Will Christie or Bondi Be Next Attorney General?

By Pat Anson, PNN Editor

PNN readers cheered last week when Attorney General Jeff Sessions was fired by President Donald Trump. Sessions angered many in the pain community when he called for further cuts in opioid production and said pain patients should “tough it out” by taking aspirin.  

“The good news is Jeff Sessions (was) forced to resign,” wrote Carole Attisano. “Finally getting a small bit of Karma you so well deserved,”

“Now let’s hope that we get somebody with some type of human conscience for those who suffer with pain,” wrote another PNN reader.

As the saying goes… be careful what you wish for.

According to CBS News, two of the early front runners to be nominated as the next Attorney General are former New Jersey Gov. Chris Christie and Florida Attorney General Pam Bondi. Like Sessions, both have been longtime critics of opioid prescribing and served last year on President Trump’s opioid commission.

CHRIS CHRISTIE

CHRIS CHRISTIE

Christie certainly has experience in law enforcement. He was a federal prosecutor and U.S. Attorney in New Jersey from 2002 to 2008.

As governor, Christie signed legislation that made New Jersey one of the first states to limit the supply of opioids for short-term, acute pain. He also bitterly opposed efforts to expand the use of medical marijuana, calling cannabis activists “crazy liberals” willing to “poison our kids” for marijuana tax revenue.   

The final report from the president’s opioid commission, which Christie chaired, took a law-and-order approach to the opioid crisis, calling for “involuntary changes” in opioid prescribing.

“This crisis can be fought with effective medical education, voluntary or involuntary changes in prescribing practices, and a strong regulatory and enforcement environment,” the commission said.

In its five public hearings, the commission heard testimony from addiction treatment activists and several people who lost loved ones to opioid overdoses. But the panel never asked for or received testimony from pain sufferers, patient advocates or pain management physicians.

Pam Bondi did not have a prominent role on the opioid commission and only joined the panel in its final weeks. Her second and last term as Florida’s Attorney General ends in January. “She has not yet made a decision as to what she will do next,” a spokesman told CNN.

Bondi has a good relationship with President Trump and was once rumored to be the next head of the White House Office of National Drug Control Policy — also known as the nation’s “drug czar.”

Bondi played a prominent in shutting down Florida’s pill mills, but critics say she has been slow to acknowledge that the opioid crisis has shifted away from prescription painkillers to heroin and illicit fentanyl.

“The problem is Bondi isn't doing enough about the heroin epidemic,” the Miami Sun Sentinel said in a 2017 editorial. “Considering that Bondi was once touted as a potential Trump drug czar — and infamously failed to investigate Trump University after receiving a major donation from Trump — it's no surprise that she was named to the commission. But she's still living off her reputation from the pill mill crack down.”

PAM BONDI

PAM BONDI

Christie also has a good relationship with the President Trump, but has urged that there be no interference with special counsel Robert Mueller’s investigation – a potential stumbling block with the president. Like Sessions, Christie could also face calls to recuse himself from the investigation because he chaired Trump’s transition team.

According to CNN, other potential contenders for Attorney General are Solicitor General Noel Francisco, Rep. John Ratcliffe, (R) Texas, former Judge John Michael Luttig, Judge Edith Jones, former Judge Janice Rogers Brown, retiring Rep. Trey Gowdy, (R) South Carolina, and Sen. Lindsey Graham, (R) South Carolina.

Matthew Whitaker, the current acting Attorney General, can serve in that temporary position for 210 days under federal law.

Sessions: Opioid Prescriptions at 18-Year Low

By Pat Anson, PNN Editor

Opioid prescriptions in the United States fell by 12 percent in the first eight months of 2018 and will decline even further in coming years, according to Attorney General Jeff Sessions.

“We now have the lowest opioid prescription rates in 18 years.  And we’re going to bring them a lot lower,” Sessions said in prepared remarks at the National Opioid Summit in Washington, DC.

Opioid prescriptions have indeed been falling for many years, but the trend appears to be accelerating as many doctors lower doses, write fewer prescriptions, or simply discharge and refuse to treat chronic pain patients.

Sessions pledged to continue fighting “the deadliest drug crisis in American history” by reducing opioid prescriptions by another third over the next three years. That’s in addition to a 44% reduction in opioid production that the DEA began in 2016.

Sessions also promised to step up efforts against healthcare professionals alleged to have overprescribed opioids. He said the Trump Administration has charged 226 doctors and 221 medical personnel with “opioid-related crimes.”

“These numbers will continue to rise,” Sessions predicted, because of new federal prosecutors and a data analytics team focused on tracking opioid prescriptions.

ATTORNEY GENERAL JEFF SESSIONS

ATTORNEY GENERAL JEFF SESSIONS

“This team follows the numbers—like which doctors are writing opioid prescriptions at a rate that far exceeds their peers; how many of a doctor's patients have died within 60 days of an opioid prescription; and pharmacies that are dispensing disproportionately large amounts of opioids,” Sessions said.

“They will help us find the doctors, pharmacists, and other medical professionals who are flooding our streets with drugs—and put them behind bars.”

At no point in his speech did Sessions discuss the impact the opioid crackdown was having on millions of chronic pain patients, who are increasingly bedridden or disabled due to lack of access to effective pain care. Earlier this year, Sessions suggested they should “tough it out” by taking aspirin.

While opioid prescriptions have fallen dramatically in recent years, they’ve yet to have much of an impact on the nation’s overdose rate.  Preliminary estimates released by the CDC this week show a modest 2.3% decline in opioid overdose deaths from September 2017 to March 2018. Over 48,000 people died from opioid overdoses during that period, with most of those deaths involving illicit fentanyl, heroin and other opioid street drugs, not prescription opioids.

Sessions said the Justice Department was taking “unprecedented action” against fentanyl traffickers at home and abroad, including the recent indictments of three Chinese nationals and dozens of Mexican drug traffickers.

“China could do more to stop these drugs from coming here.  Frankly, they’re not doing enough.  They must do more,” he said.

Cutting Rx Opioid Supply Is Not Stopping Diversion

By Roger Chriss, PNN Columnist

Drug diversion is an increasingly important factor in the opioid overdose crisis. A new report from Protenus found that 18.7 million pills, valued at around $164 million, were lost due to drug diversion in the United States during the first half of 2018. This represents a vast increase over 2017, when 20.9 million pills were diverted during the entire year.

As we’ve described previously, drug diversion in the supply chain is a vast, complex and old phenomenon. And it is rapidly worsening.

According to the textbook, “Prescription Drug Diversion and Pain,” drug thefts from hospitals “have increased significantly within the past decade as street prices have climbed sharply for diverted prescription opioids and benzodiazepines.”

In other words, the steep cuts in opioid production that began in 2017 aren’t working. And Attorney General Jeff Sessions was wrong when he said, "The more a drug is diverted, the more its production should be limited." A tightening supply has actually resulted in more diversion.

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Drug diversion can be broadly divided into three categories: clinical diversion, personal diversion and industrial diversion. The first, according to Protenus, is drug diversion by healthcare workers. The second is the sale or transfer by a patient who received a legitimate prescription to a third party. And the third is everything else, from diversion by employees at manufacturing facilities to theft in distribution centers or pharmacies.

Personal diversion has gotten substantial attention in recent years. Prescription drug monitoring databases, pain agreements, and urine drug testing are all intended to help prevent such diversion.

Clinical drug diversion is a long-standing problem in healthcare that has garnered more interest recently. The bipartisan opioid bill recently passed by Congress includes a provision that allows hospice workers to destroy opioid medication that has expired or is no longer needed by a patient. The National Institutes of Health has also awarded a grant to further expand efforts to detect opioid and other drug theft in hospital systems.

Industrial diversion is less well known, but appears to be a longstanding problem. In the book “Dopesick,” journalist Beth Macy writes that as early as 2001 the DEA was investigating lax security standards at Purdue Pharma manufacturing plants after the arrest of two Purdue employees accused of trying to steal thousands of pills.

Between 2009 and 2012, over 63,000 thefts of opioids and other controlled substances were reported to the DEA. Pharmacies (66%) and hospitals (19%) accounted for the vast majority of those drug thefts.

And in 2007, an audit of CMS Medicare Part D payments identified 228,000 prescription payments with invalid prescriber identifications for Schedule II drugs.

In other words, tens of thousands of drug thefts and hundreds of thousands of fraudulent prescriptions are occurring annually, leading to millions of prescription pills entering the illegal market. This may help explain how OxyContin entered the black market so quickly and completely.

As Beth Macy writes: “The town pharmacist on the other line was incredulous: “Man, we only got it a month or two ago. And you’re telling me it’s already on the street?””

The National Association of Drug Diversion Investigators and the DEA Diversion Control Division are attempting to address industrial diversion. But available evidence suggests there is much more work needed to secure the entire prescription drug supply chain.

As the opioid overdose crisis continues to evolve toward poly-drug substance abuse, drug diversion will play an increasingly significant role in the illegal supply of prescription pharmaceuticals unless the entire supply chain is secured. This will require far more than the easy tasks of checking a prescription database or legislating pill counts. The hard part of reducing drug diversion remains to be done.

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Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Trump Administration Proposes More Rx Opioid Cuts

By Pat Anson, Editor

For the third year in a row, the U.S. Drug Enforcement Administration is proposing another round of cuts in the supply of opioid pain medication – a 10% reduction in manufacturing quotas in 2019 for several widely used opioids.  The Trump Administration says the pain relievers are “frequently misused” and reducing their supply will help prevent addiction and abuse.

The DEA proposal involves six opioids classified as Schedule II controlled substances:  oxycodone, hydrocodone, oxymorphone, hydromorphone, morphine, and fentanyl. Some of the medications are already in short supply, forcing some hospitals to use other pain relievers to treat surgery and trauma patients.

“President Trump has set the ambitious goal of reducing opioid prescription rates by one-third in three years. We embrace that goal and are resolutely committed to reaching it,” Attorney General Jeff Sessions said in a statement. “We have already made significant progress in reducing prescription rates over the past year. Cutting opioid production quotas by an average of ten percent next year will help us continue that progress and make it harder to divert these drugs for abuse.”

The DEA has already made substantial cuts in opioid production quotas, reducing them by 25 percent in 2017, followed by another 20 percent cut in 2018.  

The production cuts have had no effect on reducing the nation’s soaring overdose rate. According to a preliminary report released this week by the CDC, over 72,000 Americans died of drug overdoses last year, a 6 percent increase from 2016. The rising death toll is primarily attributed to illicit fentanyl, heroin and cocaine. Overdoses involving prescription opioids appear to have leveled off.

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The DEA’s latest round of production cuts is in line with President Trump’s “Safe Prescribing Plan” which seeks to reduce "the over-prescription of opioids” by cutting nationwide opioid prescription fills by one-third within three years.

“We’ve lost too many lives to the opioid epidemic and families and communities suffer tragic consequences every day,” said DEA Acting Administrator Uttam Dhillon. “This significant drop in prescriptions by doctors and DEA’s production quota adjustment will continue to reduce the amount of drugs available for illicit diversion and abuse while ensuring that patients will continue to have access to proper medicine.”

‘Serious Consequences’ for Patients

But legitimate patients are losing access to opioids.  Many hospitals and hospices now face a chronic shortage of three intravenous or injectable opioids --  morphine, hydromorphone and fentanyl -- which are used to treat patients recovering from surgery or trauma. Shortages of these "parenteral" drugs have been primarily blamed on manufacturing problems, although some critics say it has been worsened by the DEA production cuts.

“The shortage has serious consequences for patients and physicians. Parenteral opioids provide fast and reliable analgesia for patients admitted to the hospital with poorly controlled pain, patients who have undergone painful procedures such as major surgery, and those who were previously on oral opioid regimens but are unable to continue treatment by mouth,” Edward Bruera, MD, an oncologist at The University of Texas MD Anderson Cancer Center, wrote in an op/ed published this week in The New England Journal of Medicine.

“Shortages of the three best-known parenteral opioids may increase the risk for medication errors when it becomes necessary to switch a patient to a less familiar drug or to use opioid-sparing drug combinations. Opioids are already among the drugs most frequently involved in medication errors in hospitals. There are also increased risks of delayed time to analgesia and of side effects resulting in unnecessary patient suffering and delayed hospital discharge.”

Although opioid prescribing guidelines are only intended for physicians treating patients with “chronic non-cancer pain,” Bruera says some cancer patients are being affected by opioid shortages and over-zealous enforcement of prescribing guidelines.

“Most hospitalized patients and almost all patients with cancer need opioids, either on a temporary basis after surgery or painful treatments such as stem-cell transplantation, or longer for cancer-related pain or dyspnea,” he wrote. “It is impossible to appropriately treat such a large number of patients unless most physicians are able and willing to prescribe opioids. There were not enough palliative care and pain specialists to meet patient needs before the shortages began, and universal referral of patients who need parenteral opioids will therefore only result in more undertreated pain.”

The rationale behind the DEA’s production cuts defy some of the agency’s own analysis. Less than one percent of legally prescribed opioids are diverted, according to a 2017 DEA report, which also found that admissions for painkiller abuse to publicly funded addiction treatment facilities have declined significantly since 2011, the same year that opioid prescriptions began dropping.

An Open Letter to Attorney General Jeff Sessions

By Fred Brown, Guest Columnist

Dear Honorable Attorney General Jeff Sessions,

Why are there are so many federal agencies, like the CDC, DEA and Justice Department, that want to take away my opioid medication?  I have a right to be treated humanely, don’t I?

I am an American citizen who has dealt with some serious and painful medical issues. Over 20 years ago, I was referred to a board-certified pain management physician.  This was due to two failed cervical surgeries that left me with chronic back pain. I had two additional surgeries to fuse my spine after the first two operations, which only made my pain even more severe. The pain physician recommended I should begin a treatment regimen that included low doses of opioid medication.  

These medications helped me to continue working and have a certain quality of life.  I knew from discussions with my physician that, over time, I would need to increase the dose as my body would become dependent on opioids. This has been necessary and over many years these medications helped me live my life.

I have tried other medical modalities such as physical and occupational therapy, biofeedback, acupuncture, counseling, and other alternative treatments.  Further, before starting on opioids, I tried various non-narcotic medicines which did not work.    

Mr. Attorney General, earlier this year, you gave a talk in Tampa and said, “People need to take some aspirin sometimes and tough it out.” 

Perhaps if someone was experiencing mild discomfort, aspirin will work.  However, when one is living with severe chronic pain, 24-hours a day, seven days a week, they very likely need strong opioids prescribed by their physician.

Opiates help patients like me get relief from severe pain. They do not take away the pain, but they help reduce it and enable us to have some quality of life.  

ATTORNEY GENERAL JEFF SESSIONS

ATTORNEY GENERAL JEFF SESSIONS

The “pill mills” have hurt many people, and most certainly the DEA should do everything it can to close them down.  But at the same time, certain patients must have high dosages of these medications. Each of us have a different metabolism and what may work for one person at one dose level may not work at all with another patient.  

When a government agency such as the DEA goes after physicians who are trying to help legitimate patients, without any idea of the patients’ history is and why they are on high doses, that is entirely wrong and inhumane!

Why are so many agencies, along with Congress, trying to keep these medications at lower dosages that will cause me to live with increased pain?  Does our nation intend to condemn citizens who have painful and excruciating disabilities to a life of agony?

I am aware the CDC made some serious mistakes when it released the 2016 Opioid Prescribing Guideline.  Some physicians believe the guideline is law and began to lower the doses of patients or even discharge them from their practice. It took CDC researchers years to admit they significantly inflated deaths from opioid prescriptions because they misreported deaths due to illegal fentanyl. 

Opioid prescriptions have been declining since 2011, while overdose deaths and suicides are at an all-time high!  This is not accidental.  CDC, FDA and DEA are chasing the wrong opioid epidemic and needlessly ruining lives of people in pain.

Mr. Attorney General, was our nation founded on the premise that our fellow citizens should live in chronic severe pain? I do not believe our Founding Fathers would want this. 

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Fred Brown lives in central Florida. Fred is disabled because of spinal fusion with laminectomy syndrome, cervical radiculitis.  He also has severe arthritis in bilateral knees with a failed knee replacement.  In addition to pain management, Fred uses "diversion of the mind" as a way of dealing with much discomfort. 

Pain News Network invites other readers to share their stories with us. Send them to editor@painnewsnetwork.org.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

DEA Adopts Rule to Further Limit Opioid Production

Pat Anson, Editor

The U.S. Justice Department has finalized a new rule that will allow the Drug Enforcement Administration to reduce the amount of opioid pain medication a drug maker can produce if it finds the opioid is being diverted or misused.

The controversial change in the opioid production quota system was adopted despite warnings from patients, doctors and drug makers that it targets the wrong the problem and could worsen shortages of some pain medications.

The DEA maintains the rule change will “encourage vigilance” on the part of opioid manufacturers to prevent their drugs from being abused.

“These common-sense actions directly respond to the national opioid epidemic by allowing DEA to use drug diversion as a basis to evaluate whether a drug’s production should be reduced,” said DEA Acting Administrator Uttam Dhillon in a statement. “This also opens the door for increased communication and better information sharing between DEA and individual states, as we work together to address the opioid problem plaguing our country.”

The final rule greatly enhances the roles played by states and other federal agencies in setting opioid production quotas. It requires DEA to share proposed quotas with state attorneys general, who could object to a quota and demand a hearing.

The rule also allows DEA to consider “relevant information” from all 50 states, the Department of Health and Human Services, Food and Drug Administration, the Centers for Disease Control, and the Centers for Medicare and Medicaid Services, before setting a quota.

"DEA must make sure that we prevent diversion and abuse of prescription opioids. Today's new rule, by taking diversion of these opioids into account, will allow the DEA to be more responsive to the facts on the ground. More importantly, it will help us stop and even prevent diversion from taking place,” said Attorney General Jeff Sessions.

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Sessions announced the proposed rule changes in April, and DEA received over 1,500 public comments during an unusually short comment period. A clear majority opposed the new rule.

“This does nothing to stop addiction or overdose deaths. Addicts will find a high anywhere and where they find it now is street drugs! Illicit drugs are what’s killing, not doctor prescribed opioids filled at a pharmacy. The reporting you all are using is inaccurate and false,” wrote Amy Vallejo.

“By creating quotas, and thereby shortages, you are committing torture,” said Kimberley Comfort, who lives with arachnoiditis, a chronic spinal disease. “There is no reason why people having surgeries, people who suffer from incurable diseases, should be left to suffer when we are a nation that has the ability to take care of its citizens. The DEA does not have a clear understanding of the so-called opioid crisis and therefore needs to cease and desist making opiates harder to get.”

“Again, we have the DEA making laws and quotas on something they should not be. Let them worry about the drugs coming in from China, Mexico etc. which are illegal,” said Sarah Yerxa. “By cutting the quotas all they are doing is sending needy pain patients to the streets, which will just raise the addiction... and overdose problem.”

Opioid Shortages

The DEA has already made substantial cuts in opioid production quotas, reducing them by 25 percent in 2017, followed by another 20 percent cut in 2018. This year’s cuts were ordered despite warnings from drug makers that reduced supplies of opioids “were insufficient to provide for the estimated medical, scientific, research and industrial needs of the United States.”

Many hospitals and hospices now face a chronic shortage of intravenous and injectable opioids, which are used to treat patients recovering from surgery or trauma. The shortage has been primarily blamed on manufacturing problems, although some critics say it has been worsened by the DEA production cuts.

“I believe Attorney General Jeff Sessions needs to sit down and talk to some of these physicians who are pain specialists and understand that what he’s doing is going to put the chronic pain patient, the post-operative patient, and the patient that comes to the emergency room in serious jeopardy,” Tony Mack, CEO and chairman of Virpax Pharmaceuticals, told PNN in an earlier interview.

“I think that Jeff Sessions is not educated well. I think he is picking on something that sounds good politically but doesn’t make sense socially. It’s socially irresponsible.”

In a public notice announcing the rule change, the DEA said it was not responsible for “perceived shortages” of injectable drugs and blamed the “manufacturer induced shortages” on “internal business decisions.”

The agency also deflected criticism that it was targeting the wrong problem. Recent studies indicate that overdoses involving illicit fentanyl, heroin and other street drugs now outnumber deaths linked to prescription opioids.   

“The DEA acknowledges that prescriptions for opioid drug products have decreased over the last several years due to the stepped up civil, criminal, and regulatory enforcement efforts of the agency. However, while there is a downward trend in prescribing, these Schedule II prescription opiates continue to have a high potential for abuse and dependence and require the annual assessment of quotas,” the DEA said.

The agency also claimed prescription opioids were “inextricably linked” to overdoses from heroin and illicit fentanyl, because many addicts start by taking pain medication from family medicine cabinets and then move on to street drugs.

The DEA statement defies some of its own analysis. Less than one percent of legally prescribed opioids are diverted, according to a 2017 DEA report, which also found that admissions for painkiller abuse to publicly funded addiction treatment facilities have declined significantly since 2011, the same year that opioid prescriptions began dropping.

Over 600 Arrested in Healthcare Fraud Sweep

By Pat Anson, Editor

Over 600 doctors, nurses, pharmacists and other medical providers have been arrested in what the U.S. Justice Department is calling its largest healthcare fraud investigation.

Most of the charges involve false claims for opioid prescriptions or addiction treatment that resulted in $2 billion in fraudulent billings to Medicare, Medicaid and other health insurers. Many of the arrests occurred weeks or months ago, and were apparently lumped together by federal agencies to make the crackdown on healthcare fraud appear to be the "largest ever." 

“This is the most fraud, the most defendants, and the most doctors ever charged in a single operation -- and we have evidence that our ongoing work has stopped or prevented billions of dollars’ worth of fraud,” said Attorney General Jeff Sessions.

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Federal officials also announced that they have excluded 2,700 individuals from participating in Medicare, Medicaid and other federal health programs, including 587 providers excluded for conduct related to opioid diversion and abuse. 

“Health care fraud is a betrayal of vulnerable patients, and often it is theft from the taxpayer,” said Sessions.  “In many cases, doctors, nurses, and pharmacists take advantage of people suffering from drug addiction in order to line their pockets. These are despicable crimes.”

A $106 million scheme uncovered in Florida alleged there was widespread fraudulent urine drug testing at a substance abuse treatment center. The owner, medical director and two employees at the sober living facility allegedly recruited patients and paid kickbacks to them for participating in bogus drug tests.

In California, an attorney at a compounding pharmacy allegedly paid kickbacks and offered incentives such as prostitutes and expensive meals to two podiatrists in exchange for bogus prescriptions written on pre-printed prescription pads. Once the fraudulent prescriptions were filled, about $250 million in false claims were submitted to federal, state and private insurers.

In Texas, a pharmacy chain owner, managing partner and lead pharmacist were accused of using fraudulent prescriptions to fill bulk orders for over one million hydrocodone and oxycodone pills, which the pharmacy then sold to drug couriers for millions of dollars. 

“Healthcare fraud touches every corner of the United States and not only costs taxpayers money, but also can have deadly consequences,” said FBI Deputy Director David Bowdich.  “Through investigations across the country, we have seen medical professionals putting greed above their patients’ well-being and trusted doctors fanning the flames of the opioid crisis.”

Since becoming Attorney General, Sessions has shown a particular interest in opioid prescriptions -- once urging pain patients to “tough it out” and take aspirin instead.

Last August, Sessions ordered the formation of a new data analysis team, the Opioid Fraud and Abuse Detection Unit, to focus solely on opioid-related health care fraud.  Five months later, Sessions launched a Justice Department task force targeting manufacturers and distributors of opioid medication, as well as physicians and pharmacies engaged in the “unlawful” prescribing of opioids.

As PNN has reported, the data mining of opioid prescriptions -- without examining the full context of who the medications were written for or why – can be problematic. Last year the DEA raided the offices of Dr. Forest Tennant, a prominent California pain physician, because he had “very suspicious prescribing patterns.” Tennant only treated intractable pain patients, many from out-of-state, and often prescribed high doses of opioids to patients because of their chronically poor health -- important facts that were omitted or ignored by DEA investigators. Tennant has not been charged with a crime, but announced plans to retire after the DEA raid.

Sessions has also proposed a new rule that would allow the DEA to punish drug makers if their painkillers are diverted or abused. If approved, the agency could reduce the amount of opioids a company would be allowed to produce, even if the drug maker had no direct role in the diversion.

Most overdoses are not linked to opioid pain medication, but are more likely associated with illicit fentanyl, heroin, anti-anxiety drugs or antidepressants.