Palmetto veterinary medicine and surgery-rock hill

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The Medicine Wolf
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A quaint story of a 'medicine' wolf is told among the Blackfoot Indians.
On one occasion when the Blackfeet were moving camp they were attacked by a number of Crow Indians who had been lying in wait for them.
The Blackfeet were travelling slowly in a long, straggling line, with the old men and the women and children in the middle, and a band of warriors in front and in the rear.
The Crows, as has been said, made an ambush for their enemies, and rushed out on the middle portion of the line.
Before either party of the Blackfoot warriors could reach the scene of the struggle many of the women and children had perished, and others were taken captive by the attacking force.
Among the prisoners was a young woman called Sits-by-the-door.
Many weary miles lay between them and the Crow camp on the Yellowstone River, but at length the tired captives, mounted with their captors on jaded horses, arrived at their destination.
The warrior who had taken Sits-by-the-door prisoner now presented her to a friend of his, who in turn gave her into the keeping of his wife, who was somewhat older than her charge. The young Blackfoot woman was cruelly treated by the Crow into whose possession she had passed.
Every night he tied her feet together so that she might not escape, and also tied a rope round her waist, the other end of which he fastened to his wife.
The Crow woman, however, was not unmoved by the wretchedness of her prisoner.
While her husband was out she managed to converse with her and to show her that she pitied her misfortunes.
One day she informed Sits-by-the-door that she had overheard her husband and his companions plotting to kill her, but she added that when darkness fell she would help her to
escape.
When night came the Crow woman waited until the deep breathing of her husband told her that he was sound asleep; then, rising cautiously, she loosened the ropes that bound her captive, and, giving her a pair of moccasins, a flint, and a small sack of pemmican, bade
her make haste and escape from the fate that would surely befall her if she remained where she was.
The trembling woman obeyed, and travelled at a good pace all night.
At dawn she hid in the dense undergrowth, hoping to escape observation should her captors pursue her.
They, meanwhile, had discovered her absence, and were searching high and low, but no tracks were visible, and at last, wearied with their unprofitable search, they gave up the chase and returned to their homes.
When the woman had journeyed on for four nights she stopped concealing herself in the daytime and travelled straight on.
She was not yet out of danger, however, for her supply of pemmican was soon exhausted, and she found herself face to face with the miseries of starvation.
Her moccasins, besides, were worn to holes and her feet were cut and bleeding, while, to add to her misfortunes, a huge wolf dogged her every movement.
In vain she tried to run away; her strength was exhausted and she sank to the ground. Nearer and nearer came the great wolf, and at last he lay down at her feet.
Whenever the woman walked on her way the wolf followed, and when she lay down to rest he lay down also.
At length she begged her strange companion to help her, for she knew that unless she obtained food very soon she must die.
The animal trotted away, and returned shortly with a buffalo calf which it had killed, and laid it at the woman's feet.
With the aid of the flint--one of the gifts with which the Crow woman had sped her unhappy
guest--she built a fire and cooked some of the buffalo meat.
Thus refreshed, she proceeded on her way.
Again and again the wolf provided food in a similar manner, until at length they reached the Blackfoot camp.
The woman led the animal into her lodge, and related to her friends all that had befallen her in the Crow camp, and the manner of her escape.
She also told them how the wolf had befriended her, and begged them to treat it kindly. But soon afterward she fell ill, and the poor wolf was driven out of the village by the Indian dogs.
Every evening he would come to the top of a hill overlooking the camp and watch the lodge where Sits-by-the-door dwelt.
Though he was still fed by her friends, after a time he disappeared and was seen no more.

AMA RESOLUTION 235 November 2018 INAPPROPRIATE USE OF CDC Guidelines FOR PRESCRIBING OPIOIDS (Entire Document)
“Resolution 235 asks that our AMA applaud the CDC for its efforts to prevent the incidence of new cases of opioid misuse, addiction, and overdose deaths; and be it further, that no entity should use MME thresholds as anything more than guidance and that MME thresholds should not be used to completely prohibit the prescribing of, or the filling of prescriptions for, medications used in oncology care, palliative medicine care, and addiction medicine care: and be it further, that our AMA communicate with the nation’s largest pharmacy chains and pharmacy benefit managers to recommend that they cease and desist with writing threatening letters to physicians and cease and desist with presenting policies, procedures and directives to retail pharmacists that include a blanket proscription against filling prescriptions for opioids that exceed certain numerical thresholds without taking into account the diagnosis and previous response to treatment for a patient and any clinical nuances that would support such prescribing as falling within standards of good quality patient care; and be it further, that AMA Policy opposing the legislating of numerical limits on medication dosage, duration of therapy, numbers of pills/tablets, etc., be reaffirmed; and be it further, that physicians should not be subject to professional discipline or loss of board certification or loss of clinical privileges simply for prescribing opioids at a quantitative level that exceeds the MME thresholds found in the CDC Guidelines; and be it further, that our AMA encourage the Federation of State Medical Boards and its member boards, medical specialty societies, and other entities to develop improved guidance on management of pain and management of potential withdrawal syndromes and other aspects of patient care for “legacy patients” who may have been treated for extended periods of time with high-dose opioid therapy for chronic non-malignant pain.
RESOLVED, that our American Medical Association (AMA) applaud the Centers for Disease Control and Prevention (CDC) for its efforts to prevent the incidence of new cases of opioid misuse, addiction, and overdose deaths
RESOLVED, that our AMA actively continue to communicate and engage with the nation’s largest pharmacy chains, pharmacy benefit managers, National Association of Insurance Commissioners, Federation of State Medical Boards, and National Association of Boards of Pharmacy in opposition to communications being sent to physicians that include a blanket proscription against filing prescriptions for opioids that exceed numerical thresholds without taking into account the diagnosis and previous response to treatment for a patient and any clinical nuances that would support such prescribing as falling within standards of good quality patient care.
RESOLVED, that our AMA affirms that some patients with acute or chronic pain can benefit from taking opioid pain medications at doses greater than generally recommended in the CDC Guideline for Prescribing Opioids for Chronic Pain and that such care may be medically necessary and appropriate, and be it further
RESOLVED, that our AMA advocate against misapplication of the CDC Guideline for Prescribing Opioids by pharmacists, health insurers, pharmacy benefit managers, legislatures, and governmental and private regulatory bodies in ways that prevent or limit patients’ medical access to opioid analgesia, and be it further
RESOLVED, that our AMA advocate that no entity should use MME (morphine milligram equivalents) thresholds as anything more than guidance, and physicians should not be subject to professional discipline, loss of board certification, loss of clinical privileges, criminal prosecution, civil liability, or other penalties or practice limitations solely for prescribing opioids at a quantitative level above the MME thresholds found in the CDC Guideline for Prescribing Opioids.””
Pain Management Best Practices Inter-Agency Task Force - Draft Report on Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations Official Health and Human Services Department Released December 2018
“The Comprehensive Addiction and Recovery Act (CARA) of 2016 led to the creation of the Pain Management Best Practices Inter-Agency Task Force (Task Force), whose mission is to determine whether gaps in or inconsistencies between best practices for acute and chronic pain management exist and to propose updates and recommendations to those best practices. The Task Force consists of 29 experts who have significant experience across the disciplines of pain management, patient advocacy, substance use disorders, mental health, and minority health.”
In addition to identifying approximately 60 gaps in clinical best practices and the current treatment of pain in the United States, HHS PMTF provided recommendations for each of these major areas of concern. In alignment with their original charter, the PMTF will submit these recommendations to Congress to become our ‘National Pain Policy’. The 60+ gaps and inconsistencies with their recommendations will serve to fill gaps in pain treatment at both the state and federal level; and the overwhelming consensus was that the treatment of pain should be multimodal and completely individualized based on the individual patient. The heart of each recommendation in each section was a resounding call for individualization for each patient, in regards to both non-pharmacological and pharmacological modalities; including individualizations in both opioid and non-opioid pharmacological treatments.
While each of the gap+recommendation sections of what is poised to become our national pain policy is extremely important, one that stands out the most (in regards to opioid prescribing) is the Stigma section. Contained in this section is one of the core statements that shows our Health and Human Services agency - the one that should have always been looked to and followed - knew the true depth of the relationship (or lack of) between the overdose crisis and compassionate prescribing to patients with painful conditions:
“The national crisis of illicit drug use, with overdose deaths, is confused with appropriate therapy for patients who are being treated for pain. This confusion has created a stigma that contributes to raise barriers to proper access to care.”
The recommendation that follows - “Identify strategies to reduce stigma in opioid use so that it is never a barrier to patients receiving appropriate treatment, with all cautions and considerations for the management of their chronic pain conditions” - illustrates an acknowledgment by the top health agency of the federal government that the current national narrative conflating and confusing compassionate treatment of pain with illicit drug use, addiction, and overdose death is incorrect and only serving to harm patients.
Since March of 2016 when the CDC Guidelines were released, advocates, patients, clinicians, stakeholders, and others, have began pointing out limitations and unintended consequences as they emerged. In order to address the unintended consequences emerging from the CDC Guidelines, this task force was also charged with review of these guidelines; from expert selection, evidence selection, creation, and continuing to current misapplication in order to provide recommendations to begin to remedy these issues.
“A commentary by Busse et al. identified several limitations to the CDC guideline related to expert selection, evidence inclusion criteria, method of evidence quality grading, support of recommendations with low-quality evidence, and instances of vague recommendations. In addition, the CDC used the criterion of a lack of clinical trials with a duration of one year or longer as lack of evidence for the clinical effectiveness of opioids, whereas Tayeb et al. found that that was true for all common medication and behavioral therapy studies.
Interpretation of the guideline, in addition to some gaps in the guideline, have led to unintended consequences, some of which are the result of misapplication or misinterpretation of the CDC guideline.
However, at least 28 states have enacted legislation related to opioid prescription limits, and many states and organizations have implemented the guideline without recognizing that the intended audience was PCPs; have used legislation for what should be medical decision making by healthcare professionals; and have applied them to all physicians, dentists, NPs, and PAs, including pain specialists.441–444 Some stakeholders have interpreted the guideline as intended to broadly reduce the amount of opioids prescribed for treating pain; some experts have noted that the guideline emphasizes the risk of opioids while minimizing the benefit of this medication class when properly managed.”
“The CDC guideline was not intended to be model legislation for state legislators to enact”
“In essence, clinicians should be able to use their clinical judgment to determine opioid duration for their patients”
https://www.hhs.gov/ash/advisory-committees/pain/reports/2018-12-draft-report-on-updates-gaps-inconsistencies-recommendations/index.html
HHS Review of 2016 CDC Guidelines for responsible opioid prescribing
The Pain Management Task Force addressed 8 areas that are in need of update or expansion with recommendations to begin remediation for each problem area:
Lack of high-quality data exists for duration of effectiveness of opioids for chronic pain; this has been interpreted as a lack of benefit Conduct studies Focus on patient variability and response for effectiveness of opioids; use real-world applicable trials
Absence of criteria for identifying patients for whom opioids make up significant part of their pain treatment Conduct clinical trials and/or reviews to identify sub-populations of patients where long-term opioid treatment is appropriate
Wide variation in factors that affect optimal dose of opioids Consider patient variables for opioid therapy: Respiratory compromise Patient metabolic variables Differences in opioid medications/plasma concentrations Preform comprehensive initial assessment it’s understanding of need for comprehensive reevaluations to adjust dose Give careful considerations to patients on opioid pain regimen with additional risk factors for OUD
Specific guidelines for opioid tapering and escalation need to be further clarified A thorough assessment of risk-benefit ratio should occur whenever tapering or escalation of dose This should include collaboration with patient whenever possible Develop taper or dose escalation guidelines for sub-populations that include consideration of their comorbidities When benefit outweighs the risk, consider maintaining therapy for stable patients on long term opioid therapy
Causes of worsening pain are not often recognized or considered. Non-tolerance related factors: surgery, flares, increased physical demands, or emotional distress Avoid increase in dose for stable patient (2+ month stable dose) until patient is re-evaluated for underlying cause of elevated pain or possible OUD risk Considerations to avoid dose escalation include: Opioid rotation Non-opioid medication Interventional strategies Cognitive behavior strategies Complementary and integrative health approaches Physical therapy
In patients with chronic pain AND anxiety or spasticity, benzodiazepine co-prescribed with opioids still have clinical value; although the risk of overdose is well established When clinically indicated, co-prescription should be managed by specialist who have knowledge, training, and experience with co-prescribing. When co-prescribed for anxiety or SUD collaboration with mental health should be considered Develop clinical practice guidelines focused on tapering for co-prescription of benzodiazepines and opioids
The risk-benefit balance varies for individual patients. Doses >90MME may be favorable for some where doses <90MME may be for other patients due to individual patient factors. Variability in effectiveness and safety between high and low doses of opioids are not clearly defined. Clinicians should use caution with higher doses in general Using carefully monitored trial with frequent monitoring with each dose adjustment and regular risk reassessment, physicians should individualize doses, using lowest effective opioid dose that balances benefit, risk, and adverse reactions Many factors influence benefits and risk, therefore, guidance of dose should not be applied as strict limits. Use established and measurable goals: Functionality ADL Quality of Life
Duration of pain following acute and severely painful event is widely variable Appropriate duration is best considered within guidelines, but is ultimately determined by treating clinician. CDC recommendation for duration should be emphasized as guidance only with individualized patient care as the goal Develop acute pain management guidelines for common surgical procedures and traumas To address variability and provide easy solution, consideration should be given to partial refill system
Human Rights Watch December 2018 (Excerpt from 109 page report)
“If harms to chronic pain patients are an unintended consequence of policies to reduce inappropriate prescribing, the government should seek to immediately minimize and measure the negative impacts of these policies. Any response should avoid further stigmatizing chronic pain patients, who are increasingly associated with — and sometimes blamed for — the overdose crisis and characterized as “drug seekers,” rather than people with serious health problems that require treatment.
Top government officials, including the President, have said the country should aim for drastic cutbacks in prescribing. State legislatures encourage restrictions on prescribing through new legislation or regulations. The Drug Enforcement Administration (DEA) has investigated medical practitioners accused of overprescribing or fraudulent practice. State health agencies and insurance companies routinely warn physicians who prescribe more opioids than their peers and encourage them to reduce prescribing. Private insurance companies have imposed additional requirements for covering opioids, some state Medicaid programs have mandated tapering to lower doses for patients, and pharmacy chains are actively trying to reduce the volumes of opioids they dispense.
The medical community at large recognized that certain key steps were necessary to tackle the overdose crisis: identifying and cracking down on “pill mills” and reducing the use of opioids for less severe pain, particularly for children and adolescents. However, the urgency to tackle the overdose crisis has put pressure on physicians in other potentially negative ways: our interviews with dozens of physicians found that the atmosphere around prescribing for chronic pain had become so fraught that physicians felt they must avoid opioid analgesics even in cases when it contradicted their view of what would provide the best care for their patients. In some cases, this desire to cut back on opioid prescribing translated to doctors tapering patients off their medications without patient consent, while in others it meant that physicians would no longer accept patients who had a history of needing high-dose opioids.
The consequences to patients, according to Human Rights Watch research, have been catastrophic.”
[https://www.hrw.org/report/2018/12/18/not-allowed-be-compassionate/chronic-pain-overdose-crisis-and-unintended-harms-us](
Opioid Prescribing Workgroup December 2018
This is material from the Board of Scientific Counselors in regards to their December 12, 2018 meeting that culminated the works of a project titled the “Opioid Prescribing Estimates Project.” This project is a descriptive study that is examining opioid prescribing patterns at a population level. Pain management is a very individualized process that belongs with the patient and provider. The Workgroup reviewed work done by CDC and provided additional recommendations.
SUMMARY There were several recurrent themes throughout the sessions.
Repeated concern was voiced from many Workgroup members that the CDC may not be able to prevent conclusions from this research (i.e. the benchmarks, developed from limited data) from being used by states or payors or clinical care systems to constrain clinical care or as pay-for- performance standards – i.e. interpreted as “guidelines”. This issue was raised by several members on each of the four calls, raising the possibility that providers or clinical systems could thus be incentivized against caring for patients requiring above average amounts of opioid medication.
Risk for misuse of the analysis. Several members expressed concerns that this analysis could be interpreted as guidance by regulators, health plans, or clinical care systems. Even though the CDC does not plan to issue this as a guideline, but instead as research, payors and clinical care systems searching for ways to reign in opioid prescribing may utilize CDC “benchmarks” to establish pay-for-performance or other means to limit opioid prescribing. Such uses of this work could have the unintended effect of incentivizing providers against caring for patients reliant upon opioids.
…It was also noted that, in order to obtain sufficient granularity to establish the need for, dosage, and duration of opioid therapy, it would be necessary to have much more extensive electronic medical record data. In addition, pain and functional outcomes are absent from the dataset, but were felt to be important when considering risk and benefit of opioids.
...Tapering: Concerns about benchmarks and the implications for tapering were voiced. If tapering occurs, guidance was felt to be needed regarding how, when, in whom tapering should occur. This issue was felt to be particularly challenging for patients on chronic opioids (i.e. “legacy” patients). In addition, the importance of measuring risk and benefit of tapering was noted. Not all high-dose patient populations benefit from tapering.
Post-Surgical Pain
General comments. Workgroup members noted that most patients prescribed opioids do not experience adverse events, including use disorder. Many suggested that further discussion of opioids with patients prior to surgery was important, with an emphasis on expectations and duration of treatment. A member suggested that take-back programs would be more effective than prescribing restrictions.
Procedure-related care. Members noted that patient factors may drive opioid need more than characteristics of a procedure.
Patient-level factors. Members noted that opioid-experienced patients should be considered differently from opioid-inexperienced patients, due to tolerance.
Chronic Pain
It was noted that anything coming out of the CDC might be considered as guidelines and that this misinterpretation can be difficult to counter. There was extensive discussion of the 50 and 90 MME levels included in the CDC Guidelines. It was recommended that the CDC look into the adverse effects of opioid tapering and discontinuation, such as illicit opioid use, acute care utilization, dropping out of care, and suicide. It was also noted that there are major gaps in guidelines for legacy patients, patients with multiple diagnoses, pediatric and geriatric patients, and patients transitioning to lower doses.
There were concerns that insufficient clinical data will be available from the dataset to appropriately consider the individual-level factors that weigh into determination of opioid therapy. The data would also fail to account for the shared decision-making process involved in opioid prescribing for chronic pain conditions, which may be dependent on primary care providers as well as ancillary care providers (e.g. physical therapists, psychologists, etc).
Patient-level factors. Members repeatedly noted that opioid-experienced patients should be considered differently from opioid-experienced patients, due to tolerance.
Members noted that the current CDC guidelines have been used by states, insurance companies, and some clinical care systems in ways that were not intended by the CDC, resulting in cases of and the perception of patient abandonment. One option raised in this context was to exclude patients on high doses of opioids, as those individuals would be qualitatively different from others. A variant of this concern was about management of “legacy” patients who are inherited on high doses of opioids. Members voiced concerns that results of this work has caused harm to patients currently reliant upon opioids prescribed by their providers.
Acute Non-Surgical Pain
Patient-level factors. Members felt that opioid naïve versus experienced patients might again be considered separately, as opioid requirements among those experienced could vary widely.
...Guidelines were also noted to be often based on consensus, which may be incorrect.
Cancer-Related and Palliative Care Pain
It was noted that the CDC guidelines have been misinterpreted to create a limit to the dose of opioids that can be provided to people at all stages of cancer and its treatment. It was also noted that the cancer field is rapidly evolving, with immunotherapy, CAR-T, and other novel treatments that affect response rates and limit our ability to rely upon historical data in establishing opioid prescribing benchmarks.
Concern that data would not be able to identify all of the conditions responsible for pain in a patient with a history of cancer (e.g. people who survive cancer but with severe residual pain). Further, it was noted that certain complications of cancer and cancer treatment may require the least restrictive long-term therapy with opioids.
The definition of palliative care was also complicated and it was suggested that this include patients with life-limiting conditions.
Overall, it was felt that in patients who may not have long to live, and/or for whom returning to work is not a possibility, higher doses of opioids may be warranted.
https://www.cdc.gov/injury/pdfs/bsc/NCIPC_BSC_OpioidPrescribingEstimatesWorkgroupReport_December-12_2018-508.pdf
CDC Scientists Anonymous ‘Spider Letter’ to CDC
Carmen S. Villar, MSW Chief of Staff Office of the Director MS D­14 Centers for Disease Control and Prevention (CDC) 1600 Clifton Road Atlanta, Georgia 30329­-4027
August 29, 2016
Dear Ms. Villar:
We are a group of scientists at CDC that are very concerned about the current state of ethics at our agency. It appears that our mission is being influenced and shaped by outside parties and rogue interests. It seems that our mission and Congressional intent for our agency is being circumvented by some of our leaders. What concerns us most, is that it is becoming the norm and not the rare exception. Some senior management officials at CDC are clearly aware and even condone these behaviors. Others see it and turn the other way. Some staff are intimidated and pressed to do things they know are not right. We have representatives from across the agency that witness this unacceptable behavior. It occurs at all levels and in all of our respective units. These questionable and unethical practices threaten to undermine our credibility and reputation as a trusted leader in public health. We would like to see high ethical standards and thoughtful, responsible management restored at CDC. We are asking that you do your part to help clean up this house!
It is puzzling to read about transgressions in national media outlets like USA Today, The Huffington Post and The Hill. It is equally puzzling that nothing has changed here at CDC as a result. It’s business as usual. The litany of issues detailed over the summer are of particular concern:
Recently, the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) has been implicated in a “cover up” of inaccurate screening data for the Wise Woman (WW) Program. There was a coordinated effort by that Center to “bury” the fact that screening numbers for the WW program were misrepresented in documents sent to Congress; screening numbers for 2014 and 2015 did not meet expectations despite a multi­million dollar investment; and definitions were changed and data “cooked” to make the results look better than they were. Data were clearly manipulated in irregular ways. An “internal review” that involved staff across CDC occurred and its findings were essentially suppressed so media and/or Congressional staff would not become aware of the problems. Now that both the media and Congresswoman DeLauro are aware of these issues, CDC staff have gone out of their way to delay FOIAs and obstruct any inquiry. Shouldn’t NCCDPHP come clean and stop playing games? Would the ethical thing be to answer the questions fully and honestly. The public should know the true results of what they paid for, shouldn’t they?
Another troubling issue at the NCCDPHP are the adventures of Drs. Barbara Bowman and Michael Pratt (also detailed in national media outlets). Both seemed to have irregular (if not questionable) relationships with Coca­Cola and ILSI representatives. Neither of these relationships were necessary (or appropriate) to uphold our mission. Neither organization added any value to the good work and science already underway at CDC. In fact, these ties have now called into question and undermined CDC’s work. A cloud has been cast over the ethical and excellent work of scientists due to this wanton behavior. Was cultivating these relationships worth dragging CDC through the mud? Did Drs. Bowman and Pratt have permission to pursue these relationships from their supervisor Dr. Ursula Bauer? Did they seek and receive approval of these outside activities? CDC has a process by which such things should be vetted and reported in an ethics review, tracking and approval system (EPATS). Furthermore, did they disclose these conflicts of interest on their yearly OGE 450 filing. Is there an approved HHS 520, HHS 521 or “Request for Official Duty Activities Involving an Outside Organization” approved by Dr. Bauer or her Deputy Director Ms. Dana Shelton? An August 28, 2016 item in The Hill details these issues and others related to Dr. Pratt.
It appears to us that something very strange is going on with Dr. Pratt. He is an active duty Commissioned Corps Officer in the USPHS, yet he was “assigned to” Emory University for a quite some time. How and under what authority was this done? Did Emory University pay his salary under the terms of an IPA? Did he seek and receive an outside activity approval through EPATS and work at Emory on Annual Leave? Formal supervisor endorsement and approval (from Dr. Bauer or Ms. Shelton) is required whether done as an official duty or outside activity.
If deemed official, did he file a “Request for Official Duty Activities Involving an Outside Organization” in EPATS? Apparently Dr. Pratt’s position at Emory University has ended and he has accepted another position at the University of California ­ San Diego? Again, how is this possible while he is still an active duty USPHS Officer. Did he retire and leave government service? Is UCSD paying for his time via an IPA? Does he have an outside activity approval to do this? Will this be done during duty hours? It is rumored that Dr. Pratt will occupy this position while on Annual Leave? Really? Will Dr. Pratt be spending time in Atlanta when not on Annual Leave? Will he make an appearance at NCCDPHP (where he hasn’t been seen for months). Most staff do not enjoy such unique positions supported and approved by a Center Director (Dr. Bauer). Dr. Pratt has scored a sweet deal (not available to most other scientists at CDC). Concerns about these two positions and others were recently described in The Huffington Post and The Hill. His behavior and that of management surrounding this is very troubling.
Finally, most of the scientists at CDC operate with the utmost integrity and ethics. However, this “climate of disregard” puts many of us in difficult positions. We are often directed to do things we know are not right. For example, Congress has made it very clear that domestic funding for NCCDPHP (and other CIOs) should be used for domestic work and that the bulk of NCCDPHP funding should be allocated to program (not research). If this is the case, why then is NCCDPHP taking domestic staff resources away from domestic priorities to work on global health issues? Why in FY17 is NCCDPHP diverting money away from program priorities that directly benefit the public to support an expensive research FOA that may not yield anything that benefits the public? These actions do not serve the public well. Why is nothing being done to address these problems? Why has the CDC OD turned a blind eye to these things. The lack of respect for science and scientists that support CDC’s legacy is astonishing.
Please do the right thing. Please be an agent of change.
Respectfully,
CDC Spider (CDC Scientists Preserving Integrity, Diligence and Ethics in Research)
https://usrtk.org/wp-content/uploads/2016/10/CDC_SPIDER_Letter-1.pdf
January 13, 2016
Thomas Frieden, MD, MPH Director Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30329-4027
Re: Docket No. CDC-2015-0112; Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain
Dear Dr. Frieden:
There is no question that there is an opioid misuse epidemic and that efforts need to be made to control it. The Centers for Disease Control and Prevention (CDC) is applauded for its steps to undertake this lofty effort. However, based on the American Academy of Family Physicians’ (AAFP’s) review of the guideline, it is apparent that the presented recommendations are not graded at a level consistent with currently available evidence. The AAFP certainly wants to promote safe and appropriate prescribing of opioids; however, we recommend that the CDC still adhere to the rigorous standards for reliable and trustworthy guidelines set forth by the Institute of Medicine (IOM). The AAFP believes that giving a strong recommendation derived from generalizations based on consensus expert opinion does not adhere to evidence-based standards for developing clinical guideline recommendations.
The AAFP’s specific concerns with the CDC’s methodology, evidence base, and recommendations are outlined below.
Methodology and Evidence Base
All of the recommendations are based on low or very low quality evidence, yet all but one are Category A (or strong) recommendations. The guideline states that in the GRADE methodology "a particular quality of evidence does not necessarily imply a particular strength of recommendation." While this is true, it applies when benefits significantly outweigh harms (or vice versa). When there is insufficient evidence to determine the benefits and harms of a recommendation, that determination should not be made.
When evaluating the benefits of opioids, the evidence review only included studies with outcomes of at least one year. However, studies with shorter intervals were allowed for analysis of the benefits of nonopioid treatments. The guideline states that no evidence shows long-term benefit of opioid use (because there are few studies), yet the guideline reports "extensive evidence" of potential harms, even though these studies were of low quality. The accompanying text also states "extensive evidence" of the benefits of non-opioid treatments, yet this evidence was from shorter term studies, was part of the contextual review rather than the clinical systematic review, and did not compare non- opioid treatments to opioids.
The patient voice and preferences were not explicitly included in the guideline. This raises concerns about the patient-centeredness of the guideline.
https://www.aafp.org/dam/AAFP/documents/advocacy/prevention/risk/LT-CDC-OpioidGuideline011516.pdf The Myth of Morphine Equivalent Daily Dosage Medscape Neuro Perspective
For far too many years, pain researchers and clinicians have relied on the concept of the morphine equivalent daily dosage (MEDD), or some variant of it, as a means of comparing the "relative corresponding quantity" of the numerous opioid molecules that are important tools in the treatment of chronic pain.
...And, most unfortunately, opioid prescribing guideline committees have relied on this concept as a means of placing (usually arbitrary) limits on the levels of opioids that a physician or other clinician should be allowed to prescribe. Although these guidelines typically bill themselves as "voluntary," their chilling effect on prescribers and adaptation into state laws[2] makes calling them "voluntary" disingenuous.
Although some scientists and clinicians have been questioning the conceptual validity of MEDD for several years, a recent study[3] has indicated that the concept is unequivocally flawed—thereby invalidating its use empirically and as a tool in prescribing guideline development.
The authors used survey data from pharmacists, physicians, nurse practitioners, and physician assistants to estimate daily morphine equivalents and found great inconsistency in their conversions of hydrocodone, fentanyl transdermal patches, methadone, oxycodone, and hydromorphone—illustrating the potential for dramatic underdosing or, in other cases, fatal overdosing.
Patients with chronic pain (particularly that of noncancer origin) who are reliant on opioid analgesia are already sufficiently stigmatized and marginalized[7] to allow this type of practice to continue to be the norm.
Although the use of MEDD in research and, to a greater extent, in practice, is probably due to unawareness of its inaccuracy, we posit that the use of MEDD by recent opioid guideline committees (eg, the Washington State Opioid Guideline Committee[8] and the Centers for Disease Control and Prevention Guideline Committee[9]) in the drafting of their guidelines is based more heavily on disregarding available evidence rather than ignorance. Furthermore, their misconduct in doing so has been more pernicious than the use of MEDD by researchers and individual clinicians, because these guidelines widely affect society as a whole as well as individual patients with persistent pain syndromes. We opine that these committees are strongly dominated by the antiopioid community, whose agenda is to essentially restrict opioid access—irrespective of the lack of data indicating that opioids cannot be a useful tool in the comprehensive treatment of carefully selected and closely monitored patients with chronic pain.
Above 100% extracted from: Medscape Journal Brief https://www.medscape.com/viewarticle/863477_2
Actual Study https://www.dovepress.com/the-medd-myth-the-impact-of-pseudoscience-on-pain-research-and-prescri-peer-reviewed-article-JPR
Are Non-Opioid Medications Superior in Treatment of Pain than Opioid Pain Medicine? Ice Cream Flavor Analogy...
In the Oxford University Press, a November 2018 scientific white paper[5] was released that examined the quality of one of the primary studies that have been used to justify the urgent call to drastically reduce opioid pain medication prescribing while claiming that patients are not being harmed in the process.
The study is commonly referred to as ‘the Krebs study’. “The authors concluded that treatment with opioids was not superior to treatment with non opioid medications for improving pain-related function over 12 months.”
Here is an excerpt from the first paragraph of the design section (usually behind a paywall) from the Krebs study that gives the first hint of the bias that led to them to ‘prove’ that opioids were not effective for chronic pain:

“The study was intended to assess long-term outcomes of opioids compared with non opioid medications for chronic pain. The patient selection, though, specifically excluded patients on long-term opioid therapy.” 

Here is an analogy given in the Oxford Journal white paper to illustrate how the study design was compromised:
If I want to do a randomized control study about ice cream flavor preferences (choices being: vanilla, chocolate, or no preference), the results could be manipulated as follows based on these scenarios:
Scenario A: If a study was done that included only current ice-cream consumers, the outcome would certainly be vanilla or chocolate, because of course they have tried it and know which they like.
Scenario B: If a study was done that included all consumers of all food, then it can change the outcome. If the majority of study participants do not even eat ice-cream, than the result would certainly be ‘no preference’. If the majority do eat ice-cream it would likely be ‘chocolate’. Although this study is wider based, it still does not reflect real world findings.
Scenario C: In an even more extreme example, if this same study is conducted excluding anyone who has ever ate ice-cream at all, then the conclusion will again be ‘no preference’ and the entire study/original question becomes so ludicrous that there is no useful information to be extracted from this study and one would logically question why this type of study would even be conducted (although we know the answer to that)
Scenario C above is how the study that has been used to shift the attitudes towards the treatment of pain in our nation's medical community was designed. “One has to look deep into the study to find that they began with 9403 possible patients and excluded 3836 of them just because they had opioids in their EMR. In the JAMA article, they do not state these obvious biases and instead begin the explanation of participants stating they started with 4485 patients and excluded 224 who were opioid or benzo users.” That is the tip of the iceberg to how it is extremely misleading. The Oxford white paper goes into further detail of the studies “many flaws and biases (including the narrow focus on conditions that are historically known to respond poorly to opioid medication management of pain)”, but the study design and participant selection criteria is enough to discredit this entire body of work. Based on study design alone, regardless of what happened next, the result would be that opioids are no more effective than NSAIDs and other non-opioid alternatives.
The DEA Is Fostering a Bounty Hunter Culture in its Drug Diversion Investigators[8]
A Good Man Speaks Truth to Power January 2019
Because I write and speak widely on public health issues and the so-called “opioid crisis”, people frequently send me references to others’ work. One of the more startling articles I’ve seen lately was published November 20, 2018 in Pharmacy Times. It is titled “Should We Believe Patients With Pain?”[9]. The unlikely author is Commander John Burke, “a 40-year veteran of law enforcement, the past president of the National Association of Drug Diversion Investigators, and the president and cofounder of the International Health Facility Diversion Association.”
The last paragraph of Commander Burke’s article is worth repeating here.
“Let’s get back to dealing with each person claiming to be in legitimate pain and believe them until we have solid evidence that they are scamming the system. If they are, then let’s pursue them through vigorous prosecution, but let’s not punish the majority of people receiving opioids who are legitimate patients with pain.”
This seems a remarkable insight from anyone in law enforcement — especially from one who has expressed this view in both Pain News Network, and Dr Lynn Webster’s video “The Painful Truth”. Recognizing Commander Burke’s unique perspective, I followed up by phone to ask several related questions. He has granted permission to publish my paraphrases of his answers here.
“Are there any available source documents which establish widely accepted standards for what comprises “over-prescription?” as viewed by diversion investigators?” Burke’s answer was a resounding “NO”. Each State and Federal Agency that investigates doctors for potentially illegal or inappropriate opioid prescribing is pretty much making up their own standards as they go. Some make reference to the 2016 CDC Guidelines, but others do not.

1. “Thousands of individual doctors have left pain management practice in recent years due to fears they may be investigated, sanctioned, and lose their licenses if they continue to treat patients with opioid pain relievers.. Are DEA and State authorities really pursuing the worst “bad actors”, or is something else going on?

Burke’s answer: “Regulatory policy varies greatly between jurisdictions. But a hidden factor may be contributing significantly to the aggressiveness of Federal investigators. Federal Agencies may grant financial bonuses to their in-house diversion investigators, based on the volume of fines collected from doctors, nurse practitioners, PAs and others whom they investigate.

"No law enforcement agency at any level should be rewarded with monetary gain and/or promotion due to their work efforts or successes. This practice has always worried me with Federal investigators and is unheard of at the local or state levels of enforcement.”

Commander Burke’s revelation hit me like a thunder-clap. It would explain many of the complaints I have heard from doctors who have been “investigated” or prosecuted. It’s a well known principle that when we subsidize a behavior, we get more of it. Financial rewards to investigators must inevitably foster a “bounty hunter” mentality in some. It seems at least plausible that such bonuses might lead DEA regulators to focus on “low hanging fruit” among doctors who may not be able to defend themselves without being ruined financially. The practice is at the very least unethical. Arguably it can be corrupting.
I also inquired concerning a third issue:

1. I read complaints from doctors that they have been pursued on trumped-up grounds, coerced and denied appropriate legal defense by confiscation of their assets – which are then added to Agency funds for further actions against other doctors. Investigations are also commonly announced prominently, even before indictments are obtained – a step that seems calculated to destroy the doctor’s practice, regardless of legal outcomes. Some reports indicate that DEA or State authorities have threatened employees with prosecution if they do not confirm improper practices by the doctor. Do you believe such practices are common?”

Burke’s answer: “I hear the same reports you do – and the irony is that such tactics are unnecessary. Lacking an accepted standard for over-prescribing, the gross volume of a doctor’s prescriptions or the dose levels prescribed to their patients can be poor indicators of professional misbehavior. Investigators should instead be looking into the totality of the case, which can include patient reports of poor doctor oversight, overdose-related hospital admissions, and patterns of overdose related deaths that may be linked to a “cocktail” of illicit prescribing. Especially important can be information gleaned from confidential informants – with independent verification – prior patients, and pharmacy information.”

No formal legal prosecution should ever proceed from the testimony of only one witness — even one as well informed as Commander John Burke. But it seems to me that it is high time for the US Senate Judiciary Committee to invite the testimony of others in open public hearings, concerning the practice of possible bounty hunting among Federal investigators.
C50 Patient, Civil Rights Attorney, Maine Department of Health, and Maine Legislature Collaborative Enacted Definition of Palliative Care
One suggestion that our organization would like to make is altering the definition of “palliative care” in such a manner that it can include high-impact or intractable patients; those who are not dying this year, but our lives have been shattered and/or shortened by our diseases and for whom Quality of Life should be the focus. Many of our conditions may not SIGNIFICANTLY shorten my life, therefore I could legitimately be facing 30-40 years of severe pain with little relief; that is no way to live and therefore the concern is a rapidly increasing suicide rate.
This is a definition that one of our coalition members with a civil rights attorney and the Maine Department of Health agreed upon and legislators enacted into statues in Maine. This was in response to a 100mme restriction. This attorney had prepared a lawsuit based on the Americans with Disability Act that the Department of Health in Maine agreed was valid; litigation was never the goal, it was always patient-centered care.
A. "Palliative care" means patient-centered and family-focused medical care that optimizes quality of life by anticipating, preventing and treating suffering caused by a medical illness or a physical injury or condition that substantially affects a patient's quality of life, including, but not limited to, addressing physical, emotional, social and spiritual needs; facilitating patient autonomy and choice of care; providing access to information; discussing the patient's goals for treatment and treatment options, including, when appropriate, hospice care; and managing pain and symptoms comprehensively. Palliative care does not always include a requirement for hospice care or attention to spiritual needs. B. "Serious illness" means a medical illness or physical injury or condition that substantially affects quality of life for more than a short period of time. "Serious illness" includes, but is not limited to, Alzheimer's disease and related dementias, lung disease, cancer, heart, renal or liver failure and chronic, unremitting or intractable pain such as neuropathic pain.
Here is the link to the most recent update, including these definitions within the entire statute: https://legislature.maine.gov/statutes/22/title22sec1726.html?fbclid=IwAR0dhlwEh56VgZI9HYczdjdyYoJGpMdA9TuuJLlQrO3AsSljIZZG0RICFZc
January 23, 2019
Dear Pharmacists,
The Board of Pharmacy has had an influx of communication concerning patients not able to get controlled substance prescriptions filled for various reasons, even when signs of forgery or fraudulence were not presented. As a result of the increased “refusals to fill,” the board is issuing the following guidance and reminders regarding the practice of pharmacy and dispensing of controlled substances:

1. Pharmacists must use reasonable knowledge, skill, and professional judgment when evaluating whether to fill a prescription. Extreme caution should be used when deciding not to fill a prescription. A patient who suddenly discontinues a chronic medication may experience negative health consequences;
   
2. Part of being a licensed healthcare professional is that you put the patient first. This means that if a pharmacist has any concern regarding a prescription, they should attempt to have a professional conversation with the practitioner to resolve those concerns and not simply refuse the prescription. Being a healthcare professional also means that you use your medication expertise during that dialogue in offering advice on potential alternatives, changes in the prescription strength, directions etc. Simply refusing to fill a prescription without trying to resolve the concern may call into question the knowledge, skill or judgment of the pharmacist and may be deemed unprofessional conduct;
   
3. Controlled substance prescriptions are not a “bartering” mechanism. In other words, a pharmacist should not tell a patient that they have refused to fill a prescription and then explain that if they go to a pain specialist to get the same prescription then they will reconsider filling it. Again, this may call into question the knowledge, skill or judgment of the pharmacist;
   
4. Yes, there is an opioid crisis. However, this should in no way alter our professional approach to treatment of patients in end-of-life or palliative care situations. Again, the fundamentals of using our professional judgment, skill and knowledge of treatments plays an integral role in who we are as professionals. Refusing to fill prescriptions for these patients without a solid medical reason may call into question whether the pharmacist is informed of current professional practice in the treatment of these medical cases.
   
5. If a prescription is refused, there should be sound professional reasons for doing so. Each patient is a unique medical case and should be treated independently as such. Making blanket decisions regarding dispensing of controlled substances may call into question the motivation of the pharmacist and how they are using their knowledge, skill or judgment to best serve the public.
   

As a professional reminder, failing to practice pharmacy using reasonable knowledge, skill, competence, and safety for the public may result in disciplinary actions under Alaska statute and regulation. These laws are:
AS 08.80.261 DISCIPLINARY ACTIONS
(a)The board may deny a license to an applicant or, after a hearing, impose a disciplinary sanction authorized under AS 08.01.075 on a person licensed under this chapter when the board finds that the applicant or licensee, as applicable, …
(7) is incapable of engaging in the practice of pharmacy with reasonable skill, competence, and safety for the public because of
(A) professional incompetence; (B) failure to keep informed of or use current professional theories or practices; or (E) other factors determined by the board;
(14) engaged in unprofessional conduct, as defined in regulations of the board.
12 AAC 52.920 DISCIPLINARY GUIDELINES
(a) In addition to acts specified in AS 08.80 or elsewhere in this chapter, each of the following constitutes engaging in unprofessional conduct and is a basis for the imposition of disciplinary sanctions under AS 08.01.075; …
(15) failing to use reasonable knowledge, skills, or judgment in the practice of pharmacy;
(b) The board will, in its discretion, revoke a license if the licensee …
(4) intentionally or negligently engages in conduct that results in a significant risk to the health or safety of a patient or injury to a patient; (5) is professionally incompetent if the incompetence results in a significant risk of injury to a patient.
(c) The board will, in its discretion, suspend a license for up to two years followed by probation of not less than two years if the licensee ...
(2) is professionally incompetent if the incompetence results in the public health, safety, or welfare being placed at risk.
We all acknowledge that Alaska is in the midst of an opioid crisis. While there are published guidelines and literature to assist all healthcare professionals in up to date approaches and recommendations for medical treatments per diagnosis, do not confuse guidelines with law; they are not the same thing.
Pharmacists have an obligation and responsibility under Title 21 Code of Federal Regulations 1306.04(a), and a pharmacist may use professional judgment to refuse filling a prescription. However, how an individual pharmacist approaches that particular situation is unique and can be complex. The Board of Pharmacy does not recommend refusing prescriptions without first trying to resolve your concerns with the prescribing practitioner as the primary member of the healthcare team. Patients may also serve as a basic source of information to understand some aspects of their treatment; do not rule them out in your dialogue.
If in doubt, we always recommend partnering with the prescribing practitioner. We are all licensed healthcare professionals and have a duty to use our knowledge, skill, and judgment to improve patient outcomes and keep them safe.
Professionally,
Richard Holt, BS Pharm, PharmD, MBA Chair, Alaska Board of Pharmacy
https://www.commerce.alaska.gov/web/portals/5/pub/pha_ControlledSubstanceDispensing_2019.01.pdf
FDA in Brief: FDA finalizes new policy to encourage widespread innovation and development of new buprenorphine treatments for opioid use disorder
February 6, 2018
Media Inquiries Michael Felberbaum 240-402-9548
“The opioid crisis has had a tragic impact on individuals, families, and communities throughout the country. We’re in urgent need of new and better treatment options for opioid use disorder. The guidance we’re finalizing today is one of the many steps we’re taking to help advance the development of new treatments for opioid use disorder, and promote novel formulations or delivery mechanisms of existing drugs to better tailor available medicines to individuals’ needs,” said FDA Commissioner Scott Gottlieb, M.D. “Our goal is to advance the development of new and better ways of treating opioid use disorder to help more Americans access successful treatments. Unfortunately, far too few people who are addicted to opioids are offered an adequate chance for treatment that uses medications. In part, this is because private insurance coverage for treatment with medications is often inadequate. Even among those who can access some sort of treatment, it’s often prohibitively difficult to access FDA-approved addiction medications. While states are adopting better coverage owing to new legislation and resources, among public insurance plans there are still a number of states that are not covering all three FDA-approved addiction medications. To support more widespread adoption of medication-assisted treatment, the FDA will also continue to take steps to address the unfortunate stigma that’s sometimes associated with use of these products. It’s part of the FDA’s public health mandate to promote appropriate use of therapies.
Misunderstanding around these products, even among some in the medical and addiction fields, enables stigma to attach to their use. These views can serve to keep patients who are seeking treatment from reaching their goal. That stigma reflects a perspective some have that a patient is still suffering from addiction even when they’re in full recovery, just because they require medication to treat their illness. This owes to a key misunderstanding of the difference between a physical dependence and an addiction. Because of the biology of the human body, everyone who uses a meaningful dose of opioids for a modest length of time develops a physical dependence. This means that there are withdrawal symptoms after the use stops.
A physical dependence to an opioid drug is very different than being addicted to such a medication. Addiction requires the continued use of opioids despite harmful consequences on someone’s life. Addiction involves a psychological preoccupation to obtain and use opioids above and beyond a physical dependence.
But someone who is physically dependent on opioids as a result of the treatment of pain but who is not craving the drugs is not addicted.
The same principle applies to replacement therapy used to treat opioid addiction. Someone who requires long-term treatment for opioid addiction with medications, including those that are partial or complete opioid agonists and can create a physical dependence, isn’t addicted to those medications. With the right treatments coupled to psychosocial support, recovery from opioid addiction is possible. The FDA remains committed to using all of our tools and authorities to help those currently addicted to opioids, while taking steps to prevent new cases of addiction.”
Above is the full statement, find full statement with options for study requests: https://www.fda.gov/NewsEvents/Newsroom/FDAInBrief/ucm630847.htm
Maryland’s co-prescribing new laws/ amendments regarding benzos and opioids
Chapter 215 AN ACT concerning Health Care Providers – Opioid and Benzodiazepine Prescriptions – Discussion of Information Benefits and Risks
FOR the purpose of requiring that certain patients be advised of the benefits and risks associated with the prescription of certain opioids, and benzodiazepines under certain circumstances, providing that a violation of this Act is grounds for disciplinary action by a certain health occupations board; and generally relating to advice regarding benefits and risks associated with opioids and benzodiazepines that are controlled dangerous substances.
Section 1–223 Article – Health Occupations Section 4–315(a)(35), 8–316(a)(36), 14–404(a)(43), and 16–311(a)(8) SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, That the Laws of Maryland read as follows: Article – Health Occupations (a) In this section, “controlled dangerous substance” has the meaning stated in § 5–101 of the Criminal Law Article.
Ch. 215 2018 LAWS OF MARYLAND (B) On treatment for pain, a health care provider, based on the clinical judgment of the health care provider, shall prescribe: (1) The lowest effective dose of an opioid; and (2)A quantity that is no greater than the quantity needed for the expected duration of pain severe enough to require an opioid that is a controlled dangerous substance unless the opioid is prescribed to treat: (a.) A substance–related disorder; (b.) Pain associated with a cancer diagnosis; (c.) Pain experienced while the patient is receiving end–of–life, hospice, or palliative care services; or (d.) Chronic pain
(C.) The dosage, quantity, and duration of an opioid prescribed under [subsection (b)] of this [section] shall be based on an evidence–based clinical guideline for prescribing controlled dangerous substances that is appropriate for: (1.) The health care service delivery setting for the patient; (2.) The type of health care services required by the patient; (3.) and The age and health status of the patient.
(D) (1) WHEN A PATIENT IS PRESCRIBED AN OPIOID UNDER SUBSECTION (B) OF THIS SECTION, THE PATIENT SHALL BE ADVISED OF THE BENEFITS AND RISKS ASSOCIATED WITH THE OPIOID.

 (2) WHEN A PATIENT IS CO–PRESCRIBED A BENZODIAZEPINE WITH AN OPIOID THAT IS PRESCRIBED UNDER SUBSECTION (B) OF THIS SECTION, THE PATIENT SHALL BE ADVISED OF THE BENEFITS AND RISKS ASSOCIATED WITH THE BENZODIAZEPINE AND THE CO–PRESCRIPTION OF THE BENZODIAZEPINE. 

(E) A violation of [subsection (b) OR (D) of] this section is grounds for disciplinary action by the health occupations board that regulates the health care provider who commits the violation.
4-315 (a) Subject to the hearing provisions of § 4–318 of this subtitle, the Board may deny a general license to practice dentistry, a limited license to practice dentistry, or a teacher’s license to practice dentistry to any applicant, reprimand any licensed dentist, place any licensed dentist on probation, or suspend or revoke the license of any licensed dentist, if the applicant or licensee: (35) Fails to comply with § 1–223 of this article.
8–316. (a) Subject to the hearing provisions of § 8–317 of this subtitle, the Board may deny a license or grant a license, including a license subject to a reprimand, probation, or suspension, to any applicant, reprimand any licensee, place any licensee on probation, or suspend or revoke the license of a licensee if the applicant or licensee: (36) Fails to comply with § 1–223 of this article.
14–404. (a) Subject to the hearing provisions of § 14–405 of this subtitle, a disciplinary panel, on the affirmative vote of a majority of the quorum of the disciplinary panel, may reprimand any licensee, place any licensee on probation, or suspend or revoke a license if the licensee: (43) Fails to comply with § 1–223 of this article.
16–311. (a) Subject to the hearing provisions of § 16–313 of this subtitle, the Board, on the affirmative vote of a majority of its members then serving, may deny a license or a limited license to any applicant, reprimand any licensee or holder of a limited license, impose an administrative monetary penalty not exceeding $50,000 on any licensee or holder of a limited license, place any licensee or holder of a limited license on probation, or suspend or revoke a license or a limited license if the applicant, licensee, or holder:
(8) Prescribes or distributes a controlled dangerous substance to any other person in violation of the law, including in violation of § 1–223 of this article;
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect October 1, 2018.
Approved by the Governor, April 24, 2018.
https://legiscan.com/MD/text/HB653/id/1788719/Maryland-2018-HB653-Chaptered.pdf

​
The Lost Woman
​
long time ago the Blackfeet were camped on Backfat Creek.
There was in the camp a man who had but one wife, and he thought a great deal of her.
He never wanted to have two wives.
As time passed they had a child, a little girl.
Along toward the end of the summer, this man’s wife wanted to get some berries, and she asked her husband to take her to a certain place where berries grew, so that she could get some.
The man said to his wife: “At this time of the year, I do not like to go to that place to pick berries.
There are always Snake or Crow war parties travelling about there.”
The woman wanted very much to go, and she coaxed her husband about it a great deal; and at last he said he would go, and they started, and many women followed them.
When they came to where the berries grew, the man said to his wife: “There are the berries down in that ravine.
You may go down there and pick them, and I will go up on this hill and stand guard.
If I see any one coming, I will call out to you, and you must all get on your horses and run.” So the women went down to pick berries.
The man went up on the hill and sat down and looked over the country.
After a little time, he looked down into another ravine not far off, and saw that it was full of horsemen coming.
They started to gallop up towards him, and he called out in a loud voice, “Run, run, the enemy is rushing on us.”
The women started to run, and he jumped on his horse and followed them.
The enemy rushed after them, and he drew his bow and arrows, and got ready to fight and defend the women.
After they had gone a little way, the enemy had gained so much that they were shooting at the Blackfeet with their arrows, and the man was riding back and forth behind the women, and whipping up the horses, now of one, now of another, to make them go faster.
The enemy kept getting closer, and at last they were so near that they were beginning to thrust at him with their lances, and he was dodging them and throwing himself down, now on one side of his horse, and then on the other.
At length he found that he could no longer defend all the women, so he made up his mind to leave those that had the slowest horses to the mercy of the enemy, while he would go on with those that had the faster ones.
When he found that he must leave the women, he was excited and rode on ahead; but as he passed, he heard some one call out to him, “Don’t leave me,” and he looked to one side, and saw that he was leaving his wife.
When he heard his wife call out thus to him, he said to her: “There is no life for me here.
You are a fine-looking woman.
They will not kill you, but there is no life for me.”
She answered: “No, take pity on me.
Do not leave me.
My horse is giving out. Let us both get on one horse and then, if we are caught, we will die together.”
When he heard this, his heart was touched and he said: “No, wife, I will not leave you. Run up beside my horse and jump on behind me.”
The enemy were now so near that they had killed or captured some of the women, and they had come up close enough to the man so that they got ready to hit at him with their war clubs.
His horse was now wounded in places with arrows, but it was a good, strong, fast horse.
His wife rode up close to him, and jumped on his horse behind him.
When he started to run with her, the enemy had come up on either side of him, and some were behind him, but they were afraid to shoot their arrows for fear of hitting their own people, so they struck at the man with their war clubs.
But they did not want to kill the woman, and they did not hurt him.
They reached out with their hands to try to pull the woman off the horse; but she had put her arms around her husband and held on tight, and they could not get her off, but they tore her clothing off her.
As she held her husband, he could not use his arrows, and could not fight to defend himself.
His horse was now going very slowly, and all the enemy had caught up to them, and were all around them.
The man said to his wife: “Never mind, let them take you: they will not kill you.
You are too handsome a woman for them to kill you.”
His wife said, “No, it is no harm for us both to die together.”
When he saw that his wife would not get off the horse and that he could not fight, he said to her: “Here, look out!
You are crowding me on to the neck of the horse.
Sit further back.”
He began to edge himself back, and at last, when he got his wife pretty far back on the horse, he gave a great push and shoved her off behind.
When she fell off, his horse had more speed and began to run away from the enemy, and he would shoot back his arrows; and now, when they would ride up to strike him with their hatchets, he would shoot them and kill them, and they began to be afraid of him, and to edge away from him.
His horse was very long-winded; and now, as he was drawing away from the enemy, there were only two who were yet able to keep up with him.
The rest were being left behind, and they stopped, and went back to where the others had killed or captured the women; and now only two men were pursuing.
After a little while, the Blackfoot jumped off his horse to fight on foot, and the two enemies rode up on either side of him, but a long way off, and jumped off their horses. When he saw the two on either side of him, he took a sheaf of arrows in his hand and began to rush, first toward the one on the right, and then toward the one on the left.
As he did this, he saw that one of the men, when he ran toward him and threatened to shoot, would draw away from him, while the other would stand still.
Then he knew that one of them was a coward and the other a brave man.
But all the time they were closing in on him.
When he saw that they were closing in on him, he made a rush at the brave man.
This one was shooting arrows all the time; but the Blackfoot did not shoot until he got close to him, and then he shot an arrow into him and ran up to him and hit him with his stone axe and killed him.
Then he turned to the cowardly one and ran at him.
The man turned to run, but the Blackfoot caught him and hit him with his axe and killed him.
After he had killed them, he scalped them and took their arrows, their horses, and the stone knives that they had.
Then he went home, and when he rode into the camp he was crying over the loss of his wife.
When he came to his lodge and got off his horse, his friends went up to him and asked what was the matter.
He told them how all the women had been killed, and how he had been pursued by two enemies, and had fought with them and killed them both, and he showed them the arrows and the horses and the scalps.
He told the women’s relations that they had all been killed; and all were in great sorrow, and crying over the loss of their friends.
The next morning they held a council, and it was decided that a party should go out and see where the battle had been, and find out what had become of the women.
When they got to the place, they found all the women there dead, except this man’s wife Her they could not find.
They also found the two Indians that the man had said that he had killed, and, besides, many others that he had killed when he was running away.
When he got back to the camp, this Blackfoot picked up his child and put it on his back, and walked round the camp mourning and crying, and the child crying, for four days and four nights, until he was exhausted and worn out, and then he fell asleep. When the rest of the people saw him walking about mourning, and that he would not eat nor drink, their hearts were very sore, and they felt very sorry for him and for the child, for he was a man greatly thought of by the people.
While he lay there asleep, the chief of the camp came to him and woke him, and said: “Well, friend, what have you decided on? What is your mind? What are you going to do?”
The man answered: “My child is lonely. It will not eat. It is crying for its mother.
It will not notice any one. I am going to look for my wife.”
The chief said, “I cannot say anything.”
He went about to all the lodges and told the people that this man was going away to seek his wife.
Now there was in the camp a strong medicine man, who was not married and would not marry at all.
He had said, “When I had my dream, it told me that I must never have a wife.”
The man who had lost his wife had a very beautiful sister, who had never married.
She was very proud and very handsome.
Many men had wanted to marry her, but she would not have anything to do with any man.
The medicine man secretly loved this handsome girl, the sister of the poor man.
When he heard of this poor man’s misfortune, the medicine man was in great sorrow, and cried over it.
He sent word to the poor man, saying: “Go and tell this man that I have promised never to take a wife, but that if he will give me his beautiful sister, he need not go to look for his wife. I will send my secret helper in search of her.”
When the young girl heard what this medicine man had said, she sent word to him, saying, “Yes, if you bring my brother’s wife home, and I see her sitting here by his side, I will marry you, but not before.”
But she did not mean what she said. She intended to deceive him in some way, and not to marry him at all.
When the girl sent this message to him, the medicine man sent for her and her brother to come to his lodge.
When they had come, he spoke to the poor man and said, “If I bring your wife here, are you willing to give me your sister for my wife?” The poor man answered, “Yes.” But the young girl kept quiet in his presence, and had nothing to say.
Then the medicine man said to them: “Go. To-night in the middle of the night you will hear me sing.” He sent everybody out of his lodge, and said to the people: “I will close the door of my lodge, and I do not want any one to come in to-night, nor to look through the door.
A spirit will come to me to-night.” He made the people know, by a sign put out before the door of his lodge, that no one must enter it, until such time as he was through making his medicine.
Then he built a fire, and began to get out all his medicine.
He unwrapped his bundle and took out his pipe and his rattles and his other things. After a time, the fire burned down until it was only coals and his lodge was dark, and on the fire he threw sweet-scented herbs, sweet grass, and sweet pine, so as to draw his dream-helper to him.
Now in the middle of the night he was in the lodge singing, when suddenly the people heard a strange voice in the lodge say: “Well, my chief, I have come. What is it?”
The medicine man said, “I want you to help me.” The voice said, “Yes, I know it, and I know what you want me to do.” The medicine man asked, “What is it?”
The voice said, “You want me to go and get a woman.” The medicine man answered: “That is what I want. I want you to go and get a woman—the lost woman.” The voice said to him, “Did I not tell you never to call me, unless you were in great need of my help?”
The medicine man answered, “Yes, but that girl that was never going to be married is going to be given to me through your help.”
Then the voice said, “Oh!” and it was silent for a little while.
Then it went on and said: “Well, we have a good feeling for you, and you have been a long time not married; so we will help you to get that girl, and you will have her.
Yes, we have great pity on you. We will go and look for this woman, and will try to find her, but I cannot promise you that we will bring her; but we will try.
We will go, and in four nights I will be back here again at this same time, and I think that I can bring the woman; but I will not promise.
While I am gone, I will let you know how I get on. Now I am going away.”
And then the people heard in the lodge a sound like a strong wind, and nothing more. He was gone.
Some people went and told the sister what the medicine man and the voice had been saying, and the girl was very down-hearted, and cried over the idea that she must be married, and that she had been forced into it in this way.
When the dream person went away, he came late at night to the camp of the Snakes, the enemy.
The woman who had been captured was always crying over the loss of her man and her child. She had another husband now.
The man who had captured her had taken her for his wife.
As she was lying there, in her husband’s lodge, crying for sorrow for her loss, the dream person came to her.
Her husband was asleep.
The dream-helper touched her and pushed her a little, and she looked up and saw a person standing by her side; but she did not know who it was.
The person whispered in her ear, “Get up, I want to take you home.”
She began to edge away from her husband, and at length got up, and all the time the person was moving toward the door.
She followed him out, and saw him walk away from the lodge, and she went after. The person kept ahead, and the woman followed him, and they went away, travelling very fast.
After they had travelled some distance, she called out to the dream person to stop, for she was getting tired.
Then the person stopped, and when he saw the woman sitting, he would sit down, but he would not talk to her.
As they travelled on, the woman, when she got tired, would sit down, and because she was very tired, she would fall asleep; and when she awoke and looked up, she always saw the person walking away from her, and she would get up and follow him.
When day came, the shape would be far ahead of her, but at night it would keep closer.
When she spoke to this person, the woman would call him “young man.”
At one time she said to him, “Young man, my moccasins are all worn out, and my feet are getting very sore, and I am very tired and hungry.”
When she had said this, she sat down and fell asleep, and as she was falling asleep, she saw the person going away from her. He went back to the lodge of the medicine man.
During this night the camp heard the medicine man singing his song, and they knew that the dream person must be back again, or that his chief must be calling him.
The medicine man had unwrapped his bundle, and had taken out all his things, and again had a fire of coals, on which he burned sweet pine and sweet grass.
Those who were listening heard a voice say: “Well, my chief, I am back again, and I am here to tell you something. I am bringing the woman you sent me after.
She is very hungry and has no moccasins. Get me those things, and I will take them back to her.”
The medicine man went out of the lodge, and called to the poor man, who was mourning for his wife, that he wanted to see him.
The man came, carrying the child on his back, to hear what the medicine man had to say.
He said to him: “Get some moccasins and something to eat for your wife. I want to send them to her.
She is coming.” The poor man went to his sister, and told her to give him some moccasins and some pemmican. She made a bundle of these things, and the man took them to the medicine man, who gave them to the dream person; and again he disappeared out of the lodge like a wind.
When the woman awoke in the morning and started to get up, she hit her face against a bundle lying by her, and when she opened it, she found in it moccasins and some pemmican; and she put on the moccasins and ate, and while she was putting on the moccasins and eating, she looked over to where she had last seen the person, and he was sitting there with his back toward her.
She could never see his face.
When she had finished eating, he got up and went on, and she rose and followed.
They went on, and the woman thought, “Now I have travelled two days and two nights with this young man, and I wonder what kind of a man he is. He seems to take no notice of me.”
So she made up her mind to walk fast and to try to overtake him, and see what sort of a man he was.
She started to do so, but however fast she walked, it made no difference.
She could not overtake him.
Whether she walked fast, or whether she walked slow, he was always the same distance from her.
They travelled on until night, and then she lay down again and fell asleep.
She dreamed that the young man had left her again.
The dream person had really left her, and had gone back to the medicine man’s lodge, and said to him: “Well, my chief, I am back again.
I am bringing the woman.
You must tell this poor man to get on his horse, and ride back toward Milk River (the Teton).
Let him go in among the high hills on this side of the Muddy, and let him wait there until daylight, and look toward the hills of Milk River; and after the sun is up a little way, he will see a band of antelope running toward him, along the trail that the Blackfeet travel.
It will be his wife who has frightened these antelope.
Let him wait there for a while, and he will see a person coming.
This will be his wife. Then let him go to meet her, for she has no moccasins.
She will be glad to see him, for she is crying all the time.”
The medicine man told the poor man this, and he got on his horse and started, as he had been told.
He could not believe that it was true. But he went.
At last he got to the place, and a little while after the sun had risen, as he was lying on a hill looking toward the hills of the Milk River, he saw a band of antelope running toward him, as he had been told he would see.
He lay there for a long time, but saw nothing else come in sight; and finally he got angry and thought that what had been told him was a lie, and he got up to mount his horse and ride back.
Just then he saw, away down, far off on the prairie, a small black speck, but he did not think it was moving, it was so far off,—barely to be seen.
He thought maybe it was a rock.
He lay down again and took sight on the speck by a straw of grass in front of him, and looked for a long time, and after a while he saw the speck pass the straw, and then he knew it was something.
He got on his horse and started to ride up and find out what it was, riding way around it, through the hills and ravines, so that he would not be seen.
He rode up in a ravine behind it, pretty near to it, and then he could see it was a person on foot.
He got out his bow and arrows and held them ready to use, and then started to ride up to it.
He rode toward the person, and at last he got near enough to see that it was his wife. When he saw this, he could not help crying; and as he rode up, the woman looked back, and knew first the horse, and then her husband, and she was so glad that she fell down and knew nothing.
After she had come to herself and they had talked together, they got on the horse and rode off toward camp.
When he came over the hill in sight of camp, all the people began to say, “Here comes the man”; and at last they could see from a distance that he had some one on the horse behind him, and they knew that it must be his wife, and they were glad to see him bringing her back, for he was a man thought a great deal of, and everybody liked him and liked his wife and the way he was kind to her.
Then the handsome girl was given to the medicine man and became his wife.

​
The Life and Death of Sweet Medicine
​
A long time ago the people had no laws, no rules of behavior- they hardly knew enough to survive.
And they did shameful things out of ignorance, because they didn't understand how to live.
There was one man among them who had a natural sense of what was right.
He and his wife were good, hard- working people, a family to be proud of.
The knew how to feel ashamed, and this feeling kept them from doing wrong.
Their only child was a daughter, beautiful and modest, who had reached the age when girls begin to think about husbands and making a family.
One night a man's voice spoke to her in a dream.
"You are handsome and strong, modest and young.
Therefore Sweet Root will visit you."
Dismissing it as just a dream, the girl went cheerfully about her chores the next day.
On the following night, however, she heard the voice again:
"Sweet Root is coming- woman's medicine which makes a mother's milk flow.
Sweet Root is coming as a man comes courting."
The girl puzzled over the words when she awoke, but in the end shrugged her shoulders.
People can't control their dreams, she thought, and the idea of a visit from a medicine root didn't make any sense.
On the third night the dream recurred, and this time it was so real that a figure seemed to be standing beside the buffalo robe she slept on.
He was talking to her, telling her: "Sweet Root is coming; he is very near.
Soon he will be with you."
On the fourth night she heard the same voice and saw the same figure.
Disturbed, she told her mother about it the next morning.
"There must be something in it," she said.
"It's so real and the voice is so much like a man's voice."
"No, its just a dream," her mother said. "It doesn't mean anything."
But from that time on, the girl felt different.
Something was stirring, growing within her, and after a few months, her condition became obvious: she was going to have a baby.
She told her parents that no man had touched her, and they believed her.
But others would not be likely to, and the girl hid her condition.
When she felt the birth pangs coming on, she went out into the prairie far from the camp and built herself a brush shelter.
Doing everything herself, she gave birth to a baby boy.
She dried the baby, wrapped him in soft moss, and left him there in the wickiup, for in her village a baby without a father would be scorned and treated badly.
Praying that someone would find him, she went sadly home to her parents.
At about the same time, an old woman was out searching the prairie for wild turnips, which she dug up with an animal's shoulder blade.
She heard crying, and following the sound, came to the wickiup.
She was overjoyed to find the baby, as she had never had one of her own.
All around the brush shelter grew the sweet root which makes a mother's milk flow; so she named the boy Sweet Medicine.
She took him home to her shabby tipi even though she had nothing to offer him but love.
In the tipi next to the old woman's lived a young mother who was nursing a small child, and she agreed to nurse Sweet Medicine also.
He grew faster and learned faster than ordinary children and was weaned in no time.
When he was only ten yearas old, he had already grown-up wisdom and hunting skill far in advance of his age.
But because he had no family and lived at the edge of the camp in a poor tipi, no one paid any attention to Sweet Medicine's exceptional powers.
That year there was a drought, very little game, and much hunger in the village. "Grandmother," he told her, "find me an old buffalo hide- any dried out, chewed up scrap with holes in it will do."
The woman searched among the refuse piles and found a wrinkled, brittle piece that the starving dogs had been chewing on.
When she brought it to Sweet Medicine, he told her, "Take this to the stream outside the camp, wash it in the flowing water, make it pliable, scrape it clean.
" After she had done this Sweet Medicine took a willow wand and bent it into a hoop, which he colored with sacred red earth paint.
He cut the buffalo hide into one long string and wove it back and forth over the hoop, making a kind of net with an opening in the center.
Then he cut four wild cherry sticks, sharpened them to a point, and hardened them in the hearth fire.
The next morning he said: "Grandmother, come with me.
We're going to play the hoop-and-stick game."
He took the hoop and the cherry-wood sticks and walked into the middle of the camp circle.
"Grandmother, roll this hoop for me," he said.
She rolled the hoop along the ground and Sweet Medicine hurled his pointed sticks through the center of it, hitting the right spot every time.
Soon alot of people, men and women, boys and girls, came to watch the strange new game.
Then Sweet Medicine cried: "Grandmother, let me hit it once more and make the hoop turn into a fat buffalo calf!"
Again he threw his stick like a dart, again the stick went through the center of the hoop, and as it did so the hoop turned into a fat, yellow buffalo calf.
The stick had pierced its heart, and the calf fell down dead.
"Now you people will have plenty to eat," said Sweet Medicine.
"Come and butcher this calf."
The people gathered and roasted chunks of tender calf meat over their fires.
And no matter how many pieces of flesh they cut from the calf's body, it was never picked clean.
However much they ate, there was always more.
So the people had their fill, and that was the end of the famine.
It was also the first hoop-and-stick game played among the Cheyenne.
This sacred game has much power attached to it, and it is still being played.
A boy's first kill is an important happening in his life, something he will always remember.
After killing his first buffalo a boy will be honored by his father, who may hold a feast for him and give him a man's name.
There would be no such feast for Sweet Medicine, all the same, he was very happy when he killed a fat, yellow calf on his first hunt.
He was skinning and butchering it when he was approached by an elderly man, a chief too old to do much hunting, but still harsh and commanding.
"This is just the kind of hide I have been looking for," said the chief.
"I will take it."
"You can't have a boy's first hide." said Sweet Medicine.
"Surely you must know this.
But you are welcome to half of the meat, because I honor old age."
The chief took the meat but grabbed the hide too, and began to walk off with it.
Sweet Medicine took hold of one end, and they started a tug-of-war.
The chief used his riding whip on Sweet Medicine, shouting: "How dare a poor nothing boy defy a chief?"
As he whipped Sweet Medicine again and again across the face, the boy's fighting spirit was aroused.
He grabbed a big buffalo leg bone and hit the old man over the head.
Some say Sweet Medicine killed that chief, others say the old man just fell down stunned.
But in the village the people were angry that a mere boy had dared to fight the old chief. Some said, "Lets whip him," others said, "Lets kill him."
After he had returned to the old woman's lodge, Sweet Medicine sensed what was going on.
He said: "Grandmother, some young men of the warrior societies will come here to kill me for having stood up for myself."
He thanked her for her kindness to him and then fled from the village.
Later when the young warriors came, they were so angry to find the boy gone that they pulled down the lodge and set fire to it.
The following morning someone saw Sweet Medicine, dressed as a Fox warrior, standing on a hill overlooking the village.
His enemies set out in pursuit, but he was always just out of their reach and they finally retired exhausted.
The next morning he appeared as an Elk warrior, carrying a crooked coupstick wrapped in otter skin.
Again, they tried to catch him and kill him, and again he evaded them.
They resumed their futile chase on the third morning, when he wore the red face paint and feathers of a Red Shield warrior, and on the fourth, when he dressed like a Dog soldier and shook a small red rattle tied with buffalo hair at his pursuers.
On the fifth day he appeared in the full regalia of a Cheyenne chief.
That made the village warriors angrier than ever, but they still couldn't catch him, and after that they saw him no more.
Wandering alone over the prairie, the boy heard a voice calling, leading him to a beautiful dark-forested land of many hills.
Standing apart from the others was a single mountain shaped like a huge tipi: the sacred mountain called Bear Butte.
Sweet Medicine found a secret opening which has since been closed (or perhaps is visible to him alone) and entered the mountain.
It was hollow inside like a tipi, forming a sarcred lodge filled with people who looked like ordinary men and women, but were really powerful spirits.
"Grandson, come in, we have been expecting you,"the holy people said, and when Sweet Medicine took his seat, they began teaching him the Cheyenne way to live so that he could return to the people and give them this knowledge.
First of all, the spirits gave him the sacred four arrows, saying,
"This is the great gift we are handing you.
With these wonderful arrows, the tribe will prosper.
Two arrows are for war and two are for hunting.
But there is much, much more to the four arrows.
They have great powers.
They contain rules by which men ought to live."
The spirit people taught Sweet Medicine how to pray to the arrows, how to keep them, how to renew them.
They taught him the wise laws of the forty-four chiefs.
They taught him how to set up rules for the warrior societies.
They taught him how women should be honored.
They taught him the many useful things by which people could live, survive, and prosper, things that people had not yet learned at that time.
Finally they taught him how to make a special tipi in which the sacred arrows were to be kept.
Sweet Medicine listened respectfully and learned well, and finally an old spirit man burned incense of sweet grass to purify both Sweet Medicine and the sacred arrow bundle.
Then the Cheyenne boy put the holy bundle on his back and began the long journey home to his people.
During his absence there had been a famine in the land.
The buffalo had gone into hiding, for they were angry that the people did not know how to live and were behaving badly.
When Sweet Medicine arrived at the village, he found a group of tired and listless children, their ribs sticking out, who were playing with little buffalo figures they had made out of mud.
Sweet Medicine immediately changed the figures into large chunks of juicy buffalo meat and fat.
"Now there's enough for you to eat," he told the young ones, "with plenty left over for your parents and grandparents.
Take the meat, fat, and tongues into the village, and tell two good young hunters to come out in the morning to meet me."
Though the children carried the message and two young hunters went out and looked everywhere for Sweet Medicine the next day, all they saw was a big eagle circling above them.
They tried again on the second and third days with no success, but on the fourth morning they found Sweet Medicine standing on top of a hill overlooking the village.
He told the two: "I have come bringing a wonderful gift from the Creator which the spirits inside the great medicine mountain have sent you.
Tell the people to set up a big lodge in the center of the camp circle.
Cover its floor with sage, and purify it with burning sweet grass.
Tell everyone to go inside the tipi and stay there, no one must see me approaching."
When at last all was made ready, Sweet Medicine walked slowly toward the village and four times called out: "People of the Cheyenne, with a great power I am approaching.
Be joyful.
The sacred arrows I am bringing."
He entered the tipi with the sacred arrow bundle and said:
"You have not yet learned the right way to live.
That is why the Ones above were angry and the buffalo went into hiding."
The two young hunters lit the fire, and Sweet Medicine filled a deer-bone pipe with sacred tobacco.
All night through, he taught the people what the spirits inside the holy mountain had taught him.
These teachings established the way of the Tsistsistas, the true Cheyenne nation.
Toward the morning, Sweet Medicine sang four sacred songs.
After each song he smoked the pipe, and its holy breath ascended through the smoke hole up into the sky, up to the great mystery.
At daybreak, as the sun rose and the people emerged from the sacred arrow lodge, they found the prairie around them covered with buffalo.
The spirits were no longer angry.
The famine was over.
For many nights to come, Sweet Medicine instructed the people in the sacred laws.
He lived among the Cheyenne for a long time and made them into a proud tribe respected throughout the plains.
Four lives the Creator had given him, but even Sweet Medicine was not immortal.
Only the rocks and the mountains are forever.
When he grew old and feeble and felt that the end of his appointed time was near, he directed the people to carry him to a place near the sacred Bear Butte.
There they made a small hut for him out of cottonwood branches and cedar lodge poles covered with bark and leaves.
They spread its floor with sage, flat cedar leaves, and fragrant grass.
It was a good lodge to die in, and when they placed him before it, he addressed the people for the last time:
"I have seen in my mind that some time after I am dead...and may the time be long...light-skinned bearded men will arrive with sticks spitting fire.
They will conquer the land and drive you before them.
They will kill the animals who give you their flesh that you may live, and they will bring strange animals for you to ride and eat.
They will introduce war and evil, strange sickness and death.
They will try and make you forget Maheo, the Creator, and the things I have taught you, and will impose their own alien, evil ways.
They will take your land little by little, until there is nothing left for you.
I do not like to tell you this, but you must know.
You must be strong when that bad time comes, you men, and particularly you women, because much depends on you, because you are the perpetuators of life and if you weaken, the Cheyenne will cease to be.
Now I have said all there is to say.
Then Sweet Medicine went into his hut to die.

​
The Legend of the Flute
​
A Brule Sioux Legend
Well, you know our flutes, you've heard their sounds and seen how beautifully they are made.
That flute of ours, the siyotanka, is for only one kind of music, love music.
In the old days the men would sit by themselves, maybe lean hidden, unseen, against a tree in the dark of night.
They would make up
their own special tunes, their courting songs.
We Natives are shy.
Even if he was a warrior who had already counted coup on a enemy, a young man might hardly muster up enough courage enough to talk to a nice-looking winchinchala - a girl he was in love with.
Also, there was no place where a young man and a girl could be alone inside the village.
The family tipi was always crowded with people.
And naturally, you couldn't just walk out of the village hand in hand with your girl, even if hand holding had been one of our customs, which it wasn't.
Out there in the tall grass and sagebrush you could be gored by a buffalo, clawed by a grizzly, or tomahawked by a Pawnee, or you could run into the Mila Hanska, the Long Knives, namely the U.S. Cavalry.
The only chance you had to meet your winchinchala was to wait for her at daybreak when the women went to the river or brook with their skin bags to get water.
When that girl you had your eye on finally came down to the water trail, you popped up from behind some bush and stood so she could see you.
And that was about all you could do to show her that you were interested, standing there grinning, looking at your moccasins, scratching your ear, maybe.
The winchinchala didn't so much either, except get red in the face, giggle, maybe throw a wild turnip at you.
If she liked you, the only way she would let you know was to take her time filling her water bag and peek at you a few times over her shoulder.
So the flutes did all the talking.
At night, lying on her buffalo robe in her parents tipi, the girl would hear that moaning, crying sound of the siyotanka.
By the way it was played, she would know that it was her lover who was out there someplace.
And if the Elk Medicine was very strong in him and her, maybe she would sneak out to follow that sound and meet him without anybody noticing it.
The flute is always made of cedarwood.
In the shape it describes the long neck and head of a bird with a open beak.
The sound comes out of the beak, and that's where the legend comes in, the legend of how the Lakota people acquired the flute.
​
Once many generations ago, the people had drums, gourd rattles, and bull-rorers, but no flutes.
At that long-ago time, a young man went out to hunt.
Meat was scarce, and the people in his camp were hungry.
He found the tracks of an elk and followed them for a long time.
The elk, wise and swift, is the one who owns the love charm.
If a man possesses Elk Medicine, the girl he likes can't help sleeping with him.
This young man I'm talking about had no Elk Medicine.
After many hours he finally sighted his game.
He was skilled with bow and arrows, and had a fine new bow and quiver full of arrows.
Yet the elk always managed to stay just out of range, leading him on and on.
The young man was so intent on following his prey that he hardly noticed where he went.
When night came, he found himself deep inside a thick forest.
The tracks had disappeared and so had the elk, and there was no moon.
He realized that he was lost and that it was too dark to find his way out.
Luckily, he came upon a stream with cool, clear water.
And he had been careful enough to bring a hide bag of wasna, dried meat pounded with berries and kidney fat, strong food that will keep a man going for a few days. After he had drunk and eaten, he rolled himself into his fur robe, propped his back against a tree and tried to rest.
But he couldn't sleep, the forest was full of strange noises; the cries of night animals, the hooting owls, and the groaning of trees in the wind.
It was as if he heard these sounds for the first time.
Suddenly there was an entirely new sound, of a kind that neither he nor anyone else had ever heard before.
It was mournful and ghost like.
It made him afraid, so that he drew his robe tightly about himself and reached for his bow to make sure that it was properly strung.
On the other hand the sound was like a song, sad but beautiful, full of love, hope, and yearning.
Then before he knew it, he was asleep.
​
He dreamed that the bird called wagnuka, the redheaded woodpecker, appeared singing the strangely beautiful song and telling him,
"Follow me and I will teach you."
When the hunter awoke, the sun was already high.
On a branch of the tree against which he was leaning, he saw a redheaded woodpecker.
The bird flew away to another tree, and another, but never very far, looking back all the time at the young man as if to say, "Come on!"
Then once more he heard that wonderful song, and his heart yearned to find the singer.
Flying toward the sound, leading the hunter, the bird flitted through the leaves, while it's bright red top made it easy to follow.
At last it lighted on a cedar tree and began hammering on a branch, making a noise like the fast beating of a small drum.
Suddenly there was a gust of wind, and again the hunter heard the beautiful sound right above him.
Then he discovered that the song came from the dead branch that the woodpecker was tapping his beak on.
He realized also that it was the wind that made the sound as it whistled through the hole the bird had drilled.
"Kola, friend," said the hunter, "let me take this branch home.
You can make yourself another."
He took the branch, a hollow piece of wood filled with woodpecker holes that was about the length of his forearm.
He walked back to the village bringing no meat, but happy all the same.
In his tipi the young man tried to make the branch sing for him.
He blew on it, he waved it around, but no sound came.
It made him sad, he wanted so much to hear that wonderful new sound.
He purified himself in the sweat lodge and climbed to the top of a lonely hill.
There, resting with his back against a large rock, he fasted, going without food or water for four days and nights, crying for a vision which would tell him
how to make the branch sing.
In the middle of the fourth night, wagnuka, the bird with the bright red top appeared saying, "Watch me." turning himself into a man, showing the hunter how to make the branch sing, saying again and again, "Watch this, now."
And in his dream the young man watched and observed very carefully.
When he awoke, he found a cedar tree.
He broke off a branch and, working many hours, hollowed it out with a bowstring drill, just as he had seen the woodpecker do in his dream.
He whittled the branch into the shape of the birds with a long neck and an open beak. He painted the top of the bird's head with washasha, the sacred red color.
He prayed.
He smoked the branch up with the incense of burning sage, cedar, and sweet grass. He fingered the holes as he had seen the man-bird do in his vision, meanwhile lowing softly into the mouthpiece.
All at once there was the song, ghost like and beautiful beyond words drifting all the way to the village, where the people were astounded and joyful to hear it.
With the help of the wind and woodpecker, the young man had brought them the first flute.