As ZIKA and EBOLA reemerge, Trump administration cuts funding to halt international epidemics

March 13th
“The White House appeared to declare victory this week for an Obama-era initiative to stamp out disease outbreaks around the world even as it moved to scale back the program…,
But the United States is set to dramatically shrink its contributions to the initiative, a point that the report omitted. The Centers for Disease Control and Prevention is preparing to narrow epidemic work from 49 countries to 10, an agency spokeswoman said.
That has alarmed health policy experts.
“It’s not a matter of if — but when — there will be another Ebola or Zika, and right now, the world isn’t ready,” said Dr. Thomas R. Frieden, who led the C.D.C. during the West African Ebola outbreak. “Many life-threatening gaps have been identified, but most of them haven’t been closed.” “ (A)

“The response to the Zika virus is fairly typical of both our strengths and weaknesses in dealing with infectious diseases, especially when they emerge. Existing drugs against other viruses were identified as potential therapeutics for Zika, efforts to develop a vaccine are underway and nearing completion, and the concern about Zika spurred some needed and valuable research. Those are encouraging signs, but these efforts were somewhat slow to get started and preceded by the usual complacency. We tend to close the barn door only after most of the horses have escaped.” (B)

May 8th
“The Government of the Democratic Republic of the Congo declared a new outbreak of Ebola virus disease (EVD) in Bikoro in Equateur Province today (8 May). The outbreak declaration occurred after laboratory results confirmed two cases of EVD.
The Ministry of Health of Democratic of the Congo (DRC) informed WHO that two out of five samples collected from five patients tested positive for EVD at the Institut National de Recherche Biomédicale (INRB) in Kinshasa. More specimens are being collected for testing.
WHO is working closely with the Government of the DRC to rapidly scale up its operations and mobilize health partners using the model of a successful response to a similar EVD outbreak in 2017.
“Our top priority is to get to Bikoro to work alongside the Government of the Democratic Republic of the Congo and partners to reduce the loss of life and suffering related to this new Ebola virus disease outbreak,” said Dr Peter Salama, WHO Deputy Director-General, Emergency Preparedness and Response. “Working with partners and responding early and in a coordinated way will be vital to containing this deadly disease.” “ (C)

May 17th
“An Ebola outbreak in the Democratic Republic of Congo has spread to a major city — Mbandaka, with a population of about 1 million people — officials said.
The country’s health minister said authorities are intensifying work to identify those who have been in contact with suspected cases. Another concern is the disease could be spread through commerce, as the city is a major trade thoroughfare on the banks of the Congo River.” (D)

May 17th
National Institutes of Health officials assured lawmakers on Thursday that U.S. health experts are following concerns of an Ebola outbreak in Africa closely and said a number of medical countermeasures have already been deployed in response.
“Obviously given our prior experience, we are on very high alert,” said Anthony Fauci, M.D., head of the National Institute of Allergy and Infectious Diseases, in response to a question about how worried the U.S. should be about reports that Ebola had been found in an urban area of the Democratic Republic of Congo….
…at least one case is now in a more populated area, he said: “Even though there is only one case there, there’s a total now of 44 cases, even though only two have been confirmed. There are 20 that are probable and 20 that are suspicious. So there are probably many more cases.”…
“We are on high alert. We are always concerned when there is Ebola. But we right now have a number of countermeasures that we were able to develop to go in and hopefully block that,” he said. “Our expectations are always cautious. Our hopes are always that we will not have the kind of outbreak that we saw in West Africa.” (E)

May 18th
“Congo at ‘Very High’ Risk as Ebola Strikes Major City. WHO raises the public-health risk to ‘very high,’ as the deadly virus reaches a large port city
Aid organizations and the Congolese government rushed supplies and health experts Friday to a major city in the Democratic Republic of Congo, after the World Health Organization raised the public-health risk from the latest Ebola outbreak to “very high.”
Congo’s threat from the deadly disease was elevated from high by the WHO, who also upped the risk to neighboring nations to high from moderate. Very high is the second-highest risk level available, below serious.” (F)

May 18th
“What’s the worse-case Ebola outbreak?
Public health officials would say it’s when the virus is spreading in a crowded urban environment that’s a major transportation hub and has dilapidated, ill-equipped health care facilities.
Unfortunately, that’s what’s happening right now in the northwest of the Democratic Republic of the Congo…
That’s why the World Health Organization along with Congolese officials and other aid agencies are scrambling to try to contain this outbreak before it grows much larger…
Congolese health officials now say there have been 45 suspected cases reported in their country since April. And 25 people have died. Laboratory testing of patient blood samples, however, has been progressing slowly; 14 of the cases have been confirmed as Ebola.
Four thousand doses of an experimental Ebola vaccine — which has to be stored at minus 60 degrees Celsius — have shipped to the DRC. Plans are being developed to try to vaccinate hundreds if not thousands in areas near where Ebola cases have been found.
Doctors Without Borders is setting up isolation wards and Ebola treatment centers both near the epicenter of the outbreak and in the port city of Mbandaka.
The Red Cross is recruiting local volunteers to collect and safely bury the dead.
“We have now 20 volunteers trained on how to do these burials,” says Karsten Voigt, operations manager for the International Federation of the Red Cross in the Democratic Republic of the Congo.” (G)

May 18th
“The Ebola outbreak in Democratic Republic of Congo can be brought under control and is not an international public health emergency, experts advising the World Health Organization said on Friday.
Earlier in the day the WHO had said the first confirmation of Ebola in Mbandaka, a city of about 1.5 million people, had prompted it to declare a “very high” public health risk to the country and a “high” risk to the region.
But the WHO’s Emergency Committee of 11 experts said the rapid response had mitigated the risk from the outbreak, which was declared 10 days ago and has killed 25 people since early April.
“Interventions underway provide strong reason to believe that the outbreak can be brought under control,” the committee said in a statement.
They decided not to declare a “public health emergency of international concern” (PHEIC), a formal alert that puts governments on notice and helps mobilise resources and research.
However, committee chairman Robert Steffen said the “vigorous” outbreak response must continue.” (H)

May 19, 2018
“ Three new cases of the often lethal Ebola virus have been confirmed in a city of more than one million people, Congo’s health minister announced, as the spread of the hemorrhagic fever in an urban area raised alarm.
The statement late on Friday said the confirmed cases are in Mbandaka, a city where a single case was confirmed earlier in the week.
There are now 17 confirmed Ebola cases in this outbreak, including one death, plus 21 probable cases and five suspected ones…
While Congo has contained several Ebola outbreaks in the past, all of them were based in remote rural areas. The virus has twice made it to Congo’s capital of 10 million people, Kinshasa, in the past but was rapidly stopped.
Health officials are trying to track down more than 500 people who have been in contact with those feared infected, a task that became more urgent with the spread to Mbandaka, which lies on the Congo River, a busy traffic corridor, and is an hour’s flight from the capital.” (I)

May 19th
“The U.S. government is preparing its most direct response yet to the outbreak that appears to have begun in April, readying staffers from the Centers for Disease Control and Prevention (CDC) to deploy to multiple communities in the Democratic Republic of Congo…
The present outbreak has raised anew questions about WHO and its capacity to respond to deadly viral threats. In the wake of the West African outbreak ago, when the ill-prepared WHO endured withering criticism for its lackluster response to the initial round of cases, the agency has undergone a remarkable round of self-flagellation, reorganizing to prioritize emergency preparedness and response while cutting bureaucracy.” (J)

(A) White House Hails Success of Disease-Fighting Program, and Plans Deep Cuts, by Emily Baumgaertner,
(B) Cannot be complacent, by Stephen S. Morse,
(C) New Ebola outbreak declared in Democratic Republic of the Congo,
(D) WHO mulling health emergency over Congo Ebola outbreak, by Susan McFarland,
(E) NIH officials on ‘high alert,’ deploying countermeasures in response to Ebola outbreak,
(F) Congo at ‘Very High’ Risk as Ebola Strikes Major City, by Nicholas Bariyo,
(G) Ebola Outbreak: How Worried Should We Be?, by Jason Beaubien,
(H) Congo’s Ebola not an international emergency, can be controlled –WHO, by Tom Miles and Fiston Mahamba,
(I) Congo says 3 new Ebola cases confirmed in large city,
(J) The Ebola superhighway: Why the new outbreak terrifies public health authorities, by Reid Wilson,

May 3rd
“we are not finished with Zika… It very well could come back.” Are we ready?
highlight and click on

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New Ebola outbreak declared in Democratic Republic of the Congo

On May 3rd we posted:
“we are not finished with Zika… It very well could come back.” Are we ready?

The Government of the Democratic Republic of the Congo declared a new outbreak of Ebola virus disease (EVD) in Bikoro in Equateur Province today (8 May). The outbreak declaration occurred after laboratory results confirmed two cases of EVD.
The Ministry of Health of Democratic of the Congo (DRC) informed WHO that two out of five samples collected from five patients tested positive for EVD at the Institut National de Recherche Biomédicale (INRB) in Kinshasa. More specimens are being collected for testing.
WHO is working closely with the Government of the DRC to rapidly scale up its operations and mobilize health partners using the model of a successful response to a similar EVD outbreak in 2017.
“Our top priority is to get to Bikoro to work alongside the Government of the Democratic Republic of the Congo and partners to reduce the loss of life and suffering related to this new Ebola virus disease outbreak,” said Dr Peter Salama, WHO Deputy Director-General, Emergency Preparedness and Response. “Working with partners and responding early and in a coordinated way will be vital to containing this deadly disease.”


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“we are not finished with Zika… It very well could come back.” Are we ready?

In 2014, I suggested several anchor principles for Ebola preparedness in New Jersey, as hospitals of all sizes and scope “marketed” their Ebola readiness, only to learn that it took well over 20/ 25 full time staff to care for one Ebola patient (and 50 in Dallas!).
These recommendations included that every hospital that certified its Emergency Room as ready for Ebola be subject to at least three separate drills using a standardized form, and then be subject to random “secret shopper” inspections; that anyone with a confirmed or suspected Ebola diagnosis be immediately transferred to a regional center hospital designated by national standardized criteria which could demonstrate that it has sufficient nursing staff “volunteers” to care for a least five patients round the clock; and that isolation hospitals be readied for instant activation, whether a closed hospital prepared for Ebola now and standing by, or a “virtual” hospital ready-to-go in military fashion.
Also there was a need to minimize Ebola patients walking into an ER unannounced, and suggested a statewide 800 number be established so patients can call ahead and be transported by a prepared ambulance team and taken to a regional center.
The Federal government, later than sooner, did exclusively designate three national bio containment facilities hospitals as Ebola Centers.
In 2016 I suggested that similar organizing principles were urgently need to be established for tiered Zika hospital preparedness by designating Zika Regional Referral Centers. More specifically:
1. There should not be an automatic default to just designating Ebola Centers as ZRRCs, although there is likely to be significant overlap.
2. Zika Centers should be academic medical centers with respected, comprehensive infectious disease diagnostic/ treatment and research capabilities, and rigorous infection control programs. They should also offer robust, comprehensive perinatology, neonatology, and pediatric neurology services, with the most sophisticated imaging capabilities (and Zika-related “reading” expertise).
3. National leadership in clinical trials.
4. A track record of successful, large scale clinical Rapid Response.
5. Organizational wherewithal to address intensive resource absorption.
6. Start preliminary planning for Zika care out of the initial designated ZRRCs.
Zika protocols will be templates for are other mosquito borne diseases lurking on the horizon, such as Chikungunya, MERS, and Dengue.

Where are we today on readiness for Zika or other emerging viruses?

“Farewell, carefree days of summer. The number of people getting diseases transmitted by mosquito, tick and flea bites has more than tripled in the United States in recent years, federal health officials reported on Tuesday. Since 2004, at least nine such diseases have been discovered or newly introduced here…
New tickborne diseases like Heartland virus are showing up in the continental United States, even as cases of Lyme disease and other established infections are growing. On island territories like Puerto Rico, the threat is mosquitoes carrying viruses like dengue and Zika…
Between 2004 and 2016, about 643,000 cases of 16 insect-borne illnesses were reported to the C.D.C. — 27,000 a year in 2004, rising to 96,000 by 2016. (The year 2004 was chosen as a baseline because the agency began requiring more detailed reporting then.).. (A)

Mosquito-borne disease epidemics happen more frequently.
Chikungunya and Zika viruses caused outbreaks in the US for the first time.
Seven new tickborne germs can infect people in the US…
The US is not fully prepared
Local and state health departments and vector control organizations face increasing demands to respond to these threats.
More than 80% of vector control organizations report needing improvement in 1 or more of 5 core competencies, such as testing for pesticide resistance.
More proven and publicly accepted mosquito and tick control methods are needed to prevent and control these diseases.” (B)

““Mosquitoes—and the viruses that they carry—are pushing up the incidence of malaria globally and causing periodic explosive outbreaks of Rift Valley fever, which first brings on flulike symptoms but can turn into a severe hemorrhagic fever akin to Ebola. Bluetongue virus, a ruminant virus spread by midges that was once confined to tropical areas, has reached as far as Norway. Studies have shown shifts in cholera transmission with recent climate variability. As emerging diseases migrate to new areas, they encounter new species, making outbreaks even more difficult to manage.
Unfortunately, writes journalist Lois Parshley in her feature article “Catching Fever,” the common enabler for the movement of each of these ailments is human-caused climate change. As weather patterns wreak more havoc, a Pandora’s box of microbes enters new terrain, stressing global public health systems…
Such alterations are happening whether we want to use the words “climate change” or not. Whether we acknowledge the scientific consensus, demonstrated in thousands of studies over decades, climate change is both real and promoted by human activities. Coastal communities are being affected by rising seas, drought-prone areas are arid for longer periods and, as our report shows, infectious agents are taking advantage of these more extreme weather patterns.” (C)

“Texas Department of State Health Services released a report its first two travel related Zika cases in Williamson County this Spring.
DSHS said it serves as a reminder for people to be cautious as they travel this summer.
Austin Public Health got a jump start on mosquito prevention with a tire drive Sunday afternoon. Dozens of people dropped of extra and abandon tires that tend to lay idle and collect water.
Ashley Hawes, APH Research Analyst said when the department surveys communities who attract mosquitoes they realized many had standing water collected by tires, bird baths, and rain gutters.
“If we can educate people of simple ways they can get rid of water in their area they can help reduce mosquitos and hopefully reduce the amount of people who get sick from diseases like West Nile and Zika,” Hawes said…
Hawes said one spoon full of water can attract about 10,000 mosquitoes “ (D)

“Two years ago, the world was gripped in Zika panic as the mosquito-borne virus infected millions and spread across 80 countries. Officials declared a global health emergency and tourists canceled their tropical vacations. Thousands of babies were born with devastating birth defects after their mothers were infected in pregnancy…
Still, “we are not finished with Zika,” said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. “Even though when you look at the number of infections, it’s dramatically down, it doesn’t mean they’re going to stay down,” Fauci said. “You’ve got to be careful when dealing with vector-borne diseases. They have a tendency to cycle in and out. It very well could come back.”…
The U.S. Centers for Disease Control and Prevention recently deactivated its emergency response system for Zika that was launched in January 2016…
The future of Zika could look like the pattern of mosquito-borne West Nile virus, which hit highs 9,862 cases in the U.S. in 2003 and hasn’t reached those numbers since. Or it could be more like dengue virus, with four subtypes that reliably infect more than 1 million people each year in the Southern Hemisphere…
“We can’t totally write it off yet,” Lawrence said. “It’s still a potential problem for people traveling. There is always the potential for changes in the virus. I don’t think the story is over.” “ (E)

“Despite the powerful technologies that scientists currently have to characterize pathogens and treat the infections they cause, the course and consequences of epidemics are still a source of surprise. Modern tools of molecular biology have enabled researchers to tear apart the Zika virus and decipher all of its genes and proteins, to map the antibodies and blood cells it mobilizes in infected individuals. But we still don’t know why some people contract the microbe with little or no illness, at most mild fever and muscle aches, while others suffer Guillain-Barré syndrome, a life-threatening paralysis. And we can’t distinguish between those pregnant women whose babies will be born deformed and others who seem to escape the most devastating neurological effects of the virus…
While the spectre of Zika in the Americas is fading, it’s wise to stay vigilant. Some experts worry that new cases of Zika recently reported in northern Mexico could presage another outbreak, with subsequent spread to U.S. border states. Relying on herd immunity is shortsighted, since over time fewer people will be infected and the virus can gain a new foothold. Indeed, the geographic distribution of Aedes aegypti, the mosquito species that transmits Zika, is expanding. The insect is infesting unexpected parts of North America and Europe; a population of A. aegypti was recently found in Washington, D.C., and appears to have survived four consecutive winters. The steady creep of climate change could bring A. aegypti farther north, where there is no herd immunity.” (F)

“An international consortium of researchers has reported that an Ebola vaccine appears to provide volunteers protection against the virus two years after they were injected — encouraging findings both for the public health community and the vaccine’s manufacturer.
An earlier study, conducted in Guinea near the end of the devastating West African Ebola outbreak, showed the vaccine from Merck, which is given in a single shot, rapidly generated protection against the virus. But how long that protection lasts remained an open question.
A fast-acting, long-lasting vaccine given in a single dose would be an effective tool for controlling dangerous Ebola outbreaks. Vaccinating health care workers, for instance, could prevent the type of spread within hospitals that, in the early days of an outbreak, can turn a smoldering outbreak into a conflagration.” (G)

“Analyses of more than 400 mice in New York City found that they carried previously unknown viruses and antibiotic-resistant bacteria.
Mice that live in the basements of New York City apartment buildings — even at the most exclusive addresses — carry disease-causing bacteria, antibiotic-resistant bugs and viruses that have never been seen before, a new study from Columbia University finds…
The viruses included nine species that had never been seen before and others that have not been known to cause human disease, according to the study, published Tuesday in the journal mBio.
But in a second study focused on bacteria, the researchers detected some of the most recognizable disease-causing pathogens, including Shigella, Salmonella, Clostridium difficile and E. coli. The scientists also found antibiotic-resistant bacteria like those that have become nearly untreatable at area hospitals…
“They are a potential source of human infection,” said Dr. W. Ian Lipkin, the epidemiologist at the Mailman School of Public Health at Columbia who was the senior author on the study. “The real message is that these things are everywhere.”” (H)

“A baby believed to have contracted a drug-resistant strain of typhoid, hospitalized in Hyderabad, Pakistan in February. Nadeem Khawer/European Pressphoto Agency
The first known epidemic of extensively drug-resistant typhoid is spreading through Pakistan, infecting at least 850 people in 14 districts since 2016, according to the National Institute of Health Islamabad.
The typhoid strain, resistant to five types of antibiotics, is expected to disseminate globally, replacing weaker strains where they are endemic. Experts have identified only one remaining oral antibiotic — azithromycin — to combat it; one more genetic mutation could make typhoid untreatable in some areas.
Researchers consider the epidemic an international clarion call for comprehensive prevention efforts. If vaccination campaigns and modern sanitation systems don’t outpace the pathogen, they anticipate a return to the pre-antibiotic era when mortality rates soared.
“This isn’t just about typhoid,” said Dr. Rumina Hasan, a pathology professor at the Aga Khan University in Pakistan. “Antibiotic resistance is a threat to all of modern medicine — and the scary part is, we’re out of options.” “ (I)

“Members of a government ethics panel have renewed their criticisms of a controversial study in which volunteers are to be deliberately infected with the Zika virus.
In an article published this month in the journal Science, panel members called for the establishment of ethics committees to review the design of such human-challenge studies, which are sometimes used to test vaccines.
“There is no way to turn back time,” said Ms. Seema Shah, a bioethicist at the University of Washington who chaired the panel and is a co-author of the new paper.
“When you’re asking someone to take a risk that won’t benefit them but may benefit others in the future, you need to know two things — that proper protections are in place, and that it’s really going to move the needle.”
With funding from the National Institutes of Health, the investigators plan to inoculate participants with potential vaccines and then to inject them with small doses of the Zika virus to test the vaccines’ effectiveness. The N.I.H. has not yet decided whether the research will proceed.
The scientists leading the trial say it is necessary to prevent a future epidemic. But Ms. Shah and other bioethicists convened by the N.I.H. concluded in 2017 that the research had “insufficient value” to justify the risks.” (J)

“A public warning and call to action, the new book “Lyme: The First Epidemic of Climate Change,” by investigative journalist Mary Beth Pfeiffer, sheds light on a tick-borne disease that recently has emerged to infect hundreds of thousands of people in the United States each year…
“There’s a problem with how we manage Lyme disease,” Pfeiffer said in a recent phone interview. “People need to be aware that we have a long way to go before we get to the point where we can adequately diagnose and treat Lyme disease and other tick-borne diseases.”..
“[Lyme] has been in the environment for millions of years. That we know.” Pfeiffer said. “But it really exploded just as climate change was getting to the point where we were noticing differences in temperature, differences in snowfall, differences in the length of growing seasons and so forth.”
“I ultimately concluded that it was the first major epidemic to move about the planet as a result of climate change,” Pfeiffer said, well aware that some readers may disagree.” (K)

“The White House appeared to declare victory this week for an Obama-era initiative to stamp out disease outbreaks around the world even as it moved to scale back the program.
The National Security Council released a report on Monday trumpeting the achievements of the multinational Global Health Security Agenda, which helps low-income countries halt epidemics before they cross borders. The report “clearly shows how the investments made by taxpayers to improve global health security are paying dividends,” White House officials said in the announcement.
But the United States is set to dramatically shrink its contributions to the initiative, a point that the report omitted. The Centers for Disease Control and Prevention is preparing to narrow epidemic work from 49 countries to 10, an agency spokeswoman said.
That has alarmed health policy experts.
“It’s not a matter of if — but when — there will be another Ebola or Zika, and right now, the world isn’t ready,” said Dr. Thomas R. Frieden, who led the C.D.C. during the West African Ebola outbreak. “Many life-threatening gaps have been identified, but most of them haven’t been closed.” “ (L)

“The response to the Zika virus is fairly typical of both our strengths and weaknesses in dealing with infectious diseases, especially when they emerge. Existing drugs against other viruses were identified as potential therapeutics for Zika, efforts to develop a vaccine are underway and nearing completion, and the concern about Zika spurred some needed and valuable research. Those are encouraging signs, but these efforts were somewhat slow to get started and preceded by the usual complacency. We tend to close the barn door only after most of the horses have escaped.” (M)

(A) Tick and Mosquito Infections Spreading Rapidly, C.D.C. Finds, by DONALD G. McNEIL Jr.,
(B) Illnesses on the rise,
(C) Our Planet, Ourselves: How Climate Change Results in Emerging Diseases, by Mariette DiChristina,
(D) DSHS reports first 2018 Zika cases in Williamson County, by Natalie Martinez,
(E) Zika retreats widely, but health experts remain concerned, by Blythe Bernhard,
(F) Is Zika Gone for Good?, by Jerome Groopman,
(G) In encouraging sign, Ebola vaccine appears to provide long-lasting protection, by HELEN BRANSWELL,
(H) New York Mice Are Crawling With Dangerous Bacteria and Viruses, by KAREN WEINTRAUB,
(I) ‘We’re Out of Options’: Doctors Battle Drug-Resistant Typhoid Outbreak, by EMILY BAUMGAERTNER,
(J) Ethicists Call for More Scrutiny of ‘Human-Challenge’ Trials, by EMILY BAUMGAERTNER,
(K) Could Lyme disease be the first epidemic of climate change?, by By Aislinn Sarnacki,
(L) White House Hails Success of Disease-Fighting Program, and Plans Deep Cuts, by EMILY BAUMGAERTNER,
(M) Cannot be complacent, by Stephen S. Morse,


June 6, 2016
Former hospital prez says: Designate local Zika centers now. Medical experts do not know if, or where, or how much, or on what trajectory the Zika virus may spread across the United States.

August 13, 2016
The ER clerk asked me “How do you spell Zika?

August 19, 2016
With little gudiance about caring for Zika patients, hospitals are planning on their own

September 7, 2016
Hospitals are developing their own Zika preparedness models. Compare the Central Florida and Johns Hopkins approaches! Which template makes more sense?

September 29, 2016
All pregnant women with Zika diagnosed at community hospitals must be referred to academic medical centers for prenatal care!

May 15, 2017
EBOLA is back in Africa. Is ZIKA next? Are we prepared?

June 10, 2017
Study Findings: Five percent of pregnant women with a confirmed Zika infection.. went on to have a baby with a related birth defect

June 21, 2017
When I was a kid the only thing as scary as the polio epidemic was practicing getting under our desks for a nuclear attack…

July 18, 2017

July 20, 2017
“Houston Braces for Another Brush With the Peril of Zika” *. But they are doing passive not active surveillance. IS YOU AREA’S HEALTH CARE SYSTEM PREPARED FOR A SURGE OF AN EMERGING VIRUS LIKE ZIKA?

July 27, 2017
Locally transmitted ZIKA case in Texas! Are we ready?

October 11, 2017
CDC deactivated its emergency response center for Zika.. The first probable locally acquired Zika case in 2017 has been confirmed in Texas….

November 7, 2017
a hand held device (was used) to measure the germ-count on some of New York City’s dirtiest surfaces

January 8, 2018
“We are arguably as vulnerable—or more vulnerable—to another (flu) pandemic as we were in 1918.”

January 11, 2018
In the ICU at Massachusetts General Hospital, nurses use Gatorade to combat flu-related dehydration (due to shortages of intravenous fluids)

January 15, 2018
The CDC postponed its briefing on preparation for nuclear war and will focus on responding to severe influenza

January 17, 2018
“Think hospitals are under a strain now, from a slightly bad flu season? Wait until a really bad one hits.”

January 20, 2018
Government Shutdown. “The CDC would furlough key staff amid one of the most severe flu seasons in recent memory….”

January 23, 2018
“ a severe (flu) pandemic, the U.S. healthcare system could be overwhelmed in just weeks.

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From REPEAL & REPLACE to WRECK & REJOICE (from Obamacare to Trumpcare)

On March 24th, 2017. “Speaker Paul Ryan (R-Wis.) on Friday said his party “came up short” in a news conference minutes after pulling the GOP healthcare bill off the House floor, acknowledging that ObamaCare will stay in place “for the foreseeable future.””

Yet on December 20th, 2017 the INDIVIDUAL MANDARE was repealed. ““When the individual mandate is being repealed that means ObamaCare is being repealed,” Trump said…“We have essentially repealed ObamaCare, and we will come up with something much better…”

“Andy Slavitt, who served as the acting administrator for the Center for Medicare and Medicaid Services under President Barack Obama, warned late Friday night that Republicans may try to repeal and replace Obamacare once again before the 2018 midterm elections. “Republicans have been meeting in secret to bring back ACA repeal,” he writes…
… Santorum and others may think that there will be a “blue wave” in 2018 no matter what, so this may be the last time the GOP has the opportunity to get rid of Obamacare. And that might make Republicans desperate enough to try again.” (R)

At the end of this post there are links to a series of over 60 posts tracking the activity between March 24th and December 20th. Laws are like sausages,” goes the famous quote often attributed to the Prussian Chancellor Otto von Bismarck, “it is better not to see them being made.”

In 2018, mostly under-the-radar, efforts are continuously underway to continue to undermine what’s left of ObamaCare.

“Republicans, having failed to repeal Obamacare, have stumbled, almost accidentally, into replacing it. For better and for worse, and with little coherent vision at work, they are making Obamacare their own. And over time, they are likely to embrace it…,
Congress has already repealed several unpopular parts of the law as part of last year’s tax legislation — most notably the individual mandate, which now expires at the end of this year, but also the Medicare cost-control board (known as the Independent Payment Advisor Board).
The executive branch has exerted its own influence on the law. In October of last year, President Trump signed an executive order calling for the expansion of association health plans and limited-duration insurance, in hopes of creating a secondary market for health plans that are cheaper and less regulated, and this year, the administration released extensive proposals for each. The administration also stopped paying the law’s cost-sharing reduction subsidies, which reimburse insurers for low-income beneficiaries. And the Department of Health and Human Services has begun allowing states to attach work requirements to Medicaid, making the program more bureaucratic, but possibly enticing red states that have so far declined to expand the program to do so…
Having failed in their repeal effort, Republicans are now in something of an arranged marriage with the health care law. These alterations are being made in a predictably haphazard fashion, with little in the way of guiding theory, but the cumulative effect is to turn Obamacare into a law that they can, if not love, at least learn to live with.”(A)

“Bigger changes are coming. The administration has proposed regulations that would allow so-called short-term health plans to be offered for nearly a year of coverage. Those plans aren’t subject to any Obamacare rules in most states, and are likely to be marketed aggressively. They are likely to cover fewer health services and be available only to the healthy — but at a lower price. Another pending rule would expand the availability of association health plans, a form of group insurance purchasing that may be attractive to small businesses looking for cheaper, less comprehensive options….
People buying those plans may face some unpleasant surprises. The plans are likely to require applicants to fill out detailed health histories, and to exclude those with prior illnesses. They also are likely to exclude or limit services — like addiction treatment, maternity care or prescription drugs — that all Obamacare plans require. Association plan buyers have tended to have problems with fraud. And some short-term plans have a history of declining to pay for serious illnesses after the fact.
But even if the new plans serve their customers well, their popularity could leave the remaining markets a bit shakier. Because the short-term plans will be open only to the healthy, the remaining customers will tend to be sicker, and more expensive to insure.” (B)

“It’s been well documented that the Trump White House has filled federal agencies with bureaucrats whose life work is destroying the very agencies they’ve been assigned to. But one is in a better position than her fellows to threaten the health of millions of Americans—and she’s been working at that assiduously.
We’re talking about Seema Verma, who as administrator of the Centers for Medicare and Medicaid Services also is effectively the administrator of the Affordable Care Act. In the Trump administration, that has made her the point person for the Trump campaign to dismantle the act, preferably behind the scenes…
Still, Verma had spent enough time in the healthcare field that observers thought she might not be totally egregious as CMS administrator. But then, during her confirmation hearing in February 2017, she let on that she didn’t see why maternity coverage really needed to be mandated for all health policies, since “some women might want maternity coverage, and some women might not want it…
It wasn’t an auspicious start. But since then she has lived down to our expectations. Verma never has concealed her hostility to Medicaid — especially Medicaid expansion, a provision of the ACA. Her animosity is fueled at least in part by ignorance (willful or otherwise) about the program. Back in November, on the very day that voters in Maine and Virginia were demonstrating full-throated support at the polls for expanding Medicaid in their states, Verma was unspooling a string of misleading statistics and suspect assertions about the program to support a policy of rolling back enrollment.” (C)

“Passing two measures aimed at stabilizing the Affordable Care Act marketplaces by infusing insurers with more funds would lower monthly premiums by 20 to 40 percent and prompt an additional 3.2 million people to get covered, says an attention-grabbing independent analysis released yesterday by the firm Oliver Wyman.
These measures – which would pay insurers for extra cost-sharing discounts for the low-income and reimburse them for their most expensive customers – are currently stuck in political limbo as leaders on Capitol Hill consider whether to include them in a massive, must-pass spending bill next week.
The bills have become emblematic of inter and intraparty disputes over how to approach a world with most of the ACA still in place. Democrats are bitter that Republicans are still chipping away at parts of the law by repealing its individual mandate and changing other provisions through the executive branch…
And Republicans can’t even agree among themselves how to handle the law now that they’ve failed to entirely wipe it from the books. (D)

“Republicans campaigned for roughly a decade, promising voters they would dismantle former President Barack Obama’s landmark health care legislation; but one of their own senators is trying to keep it alive through the 2018 election cycle…
Sen. Lamar Alexander, R-Tenn., along with Sen. Patty Murray, D-Wash., is using the deadline to sway leadership to include a proposal that would fund politically contentious Obamacare subsidies through 2019. The proposal would provide $10 billion a year for three years for these subsidies…
Additionally, the proposal would give states greater Obamacare waiver flexibility and would broaden consumer eligibility for “copper” plans. Abortion-covering health insurance plans would not receive subsidies under the proposal…
Republicans are either not thrilled about Alexander’s proposal, calling it a bad idea and one that could hurt the party going into 2018, or they think it could be one way to provide taxpayers some relief from the financial burdens Obamacare imposed.” (E)

“The House passed the $1.3-trillion omnibus spending package meant to keep the government running until Sept. 30 in a vote of 256-167, leaving the Senate barely 35 hours to get the same legislation approved by Friday at midnight to avert a shutdown.
The bill boosts funding for the National Institutes of Health, the CDC, and the Department of Veterans Affairs (VA) as well as other key agencies, but keeps funding flat for the Centers for Medicare and Medicaid Services…
The bill also does not include the health insurance stabilization bill from Sen. Lamar Alexander (R-Tenn.) and Sen. Susan Collins (R-Maine). They had wanted the omnibus package to include measures restoring for 3 years the cost-sharing reduction subsidies (monies that help insurers defray out-of-pocket costs for low-income enrollees), establishing 3 years of reinsurance (monies that help pay for the sickest of patients and keep premiums from spiking) at $10 billion per year, and streamlining the 1332 waiver process to allow states more flexibility in health plan design.” (F)

“The Trump administration hopes to move forward with a rule expanding alternatives to ObamaCare plans by this summer, Secretary of Labor Alex Acosta said Monday. The rule allows small businesses and self-employed individuals to band together to buy insurance as a group in what are known as association health plans. “We hope to have that by this summer,” Acosta said Monday during a tax reform event alongside President Trump in Florida.” (G)

“In 2012, the Supreme Court of the United States upheld Obamacare in a 5-4 ruling, with Chief Justice John Roberts writing the majority opinion. Many Obamacare opponents believe Roberts used contorted reasoning to save the law by labeling Obamacare’s individual mandate penalty a tax.
Now, six years later, 20 states have seized on the Roberts ruling to ask the courts again to undo Obamacare. These states filed a lawsuit indicating that because the December 2017 tax reform bill repealed the individual mandate penalty, there’s no longer any legal rationale for the mandate. They also argue that because there’s no “severability clause” in Obamacare, the entire law must be struck down.
If this sounds confusing, read on to unpack what’s going on with this latest attempt to undo Obamacare through the courts.
The Obamacare mandate was ruled a tax…
Opponents of the law argued Congress didn’t have the power to require individuals to purchase a product from private insurers, while the Obama administration argued authority for the mandate came from the Commerce Clause, which gives the federal government power to regulate commerce “among the several states.”” (H)

“Gov. Scott Walker has asked for a federal waiver to operate a state-based reinsurance plan designed to stabilize the state’s individual health insurance market and hold down premiums under the Affordable Care Act.
Following a 44 percent average spike in Obamacare premiums this year, Walker’s office estimates the $200 million program would lower premiums by 11 percent from what they otherwise would have been, amounting to a 5 percent decrease in premiums compared to 2018.
Under the plan, the state would pay $34 million for reinsurance in 2019, while $166 million would come from federal funds…
“We are taking action to address the challenges created by Obamacare and bring stability to the individual market,” Walker said. “Our Health Care Stability Plan provides a Wisconsin-based solution to help stabilize rising premiums in order to make health care more affordable for those purchasing in the individual market. With Washington D.C. failing to fix our nation’s health care system, Wisconsin must lead.” (I)

“The American Academy of Family Physicians and other doctor groups have unleashed detailed critiques of Trump’s effort to introduce cheaper health insurance with skimpier benefits….
“Insurers could reduce or eliminate certain essential health benefits to avoid vulnerable, expensive patients by excluding specific services,” AAFP board chair Dr. John Meigs, Jr., a family physician from Alabama wrote in a letter last week to U.S. Health and Human Services Secretary Alex Azar.
“In doing so, insurers could potentially make plans more expensive for people with long-term chronic conditions or with sudden medical emergencies,” Meigs said. “Inadequate benefits could leave this population with too little coverage to meet their health care needs.” (J)

“The Affordable Care Act (aka Obamacare) banned any hospital, doctor, or insurance company who receives federal funding from discriminating against or denying services based on sex; the Obama administration made it clear in 2016 that provision included transgender and gender-nonconforming patients…
These benefits and protections are heading for oblivion though, according to the Times. The Trump administration is pointing to a January 2017 ruling from a Texas federal judge who said the 2010 law did not cover gender identity or presentation.
“Congress did not understand ‘sex’ to include ‘gender identity,’” Judge Reed O’Connor ruled. In the Affordable Care Act, he said, Congress “adopted the binary definition of sex.” (K)

“As Republicans careen toward the midterms with tax reform under their belts and not much else, rumor has it that a small group of Republican senators are working with the White House and former Sen. Rick Santorum (R-Pa.) to revive the debate over ObamaCare repeal.
Their purpose is laudable. But, privately, conservatives across Capitol Hill are expressing concern that the proposal may not do enough to dismantle ObamaCare’s regulatory structure, reduce its colossal spending, or allow freedom to innovate outside the law’s stifling framework…
The bill’s premise — to devolve much of the health-care spending to the states — is a good starting point. But its implementing details are still unknown, leaving conservatives to wonder if the new bill will actually repeal ObamaCare and reform the health-care marketplace, or if it will simply recast much of the law’s worst elements with a few minor tweaks…
Voters are still waiting for a full repeal effort. Anything less will not suffice as a solution for candidates who will soon be elected on a message of repeal. Nor will it suffice for a party who has spent years making the same promise.” (L)

“Less than a year after the GOP gave up on its legislative effort to repeal the law, Democrats are going on offense on this issue, attacking Republicans for their votes as they hope to retake the House majority…
ObamaCare’s favorability in polls has improved since the repeal push last year, with more now favoring the law than not. A Kaiser Family Foundation poll in March found that 50 percent of the public favors the law, while 43 percent holds an unfavorable view.
GOP strategist Ford O’Connell said the political winds have shifted on the issue, turning ObamaCare into a subject Democrats want to tout and many Republicans want to duck.
“I don’t think it’s seen as a winning issue,” he said. “It’s also an issue that tends to fire up the Democratic base more so than the Republican base.”” (M)

“While Republican moves to overhaul Social Security, Medicare or Medicaid appear unlikely — at least for this year — Democrats are increasingly warning about the prospect because of the deficit concerns created by the tax plan. The GOP argues Democrats want to distract from the fact that they did not support the tax overhaul, the signature Republican achievement of Trump’s first year in office.
Democrats’ ability to sell voters on their vision for health care and warn about the possibility of cuts to Social Security and Medicare could prove crucial for candidates, such as Manchin, who are trying to win in red areas…
Polling suggests Trump and the GOP’s efforts to reshape the American health-care system have not resonated with voters. Thirty-six percent of respondents to the Economist/YouGov poll said they strongly disapprove of how the president has handled health care, compared with only 15 percent who said they strongly approve.” (N)

“People have voted with their enrollment decisions: A sizable number of Americans do not get insurance from their employers and value the coverage on Obamacare’s markets. That refutes the GOP myth that the program forces Americans to purchase junk insurance that they do not want. A recent Kaiser Family Foundation poll found that these consumers seek to guard against major medical costs, to gain the peace of mind that comes with insurance and to obtain coverage for chronic medical care, suggesting that the law serves important and durable needs.
Another fictional Republican claim is that Obamacare has been collapsing. A Kaiser study this year found that insurance markets stabilized in 2017, despite Mr. Trump’s best efforts to undermine the law. This comports with findings from the Congressional Budget Office and a range of other independent analysts…
Obamacare continues to serve an important need. What’s sad to see is how easy it would be to make it even more useful, if Republicans would focus on improvement instead of sabotage.” (O)

“What’s the secret of Obamacare’s stability? The answer, although nobody will believe it, is that the people who designed the program were extremely smart. Political reality forced them to build a Rube Goldberg device, a complex scheme to achieve basically simple goals; every progressive health expert I know would have been happy to extend Medicare to everyone, but that just wasn’t going to happen. But they did manage to create a system that’s pretty robust to shocks, including the shock of a White House that wants to destroy it…
What this says to me is that if Republicans manage to hold on to Congress, they will make another all-out push to destroy the act — because they’ll know that it’s probably their last chance. Indeed, if they don’t kill Obamacare soon, the next step will probably be an enhanced program that lets Americans of all ages buy into Medicare.” (P)

“At the outset, Obamacare had three central features:
• Insurers could not charge higher prices to people with pre-existing conditions.
• Those without coverage had to pay a penalty to the government (the “mandate”).
• Low-income people would be eligible for subsidies.
The first two provisions were necessary to prevent the death spiral, and government couldn’t mandate insurance purchases without adding subsidies for the poor.
Despite a bumpy rollout and some frustrations over shrinking choices and rising prices at health care exchanges, Obamacare was working remarkably well by most important metrics. Program costs were much lower than expected, and the uninsured rate among nonelderly Americans fell sharply — from 18.2 percent in 2010 to only 10.3 percent in 2018.
This progress is now imperiled.
The mandate — by far the program’s least popular provision — was repealed as part of tax legislation passed in December 2017. And because economists predict that its absence will slowly rekindle the insurance death spiral, we’re forced back to the policy drawing board… (Q)


(A) The G.O.P. Accidentally Replaced Obamacare Without Repealing It, by Peter Suderman
(B) Republicans Couldn’t Knock Down Obamacare. So They’re Finding Ways Around It., by Margot Sanger-Katz,
(C) How Trump’s Obamacare administrator is taking a hatchet to Obamacare, by Michael Hiltzik,
(D) The Health 202: Republicans could lower Obamacare premiums. But will they?, by Paige Winfield Cunningham,
(E) Senate May Fund Obamacare Subsidies With This Sneaky Move, by Robert Donachie,
(F) House Passes Spending Bill Without Obamacare Fix, by Shannon Firth
(G) Trump Official: Alternative to ObamaCare Plans Likely This Summer, by Peter Sullivan,
(H) States Take Another Run at Undoing Obamacare Through the Courts, by Christy Bieber,
(I) Amid rising Obamacare premiums, Walker seeks federal waiver for reinsurance program, by op 5 percent, by Lauren Anderson,
(J) Doctors Attack Trump’s Short-Term Health Plans Ahead Of Comment Deadline, by Bruce Japsen,
(K) Trump to Allow Anti-Trans Discrimination in Health Care, by BY NEAL BROVERMAN,
(L) Republicans have a long way to go toward fully repealing ObamaCare, by Rachel Bovard,
(M) GOP in retreat on ObamaCare, by BY PETER SULLIVAN,
(N) It’s not all about Trump: Democrats’ midterm chances ride on health care and Social Security, too, by Jacob Pramuk,
(O) Americans are sticking by Obamacare. If only the GOP would stop trying to kill it.,
(P) Obamacare’s Very Stable Genius, by Paul Krugman,
(Q) Back to the Health Policy Drawing Board, by ROBERT H. FRANK,
(R) Health Policy Expert Says Republicans Have ‘Secret’ Plan to Repeal Obamacare, by Cody Fenwick,


March 26, 2017
LESSONS LEARNED: TrumpRyanCare Obits

March 29, 2017
Let’s prohibit Congressmen from insurance reimbursement for Prostate Screening and Treatment

May 6, 2017
Repeal and DESTROY Obamacare

May 24, 2017

June 16, 2017
REVISE and RECALIBRATE Obamacare. Prevent Republican’s “mean” plan.

June 23, 2017
Is there more “heart” in the Senate health care bill? Or is it “meaner” than the House bill?

June 29, 2017
Perry Como sang “There’s no place like home for the holiday”….except for Republican Senators with their TrumpCare albatross

July 4, 2017
REPEAL NOW/ REPLACE LATER: “Nothing like rolling a hand grenade into ongoing negotiations…”

July 6, 2017
Cruz health care bill amendment – “….healthy people could get coverage although that coverage might not protect them if they got sick and sick people would have to pay an unaffordable amount for coverage.”

July 9, 2017
SLOW DOWN & START OVER (policy) versus REPEAL & REPLACE (politics)

July 12, 2017
What would Albert Einstein have said about TrumpCare? “The definition of insanity is doing something over and over again and expecting a different result.”

July 13, 2017
Is the new Senate health proposal a responsible bill or just “stuff” to get 50 votes?

July 15, 2017
Republican Talking Points on the new Senate Health Care Bill. Democratic Party response – “Senate Republicans spent the past two weeks putting lipstick on a pig”

July 16, 2017
Last week Senator McCain said the “Senate healthcare deal could be reached by Friday ‘if pigs fly’” (A). Now he has a deciding vote on the Republican “junk insurance” bill!

July 17, 2017
“Laws are like sausages, it is better not to see them being made.” (Otto von Bismarck). Or not made…two conservative Republican Senators kill TrumpCare….for now

July 18, 2017
After another day of Republican health care bill fiascos: “President Trump: ‘Let Obamacare Fail…I’m Not Going to Own It’

July 19, 2017
Are Republicans going to LET Obamacare die or MAKE it die? How can the individual market exchanges be stabilized?

July 20, 2017
“The vote is a reward to the ultras who sabotaged repeal and replace by allowing them to posture one more time as purists who have not forsaken the true faith.”

July 21, 2017
“McConnell is still planning votes on health-care legislation next week. But many things have to go right for his strategy to succeed, and not all of them are within his control.”

July 22, 2017
“….. the parliamentarian has taken an already very difficult process for enacting health care legislation in the Senate and made it nearly impossible….”

July 23, 2017
New York Daily News editorial: Senate Republican vote –“An embarrassment wrapped in cruelty wrapped in political disaster.”

July 24, 2017
Rep. Blake Farenthold (R-Texas) suggested….that he’d like to duel with female senators he blames for the Senate’s failure to repeal and replace ObamaCare

July 25, 2017
“These are the moments legislatively when you get creative. We’re getting creative.”

July 26, 2017
“It is clear that Mr. McConnell does not much care which of these proposals the Senate passes…. — he just wants to get a bill out of the Senate.”

July 27, 2017
Senator Graham said he could not support a “half-assed” plan that he called “politically” the “dumbest thing in history.”

July 28, 2017
The House and Senate played “dodgeball” not wanting to be held accountable when twenty million people, their constituents, would lose access to affordable care.

July 29, 2017
What Congress, President Trump and Former President Obama are saying about healthcare

August 6th
“.. here’s the first thing I thought about: feel better, Hillary Clinton could be president..” (Senator McConnell) (A) “McCain Voted Against Health Care Bill…Because it Would ‘Screw’ Arizona.” (B)

August 10, 2017
“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

August 16, 2017 |
The Trump administration “blinks”; provides Obamacare funding

August 23, 2017
For 17 years I was President and CEO of a safety net hospital. TrumpCare will “disinsure” twenty million+ people and devastate the hospitals we all depend on.

August 23, 2017
Trump told a GOP senator she could only ride on Air Force One if she voted for the healthcare bill.

September 3, 2017
TrumpCare. “If you don’t know (`or care`) where you’re going, any road will get you there.” – Lewis Carroll

September 8, 2017
“Republican plans to replace Obamacare are fading fast, but that doesn’t mean Congress is done with health care.

September 16, 2017
“Senators on the health committee are working over the weekend to try to reach an agreement on a stabilization bill for Obamacare…”

September 19, 2017
President Trump would sign the Graham-Cassidy bill if the legislation to repeal Obamacare makes it to his desk…. IT JUST MIGHT MAKE IT THERE!

September 20, 2017
TRUMPCARE. “This is the choice for America, Mr. Graham said on Tuesday: “Socialism or federalism when it comes to your health care.””

September 21, 2017
President Trump tweeted he ”.. would not sign Graham-Cassidy if it did not include coverage of pre-existing conditions. It does! A great Bill. Repeal & Replace.” IT DOESN’T!

September 22, 2017
“It ain’t over till it’s over.” (Yogi Berra). But, John McCain said he “cannot in good conscience vote for the Graham Cassidy proposal.”

September 23, 2017
TrumpGrahamCassidy. “Perhaps one of the biggest challenges for the bill will come next week when the Senate parliamentarian — an umpire of sorts for the chamber’s rules — takes a look at the bill…”

September 24, 2017
White House Director of Legislative Affairs Marc Short is defending the proposed Graham-Cassidy bill — – by countering criticism that the bill does not provide coverage for those with pre-existing conditions.

September 25, 2017
TRUMP/ GRAHAM/ CASSIDY. “If there’s a billion more going to Maine … that’s a heck of a lot,” Cassidy said.

September 26, 2017
“I personally think it’s time for the American people to see what the Democrats have done to them on health care,” said Senate Finance Committee Chairman Orrin G. Hatch (R-Utah).

September 27, 2017
Last minute Sunday night Graham Cassidy revisions included.. a pretty sweet deal for the state of Louisiana, home of one of the bill’s sponsors Sen. Bill Cassidy.

September 28, 2017

September 29, 2017
“Senate Republicans Commence Health Care Blame Game” – pointing fingers at each other. (But..Is a bipartisan deal next?)

October 1, 2017
Senator Cassidy a candidate for Health and Human Services Secretary?

October 2, 2017
Access to health care….should be considered “privileges” for those who can afford them

October 8, 2017
Trump: “I want to focus on North Korea not ‘fixing somebody’s back’,…Let the states do that.” As “synthetic repeal” of ObamaCare is underway.

October 12, 2017
Trump’s Executive Order: “By siphoning off healthy individuals, these junk plans could cannibalize the insurance exchanges.”

October 15, 2017
Trump vows to rip apart Obamacare piece by piece

October 18, 2017
“… President Donald Trump on Wednesday backed away from a bipartisan deal on healthcare reached by two senators…

October 31, 2017
Ending the subsidy for copays/ deductibles would increase the subsidy for premiums ..and ObamaCare enrollment would grow

November 9, 2017
President Trump and Republican congressional leaders falsely claim that Obamacare… is in a “death spiral.”

November 14, 2017
Senate Republicans include repeal of Obamacare’s individual mandate in the tax bill

November 20, 2017
The Republican deal with itself: repeal the Obamacare individual mandate and stabilize the individual health insurance market?

November 26, 2017
“The White House is trying kill Obamacare. Americans are throwing it a lifeline.”

November 30, 2017 | Edit
“The Senate tax bill is really a health care bill with major implications for more than 100 million Americans…..

December 2, 2017 |
“..Conference Committee “may not change a provision on which both houses agree, nor may they add anything that is not in one version or the other,”…

December 6, 2017
“…House and Senate Republicans will likely scrap Obamacare’s individual mandate in their final tax bill.”

December 8, 2017
..congressional Republicans aim to reduce spending on federal health care programs to reduce America’s deficit

December 10, 2017
Note to Sen Collins: Look Around the Poker Table- If You Can’t See the Patsy, You’re It! *

December 14, 2017
“..the compromise tax bill from House and Senate negotiators will end the health law’s requirement that all individuals buy insurance or pay a fine….”

December 17, 2017
“ the move is a winner for Republicans, who.. would otherwise have little to show for 7 years of…repeated efforts to kill Obamacare..”

December 19, 2017
“….57 % of Americans now approve of Obamacare. Only 29 % approve of the GOP’s tax cuts.”

December 20, 2017
By ending the Individual Mandate Republicans are “showing they have no clue how insurance works.”…or don’tcare…

December 21, 2017
President Trump: “When the individual mandate is being repealed that means ObamaCare is being repealed”

December 23, 2017
“It leaves us with two laws… Call the first one Obamacare… Call the second one Trumpcare”

January 10, 2018
“wreck and rejoice” – has consequences. BTW, there is a congressional exemption from ObamaCare

January 24, 2018
GOP Rep. Blames Obamacare For Sexual Harassment Allegations

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Why is there a nationwide hospital shortage of injectable opioids? – follow the money. (part 3 of a continuing case study on the opioid crisis)

“The incident command system kicked in at Brigham and Women’s Hospital about a week ago. A large team of doctors, pharmacists, and nurses began assembling every morning to confront an emerging crisis with the potential to severely undermine care for patients.
The challenge was different than it was during the Boston Marathon bombing, another event that triggered the command response. This one wasn’t rushing toward caregivers as fast. But it was similarly daunting and logistically demanding: Amid a nationwide crisis caused by too-easy access to medical painkillers, hospitals are now struggling to find enough of that same class of drugs to keep their patients’ pain controlled.
That is the reality now facing Brigham and Women’s and other medical providers across the country. Production of injectable opioids has nearly ground to a halt due to manufacturing problems, creating a shortage of staple medications used to treat a wide array of patients. Alarms are now ringing at all kinds of medical providers, from sprawling academic hospitals to small hospice programs, and many are launching efforts to conserve injectable opioids and institute safeguards to prevent dosing errors that can result from rapid changes in medication regimens.” (A)

“The shortage, though more significant in some places than others, has left many hospitals and surgical centers scrambling to find enough injectable morphine, Dilaudid and fentanyl — drugs needed for patients undergoing surgery, fighting cancer or suffering traumatic injuries. The shortfall, which has intensified since last summer, was triggered by manufacturing setbacks and a government effort to reduce addiction by restricting drug production.
As a result, hospital pharmacists are working long hours to find alternatives, forcing nurses to administer second-choice drugs or deliver standard drugs differently. That raises the risk of mistakes — and already has led to at least a few instances in which patients received potentially harmful doses, according to the nonprofit Institute for Safe Medication Practices, which works with health care providers to promote patient safety.
In the institute’s survey of hospital pharmacists last year, one provider reported that a patient received five times the appropriate amount of morphine when a smaller-dose vial was out of stock. In another case, a patient was mistakenly given too much sufentanil, which is about 10 times more powerful than fentanyl, which was the ideal medication for that situation.
In response to the shortages, doctors in states as far-flung as California, Illinois and Alabama are improvising the best they can. Some patients are receiving less potent medications like acetaminophen or muscle relaxants as hospitals direct their scant supplies to higher-priority cases. Others patients are languishing in pain because preferred, more powerful medications aren’t available, or because they have to wait for substitute oral drugs to kick in.” (B)

The shortages involve prefilled syringes of these drugs, as well as small ampules and vials of liquid medication that can be added to bags of intravenous fluids.
Drug shortages are common, especially of certain injectable drugs, because few companies make them. But experts say opioid shortages carry a higher risk than other medications.
Giving the wrong dose of morphine, for example, “can lead to severe harm or fatalities,” explained Mike Ganio, a medication safety expert at the American Society of Health-System Pharmacists.
Calculating dosages can be difficult and seemingly small mistakes by pharmacists, doctors or nurses can make a big difference, experts said.
Marchelle Bernell, a nurse at St. Louis University Hospital in Missouri, said it would be easy for medical mistakes to occur during a shortage. For instance, in a fast-paced environment, a nurse could forget to program an electronic pump for the appropriate dose when given a mix of intravenous fluids and medication to which she was unaccustomed.
“The system has been set up safely for the drugs and the care processes that we ordinarily use,”…“You change those drugs, and you change those care processes, and the safety that we had built in is just not there anymore.”
Chicago-based Marti Smith, a nurse and spokeswoman for the National Nurses United union, offered an example.
“If your drug comes in a prefilled syringe and at 1 milligram, and you need to give 1 milligram, it’s easy,” she said. “But if you have to pull it out of a 25-milligram vial, you know, it’s not that we’re not smart enough to figure it out, it just adds another layer of possible error.” (C)

Experts say opioid pills are most often the culprits behind this abuse. It is not those drugs, but the liquid form that hospitals depend upon for general surgery, sedation, trauma treatment and pain management. And it is those drugs — namely ketamine, fentanyl and hydromorphone — that are in critically low supply.
Pfizer, a major injectable drug supplier, had to stop production of the medications after the Food and Drug Administration found problems at a manufacturing facility in Kansas. Work to upgrade the facility took longer than expected, Pfizer wrote in a letter to its customers in November.
In that letter, Pfizer said syringes would not be available until 2019.
Roper St. Francis’ medication safety officer, Kim Gaillard, said the system gets 60 percent of its IV opioid drugs from Pfizer…
Clinicians have had to find solutions. Gaillard was sure to stress there are other medications in many cases. Other types of painkillers have worked just as well in some surgeries, she said. The shortage has led the hospital system to speed up its review of different ways to deal with pain.
“I know that this is alarming,” Gaillard said, “but we have other strategies.”
Leaders at MUSC restricted ketamine, fentanyl and hydromophone to the system’s intensive care unit, emergency department and operating rooms. An email circulated to MUSC prescribers cited “critical shortages.”
Clinicians were told they need to convert all patients to morphine, if possible. The email warned further restrictions are possible.
Heather Easterling, administrator of pharmacy services at MUSC Medical Center, said in a statement the pharmacy team is working with wholesalers every day to order more of the medications. The DEA’s restrictions are at the heart of the issue, she said.
The DEA’s quotas are quarterly, so Easterling said the shortages hospitals are seeing may continue at least until mid-April.” (D)

“This fact sheet provides an outline of potential actions for organizations to consider in managing the acute shortages of injectable hydromorphone, morphine, and fentanyl. Healthcare professionals should use their professional judgment in deciding how to use the information in this document, taking into account the needs and resources of their individual organizations.
Critical importance
Shortages of injectable opioids can be particularly challenging due to the range of uses in various healthcare settings, including emergency response, ambulatory surgery centers, and hospitals. Injectable opioids are used for acute, acute-on-chronic, or chronic pain that cannot be controlled by other pain management options. Some injectable opioids are used for sedation or anesthesia. Intermittent shortages of specific injectable opioids may require institutions to convert temporarily to a more available product. Not all injectable opioids are interchangeable for all indications. Improper conversion between morphine and hydromorphone caused two deaths during a similar shortage in 2010.
ISMP Medication Error Reporting
ASHP encourages the reporting of any medication errors related to drug shortages to the Medication Error Reporting page on the Institute for Safe Medication Practices (ISMP) website.
What can clinicians do to mitigate the impact?
• Switch therapy to a clinically appropriate oral or enteral opioid whenever possible. o The Pharmacy and Therapeutics (P&T) committee should review current IV-to-oral policies; there may be an opportunity to expand policies to include drug classes affected by shortages.
• Provide multimodal pain management by using parenteral and enteral alternatives to opioids. Consider nonpharmacologic treatments, local nerve blocks, or other pharmacologic adjuncts, as appropriate.
• Engage the institution’s experts in anesthesia and pain and palliative medicine to further develop guidance and formulate strategies for dealing with intermittent shortages.
• Ensure relevant institutional pain medication guidelines are up to date. o To reduce the risk of conversion errors, use a uniform opioid conversion tool that is approved by the anesthesia team and the P&T committee and distributed throughout the entire health system. o Resources like the ASHP Demystifying Opioid Conversion Calculations reference may be helpful in establishing guidelines.
• Product availability can vary by wholesaler and may change from week to week. Guiding prescribers to choose between the available injectable opioids can help institutions reserve certain opioids for specific populations or indications (for example, reserve fentanyl for operating-room use). Use systemwide communications to alert all clinicians who prescribe, dispense, or administer injectable opioids.
• Ensure the electronic health record (EHR) displays opioid options that match the products currently in stock. Do not underestimate the informatics resources that will be needed during this shortage. Inventory control strategies
• Consider reserving supplies of specific injectable opioids for specific indications and limiting the placement.” (E)

“Regrettably, we believe the forecast for drug shortages is grim. There is little relief in sight to halt the rapid escalation of shortages in large part because the conditions that lead to shortages are varied and FDA lacks the necessary regulatory authority to proactively manage potential shortages. It is not always clear what causes drug shortages, as drug companies are not required to disclose the underlying reason or notify FDA regarding a decision to stop production unless they are the sole-provider of the product and it is a medically necessary product. Few manufacturers will supply letters to healthcare providers regarding the reason behind the shortage and the anticipated duration, which is very frustrating to healthcare personnel. The drug shortage lists maintained on the ASHP and FDA Web sites attempt to provide a reason for the shortage in very general terms.
Some of the more common reasons for drug shortages include the following:
– Unavailability of bulk and raw materials used to produce pharmaceuticals, of which 80% come from outside the US
– A delay or halt of production in response to an FDA enforcement action regarding noncompliance with good manufacturing practices identified during an inspection
– Voluntary recall of a drug after the manufacturer discovers a problem with the medication, such as inadvertent bacterial or fungal contamination
– Change in the manufacturer or product formulation (e.g., inhalers without chlorofluorocarbons) that delays production
– Manufacturer’s business decision to halt production of a drug due to availability of generic products, patent expiration, market size, drug approval status, regulatory compliance requirements, anticipated clinical demand, and/or reallocation of resources to other products (FDA does not have authority to require a company to continue manufacturing a medically necessary product)
– Manufacturer mergers that narrow the focus of product lines, causing discontinuation of certain products, or move production of a drug to a new facility, causing production delays
– Poor inventory ordering practices, stockpiling before price increases, and hoarding caused by rumors of an impending shortage
– Unexpected increases in demand for a drug when a new indication has been approved, usage changes due to new therapeutic guidelines, or a substantial disease outbreak occurs
– Natural disasters that involve manufacturing facilities or that lead to demands for certain classes of medications to treat disaster victims.” (F)

“Other companies can’t make up the difference because they don’t have the capacity. Even if they did, the Drug Enforcement Administration is unwilling to give them large amounts of raw materials. The DEA implements annual caps on the amount of raw material a manufacturer can use to make opioids—one mechanism it has to try to limit the diversion of the addictive drugs amid the addiction epidemic.
The DEA has not shifted those caps to allow other manufacturers to produce enough to offset the shortage of injectable narcotics, according to Premier, which has advocated for the agency to loosen its quota restrictions.
“We understand and support the DEA’s goal to be judicious about the production of narcotics, but we believe we are in the midst of a public health crisis,” Mike Alkire, chief operating officer of Premier, said in a statement. “A temporary reallocation of supply quotas would allow others to step into the void, potentially addressing a multi-year shortage in a matter of months.”
Injectable opioids aren’t the ones getting diverted, said Scott Knoer, chief pharmacy officer at Cleveland Clinic.
“We have to do something to try to limit controlled substances, but limiting injectable opioids is not helpful for patients who need them,” he said. “ (G)

“The Drug Enforcement Administration has raised production quotas for drug manufacturers Fresenius Kabi and West-Ward Pharmaceuticals to mitigate the shortage of opioid injectables, but relief is likely months away…
Providers, lawmakers, group purchasing organizations and industry groups like the American Hospital Association have been lobbying the DEA to raise production quotas amid the shortage. In a survey of 116 member health systems, GPO and consulting group Premier found that nearly all of them are experiencing moderate-to-severe shortages of injectable opioids. More than half reported that the shortage affected patient care, including delaying or canceling surgeries or lowering patient satisfaction scores.
“We are encouraged that the DEA did transfer raw material allocations to the three other companies, and we applaud Pfizer for recognizing the need to transfer some of their excess raw material allocation to other suppliers to help meet the inpatient needs for injectable narcotics,” Todd Ebert, CEO of the Healthcare Supply Chain Association, said in an email. “However, we hope that the DEA will develop processes and procedures to recognize and respond to these market issues much more quickly in the future, as three months seems to be too long.”…
The DEA has been under immense pressure to rein in production as the opioid epidemic has worsened.
The agency reduced its production quota of opioids by at least 25% in 2016, which was the first reduction of its kind in more than two decades. But DEA-approved opioid production volumes remain high—including a 55% increase in oxycodone levels in 2017 compared with 2007, according to a July 2017 letter to the DEA signed by 16 senators…
Between 1993 and 2015, the DEA allowed production of oxycodone to increase 39-fold, along with drastic increases for other opioids, the letter said. The number of opioid prescriptions increased from 76 million in 1991 to more than 245 million prescriptions in 2014, resulting in a dramatic rise in overdoses. More than 42,000 people died from opioid overdoses in 2016, according to the Centers for Disease Control and Prevention, a five-fold increase from 1999… (H)

“Hydrocodone and oxycodone are semi-synthetic opioids, manufactured in labs with natural and synthetic ingredients. Between 2007 and 2016, the most widely prescribed opioid was hydrocodone (Vicodin). In 2016, 6.2 billion hydrocodone pills were distributed nationwide. The second most prevalent opioid was oxycodone (Percocet). In 2016, 5 billion oxycodone tablets were distributed in the United States.
The International Narcotics Control Board reported that in 2015, Americans represented about 99.7% of the world’s hydrocodone consumption.” (I)

“Governments allege that opioid companies unreasonably interfered with the public’s health by oversaturating the market with drugs and failing to implement controls against misuse and diversion, thereby creating a public nuisance.” (J)

So why didn’t manufacturers switch to a higher percentage of injectable opioids?
“Part of the issue is that there are a limited number of manufacturers that produce syringes of opioids. The products are heavily regulated given the complexity of making a syringe and the return on investment is slim.” (H)

(A) Hospitals are confronting a new opioid crisis: an alarming shortage of pain meds, by Casey Ross,
(B) Opioid shortages leave US hospitals scrambling, by Pauline Bartolone,
(C) The Other Opioid Crisis: Hospital Shortages Lead To Patient Pain, Medical Errors , by Pauline Bartolone,
(D) South Carolina hospitals dealing with ‘critical shortage’ of opioids, by Mary Katherine Wildeman,
(E) Injectable Opioid Shortages Suggestions for Management and Conservation (Compiled by ASHP and the University of Utah Drug Information Service, March 20, 2018),
(F) Drug Shortages Threaten Patient Safety,,
(G) Injectable opioid shortage compromises care, by Alex Kacik,
(H) DEA lifts production quotas to ease injectable opioid shortage, by Alex Kacik,
(I) Opioid Crisis Fast Facts,
(J) Drug Companies’ Liability for the Opioid Epidemic, by Rebecca L. Haffajee and Michelle M. Mello,

Part 1
CASE STUDY ON THE OPIOID CRISIS. “We still have lacked the insight that this is a crisis, a cataclysmic crisis”

Part 2
“In 2016, more than 40 percent of opioid overdose deaths in the U.S. involved a prescription opioid.”

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“In 2016, more than 40 percent of opioid overdose deaths in the U.S. involved a prescription opioid.”

I have recently been posting CURATED CONTEMPORANEOUS CASE STUDIES with the objective of developing real-time health care policy information and analysis.
The OPIOID CRISIS has been a real challenge absent any federal government leadership for state governments, public health agencies, hospitals, and the public.
So this post is to catch-up on the various threads out there since the initial case study:
CASE STUDY ON THE OPIOID CRISIS. “We still have lacked the insight that this is a crisis, a cataclysmic crisis”
And I think it will continue with various well intentioned initiatives but no evidenced-based platform.

“Surgeon General Jerome Adams is issuing a rare public health advisory on Thursday, calling for friends and family of people at risk for opioid overdoses to carry the OD-reversal medication naloxone. He likened the treatment to other livesaving interventions, such as knowing how to perform CPR or use an EpiPen.
The recommendation comes in the form of a surgeon general’s advisory, a tool used to draw attention to major public health issues. The last one, focused on drinking during pregnancy, was issued in 2005.
“What makes this one of those rare moments is we’re facing an unprecedented drug epidemic,” Adams told STAT in a phone interview Wednesday.
Tens of thousands of Americans are dying from drug overdoses each year, largely driven by opioids. While paramedics — and increasingly, police officers — carry naloxone, they often arrive too late for it to save someone’s life. In countless cases, family members and friends — often other people using drugs — have reported using naloxone to save an overdose victim, and the idea is that if more people have naloxone on hand, more people could be saved.
“It’s easy to use, it’s lifesaving, and it’s available throughout the country fairly easily,” Adams said.” (A)

“Dr. Nora Volkow has heard a frightening scenario play out around the country. People are administering naloxone to synthetic opioid drug users who have overdosed. But the antidote doesn’t work well. So they give another dose. And it’s only after multiple doses — four, five, even six times — that drug users finally come to their senses.
Naloxone is the only widely available drug to reverse opioid overdoses. But anecdotal reports of its limitations against synthetic opioids are on the rise. Spurred by that public health threat — as well as a booming commercial market for the antidote — drug companies, researchers, and health officials are eagerly eyeing the development of new treatments to augment the use of naloxone or, in some cases, potentially replace it.
“The strategies we’ve done in the past for reversing overdoses may not be sufficient,” Volkow, director of the National Institute for Drug Abuse, said in a recent speech at the 2018 National Rx Drug Abuse and Heroin Summit. “We need to develop alternatives solutions to reversing overdoses.”..
“Naloxone seemed to be great for the older opioids,” Kuchera said. “But now that we’re encountering these nonmedical, ungodly [opioids] like carfentanil … we need to get with the times.” (B)

“Gov. Phil Murphy wants to spend $100 million to fight opioid addiction in New Jersey. But exactly how that money would be allocated is an open question.
The governor, speaking at a recovery house for people with drug addiction in Trenton on Tuesday, said the money would come from his proposed budget.
It would include $87 million on prevention, treatment and recovery, and another $13 million on new technology for treatment centers. The funds would go to, among other things, outpatient treatment.
But beyond that, further details were scant even though Murphy told reporters his administration had “taken a couple of months across all of our departments to do a deep dive” study about how to use state money to fight the opioid scourge.
“We must be strategic,” Murphy said. “We cannot just blindly throw money at the opioid problem.” (C)

“Gov. Phil Murphy has steered the ship of state away from many of former Gov. Chris Christie’s preferred destinations, reversing policies and ending programs in largely predictable fashion. That’s what happens when gubernatorial ideologies change so starkly. Murphy brings a very different governing philosophy to the big chair.
To his credit, however, Murphy hasn’t arrived in office hellbent on erasing every piece of his predecessor’s legacy — in contrast to a certain current occupant of the White House. For instance Murphy hasn’t derailed one of the last crusades of Christie’s tenure — combating the opioid addiction epidemic. In fact, Murphy wants to enhance it. On Tuesday he unveiled his own $100 million plan dedicated to the crisis.
The initiative in many respects serves as a continuation of Christie’s efforts, but don’t expect Murphy to characterize it that way. He won’t go that far in acknowledging previous work. Murphy’s approach will also include some key differences…
In general, however, under Murphy officials will look more toward developing community-based outpatient services and maximizing efforts to connect patients with those services…
While this plan unfolds, another piece of the opioid puzzle is expansion of the medicinal marijuana program and possible legalization of pot. Wider access to cannabis could serve to mute the opioid crisis by providing patients with less addictive pain-relief alternatives.
Let’s just hope the analytics offer up the right solutions.” (D)

“A particularly heartbreaking aspect of New Jersey’s opioid epidemic is the growing need for effective care for pregnant women, new mothers, and newborn babies struggling to break free of a dependence on painkillers, alcohol or illicit drugs like heroin.
Yesterday, the state Department of Health launched a public education campaign to increase awareness about these painful facts, connect healthcare providers with proven treatment protocols for babies born exposed to these drugs, and help pregnant women who are under the influence of opiates learn about and connect with healthier options before they give birth…
But as the opioid crisis swells, so does its impact on maternal health: Since 2008, New Jersey cases of Neonatal Abstinence Syndrome (NAS) — which occurs when infants are exposed to drugs or alcohol in the womb — more than doubled to 685 babies in 2016, according to state statistics. Nationwide, there were enough NAS babies in 2012 for one to be born every 25 minutes.
“Babies that are exposed to drugs in the womb are at risk of prematurity, birth defects and withdrawal symptoms such as seizures and vomiting,” said health commissioner Dr. Shereef Elnahal. “By encouraging pregnant women to seek help, their addiction can be treated to reduce the impact to their unborn child.” (E)

“California lawmakers advanced 10 opioid-related bills Tuesday in an effort to address the drug abuse crisis in the state, including a proposal that would let California share prescription records with other states.
Half of the bills passed by a legislative committee would increase monitoring or make it easier to track opioid prescriptions to help police and doctors spot problematic prescriptions. Others would place limits on doctors prescribing the addictive drugs to children or increase access to addiction treatments…
Low’s AB1751 would allow California’s justice department to share prescription records with other states. It’s aimed at making it easier to spot patients who cross state lines to get more prescriptions for opioid drugs.
Opponents are concerned the bill doesn’t do enough to safeguard patients’ privacy. The bill limits data sharing to states that meet certain security standards, but Samantha Corbin, a lobbyist representing the Electronic Frontier Foundation, said the requirements don’t provide enough protection for patients.
Megan Allred of the California Medical Association, a trade group that represents doctors, raised concerns about many of the bills and echoed the Electronic Frontier Foundation’s worries about privacy.
The proposal passed out of the committee unanimously.
Another bill, AB2741, passed Tuesday by the committee would limit doctors from prescribing more than five days’ worth of opioid drugs to minors unless it is medically necessary. The bill also requires doctors to discuss risks posed by the addictive drugs with children and their caretakers and requires a guardian to sign a consent form.
“Overprescribing of opioid medications has directly contributed to the addiction crisis,” said Autumn Burke, a Los Angeles Democrat who authored the bill.
The California Medical Association opposes the legislation because it doesn’t give doctors enough discretion, Allred said.” (F)

“Governor Scott Walker plans to sign two bills into law aimed at opioid abuse prevention.
The first bill, Assembly Bill 906, includes creating grant programs related to drug trafficking, evidence-based substance abuse prevention, juvenile and family treatment courts, and drug treatment for inmates of county jails. It also creates two attorney positions in the Department of justice to assist the division of criminal investigation in the Wausau and Appleton field offices, and to assist district attorneys in the prosecution of drug-related offenses.
The second bill, Assembly Bill 907, includes continuing education in prescribing controlled substances for health care practitioners, maintenance and detoxification treatment provided by physician assistants, and advanced practice nurse prescribers. It also requires school boards to provide instruction about drug abuse awareness and prevention, and includes providing $50,000 of funding to the Department of Children and Families to develop and maintain online training resources for social services workers who deal with substance abuse-related cases.” (G)

“New York made history this past week when it became the first state to work out a deal to hold the pharmaceutical industry responsible for at least some of the financial costs of the deadly and growing opioid drug epidemic.
Those costs have thus far been borne by taxpayers, as people addicted to powerful prescription painkillers, heroin, fentanyl and other opioids cycle in and out of ambulances, emergency rooms, jails, courts, rehabilitation centers and social service programs. In 2016, more than 3,000 New Yorkers overdosed on the drugs and died.
But the passage Saturday of the Opioid Stewardship Fund in the 2018-19 state budget will now require opioid manufacturers and distributors to pay into a $100 million annual fund designed to cover the costs of prevention, treatment and recovery programs. It was cheered by substance abuse providers and addiction recovery advocates, who say it’s only right that the industry which helped create the crisis should help pay for it.
“When BP polluted our ocean they had to pay for the cleanup,” said Stephanie Campbell, executive director of Friends of Recovery – New York. “I would suggest that the opioid industry has polluted our environment. They have contributed to the flooding of the market with opioids, which have proven addictive and deadly, and made incredible profits while doing it.”… (H)

“Jessica Hulsey Nickel had only just begun to speak at a House hearing last month when a man in the back corner of the committee room stood, unfurling a paper banner and shouting toward the witness stand.
“I would like to know how much money the Addiction Policy Forum has received from the pharmaceutical industry,” yelled Randy Anderson, a well-known addiction treatment and recovery advocate in Minneapolis. “We’ve asked the question and no one will tell us. I figured I’d fly here today and ask.”
A congressman tried to gavel Anderson quiet. Committee aides scurried to fetch police. Nickel — the target of Anderson’s protests and Addiction Policy Forum’s president and CEO — ignored the interruption and continued with her testimony about legislation that would reshape federal laws regulating addiction treatment. When the hearing finished two hours later, no one besides Anderson had raised questions about potential conflicts of interest.
Despite Anderson’s difficulty in getting her attention, Nickel’s three-year-old nonprofit is increasingly in the spotlight, both for its high-profile advocacy work and its close ties with drug makers. The vast majority of the group’s funding comes from pharmaceutical companies, some of whose executives sit on its advisory board. Overshadowed by APF’s funding sources, however, is a more striking connection: Until last fall, Nickel was concurrently working as a lobbyist for Alkermes, the maker of a drug used to treat opioid addiction, while heading the nonprofit.” (I)

“In 2016, more than 40 percent of opioid overdose deaths in the U.S. involved a prescription opioid.
So hospitals around the country are thinking hard about whether they should be prescribing as many opioids as they do. Geisinger, a health service organization serving patients in Pennsylvania and New Jersey, has managed to reduce its prescriptions by more than 50 percent over the past few years.
Back in 2012, Geisinger realized its patients were not really satisfied with the way their pain was being controlled. Health workers looked through the electronic database and realized that, in some cases, doctors were prescribing more opioids than their patients needed. Paradoxically, that can sometimes make the pain worse.
Michael Evans, the chief pharmacy officer at Geisinger, said the organization showed those doctors what they had found.
“And, most of the time, the reaction from the prescribers is, ‘Wow, I had no idea I was prescribing like that,’” he said.
The pharmacists worked with doctors to come up with better ways of treating pain, depending on the cause.
In cases of patients with lower back pain, physical therapy proved more effective than medication. And when doctors determined painkillers were a necessity, they went through a longer list of alternatives before prescribing opioids.
It turned out, a lot of patients didn’t need opioids after all. (J)

“Hospitals in New Hampshire have agreed to kick in $50 million toward the state’s opioid epidemic efforts, just the latest example of hospitals taking significant steps toward addressing the crisis.
The funding will be invested over the next five years into a number of the state’s opioid programs, Gov. Chris Sununu announced Friday.
“It is the single largest secured financial investment the state has ever seen in funding substance abuse disorder programs,” Sununu said.
Sununu told the Associated Press that the alliance is a “great example of planning in the long-term” and “simply not accepting the way we used to do it.”
It makes sense for hospitals and other providers to take the lead on combatting the opioid crisis since they’re on the front lines of patient care, Joseph Pepe, CEO of Catholic Medical Center in Manchester, told the outlet.
“We understand how essential it is to invest in programs to address substance abuse disorder,” Pepe said. “By working together, like we are today, we can make a life-saving difference.” (K)

“In response to the opioid overdose crisis, federal Medicare officials are considering new rules that would discontinue payment for long-term, high-dose opioid therapy beginning in 2019. The vote on the new rules takes place Monday.
This is an ill-advised approach. Currently, some 1.6 million people receive opioid medication through Medicare equivalent to 90 mg per day of morphine or more. Sharp cutbacks in doses will result in hundreds of thousands of men and women with chronic pain developing withdrawal, craving and poor pain control.
While I too have deep concern about the opioid epidemic gripping our country, this outrageously short-sighted plan by the federal Centers for Medicare and Medicaid Services has the potential to cause grave harm. It could drive hundreds of thousands of people to extreme measures to avoid unintended and profoundly miserable outcomes.
Moreover, the proposal doesn’t address the real cause of most opioid overdose deaths. Earlier on in the opioid epidemic, most overdose deaths and emergency department visits resulted among chronic pain patients who were taking prescription opioids. But since then, the opioid epidemic has rapidly transitioned into an illicit drug problem.
Yet the dose-reduction proposal is aimed at this old problem, and seems blind to the current reality. To be clear: Drastic dose reductions for patients who are physically dependent on opioid therapy too often causes individuals to turn in desperation to far more dangerous and addictive illicit drugs like fentanyl and heroin.
We must do all we can to prevent individuals from developing addiction to these street drugs. Heroin and fentanyl are readily available, inexpensive, highly purified, look identical to prescription painkillers, and are peddled the same way pizzas are delivered.”
In my state of North Carolina and others around the nation, the situation is rapidly deteriorating, with far more people overdosing and dying from street-purchased opioids than from prescription painkillers.
The Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain, the de facto standard for safe opioid practice in our country, recommends that prescribers “should avoid increasing dosage to 90 mg of morphine or equivalent (MME) or more per day or carefully justify a decision to titrate dosage to 90 MME or more per day.” The new proposal flies in the face of these expert recommendations by mandating lower dosages, rather than allowing doctors to make reasoned decisions.
The CDC Guideline also contains extensive safety measures, widely agreed upon though largely ignored by prescribers. (L)

“Instead, we need a rational drug policy both to rein in the excessive prescribing of opioids and to help the people who are already dependent on them.
First, we need a national prescription database. The state-level databases that we have now are not enough. They allow clinicians to identify patients who “doctor shop” and are high consumers of opioids, but patients can still fill their prescriptions in nearby states, and no one is the wiser.
We also have to deal with doctors who contribute to the epidemic. The Drug Enforcement Administration, using that national prescription database, should identify clinicians, particularly those who aren’t pain specialists, who are outliers in their opioid prescribing patterns, review their treatments and clamp down on inappropriate and excessive prescribing.
This is tricky; we do not want to discourage doctors from adequately treating pain out of fear of legal sanction. But those who adhere to current standards of care should have little to fear.
Finally, reasonable drug policy has to take account of the fact that opioid-dependent individuals have different levels of tolerance, which means there cannot be a one-size-fits-all guideline, like the Medicare proposal, to limit prescribing.
To be sure, there is solid evidence that nonopioid treatments are safer and just as effective as opioids for certain types of chronic pain — and it’s critical that we improve pain education for all health care professionals so this becomes common knowledge.
But for those who are dependent on opioids, doctors must have the ability to adjust treatment to the neurobiological and clinical reality. The fact is that an opioid-dependent brain requires considerable time to adapt to any change in treatment.
Any opioid policy that ignores this will not just throw an untold number of people into withdrawal and misery; it could well unleash a synthetic opioid epidemic of staggering lethality.” (M)

“The new Director of the CDC…” called the opioid-driven surge in drug overdose deaths “the public health crisis of our time,” and he stressed the importance of getting treatment for addicts and enhancing the CDC’s tracking of the epidemic. “We will help bring this epidemic to its knees,” he said.”” (N)

“It took several months and a team of half a dozen doctors, nurses and therapists to help Kim Brown taper off the opioid painkillers she’d been on for two years.
Brown, 57, had been taking the pills since a back injury in 2010. It wasn’t until she met Dr. Dennis McManus, a neurologist who specializes in managing pain without drugs, that she learned she had some control over her pain.
“That’s when life changed,” she said.
During a 12-week series of appointments at McManus’ clinic in Peoria, Ill., Brown learned new ways to prevent and cope with pain, as she gradually reduced her opioid doses.
Roughly a third of Americans live with chronic pain, and many of them become dependent on opioids prescribed to treat it. But there’s a growing consensus among pain specialists that a low-tech approach focused on lifestyle changes can be more effective.
This kind of treatment can be more expensive — and less convenient — than a bottle of pills. But pain experts say it can save money over the long term by helping patients get off addictive medications and improving their quality of life.
She has just learned how to manage life with it.” (O)

“I’m feeling human again, thanks.
After three weeks of living in opioid hell – of constantly being sick to my stomach, of throwing up, of having the shakes and feeling depressed and crying – my body and brain are back to normal.
I’m no longer high and messed up on painkillers.
I’m no longer trying to withdraw from them.
And I have a new, up-close-and-personal understanding of the country’s opioid epidemic and how easy it is for a 70-something guy like me to become addicted to potent pain pills.
My opioid nightmare started on March 13 when I had my left knee replaced. The surgery went fine, but with knee replacement all the pain comes during recovery.
When I was released from the hospital on March 15 my doctor wrote me a prescription for oxycodone.
Fifty pills. Two every four hours at first, then one every 12 hours.
Hello opioid addiction.”…
I now understand how powerful and dangerous opioids are. And how important it is to have a loving family at home to take care of you when you’re taking them or trying to get off them.
During the last few days I’ve run into several other guys who had their knees replaced.
What they said made me feel kind of stupid.
One guy said he never touched oxycodone. He took Tylenol 3, which has codeine but is less potent.
When I ran into George Thomas, the retired foreman of my father’s ranch, he told me he had had both of his knees replaced.
When I told him I was still recovering from opiates, he said, “I didn’t take anything.”
OK, well.
I’m not as tough as old George.
I know opioids are valuable weapons against pain, and that before they were over-prescribed to help create the current crisis they were often under-prescribed.
But if I have to have my other knee replaced, I’m going to take Tylenol 3 and keep the oxycodone in the box.” (P)

“Experts have proposed using medical marijuana to help Americans struggling with opioid addiction. Now, two studies suggest that there is merit to that strategy.
The studies, published Monday in the journal JAMA Internal Medicine, compared opioid prescription patterns in states that have enacted medical cannabis laws with those that have not. One of the studies looked at opioid prescriptions covered by Medicare Part D between 2010 and 2015, while the other looked at opioid prescriptions covered by Medicaid between 2011 and 2016.
The researchers found that states that allow the use of cannabis for medical purposes had 2.21 million fewer daily doses of opioids prescribed per year under Medicare Part D, compared with those states without medical cannabis laws. Opioid prescriptions under Medicaid also dropped by 5.88% in states with medical cannabis laws compared with states without such laws, according to the studies.
“This study adds one more brick in the wall in the argument that cannabis clearly has medical applications,” said David Bradford, professor of public administration and policy at the University of Georgia and a lead author of the Medicare study.” (Q)

“Human resource departments should be a first line of defense in dealing with the opioid crisis, and more employers need to do a better job in readying assistance for workers who may be addicted to opioids or other substances, a group of health care experts urged.” (R)

“With deaths from opioid overdose rising steeply in recent years, and a large segment of the population reporting knowing someone who has been addicted to prescription painkillers, the breadth of the opioid crisis should come as no surprise, affecting people across all incomes, ages, and regions. About four in ten people addicted to opioids are covered by private health insurance and Medicaid covers a similarly large share.
Private insurance covers nearly 4 in 10 non-elderly adults with opioid addiction
The cost of treating opioid addiction and overdose has risen, even as opioid prescription use has fallen among people with large employer coverage…
We find that opioid prescription use and spending among people with large employer coverage increased for several years before reaching a peak in 2009. Since then, use of and spending on prescription opioids in this population has tapered off and is at even lower levels than it had been more than a decade ago. The drop-off in opioid prescribing frequency since 2009 is seen across people with diagnoses in all major disease categories, including cancer, but the drop-off is pronounced among people with complications from pregnancy or birth, musculoskeletal conditions, and injuries.
Meanwhile, though, the cost of treating opioid addiction and overdose – stemming from both prescription and illicit drug use – among people with large employer coverage has increased sharply, rising to $2.6 billion in 2016 from $0.3 billion 12 years earlier, a more than nine-fold increase.” (S)

“Much as the role of the addictive multibillion-dollar painkiller OxyContin in the opioid crisis has stirred controversy and rancor nationwide, so it has divided members of the wealthy and philanthropic Sackler family, some of whom own the company that makes the drug.
In recent months, as protesters have begun pressuring the Metropolitan Museum of Art in New York City and other cultural institutions to spurn donations from the Sacklers, one branch of the family has moved aggressively to distance itself from OxyContin and its manufacturer, Purdue Pharma. The widow and one daughter of Arthur Sackler, who owned a related Purdue company with his two brothers, maintain that none of his heirs have profited from sales of the drug. The daughter, Elizabeth Sackler, told The New York Times in January that Purdue Pharma’s involvement in the opioid epidemic was “morally abhorrent to me.”
Arthur died eight years before OxyContin hit the marketplace. His widow, Jillian Sackler, and Elizabeth Sackler, who is Jillian’s step-daughter, are represented by separate public relations firms and have successfully won clarifications and corrections from media outlets for suggesting that sales of the potent opioid enriched Arthur Sackler or his family.
But an obscure court document sheds a different light on family history — and on the campaign by Arthur’s relatives to preserve their image and legacy. It shows that the Purdue family of companies made a nearly $20 million payment to the estate of Arthur Sackler in 1997 — two years after OxyContin was approved, and just as the pill was becoming a big seller. As a result, though they do not profit from present-day sales, Arthur’s heirs appear to have benefited at least indirectly from OxyContin.” (T)

“In 2015, when they unveiled the city’s plan to battle opioid-related deaths, Mayor Bill de Blasio and his wife, Chirlane McCray, said that from that day on, New Yorkers would be able to get the overdose-reversing drug naloxone at participating pharmacies without a prescription.
“Anyone who fears they will one day find their child, spouse or sibling collapsed on the floor and not breathing now has the power to walk into a neighborhood pharmacy and purchase the medication that can reverse that nightmare,” Ms. McCray said, with the mayor by her side.
But three years later, an examination by The New York Times has found that of the 720 pharmacies on the city’s list of locations that provide the drug, only about a third actually had it and would dispense it without a prescription. The list is used on the city’s website, the NYC Health Map, the Stop OD NYC app and when someone calls 311.
Phone calls placed to every pharmacy on the list last month found compliance with the program to be spotty, at best.
In the Bronx, which is battling a surge in heroin use and where more people died of opioid-related overdoses than in any other borough in 2016, only about a quarter of the more than 100 pharmacies on the list had the drug and followed the protocol. Requests for it were often met with bewilderment.” (U)

(A) In rare advisory, surgeon general urges public to carry overdose-reversal medication, by ANDREW JOSEPH,
(B) The next naloxone? Companies, academics search for better overdose-reversal drugs, by MAX BLAU,
(C) Murphy wants to spend $100M to fight opioid addiction (but none on Christie-like ads), by Matt Arco,
(D) EDITORIAL: A different take on opioid crisis,
(E) Rise in Opioid-Exposed Newborns in NJ Prompts State Awareness Campaign,
(F) California lawmakers advance measures to curb opioid crisis, by Sophia Bollag,
(G) Gov. Walker to sign bills addressing opioid crisis,
(H) N.Y. gets pharma to pay up amid opioid epidemic, but concerns linger, by Bethany Bump,
(I) With the drug industry as its partner, an addiction policy group invites tough questions, by LEV FACHER,
(J) How a Pa. health system reduced opioid prescriptions by more than half, by Alan Yu,
(K) New Hampshire hospitals take aim at the opioid epidemic, invest $50M in state initiatives,
(L) New rules could worsen the opioid crisis, not help it, by LARRY GREENBLATT,
(M) Ordering Five Million Deaths Online, by Richard A. Friedman,
(N) CDC director pledges to bring opioid epidemic “to its knees”,
(O) For chronic pain, a change in habits can beat opioids for relief, by Christine Herman,
(P) Conservative columnist: My personal trip through opioid hell and back, by Michael Reagan,
(Q) Medicare, Medicaid Opioid Scripts Decline in Medical Marijuana States, by Judy George,
(R) The Opioid Discussion: HR departments must do more to assist opioid-addicted employees A panel presented by NJBIZ, by Vince Calio,
(S) A look at how the opioid crisis has affected people with employer coverage, by Cynthia Cox, Matthew Rae and Bradley Sawyer,
(T) Sacklers Who Disavow OxyContin May Have Benefited From It, by David Armstrong,
(U) Overdose Antidote Is Supposed to Be Easy to Get. It’s Not, by ANNIE CORREAL,

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Can/should health care workers be fired for using appropriately prescribed medical or legally purchased recreational marijuana?

“Whether your employee is driving a truck cross-country or working in your ICU, there is almost always a protection that allows employers to enforce policies to protect those that they’re serving,” … “That applies no matter what the cannabis laws are in your state. You’re dealing with employees that are directly impacting the health and safety of individuals, so the obligation of protecting the people you are serving is paramount.” (A)

“Acceptance of medical marijuana, and the patients who medicate with marijuana, is sweeping state legislatures across the country. Of the 21 states that have passed laws addressing medical marijuana, nine have done so in the past three years. A growing number of Americans appear willing to allow those with chronic illness or pain to alleviate their symptoms with the plant, quite apart from the issue of recreational use, which Colorado and Washington State recently approved.
But even as recreational usage is gaining acceptance, people who medicate with marijuana across most states can still get fired for failing their employers’ drug test. Both Washington and Colorado have legalized recreational marijuana use, but it’s still unclear whether employees’ jobs are protected in those states if they smoke off duty — either for recreation or medical use. In Colorado, for instance, the marijuana law allows employers to impose any drug policies they see fit.
There are a lot of unanswered questions, and it’s time for U.S. lawmakers to clarify how companies should treat these cases. Regardless of a state’s law, using marijuana remains a violation of federal law. This conflict has important consequences in the workplace: Employees are left with no protection and employers with little guidance.” (B)

“Since the passage of Proposition 64 making recreational cannabis legal in California, there has been some confusion among employers as to whether they are required to accommodate an employee’s use or possession of the drug.
What should an employer do, for instance, if a new employee tests positive for cannabis? Since use of cannabis for medicinal purposes has been legal since 1996, what if a worker presents a doctor’s note for it? Are employees now allowed to smoke, vape or nibble cannabis edibles while at work? What if an accident occurs and an employee subsequently tests positive for cannabis?
The short answer is that employers do not have any obligation to accommodate cannabis use…
Although legal issues have arisen over the termination of workers for cannabis use, employers are protected by language in the law.
“Prop. 64 does nothing to change an employer’s right to drug testing or termination. There is a clause specifically written into the legislation that expressly protects an employer’s right to do so….”
“Under California law, an employer may require pre-employment drug tests and take illegal drug use into consideration in making employment decisions,” the ruling said.
“The law in this case immunizes employees from criminal law but doesn’t change an employer’s drug policy,” Largent said….
However, employers who do not have a well-documented cannabis policy could expose themselves to allegations of discrimination.
“I advise clients to modify their policy if necessary to make clear it’s illegal, giving employees clear expectations,” …
Employers should make it clear that marijuana use is included in a restrictive policy.
“It’s one thing to have a policy; it’s another thing to enforce it,” … “I tell people, you don’t want to have a policy if you’re not willing to enforce it. If an employer is going to test for drugs, they should let the employees know they are going to do it….” (C)

“Q: But what about people with a doctor’s recommendation to use marijuana for a medical condition? Employers can’t prohibit them from taking their medicine, right? Or fire them?
“In California, there are no workplace provisions protecting the rights of medical marijuana patients. There is no law requiring accommodation for medicating on the job or protection from termination.
In fact, the state Supreme Court has ruled that companies can fire workers who fail drug tests even if they present evidence of a doctor’s recommendation for legal medicinal use.
In a landmark case, Carmichael resident Gary Ross was fired after 10 days as a lead systems administrator for a Sacramento firm RagingWire Telecommunications. Ross, an Air Force veteran, made no secret when he was hired – and drug tested – that he had a medical marijuana recommendation for service-related back-pain and spasms. But he was let go anyway as soon as his pre-employment drug test came up positive.
In 2008, the Supreme Court rejected Ross’ claim of job discrimination under the California Fair Employment and Housing Act. It said California’s 1996 Proposition 215 medical marijuana law contained nothing “to address respective rights of employers and employees.”
Four states – Arizona, Delaware, New York, and Minnesota – offer limited anti-discrimination protections for people with doctors’ recommendations for medical marijuana use. The rules require that employers demonstrate impairment on the job rather than just a positive test for pot, which can stay in the system for days or weeks.” (D)

“On November 8, 2016, Florida voters approved the legalization of medical marijuana. Although not legal under Federal law, the effect of voters amending the Florida Constitution to allow for such use creates an immediate conflict of laws.
Many health care professionals ask what will be the impact on them of medical marijuana. On January 17, 2017, the Florida Department of Health issued its first draft of proposed rules for regulation…
Can DOH discipline the license of a physician, nurse, or other health care professional for use of medical marijuana?
Yes. This is where the issue gets complicated.
While hypothetically, a nurse could get a certification from a physician that he/she has a “debilitating medical condition”[ii] that requires medical marijuana, Florida law still prohibits licensed health care providers from being impaired at work.
The law regulating licensed health care professionals prohibits practicing with an impairment or while impaired…
In my review of the law and conversations with DOH officials, it is my impression that a licensed health care worker that uses medical marijuana would run the risk of termination from employment, discipline of their license by DOH, or both.
The very language of Amendment 2 states: “Nothing in this section shall require any accommodation of any on-site medical use of marijuana in any correctional institution or detention facility or place of education or employment, or of smoking medical marijuana in any public place.” [emphasis added]. This language now in the Florida Constitution appears to preclude use of medical marijuana in the work place.
Similarly, the Amendment also states: “Nothing in this section allows for a violation of any law other than for conduct in compliance with the provisions of this section.” Any other law would include Chapters 456, Florida Statutes and all other regulations governing health care licensees. Therefore, it is safe to assume that the medical marijuana amendment was not meant to override existing health care regulations.
However, our democracy provides for citizens the ability to ask the courts to interpret laws. To the extent someone may want to argue there is a conflict between the law governing medical marijuana and health care license regulations we may see a different interpretation. Stay tuned.
“The safe course of action would be to assume that your regulatory Board would not approve if you tested positive for marijuana, even if you had a valid certification to use medical marijuana.” (E)

Another question posed by a reader asked, “Can a nurse be fired for using recreational marijuana on his or her day off, when recreational use is legal in the nurse’s state?”…
The take-home message for nurses (and all healthcare professionals) is: If you want to protect your career, don’t use marijuana recreationally, even if it is legal in your state and even if you use on your own time and off premises. It is still illegal under federal law. If you decide to take a legal risk and partake in marijuana, don’t do so for at least a month before you will be working. Employers don’t all conduct random drug tests, but some do, and sometimes nurses are included in widespread drug testing, even if the individual nurse has not been accused of being impaired. It is so much easier to prevent this legal problem than to deal with it after being fired.
Furthermore, we don’t know how Boards of Nursing stand on the issue. Nurses have reported that they have lost their licenses and/or been referred to impaired nurse programs for testing positive for marijuana. We don’t know how every Board of Nursing would act on any given day, but at minimum, a firing would lead to a report to the Board of Nursing, and then the burden is on the nurse to prove he or she was not impaired at work. That, too, is more easily prevented than dealt with after the nurse is reported.” (F)

“Recreational marijuana laws are still relatively new, but more states are considering and passing these types of laws each year. However, these laws generally do not protect employees from being fired for legal, off-duty recreational use. Many state laws expressly state that they are not intended to interfere with an employer’s ability to enforce zero-tolerance drug policies. For example, California’s recreational marijuana law states that employers are allowed to continue to test employees and applicants for marijuana and maintain a drug-free workplace.” (G)

“The overwhelming majority of states believe patients should be able to medicate with marijuana. But legalizing marijuana use without protecting the rights of people who use it frustrates the spirit of the law and voters’ intent: it forces seriously ill people to choose between receiving the benefits of marijuana and their job. This conflict frustrates the growing market for marijuana. Only nine states seem to have found the balance between protecting a patient’s right to medicate with marijuana and an employer’s right to a productive workforce. The rest of the states should follow their example: following the law should not cost you your job.” (H)

“If you’re a federal contractor, you can’t allow any marijuana use, regardless of what state law says,” Urban notes.
For employers with a choice, the question becomes whether you really want to take this hard-line stance on marijuana, DiNome says.
“You may not attract the best work force in your state if the state allows the use of marijuana, medically or recreationally,” he says. “You would have to consider that some educated, qualified people come to your state because that substance is legal, and whether you want to eliminate all of those people as potential employees.”… (A)

(A) Legal Marijuana Requires Reassessing Hospital Drug Policies, by Greg Freeman,
(B) Can you get fired for smoking medical marijuana?, by Kabrina Krebel Chang,
(C) Workplace cannabis: What employers and employees need to know, by CYNTHIA SWEENEY,
(D) Can I get fired for using legal recreational marijuana? An FAQ for California workers, by Peter Hecht,
(E) Medical Marijuana & Healthcare Professionals, by Jeff Howell,
(F) Marijuana and Your Job: What You Need to Know, by Carolyn Buppert,
(G) Can I Be Fired from My Job for Using Legal Marijuana?, by Sachi Barreiro,
(H) You can be fired for using marijuana even when it’s legal, by Kabrina Krebel Chang,

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