After Action Report : California Medical Board "Interested Parties Meeting," November 15, 2022

Colleagues and friends.

The following is my after-action report on the California Medical Board meeting yesterday. Courtesy copies have been sent to the Administrative Secretary of the Board, to the Office of National Drug Control Policy in the Office of the President, to the Board of Scientific Counselors of the National Center for Injury Prevention and Control of the US CDC, for forwarding to all members of the BSC, to Dr Nora Volkow, director of the National Institute on Drug Abuse and to the HHS Assistant Secretary for Planning and Evaluation.

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After Action Report

California Medical Board Interested Parties Meeting, November 15, 2022

Richard A. Lawhern PhD

A California Medical Board task force led by Dr Richard Thorp and William Prasifka conducted a live-stream Webex meeting from 2-4 PM Pacific time on November 15, 2022. The purpose was to solicit public comments from parties interested in the second draft of revisions to the California Guidelines on Prescription of Controlled Substances.

I and three others submitted written comments before a November 9 deadline, that were posted on the CMB meeting website. Several others submitted written comments after the deadline. About 16 to 20 patients, caregivers, and a few clinical professionals (one of whom represented the California chapter of the American Medical Association) spoke in the session. The initial round of comments was limited to three minutes per speaker. Several of us were permitted to add further comments after all speakers had a turn in the initial round.

What follows here is my good faith effort to capture the major themes in the public comments. This is not a precise rendering or a direct quote. Audio and transcriptions of the session should be posted to the Medical Board website within a few days. Because I speak and write so frequently on related subjects, I must acknowledge that my own work may influence my interpretation of others’ comments.

Introductory Remarks

Dr Richard Thorp introduced the session by explaining the work of the Task Force during 2021. This was the second Interested Parties Meeting, following an earlier review of the first draft of revised guidelines in July of this year. The Task Force hopes to complete its work and publish revised guidelines early in 2023. Dr Thorp stated that the purpose of the Task Force has been to ensure that pain patients receive whatever therapies are medically indicated for management of their pain, including opioid analgesics. He acknowledged damage done to patients and clinicians by the California Death Certificate Project and thanked all participants for their engagement. Then he turned the meeting over to Mr Prasifka, to record the comments of those who wished to speak

Major Themes

Early in the session, Kristen Ogden sounded a theme that was supported by several others. To paraphrase, “good intentions are not enough while doctors are deliberately being terrorized by the DEA.”

Hundreds of patients in the Los Angeles area have been cut off from pain treatment due to the unjustified and arbitrary issuance of a DEA suspension order revoking the prescribing privileges of Dr David Bachoff. This clinician has been treating many of the former patients of Dr Forrest Tennant , who were earlier cut off from treatment by a court-sanctioned attack on Tennant’s prescribing privileges. California doctors have been so terrorized by the DEA that major pain treatment centers in the Los Angeles area are turning away Bachoff’s patients. Many are approaching expiration of their prescriptions.

Patients urged Dr Thorp to open immediate discussion with the Governor of California, to urge the Governor to call the US President to request an emergency “stand down” order to the DEA, citing a rising danger of suicides among patients being denied care. A double suicide was noted by name from days just before the meeting. Other suicides are widely known during the past two years. More can reliably be predicted.

Thorp appeared to be conflicted concerning this recommendation, stating that the California Board of Medicine has no authority over the DEA. Public participants were not sympathetic. Several returned to this theme, advocating for a “stand up and be counted” approach.

Several other observations and recommendations were offered by other participants.

* One participant urged inclusion of more material supporting use of Buprenorphrine in both addiction treatment and pain treatment.

* If the intention of the California guidelines is to facilitate appropriate medical treatment for pain, then the guidelines are nowhere close to being ready for publication.

* Emphasis on “risk” in the 2nd draft guidelines is excessive and scientifically unjustified, reflecting similar anti-opioid bias in the CDC guidelines.

* CDC has substantially – and knowingly -- misrepresented risks and benefits of opioid analgesics. CDC guidelines and policy should be actively repudiated by all State Medical Boards and legislators, including California.

* California guidelines need to be significantly rewritten to focus on protecting clinicians from persecution by law enforcement agencies that are unqualified to practice medicine or public health policy.

* The California Medical Board needs to advocate publicly for amendments to the California Patient Bill of Rights, to incorporate language recently passed by Minnesota and other States that significantly limits liability of physicians who prescribe opioid analgesics.

While I personally “led the charge” on the following points, my input was directly supported by two practicing clinicians.

* The California guidelines completely ignore influences of genetics in opioid metabolism. Genetic variation between patients is so wide that there can never be a one-size-fits-all criterion for either risks or benefits. Narxcare and similar instruments used by State PDMPs to deny pain care are scientifically invalid and discriminatory.

* In fact, the contribution of prescription opioids to the US opioid crisis is so small that it gets lost in the noise from illegal street drugs. The entire trials literature for opioid analgesics is flawed by inappropriate methods and confirmation bias on the part of investigators. Over-prescribing is a mythology. MMED is junk science. Under-treatment of pain and social determinants of health are the real “health crisis” in America.

* California does not need to re-invent the wheel for pain practice. Well-known frameworks for clinical practice in prescribing opioids already exist and should be addressed by the California guidelines. One framework with a 35-year history is the World Health Organization “Analgesic Ladder”.

Summary

Though meeting participants thanked the California Task Force for their expressed good will, not one public participant declared satisfaction with the second draft of the California guidelines on prescription of controlled substances. Many advocated for substantial reorientation of the guidelines to protect clinicians from arbitrary persecution.

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