Under-treatment of Pain

RSS Feed for this category

Pain Medicine: Pain Relief Network Sues State of Washington Over Narcotic Prescribing Guidelines

The Pain Relief Network (PRN), a nonprofit organization waging a lonely battle to protect the rights of doctors who prescribe opioid pain relievers and patients who receive them, has filed a lawsuit against the state of Washington over prescribing guidelines promulgated in March 2007 by the state Department of Health.

The guidelines are designed to guide physicians through the minefields of narcotic prescribing in a time where they face a rising clamor for the relief of pain at the same time they face the threat of arrest and prosecution by federal or state agents intent on stopping narcotic drug abuse. But PRN alleges that Washington's guidelines deter doctors from prescribing opiates and have had an undue negative influence on prescribing practices across the country.

The guidelines, which only apply to the treatment of chronic pain -- not cancer pain, acute pain or hospice care -- recommend that daily opioid doses not exceed 120 milligrams of morphine or the equivalent if both pain and physical function are not improving. PRN argues that the guidelines are inflexible and fail to account for the needs of real patients.

According to the complaint filed late last month on behalf of a Washington state doctor and a group of Washington state pain patients, plaintiffs seek an injunction blocking the guidelines from being used. The complaint argues that the Washington guidelines violate both state laws and federal civil rights laws.

Pain Relief Network Sues State of WA

As always, we ask that you help PRN fight to protect the rights of patients and the doctors who treat them. Please click the link below.

Link

Pain Treatment Advocacy Group Sues State of WA

Jun 25, 2008

By: Donna Gordon Blankinship

The Associated Press SEATTLE - A pain treatment advocacy group filed suit Wednesday in federal court to challenge the restrictions Washington state officials have put on prescription pain medication.

The nonprofit Pain Relief Network says the guidelines for prescribing narcotics, written by the Washington state Department of Health and published in March 2007, have influenced pain treatment across the country and have made doctors afraid to give opiate prescriptions[...]

Complaint for Declaratory and Injunctive Relief, Damages a class action lawsuit by Laura Cooper (lead attorney) et al., Filed: 2008-06-24

Exhibit 1: The WA state Opioid Dosing "Guidelines" by Agency Medical Directors Group (AMDG); Mar. 2007; Filed 2008-06-24

Exhibit 2: Findings of Fact Laura Cooper, Esq.; Filed 2008-06-24 www.painreliefnetwork.org

Location: 
WA
United States

Pain Medicine: Kansas Doctor Fights Back, Attacks Federal Prosecution and Controlled Substances Act as Unconstitutional

Lawyers for a Haysville, Kansas, physician facing a 34-count federal indictment alleging he acted as a drug dealer in prescribing pain medications fought back last Friday, filing in federal court a motion to dismiss both the indictment and federal Controlled Substances act (CSA) as unconstitutional. Attorneys for Dr. Steven Schneider argued that federal prosecutors in Wichita improperly claimed authority over the regulation of medicine.

Schneider and his wife, a nurse at his Haysville clinic, were arrested in December amidst great fanfare from prosecutors, who referred to the general care, ambulatory, and pain relief clinic as a "pill mill" and asserted Schneider was "linked" to 56 deaths. They remained in jail held without bond until last month, when they were finally released pending trial.

Schneider is only the latest of dozens of physicians arrested and tried by federal prosecutors over their pain medication prescribing practices in recent years. With the DEA and Justice Department prosecutors asserting that they know best medical practices and willing to arrest doctors whose practices they disagree with, the field of pain relief medicine has been plagued by the tension between the imperatives of pain relief and those of drug control.

Schneider and his lawyers want the government out of the doctor's office. "This case is an effort by the federal government to define and regulate the practice of medicine masquerading as a criminal prosecution," wrote Schneider's legal team, which includes nationally known specialists. "This case should not be about whether Dr. Schneider fell short of the standard of care for certain patients, but whether he engaged in the legitimate practice of medicine."

Schneider's medical conduct should be a matter for the state medical board, not the federal criminal apparatus, the lawyers wrote. "All of the accusations against Dr. Schneider and Ms. Atterbury [Mrs. Schneider] revolve around matters of medical science, professional judgment, and evolving standards of practice. However, by seizing on widespread ignorance and hysteria surrounding the use of opioid analgesics in the treatment of chronic pain, the government has endeavored to shoehorn these matters, which bear no relevance to criminal culpability, into the rubric of drug dealing and health care fraud. With regard to the charges related to the Controlled Substance Act ('CSA'), the sole question should be whether Dr. Schneider was a drug dealer 'as conventionally understood.' Instead, the government confounds this question with irrelevant facts and improper standards."

The CSA is unconstitutional on its face as "impermissibly vague" when it comes to providing guidance for physicians and as applied in this particular indictment, the lawyers argued. "As applied in the Indictment, the CSA fails to adequately and meaningfully inform physicians of what conduct is proscribed, largely because such conduct is arbitrarily and unilaterally determined by enforcement authorities lacking knowledge and expertise with respect to issues of medical science and ethics."

No word yet on when a ruling on the motion is expected. But the direct attack by the federal government's drug war apparatchiks on pain doctors and the patients they serve has now provoked a counterattack aimed right at the drug war's jugular vein.

The Pain Relief Network: Update 5-19-08 -- Schneider Defense Calls DOJ Prosecution Unconstitutional

Schneider Defense Calls DOJ Prosecution Unconstitutional: Read the Briefs



kansas

As always, we ask that you help PRN fight to protect the rights of patients and the doctors who treat them. Please click the link below.

DonateNow

Schneider defense calls DOJ prosecution Unconstitutional

This case is an effort by the federal government to define and regulate the practice of medicine masquarading as a criminal prosecution. This case should not be about whether Dr. Schneider fell short of the standard of care for certain patients, but whether he engaged in the legitimate practice of medicine [...]

Memorandum of points and authorities in support of the defendants' joint motion for absention

The federal government has usurped the authority of the State of Kansas to regulate medicine within the State by bringing a halt to its regulatory process, and assuming that authority, impermissibly, through the federal criminal process. If any part of the Indictment is not dismissed as unconstitutional or otherwise defective, this Court should abstain, allowing the State process to run its course [...]

Competetive Enterprise Institute Joins Pain Relief Network in the battle against untreated pain

May 16, 2008
Cei.orgToday, millions of Americans live in chronic pain, without adequate access to prescription pain medications, because their doctors are too afraid of being harassed or even arrested by the Drug Enforcement Administration to prescribe sufficient doses. Everyone agrees that doctors should not be using their positions to supply addicts with narcotics or feed the illicit drug market. Many doctors, however, have been arrested or threatened with loss of their medical licenses simply for prescribing opiate-based pain medications in doses that federal drug authorities believe are too high [...]



www.painreliefnetwork.org

Doctor fights prosecutors' efforts to gag him, supporters

Location: 
Wichita, KS
United States
Publication/Source: 
Fort Mill Times (SC)
URL: 
http://www.fortmilltimes.com/124/story/136607.html

Pain Treatment: Prosecutors in Case Seek to Shut Up Doctor, Critics

Federal prosecutors in the case of Haysville, Kansas, physician Dr. Steven Schneider and his wife, who were indicted for allegedly operating a "pill mill" by prescribing to pain patients, asked a federal judge last Friday for a gag order to keep Schneider and his supporters from making their case in the court of public opinion.

The case of the Schneiders has attracted the attention of pain treatment advocates critical of heavy-handed federal government attacks on pain doctors, including the Pain Relief Network. The network's leader, Siobhan Reynolds, has been instrumental in mobilizing Schneider's patients in support of their doctor and in opposition to the federal prosecution. Prosecutors sought a temporary injunction to bar Schneider, his wife, other family members, and PRN's Reynolds from talking to the media.

"We strongly oppose a gag order because we believe in the public's access to the justice system," defense attorney Lawrence Williamson told the court. "We think the request is overbroad and not supported by law at all." While prosecutors accused the defense of trying to taint the jury pool, Williamson said that was not the case. "We are often contacted by media to respond to allegations that are made by the government and if the public has questions to the allegations we should be able to respond to those within the rule," Williamson said.

Prosecutors had no problem with media coverage of the case when they trumpeted the arrests of Schneider and his wife back in December, and they remained quiet when local media ran stories supportive of the prosecution. But questions raised in the press by Reynolds and other supporters about the 34-count indictment of Schneider accusing him of a variety of crimes related to his prescribing of opioid pain medications have the feds seeking to silence their foes.

Prosecutors claimed Reynolds told a patient that if he was going to kill himself because of lack of access to pain medications, he should do it publicly -- a charge Reynolds angrily rejected, calling it "absolutely false."

"This is just a wild allegation," Reynolds said. "Basically it was put out there to try to smear me. The Pain Relief Network works very hard to try to stop the suicides going on across the country because of untreated pain, the epidemic of untreated pain," she told the Associated Press. "I'm shocked that the government would try to get a gag order against a political activist. I find that stunning."

Pain Treatment: INCB Calls for Greater Access to Opioid Medicines in Developing World

As part of its 2007 Annual Report, released Wednesday, the International Narcotics Control Board (INCB) issued a press release saying that "ensuring access to pain treatment medicines is vital and possible." Millions of people around the world are suffering chronic and acute pain because narcotic pain medications are not being sufficiently used, the group said.

The INCB is a 23-member independent commission that works with the UN Office on Drugs and Crime (UNODC), its Commission on Narcotic Drugs (CND) and other international organizations to monitor implementation of the series of international treaties that form the legal backbone of the global prohibition regime. While its remit includes ensuring adequate supplies of drugs are available for medical and scientific uses, it spends most of its resources trying to prevent any deviations from the global prohibitionist drug policy status quo. (See related story here.)

According to the INCB, while global consumption of opioid pain relievers has more than doubled in the past decade, the vast majority of that growth has occurred in Europe and North America, which together accounted for 89% of global morphine consumption in 2006. By contrast, the 80% of the global population that lives in developing countries consumed only 6% of the morphine supply. In some countries, access to morphine is "extremely low and almost non-existent for most of the population," the group said.

The situation is similar for some other opioids such as fentanyl and oxycodone. In 2006, Europe and North America accounted for 96% of global fentanyl consumption and 97% of oxycodone, the group reported.

The lack of sufficient access to these powerful pain medications is "due to diverse interrelated factors such as inadequate medical education of health professionals and lack of knowledge and skills in pain treatment, public attitude, regulatory impediments or economic constraints," the INCB said. In a slap at proposals to deal with Afghan opium production by licensing it and diverting it into the legal medicinal market, as the Senlis Council has suggested, the INCB said global supply was at high levels and not the problem.

"Suggestions to further increase the supply of raw materials by using opium from the illicit production in Afghanistan do not address the cause of the problem. Governments should focus on measures to increase demand for pain-relief medication in line with the recommendations of INCB and WHO," said INCB President Philip Emafo.

The INCB said it urged governments to identify obstacles to adequate access to narcotic pain medications and to take steps to improve their availability. It also announced that, in consultation with the World Health Organization (WHO), it had created the Access to Controlled Medications Program to address identified impediments. The group urged all governmental and concerned international organizations to cooperate with the WHO, and called on governments to pony up some cash to pay for it.

Pain Wars in the Heartland: With Their Doctor Behind Bars, Kansas Patients Wonder Where To Turn

In a drama that has been played out all too many times across the country in recent years, the Justice Department's campaign against prescription drug abuse -- if you can call it that -- came in crushing fashion to Haysville, Kansas, last month. Now, a popular pain management physician and his nurse wife are being held without bond and more than a thousand patients at his clinic are without a doctor, but the US Attorney and the Kansas Board of Healing Arts say they are protecting the public health.

It all started December 20, when federal agents arrested Dr. Stephen Schneider, operator of the Schneider Medical Clinic, and his wife and business manager, Linda, on a 34-count indictment charging them with operating a "pill mill" at their clinic. The indictment charges that Schneider and his assistants "unlawfully" wrote prescriptions for narcotic pain relievers, that at least 56 of Schneiders' patients died of drug overdoses between 2002 and 2007, and that Schneider and his assistants prescribed pain relievers "outside the course of usual medical practice and not for legitimate medical purpose."

In their press release announcing the arrests, federal prosecutors also said that four patients died "as a direct result of Schneider's actions," but the indictment does not charge Schneider or anyone else with murder, manslaughter, or negligent homicide. In all four deaths, the patients died of drug overdoses, with prosecutors claiming Schneider ignored signs they were becoming addicted to the drugs or abusing them.

A handful of Schneider's former patients have filed malpractice lawsuits, claiming they became addicted as a result of his treatments. The Kansas Board of Healing Arts was investigating several complaints against Schneider before it backed off at the beginning of 2007 at the request of federal prosecutors seeking to build their case. (The US Attorney's office in Wichita denies that it asked the board to desist, but the board insists that is in fact the case.)

Under pressure from state legislators, the board acted this week, suspending Schneider's license to practice and effectively shutting down his clinic, which had remained open with physicians' assistants writing prescriptions. That move came as a surprise to Schneider's patients and supporters, who had been engaged in negotiations with the board to keep the clinic open.

But if federal prosecutors, the state board and a few patients are painting Schneider as a Dr. Feelgood, for some of his patients, he was a life-send. Debbie Sauers was one of those patients. Suffering from the after-effects of a dissecting aortic aneurysm and chronic pain from four failed back surgeries, the former nurse said she now has nowhere to go. "The clinic is shut as of tomorrow, and today was the last day to get prescriptions filled," she said Wednesday. "Dr. Schneider was the only one who would treat me with pain medicine, and now I don't know what I'm going to do," she said.

Her efforts to find another doctor to take her on have been a stark exemplar of the stigmatization faced by pain patients whose physician is accused of being a pill-pusher. "I've had doctors' offices refuse to see me or laugh in my face or tell me to check into drug rehab when I tell them I was one of Dr. Schneider's patients," she said. "If you go to the ER, they hand you a list of drug rehab places. They put my doctor in jail, and no one will treat me now." Sauers is currently on massive doses of morphine and high-dose Lortab and says her cardiologist tells her a rapid withdrawal could kill her. "I don't know what to do," she repeated.

Darren Baker is another patient who swears by Dr. Schneider. The operator of a tree gardening service, Baker has bone spurs in his knees from years of climbing, and two years ago, he fell out of a tree, shattering both his heels. "They put all kinds of hardware in my heels, and I have to have pain medications just to walk," he said. "With the pain meds, I can't walk real well, but without them, I can't walk, period. Dr. Schneider was the only one who would treat me."

Now, like Sauers, Baker is in search of a doctor. "I haven't found one yet," he said. "I got a list today, but most of them are turning you away if you're associated with Dr. Schneider. If I can't get another doctor, I won't have any option except to retire and go on disability. I take my medicine to be a productive member of society," he said angrily. "I need my meds to survive and pay my bills and fight the daily grind. This really goes against our constitutional rights. How the hell can I pursue happiness lying in bed?"

If convicted, the Schneiders face a minimum of 20 years in federal prison, and given the multitude of counts, they could theoretically face centuries. While, since their arrests, they have been excoriated in the Kansas press and by politicians, they have also received strong support, not only from patients, but also from a national pain advocacy organization, the Pain Relief Network. Headed by Siobhan Reynolds, a former documentary film maker turned crusader after her life partner suffered horrendously from lack of adequate pain treatment before dying in 2006, the network has done highly effective advocacy on cases ranging from that of imprisoned Northern Virginia pain specialist Dr. William Hurwitz to wheelchair-bound, formerly imprisoned, and now pardoned Florida pain patient Richard Paey.

Reynolds senses a similar injustice on the Kansas prairies. "Dr. Schneider is a wonderful doctor and he ran a wonderful clinic," she said. "But the Justice Department comes in here and after the fact characterizes his medical practice as drug dealing and also after the fact decides that a patient death is caused not by a doctor but by a 'drug dealer,' making it now tantamount to murder, with a 20-year mandatory minimum. If anyone wonders why doctors don't take care of sick people, this is why."

The root of the problem, said Reynolds, is the Controlled Substances Act, under which the Justice Department determines what constitutes proper medical practice and what doesn't. "Under the act, the exchange of money for drugs is presumptively illegal, and doctors have to show they are doing medicine in an 'authorized fashion' approved by the Justice Department. Under the act, doctors are effectively presumed guilty until proven innocent. It's backwards, and it helps explain why it is so difficult to win these cases," she said.

The Pain Relief Network will shortly bring a federal lawsuit challenging the Controlled Substance Act, Reynolds said. "The act is profoundly unconstitutional and unlawful. It reverses the presumption of innocence, and we think we can win that challenge, even if we have to go to the Supreme Court."

While the network had vowed to file the lawsuit last month, it hasn't happened yet. That's because the network has been too busy putting out fires in Kansas, she said, adding that the lawsuit will be filed soon.

Meanwhile, Dr. Schneider and his wife remain jailed without bond at the request of federal prosecutors pending a first court date later this month. His patients are now scrambling to find replacement doctors with little success, especially now that other local doctors see what could await them if they apply aggressive opioid pain management treatments. And a chill as cold as the February wind is settling in over pain treatment on the Kansas plains.

Perhaps Dr. Schneider is guilty of failing to adequately screen his patients, said Darren Baker, but that's not a crime. "Pain meds are narcotics," he said. "Some people have to have them to survive, but other people just want them. I think Dr. Schneider should have covered his ass more. A drug addict is going to get his drugs, whether through a doctor or on the street. They can buffalo a doctor. But when they abuse their prescriptions, how can it be the doctor's fault? Maybe he could have done things differently, but he operated in good faith."

Pain Medicine: Advocacy Group to Challenge Controlled Substances Act In Lawsuit Aimed at Protecting Physicians, Patients

Haysville, Kansas, physician Dr. Stephen Schneider and his nurse wife, Linda Schneider, were arrested on a 34-count federal indictment last month for allegedly improperly prescribing opioid pain medications and causing the deaths of at least four patients. The Schneiders are only the latest pain management health care providers to fall victim to the federal government's war against prescription drug abuse and diversion, and now a leading pain relief advocacy group is vowing to take the government to court to block further harassment of physicians and the pain-ridden patients who rely on them.

Last Friday, the Pain Relief Network announced it will seek a civil injunction barring the Justice Department from prosecuting the Schneiders. But the lawsuit could have much broader implications than the couple's freedom. It will argue that the way the federal Controlled Substances Act is applied to doctors and patients is unconstitutional.

"I want a judge to take a look at this and see if the United States has authority to prosecute," Pain Relief Network head Siobhan Reynolds said during a press briefing last Friday. Reynolds cited a ruling in a similar case that such prosecutions give the government unrestrained power to interfere in the doctor-patient relationship.

The real victims of the government's crackdown on the Schneiders and other health care professionals prescribing opioid pain medications are patients, said Reynolds. "These patients are in real harm's way," Reynolds said. "They are being attacked by the Department of Justice."

While some of Dr. Schneider's former patients have filed malpractice lawsuits claiming they became addicted because of his prescribing, other patients said he had been a godsend and that they are suffering now without him.

One was Jamie McGuire, 49, who had been receiving pain meds for severe arthritis in his spine, hips, and shoulders resulting from an auto accident. Since Schneider was jailed, he has been unable to even get a referral to another doctor. "I think they railroaded him," he said of the prosecution. McGuire told reporters he is almost out of pain medication and his situation is dire. "If they don't do something, I will take myself out," McGuire said.

Another patient, Martin Beatty, 46, also showed up to support his doctor. He said he opted for a regime of pain meds rather than surgery or steroids after falling from a roof 12 years ago and had been a patient of Schneider's for three years. He admitted being dependent on his pain meds, but said that shouldn't matter. "Addiction doesn't mean I am going to be a bad person," Beatty said. Now he worries about going through withdrawal without being under a physician's care.

This week, patients and advocates continued to fight for Dr. Schneider, who, along with his wife, remains jailed. They gathered at his offices to show support and sign petitions, one to join the federal lawsuit, the other to keep the Kansas Board of Healing Arts from moving to suspend his license. According to Reynolds, the clinic will be forced to close because the physician assistants now writing prescriptions are doing so under the auspices of working for a clinic owned by a licensed physician. Other doctors who once practiced at the clinic have been run off by fears of federal prosecution, she said.

"Right now we are calling on the medical board to refrain from joining in this attack on this clinic. This clinic has been hobbled by the Justice Department. These patients are living in mortal fear," Reynolds said.

Pain Medicine: Emergency Room Doctors More Likely to Prescribe Opioids to Whites Than Minorities

A new study has found that while emergency room prescribing of opioid pain medications for ER patients complaining of pain has increased in recent years, doctors are less likely to prescribe them for minority patients than white ones. Even in cases where patients complain of severe pain, such as kidney stones, the difference holds.

The study, "Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments," was published this week in the Journal of the American Medical Association. It analyzed more than 150,000 ER visits between 1993 and 2005 and found racial differences in prescribing in all US regions, in both urban and rural hospitals, and for all types of pain.

The study found that the prescribing of drugs for pain in the ER rose during the period in question, from 23% of those complaining of pain in 1993 to 37% in 2005. That increase reflects increased understanding of the necessity of pain management by physicians. Now, doctors in accredited hospitals must ask patients about pain, just as they monitor vital signs. But while prescribing is on the increase, the racial divide remains.

According to the study, 31% of white patients in pain were prescribed opioids, compared to 28% of Asians, 24% of Hispanics, and 23% of blacks. When it comes to the severe pain related to kidney stones, whites got opioids 72% of the time, compared to 68% for Hispanics, 67% for Asians, and only 56% for blacks.

"The gaps between whites and nonwhites have not appeared to close at all," said study coauthor Dr. Mark Pletcher of the University of California, San Francisco.

Researchers are looking for reasons for the discrepancy. Pletcher suggested to the Associated Press that minority patients "may be less likely to keep complaining about their pain or feel they deserve good pain control."

Linda Simoni-Wastila of the University of Maryland, Baltimore, School of Pharmacy told the AP the findings could reveal some doctors' suspicions that minority patients could be drug abusers lying about pain to get narcotics. She said that according to her own research, blacks are the least likely group to abuse prescription drugs.

The study's authors suggested that the finding could indicate either that doctors are less likely to see signs of pain reliever abuse in white patients or that they are underrating pain in minority patients. Whatever the reason, it seems that the racial injustice associated with drug prohibition reaches even into the emergency room.

"It's time to move past describing disparities and work on narrowing them," Dr. Thomas Fisher, an emergency room doctor at the University of Chicago Medical Center who was not involved in the study, told the AP. Fisher, who is black, said that even he needed to be careful not to let subconscious assumptions inappropriately influence his prescribing decisions. "If anybody argues they have no social biases that sway clinical practice, they have not been thoughtful about the issue or they're not being honest with themselves," he said.

Drug War Issues

Criminal JusticeAsset Forfeiture, Collateral Sanctions (College Aid, Drug Taxes, Housing, Welfare), Court Rulings, Drug Courts, Due Process, Felony Disenfranchisement, Incarceration, Policing (2011 Drug War Killings, 2012 Drug War Killings, 2013 Drug War Killings, 2014 Drug War Killings, 2015 Drug War Killings, Arrests, Eradication, Informants, Interdiction, Lowest Priority Policies, Police Corruption, Police Raids, Profiling, Search and Seizure, SWAT/Paramilitarization, Task Forces, Undercover Work), Probation or Parole, Prosecution, Reentry/Rehabilitation, Sentencing (Alternatives to Incarceration, Clemency and Pardon, Crack/Powder Cocaine Disparity, Death Penalty, Decriminalization, Defelonization, Drug Free Zones, Mandatory Minimums, Rockefeller Drug Laws, Sentencing Guidelines)CultureArt, Celebrities, Counter-Culture, Music, Poetry/Literature, Television, TheaterDrug UseParaphernalia, ViolenceIntersecting IssuesCollateral Sanctions (College Aid, Drug Taxes, Housing, Welfare), Violence, Border, Budgets/Taxes/Economics, Business, Civil Rights, Driving, Economics, Education (College Aid), Employment, Environment, Families, Free Speech, Gun Policy, Human Rights, Immigration, Militarization, Money Laundering, Pregnancy, Privacy (Search and Seizure, Drug Testing), Race, Religion, Science, Sports, Women's IssuesMarijuana PolicyGateway Theory, Hemp, Marijuana -- Personal Use, Marijuana Industry, Medical MarijuanaMedicineMedical Marijuana, Science of Drugs, Under-treatment of PainPublic HealthAddiction, Addiction Treatment (Science of Drugs), Drug Education, Drug Prevention, Drug-Related AIDS/HIV or Hepatitis C, Harm Reduction (Methadone & Other Opiate Maintenance, Needle Exchange, Overdose Prevention, Safe Injection Sites)Source and Transit CountriesAndean Drug War, Coca, Hashish, Mexican Drug War, Opium ProductionSpecific DrugsAlcohol, Ayahuasca, Cocaine (Crack Cocaine), Ecstasy, Heroin, Ibogaine, ketamine, Khat, Marijuana (Gateway Theory, Marijuana -- Personal Use, Medical Marijuana, Hashish), Methamphetamine, New Synthetic Drugs (Synthetic Cannabinoids, Synthetic Stimulants), Nicotine, Prescription Opiates (Fentanyl, Oxycontin), Psychedelics (LSD, Mescaline, Peyote, Salvia Divinorum)YouthGrade School, Post-Secondary School, Raves, Secondary School