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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Even as opioids flood American communities and fuel widespread addiction, hospitals are facing a dangerous shortage of the powerful painkillers needed by patients in acute pain, according to doctors, pharmacists and a coalition of health groups.
The shortage, though more significant in some places than others, has left many hospitals and surgical centers scrambling to find enough injectable morphine, Dilaudid and fentanyl — drugs given to patients undergoing surgery, fighting cancer or suffering traumatic injuries. The shortfall, which has intensified since last summer, was triggered by manufacturing setbacks and a government effort to reduce addiction by restricting drug production.
As a result, hospital pharmacists are working long hours to find alternatives, forcing nurses to administer second-choice drugs or deliver standard drugs differently. That raises the risk of mistakes — and already has led to at least a few instances in which patients received potentially harmful doses, according to the nonprofit Institute for Safe Medication Practices, which works with health care providers to promote patient safety.” (R)

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

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

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

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

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

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

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

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

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

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

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

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

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Other posts that are part of this Case Study:

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

August 9, 2017

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

August 11, 2017

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

August 17, 2017

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

August 22, 2017

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

September 1, 2017 | Edit

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

September 14, 2017

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

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

October 19, 2017

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

October 29, 2017

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

November 29, 2017

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

December 9, 2017

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

January 6, 2018

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

January 14, 2018 | Edit

Opioid commission member: Our work is a ‘sham’

January 24, 2018