On July 4th as we respect and admire hospital staff members who are working 24/7, it is interesting to look at hospital care during the Revolutionary War

From 1967 to 1970, during the Vietnam War, I served first as a 2nd Lieutenant and Chief Administrative Officer of the 4th Casualty Staging Flight attached to Wilford Hall USAF Medical Center, Lackland AFB in San Antonio, Texas. We received combat casualties still in battlefield bandages, often within 24 hours of injury, and either admitted them to Wilford Hall or further transported them to hospitals near home.

Here’s what hospital care looked like during the Revolutionary War period.

“When the Revolutionary War began its actual skirmishes in 1776, early attempts to prepare for the medical needs related to War were made in the City of New York. During the spring and summer of 1776, Samuel Loudon was publishing his newspaper the New York Packet, in which he included numerous articles and announcements regarding the Continental Army. On July 29, for example, came the following announcement written by Thomas Carnes, Stewart and Quartermaster to the General Hospital of King’s College, New York. Anticipating an increase demand for medically trained staff, he filed the following request for volunteers:
“GENERAL HOSPITAL New-York, July 29, 1776 Wanted immediately in the General Hospital, a number of women who can be recommended for their honesty, to act in the capacity of nurses: and a number of faithful men for the same purpose…King’s College, New York” (A)

“One of the most famous surgeons, and the first, was Cornelius Osborn. He was recruited in the Spring of 1776 and had little training even as a physician. The Continental Congress was even concerned about the well-being of the troops and the militia. They passed several ordinances and helped establish the order for the several field Hospitals during the War. The hospitals served about 20,000 men in the fight. Each hospital was required for each surgery to have at least one physician or surgeon, and one assistant, which was usually and apprentice of some sort. Each hospitals staff numbers varied on how many wounded it served and the severity of the wounds….
Most of the deaths in the Revolutionary War were from infection and illness rather than actual combat. The common practice if a limb was badly infected of fractured was amputate it. Where most amputees died of gangrene a result of not properly cleaning instruments after surgeries. Only 35% of amputees actually survived surgery. There was no pain killers quite developed back then. So at most the patient were given alcohol and a stick to bite down on while the surgeon worked. Two assistant would hold him down, a good surgeon could perform the entire process in a mere 45 seconds, after which the patient usually went into shock and fainted. This allowed the surgeon to stich up the wound, and prepare for the next amputation. Another way they decided to clean wounds, disease, or infection was by applying mercury directly to the cut of injured space, and letting it run through the blood stream which usually resulted in death.” (B)

“To seek treatment for any serious ailment, a soldier would have had to go to a hospital of sorts. Military regiments had a surgeon on staff to care for the men, so the soldier’s first stop would be with the surgeon. During battles, the surgeon could be found in a makeshift or “flying” hospital that consisted of a tent, an operating table, and some medical equipment. If the surgeon could not treat the soldier, he might be sent to a hospital. Many regimental hospitals were in nearby houses, while general hospitals for more in-depth treatment were sometimes set up in barns, churches, or other public buildings. The conditions were often cramped, which resulted in the rapid spread of contagious illnesses and infections….
Woe to the soldier who required surgery after being wounded on the battlefield! The conditions in “flying” hospitals were deplorable. Not only was the operating room simply a table in a tent, but there was little thought given to keeping the table and tools clean. In fact, wounds were sometimes cleaned using plain water from a bucket, and the used water would be saved to clean out the next soldier’s wounds as well. (C)

Hospitalization was a serious problem during the American Revolutionary War. Plans were made quite early to care for the wounded and sick, but at the best they were meager and inadequate. However on April 11, 1777 Dr. William Shippen Jr., of Philadelphia was chosen Director General of all the military hospitals for the army. Consequently the reorganization of hospital conditions took place.
Four hospital districts were created: Easter, Northern, Southern and Middle. The wage scale was as follows: Director General’s pay $6.00 a day and 9 rations; District Deputy Director $5.00 a day and 6 rations; Senior Surgeon $4.00 a day and 6 rations; Junior Surgeon $2.00 and 4 rations; Surgeon mate $1.00 and 2 rations.
After the battle of Brandywine, September 11, 1777, hospitals were established at Bethlehem, Allentown, Easton and Ephrata. After the battle of Germantown, October 4, 1777, emergency hospitals were organized at Evansburg, Trappe, Falkner Swamp and Skippack. Hospitals at Litiz and Reading were also continued. By December 1777, new hospitals were opened at Rheimstown, Warwick and Shaeferstown. Yellow Springs (now Chester Springs) an important hospital was organized under the direction of Dr. Samuel Kennedy. At Lionville, Uwchlan Quaker Meeting House was also made a hospital for a time. Apothecary General Craigie’s shop, Carlisle, was the source of hospital drugs….
It seems there was carelessness in making necessary health reports, consequently Washington ordered on January 2, 1778: “Every Monday morning regimental surgeons are to make returns to the Surgeon Gen’l. or in his absence to one of the senior surgeions, present in camp or otherwise under the immediate care of the regimental surgeons specifying the mens names Comps. Regts. and diseases.” [Weedon’s Valley Forge Orderly Book, p. 175]
January 13, 1778. “The Flying Hospitals are to be 15 feet wide and 25 feet long in the clear and the story at least 9 feet high to be covered with boards or shingles only without any dirt, windows made on each side and a chimney at one end. Two such hospitals are to be made for each brigade at or near the center and if the ground permits of it not more than 100 yards distance from the brigade.” [Weedon’s Valley Forge Orderly Book, p. 191] The Commander-in-Chief always solicitous about the comfort of his soldiers issued the following order January 15, 1778: “The Qr. Mr. Genl. is positively ordered to provide straw for the use of the troops and the surgeons to see that the sick when they are removed to huts assigned for the hospital are plentifully supplied with this article.” [Weedon’s Valley Forge Orderly Book, pp. 192-199-204-216] “ (D)

(A) https://brianaltonenmph.com/6-history-of-medicine-and-pharmacy/hudson-valley-medical-history/revolutionary-war-doctor/
(B) https://prezi.com/uwl_a877t2ia/hospitals-and-medicine-during-the-revolutionary-war/
(C) http://www.dosespot.com/medicine-in-the-revolutionary-war
(D) http://www.ushistory.org/valleyforge/served/surgeons.html

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

“The drug industry was more than willing to meet the need of increased opioid administration and more than willing to advance its usage…..
Adding to this pressure to overprescribe powerful analgesics was the decision by Medicare to adjust payments to hospitals according to their Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. This naïve thought put medical treatment on par with any other commodity. But, medicine is different—often patients have an erroneous view of what is in their best interest. Thus, they may be dissatisfied with appropriate medical decisions. In response, many hospitals have fostered a hotel-like approach to please patients.
This practice has led to patients being discharged with a plethora of powerful analgesics to assure hospitals receive excellent scores.
These series of missteps by the medical establishment, the government and public desire has led, in our nation, to drug overdoses (primarily opioids) as the leading cause of accidental deaths.” (A)

“In a recent letter to the Health and Human Services inspector general, Johnson noted that opioid problems appeared much worse from 2013 to 2015 in states that expanded Medicaid under the Affordable Care Act than those that didn’t, based on Census data and statistics from the Centers for Disease Control and Prevention…
Overall, overdose deaths per million residents increased twice as fast in Medicaid expansion states than in non-expansion states.
Correlation doesn’t automatically equal causation, but Johnson provides reason to think it exists in this case. Based on police comments, he reports someone with a Medicaid card can obtain up to 240 oxycodone pills for as little as a $1 co-pay. Those pills can then be resold for $4,000 on the black market.
It’s not unreasonable to think some people will exploit the system for fast cash, especially since others (taxpayers) foot almost all up-front costs.” (B)

“We need a plan. Now that the President has labeled this as a national health emergency, we need to act on this momentum to effectively combat this crisis….
Addiction is an illness, and we must start treating those struggling with substance abuse like patients.
Part of this approach must include improving access and use of treatment and recovery services, offering support to people who have become addicted, and using research data to prevent high-risk populations from ever encountering opioids. And we need more post-treatment rehabilitation programming that reintegrates recovering patients into society.
And importantly, we need to focus on prevention and improve education and training for the physicians and healthcare professionals who are on the front lines of this crisis. Similarly, we all need to understand the dangers of opioid abuse and the risk of addiction and overdose.
Federal money should go towards funding innovative solutions– (C)

“Following on the heels of last week, advocates, social service providers and people with a history of drug use staged a protest on Thursday at the office of Governor Andrew Cuomo to raise the visibility of the epidemic of overdose raging across the state and demand bolder political action.
Protestors called on the Governor to: 1) guarantee universal access to sterile syringes, naloxone, buprenorphine and methadone to every New York State resident struggling with a heroin or opioid addiction; 2) mandate that every Office of Alcohol and Substance Abuse Services (OASAS) funded program at least offer buprenorphine and/or methadone to people using opioids; 3) support the creation of safer consumption spaces, also known as supervised injection facilities.

New York State does need to ensure immediate access to drug treatment on demand for all its residents, but to tackle the overdose crisis it must also ensure that the treatment offered adopts evidenced-based approaches that work. Additionally, many New Yorkers, especially those in rural counties, have limited or no access to proven public health interventions like sterile syringe access, naloxone, buprenorphine or methadone, leading them to continued heroin and opioid use.” (D)

“Physicians are increasingly being asked for pain medication and some struggle to determine how to prescribe appropriately. It may be obvious that a patient needs some pain management after a procedure or while managing a painful condition. And it might be clear that an endless supply of opioids puts a person at high risk for addiction. But how much is enough? How much is too much? Three tablets? Six? 12?…
Practicing Wisely™, a new initiative aimed at developing measures of clinical appropriateness, does just this. States can use the program’s opioid measures to track variation in physician prescribing behavior for specific cases of opioid use, such as prescription rates following a C-Section. Comparing physicians’ prescribing patterns to the prescribing patterns of like-specialty physicians, performing the same procedure on a similar patient population can help to identify physician outliers. That is, physicians whose prescription rate deviates constantly from the rates of their peers for a given type of opioid use. Importantly, physicians can gain insight into how their peers are responding to demand for opioids and can consider any adjustments to their own behavior that might be more in line with what is typical among a similar population.
To manage and (eventually) reverse the opioid epidemic, state Medicaid programs should now take a deeper look at the role prescribing plays, and they can tackle the “gray” area of appropriate prescribing through the deployment of appropriateness measures.”(E)

“In the wake of President Trump declaring the opioid epidemic “a national emergency,” Express Scripts, the nation’s largest pharmacy benefit manager (PBM), has rolled out a new opioid management program that will limit the number and strength of opioid drugs to first-time patients…
Express Scripts’ Advanced Opioid Management solution is expected minimize early exposure to opioids while helping prevent progression to overuse and abuse, while ensuring access to medication patients need.
In a pilot study, the PBM observed a 38% reduction in hospitalizations and a 40% reduction in emergency room visits after educating patients about the risk of opioid use. An educational letter was also sent out to providers who showed high prescribing patterns and held counseling calls. Among this subset, a 19% decrease in the day’s supply of opioid dispensing during six-months of follow up, was observed.
Meanwhile, the American Medical Association (AMA) has found fault with the program, saying that treatment decisions should be left to physicians and their patients.
Here are 7 things to know about Express Scripts’ program to limit opioids:..” (F)

“Three local library systems are training staff in the use of the opioid overdose antidote naloxone and others are considering the move as more government agencies are joining the fight against Maryland’s opioid epidemic.
Library staff in Harford, Carroll and Anne Arundel counties have begun to offer training in administering naloxone, also known by its brand name, Narcan.
Meanwhile, library systems across the region are giving patrons access to a database of ebooks, audiobooks and other resources on addiction, recovery and the opioid epidemic, part of an effort to make libraries a greater resource for people confronting drug abuse.” (G)

“Mr. President, if you are serious about stopping America’s opioid crisis, instruct Attorney General Jeff Sessions to have the Department of Justice join in these legal actions, bringing the investigatory and legal weight of the FBI to battle the multibillion-dollar pharmaceutical opioid industry and the largest distributors and retailers of the drugs. Don’t waste federal resources on isolated overprescribing doctors and puny drugstores — the states can handle those cases. Tell Sessions to nip this tsunami in the bud by going after entities that garner more than a billion dollars a year off opioids. Tell Sessions to nip this tsunami in the bud by going after entities that garner more than a billion dollars a year off opioids.
Stop the export of America’s opioid crisis.
Stop the import of fake and copycat foreign-made opioids. “ (H)

“Dr. Leslie Blackhall handled that case and two others at the University of Virginia’s palliative care clinic, and uncovered a wider problem: As more people die at home on hospice, some of the powerful, addictive drugs they are prescribed are ending up in the wrong hands.
Hospices have largely been exempt from the national crackdown on opioid prescriptions because dying people may need high doses of opioids. But as the nation’s opioid epidemic continues, some experts say hospices aren’t doing enough to identify families and staff who might be stealing pills. And now, amid urgent cries for action over rising overdose deaths, several states have passed laws giving hospice staff the power to destroy leftover pills after patients die.” (I)

(A) America’s self-inflicted opioid crisis, by Ken Fisher, http://medicaleconomics.modernmedicine.com/medical-economics/news/america-s-self-inflicted-opioid-crisis?page=0%2C1
(B) Government’s role in opioid crisis deserves review, http://newsok.com/article/5560720
(C) Abuse Deterrent Formulations are a Critical Step in Solving the Opioid Crisis, by Doug Schoen , https://www.forbes.com/sites/dougschoen/2017/08/18/abuse-deterrent-formulations-are-a-critical-step-in-solving-the-opioid-crisis/#708e9a174b87
(D) CityViews: Calling Out Cuomo for the Opioid Crisis, By Jeremy Saunders, http://citylimits.org/2017/08/18/cityviews-calling-out-cuomo-for-the-opioid-crisis/
(E) How Medicaid Programs Are Managing the Opioid Crisis, by Parie Garg, http://health.oliverwyman.com/transform-care/2017/08/how_medicaid_program.html
(F) Seven things to know about Express Scripts’ plan to limit opioids, by Tracey Walker, http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/seven-things-know-about-express-scripts-plan-limit-opioids
(G) Libraries join opioid addiction fight through Narcan training, by Mina Haq and Jon Kelvey, http://www.baltimoresun.com/health/bs-md-library-opioid-resources-0809-story.html
(H) How Not to Handle the Opioid Crisis, by LAURIE GARRETT, http://foreignpolicy.com/2017/08/22/how-not-to-handle-the-opioid-crisis/
(I) Dying At Home In An Opioid Crisis: Hospices Grapple With Stolen Meds, by Melissa Bailey, http://khn.org/news/dying-at-home-in-an-opioid-crisis-hospices-grapple-with-stolen-meds/

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The PSA experts’ kerfuffle! Is there an evidence-based algorithm?

Recently I was listening to a health call-in show on public radio during which a urologist gave advice on the diagnosis protocol for prostate cancer seemingly different and more aggressive from the one used by my urologist.
I remember when the “gold standard” for PSA prostate screening was a score of 4 or below. Then lost favor and PSA trajectory became the new GS, more specifically and increasing PSA score over time was cause for alarm. It seems that expert advice changes every few years resulting in less guidance on what to do rather than more evidenced-based recommendations.

So I started Googling:
“It can be hard for physicians to follow current thinking of experts on medical care. It must be exponentially harder for the public to make sense of it. Recently, the United States Preventive Services Task Force changed its recommendation on prostate cancer screening from a D (that is, don’t do it) to a C (discuss it with your doctor).”
“Five years ago, the task force gave prostate cancer screening a D recommendation because there are real harms from over-diagnosis of the disease. Over-diagnosis leads to unnecessary treatments, and a newly discovered cancer could lead to no symptoms or harm over the patient’s lifetime. The treatments for prostate cancer, including radiation and prostatectomy, have high levels of adverse events. About 75 percent of all the men treated will have impotence, incontinence or both.”
Further, at the time of the 2012 statement, there appeared to be little evidence that screening with a prostate-specific antigen blood test (PSA) reduced prostate cancer mortality. With no clear benefit, and significant harms, a D recommendation seemed appropriate.
…..I’m sure the nuances of A, B, C and D recommendations can be confusing to the public. They can also make it seem as if experts are constantly changing their minds. But this is how we want our experts to react: When new evidence is found, it should be added to older evidence to change our thinking when appropriate. (A)

“For years, doctors have used a PSA blood test to screen men for prostate cancer. The test measures a protein made by the prostate gland, called a prostate-specific antigen (PSA).
But the PSA test can do more harm than good. Here’s why: The test is often not needed.
Most men with high PSAs don’t have prostate cancer. Their high PSAs might be due to: An enlarged prostate gland; A prostate infection; Recent sexual activity; A recent, long bike ride.
Up to 25% of men with high PSAs may have prostate cancer, depending on age and PSA level. But most of these cancers do not cause problems. It is common for older men to have some cancer cells in their prostate glands. These cancers are usually slow to grow. They are not likely to spread beyond the prostate. They usually don’t cause symptoms, or death.
Studies show that routine PSA tests of 1,000 men ages 55 to 69 prevent one prostate cancer death. But the PSA also has risks.
There are risks to getting prostate cancer tests and treatments…” (B)

When is a PSA test needed?
If you are age 50 to 74, you should discuss the PSA test with your doctor. Ask about the possible risks and benefits.
Men under 50 or over 75 rarely need a PSA test, unless they have a high risk for prostate cancer.
You are more likely to get prostate cancer if you have a family history of prostate cancer, especially in a close relative such as a parent or sibling.
Your risks are higher if your relative got prostate cancer before age 60 or died from it before age 75. These early cancers are more likely to grow faster.
If you have these risks, you may want to ask your doctor about getting the PSA test before age 50.(C)

Talk to your urologist about Watchful Waiting and Active Surveillance
“Active surveillance is often used to mean monitoring the cancer closely. Usually this approach includes a doctor visit with a prostate-specific antigen (PSA) blood test and digital rectal exam (DRE) about every 6 months. Prostate biopsies may be done every year as well. If your test results change, your doctor would then talk to you about treatment options.
Watchful waiting (observation) is sometimes used to describe a less intensive type of follow-up that may mean fewer tests and relying more on changes in a man’s symptoms to decide if treatment is needed.”
“One of these approaches might be recommended if your cancer: Isn’t causing any symptoms; Is expected to grow slowly (based on Gleason score); Is small; Is just in the prostate…
Watchful waiting and active surveillance are reasonable options for some men with slow-growing cancers because it is not known whether treating the cancer with surgery or radiation will actually help them live longer. These treatments have definite risks and side effects that may outweigh the possible benefits for some men. Some men are not comfortable with this approach, and are willing to accept the possible side effects of active treatments to try to remove or destroy the cancer.” (D)

I f you wind up having a biopsy, consider getting a second opinion before starting one of the various therapies available.
Options include: Surgery. Radiation therapy. Cryotherapy (cryosurgery). Hormone therapy; chemotherapy; Vaccine treatment; Bone-directed treatment (E)

And always keep your primary care physician involved, the doctor who knows you best.

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

(A) The ABCs and Ds of Whether to Get Prostate Cancer Screening, by Aaron E. Carroll, https://www.nytimes.com/2017/06/26/upshot/the-abcs-and-ds-of-whether-to-get-prostate-cancer-screening.html
(B) PSA Blood Test for Prostate Cancer http://www.choosingwisely.org/patient-resources/psa-test-for-prostate-cancer/
(C) PSA Blood Test for Prostate Cancer http://www.choosingwisely.org/patient-resources/psa-test-for-prostate-cancer/
(D) Watchful Waiting or Active Surveillance for Prostate Cancer, https://www.cancer.org/cancer/prostate-cancer/treating/watchful-waiting.html
(E) Treating Prostate Cancer https://www.cancer.org/cancer/prostate-cancer/treating.html

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

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

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

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

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


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

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

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

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


(A) Opioid crisis: Trump’s drug czar vows to take on doctors and dealers, help addicts, by Elizabeth Llorente, http://www.foxnews.com/us/2017/08/11/opioid-crisis-trumps-drug-czar-vows-to-take-on-doctors-and-dealers-help-addicts.html
(B) Hospitals Innovate New Strategies to Fight Opioid Crisis, by Rick Pollack, http://blog.aha.org/post/170811-hospitals-innovate-new-strategies-to-fight-opioid-crisis-
(C) Opioid Overdose ICU Admissions Increasing, by Salynn Boyles, https://www.medpagetoday.com/psychiatry/addictions/67240
(D) Allegheny Health Network Establishes Center of Excellence to Address Opioid Crisis, https://www.ahn.org/news/8-15-2017/allegheny-health-network-establishes-center-excellence-to-address-opioid-crisis
(E) Maine Joins Probe of Drug Companies’ Role in Opioid Crisis, by By MAL LEARY, http://mainepublic.org/post/maine-joins-probe-drug-companies-role-opioid-crisis#stream/0
(F) Don’t blame addicts for America’s opioid crisis. Here are the real culprits, by Chris McGreal, https://www.theguardian.com/commentisfree/2017/aug/13/dont-blame-addicts-for-americas-opioid-crisis-real-culprits
(G) Drug wholesaler cites rehab clinics, pharmacies for possible fault for opioid crisis, http://www.pharmacist.com/article/drug-wholesaler-cites-rehab-clinics-pharmacies-possible-fault-opioid-crisis


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The Trump administration “blinks”; provides Obamacare funding

.“The Trump administration will make this month’s Obamacare payments to insurers, a White House spokesman confirmed today, despite the president’s repeated threats to cut off the subsidies and potentially tip the insurance markets into turmoil.
It’s widely anticipated that insurers would jack up premiums or exit the Obamacare markets altogether if the subsidies, worth about $7 billion this year, are eliminated. Insurance premiums for the most popular Obamacare plans would likely rise by 20 percent next year if the payments are stopped, according to a Tuesday CBO analysis…
At issue are subsidies that insurers rely on to reduce out-of-pocket costs for low-income Obamacare customers. Insurers would still be on the hook to provide the discounted rates even if the federal payments stop.” (A)

If payments were not made…
“CBO -If President Trump decides to cut off payments to insurance companies called for under the Affordable Care Act…. it’s going to cost taxpayers — about $194 billion over 10 years.
An analysis by the Congressional Budget Office released Tuesday found that ending cost-sharing reduction payments to insurers, a move that President Trump is contemplating, would raise the deficit by $194 billion over 10 years.
If President Trump decides to cut off payments to insurance companies called for under the Affordable Care Act, it’s going to cost him.
Or, more accurately, it’s going to cost taxpayers — about $194 billion over 10 years….
The deficit figure comes from the Congressional Budget Office, which on Tuesday released an estimate of the budget impact of ending what is known as cost-sharing reduction payments. Those are payments the federal government makes to insurance companies to reimburse them for the discounts on copays and deductibles that they’re required by law to give to low-income customers. (B)

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

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

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

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

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

(A) Trump administration will make this month’s Obamacare payments but leaves program’s future in limbo, by PAUL DEMKO, http://www.politico.com/story/2017/08/16/trump-obamacare-subsidy-payments-241712
(B) CBO Predicts Rise In Deficit If Trump Cuts Payments To Insurance Companies, by Alison Kodjak, http://www.npr.org/sections/health-shots/2017/08/15/543714171/cbo-predicts-rise-in-deficit-if-trump-cuts-payments-to-insurance-companies
(C) GOP DOOMED ITS OWN HEALTH CARE PROPOSALS WITH ‘POLITICS OF DESTRUCTION’, by JILL QUADAGNO, http://www.newsweek.com/gop-doomed-health-care-proposals-politics-destruction-650700
(D) Five tough decisions for the GOP on healthcare, by RACHEL ROUBEIN AND NATHANIEL WEIXEL, http://thehill.com/policy/healthcare/345385-five-tough-decisions-for-the-gop-on-healthcare
(E) Around 4 in 5 Americans Want the Effort to Repeal Obamacare to End, Poll Finds, Alan Fram, http://time.com/4896747/obamacare-repeal-poll-trump-gop-aca/
(F) Most Trump voters don’t want Trump to sabotage Obamacare, Updated by Sarah Kliff, http://time.com/4896747/obamacare-repeal-poll-trump-gop-aca/
(G) Our View: Let governors have a crack at Obamacare, http://azdailysun.com/news/local/our-view-let-governors-have-a-crack-at-obamacare/article_1f2dc4ca-dbb7-5f41-92e9-a30dde58f55a.html

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American College of Physicians Says Hate Crimes are Public Health Issue

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

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

The new policy reads in full:

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


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

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

“President Donald Trump declared the opioid crisis a national emergency Thursday, a designation that would offer states and federal agencies more resources and power to combat the epidemic.
In a statement released late in the day, the White House said, “building upon the recommendations in the interim report from the President’s Commission on Combating Drug Addiction and the Opioid Crisis, President Donald J. Trump has instructed his Administration to use all appropriate emergency and other authorities to respond to the crisis caused by the opioid epidemic.”
“The opioid crisis is an emergency, and I am saying, officially, right now, it is an emergency. It’s a national emergency,” Trump said earlier at his golf club in Bedminster, New Jersey. “We’re going to spend a lot of time, a lot of effort and a lot of money on the opioid crisis. It is a serious problem the likes of which we have never had.”
Trump’s actions come just two days after Health and Human Services Secretary Tom Price suggested declaring a national emergency was unnecessary. (C)

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

“For the past 50 years, we have been waging a war on drugs that has relied nearly exclusively on supply control and tough punishment. It hasn’t worked….
Why has it failed? The medical community declared nearly 70 years ago that drug and alcohol addiction and dependence are medical disorders. We can’t punish diabetes or cancer away. So why do we think getting tough on addiction would work?
To complicate the landscape, approximately 40% of opioid-dependent individuals have depression, anxiety, or bipolar disorder, and some have other co-occurring psychiatric disorders. Post-traumatic stress disorder and personality disorders are also present, though less frequently. Punishment is not only ineffective; it often exacerbates these mental health problems…
Drug abuse is a public health problem. It is time we treat it that way. (E)


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

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



(A) Landmark report by Surgeon General calls drug crisis ‘a moral test for America’, by Lenny Bernstein, https://www.washingtonpost.com/national/health-science/landmark-report-by-surgeon-general-calls-drug-crisis-a-moral-test-for-america/2016/11/16/4214bf2a-ac49-11e6-977a-1030f822fc35_story.html?utm_term=.3adfcafb8a98
(B) Finding Solutions to the Prescription Opioid and Heroin Crisis: A Road Map for States, National Governors Association, https://www.nga.org/files/live/sites/NGA/files/pdf/2016/1607NGAOpioidRoadMap.pdf
(C) Trump: ‘The opioid crisis is an emergency’, by Wayne Drash and Dan Merica, http://www.cnn.com/2017/08/10/health/trump-opioid-emergency-declaration-bn/index.html
(D) Trump Says He Intends To Declare Opioid Crisis National Emergency, by Brian Naylor and Tamara Keith, http://www.npr.org/2017/08/10/542669730/trump-says-he-intends-to-declare-opioid-crisis-national-emergency
(E) Trump Clearly Has No Clue How to Stop the Opioid Epidemic, by William R. Kelly, http://fortune.com/2017/08/09/trump-opioid-briefing-speech-crisis-epidemic-war-on-drugs/
(F) Drug industry faces ‘tidal wave’ of litigation over opioid crisis, David Crow, https://www.ft.com/content/36e93cee-7e39-11e7-9108-edda0bcbc928
(G) SERIOUS ABOUT THE OPIOID CRISIS? THEN DON’T SLASH MEDICAID, by DOUG WIRTH, http://www.newsweek.com/serious-about-opioid-crisis-then-dont-slash-medicaid-649222


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