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

“The opioid crisis has cost the U.S. $1 trillion since 2001, according to Altarum, a nonprofit health research firm. Those costs have been increasing more rapidly over the past few years, and Altarum projects they’ll grow by another $500 billion just by 2020.
By the numbers:
Most of that $1 trillion comes from lost wages, productivity and tax revenue, Altarum said.
The health care system directly bore about a quarter of the total financial burden — $215 billion — largely from emergency treatment of overdoses.
The human cost: Roughly 64,000 people died of drug overdoses in 2016, driven by a recent surge in deaths from fentanyl, heroin and prescription opioids — making today’s addiction crisis worse than the HIV epidemic at its peak.
Between the lines: “Lost wages and productivity” can seem like a nebulous cost, but it’s a good way to think about the ripple effects of this crisis beyond the people who die from it. When 116 people per day are dying from opioid-related overdoses, at an average age of just 41, their “lost wages and productivity” are a partial measure of the hole that’s left in their families and their communities.” (A)

“The omnibus bill adds $3.3 billion to address the opioid and mental health crisis in fiscal year 2018, with a focus on public health efforts. Here are some of the big programs:
$1.4 billion will go to the Substance Abuse and Mental Health Services Administration, including $1 billion for a new State Opioid Response Grant program and a $160 million increase in the Mental Health Block Grant
$500 million for the National Institutes of Health for more opioid addiction research
$350 million to the Centers for Disease Control and Prevention (CDC) for opioid overdose prevention, surveillance, and improving state prescription drug monitoring programs
$415 million for the Health Resources and Services Administration to, among other efforts, improve access to addiction treatment in rural and other underserved areas
$100 million to the Administration for Children and Families to help children whose parents misuse drugs
An additional $299.5 million to the Department of Justice’s anti-opioid grant funding
An additional $500 million to the Department of Veterans Affairs for mental health programs
An additional $94 million to Food and Drug Administration efforts to inspect mail for illicit drugs
All of this is on top of the $500 million in fiscal year 2018 approved in the 21st Century Cures Act to combat the opioid epidemic.
The concern here, as usual, is that even this large commitment of money is not enough. When Congress first announced its spending deal — to add $6 billion over two years to combat the opioid crisis — earlier this year, Sarah Wakeman, the medical director at the Massachusetts General Hospital Substance Use Disorder Initiative, told me that “[i]t’s hard to imagine $6 billion being enough, especially when you think about the annual budget for other illnesses like HIV, which is $32 billion.”
Any increase is, of course, welcome. But when dealing with one of the worst public health crises in history, Congress will have to go really big — and it’s just not there yet.” (B)

“President Donald Trump, targeting the U.S. opioid epidemic, called again on Monday for the execution of drug dealers, a proposal that so far has gained little support in Congress, amid criticism from some drug abuse and criminal justice experts.
At an event in Manchester, New Hampshire, Trump unveiled an anti-opioid abuse plan, including his death penalty recommendation and one for tougher sentencing laws for drug dealers…,
The White House did not offer examples of when it would be appropriate to seek the death penalty for drug dealers and referred further questions to the Justice Department.” (C)

“On Monday, President Donald Trump unveiled his latest plan to address the opioid epidemic, once again suggesting the death penalty for drug dealers.
“We can have all the blue ribbon committees we want, but if we don’t get tough on the drug dealers, we’re wasting our time,” he said at a New Hampshire event to announce the White House’s Initiative to Stop Opioid Abuse. “Just remember that: We’re wasting our time. And that toughness includes the death penalty.”
Though the plan includes initiatives to increase access to treatment and reduce the flow of drugs, Trump’s speech focused on cracking down on drug dealers. As he said, “I love tough guys—we need tough guys.” But the president’s initiative overlooks the glaring reality that drug dealers and drug users are often the same people, selling drugs to feed their own addictions. “I think it reflects a lack of a broader understanding of the factors in this crisis,” said Sen. Maggie Hassan (D-N.H.) in a statement. “Law enforcement have been the first people to tell us we can’t enforce our way out of this.”….
Critics say that the plan is yet another example of the president talking a big game when it comes to opioids but not following up with action. Trump did not call for more funding for the epidemic even though paying for the plans’ provisions would likely far exceed the $6 billion the administration budgeted to address the epidemic over the next two years. “Policy without budget is just hot air,” Humphreys said. While Trump has repeatedly promised to address the epidemic, his actions suggest otherwise: His budget requests have included cuts to the Centers for Disease Control and Prevention, the National Institutes of Health, Medicaid, and the Office of National Drug Control Policy.
Still, Trump assured the audience he was prioritizing the issue. “I don’t want to leave at the end of seven years and have this problem,” Trump said. “We’re gonna solve it with brains, we’re gonna solve it with resolve, we’re gonna solve with toughness. Toughness is the thing that they most fear.” (D)

“President Trump walked through core elements of his administration’s three-pronged attack on the opioids epidemic during a visit to New Hampshire, while simultaneously pushing for voter support in the next election.
“This is about winning a very, very tough problem … I don’t want to leave at the end of 7 years and have this problem,” he said.
The president declared the opioid epidemic a public health emergency in October, but has been criticized for not offering tangible support for it….
Trump framed his border wall plan as part of the opioid fight, saying it was needed “to keep the damn drugs out.”
Similarly, eliminating “sanctuary cities,” another frequent Trump target, is critical to “stopping the drug addiction crisis.”
The president’s comments directly addressing the opioid crisis focused primarily on law enforcement.
“Whether you are a dealer or doctor or trafficker or a manufacturer, if you break the law and illegally pedal these deadly poisons, we will find you, we will arrest you and we will hold you accountable,” he said to booming applause.” (E)

“President Trump spoke Monday of using federal prosecutors to pursue “major litigation” against drug manufacturers alleged to have played a role in creating a nationwide epidemic of opioid abuse.
Speaking in New Hampshire at the White House’s rollout of a national opioids strategy, the president expanded upon a Department of Justice release last month in which Attorney General Jeff Sessions pledged to “hold accountable those whose illegality has cost us billions of taxpayer dollars.”
“Our Department of Justice is looking very seriously into bringing major litigation against some of these drug companies,” Trump said. “We will bring it at a federal level. Some states are already bringing it, but we are thinking about bringing it at a very high federal level, and we will do a job.”
DOJ filed a statement of interest on March 1 in a federal court in Ohio, asking the judge collectively overseeing hundreds of opioid-related lawsuits to allow federal lawyers 30 days to decide whether the United States would participate in the legal proceedings.
Manufacturers, including Purdue, Endo Pharmaceuticals, Insys, Janssen, and Teva, have faced scrutiny and often aggressive legal action from state and local governments seeking compensation for what many plaintiffs allege are the costs resulting from the companies’ disingenuous marketing tactics. In 2006, Purdue and several high-ranking executives paid a collective $635 million in fines pertaining to the marketing of its opioid painkiller, OxyContin, which understated the drug’s addictiveness…
The president also name-checked two drug companies that manufacture various forms of the overdose-reversal drug naloxone: Adapt Pharma, which makes the nasally administered Narcan, and Kaleo, which makes Evzio, an automatic injector that has drawn scrutiny for its price tag but drew congratulations from Trump for having distributed more than 300,000 units for free.” (F)

“The U.S. Department of Justice plans to hold providers accountable per a new large-scale effort to tackle the opioid crisis, Deputy Attorney General Rod Rosenstein reiterated here Wednesday.
Addressing the annual policy conference sponsored by America’s Health Insurance Plans, Rosenstein said the new opioids task force announced by Attorney General Jeff Sessions last week will hold everyone accountable; he then specifically cited physicians.
The proliferation of prescription painkillers, including opioids, has countered the ethos of “do no harm,” Rosenstein said, noting that the average American life expectancy has decreased along with the 21st century opioid spread — after nearly doubling over a century. “These drugs have caused a lot of collateral damage,” Rosenstein said, including costing American healthcare more than $1 trillion this century.
In addition to the Task Force, Rosenstein cited as another solution the Justice Department’s involvement with the new Joint Criminal Opioid Darknet Enforcement team; it has been established in large part to counter the flow of painkillers, especially synthetics such as fentanyl, from foreign countries into the U.S.
“We ought to all be about prevention,” he said, citing over-prescription as a major cause of the opioids crisis.
Rosenstein asked insurance companies to utilize their monitoring systems to identify patients receiving too many painkillers and those receiving them for conditions that don’t warrant them. “We recognize that you have a financial incentive” to limit prescriptions, he noted.
Rosenstein also encouraged providers, insurers and others to follow the CDC’s 2016 opioid guidelines…
“The pharmaceutical industry is almost completely responsible for this epidemic,” Fugh-Berman said, citing misleading advertising and their practice of hiring “thought leaders” to shame providers into prescribing more opioids. These individuals told physicians they were “torturing our patients” by not issuing painkillers whenever they complained of pain.
Pharmaceutical companies “misused” medical literature by consistently citing small-scale studies and research letters as evidence for supporting opioid prescriptions, she said. They also published ghostwritten articles in medical and consumer publications, and launched disease awareness campaigns. In addition, they funneled money to medical advocacy groups, including the U.S. Pain Foundation ($2.9 million during 2012-2017) and the American Academy of Pain Medicine ($1.2 million) to promulgate messages such as “restricting opioids in any way disadvantages pain patients” and “the needs of patients with [opioid use disorder] must be balanced with the needs of pain patients.” (G)

“Public health experts also warned that the amount of funding included in the spending plan for the opioid crisis may not meet need. Congress set aside more than $4 billion to be split among several opioid initiatives, including for law enforcement and additional research.
That is just a drop in the bucket, though, compared to what is needed to fully mobilize against the drug addiction epidemic, according to an article from the Associated Press. A recent report from the White House estimates that the opioid epidemic cost more than $500 billion in 2015…
In response, states are stepping up to fill the gaps, according to the article. Ohio Gov. John Kasich estimates that the state is spending $1 billion a year on opioid programs, while New Jersey has put $200 million toward combating the crisis.” (H)

“The president went on at length about his preposterous proposal to fight the scourge of drugs by executing drug dealers — an idea that many experts say would not stand up in court and would do little to end this epidemic. He also reprised his cockamamie idea to build a wall along the nation’s southern border, arguing that it would “keep the damn drugs out,” and accused so-called sanctuary cities of releasing “illegal immigrants and drug dealers, traffickers and gang members back into our communities.”
It was Mr. Trump playing his greatest “law and order” hits — as usual, full of sound and fury but signifying nothing.
Mr. Trump seems so enamored with autocrats and strongmen that he wants the United States to imitate governments like China and the Philippines by executing drug dealers, claiming such countries “don’t have a drug problem” because of their brutality. This is patently absurd. While it is hard to analyze the experience of many of these countries because they do not collect and publish reliable data about substance use, experts say it is clear that they have not eliminated drug abuse or the crime that often accompanies it. More broadly speaking, many scholars have concluded that there is no good evidence that capital punishment deters crime.” (I)

“Republican and Democratic governors don’t agree on much in the healthcare space but when it comes to opioids there is consensus: Real dollars are needed.
Governors pressed senators for more funding to help tackle the opioid epidemic, as well as flexibility for states in tailoring spending to suit their specific needs, during a hearing of the Senate Health, Education, Labor and Pensions (HELP) Committee on Thursday.
Gov. Larry Hogan (R-Md.) thanked Congress for the $6 billion secured in its budget agreement to fight the opioid and heroin crisis, but “it’s a drop in the bucket compared to what we actually need,” he said.
Maryland, a small state, has already spent $500 million to battle the opioid epidemic alone, he continued.
“Six billion stretched across the country is not going to go very far … It’s the long-term recovery support services that we’re going to need a way to pay for.” “ (J)

“Congress sent states hundreds of millions of dollars to fight an opioid crisis claiming more than 100 lives a day — money they’ve largely been unable to spend after a year.
Mixed signals from the Trump administration on how to use the money and state challenges ramping up their efforts have left untouched more than three-quarters of the $500 million Congress set aside under the 21st Century Cures Act in late 2016.
As President Donald Trump heads to hard-hit New Hampshire today to tout his plan to combat the crisis, the slow drip of dollars into communities hit hard by addiction has put state officials in a bind and frustrated addiction experts and some treatment organizations.
“This is a total failure,” said Andrew Kolodny, former chief medical officer at Phoenix House and now a Brandeis University researcher, likening the situation to food and water “stuck in an airport somewhere, while people are starving to death.”
The grants for opioid addiction and prevention efforts were part of a $1 billion commitment over two years authorized in the Cures Act, which then-President Barack Obama signed just before leaving office.
But state officials were quickly caught in a dilemma: They were happy to receive new money, but it was guaranteed for only two years, making it difficult to get long-term commitments from health care providers and others to build programs and hire a workforce.” (K)

“Former Novartis sales reps from around the U.S. are expected to testify they were “essentially buying” prescriptions in exchange for providing doctors with paid speaking engagements, fancy meals, and alcohol in a closely watched lawsuit that is being pressed by the federal government.
And both doctors and sales reps are expected to testify that payments were made for speaking engagements that never took place, and that many of these events had little to no educational content, but were really just schmoozefests, according to a court filing on Monday by federal prosecutors.” (L)

“As tens of thousands of Americans die from prescription opioid overdoses each year, an exclusive analysis by CNN and researchers at Harvard University found that opioid manufacturers are paying physicians huge sums of money — and the more opioids a doctor prescribes, the more money he or she makes.
In 2014 and 2015, opioid manufacturers paid hundreds of doctors across the country six-figure sums for speaking, consulting and other services. Thousands of other doctors were paid over $25,000 during that time.
Physicians who prescribed particularly large amounts of the drugs were the most likely to get paid.
“This is the first time we’ve seen this, and it’s really important,” said Dr. Andrew Kolodny, a senior scientist at the Institute for Behavioral Health at the Heller School for Social Policy and Management at Brandeis University, where he is co-director of the Opioid Policy Research Collaborative.
“It smells like doctors being bribed to sell narcotics, and that’s very disturbing,” said Kolodny, who is also the executive director of Physicians for Responsible Opioid Prescribing.
The Harvard researchers said it’s not clear whether the payments encourage doctors to prescribe a company’s drug or whether pharmaceutical companies seek out and reward doctors who are already high prescribers.
“I don’t know if the money is causing the prescribing or the prescribing led to the money, but in either case, it’s potentially a vicious cycle. It’s cementing the idea for these physicians that prescribing this many opioids is creating value,” said Dr. Michael Barnett, assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health.” (M)

“Gov. Rick Scott signed legislation Monday in Boca Raton that limits opioid prescribing and provides tens of millions in new funding to combat an overdose epidemic that is killing more than 1,000 people in South Florida every year.
Flanked by elected leaders and law enforcement, Scott said the Legislature set aside $65 million to expand treatment and provide the overdose antidote naloxone to law enforcement and paramedics.
The package also will impose a three-day limit on most opioid prescriptions, though doctors could provide a seven-day supply if “medically necessary.” Previously, state law didn’t limit opioid prescriptions.
The new limits would not apply to patients with pain related to “cancer, terminal illness, palliative care or serious traumatic injuries.” Physicians will now be required to check a prescription-monitoring database to prevent doctor shopping.
“The best thing we can do is stop drug addiction before it happens,” Scott said. “This bill should have an impact on that.” “ (N)

“Fresh on the heels of President Donald Trump’s plan to tackle the opioid crisis, House lawmakers this week plan to introduce more than two dozen bills aimed at ending the epidemic, ranging from better access to treatment programs to exploring opioid alternatives for pain…
One of the bills, called the Preventing Overdoses While in Emergency Rooms act, or POWER act, is a bipartisan measure that seeks to provide patients who have overdosed better access to treatment when they get discharged from emergency rooms.
The bill would set up protocols for emergency rooms around the nation on how best to discharge overdose patients, making sure they have the opioid overdose antidote naloxone and access to other medication-assisted treatment, as well as being linked up with peer-support specialists and other treatment programs that best fit the patient….
The bills range from efforts to explore non-addictive alternatives for pain to easier ways to dispose of extra opioid pills to better data sharing of a patient’s medical records with health care providers.
Several bills seek to give the US Food and Drug Administration more authority and new methods to streamline its efficiency and effectiveness. One measure seeks to accelerate bringing a breakthrough treatment for pain to the market. The proposals also want to study the long-term efficacy of opioids and allow for the FDA to consider the potential for drug abuse before bringing a new drug to the market.
CNN spoke with multiple health policy experts about the legislative initiative. While they lauded the efforts being put forward, every one of them said Congress and President Trump need to back any such plan with tens of billions of dollars in new funding.” (O)

“When President Trump spoke of the White House’s new plan to stop the opioid crisis in New Hampshire on Monday his core focus was on the bad guys and his answer was tougher penalties.
When top leaders from the Department of Health and Human Services and the National Institutes of Health pitched the same plan, the focus shifted to the victims of the epidemic and a kinder, gentler approach: science and public health.
HHS Secretary Alex Azar, JD, NIH Director Francis Collins, MD, PhD, and Nora Volkow, MD, director of the National Institute on Drug Abuse (NIDA) pitched the president’s opioid initiative to reporters during a press briefing on Wednesday afternoon.
Collins and Volkow spoke of the NIH’s work to develop non-addictive alternatives to opioids, new formulations of naloxone, and one day, a vaccine to prevent addiction.
To do these things, scientists need to better understand the neurobiology of pain and to locate new drug targets — information private industry is eager to leverage, Collins said.
He described research involving a 17-year-old man with congenital insensitivity to pain and temperature — research that could ultimately “point us to a new idea about how to provide pain relief to people who aren’t born like this young guy, but who might on a temporary basis benefit” from an inability to feel pain.” (P)

“For once, Casey is optimistic about his future. After 16 years of struggling with drug addiction, he no longer feels the need to use. He has a steady job doing hazard tree removal for a Fortune 500 energy company. He’s working on getting specialized training for a license to help him land better-paying jobs. He’s even going to the gym.
But Casey, who asked that I only use his first name for this story, knows this could have turned out very differently. In fact, it had the past few times he was released from prison. Before, he had relapsed as quickly as a matter of days — not only exposing himself to the risk of a deadly overdose but leading to a spiral of drug use that hindered just about every aspect of his life and, often, landed him in prison again.
The big difference: This time, he got treatment — real treatment — while he was in prison…
In other words, the majority of state prisons don’t offer full access to what experts say is the mainline form of treatment for opioid addiction — and the kind of treatment that has helped Casey get his life back in order…
When an inmate addicted to opioids is released from prison, his chances of a fatal overdose are massively elevated: According to a 2007 study published in The New England Journal of Medicine, former inmates’ risk of a fatal drug overdose is 129 times as high as it is for the general population during the two weeks after release. Other studies have backed this up, putting the increased risk of overdose death in the tens of times or above 100 times.” (Q)

“Even as opioids flood American communities and fuel widespread addiction, hospitals are facing a dangerous shortage of the powerful painkillers needed by patients in acute pain, according to doctors, pharmacists and a coalition of health groups.
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 given to 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.” (R)

“An important study published this week in JAMA suggests what we in the Slow Medicine community had suspected: opioids may be no better than non-opioid analgesics for patients with chronic pain. Despite the widespread use of opioids for the management of chronic pain, as well as guidelines suggesting they are an appropriate therapy for chronic pain, there had been disconcertingly little evidence on the topic. The best studies were no longer than 12 weeks in duration and involved only a small number of subjects.
This new JAMA study is also small, involving 240 patients with severe chronic back pain or pain from osteoarthritis of the hip or knee. However, investigators tracked pain-related function for a full year. Compared to non-opioid analgesic therapy, opioids resulted in similar functionality at 1 year, and pain intensity was slightly improved in the non-opioid therapy group. As anticipated, rates of adverse effects were higher in the opioid therapy group. These results follow another JAMA study published in the fall suggesting that non-opioid therapy may be as effective as opioids in treating acute pain in the emergency room.
With this information, coupled with growing evidence about the epidemic of opioid abuse, the role of opioids in pain management outside of the palliative setting is growing increasingly narrow. Nevertheless, there remain millions of Americans who depend on opioids, and we must be compassionate in managing their care, even if we now know it is not an effective pain treatment strategy.” (S)

“Dr. Mark Rosenberg of St. Joseph’s Regional Medical Center in Paterson told the story of being approached by a man named Michael at an event who wanted to thank him for saving his life when he was in the emergency department for a heroin overdose.
“I said to him, ‘Michael, how did you get started on opioids?’ And he laughed and said, ‘Doc, you were the one who gave me my first prescription. I came in with a shoulder injury and you gave me some opioids.’ This is before we started ALTO,” he said, referring to the hospital’s Alternatives to Opiates program. “I was part of the problem, as most physicians across the country were part of the problem.”
Rosenberg remembers reading articles in the late 80s that said opioids were not addictive and should be given to patients in pain. Today, health care providers write over 250 million prescriptions for painkillers every year.
“We ended up with an entire society that is dependent on opioids, in part by a mistake of the drug companies, physicians, researchers alike,” he said…
In 2016, Rosenberg launched the Alternatives to Opiates program, otherwise known as ALTO. Emergency departments like the one at St. Joseph’s in Wayne now have protocols to manage pain without using opioids.
“We use them for certain conditions like kidney stones, back pain, headaches,” said Dr. Marjory Langer.
Rosenberg told the Passaic County Drug Policy Advisory Committee his method is not substituting a lesser pain medication for an opioid; it’s a layering treatment.
“I may be giving a nerve block so you don’t have any pain from the fracture, or I may be giving you a trigger point injection so your muscle spasm actually goes away,” said Rosenberg.
He says the results of the ALTO program have been positive.
“In the first year, we were able to get a 57 percent reduction in opioid use. In the second years, we have a total of an 82 percent reduction of opioid use in the emergency department,” he said.” (T)

“A program at St. Joseph’s Healthcare System that began a revolutionary change in the way emergency rooms handle opioid prescriptions is going national.
One of the creators of the Alternatives to Opiates program, Dr. Mark Rosenberg, is testifying on Capitol Hill on Thursday on a bill that would create a national demonstration of the success he has seen in New Jersey.
This is just the latest bout of attention the program has received on a national level.
Recent articles from Colorado, Massachusetts and Washington state have highlighted the ALTO program — without crediting St. Joseph’s or the team of doctors there. Two new bipartisan bills in Congress are highlighting it as well, aiming to set up a nationwide demo and study the results.” (U)

“The amount of opioids prescribed after gynecologic surgery declined by almost 90% with few complaints from patients after implementation of a restrictive prescription protocol, as reported here at the Society of Gynecologic Oncology (SGO) meeting.
Over a 6-month period, the total opioid pill count declined by 89% as compared with historical prescribing practices. The total included a 73% reduction the number of pills dispensed after open surgery and 97% after minimally invasive procedures.
Patients undergoing ambulatory/minimally invasive procedures and with no history of chronic pain received only prescription-strength ibuprofen or acetaminophen at discharge. Those with a history of opioid exposure or chronic pain, received a 3-day supply (12 pills) of hydrocodone-acetaminophen (Norco) or oxycodone-acetaminophen (Percocet).
Patients undergoing open surgery received either nonopioid pain medication or a 3-day opioid prescription at discharge. If a patient used an opioid for pain in the previous 24 hours, then a 3-day supply consisting of 24 pills (two every 6 hours) was prescribed.” (V)

“The (American Dental) Association on March 26 announced a new interim policy on opioids that supports prescription limits and mandatory continuing education for dentists.
The new policy, officially titled Interim Board Policy on Opioid Prescribing, is believed to be one of the first of its kind from a major health professional organization.
“I call upon dentists everywhere to double down on their efforts to prevent opioids from harming our patients and their families,” said ADA President Joseph P. Crowley. “This new policy demonstrates the ADA’s firm commitment to help fight the country’s opioid epidemic while continuing to help patients manage dental pain.”
In the interim policy, the Association says it supports the following:
Mandatory continuing education on prescribing opioids and other controlled substances.
Prescribing limits on opioid dosage and duration of no more than seven days for the treatment of acute pain, consistent with the Centers for Disease Control and Prevention’s evidence-based guidelines.
Dentists registering with and utilizing prescription drug monitoring programs to promote the appropriate use of opioids and deter misuse and abuse.” (W)

“The White House’s national strategy to combat the opioid crisis, unveiled last week, would expand a particular kind of addiction treatment in federal criminal justice settings: a single drug, manufactured by a single company, with mixed views on the evidence regarding its use.
Federal prisons should “facilitate naltrexone treatment and access to treatment” to inmates as they transition out of incarceration, according to a fact sheet circulated by the administration. A White House spokesman later confirmed to STAT that the document referred specifically to naltrexone in its injectable form…
When asked about the plan, administration health officials themselves expressed doubts about the approach.
“We don’t per se favor one drug over the other, because some patients respond better to one or the other,” said Nora Volkow, the director of the National Institute on Drug Abuse, at a press event on Tuesday. “It is clear that treatment in the prison system significantly improves outcomes, whether it’s [with naltrexone or buprenorphine].”
Health secretary Alex Azar was unfamiliar with the proposal to provide Vivitrol exclusively, saying in response to a STAT question: “I have a feeling that was an inadvertent reference. I think the key thing was the prison population, as opposed to any one product.”
Azar, who was sworn in as health secretary in late January, walked back his remark 15 minutes later, citing “staff-level discussions” and a directive from the Substance Abuse and Mental Health Services Administration that anyone “coming out of prison or a detox program should in fact be put on naltrexone, but that doesn’t mean it’s the best form [of MAT] for all populations.” (X)

“Former U.S. representative Patrick Kennedy, a Democrat who served on President Donald Trump’s opioid commission last year, said there are clear solutions but that Congress needs to devote more money to them.
“We still have lacked the insight that this is a crisis, a cataclysmic crisis,” he said.” (Y)

“Two bills which passed both Oregon’s House and Senate with unanimous bipartisan support are set to receive Governor Kate Brown’s signature on Tuesday, March 27.
House Bill 4143 will require the Department of Consumer and Business Services to study stumbling blocks in methods of effective treatment for recovery from substance abuse—particularly opiate addiction—and provide a report to lawmakers by June 30 of this year.
House Bill 4137 charges a new Director of the Alcohol and Drug Policy Commission with providing recommendations for a comprehensive plan to address addiction, prevention, treatment and recovery by December 31 of this year. The bill also declares a public health “emergency.”
While neither bill directly provides the means for combating the opioid crisis, both were drafted to give lawmakers the best and most recent information—a roadmap—so that subsequent legislation and programs can more effectively create change.” (Z)

“Medicare officials thought they had finally figured out how to do their part to fix the troubling problem of opioids being overprescribed to the old and disabled: In 2016, a staggering one in three of 43.6 million beneficiaries of the federal health insurance program had been prescribed the painkillers.
Medicare, they decided, would now refuse to pay for long-term, high-dose prescriptions; a rule to that effect is expected to be approved on April 2. Some medical experts have praised the regulation as a check on addiction.
But the proposal has also drawn a broad and clamorous blowback from many people who would be directly affected by it, including patients with chronic pain, primary care doctors and experts in pain management and addiction medicine.
Critics say the rule would inject the government into the doctor-patient relationship and could throw patients who lost access to the drugs into withdrawal or even provoke them to buy dangerous street drugs. Although the number of opioid prescriptions has been declining since 2011, they noted, the rate of overdoses attributed to the painkillers and, increasingly, illegal fentanyl and heroin, has escalated.” (AA)

“The Global Center for Health Innovation (Global Center) and Accenture have formed a working group to explore data-driven solutions that better integrate the continuum of addiction services (first responders, ER and inpatient, outpatient, behavioral health) to improve treatment and move toward prevention. The group’s formation was announced at the Global Center’s second Executive Briefing, The Role of Private Capital in Attacking the Opioid Crisis.” (BB)

“In 2017, the Centers for Disease Control and Prevention (CDC) warned that life expectancy in the United States dropped for the second year in a row — and drug overdoses are the single biggest reason why.
As states and communities on the front lines struggle to respond to the opioid crisis, Washington has only nibbled around the edges. Politicians and policymakers make vague promises, treating the crisis as if it is a novel, intractable problem. It is neither.
America has addressed this kind of public health emergency before, and we call on Congress to do so now.
Three decades ago, another epidemic that was highly stigmatized, greatly misunderstood and severely underestimated was spreading through our country and killing tens of thousands of otherwise healthy people each year. That epidemic was HIV/AIDS.
In the 1980s, stigma prevented many Americans from acknowledging their infections or seeking treatment. Evolving treatment protocols were new and complex, and few doctors were trained in how to use them to provide care for patients. Our existing medical infrastructure was not equipped to efficiently distribute information and resources to communities trying to understand, treat and prevent the spread of the epidemic.
The federal government alone possessed the resources capable of addressing the epidemic, but for years Washington refused to devote meaningful resources to combating HIV/AIDS, even as it continued to kill more Americans day after day. This inaction ended because people with HIV/AIDS and their loved ones fought back, side by side with doctors, scientists and lawmakers representing communities devastated by the disease.
In 1990, our colleagues in Congress — Rep. Henry Waxman, Sen. Ted Kennedy, and Sen. Orrin Hatch — worked together to pass the bipartisan Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, named after an Indiana teenager who was diagnosed with AIDS at the age of 13. Ryan White bravely fought AIDS-related discrimination and became a leading national voice on AIDS education before his untimely death — 28 years ago next month.
The Ryan White CARE Act recognized the gravity — and the urgency — of the HIV/AIDS crisis by setting forth a comprehensive approach to treatment and providing significant new funding for individualized support services..…
The program they created provides vital services to more than half a million people every year. Although the HIV/AIDS epidemic is by no means over, life-saving medications are available, new infections have plummeted and science — rather than stigma — guides medical care.
It is time for Congress to show the same political courage that our colleagues showed nearly 30 years ago. That’s why we intend to introduce legislation to establish a comprehensive system for funding and local decision-making to address opioid addiction and substance use that is modeled directly on the highly successful Ryan White CARE Act…
President Trump’s declaration that the opioid crisis is a public health emergency has amounted to little more than empty words. His latest response to this epidemic — an announcement that he will seek the death penalty for drug dealers — is the crudest indication yet of how little he understands about what the problem is or how to fix it.
We propose a different approach. The Ryan White CARE Act is an enduring example of what Congress can achieve when it works to help states and communities address a national public health crisis by providing significant federal support…
American families — not just in Maryland or in Massachusetts, but all across this country — desperately need us to take action against an epidemic terrorizing every single community. Urban, suburban and rural; poor, middle-class and wealthy; red, blue and purple. We urge our colleagues to join us in this effort, to show courage, to combat ignorance and ill-informed stigmas and to step up with significant new resources. This isn’t about politics. This is about saving lives.” (CC)

(A) Opioid crisis has cost the U.S. $1 trillion, by Sam Baker, https://www.axios.com/opioid-crisis-has-cost-the-us-1-trillion-1518490361-3f5c1717-7bc2-445a-961c-0200d76f3f78.html
(B) Congress’s omnibus bill adds $3.3 billion to fight the opioid crisis. It’s not enough, by German Lopez, https://www.vox.com/policy-and-politics/2018/3/22/17150294/congress-omnibus-bill-opioid-epidemic
(C) Trump Pushes Drug-Dealer Death Penalty As Opioid Crisis Response, by Roberta Rampton, https://www.huffingtonpost.com/entry/donald-trump-opioids-death-penalty_us_5ab006b6e4b0e862383a6489
(D) Trump Doesn’t Understand the Opioid Crisis. Just Check Out His Latest Proposal, by JULIA LURIE, https://www.motherjones.com/politics/2018/03/trump-doesnt-understand-the-opioid-crisis-just-check-out-his-latest-proposal/
(E) Trump Talks Up Major Offensive on Opioids. Death penalty for certain traffickers; ‘on demand’ treatment for veterans, by Shannon Firth, https://www.medpagetoday.com/publichealthpolicy/opioids/71855
(F) DOJ weighing ‘major litigation’ against opioid makers, Trump says, by LEV FACHER, https://www.statnews.com/2018/03/19/trump-opioid-department-of-justice/
(G) DOJ Repeats Threat to Hold Opioid Prescribers Accountable, by Ryan Basen, https://www.medpagetoday.com/publichealthpolicy/opioids/71661
(H) Public health experts skeptical that spending plan will lead to gun violence research, effectively address opioid crisis, by Paige Minemyer, https://www.fiercehealthcare.com/regulatory/2018-spending-plan-cdc-gun-violence-research-opioids-public-health?utm_medium=nl&utm_source=internal&mrkid=654508&mkt_tok=eyJpIjoiWXpRNE56aGpaVFl3TXpZeiIsInQiOiJad0h3VjJoQWd6YjY3R0twYUg5anYzVjRpZ3NHMHBZZktjRUJxWW5XdkVNVFNkWGRIRUNxeUpqckJLT1BFMFpGcWZwc0xUMHZzRCtmbDBGMkFkUFNYREdsYUFrVHg4aTNmVGhPYk1jR213WnpTbk5VdkRUZjRsXC9VMkxaRDhzbzkifQ%3D%3D
(I) Trump’s Bluster on the Opioid Epidemic, by THE EDITORIAL BOARD, https://www.nytimes.com/2018/03/20/opinion/trumps-bluster-on-the-opioid-epidemic.html
(J) D.C. Week: States Plead for Federal $$ in Opioid Fight, by Shannon Firth, https://www.medpagetoday.com/washington-watch/washington-watch/71685?xid=nl_mpt_DHE_2018-03-12&eun=g1223211d0r&pos=1&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%202018-03-12&utm_term=Daily%20Headlines%20-%20Active%20User%20-%20180%20days
(K) Hundreds of millions in state opioid cash left unspent, by RACHANA PRADHAN and BRIANNA EHLEY, https://www.politico.com/story/2018/03/19/opioid-crisis-funding-unspent-468658
(L) Former Novartis sales reps will testify they ‘essentially’ bought prescriptions by wooing doctors, by ED SILVERMAN, https://www.statnews.com/pharmalot/2018/03/20/former-novartis-sales-reps-bribes-doctors/
(M) CNN Exclusive: The more opioids doctors prescribe, the more money they make, by Aaron Kessler, Elizabeth Cohen and Katherine Grise, https://www.cnn.com/2018/03/11/health/prescription-opioid-payments-eprise/index.html
(N) Gov. Scott signs opioid package that includes millions to fight South Florida epidemic, by Skyler Swisher, http://www.sun-sentinel.com/news/florida/fl-reg-rick-scott-opioids-bill-20180319-story.html
(O) This is how lawmakers plan to end the opioid crisis, by Wayne Drash, https://www.cnn.com/2018/03/20/health/house-bills-opioid-legislation/index.html
(P) NIH, HHS to Fight Opioids Epidemic with Science, by Shannon Firth, https://www.medpagetoday.com/publichealthpolicy/opioids/71904
(Q) How America’s prisons are fueling the opioid epidemic, by German Lopez, https://www.vox.com/policy-and-politics/2018/3/13/17020002/prison-opioid-epidemic-medications-addiction
(R) The other opioid crisis: Hospital shortages lead to patient pain, medical errors, https://www.news-medical.net/news/20180316/The-other-opioid-crisis-Hospital-shortages-lead-to-patient-pain-medical-
(S) Slow Medicine: Role Narrows for Opioids in Chronic Pain, by Pieter Cohen, MD, and Michael Hochman, https://www.medpagetoday.com/blogs/slowmedicine/71664
(T) St. Joseph’s ER has reduced opioid use by 82 percent, BY Leah Mishkin, https://www.njtvonline.org/news/video/st-peters-alternatives-opioids/
(U) St. Joseph’s ALTO opioids program to go national, by Anjalee Khemlani, http://www.roi-nj.com/2018/03/20/healthcare/st-josephs-alto-program-to-go-national/
(V) Women Do Well Without Opioids after Gyn Surgery, by by Charles Bankhead, https://www.medpagetoday.com/meetingcoverage/sgo/72003
(W) ADA adopts interim opioids policy, by Jennifer Garvin, https://www.ada.org/en/publications/ada-news/2018-archive/march/ada-adopts-interim-opioids-policy?nav=news&utm_source=STAT+Newsletters&utm_campaign=8abdf7c408-MR&utm_medium=email&utm_term=0_8cab1d7961-8abdf7c408-149527969
(X) Trump opioid plan writes in favoritism to single company’s addiction medication, by LEV FACHER, https://www.statnews.com/2018/03/26/trump-opioid-plan-alkermes-vivitrol/
(Y) States: Federal money for opioid crisis a small step forward, by GEOFF MULVIHILL, http://www.concordmonitor.com/States-Federal-money-for-opioid-crisis-a-small-step-forward-16435985
(Z) GOVERNOR BROWN WILL SIGN NEW LAWS TO COMBAT OPIOID CRISIS, by Jamie Parfitt, http://www.kdrv.com/content/news/Governor-Brown-Will-Sign-Legislature-to-Combat-Opioid-Crisis-477954183.html
(AA) Medicare Is Cracking Down on Opioids. Doctors Fear Pain Patients Will Suffer., by JAN HOFFMAN, https://www.nytimes.com/2018/03/27/health/opioids-medicare-limits.html
(BB) Global Center for Health Innovation and Accenture Form a Working Group to Address Opioid Epidemic, http://www.wlns.com/ap-top-news/global-center-for-health-innovation-and-accenture-form-a-working-group-to-address-opioid-epidemic/1083225045
(CC) Treat the opioid crisis like the HIV/AIDS epidemic: Elizabeth Warren & Elijah Cummings, https://www.usatoday.com/story/opinion/2018/03/29/new-legislation-treat-opioid-crisis-hiv-aids-epidemic-congressman-cummings-senator-warren-column/459036002/

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Other posts that are part of this Case Study:

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

August 9, 2017

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

August 11, 2017

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

August 17, 2017

“To manage and (eventually) reverse the opioid epidemic, state Medicaid programs should now take a deeper look at the role prescribing plays…”,

August 22, 2017

Opioid Crisis. ““We got here in part because there was a paper done in the 1980s by a well-meaning physician that said opioids are not addictive….

September 1, 2017 | Edit

The rise of ‘grandfamilies’: Opioid crisis requires more Hoosier grandparents to raise children..

September 14, 2017

Congress blocked DEA action against drug companies suspected of flooding the country with prescription narcotics, http://doctordidyouwashyourhands.com/2017/10/congress-blocked-dea-action-against-drug-companies-suspected-of-flooding-the-country-with-prescription-narcotics/
October 17, 2017

“At a time when the United States is in the grip of an opioid epidemic, many insurers are limiting access to pain medications that carry a lower risk of addiction or dependence…..”

October 19, 2017

“…the president.. reversed course to instead declare opioids a public health emergency, a move that releases no new funding to contend with a drug crisis….”

October 29, 2017

Facebook users can easily find these drugs – Oxycodone, Hydrocodone, and Percocets,

November 29, 2017

“White House counselor Kellyanne Conway will be the point person for the Trump administration’s opioid crisis efforts…

December 9, 2017

The Trump administration “… hasn’t done squat” about the Opioid Crisis – but is prosecuting marijuana offenses & fired all HIV/AIDS Commission members

January 6, 2018

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

January 14, 2018 | Edit

Opioid commission member: Our work is a ‘sham’

January 24, 2018

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