The Law relating to Baclofen Prescription

[Otter]

I thought I would start a new thread to clear up some confusion about the legal position of doctors over prescribing Baclofen.

Our GP initially refused to go above 100 mg or even up to that level. She then agreed to go up to 100 mg when advised to by Jonathan Chick. Now she has been advised by a new doctor to go above that level she has done so.

It is about knowledge and experience using the medication and assessing the risks and benefits. Professional negligence can result from failing to prescribe properly and failing to take into account new developments in medicine.

The law on the subject in England, which is the same as all other common law countries and the US is set out in a case called Bolitho. You can refer to this when you talk to your doctor. A doctor has to look at the risks and benefits of Baclofen and compare them with the risks of allowing a patient to remain alcoholic.

Bolitho is a House of Lords decision on the standard of care in negligence cases against doctors. The House of Lords in 1957 in a case called Bolam said that doctors could not be held negligent if they followed practices which were also followed by a responsible body of experts. That decision was often criticized as it suggested that whatever doctors generally do for patients, so long as they all do it or there are some responsible doctors who say the practice is acceptable, there is nothing a patient can do about it. If you become ill because your doctor does not follow a new treatment the doctor could not be held responsible for what happens to you.

In other words, in the case of alcoholism, a doctor could not be criticized for following the accepted treatments for alcoholism.


The House of Lords in Bolitho changed that by reinterpreting Bolam. Here is what they said:


"...in cases involving, as they so often do, the weighing of risks
against benefits, the judge before accepting a body of opinion as
being responsible, reasonable or respectable, will need to be satisfied that, in forming
their views, the experts have directed their minds to the question of
comparative risks and benefits and have reached a defensible conclusion on the
matter. There are decisions which demonstrate that the judge is
entitled to approach expert professional opinion on this basis. For example, in
Hucks v. Cole [1993] 4 Med.L.R. 393 (a case from 1968), a doctor
failed to treat with penicillin a patient who was suffering from
septic spots on her skin though he knew them to contain organisms
capable of leading to puerperal fever. A number of distinguished
doctors gave evidence that they would not, in the circumstances, have
treated with penicillin. The Court of Appeal found the defendant to
have been negligent. Sachs L.J. said, at p. 397:
"When the evidence shows that a lacuna in professional practice exists by
which risks of grave danger are knowingly taken, then, however small the risk, the
court must anxiously examine that lacuna?particularly if the risk can be easily and
inexpensively avoided. If the court finds, on an analysis of the reasons given for
not taking those precautions that, in the light of current professional
knowledge, there is no proper basis for the lacuna, and that it is definitely
not reasonable that those risks should have been taken, its function is to state that
fact and where necessary to state that it constitutes negligence. In such a case the practice
will no doubt thereafter be altered to the benefit of patients."
On such occasions the fact that other practitioners would have done the same thing as the
defendant practitioner is a very weighty matter to be put on the
scales on his behalf; but it is not, as Mr. Webster readily conceded,
conclusive. The court must be vigilant to see whether the reasons
given for putting a patient at risk are valid in the light of any
well-known advance in medical knowledge, or whether they stem from a
residual adherence to out-of-date ideas."


It is interesting that, having heard Dr. Ameisen, doctors at the McLean Medical School at Harvard University asked him to write up a prescribing schedule for Baclofen to be used immediately. I can only think that they were intelligent doctors who were enlightened about their ethical and legal responsibilities to their patients.


That is the law so when you go to your doctor with articles about Baclofen and stories from here about its success take this statement of the law and maybe then they will start to listen...and maybe their PCT will start to listen as well.

[Otter]

The Law relating to Baclofen Prescription

Now, here is the position as stated by the GMC in a letter to me which shows that a doctor is perfectly entitled to prescribe Baclofen off licence.:

Thank you for your email where you have raised concerns about your wife’s care relating to off-label prescribing of baclofen. I am responding on behalf of my colleague Suzanne Wood and I apologise for the delay in getting back to you. I hope this has not caused too much inconvenience.

It may be helpful if I begin by explaining our role. As the statutory regulator for the medical profession, we license doctors to practise medicine in the UK and issue guidance for doctors on the general standards of good practice that we expect them to adhere to in all aspects of their medical practice.Good Medical Practice is our core ethical guidance for doctors and this is supported by a range other topic-specific guidance documents.

We are not in a position to advise doctors about the suitability or otherwise of particular treatments as our remit does not extend to collecting, analysing or disseminating clinical information. We do not therefore, produce clinical guidance. Information about the effectiveness of medical treatments, and the risks and benefits attached to them, is available from a wide range of sources including government health departments and regulatory agencies, the medical royal colleges, and independent organisations such as medical research journals and other publications.

It is the role of the Scottish Intercollegiate Guidelines Network (SIGN) to develop evidence-based clinical practice guidelines for the NHS in Scotland. The guidelines help doctors provide effective and appropriate healthcare in the management of patients’ clinical conditions. You can view on their website information about proposing a guideline topic: Suggest a Guideline Topic.

There are a number of principles in Good Medical Practice and our supplementary ethical guidance which are relevant to your query.

Good Medical Practice makes clear that doctors must follow the guidance on providing good clinical care (paragraphs 2‑11), keeping their knowledge and skills up to date (paragraphs 12‑13) and on maintaining and improving their performance (paragraph 14).

You note your concern about the doctor’s refusal to investigate your wife's condition and treatment. Paragraph 2 of Good Medical Practice is quite clear that in providing good clinical care, doctors must adequately assess the patient’s condition, provide or arrange advice, investigations or treatments where necessary and to refer a patient to another practitioner, when this is in the patient’s best interests.

We expect doctors to provide effective treatments based on the best available evidence (see paragraph 3c of Good Medical Practice). They must also do their best to ensure that any treatment they offer is in the patient’s best interests, and they must be satisfied that the prescribing is safe and responsible. Our guidance Good practice in prescribing medicines provides good practice advice on prescribing: It states that doctors must:

b. Be in possession of, or take, an adequate history from the patient, including: any previous adverse reactions to medicines; current medical conditions; and concurrent or recent use of medicines, including non-prescription medicines.
c. Reach agreement with the patient on the use of any proposed medication, and the management of the condition by exchanging information and clarifying any concerns. The amount of information you should give each patient will vary according to factors such as the nature of the patient's condition, risks and side effects of the medicine and the patient's wishes. Bearing these issues in mind, you should, where appropriate
i. Establish the patient's priorities, preferences and concerns and encourage the patient to ask questions about medicine taking and the proposed treatment
ii. Discuss other treatment options with the patient
iii. Satisfy yourself that your patient has been given appropriate information, in a way they can understand, about: any common adverse side effects; potentially serious side effects; what to do in the event of a side-effect; interactions with other medicines; and the dosage and administration of the medicine; (see Consent: patients and doctors making decisions together)
iv. Satisfy yourself that the patient understands how to take the medicine as prescribed
v. Satisfy yourself that the patient is able to take the medicine as prescribed.

As you are aware, this guidance includes advice on prescribing medicines for use outside the terms of their label (off-label). It states:

19. You may prescribe medicines for purposes for which they are not licensed. Although there are a number of circumstances in which this may arise, it is likely to occur most frequently in prescribing for children...

20. When prescribing a medicine for use outside the terms of its licence you must:

a. Be satisfied that it would better serve the patient's needs than an appropriately licensed alternative

b. Be satisfied that there is a sufficient evidence base and/or experience of using the medicine to demonstrate its safety and efficacy. The manufacturer's information may be of limited help in which case the necessary information must be sought from other sources

c. Take responsibility for prescribing the medicine and for overseeing the patient's care, monitoring and any follow up treatment, or arrange for another doctor to do so (see also paragraphs 25-27 on prescribing for hospital outpatients)

d. Make a clear, accurate and legible record of all medicines prescribed and, where you are not following common practice, your reasons for prescribing the medicine.

Our guidance Consent: patients and doctors making decisions together sets out principles for good practice in making decisions. A core principle of this guidance is that doctors must work in partnership with patients to ensure good care. This means listening to patients and respecting their views about their health; responding to their questions, concerns and preferences; and sharing with patients the information they want and need such as the treatment options available to them.

Taking all of this into account, doctors should make reasonable efforts to investigate potential treatments that are brought to their attention and as you note, where the manufacturer’s information on off-licence use is limited then doctors must use other sources, for example advice from medical royal colleges. Where a medicine is outside of their area of competence they should consult and seek advice from colleagues or other bodies where appropriate. But the GMC is not in a position to order a doctor to provide the treatment that you, or your wife, many want. Doctors have to use their professional judgement to make good decisions based on the best available evidence, seeking advice where appropriate, to ensure that the medicines they prescribe are appropriate and responsible and in the patient’s best interests.

In response to your question about indemnity insurance, doctors have a duty to arrange their own liability insurance with a medical defence body of their choice to cover any part of their practice not covered by an employer's indemnity scheme. For further information you may wish to contact theMedical Defence Union (UK wide) or the Medical and Dental Defence Union of Scotland.

I hope this is helpful in explaining our role and our guidance on the issues you have raised.

Yours sincerely


Olivia Stapleton
Policy Officer
Standards & Ethics Section
Telephone: 0020 7189 5378
Website: GMC | Home

[GettingSerious]

The Law relating to Baclofen Prescription

With all due respect, Bolitho is not, nor is it similar to, the current U.S. standard. At the risk of TMI on the internet, I'm a medical malpractice attorney. This is what I do for a living. The standard in the U.S., at least as I understand it, is a reasonableness standard. This is basically the same as the ordinary negligence standard, but specific to a doctor. It is state by state, however, so there is the possiblity that some states resemble this Bolitho case. I have never heard of it, however, so it is not something that factors into american jurisprudence as far as I can tell.

[GettingSerious]

The Law relating to Baclofen Prescription

Oh, and believe me, if anyone filed a lawsuit against some of these prescribing physicians, there is a very good chance of a very negative result. In my state, I would also consider it probable that they would face some sort of censure from whatever medical oversight committee oversees practice & standards. This is why I am so admiring of the physicians whose names I will not repeat here. Unfortunately, medicine moves extremely slowly. When the standard is set by what the majority does, it takes a looooong time for any type of new treatment to gain acceptance, no matter how successful. Doctors are scared, as they should be. Imagine if you could get sued for every single interaction you had at work throughout the day. Pretty sobering, no pun intended.

[Otter]

The Law relating to Baclofen Prescription

I suppose saying it is the same in the US is a bit of a leap. There was a doctrine of "local practice" which I understood to mean that doctors could rely on what was done in their local area. There was also a defence argument in other areas of professional negligence called "state of the art". Perhaps that related to claims against architects and engineers and not doctors. What it meant is that professionals could rely on the generally accepted practice in a particular field at the time. I had thought, although I never looked into it, that this defence had died a death a long time ago in the US. Of course, each state is different.

When you say that the standard is one of reasonableness I am not sure that goes far enough. The issue is who decides what is reasonable. The Bolam case says that it is up to the medical practice to set the standard of what is reasonable whereas Bolitho makes that a decision for the courts. My reading of the two cases is that Bolitho brings the English law up to date with what the position is in the US (generally, I suppose) that the courts have to decide what is reasonable based on their assessment of evidence presented to them and it is not for the court to defer to the generally accepted practice. If a new practice or medicine is found, a doctor can no longer say that he just followed that accepted practice and ignored the newer practice or medicine and thereby avoid liability.

When I said it is the same in the US I just meant that, as far as I was aware, the position as stated in Bolitho, that it is the court that decides what is reasonable was the position in US courts for many years and that both the local practice and state of the art defences had not been accepted in American courts for many years. Certainly, that was my understanding of the situation as long ago as the 1980s but I have been out of the area for many years.

I always admired American jurisprudence, over English because it took a more progressive approach. I hear what you are saying about getting a negative result but all claims in negligence started out as novel. So why should a doctor who knows about Baclofen not be held to account for not looking into it, not prescribing it, not giving his patient a chance at recovery. I think it would be one thing if a doctor went down the route of, say Naltrexone treatment or Campral, as opposed to Baclofen, having examined the material on it. However, not looking at advances in medical treatments of alcohol when they are now all over the net and being used at Harvard University and, instead, doing absolutely zero for a patient verges on idiocy, forget about negligence.

Our GP has been forced to prescribe now and I would say she would be negligent if she did not prescribe in light of the huge and apparent and very real improvement in my wife's health. There are a huge number of people who have now been successfully treated and lots of literature on it. There is nothing equivalent to Baclofen treatment and it is becoming clearer each day that it works for a large percentage of people who use it. If any other new drug came onto the market and was as successful it would be heralded as a miracle cure. The problem with Baclofen is not about advances in medicine, the medicine is there. The problem is that most people, including doctors are mired in an old way of looking at alcoholism and stigmatize alcoholics just like everyone else does. They are not trained in treating alcoholism as a medical condition, don't specialize in it, won't have alcoholics in their offices or hospitals....

If you are saying that in most US States the Bolam position of 1957 is still the law, I would worry. Bolam has been hugely criticized here because it allows the medical profession to remain static and removes the oversight of courts in ensuring that doctors keep up to date with medical advances by sticking to the "majority" view. Surely that is not right and if it is maybe I can send you a copy of Bolam and Bolitho and you can use them to change the law over there.

[Otter]

The Law relating to Baclofen Prescription

GettingSerious;1088323 wrote: With all due respect, Bolitho is not, nor is it similar to, the current U.S. standard. At the risk of TMI on the internet, I'm a medical malpractice attorney. This is what I do for a living. The standard in the U.S., at least as I understand it, is a reasonableness standard. This is basically the same as the ordinary negligence standard, but specific to a doctor. It is state by state, however, so there is the possiblity that some states resemble this Bolitho case. I have never heard of it, however, so it is not something that factors into american jurisprudence as far as I can tell.

Actually, this is not correct. The standard in all "common law" jurisdictions and the US is one of reasonableness. The issues, which this post misses is that the old law, pre Bolitho was that the profession determined what was reasonable and that a doctor could rely on established practices rather than conducting his own benefit/risk analysis.

What is interesting is that with the release of the Glasgow study it is now arguable that it would be unreasonable for a professional NOT to prescribe Baclofen for alcoholism given that senior experts have expressed a view that it does reduce alcohol consumption and they have based that opinion on 1) a clinical trial over 2 years, 2) clinical studies 3) previous trials 4) medical literature on Baclofen.

A doctor who has a patient presenting with serious alcoholism who does not now consider prescribing would be negligent, in my experience as a lawyer of 30 years standing including experience in medical malpractice litigation.

There is no corresponding evidence from any medical professional or in any medical journal that I have found in two years researching into this issue that would give any doctor support for refusing to consider prescribing Baclofen in light of the potential risks of continued consumption of alcohol versus risks of Baclofen.

I responded to the above post by PM pointing this out and seeking some discussion but received no answer.

[Otter]

The Law relating to Baclofen Prescription

This thread is for all the medical professionals who lurk on this site. Please bear in mind that the limitation of actions for professional liability claims varies from 3 to 6 years depending on where you are. It is not a question of what the claims record is now. You have to consider whether you have knowledge of this treatment now, then consider the patients you have who may benefit from it. Then you have to consider what the state of play will be in terms of Baclofen use in a year, two years and so on because you can be sued for negligence if you fail now to advise patients of the possibility that they may benefit from this treatment.

If you fail to advise patients of this treatment you take the risk that in a few years time you may be asked why you did nothing about this treatment and when you would/should have been aware of the treatment. You will have to ask yourselves whether you acted on this information which is now available over the internet, what steps you have taken to keep up with medical advances in treatment of alcoholism and what you based your decision to do nothing/something about it.

You can get all the information about Baclofen and contact details of specialists in alcoholism in the UK and the US on Home - Baclofen UK.

[Cassander]

The Law relating to Baclofen Prescription

Whoa! Hold on, guys. Slow down. There shouldn't be any argument here. At least not yet!

I think Otter has done a good job, as usual, of bringing to our attention the state of the law in England (and Scotland?) and perhaps the other Commonwealth countries.

I'm intrigued by the notion that even if Big Pharma (estimated 2010 global revenues 450 billion dollars -- source:List of pharmaceutical companies - Wikipedia, the free encyclopedia) won't spend a million dollars to conduct conclusive clinical testing on a treatment for a disease which, each year, costs in the United States (alone) an estimated 185 billion dollars (according to the National Institute on Alcohol Abuse and Alcoholism), the medical community may -- may -- eventually be forced to consider baclofen because it would be unreasonable not to.

I'm also intrigued by GS's reaction that doctors in the US might be facing liability for prescribing baclofen. On consideration, GS, do you really think so? There is plenty of evidence that baclofen is safe (its been on the market for over 40 years) and there are a growing number of research reports, including several posted here over the past few weeks, that demonstrate the efficacy of baclofen. In light of these considerations, GS, do you think US doctors really face liability? On what theory? Certainly off-label prescribing is fairly common place in the US...Do you think liability concerns are really the reason they don't prescribe baclofen? Or is it more a case of ignorance...Since you are in the field (plaintiff or defense?) and you've returned to the board it would be interesting to hear your thoughts...

Cassander

[Otter]

The Law relating to Baclofen Prescription

Hi Cass

I don't think she has come back to the forum since her first two posts.

We keep going round and round in circles.

How does one push for change with this medication? And why bother doing it at all, most will say. This is a forum. I have said it before. If it was a car with a problem it would be recalled after "anecdotal" evidence of a failure of a part and every one would be recalled. Here we have a whole "system" of dealing with alcoholism, not as an illness, but as a moral choice which just lets people suffer and die.

That changed when Ameisen isolated the cause of anxiety based alcoholism and set out very clearly the mechanism involved and the treatment. So, why no change in the medical profession?

Did the motor industry start recalling cars as a public relations gesture or because they got hammered with law suits?

And did all the Pinto owners go on a forum and argue about whether, maybe, it was not the design that made the car unsafe at any speed because most of them were quite happy with the car, thank you very much.

I am going to make a concerted effort to stop posting here because I don't feel I can actually support people here in the way they need support. This forum is about people finding help from fellow sufferers who have been there like them and can help them find a way out. I cannot do that. I also get very frustrated by the way things I post, whether they are great gems or not, just get lost amongst thousands of other posts.

Just think about it. Here is a forum which has thousands of viewers a day including doctors. You go onto it and post something which just MIGHT be so important that it could change everything if the right people viewed it, such as a warning to the medical profession that, as a whole, they should start considering prescribing Baclofen. They should, maybe, quake in their boots thinking about potential negligence claims against them. Then, maybe, thousands, maybe millions of people could be saved from this scourge....

And then, someone posts a joke about a Nun on a train! Then another post or maybe a whole string of posts about why someone felt it necessary to do something because someone else did something and so on and on and on and on.....and all my work disappears into an impenetrable fog.

The energy I have exerted.... I feel like I have been pushing a pea up a mountain with my nose for the past year. Stop...do something else....I say to myself.

In the immortal words of Roberto Duran. NO MAS.

[Cassander]

The Law relating to Baclofen Prescription

Otter;1186139 wrote: Hi Cass

I don't think she has come back to the forum since her first two posts.

We keep going round and round in circles.

How does one push for change with this medication? And why bother doing it at all, most will say. This is a forum. I have said it before. If it was a car with a problem it would be recalled after "anecdotal" evidence of a failure of a part and every one would be recalled. Here we have a whole "system" of dealing with alcoholism, not as an illness, but as a moral choice which just lets people suffer and die.

That changed when Ameisen isolated the cause of anxiety based alcoholism and set out very clearly the mechanism involved and the treatment. So, why no change in the medical profession?

Did the motor industry start recalling cars as a public relations gesture or because they got hammered with law suits?

And did all the Pinto owners go on a forum and argue about whether, maybe, it was not the design that made the car unsafe at any speed because most of them were quite happy with the car, thank you very much.

I am going to make a concerted effort to stop posting here because I don't feel I can actually support people here in the way they need support. This forum is about people finding help from fellow sufferers who have been there like them and can help them find a way out. I cannot do that. I also get very frustrated by the way things I post, whether they are great gems or not, just get lost amongst thousands of other posts.

Just think about it. Here is a forum which has thousands of viewers a day including doctors. You go onto it and post something which just MIGHT be so important that it could change everything if the right people viewed it, such as a warning to the medical profession that, as a whole, they should start considering prescribing Baclofen. They should, maybe, quake in their boots thinking about potential negligence claims against them. Then, maybe, thousands, maybe millions of people could be saved from this scourge....

And then, someone posts a joke about a Nun on a train! Then another post or maybe a whole string of posts about why someone felt it necessary to do something because someone else did something and so on and on and on and on.....and all my work disappears into an impenetrable fog.

The energy I have exerted.... I feel like I have been pushing a pea up a mountain with my nose for the past year. Stop...do something else....I say to myself.

In the immortal words of Roberto Duran. NO MAS.

Yes, its true, Otter, that we go round and round. And yes its true that mwo is imperfect. Big surprise in the world of alcoholism! No wonder the medical profession washed its hands of it 70 years ago and handed the problem off to AA.

Yes, mwo is imperfect, to say the least. Downright painful! Except when its doing what its supposed to do, which is to provide realtime support to alcoholics in recovery.

As for me, as I said, I am still learning, so I don't feel like my time is wasted.

But I don't think your efforts are wasted either.

The word is getting out. There are newbies coming all the time and plenty of lurkers behind them.

Two important studies were published this year. The big one is underway in Amsterdam and another important one is starting in France.

More and more doctors around the world are aware of bac.

And these things are always exponential. You know what that means. In the beginning only 2 or 4 or 16 people know. But as the exponent goes up, the numbers become serious. Exponentially.

If I were more tech savvy I would publish a graph of how long it took for cell phone use to catch on or email use or marathon running or some neighborhood's gentrification. You would see a long horizontal line along the x-axis and then a hockey stick vertical line up the y-axis. Maybe one of our young friends (you know who you are!) will find such a graph and post it.

Anyway, we are really only in year 2 or at best year 3 and there has been tremendous progress.

You are right, mwo is not the (whole) answer, but the word is getting out.

We need to be patient.

Cassander

[Lo0p]

The Law relating to Baclofen Prescription

Pfft...Call me out like that! :H

I will if I can, I'm late for work right now!!

[Greg]

The Law relating to Baclofen Prescription

I was surprised to be told by a local drug and alcohol counsellor, here in a smallish Australian city, that baclofen was one of the options for alcoholism treatment. That was without me ever having mentioned it to her. I also know an addiction specialist in Sydney who is aware of it, although he has refused to go above 100 mg per day in the past. News of it is definitely going around.

[slipstream2]

The Law relating to Baclofen Prescription

I've been on Baclofen for the past 2 years, initially prescribed by an addiction clinic in Melbourne. So news is going around, slowly but surely.

[LadyLush]

The Law relating to Baclofen Prescription

My doctor is now 'in'.. Thanks to all of you. I now have a legit prescription.
Thanks so much.


LL

[Otter]

The Law relating to Baclofen Prescription

Cassander;1186144 wrote: Yes, its true, Otter, that we go round and round. And yes its true that mwo is imperfect. Big surprise in the world of alcoholism! No wonder the medical profession washed its hands of it 70 years ago and handed the problem off to AA.

Yes, mwo is imperfect, to say the least. Downright painful! Except when its doing what its supposed to do, which is to provide realtime support to alcoholics in recovery.

As for me, as I said, I am still learning, so I don't feel like my time is wasted.

But I don't think your efforts are wasted either.

The word is getting out. There are newbies coming all the time and plenty of lurkers behind them.

Two important studies were published this year. The big one is underway in Amsterdam and another important one is starting in France.

More and more doctors around the world are aware of bac.

And these things are always exponential. You know what that means. In the beginning only 2 or 4 or 16 people know. But as the exponent goes up, the numbers become serious. Exponentially.

If I were more tech savvy I would publish a graph of how long it took for cell phone use to catch on or email use or marathon running or some neighborhood's gentrification. You would see a long horizontal line along the x-axis and then a hockey stick vertical line up the y-axis. Maybe one of our young friends (you know who you are!) will find such a graph and post it.

Anyway, we are really only in year 2 or at best year 3 and there has been tremendous progress.

You are right, mwo is not the (whole) answer, but the word is getting out.

We need to be patient.

Cassander

Cass,

No. we don't need to be patient. I don't need to be patient and I don't want to be patient.

What is 2,000,000 divided by 365 divided by 24? 228.

That is how many people died over the last hour from alcoholism. That is like a plane crashing every hour while we say "just be patient". You yourself asked why are people not shouting about Baclofen from the rooftops. Are you? If you have a friend who is the president of a university, get in touch with him and bend his arm until it hurts and get him to spread this around the faculties in his university to get some debate going, maybe some research, maybe some papers written. You are very persuasive in what you are saying. Say it to someone like your friend, and don't give up until they get the message and do something.

I think we all agree, this site is great for support, when it works.

The problem is that as a group gets bigger the interactions get more complex and the thing collapses under its own dead weight, the information gets lost etc. etc.

Just think of the families of those 228 people who died over the last hour while we all have been doing what precisely. And think about something you could do over the next hour, like sending an email or just mentioning this site or Baclofen to someone so that the word gets out there faster and the carnage ends.