essential oils, herb and PT. I currently walk 3 miles almost every day and eat a healthy diet. While these things help me deal with my chronic pain I still can not function without my opioid pain medication. I have been on them for 20 years. About 10 years ago I came off of my pain medication for approximately 2 years because I wanted to see how my body felt. During that year my life went down hill. I barely made it too work because I was in so much pain, I was not able to do any chores around the house, I never had sex with my husband, I was unable to exercise and I had no social life at all. The pain was so severe that I could not be around my grandchildren. Then in March of 2011 I was in an accident that resulted in a 60% burst fracture. Since the accident I have remained on pain medication Oxycontin. I experienced an unusually long recovery time because of the osteoporosis. I was not a candidate for "cement" fill because the vertebra was shattered and the "cement" would have leaked though the veterbra which would have caused me to be paralyzed. This was confirmed by two orthopedic surgeon. I also want to mention that I had both my knees replaced in 2016 and 2017. Knee replacements do not make you 100% pain free.

After my burst fracture in 2011 I was put back on Oxycontin. I built tolerance to the Oxycontin because my recovery time was so long and because I was in a great deal of knee pain. My orthopedic surgeon wanted me to wait until I was 60 before he would replaced my knees I would not turn 60 until 2016. During the time with my PCP I felt that my pain was adequately managed. I held a job, was able to have limited visits with friends and family and exercise 3 times per week. In 2014 my Primary Care Physician (PCP) told me that things were changing...that due to opioid overdoses the CDC was writing guidelines for opioid prescribing and he felt I would be better served going to a Pain Management Doctor (PMD). The first thing the PMD did was cut my Oxycontin in half. His reasons were that the drugs were no longer working for me. This was devastating for me and my life completely changed over night. I was no longer able to work, exercise or socialize. During the next 4 weeks he lowered my meds 2 more times. I suffer terribly but despite excruciating pain I try really hard to do the things I HAVE to do to try and help my pain and stop my osteoporosis from getting worse. Now my doctor says he does not know how much longer he can continue to prescribe my opioid pain medication. I can not take even more pain. Please do not prevent doctors from prescribing pain medication to chronic pain patients. Please do not take away my pain medication I would lose the ability to function. There has got to be a way to handle this opioid (heroin) crisis without making pain patients suffer. It is inhumane, torture and cruel. We are suffering we are losing hope and some of us are contemplating sucide. I am begging you don't take our meds away. Sincerely Kathy Dominick

", "comment_id": "HHS-OS-2018-0009-0006", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0009-0006", "comment_date": "2018-05-24T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-09379", "commenter_fname": "Katherine", "commenter_lname": "Dominick", "comment_length": 3899}, {"text": "Any coordinated federal policy on pain management must start with the role of government. Government has a compelling public interest in prosecuting pill mills and shutting down the illicit drug trade. Government should have no role in regulating what dosages physicians prescribe to legitimate patients.

Patients in pain management need two things from the federal government:

1) The CDC must immediately revise opioid prescribing guidelines to clarify that benchmark dosages do not apply in cases where pain is intractable, the painful condition is expected to last a lifetime, and other treatments have been ineffective or do not yet exist. Patients with a lifelong diagnosis of intractable pain should get the same exceptions from dosage limitations that cancer patients get - at the doctor's office, at the pharmacy, and for every insurance plan covering prescription medication.

2) The DEA and state medical boards must never target physicians for disciplinary review based solely on number and dosage of opioid prescriptions, absent other evidence of criminal activity. Doctors who specialize in treating intractable pain will prescribe more pain medicine at higher dosages. Treating this as a warning sign in itself is, in effect, federal discrimination against patients with disabilities.

For the last twenty years I've been in pain management for a lifelong condition called IC/BPS. There is no cure, and the cause is unknown; the most likely theory is that it's autoimmune.

To give you an idea what that is, imagine your body is mis-programmed to punch bloody holes in your bladder 24/7. Imagine urine dripping in from your kidneys feels exactly like salt on a hundred razor cuts, and the only (partial) relief is peeing.

Unfortunately I am one of the 5% with my diagnosis for whom all known treatments (diet, non-opioid medication, electrical stimulation, weeks in a multidisciplinary pain clinic, physical therapy, meditation/hypnosis/mindfulness, alternative medicine, pouring various medications into my own bladder through a catheter multiple times daily, and all other treatments currently known to science) have no effect.

Barring a research miracle, this will continue for the 40+ years I have left to live.

Combined with other coping strategies, pain medication gives me a productive, near-normal life. Pain medication has allowed me to earn a doctorate, teach college, and raise a healthy, happy son with my loving husband.

With my current treatment, managed by a pain specialist, I can be away from a toilet for up to an hour. I can teach class, fly on a plane, and walk in the park with my child. In twenty years, I have never achieved that level of functionality with any other treatment. At or below dosages recommended by the CDC, I get approximately ten minutes between bathroom visits. Needless to say, this is not consistent with working, parenting, or any semblance of a normal life.

Consider an analogy: Suppose you are visually impaired, and need a cane to get around. Suppose there's a national epidemic of people beating each other with canes. Would the solution be to make canes illegal? Clearly not - this would deny millions of Americans with disabilities a legal accommodation they need to participate in society.

My lifelong disability requires pain medication as an accommodation for me to participate in society, just as a person who uses a wheelchair requires a ramp.

Please reject the false and insidious narrative that opioid medication is only for cancer and end-of-life care. I am living proof, there is such a thing as palliative care - care for a disease with no known treatments remaining - that is not also end-of-life care.

As your task force meets, you may hear stories of chronic pain patients started on long-term medication too soon, before non-opioid treatments had been fully exhausted. Please also remember, your policy must serve patients for whom that is not remotely the case.

When you hear the claim that "quality of life is always better without opioids," I urge you to please remember me.", "comment_id": "HHS-OS-2018-0009-0005", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0009-0005", "comment_date": "2018-05-24T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-09379", "commenter_fname": "Anonymous", "commenter_lname": "Anonymous", "comment_length": 4207}, {"text": "I am a long term chronic pain patient who uses opiates to have any quality of life at all. I have RA, Sjogrens Syndrome, Fibromyalgia, Osteoarthritis, ulcerative colitis, intercystial cystitis I have had pain since I was a child. We were too poor at the time to have it doctored so I was given aspirins. Then I took ibuprofen until I developed ulcers of the esophagus and even developed Barrents esophagus. Opiates are the only thing I can take safely now. Have you ever felt so ill that you couldnt get up to go to the doctor? As a pain patient, my life is now knowing I have to go over to my doctors office every month to get a script to fill. It doesnt matter how exhausted I am or how much pain I am in, it has to go like that now. A blizzard could be on its way and you still cant get them filled any sooner than the exact date. I would think that electronic scripts would be way more crime proof than this way. I dont have an issue getting my blood pressure meds, stomach meds or any other filled. I get to the pharmacy counter where I have to prove myself to get a drug that is prescribed by a doctor. A doctor who knows and has already assessed my need for it. Meanwhile, I see people buying carts of alcohol and carton of cigarettes. No issue. No explaining. Every month I live in fear of being cut off or tapered down. If the DEA is going into the addiction prevention business, they should include alcohol and tobacco as they are drugs. I have been working for a drug prevention coalition in my area for 15 years. I understand addiction and drug trends. The opiate/heroin issue is fading replaced by meth for adults and vaping for youth. The outcries to fix the opiate issue will lessen because the suburbs will feel safe again. Meth is considered a redneck drug and there will be no outcry to fix that ...Meanwhile, pain patients will be the true victims of this war. I urge you to stop trying to baby proof the world. It doesnt work.", "comment_id": "HHS-OS-2018-0009-0057", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0009-0057", "comment_date": "2018-05-24T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-09379", "commenter_fname": "Donna", "commenter_lname": "Thacker", "comment_length": 1946}, {"text": "Too many chronic pain patients are going to be suffering even more because their doctors are afraid to prescribe pain medications now. You need to figure out where the people who are dying from opiates are getting them from. The people that I have heard of that have died bought them from someone not knowing that they were laced with fentanyl. I think you are targeting the wrong audience. You don't know how despairing it is when your doctor tells you that they will not treat your pain anymore.", "comment_id": "HHS-OS-2018-0009-0099", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0009-0099", "comment_date": "2018-05-26T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-09379", "commenter_fname": "Traci", "commenter_lname": "Morgan", "comment_length": 501}, {"text": "I've been dealing with Pain Management for several years now, its always the same band aid fixes used by different doctors that have short lived results.

I'm 51 years old, I have Osteoarthritis, degenerate joint disorder, spinal stenosis, Fibromyalgia, and compilations from hip replacement. Theses are the major issues I have that have also caused smaller issues that have become quite painful in just dealing with daily living.

I've been given oral medications, topical medications, spinal injections, and physical therapy. I've had several operations that have led to more complications, total hip replacement led to infections and multiple surgeries. Shoulder surgery led to muscle wasting and limited use of my left arm, and finally neck surgery where fixtures backed out and now my neck wants to go forward.

Now i'm on the verge to start yet again more issues that came from complications, the roto cuffs in both my arms have been effected. Along with the trap muscles in my shoulders are in constant spasm due to both my neck and shoulder issues. I know how the proces works, you go see your family physician who in turn will send me to see a Orthopedic surgeion. I will undergo MRI's, Xrays, and maybe changes in my medications, I am now at the point where it may involve some type of surgery again. But I know that no matter what is done to me I will be in chronic pain for the rest of my life.

I used to work for a major health insurance company I fully understand benefits and the changes that have been made concerning opid medications. Now we have alternative medications and services that are out there but are non covered by the Health insurance companies and guidelines. Through several of the persons who have preformed physical thereapy on my person have advised me things and then would say but its none covered. I want to address this now.

Acupuncture: Per my health insurance which is Medicare they will purchase or rent a muscle stimulator or Tens unit but not cover Acupuncture. As a person who is looking for releif how am I to know what will and will not work if I'm given a band aid of a Tens unit that after a period of time I keep turning it up to dull the nerves in my body to the point it doesn't work any more? Can I try Acupuncture? No its a none covered benfit under my health insurance, As a widow living on social security disability this will not fit in my budget. So I can not tell you if this will work for me to help control pain.

Physical massage therapy: I can have as a covered benefit if my Doctor prescribes physical therapy part of this therapy can be Physical massage but its limited to moduals of time and never extends past that. As I have a person preforming physical therapy on my body in the form of the modual of physical massage I am always being told I would benefit from more massage. But due to the limitations in benefits and services this is a Non covered Benefit by pretty much every single health insurance company.

Medical marijuana: Yes I carry a Medical marijuana card but lets look at this please. One obtaining a card is not covered by Health insurance. The fee was $200 for a doctor to approve and confirm I meet one or more of the conditions. Next its either $50 dollars for the card that is full price on the website or $25 dollars if your on assistance programs. Then you will have follow up appointments with the physician that is $100 each. Then finally the products weather its oils, foods, vaps and so on all of that is out of my pocket. As a person living on assistance and social security disability plus a recent widow, this all is a huge hit on my pocket.

So in the years that I've required Pain management so much has changed that I feel I have no quality of life anymore. Since I'm a recent widow things have gotten worse on my end in just normal home management. Yes you have a Opid problem in the united states but this has caused us the people who are suffering already limited on what we can and can not do to give us just a moment rest, a good nights sleep, or maybe some quality in life.

I've given up on what anyone can do to help me, being a chronic pain sufferer I now have medical issues I've never thought I would have to deal with besides Pain. High blood pressure, Diabietes type II, Insomia, Depression, Anexity, Concentration issues, forgetfulness, liver monitoring due to medications. And the Physicians will have a pill for everyone of them issues but the one thing that is making my life a total hell. PAIN

", "comment_id": "HHS-OS-2018-0009-0104", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0009-0104", "comment_date": "2018-05-26T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-09379", "commenter_fname": "Sharon", "commenter_lname": "Williams", "comment_length": 4674}, {"text": "My mother was continually cut down on her pain medication by her doctor. She has had Hepatitis C since her early 20s and has tried interferon treatments several times and it didnt work. This last time almost killed her. This disease has caused many issues for her and pain. She has never abused her medication. , never llost them, never dropped them in the toilet, never had them stolen or any other reason that actual addicts claim when trying to seek more. To lump everyone together is absurd! Each patient should be treated differently. If a patient gives any of the above excuses yes cut them off! But for Gods Sake dont punish the people who are not a problem and need help with their pain! I hope a solution is found soon so people suffering can find some relief and not by the way of suicide which I believe a lot of people will choose if they feel they cannot live with the immense pain they are in. ", "comment_id": "HHS-OS-2018-0009-0088", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0009-0088", "comment_date": "2018-05-26T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-09379", "commenter_fname": "Josie", "commenter_lname": "Mannor", "comment_length": 909}, {"text": "I am sure that these all sound very similar since we are all left out in the cold with no help. I personally was cold turkeyed off my pain meds and it was awful. I am not a criminal I am sick with incurable diseases. Shame on every single person who is allowing needless suffering by MILLIONS!!!! How sad and pathetic a world we live in when we are forced to suffer all day everyday because of nonsense and numbers that are incorrect. None of us did anything wrong or asked for this to happen and I'm sure if whomever makes decisions spent time in our bodies they would think and feel alot different. We forgot along the way about putting ourselves in others shoes. We also have forgotten compassion and empathy. Someone NEEDS to make this right.

Thanks for reading,
Haley S from Montana
", "comment_id": "HHS-OS-2018-0009-0091", "comment_url": "https://api.regulations.gov/v4/comments/HHS-OS-2018-0009-0091", "comment_date": "2018-05-26T04:00:00Z", "comment_title": "Comment on FR Doc # 2018-09379", "commenter_fname": "Haley", "commenter_lname": "Starkel", "comment_length": 815}]}, {"id": "FDA-2014-N-0233", "title": "Center for Drug Evaluation and Research; Use of Innovative Packaging, Storage, and/or Disposal Systems to Address the Misuse and Abuse of Opioid Analgesics; Request for Comments", "context": "2014-08-22T11:57:35Z", "purpose": "Nonrulemaking", "keywords": ["cder", "cder2013144"], "comments": [{"text": "See attached file(s).", "comment_id": "FDA-2014-N-0233-0014", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-0233-0014", "comment_date": "2014-06-16T04:00:00Z", "comment_title": "Comment from Oncology Nursing Society (ONS)", "commenter_fname": null, "commenter_lname": null, "comment_length": 21}, {"text": "The Notice seeks commentary on PREVENTING ACCIDENTAL USE by someone for whom the medication was not prescribed. This is a critically-important objective because opioids are currently the number one cause of child poisonings in the US, even with the implementation of universal child safe dispensing.

Divert-X – the dispensing and behavioral monitoring system under development by Vatex – tackles the prescription drug abuse crisis directly by seeking to separate authentic patients from those who are exaggerating the intensity and duration of symptoms. Those who subvert the system to feed an addiction or sell their medications are far less likely to demonstrate the spectrum of dosing behaviors exhibited by compliant, authentic patients. A healthcare insurer has permitted Vatex to pilot Divert-X in a region it serves so that Vatex can demonstrate the efficacy of the intervention via robust science.

Divert-X packaging is assembled in pharmacies in order to have a broad impact. A dispensing system must be agnostic to dose, dosage form, and manufacturer to cater for all the forms of Controlled Substances that are diverted and misused. The broad applicability of Divert-X will greatly assist its adoption if shown to be effective. Unit dose packaging that meets F1 level requirements will be suitable for packaging any medication regardless of toxicity. Based on current Poison Prevention Packaging Act (PPPA) criteria (1-2), a blister system certified to an F1 level is far safer than a certified pharmacy dispensing bottle (assuming both fail). Specifically, if F1-certified packaging fails, then a single dose is available to a child; conversely, if a pharmacy dispensing bottle fails, then the entire contents are available to the child. Hence, blister systems have a role in opioid safety because opioids are currently the number one cause of child poisonings in the US, even with the implementation of universal child safe dispensing mandates (3). While factory-assembled blister packs have been certified to an F1 level, no child-safe features have been added to any blister system assembled in a pharmacy because no market need has existed to date. The main existing market for pharmacy-assembled blisters is long-term care facilities, and these facilities are exempt from PPPA requirements because their medication management practices are similar to hospitals. All Vatex products will achieve F1 certification prior to commercialization.

The Notice also seeks commentary on packaging approaches to minimize in-home theft of medication by teens, visitors, caregivers, etc. Because blister packaging allows inventory assessment via a quick visual inspection and because blister packaging averts substitution schemes that use lookalike pills, this will have a preventive impact. Additionally, patients using Divert-X can obtain recent dose-removal times via telephone, text message, etc. in order to conduct their own diligence. Most importantly, Divert-X provides strong incentives for returning unused medications soon after they are dispensed. These incentives are the subject of a separate submission to this docket (search for “Safe Disposal”).

Because Divert-X will be challenged by users who are looking to subvert it, the packaging must possess many features to dissuade tampering but highlight it when it occurs. A tamper assessment by the pharmacist is the final step in the Divert-X cycle prior to obtaining a final score. Vatex is advantaged by the fact that the adhesives already in use for in-pharmacy assembly are far stronger than the materials used to make the packaging. Vatex has assessed products from all North American manufacturers of pharmacy-fill cards; in all cases, the cardstock and foils fail when attempts are made to disassemble or subvert a blister card. The strength of the seal itself serves as a child-safety feature. The strength of the seal relative to the materials of construction is a key in making tampering evident. Tamper-resistance features and child-proof features augment each other, and they are tested together under PPPA certification.

The PPPA provides and mandates all details needed for child-resistant package testing, but the packaging must also be useable by senior adults in order to obtain any certification. Hence, the PPPA also provides mandated protocols for determination of the Senior Adult Use Effectiveness score (1-2). The design of PPPA trials, for children and senior adults, are mandated to a very high level of detail, to include items such as the text of all allowable verbal interactions between testers and participants, the text of consent forms to be used, and scoring requirements. All Vatex products will achieve F1 certification prior to commercialization.

[please see the accompanying PDF attachment to view the references]", "comment_id": "FDA-2014-N-0233-0012", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-0233-0012", "comment_date": "2014-06-16T04:00:00Z", "comment_title": "Comment from Vatex Explorations, LLC", "commenter_fname": null, "commenter_lname": null, "comment_length": 4899}, {"text": "See attached file(s)", "comment_id": "FDA-2014-N-0233-0018", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-0233-0018", "comment_date": "2014-06-16T04:00:00Z", "comment_title": "Comment from Generic Pharmaceutical Association (GPhA)", "commenter_fname": null, "commenter_lname": null, "comment_length": 20}, {"text": "See attachment", "comment_id": "FDA-2014-N-0233-0028", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-0233-0028", "comment_date": "2014-06-16T04:00:00Z", "comment_title": "Comment from Pharmaceutical Care Management Association (PCMA)", "commenter_fname": null, "commenter_lname": null, "comment_length": 14}, {"text": "The problem with opioids is not, generally speaking, a problem to be solved with technology. The problem is that there are too many legal opioids, and that physicians are too quick to prescribe them:

- One in seven pregnant women has been prescribed an opioid at some point during her pregnancy (http://www.medpagetoday.com/PainManagement/BackPain/44603)

- Nearly 50 percent of adolescents who visit a doctor complaining of a headache receive a prescription for one or more narcotics (http://www.medpagetoday.com/Pediatrics/GeneralPediatrics/44647)

- More than 25 percent of Americans who use opioids for non-medical indications 200 or more days per year have been prescribed these drugs by a doctor (http://www.upi.com/Health_News/2014/03/03/Prescription-painkiller-abusers-often-get-them-from-a-doctor/UPI-70241393880460/)

With the average doctor visit lasting less than 20 minutes (http://www.asrn.org/journal-world-news-nursing-report/7-average-doctor-visit-grows-by-32-seconds-over-10-years.html), many physicians don't feel they can take the time to discuss pain management strategies -- or lifestyle changes -- with patients who visit them complaining of chronic pain. The situation is even worse in emergency rooms, where doctors may prescribe painkillers to addicts just to clear the decks for true emergency patients. Approving more painkillers -- opioid analgesics and others -- is only going to make it easier for doctors to take the easy way out and prescribe them for people who could solve their pain problems another way.

Creating a new surveillance state, in which people prescribed pain medication are tracked, is not the solution. There is little enough medical privacy in this country. The FDA seems to think that it can make everyone happy by making dangerous drugs plentiful (nice payout to pharmaceutical firms) and then handing out naloxone auto-injectors for when things go wrong. Sometimes, the right answer is to do less: approve fewer pain drugs, prescribe pain drugs less often, track fewer patients. Ask people to manage their pain in other ways -- lose the weight that is causing the back pain, take the physical therapy that will make movement less painful, go through a pregnancy without the lifestyle drugs that will harm your baby. ", "comment_id": "FDA-2014-N-0233-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-0233-0005", "comment_date": "2014-05-02T04:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 2317}, {"text": "Please see attached executive summary report (PDF format) and associated spreadsheet (Microsoft EXCEL format).", "comment_id": "FDA-2014-N-0233-0006", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-0233-0006", "comment_date": "2014-05-28T04:00:00Z", "comment_title": "Comment from Luis Zuluaga", "commenter_fname": null, "commenter_lname": null, "comment_length": 110}, {"text": "Please see the attached comments of the National Association of Chain Drug Stores regarding Public Docket No. FDA–2014–N–0233; “Use of Innovative Packaging, Storage, and/or Disposal Systems to Address the Misuse and Abuse of Opioid Analgesics.”", "comment_id": "FDA-2014-N-0233-0009", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-0233-0009", "comment_date": "2014-06-05T04:00:00Z", "comment_title": "Comment from National Association of Chain Drug Stores", "commenter_fname": null, "commenter_lname": null, "comment_length": 274}, {"text": "The Notice seeks information on the EFFECTIVENESS and ACCEPTABILITY of interventions that can be applied to reducing the prescription drug crisis. Vatex leverages established behavioral science to reduce diversion and misuse of Controlled Substances.

Divert-X – the dispensing and behavioral monitoring system under development by Vatex – tackles this problem directly by seeking to separate authentic patients from those who are exaggerating the intensity and duration of symptoms. Those who subvert the system to feed an addiction or sell their medications are far less likely to demonstrate the spectrum of dosing behaviors exhibited by compliant, authentic patients. A healthcare insurer has permitted Vatex to pilot Divert-X in a region it serves so that Vatex can demonstrate the efficacy of the intervention via robust science.

The theory of action for our efforts is straightforward and evidence-based: checks & balances for oversight of psychoactive, addictive drugs promote thoughtful use, safer behaviors, and accountability. The Vatex hardware advancements are described in a separate submission to this Docket (search for “Hardware Design”) and are used to gather objective data on actual medication-use behaviors. These objective data are currently unavailable for individual patients. The application of proprietary analytics for assessing behavioral markers collected by the packaging is used in a management system designed to reduce diversion and misuse. The management system is termed “Active MTM” and is described in a separate submission to this Docket (search for “Management Systems”).

Several behavioral “big data” analogies to the Vatex approach exist. For example, insurers use real-time analytics to remotely uncover dishonest doctors and prevent “pay and chase” schemes (1). Brick-and-mortar and online casinos use real-time analytics to intervene in gambling addiction (2). Efforts of online gambling companies to identify problem gamblers are directly analogous to Divert-X because all data are collected remotely, in real-time, in fine detail, and are related to addiction (2-6). Another analogy is the proprietary credit scoring systems used by the consumer finance industry known as debt-repayment risk algorithms (7-9). The study of hidden human behavior has become central to several subfields of economics and finance (10). Because of this longstanding research focus, the behavioral and economics literature has firmly established that people are more accountable for their actions when they are being scored or merely aware that they might be scored (10-30), but the scoring system must remain somewhat opaque so that it is not subverted. For example, details of banking algorithms (used to score customers and employees) are tightly-held secrets (10). Similarly, the detailed methodology behind medication-use scoring will not be shared with the public generally in order to leverage behavioral science and to protect from subversion.

Vatex sees strong parallels between the human desire to be seen as a good credit risk (rewards include improved loan pricing, employability in high-value positions, lower insurance rates (31-32)) and the desire to be seen as a credible patient (rewards include enhanced trust between provider and patient, straightforward access to needed medications, improved care quality). Bringing trust back to Controlled Substance prescribing and reducing patient-access disparities are key long-term Vatex goals. Employing a sophisticated device as an integral part of dispensing will emphasize to the patient, the family, and caregivers the serious safety risks associated with Controlled Substances. Because many people do not understand the risks of their medications, the packaging itself serves to warn (a behavioral “nudge” (33)) and should result in greater caution being taken to comply with prescribed regimens. Hence, the Divert-X packaging emphasizes safe-use and educational principles.

Precedent from the medical, behavioral, and economics literature show that Divert-X is likely to be a high-impact system. Vatex is combining key refinements of historical systems with its own innovation to address a pressing problem. The medical literature is replete with studies (34-37) showing that compliance to medications not regulated by DEA can be increased through a variety of actions with corresponding improvements in health and cost. Improving compliance to Controlled Substance regimens is much more challenging, however, because overconsumption is spurred by experimentation and addiction, because of the financial windfall for those patients who divert their ongoing prescriptions (38-43), and because current clinical tools cannot separate authentic patients from those exaggerating the intensity and duration of disease (44-49). Hence, the literature describing methods that improve Controlled Substance adherence is sparse. A single Europ [please see the PDF provided for the full version with references]

", "comment_id": "FDA-2014-N-0233-0013", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-0233-0013", "comment_date": "2014-06-16T04:00:00Z", "comment_title": "Comment from Vatex Explorations, LLC", "commenter_fname": null, "commenter_lname": null, "comment_length": 5135}, {"text": "The Notice seeks information on PAYER INCENTIVES and the feasibility of implementation of interventions that can be applied to reducing the prescription drug crisis. Innovative packaging that reduces opioid misuse can generate significant economic benefit by reducing the excess medical costs consequential to abuse and fraud. Outcomes improving financial returns for private and public healthcare payers will drive implementation of an evidence-based drug safety system.

Divert-X – the dispensing and behavioral monitoring system under development by Vatex – tackles prescription medication abuse by seeking to separate authentic patients from those who are exaggerating the intensity and duration of symptoms. Those who subvert the system to feed an addiction or sell their medications are far less likely to demonstrate the spectrum of dosing behaviors exhibited by compliant, authentic patients. A healthcare insurer has permitted Vatex to pilot Divert-X in a region it serves so that Vatex can demonstrate the efficacy of the intervention via robust science.

The insurance community - private, Medicare, Medicaid, workers’ compensation, self-insured employers, and VA - will be the customer base for Divert-X. The market for an IT service to infer patient behavior towards opiates and other Controlled Substances and to provide actionable information must be developed. Vatex expects that data from Divert-X pilots will successfully demonstrate the identification of anomalous patient behaviors and reduction in the misuse and diversion of medications. This will allow an estimate to be made quantifying the economic benefit from the introduction of Divert-X. The economic outcome will be used to petition medical insurance companies and government payers that the use of the system will generate significant healthcare savings for their organizations.

Currently there are no technology-driven methods to differentiate between legitimate opiate patients and those abusing and diverting. Without effective tools, medical practice involving Controlled Substances has devolved to speculative, ineffective patient profiling (1-5), spawning numerous lawsuits and administrative actions (6-9), documented discussion of how to lie to patients (10-12), public battles between pharmacy and physician groups (13-15), and uncertainty expressed by DEA in court regarding how to establish the legitimacy of prescriptions (16). In the 2011 Government Accounting Office publication ‘Prescription Pain Reliever Abuse’ (17), DEA officials report that “based on the available prescription and sales data, there is no method to calculate which prescriptions are issued for a legitimate medical purpose by a practitioner acting in the usual course of professional practice and which are not.” As a result of the inability to identify and take broad action against diverters, the DEA increase their quota for opiate and Controlled Substance production based on demand- which naturally includes diverted medications. The recent Compounded Annual Growth Rates for opiate and stimulant DEA quotas are a staggering 27.0% and 33.4% respectively (18-19). Because Divert-X establishes dose-level accountability, it will reduce fraud, street medication supply, and diversion. It will provide an objective means to identify patients who are misusing opiates and other Controlled Substances and provide a novel method to combat the epidemic.

The Vatex sales channel will be direct to insurers. We expect that insurers will mandate the use of Divert-X for opiates and other Controlled Substances for their patient populations once they are convinced of the magnitude of savings that it will generate. The high volume of Controlled Substance prescribing will ensure that pharmacies are responsive to the dictates of health insurance payers to dispense using Divert-X. In order to facilitate the cooperation of pharmacies, the Divert-X device is designed so that it can be filled in a very efficient manner with only a moderately longer pharmacy process. A dispensing fee for Divert-X will be paid to the pharmacy that is in excess of and in addition to standard medication dispensing fees. Divert-X adoption will therefore create a new source of revenue for the pharmacy, which will facilitate co-operation.

Extrapolation from a 2007 insurance industry estimate (20) suggest that opiate misuse results in at least $100 billion in excess annual medical costs for insurers driven by the costs of emergency room visits, increased physician visits, diagnostic and drug-test spending, falls and other accidents, and abuse treatment programs. When this economic burden is considered against the annual volume of 200 million opiate prescriptions, abuse and fraud can be estimated to cause an average hidden cost burden of $500 in excess medical spending added to every prescription. Vatex’ corporate goal is to reduce Controlled Substance misuse and [please see the PDF provided for the full version with references]", "comment_id": "FDA-2014-N-0233-0022", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-0233-0022", "comment_date": "2014-06-16T04:00:00Z", "comment_title": "Comment from Vatex Explorations, LLC", "commenter_fname": null, "commenter_lname": null, "comment_length": 5080}, {"text": "Friday, June 6, 2014

Colleen Brennan, Center for Drug Evaluation and Research
Office of Surveillance and Epidemiology
Food and Drug Administration
10903 New Hampshire Ave., Bldg. 22, Rm. 4410
Silver Spring, MD 20993-0002

Re: Docket No. FDA–2014–N–0233; “Use of Innovative Packaging, Storage, and/or
Disposal Systems to Address the Misuse and Abuse of Opioid Analgesics”

Ms. Brennan,

PillGuard Medication Delivery Systems appreciates the opportunity to comment on innovative packaging, storage, and disposal systems, technologies or designs (“designs”) that could be used to prevent or deter misuse and abuse of opioid analgesics by patients and others.

In 2003, Dr. Robert Muncy and I were discussing the widespread abuse of controlled prescription medications in areas of Kentucky. As doctors, we were concerned that legitimately prescribed medications were being diverted and abused in many ways. Hoping to help alleviate the complex problems and the human tragedy associated with the widespread and growing abuse of dangerous prescription drugs, we wanted to create a device that would both reduce current levels of prescription drug abuse, and help prevent future abuse of prescription medications. Moreover, we wanted to increase public health and safety in our communities. We further realized that both our state and federal governments could benefit from a reduction in the skyrocketing costs for law enforcement, criminal justice, health care, and social services associated with prescription drug abuse. We saw a need for a better-protected pill bottle designed to prevent diversion of dangerous medications and took the idea to the University of Kentucky Center for Manufacturing.

Powerful prescription medications can be life saving when taken under the supervision of a physician, but when abused, they can be just as life threatening as illicit drugs. The team concluded that the new kind of pill dispenser envisioned by the doctors should be one that: (a) would allow dispensing of a prescribed medication only in the prescribed amount no faster than the prescribed rate; (b) would detect tampering if someone were to try to break open the container or to otherwise forcibly remove the medication early; and (c) upon detection of tampering, pharmacists could be alerted.

The PillGuard medicine dispenser will address the prescription drug abuse problem by allowing doses of dangerous drugs only at carefully regulated times. Controlling the time of delivery for addictive medication will deter over dosage and criminal action. Misrepresenting the facts and current state of our company, commenter Divert-X (ID: FDA-2014-N-0233-0010) indicated that our company closed in early 2014 due to reimbursement factors. On the contrary, this past week we launched a pilot program at the James A. Haley Tampa VA Medical Center to demonstrate the effectiveness of the device on our nation's veterans. The Department of Veterans Affairs likely recognizes the immense danger to the "take as needed" approach and attributes that approach to the growing issue of abuse of controlled substances.

While PillGuard, other limited access devices, tamper-resistant formulations, smart blister packaging, dispensing and behavioral monitoring systems, and other abuse deterrent technologies will not likely eliminate our nation's prescription drug abuse problem, they can deter a large percentage of illegal abusers. With more assurance that the patient will not take their pills more frequently than prescribed or sell them all on the street, physicians can be more willing to prescribe these highly addictive medications when they will improve the patient’s health. The attachment recommends specific device characteristics and addresses several of the topics of interest.

We thank the FDA for allowing us to comment on this important matter and pledge our support to the FDA in fighting this national epidemic.

Sincerely,

Dr. Anthony McEldowney
CEO, PillGuard Medication Delivery Systems
(304) 514-9426
anthony.mceldowney@rammllc.com
", "comment_id": "FDA-2014-N-0233-0019", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2014-N-0233-0019", "comment_date": "2014-06-16T04:00:00Z", "comment_title": "Comment from PillGuard Medication Delivery Services", "commenter_fname": null, "commenter_lname": null, "comment_length": 4236}]}, {"id": "FDA-2013-P-1289", "title": "Stay of Action on the Implementation of Labeling Changes of Neonatal Opioid Withdrawal Syndrome (NOWS) Extended-Release and Long-Acting Opiod Analgesics.", "context": "2014-12-05T11:40:02Z", "purpose": "Nonrulemaking", "keywords": ["cder", "2013-8425", "citizen petition", "stay of action", "open", "neonatal opioid withdrawal syndrome", "NOWS", "extended-release", "long-acting"], "comments": [{"text": "The American College of Obstetricians and Gynecologists strongly opposes the black box warning on long-acting opioid medications directed toward pregnant women.
Women who are pregnant and dependent on opioid medications should not be withdrawn from these medications during pregnancy whether they be prescribed or illegally obtained. Withdrawal from opioids during pregnancy is known to cause extreme fetal distress and fetal death. Neonatal Abstinence Syndrome, which MAY result following maternal opioid use, is a fully treatable condition without subsequent patho-physiology for the child. The warning proposed by the FDA concerning infant death has not been substantiated.
Moreover, opioid medications are the safest choice for use by pregnant women who experience moderate to severe pain. They should not be denied adequate pain relief and untreated maternal pain further stresses the fetus. Please reconsider this warning. Thank you.", "comment_id": "FDA-2013-P-1289-0004", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2013-P-1289-0004", "comment_date": "2014-02-11T05:00:00Z", "comment_title": "Comment from American College of Obstetricians and Gynecologists", "commenter_fname": null, "commenter_lname": null, "comment_length": 956}, {"text": "Please see the attached comment in support of National Advocates for Pregnant Women's Petition for Stay of Action. ", "comment_id": "FDA-2013-P-1289-0005", "comment_url": "https://api.regulations.gov/v4/comments/FDA-2013-P-1289-0005", "comment_date": "2014-02-11T05:00:00Z", "comment_title": "Comment from Anonymous", "commenter_fname": null, "commenter_lname": null, "comment_length": 119}]}] \ No newline at end of file