Opioid Crisis. President Trumps “thoughts and prayers have helped.. “But additional funding and resources would be more helpful.”

President Donald Trump in October promised to “liberate” Americans from the “scourge of addiction,” officially declaring a 90-day public health emergency that would urgently mobilize the federal government to tackle the opioid epidemic.
That declaration runs out on Jan. 23, and beyond drawing more attention to the crisis, virtually nothing of consequence has been done…
A senior White House official disputed the assessment of inaction, saying the emergency declaration has allowed the president to use “his bully pulpit to draw further attention to this emergency that he inherited.” The official added that the declaration has enabled federal agencies to “really change their focus and prioritize the crisis,” and that getting an effective media campaign underway “takes time.”…
In West Virginia, which has the highest drug overdose death rate in the country, Public Health Commissioner Rahul Gupta hasn’t seen any significant change under Trump’s emergency order. “His thoughts and prayers have helped,” Gupta said. “But additional funding and resources would be more helpful.”..
State health officials and policy experts say billions of dollars in new funding are needed to make a dent in the crisis. The Public Health Emergency Fund, which HHS could tap under the Trump declaration, has a balance of just $57,000, and the administration hasn’t proposed replenishing it. Rather than asking for new money, the administration can move funds around in existing agency budgets — but that just means taking money away from other health programs….
The White House official said the administration is “actively in discussion with Congress” about funding for the crisis.” (A)

Congress approved bipartisan legislation in 2016 that authorized $1 billion over two years for opioid crisis response grants to states, which was signed into law by Obama. The first $500 million was doled out last year. The rest is being held up in a larger fight over a bill to fund the government, but it is eventually expected to be appropriated and distributed to states. And other money that Trump has touted comes from the CDC and the Substance Abuse and Mental Health Services Administration — agencies whose budgets were kept mostly flat under the 2017 spending bill and would have been cut in Trump’s budget proposal for 2018…
The administration has emphasized a law-and-order approach, cracking down on drug offenses and trying to cut the flow of illegal drugs into the country. Attorney General Jeff Sessions recently challenged states that have voted to legalize marijuana.
Trump’s health department has routinely touted its “five-point” strategy to combat the opioid crisis: prevention, treatment and recovery; expanding access to the overdose reversal drug naloxone; improving data about the scope of the crisis; and supporting research on pain and how it is managed.
Nevertheless, Eric Hargan, the acting HHS secretary, said in November that the president was leaving it to Congress to decide whether more money should be appropriated. Democrats argued hypocrisy. (B)

“A majority of the public considers addiction to prescription pain medication a major problem nationally (53%) but does not deem it a national emergency (28%) (Politico–HSPH, 2017). Substantially fewer people see it as an emergency (16%) or a major problem (38%) in their own community (PBS–Marist, 2017). In a list of national health problems, abuse of prescription painkillers ranks fifth in the proportion of the public that considers it an extremely serious disease or health condition facing the country (28%; KFF, April 2016). Concern about prescription-drug abuse as a public health problem has grown over time. Nearly 4 in 10 people (38%) currently believe it’s an extremely serious public health problem, double the proportion (19%) who believed so in 2013 (Pew, 2013 and 2017). More than 6 in 10 (63%) believe that the problem of addiction to prescription pain medications has increased in the past year, 26% think it has stayed about the same, and only 2% believe it has decreased (PBS–Marist, 2017)….
An important finding from our review is that at a time when public- and private-sector leaders are seeking a substantial increase in government funding for opioid-addiction treatment programs and legislation requiring insurers to offer coverage for these treatments, polls show a large share of the public uncertain about the long-term effectiveness of treatment. Over the next few years, this impression could affect family referrals to treatment programs, as well as public support for them and for a government requirement that insurance cover their cost. There is a clear need for the medical and scientific communities to educate the public about the issues surrounding the potential effectiveness of treatment.” (C)

“Pharmaceutical manufacturers such as Purdue Pharma, Endo International plc (ENDP – Get Report) , Teva Pharmaceutical Industries Ltd. (TEVA – Get Report) , Johnson & Johnson Inc. (JNJ – Get Report) and Allergan plc. (AGN – Get Report) as well as distributors Cardinal Health Inc. (CAH – Get Report) , McKesson Corp. (MCK – Get Report) and AmerisourceBergen Corp. (ABC – Get Report) have all been challenged by various parties to take action in the opioid epidemic…
Ohio is ground zero, where ten people die every day from opioids leaving behind families and friends and creating holes in cities and towns in the Buckeye state that don’t heal easily. And there is a cost beyond the human. Children moved from addicted parents to foster care cost $45 million a year. Indeed, half the kids in foster care come from parents addicted to opioids. Counseling and medication costs $216 million a year. Treating kids who are born drug dependent adds another $130 million. Ohio estimates that work lost because of the opioid crisis, fatal overdoses, and medical expenses costs $4 billion a year. From 2011 to 2015 3.8 billion doses of opioid meds were prescribed in Ohio. The state only has 11.6 million residents. In 2016, it lost 4,050 of those residents to overdoses of opioids, heroin and fentanyl, a dangerous synthetic opioid, according to Ohio’s own data…
While the pharmaceutical companies may not be beating a path to Columbus to talk to DeWine, that doesn’t mean they aren’t responding. A spokesman for Janssen said in an email “We believe the allegations in the lawsuit against our company are both legally and factually unfounded. Responsibly used opioid-based pain medicines give doctors and patients important choices to help manage the debilitating effects of chronic pain. Janssen has acted in the best interests of patients and physicians with regard to opioid pain medicines, which are FDA-approved and carry FDA-mandated warnings about possible risks on every product label.”…
McKesson, the San Francisco-based drug distributor, has spent its share of time in the harsh glare of the media spotlight. Investigative stalwart 60 Minutes and the Washington Post teamed up on a December report that showed the infighting between the Drug Enforcement Agency and the Justice Department over how best to go after McKesson regarding allegations that the company had been careless in its distribution and sale of opioids. While the DEA felt it had a criminal case against the company and more than enough evidence of wrongdoing for federal prosecutors, the case never saw the inside of a courtroom. Prosecutors maintained the case didn’t merit criminal charges and wasn’t strong enough. At one point the DOJ allegedly suggested the DEA become friendlier with the pharmaceutical industry.
Instead the DOJ huddled with a team of lawyers defending McKesson, negotiating a settlement that included a $150 million fine and a suspension of four of McKesson’s drug warehouses and increased staffing as well as McKesson hiring an independent monitor.” (D)

“A federal judge on Tuesday set a goal of doing something about the nation’s opioid epidemic this year, while noting the drug crisis is “100 percent man-made.”
Judge Dan Polster urged participants on all sides of lawsuits against drugmakers and distributors to work toward a common goal of reducing overdose deaths. He said the issue has come to courts because “other branches of government have punted” it.
The judge is overseeing more than 180 lawsuits against drug companies brought by local communities across the country, including those in California, Illinois, Kentucky, Ohio and West Virginia. Municipalities include San Joaquin County in California; Portsmouth, Ohio; and Huntington, West Virginia.
Polster said the goal must be reining in the amount of painkillers available.
“What we’ve got to do is dramatically reduce the number of pills that are out there, and make sure that the pills that are out there are being used properly,” Polster said during a hearing in his Cleveland courtroom. “Because we all know that a whole lot of them have gone walking, with devastating results.”
The judge said he believes everyone from drugmakers to doctors to individuals bear some responsibility for the crisis and haven’t done enough to stop it…
Polster likened the epidemic to the 1918 flu which killed hundreds of thousands of Americans, while pointing out a key difference.
“This is 100 percent man-made,” Polster said. “I’m pretty ashamed that this has occurred while I’ve been around.” (E)

“The epidemic of drug overdose deaths is a national disaster. It claimed more than 64,000 lives in 2016, many of them by opioid overdoses. That’s far more than the number of deaths from HIV/AIDS in the peak year of 1995…
About half of opioid overdose deaths occur among men and women ages 25 to 44; it’s reasonable to assume that many are parents. Imagine the impact on a child when a parent overdoses at home or in a grocery store. Statistics can’t tally the trauma felt by a seven-year-old who calls 911 to get help for an unconscious parent, or the responsibility undertaken by a twelve-year-old to feed and diaper a toddler sibling, or the impact of school absences and poor grades on a formerly successful high school student.
Parental overdoses have an immediate impact on children. There’s also a cumulative impact as these children become adults and are themselves at risk from the same influences that drove their parents to drugs, overdoses, and early deaths.
Who are these children and adolescents? Newborns whose mothers are addicted to opioids. These babies may undergo withdrawal themselves and need special treatment. Children of all ages at risk for accidental ingestion or inhalation of toxic substances. Children living with an addicted parent, dealing with constant uncertainty and fear. Children who have taken over the role of family caregiver for younger siblings or for their addicted parents. Children who are removed from their homes and placed in foster or kinship care. Some of these children have unmet mental health care needs. Very young children exposed to toxic levels of stress that impair brain development.
No one knows how many of these vulnerable children there are in the U.S. because no one is counting. As a point of comparison, an advisory group to the British government estimated that there are between 250,000 and 350,000 children of drug abusers in the U.K. — about one for every drug user. The title of its report, Hidden Harm, applies equally well to American children. They remain hidden in families with addiction until a crisis erupts and law enforcement or child welfare agencies get involved.” (F)

“Policymakers mistakenly focus on doctors treating their patients in pain. By intruding on the patient-doctor relationship they impede physician judgment and increase patient suffering. But another unintended consequence is that, by reducing the amount of prescription opioids that can be diverted to the illicit market, they have driven nonmedical users to heroin and fentanyl, which are cheaper and easier to obtain on the street than prescription opioids, and much more dangerous.
Data from the Centers for Disease Control and Prevention show that from 2006 to 2010 the opioid prescription rate tracked closely with the opioid overdose rate, at roughly 1 overdose for every 13,000 prescriptions. Then, after 2010, when the prescription rate dropped and it became more difficult to divert opioids for nonmedical use, the overdose rate began to climb as nonmedical users switched over to heroin and fentanyl. There is a dramatic negative correlation between prescription rate to overdose rate of -0.99 since 2010.
The overdose rate is not a product of doctors and patients abusing prescription opioids. It is a product of nonmedical users accessing the illicit market.
The problem will not get better—it will probably only get worse—as long as we continue to call this an “opioid crisis.” The title is too nonspecific. This is a crisis caused by drug prohibition—an unintended consequence of nonmedical drug users accessing the black market in drugs. Policymakers should stop harassing doctors and their patients and shift the focus to reforming overall drug policy. A good place to start would be to implement harm reduction measures, such as safe syringe programs, making Medication Assisted Treatments like methadone and suboxone more readily available, and making the opioid antidote naloxone available over-the-counter, so it can be easier for opioid users to obtain. Even better would be a sober reassessment of America’s longest war, the “War on Drugs.”
Renaming the problem a “heroin and fentanyl crisis” might be a way to trigger a refocus.” (G)

“Attorney General Jeff Sessions’ reversal of an Obama-era policy that let legalized marijuana proliferate in many states across the U.S. may affect states that have medical marijuana and recreational pot use laws. It’s too early, though, to tell just how significant the impact will be.
On Thursday, Sessions rescinded a decision made in 2013 that adopted a policy of non-interference with marijuana-friendly state laws, the New York Times reported…
“Federal law normally trumps state law, so a violation of a federal criminal statute could result in significant penalties including imprisonment, even if the act is lawful under state law,”…With Sessions’ decision, people selling or using marijuana for medical purposes could be prosecuted. “As a result, it would pose a chilling effect on the use of marijuana for needed medical purposes, even if prescribed by a doctor in accordance with state law,”.
While medical marijuana can’t be legally prescribed, possessed, or sold under federal law, its use to treat some medical conditions is legal under many state laws, according to the American Cancer Society. Currently, 29 states have medical marijuana laws. The Sessions decision could put the kibosh on many of those “compassionate use” laws, though.
“It could exclude one of the key ways that physicians can help their patients and reduce suffering. It might also result in greater use of less effective and more addictive medications such as opioids,” Gostin says.
Currently, the U.S. is experiencing an opioid epidemic. Since 1999, the number of overdose deaths involving opioids quadrupled, and prescription opioids are a driving factor in the increase, according to the U.S. Centers for Disease Control and Prevention…
Under the Sessions policy reversal, a cancer patient currently using a marijuana-based drug to ease pain or nausea may have that right taken away.” (H)

“The opioid epidemic is now a full-blown national crisis, yet the federal government continues to dawdle. President Donald Trump declared opioid addiction a public health emergency, and he talks a tough game. But he has not taken forceful action. If he will not lead, Congress must — and now, before the crisis grows even worse…
This is a solvable problem, and through philanthropy we can make some progress. But real success requires much bolder leadership — and a far greater sense of urgency — from both elected officials and industry leaders…
We must stop doctors from over-prescribing opioids, especially when non-addictive pain medications (such as ibuprofen or acetaminophen) would be just as effective. More aggressive action is needed.
The Food and Drug Administration should allow only doctors who complete specialized education in pain management to prescribe opioids for more than a few days, a move FDA Commissioner Scott Gottlieb is considering. ..
Insurers and pharmacy benefit managers must better oversee opioid prescriptions. CVS Caremark has moved to limit coverage for opioid prescriptions. Others should follow its lead. These companies exist to help people lead better, healthier lives, and they should not be complicit actors in an addiction and overdose epidemic…
We must hold pharmaceutical companies accountable for the supply of prescription opioids.,,
We must start treating those with addiction disorders when they come in contact with emergency rooms, hospitals and clinics. …
We must stop stigmatizing the medications that have been proven to help people recover…
The federal government should incentivize cities and states to offer treatment to inmates, as New York City and a handful of other localities do…
We must develop better data. Existing statistics on misuse and overdose are out of date and often inaccurate….
We must do more to block the importation of heroin — and of fentanyl, much of which originates in China….” (I)

“What can health care providers do to address these problems?..
Researchers called persistent prescription opioid use “one of the most common complications after elective surgery.”
This is not to say that patients should be left writhing in pain in their hospital beds: We need to start using a multi-disciplinary and multi-modal approach to pain management. Surgeons need to engage in early education with their patients about post-operative pain management and the risks of medications, as well as setting realistic expectations about what post-surgery pain will be like.
Additionally, health care providers need to identify those most vulnerable to opioid addiction, including those with mental health issues or pre-existing substance abuse, and establish more sensitive processes that ensure they experience as little pain as possible without relying on potentially dangerous opioids.
We also need to rely more heavily on other medications in our arsenal, such as acetaminophen, non-steroidal anti-inflammatories, muscles relaxants and nerve agents. And health care providers need to be innovative and creative and find different ways to implement pain medication delivery, using methods like steroid injections and epidural catheters.
Providers must also work harder to encourage those who do develop addictions to enlist in rehabilitation, and they should involve more frequently other specialists in crafting and carrying out treatment plans, especially pain management doctors and psychologists.
Most importantly, all providers need to look in the mirror and ask themselves if we are being good stewards of prescribing practices, or if we are part of the problem we see in the news.” (J)

“The USC-Brookings Schaffer Initiative for Health Policy’s Jason N. Doctor and Michael Menchine also say that emergency rooms are playing a significant role in the opioid crisis. First, emergency room visits are a notable source of the over-prescription of opioids—often with deadly consequences. Narcotic overdose is the eighth leading cause of death within one week of an emergency room visit.
Additionally, emergency rooms are often on the frontlines of treating those harmed by the epidemic. Currently, there are over 300,000 estimated annual emergency department visits for opioid overdose.
To address the crisis, Doctor and Menchine explain Congress and the Trump administration will have to focus on reducing population exposure to opioids, creating demand for safe and effective treatments, and the effective use of emergency departments. They recommend that the current administration and Congress fund additional resources to emergency rooms, including:
The development of opioid dependence screening tools for the emergency department;
Training to emergency department staff on how to address potentially opioid dependent individuals in an ethically neutral manner;
The expansion of referral sources for outpatient addiction specialty clinics (particularly for uninsured patients or those with Medicaid insurance);
Reduced administrative barriers to becoming a Buprenorphine prescriber; and
The development of a financial reimbursement model for prescription opioid screening or treatment in emergency room settings.” (K)

“Doctors at some of the country’s largest hospital chains admit they went overboard with opioids to make people as pain-free as possible.
Now the doctors shoulder part of the blame for the country’s opioid crisis. In an effort to be part of the cure, they’ve begun to issue an uncomfortable warning to patients: You’re going to feel some pain…
Opioid addiction is a reality that has been completely disconnected from where it often starts — in a hospital….
So the nation’s largest private hospital chain is rolling out a new protocol prior to surgery. It includes a conversation Schlosser basically never had when he was practicing medicine.
“We will treat the pain, but you should expect that you’re going to have some pain. And you should also understand that taking a narcotic so that you have no pain really puts you at risk of becoming addicted to that narcotic,” Schlosser tells patients.
Besides issuing the uncomfortable warning, sparing use of opioids also takes more work on the hospital’s part — trying nerve blocks and finding the most effective blend of non-narcotics. Then after surgery, the nursing staff has to stick to it. If someone can get up and walk and cough without doubling over, maybe they don’t need potentially addictive drugs, or at least not high doses of them.” (L)

Five Big Ideas to Confront the Opioid Crisis
1. Stop overprescribing
2. Treat opioid addiction as the public health crisis that it is
3. Stop the deaths
4. Guarantee Access to Treatment
5. Invest in data and knowledge” (M)

“In New York City, opioid addiction treatment is sharply segregated by income, according to addiction experts and an analysis of demographic data provided by the city health department. More affluent patients can avoid the methadone clinic entirely, receiving a new treatment directly from a doctor’s office. Many poorer Hispanic and black individuals struggling with drug addiction must rely on these highly regulated clinics, which they must visit daily to receive their plastic cup of methadone…
This is what opioid addiction recovery is like for more than 30,000 patients enrolled in New York City’s approximately 70 methadone-based treatment programs, which provide medication-assisted treatment, counseling and other social services. Hundreds of thousands of patients across the country are enrolled in similar programs, which often receive government funding and are covered by Medicaid in New York.
For more than 40 years, methadone was the most effective method for people addicted to heroin to keep their cravings in check. But in 2002, the Food and Drug Administration approved another medication to treat opioid addiction: buprenorphine, sold most widely in a compound called Suboxone. Both methadone and buprenorphine are extremely effective in keeping recovering users from relapsing, according to medical research, but Suboxone is engineered to reduce the possibility of abuse and overdose. Crucially, the medication can be prescribed in doctors’ offices and then taken at home.
Many hoped that buprenorphine could mean an end to the daily hurdles to receiving treatment for tens of thousands of patients: no additional commute, no security check, no waiting, no line for the plastic cup.
But today in the city, that is primarily true only for middle-class or upper-middle-class patients seeking help with their addiction.” (N)

“In May 2016, Taylor Weyeneth was an undergraduate at St. John’s University in New York, a legal studies student and fraternity member who organized a golf tournament and other events to raise money for veterans and their families.
Less than a year later, at 23, Weyeneth, was a political appointee and rising star at the Office of National Drug Control Policy, the White House office responsible for coordinating the federal government’s multibillion dollar anti-drug initiatives and supporting President Donald Trump’s efforts to curb the opioid epidemic. Weyeneth would soon become deputy chief of staff.
Weyeneth’s brief biography offers few clues that he would so quickly assume a leading role in the drug policy office, a job recently occupied by a lawyer and a veteran government official. His only professional experience after college and before becoming an appointee was working on Trump’s presidential campaign.
Weyeneth’s ascent from a low-level post to deputy chief of staff is due in large part to staff turnover and vacancies. The story of his appointment and remarkable rise provides insight into the Trump administration’s political appointments and the troubled state of the drug policy office.” (O)

(A) Trump declared an opioids emergency. Then nothing changed, by BRIANNA EHLEY, https://www.politico.com/story/2018/01/11/opioids-epidemic-trump-addiction-emergency-order-335848
(B) How can we solve the opioid crisis?, by Sarah Karlin-Smith, https://www.politico.com/video/2017/11/02/how-can-we-solve-the-opioid-crisis-064251
(C) The Public and the Opioid-Abuse Epidemic, by Robert J. Blendon, and John M. Benson, http://www.nejm.org/doi/full/10.1056/NEJMp1714529#t=article
(D) America’s Opioid Crisis Looks a Lot Like Big Tobacco Spats of Yesteryear, by Bill Meagher, https://www.thestreet.com/story/14397159/1/how-opioid-crisis-of-today-resembles-big-tobacco-lawsuits-battles.html
(E) Judge urges action on ‘100 percent manmade’ opioid crisis, by ANDREW WELSH-HUGGINS, http://abcnews.go.com/Health/wireStory/judge-urges-action-100-percent-manmade-opioid-crisis-52235186
(F) The statistics don’t capture the opioid epidemic’s impact on children, by CAROL LEVINE, https://www.statnews.com/2018/01/02/opioid-epidemic-impact-children/?utm_source=STAT+Newsletters&utm_campaign=073963a01b-First_Opinion&utm_medium=email&utm_term=0_8cab1d7961-073963a01b-150519373
(G) Stop Calling it an Opioid Crisis—It’s a Heroin and Fentanyl Crisis, by JEFFREY A. SINGER SHARE, https://www.cato.org/blog/stop-calling-it-opioid-crisis-its-heroin-fentanyl-crisis
(H) Could Jeff Sessions’ Marijuana Ruling Make the Opioid Crisis Even Worse?, by MARY BROPHY MARCUS, https://www.menshealth.com/health/jeff-sessions-marijuana-policy-opioid-crisis
(I) A Seven-Step Plan for Ending the Opioid Crisis, by Michael R. Bloomberg, https://www.bloomberg.com/view/articles/2018-01-10/a-seven-step-plan-for-ending-the-opioid-crisis
(J) Dr. Jacquelyn Corley To fix the opioid crisis, doctors like me may have to let patients be in pain, https://www.nbcnews.com/think/opinion/fix-opioid-crisis-doctors-me-may-have-let-patients-be-ncna836141
(K) The far-reaching effects of the US opioid crisis, by Brennan Hoban, https://www.brookings.edu/blog/brookings-now/2017/10/25/the-far-reaching-effects-of-the-us-opioid-crisis/
(L) Hospitals Brace Patients For Pain To Reduce Risk Of Opioid Addiction, by BLAKE FARMER, https://www.npr.org/sections/health-shots/2018/01/09/576584541/hospitals-brace-patients-for-pain-to-reduce-risk-of-opioid-addiction
(M) CONFRONTING OUR NATION’S OPIOID CRISIS, https://assets.aspeninstitute.org/content/uploads/2018/01/AHSG-Final-Report-2017_compressed-2.pdf
(N) Opioid Addiction Knows No Color, but Its Treatment Does, by JOSE A. DEL REAL, https://www.nytimes.com/2018/01/12/nyregion/opioid-addiction-knows-no-color-but-its-treatment-does.
(O) Trump’s response to opioid epidemic includes 24-year-old helping lead drug policy office, by Robert O’Harrow Jr., http://www.chicagotribune.com/news/nationworld/politics/ct-trump-drug-policy-office-20180113-story.html

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