Amid a rising toll of opioid overdoses, recommendations discouraging their use to treat pain seem to make sense. Yet the devil is in the details: how recommendations play out in real life can harm the very patients they purport to protect. A new proposal from the Centers for Medicare and Medicaid Services to enforce hard limits on opioid dosing is a dangerous case in point.

There’s no doubt that we needed to curtail the opioid supply. The decade of 2001-2011 saw a pattern of increasing prescriptions for these drugs, often without attention to risks of overdose or addiction. Some patients developed addictions to them; estimates from the Centers for Disease Control and Prevention range from 0.7 percent to 6 percent. Worse, opioid pills became ubiquitous in communities across the country, spread through sale, theft, and sharing with others, notably with young adults.

The prescribing tide has turned: Private and governmental data show that the number of prescriptions for opioids has been falling since 2012. Reassuringly, federal surveys show that misuse of pain relievers bottomed out in 2014-15.


Nevertheless, the CDC produced a guideline in 2016 that recommended shorter durations for opioid prescriptions and the use of non-drug treatments for pain. It also suggested keeping opioid doses lower than the equivalent of 90 milligrams of morphine. As the guideline acknowledged, its recommendations reflected weak scientific evidence. Problematically, it was silent on how to care for patients already receiving doses higher than the 90 milligram threshold.

To its credit, the guideline endorsed treating patients as individuals, not numbers. A CDC official wrote to one patient that the guideline “is not a rule, regulation, or law. … It is not intended to take away physician discretion or decision-making.”

Unfortunately, these mitigating features were undermined by intemperate publicity that vilified opioids for pain. Opioids for pain “are just as addictive is heroin,” proclaimed CDC Director Dr. Tom Frieden. Such statements buttress a fantasy that the tragedy of opioid overdoses and deaths will be solved in doctors’ offices, primarily by upending the care of 5 to 8 million Americans who receive opioids for pain, even when most individuals with opioid addiction did not start as pain patients.

The progression of the guidelines from “voluntary” to “enforceable” has culminated in a draft policy from CMS. It would block all prescriptions above the CDC threshold of 90 milligrams unless complex bureaucratic barriers are surmounted. Many pharmacy plans are already enforcing this approach. Under that plan, many patients suffering with chronic pain would lose access to the medicines they are currently taking, all in the name of reversing a tide of death increasingly defined by non-prescribed opioids such as heroin and fentanyl.

The logic of doing this is untested. There have been no prospective clinical studies to show that discontinuing opioids for currently stable pain patients helps those patients or anyone else. While doing so could help some, it will destabilize others and likely promote the use of heroin or other drugs. In effect, pain patients currently taking opioids long-term have become involuntary participants in an experiment, with their lives at stake.

Turning the voluntary guidelines into strict policy is unfortunate for three reasons.

First, it reflects a myopic misunderstanding of addiction’s causes, one at odds with a landmark report issued by the US surgeon general in November 2016. While the supply of drugs matters, whether people develop addiction to opioids reflects diverse factors including age, biology, and whether their lives include opportunities for rewarding activities like work and family or lacks those opportunities. Restricting prescriptions through aggressive regulation invites the outcomes seen in Prohibition, 90 years ago. To be fair to Prohibition, cirrhosis deaths did decline. But echoing that era’s gangsters and moonshine, we now face a galloping criminal trade in drugs of greater potency and lethality. Overdoses have skyrocketed, mostly from heroin and illicit fentanyl. In a Massachusetts review of overdoses, just 8 percent of those who had overdosed had received opioid prescriptions in the prior month.

Second, we have alternatives to bureaucratic controls. These include promoting and paying for treatments that de-emphasize pills. Important work by the Department of Veterans Affairs shows how to identify patients with elevated risk for harm from opioids and how to mitigate the risks.

Third and most troubling is the increasingly inhumane treatment of patients with chronic pain. Fearing investigation or sanction, physicians caring for patients on long-term opioids face a dire choice: to involuntarily terminate prescriptions for patients who are otherwise stable, or to carry on as embattled, unprotected professionals, subject to bureaucratic muscle and public shaming from every direction.

In this context, we cannot be surprised by a flurry of reports, in the press, social media, and the medical literature describing pain patients entering acute withdrawal, losing function, committing suicide, or dying in jail. The CMS policy, if adopted, will accelerate this trend.


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Many of our colleagues in addiction medicine tell us they are alarmed by the widespread mistreatment of pain patients. We receive anecdotes every week from physicians and pharmacists, most of them expert in addictions, describing pain patients who have involuntarily lost access to their pain medications and as a result have been reduced from working to bedridden adults, or who have become suicidal.

This loss of access occurs several ways. A pharmacy benefit program may refuse to cover the prescription because it has already enacted the changes that CMS is proposing to make mandatory. A physician may feel threatened by employers or regulators, and believes his or her professional survival depends on reducing opioid doses — involuntarily and without the patient’s consent — to thresholds that the CDC itself described as voluntary and not mandatory. Or state regulators have imposed such burdensome requirements that no physician in a given region can sustain prescriptions for their patients. Such patients are then “orphaned,” compelled to seek treatment from other physicians across the country.

Given the expertise in addiction among these physicians, it should be particularly worrisome that they believe the present pill-control campaign has gone too far. And yet, the ethics are clear: It should never be acceptable for us to countenance the death of one patient in the avowed service of protecting others, even more so when the projected benefit is unproven.

Surgeon General Dr. Vivek Murthy made an underappreciated declaration in a recent interview with the New England Journal of Medicine. “We cannot allow the pendulum to swing to the other extreme here, where we deny people who need opioid medications those actual medications. … We are trying to find an appropriate middle ground,” he said.

As addiction professionals, we agree wholeheartedly.

Stefan G. Kertesz, MD, and Adam J. Gordon, MD, are physicians in both internal medicine and addiction medicine. Dr. Kertesz is an associate professor of preventive medicine at the University of Alabama at Birmingham School of Medicine; Dr. Gordon is a professor of medicine at the University of Pittsburgh School of Medicine and editor of the journal Substance Abuse. The views expressed here are their own and do not reflect positions held by their employers.

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  • Hey Pain Patients or Doctors who still care –

    Why are they trying to kill us? Given how and what they are (or are not) doing, I can only come to that as the goal.

    We NEED HELP. We NEED MEDICATION AND we are NOT DRUG ADDICTS, damn it! But we will all be dead or felons before this situation improves for us.

    Sorry. Needed to vent.

  • The only thing that can or will be accomplished by continuing on this witch hunt, which is obviously designed to target only legitimate pain patients who are compliant, because no measures imposed or suggested have ANY hope or chance of monitoring, tracking, tracing or controlling any substance, any group or any trend EXCEPT LEGAL, LEGITIMATE COMPLIANT PATIENTS WHO LIVE IN AGONY AND ARE NOW BEING DISCRIMINATED AGAINST BY THE SYSTEM THAT SHOULD BE PROTECTING US.

    The stats are used to say whatever (most of which “information” doesn’t even APPEAR logical if people turn off their sheeps’ brains and READ THE TRUE STATS – check out the 122 pg document published by the CDC.) NO one cares about the truth.
    ● Here are some interesting facts. Per the CDC, in 2012…
    ☆ Smoking killed more than
    ♧ Illicit drug use (meaning NOT legitimate patient deaths, not suicides, etc.)
    ♢ Alcohol use
    ♤ Motor vehicle deaths ¤ HIV
    ♧ Microbial / Toxic substances

    Where is the illegalization of tobacco products? Or does it have more to do with the taxes collected at both the state AND federal level?
    Remember the gateway drug? Remember ‘Just Say NO!’?
    Remember the fried egg which represented our brains on drugs? Now Marijuana is USEFUL medically? And LEGAL? !?!?

    Is it safe to eat eggs yet? Pain patients DIE at a far faster and earlier rate than even the clinically depressed population. Why do we deserve to have that statistic continue to be ignored while exponentially increasing because of this made up (by definition cannot be an) epidemic? Jesus Christ.

  • My mom is in extreme pain. She has been on oxycodone for over 8 years and they have cut her medication for the 2nd time in 2 months! What is she suppose to do now!? She hasn’t got out of the bed for 3 days. I’m extremely worried.

  • I am shocked that I had a injury on November 27th and been on norco
    To present day my surgery was schedule then was denied. They said they where waiting on paperwork for a doctor and that paperwork was received still know word.. so what happens when I get hooked on these norco pills I guess I will be like millions of Americans
    Turn too street drugs all I want is a surgery that I was told I would get and looking for any help I can get
    Thank you ray

    • You won’t. Take them as prescribed until you no longer need them, switch to aleve and d/c use. Count your blessings that you have them. Quit complaining to people who want to die.
      Or, and my suggestion personally, just be in pain and deal,we have to. At least you have hope of the pain diminishing over time.

    • Be thankful. 90 percent of people in your situation are having to suck it up and hurt, while the people scheduling surgery drag their feet. YOU are fortunate enough to be afforded a modicum of relief. Since you aren’t completely miserable:
      1) You might want to research your planned surgery and find out if there are
      alternatives that might be appropriate. There may or may not be.
      2) Find out about the surgeon, make sure he/she is REALLY the best choice
      you (fame and best choice aren’t ALWAYS synonymous though
      3) Thank your luck stars a second time.
      4) Never, eve complain about having pain meds when you are surrounded by
      suffering patie. Ever.

    • Ray, are you seriously complaining about having adequate pain control prior to your surgery? You’re complaining that they keep rescheduling your surgery? Well, guess what? The majority of chronic pain patients no longer have that option. Many of the ones who are still receiving a small amount of pain medication are being forced to have injections which have NEVER been studied nor approved by the FDA. Others are being forced into unnecessary surgeries that often do more harm than good. You’d better thank your lucky stars you’re doctor is prescribing you medication to control your pain cause most who are in CONSTANT SEVERE pain due to incurable diseases and inoperable injuries and will be in that same amount of pain until the day they die sure as hell aren’t. As more and more chronic pain patients are losing access to doctors who will continue prescribing them the medication that gave them some quality of life, more and more suicides are happening. Quit your complaining and toss out your pills if you’re so afraid of addiction. No one is forcing them down your throat.

  • I think this is ridiculous I have had neck n back surgery. Still have torn rotator cuff that needs surgery n another back surgery I’ve got off opioid several times over last few years for months with no withdrawal because I tamper myself down n my gastroligist Dr told me it’s worse for me to replace my pain medicine with it, Tylenol taking 2 every 6 hours is giving my liver a good chance for damage. This law is basically about overdoses of herion I have a son addicted to herion and wasn’t on opiodspriorand most if the young people who are on it now just tried it with a buddy not because they were on iPods. So people who are in chronic pain 24/7 are the ones being hurt my surgeon told me I would be on pain meds probably the rest of my life all he was able to do was stop bone n spurs from griwing into my spinal cord. I see a pychratrist and I’m sbout to go into a new pain management Dr who my surgeon referred me to. I’m hoping with the swab of mouth test it shows how much of ur meds ur taking call me in for pill counts I’m ok with it I just have gone this last montth with only otc, meds I’m in severe pain n would like a little relief if only for a few hours a day pain constant is what will have a patient that’s cut off turn to street drugs trying to not hurt. Figure out ur patients who really need it monitor them close n that’s how this should be it’s unbelievable that others suffer because of the ones who abuse , sell or have addiction to hetion out problem and effects our pain. All I can do for my son addicted to herion is pray I’ve tried n do daily to reach him. But it was herion that got him addicted lets call real

  • I went in for an appointment, saw a new doctor as they are incredibly busy to get surprised with her decreasing my medication at the busiest time of year for my job as well as the main time of year I experience major flares because of the season and amount of work I have to put in.
    Without my medication I can’t function properly to work as I need to and I am afraid I will get to a poo t where I am unable to function properly when I’m taken off them all together.
    I didn’t Sean pain mgmt help for 6 years after my diagnosis and I haven’t once use my condition to het out of work.
    Yet now I have to face the fact that soon I will not be able to just push through with help of the medication, I will have to accept that I will be a useless member of society because a percentage that don’t need the medication misused/abused prescription medication and I and many others have to suffer.
    This isn’t fixing the problem, and I gaurentee it will create a different problem in the end.

  • Now the CDC is playing the role God. As a chronic pain patient I can absolutely, unequivocally state that if I am shut off of my medication I take for a shattered disc in my lower spine, I will no longer be any type of functional ANYTHING! Before I was put on what I’m currently taking (and have been on the same dose & same medications for the past 5 years) I couldn’t even walk, have had to crawl and drag myself from my bed to the bathroom (we have one in our master bedroom-thankfully.) The pain medications I take allow me to get out of my bed, allow me to sit on the couch even for a bit, allow me to sit and talk and hug my children & now the CDC/Feds want to take this little bit of light away??!! I am sooo far from an addict….I am a Chronic Pain Patient. Every moment of every day I feel pain. It never goes fully away but with the meds I can manage, without them I’m pretty much a vegetable. This is so wrong. STOP harming pain patients! Stop rewarding the addict! How many “treatment” centers have popped up all over the United States??!! Addiction’s big business. A private run clinic makes over $100,000.00 per PATIENT. I wouldn’t doubt that pharma companies have a hand in those too. How many times does a heroin addict relapse? 7? 8? 9 times?? Just one patient is a goldmine.

    These past few months I’ve already been dropped down 3 times on my medications and have been threatened that I will be removed from all of them. My Primary Care Doctor doesn’t care about anything but her wallet and license. When I called Patient Advocate I was told that they can’t and won’t help. I called a few attorney’s, never even received a call back! I don’t know where to go or what else to do except lay in bed in absolute agony every second of every day.
    My Primary Care Doctor (PCP), heir office or someone in hat office has tampered with my urine making it seem like I’m taking something I shouldn’t have and so doing, was labeled as a “drug seeker” by my so called PCP. I WANT to know what was in my urine as well!! I have not, and am not taking what I was accused of taking! The meds in my urine showed Hydrocodone–I’m either taking Vicodan or Percocet (such a joke compared to the meds I’ve been on since my disc shattered in my lower spinal cord, 2004). My PCP refuses to even consider the possibility of any tampering in my urine or that someone read them incorrectly. They don’t even do the urine testing in the entire state of Vermont but instead send them out to Minnesota! But nothing could possibly go wrong with THAT…
    They ARE using brand new test guidelines–I’d like to hope that someone’s reading them incorrectly because the thought of someone doing that to me deliberately really messes with my head….
    I’ve also almost died from a mix up in my medications, ended up in the hospital diagnosed with Stephen’s John’s Disease. The E.R. Dr. told me point blank that if I would have taken 1 (just 1!) more pill I wouldn’t be here, I would have died. I have 0 interest in dying and 0 interest in taking a crap load of medication that won’t help me and I will not mix any meds that I don’t know about & don’t take any “street drugs” either. The meds I’m currently taking have taken my former Dr. and I a long time to get to. I’ve taken/tried so many different medications, techniques, therapy-from Psychologists, physical therapy, T.E.N.S unit, injections, nerve specialists, spinal cord specialists. I’ve tried EVERYTHING that the United States has to offer for Chronic Pain Patients short of taking any illegal drugs such as Heroin. BUT, I can see why Chronic Pain Patients have had to turn to them especially if your damn Doctor shuts you off all for big bonus payments. This is a massive issue and massive problem. We need Doctors who took their Hippocratic Oath to actually stand up FOR the patient not throw them to the curb then because they went to Heroin because you can’t/won’t help to manage their pain.
    I sincerely wish there was something I could do to avoid the E.R., to avoid turning to Heroin or something like it, the way it’s being pushed in my state, I really have no hope of that happening.
    The new Federal “Law” put in place in 2016 effectively set the death toll for ALL Chronic Pain Patients. If they think it’s going to help to deter addiction they’ve got a major eye opener coming….more people will be turning to illegal street drugs & more people than ever will be a slave to Heroin or any other drug that is or comes out to make them get “high.” I wrote this before reading any comments. I just happened to scroll down after I was done commenting and see another comment made by Maria Wakili. I’m in the same exact boat–I’ve literally been bawling constantly and every 2 blipping weeks my so called PCP keeps dropping my med strength until as she puts it “I’m at a a comfortable spot without any narcotics, I won’t write any more of them for you because I can’t lose my medical licence.” But it’s okay if I lose my damn mind from being in so much pain & agony. It’s okay if I’m confined to bed and only go from it to the toilet. This isn’t a way to treat any patient let alone a Chronic Pain Patient. This is cruel & inhumane.

    • Update…In regards to my urine being tampered with I’ve found out some extremely interesting facts. Such as the medication I was taking. There are several different manufacturer’s that make Oxycontin & Oxycodone. Due to pressure from the government in 2010, these pharma companies had to change the chemicals to try to stop the flood of addiction in the Oxy 20’s, 40’s, 60’s, 80’s and 100’s different chemicals were used to they couldn’t be chopped down and snorted. In small cases of individuals these “alien” ingredients in the pills cause them to produce norhydrocodone. When a Dr. sees THAT in your urine it’s automatically assumed that you’ve been on or are currently taking either Vicodin or Lortab and they immediately start tapering your pain medications. Every 2 weeks you’r dropped down in dosage until they’ve pretty much forced a Chronic Pain Person to go & start taking illegal drugs just to control the pain!! How the fuck is limiting my medications so that I’m in constant agony every moment of every single day without fail making me have a better, more productive life?! These damn doctors will turn more people onto heroin. Because they can’t get the meds used to make the heroin they’ll use anything else at hand so how is any ER going to be able to counter an overdose when they have no clue what it is that they;ve taken?! How many times are we using the narco pen? 7 to 10 times on just 1 addict. Once he or she is feeling better they go right back to the heroin. There will be many, many more deaths.

    • I’m so sorry. I have thought about the same thing with using heroin because my doctor doesn’t give a crap about my pain. I have had 17 lumbar epidurals, 6 injections in each hip, I can’t remember how many in my neck, about 10 trigeminal blocks, and 2 facet blocks which on the last one I got Sepsis and almost died. Been through all the therapy crap nothing works. I have been on pain pills for 13 years and during those times I told my doctor that I had friends die from abuse and I wanted to taper down for a few weeks and that way when I went back up it seems to feel better too. I did that every 3 about years. My old doctor was impressed with my will power. I feel like when you hurt so bad and really need them you don’t get addicted you are dependant for somewhat a normal life! Now I am tired of being treated like a criminal by my doctor. The look I get at my pharmacy when they look at my script and say,”Let me see if we have this.” every time. I’m feel that maybe I should just say screw this suffering and use heroin for a bit. Then go to one of the clinic and get the free help where they give you methadone or Suboxone. It goes against everything I have ever stood for. I have always followed the law and been a good citizen but right now I feel that being a good person isn’t getting me anything but misery. I’m disabled and can’t work and I have been lonely for over a year since they cut my meds and I really can’t do anything so I’m starting to feel like I should just say screw it and go for it.

    • File a complaint with your State Board of Medical Examiners, asking that the doctor who has deserted you be sanctioned for patient abandonment. If you can’t afford a lawyer to inform you of how to get your complaint heard, you might try the nearest office of Legal Aid. Most large cities in the US have one.

    • I’ve tried calling Legal Aid. They’ll give you 1 or 2 attorney’s to call but don’t expect a call back. I’ve also written to my state’s Senators. No response. Had 1 Dr. send a referral to a Pain Management place but as of the past 8 months they’ve been literally picking & choosing who they’ll accept as a patient.
      So basically the answer to your question is NO

  • I have been on strong opiate medications for about 7 years, roughly estimating. I have never overdosed or abused my mediation. I developed pain that lead to rheumatoid arthritis that is heriditary in my family. As a medical professional, I am appalled and not including terrified of having the medication that makes my very life tolerable to live. These strict and new unfair laws, limiting opiate medication use is very and irresponsible and dangerous. I believe that all there doing is creating a new problem. As chronic pain patients and others on these medations will have three alternatives. One, turn to heroin, two become a useless bedridden individual , or God forbid, commit suicide. I believe this should be looked as a individual case to case situation. Why should responsible chronic pain patients be made to pay the price of those who don’t use their medications properly ? Someone has to speak up for us responsible chronic pain mediation individuals. I’m am a good single parent of four children and an honest law abiding citizen. I find myself now being looked down upon not to mentioned stigmatized ! I’m am highly disturbed and want to to do something about it. I don’t know how, but I will find a way to advocate for my fellow chronic pain patients.

    • I agree with you 100%… I too am in the same situation as you, I have been a model been patient for years, and was awarded Social Security disability for reason after working many many years.… I don’t understand why our pain doctors don’t have petitions for us to sign to take to our local congressman, governors or something?? It doesn’t seem like they are worrying about us at all, every month since January I going to the office jump through all of their Hoops, and my medicine is drop down every month and the next two months I will be at the 90 morphine equivalency, but I have heard that they are going to continue to drop or levels down this is insane the stress it has caused me Makes pain worse…my blood pressure is through the roof every time I go into their office, and I tell them it’s because my pain is so bad now I cannot hardly do what is expected of me from my family and unfortunately I am a grandparent who has been left to take care of two small grandchildren who do not understand why their grandma can’t hardly do anything anymore I live in A small town in Arizona I wish something could be done… Any advice out there ???

    • I must say that i have been on pain medication for almost 20 yrs. With the same dr for 15, and the same dosage for 5 years. I take my meds like i am suppose to and dont appreciate the fact that i will be one of the people that will be bed ridden or commit suicide because i refuse to try and just deal with life and be in severe chronic pain. I dont drink or do street drugs. Or play these stupid games with pills. I did not ask to be put on these meds, a pain dr started me on them. I already have a very low quality of life and if Jesus is not going to take me, i refuse to suffer. Ive been thru spinal surgery in 1999 & 2000. I have nerve damage in my arms, 11 herniated disc, lumbar radiculopathy, degenerative disc disease, fibromyalgia, arthritis, stenosis, myelopathy, and its only getting worse the older i get. I have a lung condition, stomach condition, had an umbilical/abdominal hernia repair in 2006, and now my vocal cords have a problem too. My entire body hurts every day while taking a high dose of meds. And now im being told that i have to spend $100 of my $755 check to keep taking my meds. I have to pay for the muscle relaxers that agree with my body. I think it is utterly disgusting that honest law abiding citizens that try to live a decent life with integrity am being forced to kill myself or break the law. I know for a fact that i could drink and do drugs and not have terrible pain. What has happened to our civil rights and the ADA. Its bad enough that i have to live in a dump of a mobile home with slumlords that own it. But i refuse to lay in bed and suffer like hell because some idiots that dont have a medical problem can limit my pain med intake. I take my drug tests and pass them. I have not been high on my pain medicine yet. Why do they even make it? Is this medicine not made for PAIN. NOT JUST AFTER SURGERY PAIN. NEXT THEY WILL BE MAKING US HAVE SURGERY AND BE WIDE AWAKE. WOULD IT HELP THE OPIOD PROBLEM IF I SOLD THEM JUST TO PAY FOR WHAT I NEED. OR TRADE ONE KIND FOR ANOTHER? Hell no it wouldnt!!! It will only add to the problem. If the people that are making these laws had to deal with what i do on a daily basis, i bet they would change these laws. Im just appauled that because i have severe chronic pain im being looked at as a lower class citizen. I am almost 59 yrs old, i was in a car wreck at 17 and now im paying for it. And its a down right shame that i have to fight in order to just be a decent person. My nerves are shot from this stress thats been put on me by this mess. Its unfair, its ungodly, and absolutely makes no sense. Maybe its time that i just take my screwed up life and give the air i breathe to someone that sells heroin on the streets. Ive never seen it. Ive never put a needle in my arm. But i would be better off if i was just dead. My father spent 20 yrs in the air force. The first 16 yrs of my life. And i have to end my own life because my country could care less if i live or die. How damn sickening is this? I refuse to lay in bed every day and suffer because other idiots abuse the meds that i need.

    • Maria…..I’m in the same boat as you, could literally have written exactly what you did. I’m just as scared as you as well. The only thing allowing me to not be bedridden is Fentanyl. I’ve never abused it, never went into an hospital or E.R. for an overdose but yet I too am being punished, looked down on, spoken to as if I AM a Heroin addict. Totally unprofessional comments, innuendos. Absolute b.s. I’ve never been arrested, have had 1 parking ticket in about 40 years of driving, pay my taxes, etc…. but yet have a rotten PCP that will not stand up for their patient only for the paycheck.

      I can certainly commiserate with you Maria….

  • Cindi, I have no idea why tramadol should even be limited. It’s not an opioid but for some reason, they lumped it in with opiates which makes me wonder if this really is a ploy to undermine pain patients in general no matter what meds they take! Makes absolutely no sense that tramadol is limited.

    • Luanne, they are limiting Tramadol because it has been in the system of several people who have overdosed recently. It’s not dangerous in and of itself. Again the problem lies with addicts and criminal behavior, buying Tramadol without prescriptions, mixing with Alcohol, Xanax, other strong pain relievers, then people get upset when they stop breathing due to stupid choices.

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