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

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

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

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

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

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

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

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

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

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

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

(A) Hospitals are confronting a new opioid crisis: an alarming shortage of pain meds, by Casey Ross, https://www.statnews.com/2018/03/15/hospitals-opioid-shortage/
(B) Opioid shortages leave US hospitals scrambling, by Pauline Bartolone, https://www.cnn.com/2018/03/19/health/hospital-opioid-shortage-partner/index.html
(C) The Other Opioid Crisis: Hospital Shortages Lead To Patient Pain, Medical Errors , by Pauline Bartolone, https://www.washingtonpost.com/national/health-science/the-other-opioid-crisis-hospital-shortages-lead-to-patient-pain-medical-errors/2018/03/16/91d2c6fe-28fa-11e8-a227-fd2b009466bc_story.html?noredirect=on&utm_term=.d44201ad0fd6
(D) South Carolina hospitals dealing with ‘critical shortage’ of opioids, by Mary Katherine Wildeman, https://www.postandcourier.com/health/south-carolina-hospitals-dealing-with-critical-shortage-of-opioids/article_33c49db6-2c7a-11e8-b468-eb78b128b456.html
(E) Injectable Opioid Shortages Suggestions for Management and Conservation (Compiled by ASHP and the University of Utah Drug Information Service, March 20, 2018), https://www.ashp.org/-/media/assets/drug-shortages/docs/drug-shortages-iv-opioids-faq-march2018.ashx
(F) Drug Shortages Threaten Patient Safety, https://www.medscape.com/viewarticle/727958,
(G) Injectable opioid shortage compromises care, by Alex Kacik, http://www.modernhealthcare.com/article/20180321/TRANSFORMATION03/180329986
(H) DEA lifts production quotas to ease injectable opioid shortage, by Alex Kacik, http://www.modernhealthcare.com/article/20180414/NEWS/180419944
(I) Opioid Crisis Fast Facts, https://www.cnn.com/2017/09/18/health/opioid-crisis-fast-facts/index.html
(J) Drug Companies’ Liability for the Opioid Epidemic, by Rebecca L. Haffajee and Michelle M. Mello, http://www.nejm.org/doi/full/10.1056/NEJMp1710756

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

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

I have recently been posting CURATED CONTEMPORANEOUS CASE STUDIES with the objective of developing real-time health care policy information and analysis.
The OPIOID CRISIS has been a real challenge absent any federal government leadership for state governments, public health agencies, hospitals, and the public.
So this post is to catch-up on the various threads out there since the initial case study:
CASE STUDY ON THE OPIOID CRISIS. “We still have lacked the insight that this is a crisis, a cataclysmic crisis” https://doctordidyouwashyourhands.com/2018/03/case-study-on-the-opioid-crisis-we-still-have-lacked-the-insight-that-this-is-a-crisis-a-cataclysmic-crisis/
And I think it will continue with various well intentioned initiatives but no evidenced-based platform.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(A) In rare advisory, surgeon general urges public to carry overdose-reversal medication, by ANDREW JOSEPH, https://www.statnews.com/2018/04/05/surgeon-general-advisory-naloxone/
(B) The next naloxone? Companies, academics search for better overdose-reversal drugs, by MAX BLAU, https://www.statnews.com/2018/04/10/next-naloxone-overdose-reversal-drugs/
(C) Murphy wants to spend $100M to fight opioid addiction (but none on Christie-like ads), by Matt Arco, http://www.nj.com/politics/index.ssf/2018/04/phil_murphy_wants_to_spend_100m_to_fight_opioid_ad.html
(D) EDITORIAL: A different take on opioid crisis, https://www.mycentraljersey.com/story/opinion/editorials/2018/04/05/editorial-different-take-opioid-crisis/33552363/
(E) Rise in Opioid-Exposed Newborns in NJ Prompts State Awareness Campaign, http://www.njspotlight.com/stories/18/04/09/rise-in-opioid-exposed-newborns-in-nj-prompts-state-awareness-campaign/
(F) California lawmakers advance measures to curb opioid crisis, by Sophia Bollag, http://www.kcra.com/article/california-lawmakers-advance-measures-to-curb-opioid-crisis/19736309
(G) Gov. Walker to sign bills addressing opioid crisis, http://www.wsaw.com/content/news/Gov-Walker-to-sign-bills-addressing-opioid-crisis-479088493.html
(H) N.Y. gets pharma to pay up amid opioid epidemic, but concerns linger, by Bethany Bump, https://www.timesunion.com/news/article/NY-gets-pharma-to-pay-up-amid-opioid-epidemic-12802636.php
(I) With the drug industry as its partner, an addiction policy group invites tough questions, by LEV FACHER, https://www.statnews.com/2018/04/05/drug-industry-addiction-policy-forum/
(J) How a Pa. health system reduced opioid prescriptions by more than half, by Alan Yu, https://whyy.org/articles/how-a-pa-health-system-reduced-opioid-prescriptions-by-more-than-half/
(K) New Hampshire hospitals take aim at the opioid epidemic, invest $50M in state initiatives, https://www.fiercehealthcare.com/hospitals-health-systems/new-hampshire-hospitals-take-aim-at-opioid-epidemic-invest-50m-state?mkt_tok=eyJpIjoiWVRKa1ltUmxZV0kxTWpabCIsInQiOiJRbUJKN29ubnc4aWp5YytEYWRBREk3YUdjNUozQWJsMmRBNEJXSVk3c2V6WWVKeFc4ZGRsMEUrT2QyendwTGtvS1p1OEhDSmZUTndMaFVTbkZneEgyTHFkNVk3VXNOcmQxNFwvbjNnc09IcU1oQmxDMFYwSXVFMlh2Z01HdW9makEifQ%3D%3D&mrkid=654508
(L) New rules could worsen the opioid crisis, not help it, by LARRY GREENBLATT, http://thehill.com/opinion/healthcare/381058-new-rules-could-worsen-the-opioid-crisis-not-help-it
(M) Ordering Five Million Deaths Online, by Richard A. Friedman, https://www.nytimes.com/2018/04/04/opinion/carfentanil-fentanyl-opioid-crisis.html
(N) CDC director pledges to bring opioid epidemic “to its knees”, https://www.cbsnews.com/news/cdc-director-pledges-to-bring-opioid-epidemic-to-its-knees/
(O) For chronic pain, a change in habits can beat opioids for relief, by Christine Herman, https://whyy.org/npr_story_post/for-chronic-pain-a-change-in-habits-can-beat-opioids-for-relief/
(P) Conservative columnist: My personal trip through opioid hell and back, by Michael Reagan, http://www.nj.com/opinion/index.ssf/2018/04/the_story_of_my_personal_trip_through_opioid_hell.html
(Q) Medicare, Medicaid Opioid Scripts Decline in Medical Marijuana States, by Judy George, https://www.medpagetoday.com/neurology/opioids/72105
(R) The Opioid Discussion: HR departments must do more to assist opioid-addicted employees A panel presented by NJBIZ, by Vince Calio, http://www.njbiz.com/article/20180402/NJBIZ01/180409998/the-opioid-discussion-hr-departments-must-do-more-to-assist-opioidaddicted-employees
(S) A look at how the opioid crisis has affected people with employer coverage, by Cynthia Cox, Matthew Rae and Bradley Sawyer, https://www.healthsystemtracker.org/brief/a-look-at-how-the-opioid-crisis-has-affected-people-with-employer-coverage/#item-start
(T) Sacklers Who Disavow OxyContin May Have Benefited From It, by David Armstrong, https://www.propublica.org/article/sacklers-who-disavow-oxycontin-may-have-benefited-from-it?utm_source=STAT+Newsletters&utm_campaign=431b02b011-MR&utm_medium=email&utm_term=0_8cab1d7961-431b02b011-149527969
(U) Overdose Antidote Is Supposed to Be Easy to Get. It’s Not, by ANNIE CORREAL, https://www.nytimes.com/2018/04/12/nyregion/overdose-antidote-naloxone-investigation-hard-to-buy.html