As Washington dawdles, the States step in on the opioid crisis, with initiatives and lawyers

“It has to be both law enforcement and health, we have to do more of everything because of the crisis that we’re in,” said Baum, acting director of the White House Office of National Drug Control Policy…
“We need to draw a distinction between people who are basically engaged in drug use, drug possession, and people who are traffickers and significant dealers and violent criminals,” Baum said.
“They’re different people,” he said. “People that are drug traffickers deserve a significant penalty for their crime, they’re threatening the health and safety of our citizens. People that are drug users have an addiction problem, a substance abuse disorder, and I really want to get them into treatment.”” (A)

“More than 140 Americans die from a drug overdose every day – that’s more than from gun homicides and car crashes combined. Most of these deaths are due to prescription painkillers, heroin and other opioids. The opioid crisis in our country is severe enough that yesterday President Donald Trump signaled his intention to declare it a national emergency.
Hospitals and health systems serve on the front lines in this crisis every day. We’re using many strategies to help: implementing standard protocols for prescribing opioids; promoting state prescription drug monitoring programs; and encouraging alternative pain-management strategies, for instance. And because we can’t solve this problem alone, we’re also partnering with schools, state and local health departments, law enforcement, pharmacies, treatment and prevention programs, and other community stakeholders in this fight.” (B)

“Deaths associated with opioid overdoses in hospital intensive care units nearly doubled over a seven-year period from 2009 and 2015, and the costs of treating overdose victims in the ICU has skyrocketed, researchers report.
The average cost of caring for an opioid overdose patient in the ICU increased by 58% from $58,500 to $92,400, according to a retrospective analysis of hospital billing records from 162 hospitals in 44 states.
Admissions to ICUs linked to opioid overdoses increased by 34% at the hospitals from January of 2009 to September 2015, according to the analysis appearing online in Annals of the American Thoracic Society.” (C)

“Allegheny Health Network (AHN), a Highmark Health company, announced today the establishment of a new, comprehensive program designed to help patients with opioid-related substance use disorders receive the health and community-based care and support they need to recover from their illness and maintain long-term wellness….
Patients identified as having an opioid use disorder and requesting treatment are referred to a half-day clinic at the primary care office where they are introduced to treatment options including Medication-Assisted Treatment (MAT) and outpatient therapy. MAT combines medication to reduce urges and withdrawal symptoms with on-site behavioral health therapy. Further, patients can be connected with various community-based resources to address social issues such as employment and housing. For patients who are in need of higher levels of treatment, referrals are made to inpatient, residential or intensive outpatient programs.
“Many of the patients we see with addiction to opioids often have underlying issues related to their behavioral and/or physical health,” ….. “It’s about surrounding the person with a range of services and resources, which address all of their challenges, to give them the very best chance at overcoming their addiction.” “(D)


Maryland, Massachusetts, Arizona, Florida, Minnesota, NYC, Pennsylvania, West Virginia

“Maine Attorney General Janet Mills says she’s taking part in a multistate investigation into the role of the nation’s drug companies may have played in creating the opioid crisis.
Mills says more Mainers have died from prescription opioids since 2010 than from illicitly obtained opioids. She says there is no doubt that these highly addictive pain medications have been overprescribed in Maine — and she says several states are cooperating in the probe.
“Certain manufacturers have misled the public, and misled health care providers for 20-something years now, and caused a surge in pharmaceutical prescriptions of opioids that have devastated people’s lives,” she says.” (E)

“That is straight out of the opioid manufacturers’ playbook. Facing a raft of lawsuits and a threat to their profits, pharmaceutical companies are pushing the line that the epidemic stems not from the wholesale prescribing of powerful painkillers – essentially heroin in pill form – but their misuse by some of those who then become addicted.
In court filings, drug companies are smearing the estimated two million people hooked on their products as criminals to blame for their own addiction. Some of those in its grip break the law by buying drugs on the black market or switch to heroin. But too often that addiction began by following the advice of a doctor who, in turn, was following the drug manufacturer’s instructions….
But as the president’s own commission noted, this is not an epidemic caused by those caught in its grasp. “We have an enormous problem that is often not beginning on street corners; it is starting in doctor’s offices and hospitals in every state in our nation,” it said.” (F)

“Cardinal Health filed the notice in the U.S. District Court for the Southern District of West Virginia, naming more than 1,900 businesses as “wholly or partially” at fault for diverting opioid analgesics for illegal use, including dozens of pharmacies, hundreds of physicians, and several mail-in pharmacies.” (G)


(A) Opioid crisis: Trump’s drug czar vows to take on doctors and dealers, help addicts, by Elizabeth Llorente,
(B) Hospitals Innovate New Strategies to Fight Opioid Crisis, by Rick Pollack,
(C) Opioid Overdose ICU Admissions Increasing, by Salynn Boyles,
(D) Allegheny Health Network Establishes Center of Excellence to Address Opioid Crisis,
(E) Maine Joins Probe of Drug Companies’ Role in Opioid Crisis, by By MAL LEARY,
(F) Don’t blame addicts for America’s opioid crisis. Here are the real culprits, by Chris McGreal,
(G) Drug wholesaler cites rehab clinics, pharmacies for possible fault for opioid crisis,


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The Trump administration “blinks”; provides Obamacare funding

.“The Trump administration will make this month’s Obamacare payments to insurers, a White House spokesman confirmed today, despite the president’s repeated threats to cut off the subsidies and potentially tip the insurance markets into turmoil.
It’s widely anticipated that insurers would jack up premiums or exit the Obamacare markets altogether if the subsidies, worth about $7 billion this year, are eliminated. Insurance premiums for the most popular Obamacare plans would likely rise by 20 percent next year if the payments are stopped, according to a Tuesday CBO analysis.
The administration’s decision was immediately denounced by an influential GOP House conservative, suggesting mounting tensions among Republicans about how to move forward on health care after the repeal effort collapsed in the Senate late last month.
At issue are subsidies that insurers rely on to reduce out-of-pocket costs for low-income Obamacare customers. Insurers would still be on the hook to provide the discounted rates even if the federal payments stop.” (A)

If payments were not made…
“CBO -If President Trump decides to cut off payments to insurance companies called for under the Affordable Care Act…. it’s going to cost taxpayers — about $194 billion over 10 years.
An analysis by the Congressional Budget Office released Tuesday found that ending cost-sharing reduction payments to insurers, a move that President Trump is contemplating, would raise the deficit by $194 billion over 10 years.
If President Trump decides to cut off payments to insurance companies called for under the Affordable Care Act, it’s going to cost him.
Or, more accurately, it’s going to cost taxpayers — about $194 billion over 10 years….
The deficit figure comes from the Congressional Budget Office, which on Tuesday released an estimate of the budget impact of ending what is known as cost-sharing reduction payments. Those are payments the federal government makes to insurance companies to reimburse them for the discounts on copays and deductibles that they’re required by law to give to low-income customers.
The reports also says premiums for benchmark plans sold on the Affordable Care Act exchanges will rise about 20 percent next year and about 25 percent by 2020. The cost to consumers, however, would stay the same or even decline, because the premium increases would be offset by tax credits, which we explain further below.
Trump threatened repeatedly to cut off the payments, which he has called “bailouts,” during the unsuccessful effort by Senate Republicans to repeal and replace the Affordable Care Act, also known as Obamacare.” (B)

“The public had also changed its tune. Although Medicaid had started as a program of welfare medicine, over time it had expanded well into the middle class. A 2011 poll found that 85 percent of respondents opposed cuts to Medicaid. Medicaid had become as popular as social security and Medicare.”
That shift in public opinion left Republicans without a coherent message for rallying support to repeal. Robbed of their big government bluff, Republicans could only lambast Obamacare for reasons the public no longer believed. Meanwhile, Democrats drew upon an alternative message, defining Republicans’ health care plans as divisive and un-American. When House Speaker Paul Ryan praised the House bill as “an act of mercy,” Rep. Joe Kennedy (D-Mass.) fired back: “With all due respect to our speaker, he and I must have read different Scripture. The one that I read calls on us to feed the hungry, to clothe the naked, to shelter the homeless and to comfort the sick. It reminds us that we are judged not by how we treat the powerful, but by how we care for the least among us.” “ (C)

Here are five decisions looming for the GOP. Should there be one more effort at ObamaCare repeal? Should we work with Democrats? Should we back legislation to make key payments to insurers? What’s to be done with CHIP? What’s to be done with ‘bare’ counties? (D)

“Around 4 in 5 want the Trump administration to take actions that help Obama’s law function properly, rather than trying to undermine it. Trump has suggested steps like halting subsidies to insurers who reduce out-of-pockets health costs for millions of consumers. His administration has discussed other moves like curbing outreach programs that persuade people to buy coverage and not enforcing the tax penalty the statute imposes on those who remain uninsured.
Just 3 in 10 want Trump and Republicans to continue their drive to repeal and replace the statute. Most prefer that they instead move to shore up the law’s marketplaces, which are seeing rising premiums and in some areas few insurers willing to sell policies. “(E)

“This much becomes clear looking at the latest polling data from the Kaiser Family Foundation, which finds that 60 percent of Americans think it’s a “good thing” that the Senate health care bill failed — and 78 percent expect the Trump administration to “do what they can” to make the law work better.
Right now, President Trump is not doing what he can to make Obamacare work. His administration remains cagey about whether it will continue to pay key subsidies. It has not let the thousands of insurance enrollment workers across the country know what type of outreach campaigns it will run, if any. Many insurance plans are nervous that the Trump administration won’t enforce the mandate to purchase coverage, and they are jacking up their premiums as a result.
Trump seems to have had, for months now, a theory about how Obamacare’s failure could play to his advantage. If the marketplaces blew up, he seemed to expect that voters would blame former President Barack Obama for a poorly drafted law — and that Congress would rush to fix these problems with a repeal-and-replace package.” (F)

Interestingly, a bipartisan group of governors has already issued their recommendations.
“Congress should be working to make health care more affordable while stabilizing the health insurance market, but this bill and similar proposals won’t accomplish these goals,” said one statement issued by 13 governors – seven Democrats and six Republicans. “The bill still threatens coverage for millions of hardworking, middle-class Americans.”
The governors then go on to get into the policy weeds on reinsurance, waivers and drug formularies, among others. Their overriding concerns, however, are to retain control over the health insurance markets within each of their states while shoring up and expanding the private insurance market through federal dollars.
So how can America achieve universal coverage regardless of pre-existing conditions — which is what most polls show most Americans want – but at an affordable price? The group of bipartisan governors is not quite ready for a single, national insurance system. But they are willing to consider benchmark standards similar to Obamacare, then have the federal government step in with bigger subsidies for the sickest patients with the highest claims. Under the ACA, those patients cannot be charged higher premiums because of their pre-existing health conditions. Insurers say they cannot sustain those losses without charging higher premiums to those patients or getting financial help.” (G)

(A) Trump administration will make this month’s Obamacare payments but leaves program’s future in limbo, by PAUL DEMKO,
(B) CBO Predicts Rise In Deficit If Trump Cuts Payments To Insurance Companies, by Alison Kodjak,
(D) Five tough decisions for the GOP on healthcare, by RACHEL ROUBEIN AND NATHANIEL WEIXEL,
(E) Around 4 in 5 Americans Want the Effort to Repeal Obamacare to End, Poll Finds, Alan Fram,
(F) Most Trump voters don’t want Trump to sabotage Obamacare, Updated by Sarah Kliff,
(G) Our View: Let governors have a crack at Obamacare,

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American College of Physicians Says Hate Crimes are Public Health Issue

At a recent meeting of their Board of Regents, the American College of Physicians (ACP) adopted a new policy statement recognizing hate crimes as a public health issue.

“It is imperative that physicians, and all people, speak out against hate and hate crimes and against those who foster or perpetrate it, as was seen in the tragic events that occurred in Charlottesville, Virginia,” said Jack Ende, MD, MACP, president, ACP. “In particular for physicians, they must educate the public that hate crimes are a public health issue, exacting a toll on the health of those directly victimized and on the health of the entire community. We must seek policies of inclusion and non-discrimination, as called for in our recent policy statement.”

The new policy reads in full:

ACP opposes prejudice, discrimination, harassment and violence against individuals based on their race, ethnic origin, ancestry, gender, gender identity, nationality, primary language, socioeconomic status, sexual orientation, cultural background, age, disability, or religion.
Hate crimes directed against individuals based on their race, ethnic origin, ancestry, gender, gender identity, nationality, primary language, socioeconomic status, sexual orientation, cultural background, age, disability, or religion are a public health issue.
ACP opposes all legislation with discriminatory intent upon individuals based on their race, ethnic origin, ancestry, gender, gender identity, nationality, primary language, socioeconomic status, sexual orientation, cultural background, age, disability, or religion.
ACP supports the development and implementation of anti- discrimination and hate crime laws.
ACP supports the collection and publication of statistics on hate crimes. More research is needed on the impact of hate crimes on public health, understanding and preventing hate crimes, and interventions that address the needs of hate crime survivors and their communities.
“We offer our deepest condolences to the family and friends of Heather Heyer, Lieutenant H. Jay Cullen and Trooper-Pilot Berke M.M. Bates,” continued Dr. Ende. “We hope for the recovery of those injured and are grateful to the first-responders, physicians, nurses and hospital staff who are treating them.”

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When I was appointed President and CEO of LibertyHealth/ Jersey City Medical Center in 1989 one of our goals was to become a top tier New Jersey teaching hospital.

Doing that required being a risk taker, not being risk averse. So here are vignettes about some risks taken over 17 years, some with success, some with failure, and some with mixed results. These examples are from my experience. Recognizing the new health care industry algorithm is more complicated, being a risk-taker is still essential for organizational and professional success.

“A ship in harbor is safe, but that is not what ships are built for.” John Augustus Shedd.

Jersey City Medical Center provides EMS services to Jersey City and paramedic services to Hudson County. In the early 1990’s portable, almost self-operating defibrillators became available so our EMS Director (Mary Beth Ray Simone) proposed that we train our EMTs and paramedics and put defibrillators in each of our EMS trucks. This raised eyebrows at the State Department of Health and litigation by the county’s many volunteer ambulance corps. We persisted and now, of course, defibrillators are pervasive in train and bus stations, sports stadiums and arenas, college campuses….everywhere.

“Only those who dare to fail greatly can ever achieve greatly. “ Robert F. Kennedy

In 1989 Jersey City Medical Center was a second-tier, unaffiliated teaching hospital. The University of Medicine and Dentistry of New Jersey (UMDNJ) had a medical education monopoly in New Jersey with two allopathic and one osteopathic medical schools. There were no other medical schools in the state. The President of UMDNJ (now Rutgers) refused to consider JCMC as an affiliate, rather trying to build a network of referring community hospitals, including the half dozen in Hudson County.
So JCMC became the first hospital in New Jersey with an out-of-state medical school affiliation and became a major teaching affiliate of Mount Sinai School of Medicine. The medical staffs at all three of our hospitals were against it and most Board members underestimated the importance of a first class medical school affiliation to the success of our new hospital.
We had a choice with Mount Sinai of our residency training programs in medicine, pediatrics and obs/gyn being free-standing, affiliated, or sponsored. Sponsored meant the most oversight and control from Mount Sinai and that’s what we chose with every residency program director opposed.
The biggest success story with Mount Sinai was a totally integrated Emergency Room when we opened the new hospital enabling the recruitment of a terrific cadre of Emergency Medicine trained physicians.

“What you have to do and the way you have to do it is incredibly simple. Whether you are willing to do it is another matter.” Peter Drucker

At our two community hospitals being a department chair or division chief was much sought after. Both had a history of the positions going to the “next in line” but to my dismay allowed non board certified physicians to garner these roles. When it was proposed that a system wide standard of board certification be put in place it was successfully opposed by lobbying Board members against it; of course the physicians had leverage as the board members doctors.

“Do one thing every day that scares you.” Eleanor Roosevelt

When we moved from our old facility to our new hospital in 2004 we made the entire campus smoking-free and mandated the smoking-free campuses for our two community hospitals as well. First this was a public health commitment so staff and visitors didn’t have to walk through the blue haze of smoke at entrances. But I had also noticed the same people smoking outside time-after-time, while their colleagues inside were working. Smokers were offered smoking cessation assistance. But the biggest negative reaction was from Board members who smoke and were now prohibited from doing so. Of course now almost all hospitals are totally smoking-free. (There was an interesting discussion about whether or not psychiatric inpatients should be allowed to smoke but that was ended as well.)

“Life is being on the wire, everything else is just waiting.” Karl Wallenda

For many years cardiac cath labs were restricted by the state’s Certificate of Need process. Then there was a “call” which would allow any hospital that met certain standards to apply to open a diagnostic cath lab (not interventional). It didn’t make sense to have a lab at one of our community hospitals but again Board members were pressured and an application was submitted.
In the next year dozens of cath labs opened in NJ, including three in Hudson County including one in our community hospital. Only one survived, not ours, because it was also part of interventional cardiology pilot program that allowed certain types of intervention without onsite cardiac surgery. (Parenthetically we helped get them into the pilot program with the proviso that JCMC would be their referral center. They reneged and sent all their referrals to Newark.)

“Trust your own instinct. Your mistakes might as well be your own, instead of someone else’s.” Billy Wilder

The lane to top tier hospital in New Jersey was cardiac surgery. We had secured a Certificate of Need for cardiac surgery while building the new hospital but it would expire one year after we moved in to the new hospital. Our patient mix 30% commercially insured and 70% Medicaid and Charity Care, not very promising from a reimbursement perspective since CS was expensive to staff and required a massive capital infusion to build the necessary specialized facilities.
Everyone except our Chief Medical Officer was against proceeding including the Chairman of the Board who said to me “Jon, I am against this project but will defer to you as President, but your job is on the line.”
We opened the unit in collaboration with Mount Sinai (there was no way we could start a program on our own) and the game changer was interventional cardiology, whereby according to American College of Cardiology guidelines certain patients had to be transported to hospitals with interventional cardiac cath labs and we had the only one in the county. This led to more cardiac surgery cases and a flip of the cardiac surgery payer mix to 70% commercially insured and 30% Medicaid and Charity Care.

Soon after I left one community hospital was closed, the other sold, and the affiliation with Mount Sinai was terminated, but the cardiac surgery and emergency medicine stayed on a very positive trajectory.

“The biggest risk is not taking any risk… In a world that changing really quickly, the only strategy that is guaranteed to fail is not taking risks.” Mark Zuckerberg


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“We would never tolerate a situation where only one in 10 people with cancer or diabetes gets treatment, and yet we do that with substance-abuse disorders,” (A)

“Having recognized the widespread and devastating nature of the opioid crisis, governors are taking action to stem the tide of opioid use disorder and overdose.
States are uniquely positioned to do this work, because they play a central role in protecting public health and safety; regulating health care providers; establishing prescription drug monitoring programs (PDMPs); and paying for care through Medicaid, state employee benefits, corrections and other health programs. Current evidence suggests that the most effective way to end the opioid crisis is to take a public health approach focused on preventing and treating opioid use disorder as a chronic disease while strengthening law enforcement efforts to address illegal supply chain activity. This road map uses a public health intervention model to guide state activities in targeting the problem with health care and law enforcement strategies. A monitoring and evaluation component is included to help states assess the effectiveness of those efforts and inform future activities.” (B)

“President Donald Trump declared the opioid crisis a national emergency Thursday, a designation that would offer states and federal agencies more resources and power to combat the epidemic.
In a statement released late in the day, the White House said, “building upon the recommendations in the interim report from the President’s Commission on Combating Drug Addiction and the Opioid Crisis, President Donald J. Trump has instructed his Administration to use all appropriate emergency and other authorities to respond to the crisis caused by the opioid epidemic.”
“The opioid crisis is an emergency, and I am saying, officially, right now, it is an emergency. It’s a national emergency,” Trump said earlier at his golf club in Bedminster, New Jersey. “We’re going to spend a lot of time, a lot of effort and a lot of money on the opioid crisis. It is a serious problem the likes of which we have never had.”
Trump’s actions come just two days after Health and Human Services Secretary Tom Price suggested declaring a national emergency was unnecessary.
“We believe that at this point, the resources that we need or the focus that we need to bring to bear to the opioid crises can be addressed without the declaration of an emergency,” Price said, “although all things are on the table for the president.” “(C)

“The chairman of the president’s opioid commission, New Jersey Gov. Chris Christie, thanked the president “for accepting the first recommendation” of the commission’s report.
“It is a national emergency and the president has confirmed that through his words and actions today, and he deserves great credit for doing so,” Christie said.
It’s not exactly clear what making the declaration will mean for federal efforts to combat the opioid crisis. But a number of states say similar declarations have helped.
The commission’s report to the president said a declaration “would empower your cabinet to take bold steps and would force Congress to focus on funding and empowering the Executive Branch even further to deal with this loss of life.”” (D)

“For the past 50 years, we have been waging a war on drugs that has relied nearly exclusively on supply control and tough punishment. It hasn’t worked.
Despite the logic of limiting the availability of drugs and threatening and punishing those who are involved in the drug trade and using drugs, the report card for this tough method of enforcement is bleak. We have invested more than $1 trillion during the past 45 years in the war on drugs. Yet there is essentially no evidence in support of the success of that effort.
Why has it failed? The medical community declared nearly 70 years ago that drug and alcohol addiction and dependence are medical disorders. We can’t punish diabetes or cancer away. So why do we think getting tough on addiction would work?
To complicate the landscape, approximately 40% of opioid-dependent individuals have depression, anxiety, or bipolar disorder, and some have other co-occurring psychiatric disorders. Post-traumatic stress disorder and personality disorders are also present, though less frequently. Punishment is not only ineffective; it often exacerbates these mental health problems.
Punishment also does not deter those with substance use disorders. Today, the vast majority of individuals who enter the U.S. criminal justice system have problems with drug addiction, dependence, or abuse. The recidivism rate for those with such disorders is nearly 80%. The reason is simple: Punishment does nothing to address drug abuse, dependence, or addiction.
It’s time to stop disregarding scientific and clinical evidence and get realistic about how we should address the drug problem. The evidence is unequivocal—we cannot effectively control supply. There is simply too much money to be made on the sale of illicit drugs.
We should therefore recalibrate drug policy by dramatically ramping up evidence-based strategies of demand reduction. The only way to reduce the incidence of substance use disorders is effective treatment. Ideally, that should occur outside the confines of the justice system with community-based treatment. Those who end up in the justice system should be diverted to treatment, not simply locked up.
Drug abuse is a public health problem. It is time we treat it that way. (E)


Some updates:
“Companies that make or distribute opioid painkillers are facing a “tidal wave” of litigation as US officials seek to raise funds to fight the country’s addiction epidemic and punish those they accuse of fueling the crisis.
The number of government officials launching legal action against drugmakers and wholesalers has soared in the past year in what some lawyers see as a harbinger of a settlement that could echo the more than $200bn extracted from the tobacco industry in 1998.
At least 30 states, cities and counties have either filed lawsuits or are formally recruiting lawyers using a process that tends to prelude full-blown legal action, according to a Financial Times analysis.” (F)

“……. Republicans are still considering making dramatic cuts to Medicaid that would severely handicap efforts to overcome the opioid epidemic. Now more than ever, we need to ensure that resources are available to help those struggling with opioid addiction, and Medicaid is the backbone to support these efforts.” (G)



(A) Landmark report by Surgeon General calls drug crisis ‘a moral test for America’, by Lenny Bernstein,
(B) Finding Solutions to the Prescription Opioid and Heroin Crisis: A Road Map for States, National Governors Association,
(C) Trump: ‘The opioid crisis is an emergency’, by Wayne Drash and Dan Merica,
(D) Trump Says He Intends To Declare Opioid Crisis National Emergency, by Brian Naylor and Tamara Keith,
(E) Trump Clearly Has No Clue How to Stop the Opioid Epidemic, by William R. Kelly,
(F) Drug industry faces ‘tidal wave’ of litigation over opioid crisis, David Crow,


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“In politics you can tell your friends from your enemies, your friends are the ones who stab you in the front”.* Look at what the Republicans are saying about each other now about health care

First prize goes to..
“Sen. Ron Johnson suggested that fellow Republican Sen. John McCain’s brain tumor and the after-midnight timing of the vote were factors in the Arizona lawmaker’s decisive vote against the GOP health care bill.
In a radio interview Tuesday with AM560 ‘‘Chicago’s Morning Answer,’’ Johnson answered questions about the collapse of the years-long Republican effort to repeal and replace Barack Obama’s Affordable Care Act, his criticism of the process and McCain’s dramatic vote.
In the early morning hours July 28, the Senate narrowly rejected the legislation, with McCain joining Sens. Lisa Murkowski of Alaska and Susan Collins of Maine, delivering a serious blow to President Donald Trump’s agenda.
McCain, who had been diagnosed with brain cancer, had returned to the Senate that week for the critical votes, lifting GOP hopes and then dashing them.
‘‘He has a brain tumor right now. That vote occurred at 1:30 in the morning. Some of that might have factored in,’’ Wisconsin’s Johnson said.
That surprised the interviewer, who asked, ‘‘Really?’’ and wondered whether the senator’s illness and the late night affected his judgment.
Johnson said he didn’t want to speak for any other senator, ‘‘I don’t know exactly what. … I really thought John was going to vote yes.’’ (A)

And tied for second place…
President Trump and Senate Majority Leader Mitch McConnell (R-Ky.) are publicly criticizing one another as Republicans point fingers over why they have struggled to score political wins.
The public shots between the GOP president and Senate leader follow growing conservative criticism of McConnell, who has become a target for two right-wing candidates in an Alabama Senate race.
Conservatives suspicious of McConnell have used his failure to win a victory on ObamaCare repeal against him.
And they’ve found an ally, at least temporarily, in Trump.
“Senator Mitch McConnell said I had ‘excessive expectations,’ but I don’t think so,” the president said on Twitter Wednesday. “After 7 years of hearing Repeal & Replace, why not done?”
Trump criticized McConnell a second time on Thursday, asking his supporters on Twitter: “Can you believe that Mitch McConnell, who has screamed Repeal & Replace for 7 years, couldn’t get it done.”
Trump was responding to McConnell’s remarks in Kentucky that the president’s “excessive expectations” were partly to blame for the perception that Republicans hadn’t accomplished anything.
“Our new president has of course not been in this line of work before and I think had excessive expectations about how quickly things happen in the democratic process,” McConnell said during a Rotary Club event.
He added that were “artificial deadlines” on how long it took to pass bills that were “unrelated to the reality of the complexity of legislating.” Instead, he hopes GOP voters will wait until the end of 2018, when the 115th Congress wraps up, to judge their accomplishments. (B)

“President Donald Trump resumed his public feud with Senate Majority Leader Mitch McConnell Thursday over his party’s failure to repeal and replace the Affordable Care Act, a sign of the fraught relationship between two branches of government that are both controlled by Republicans.
“Mitch, get back to work and put Repeal & Replace, Tax Reform & Cuts and a great Infrastructure Bill on my desk for signing. You can do it!” Trump tweeted, his third tweet in two days calling out the Senate majority leader.
“Can you believe that Mitch McConnell, who has screamed Repeal & Replace for 7 years, couldn’t get it done. Must Repeal & Replace ObamaCare!” the President tweeted earlier.
The tweets continues a public exchange of criticism between the two GOP leaders this week, exhibiting further tension between the White House and Congress, both of whom have an ambitious policy agendas that have struggled to make progress. On Tuesday, McConnell said Trump had “excessive expectations” for the legislative process and suggested there was a false perception that Congress is underperforming in part “because of too many artificial deadlines unrelated to the reality of the legislature, which may have not been understood.”
Trump responded to that criticism Wednesday, tweeting: “Senator Mitch McConnell said I had ‘excessive expectations,’ but I don’t think so. After 7 years of hearing Repeal & Replace, why not done?” (C)

“The phone call, first reported by The New York Times, and comments at Bedminster mirror what Trump has said in private, according to four White House officials and Trump friends: that he is preparing to distance himself from Republicans in Congress if they aren’t successful in passing legislation and that he will not take the blame for them if they can’t.
Increasingly, these people say, the president is prepared to cast himself as an outsider — and Congress as an “insider” Washington institution. He has reminded advisers his poll numbers are higher than Congress’ and that he ran against Washington — and wants bills to sign — and will blast his own party if he doesn’t get them. Trump believes that his supporters will largely blame Congress instead of him, two people who have spoken to him said.” (D)

*attributed to many

(A) GOP senator suggests brain tumor affected McCain health care vote. By By Donna Cassata,
(B) McConnell, Trump point fingers, by Jordain Carney,
(C) Trump to McConnell in third tweet: ‘Get back to work,’ ‘You can do it!’, by Ashley Killough,
(D) Behind the Trump-McConnell feud, by JOSH DAWSEY,


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“For most of my surgical career, I gave out opioids like candy….” “With approximately 142 Americans dying every day”….” We need to take away the matches, not put out the fires.”

“President Donald Trump on Tuesday vowed his administration would beat the opioid epidemic by beefing up law enforcement, strengthening security on the southern border to stop illegal drugs from entering the country.
Trump, joined in Bedminster, New Jersey, by Health and Human Services Secretary Tom Price and other administration officials, emphasized a tough law-and-order approach, rather than new treatment or social programs, as the White House’s primary strategy for halting an epidemic that kills 142 Americans every day, according to federal statistics. (A)

“President Trump declined yesterday to declare the opioid epidemic sweeping the United States a national emergency, despite a recommendation last week by his own commission. Trump’s top health administrator, Health and Human Services Secretary Tom Price, argued that extra step wouldn’t have helped much anyway — and experts tend to agree. (B)

“How did this happen?
In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to prescription opioid pain relievers, and healthcare providers began to prescribe them at greater rates. This subsequently led to widespread diversion and misuse of these medications before it became clear that these medications could indeed be highly addictive. Opioid overdose rates began to increase. In 2015, more than 33,000 Americans died as a result of an opioid overdose, including prescription opioids, heroin, and illicitly manufactured fentanyl, a powerful synthetic opioid. That same year, an estimated 2 million people in the United States suffered from substance use disorders related to prescription opioid pain relievers, and 591,000 suffered from a heroin use disorder (not mutually exclusive). Here is what we know about the opioid crisis:
Roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them; Between 8 and 12 percent develop an opioid use disorder; An estimated 4 to 6 percent who misuse prescription opioids transition to heroin; About 80 percent of people who use heroin first misused prescription opioids.
This issue has become a public health crisis with devastating consequences including increases in opioid misuse and related overdoses, as well as the rising incidence of neonatal abstinence syndrome due to opioid use and misuse during pregnancy. The increase in injection drug use has also contributed to the spread of infectious diseases including HIV and hepatitis C. As seen throughout the history of medicine, science can be an important part of the solution in resolving such a public health crisis.” (C)

President Trump’s commission on the opioid crisis asked him Monday to declare a national emergency to deal with the epidemic.
The members of the bipartisan panel called the request their “first and most urgent recommendation.”
Mr. Trump created the commission in March, appointing Gov. Chris Christie of New Jersey to lead it. The panel held its first public meeting last month and was supposed to issue an interim report shortly afterward but delayed doing so until now. A final report is due in October.
“With approximately 142 Americans dying every day, America is enduring a death toll equal to Sept. 11 every three weeks,” the commission members wrote, referring to the 9/11 terrorist attacks. “Your declaration would empower your cabinet to take bold steps and would force Congress to focus on funding and empowering the executive branch even further to deal with this loss of life.”
In addition to seeking an emergency declaration, the commission proposed waiving a federal rule that sharply limits the number of Medicaid recipients who can receive residential addiction treatment.
It also called for expanding access to medications that help treat opioid addiction, requiring “prescriber education initiatives” and providing model legislation for states to allow a standing order for anyone to receive naloxone, a drug used to reverse opioid overdoses. (D)

“Drug wholesalers shipped 780 million hydrocodone and oxycodone pills to West Virginia in just six years, a period when 1,728 people fatally overdosed on these two painkillers, according to an investigation by the Charleston Gazette-Mail.
That amounts to 433 of the frequently abused opioid pills for every man, woman and child in the state of 1.84 million people….
The drug distributors say they’re just middlemen in a highly regulated industry and that pills would never get in the hands of addicts and dealers if not for unscrupulous doctors who write illegal prescriptions, and pharmacists who turn a blind eye. (E)

“My own “Aha!” moment came recently after my father had gallbladder surgery and recovered comfortably at home with a single ibuprofen tablet. Wow. It directly contradicted my residency training 15 years ago, when I was taught to give every surgical patient a prescription for 30 to 90 opioid tablets upon discharge. Some of my mentors told me that overprescribing prevents late night phone calls asking for more. The medical community at that time ingrained in all of us that opioids were not addictive and urged liberal prescribing. So that’s exactly what we did.
The hundreds of excessive opioid prescriptions I wrote in 2015 alone (the last year for which national data are available) were a tiny part of the country’s 249 million opioid prescriptions filled that year, almost one for every American adult. Last year, America produced 14 billion opioid pills (40 for every U.S. citizen), mostly paid for by the American public in the form of tax dollars or increasing health insurance premiums.
Take C-section for example, one of the most common operations paid for by Medicaid tax dollars. Some doctors appropriately prescribe five to 10 opioid tablets after the procedure (in combination with non-opioid meds as recommended by the American Pain Society), while other doctors are still doing what I did for years — give every patient a bottle of 30-60 highly addictive opioid tablets.

We need to take away the matches, not put out the fires.” (F)




(A) Trump says he’ll beat opioid epidemic with law-and-order approach, by BRIANNA EHLEY,
(B) The Health 202: Trump doesn’t need to declare the opioid crisis a national emergency, by Paige Winfield Cunningham,
(C) Opioid Crisis,
(D) White House Panel Recommends Declaring National Emergency on Opioids, by ABBY GOODNOUGH, (A
(E) Probe reveals flood of 780M painkillers in 6 deadly years in West Virginia,
(F) Doctors like me must stop overprescribing opioids, by Marty Makary,

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