“The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped.” – Hubert Humphrey
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Pharmacist Steve steve@steveariens.com 502.938.2414
Drug diversion is a massive problem. It plagues the entire drug supply chain, from manufacturer through wholesaler and distributor, to drug stores and dispensaries, all the way to consumers. It is particularly important for opioid pain medications because of the ongoing opioid crisis.
It is well established that the non-medical use of pharmaceutical drugs is an increasing public health concern. Most pharmaceutical drugs used non-medically are obtained from family and friends. There is little to no organized crime involved. And importantly, doctor shopping is rare.
An under-appreciated issue here is scale.
According to the DEA, less than 1 percent of legally prescribed opioids are diverted.
The sharing or selling of individual prescription pills is small compared to the impact of diversion higher up in the supply chain. For instance, Effingham Health systems just agreed to pay a $4.1 million settlement as a result of a DEA investigation into reports that tens of thousands of oxycodone tablets were believed to have been diverted for four years.
Similar reports about large-scale diversion abound. The Associated Press reported incidents of diversion at about 1,200 VA facilities rose from 272 in 2009 to 2,926 in 2015.
And in 2013 Walgreens was charged $80 million for poor record-keeping and dispensing violations that let millions of doses of controlled substances to enter the black market.
In 2007, the Drug Enforcement Administration estimated that prescription drug diversion in the United States was a $25 billion-a-year industry.
About one of every four thefts of methadone and OxyContin were attributed by the DEA to employee pilferage at pharmacies, hospitals and other healthcare facilities.
More recently, a 2017 survey by Porter Research, 96 percent of healthcare workers said drug diversion occurs frequently in healthcare. And 65 percent believe most diversion goes undetected.
Pill mills are even worse. In the book “American Pain,” journalist John Temple describes the impact of Florida pill mills on the east coast a decade ago.
“Florida pumped millions upon millions of doses of those narcotics—oxycodone, mostly—northward, not through a major criminal organization like the cartels of Mexico, but via thousands of individuals who streamed up and down Interstate 75 or flew from Tri-Sate Airport in Huntington, West Virginia, to Miami International, on a flight nicknamed the Oxy Express,” Temple wrote.
And none of this is remotely new. In the book “Dark Paradise,” historian David Courtwright explains: “Diversion from maintenance programs posed a real danger, given that perhaps half of all licitly manufactured barbiturates and amphetamines ended up on the black market.”
So the claim by Attorney General Jeff Sessions that “It’s a common sense idea: the more a drug is diverted, the more its production should be limited” is both simplistic and misguided.
Sessions is assuming that limiting production will reduce diversion. But economic theory suggests the opposite may be true. Reducing supply leads to scarcity, which generally increases value. This in turn may create stronger incentives to divert more opioids into the black market.
Moreover, there is no evidence that people who divert medication are aware of and responding to DEA production quotas. Instead, the consensus is that people divert what they need and think they can get away with. In other words, diversion is an exercise in what economists call the “Tragedy of the Commons,” in which individuals each use a collective resource for their own benefit without regard for the effects on others.
And Sessions’ idea implies that reducing production won’t have any effect on medical practice. But there is an abundance of evidence to the contrary. There is an ongoing shortage of injectable opioids at hospitals around the country. And despite claims to the contrary, opioid analgesics cannot always be replaced or substituted with other pain relievers.
Thus, more intelligent and nuanced approaches are needed. For instance, the NIH is sponsoring research to use advanced data analytics to detect drug theft and diversion in hospitals. Similar efforts at wholesalers, distributors, pharmacies and dispensaries are worth considering.
So while diversion is a major problem, it is neither new nor limited to individual consumers with prescriptions for opioids or other medications that have a street value or abuse potential. The seemingly obvious response of reducing supply could easily backfire. Instead, securing the entire supply chain, from manufacturer through distributor to point-of-sale to consumers, is a vital step in making sure that only the intended recipients of pharmaceutical drugs have access to them.
TWINSBURG, Ohio — In response to the nation’s opioid epidemic, Rite Aid’s pharmacy benefit manager, EnvisionRx, has enhanced its opioid and pain management program to make prescription fill limits and monitoring part of the program.
“As our nation endures a health crisis around opioid dependency, we are in a unique position to change the way opioids are used by our members,” said Frank Sheehy, CEO of pharmacy services and healthcare company EnvisionRxOptions. “Prescription fill limits and monitoring as a part of our pain management program will help minimize the risk of opioid addiction, especially for those patients who are being prescribed opioids for the first time.”
The EnvisionCare Pain Management program now includes pre-emptive prescription strategies, such as limiting first-time fills to seven days, prior authorizations on certain medications and shortened windows to refill prescriptions. This program aligns with the healthcare company’s overall pain management strategy, as well as the guidelines set by the Centers for Disease Control and Prevention.
EnvisionCare Pain Management, which includes an opt-out feature for clients not wishing to implement this program, focuses on patient safety through communication, education and outreach, as well as interventions that avoid excessive dosing and dangerous drug combinations, ensuring pain is managed safely before and after the first dose.
The program contains pre-dispense, concurrent and retrospective measures, such as:
Clinically focused safeguards, like a seven-day limit on prescriptions for patients who have not used an opioid in the past three months, step therapy for extended-release opioids and prior authorization for extremely high dosages (greater than 200 Morphine Milligram Equivalents (MME)).
Safer dispensing practices, including real-time drug utilization reviews at the pharmacy to promote proper dispensing and point-of-sale alerts for excessively high dosages or those who have been prescribed dangerous drug combinations.
Supplemental, detailed reviews, in addition to those the pharmacist performs at the time of dispense, to identify patients who may be filling high dosage opioids, and/or receiving prescriptions from multiple prescribers and dispensers. These reviews, paired with a shortened refill window requiring patients to have exhausted 85 percent of their medication supply before a refill will be dispensed, help identify dangerous long-term utilization and members who may be in need of intervention.
“We firmly believe that by reducing the number of opioids in the hands of a new patient right from the start, we can significantly decrease the possibility of dependence and addiction,” said Sheehy. “While opioid use can have positive results for pain management, we have a responsibility to protect our members by addressing pain in an appropriate way and better educating patients about the risks accompanying opioids.”
Jo Anna Krohn is used to emergency calls. As director of Port 45 Recovery in Portsmouth, Krohn works with addicts in an area that is seen by some as ground zero for the nation’s opioid epidemic.
But last fall, she received a call that left her panicked.
It was from a local pharmacist warning that he could no longer stock a generic version of Suboxone because the state was reimbursing him so little for it that he was losing money. Most of the 165 recovering addicts being treated at Port 45, about 90 miles south of Columbus near the Ohio River, rely on the medication to stay clean.
“It was very frightening,” Krohn recalled.
Roger Flautt, pharmacy manager for Blackburn’s Pharmacy in nearby New Boston, said his was one of a handful of area pharmacies that continued stocking the drug even though “we were losing our shirts.”
“I thought this was going to be a disaster. When tablets weren’t available a year ago (because of a manufacturing issue), overdoses tripled,” Flautt said. “When this drug is not on the market, overdoses go up.”
Pharmacists in Dayton, Marysville, Circleville and other Ohio cities told The Dispatch that they, too, saw a rapid decline in reimbursements — drops of nearly 80 percent — for generic Suboxone last fall, endangering the recovery of innumerable addicts caught up in the state’s opioid crisis.
The decision to slash rates was made by CVS Caremark, which is by far the state Medicaid program’s largest pharmacy benefit manager. And it remains one the nation’s most stark examples of the potentially life-and-death impact of hidden price manipulation by these PBMs — little-known middlemen in the drug supply chain that, on the one hand, decide how much money to give pharmacies for each drug and, on the other, determine how much taxpayers pay through Medicaid for those same drugs.
The furor caused by last fall’s crisis proved a tipping point that sparked a wave of legislation and investigation into the secretive world of prescription-drug pricing.
The pharmacists say they were forced into the painful position of deciding whether to stop stocking generic Suboxone — and in effect pushing addicts in the fragile early stages of recovery back onto the streets — or find themselves being forced out of business.
“It felt bad. It felt real bad,” Nnodum Iheme, owner of Zik’s Family Pharmacy in Dayton, said of his conclusion that he had to stop selling the medication to keep serving his many other Medicaid customers. “As a professional, you’re here to help patients get well.”
Last year’s harrowing reimbursement dip caused such an outcry that the Department of Medicaid got involved, demanding that CVS Caremark increase reimbursements.
“Basically, (CVS) talked us through how they set prices, their process and that sort of thing,” said Patrick Stephan, the Medicaid Department’s director of managed care.
“We basically sort of cut them off and said, ‘This isn’t acceptable,’ Stephan said. “The (Medicaid managed-care) plans are contractors to us. You’re a subcontractor to the plans. We contract with you to manage a line of business; not to make headaches like this. That’s unacceptable, so whatever needs to be done, this needs to be fixed.’”
According to a timeline provided by the Department of Medicaid, the reimbursement drop for generic Suboxone happened in November, department officials met with CVS officials on Dec. 18 and by January reimbursements had gone back up.
However, an official with Ohio’s largest managed-care provider, Dayton-based CareSource, gave a different version. James Gartner, the company’s vice president for pharmacy, said he was very concerned about the Suboxone reimbursement cut, so he met with CVS officials and they addressed it within 24 hours. But Gartner, who sits on a CVS advisory board, said the company “gave me no exact reasons” why the dip occurred in the first place.
Officials with another Medicaid managed-care plan, Molina Healthcare, said they were unaware of any reductions in reimbursements for generic Suboxone.
“We would reach out to our PBM if we noticed a problem with our members’ accessing the drugs they need, but we did not see that happen last fall,” said Molina spokeswoman Laura Murray.
In any case, CVS quickly restored reimbursements. But for many, that raised more questions than it answered.
Medicaid contracts with five managed-care plans. In turn, four of those hired CVS to manage pharmacy benefits. But Stephan said the plans had to appeal to the Medicaid department for help in persuading a company that is, in essence, its employee to help keep medication available to Ohio’s recovering heroin addicts.
“We did sort of turn the heat up on (the managed-care plans) significantly,” he said. “They collectively said, ‘We hear you. We’re talking to CVS Caremark. We think if you guys have a meeting directly with them it would be helpful. It would help us.’ So we did that.”
The episode pointed out another big problem with the way the state’s Medicaid system handles prescription drugs, said Ohio Sen. David Burke, R-Marysville.
A pharmacist himself, Burke chairs the Joint Medicaid Oversight Committee, which has been digging into the drug-pricing issue. He said that after CVS cut reimbursements late last year, he was losing $100 on each prescription of generic Suboxone he filled. That, he said, led to “inventory issues” at his pharmacy. Then, after CVS got its talking to, reimbursements jumped so much that he was actually making $80 on each prescription he filled.
“A $180 shift in a month, what is that tied to?” Burke asked. “How did you go from negative $100 to positive $80 after rebate? What costs are you even using? You weren’t using any. That’s the thing. You just pick another number to stop people from bitching, but you’ve done nothing to address the real issue. It’s just how much do I have to pay you to get you to shut up?”
CVS disputed Burke’s assessment.
“CVS Caremark implemented changes to the reimbursement for some medications, including for Suboxone, to pharmacies in its network last October,” Mike DeAngelis, senior director of corporate communication for CVS Health, said in an email.
“These changes, which can occur frequently based on factors such as our best understanding of the marketplace and product availability, are made as part of our responsibility as a PBM to balance the need to fairly compensate the pharmacies in our network while providing a cost-effective benefit to our clients,” DeAngelis said.
“CVS Caremark continuously monitors the marketplace, and based on that monitoring, we increased the pharmacy reimbursement rates for Suboxone the following month,” he said. “As we’ve previously stated, independent pharmacies are reimbursed at a higher rate overall than the chain pharmacies in our network, including CVS Pharmacy.”
Yet a Dispatch examination of the National Average Drug Acquisition Cost database, which shows what pharmacies across the country are receiving for each drug, showed no movement in the price for any type of Suboxone over the final three quarters of 2017. A similar look at Ohio’s Medicaid drug-utilization database, which shows how much taxpayers are being charged by the PBMs for each drug, also shows little movement in the price tag for Suboxone.
To investigate the truth of CVS’ claims for Suboxone and all of the thousands of other drugs covered by the state Medicaid program, Burke, Rep. Scott Lipps, R-Franklin, and the Medicaid department are undertaking multiple efforts to peel back the veil of secrecy regarding how CVS and other pharmacy benefit managers handle drug prices. Those who are investigating say they suspect use of that secrecy to gouge taxpayers, consumers and local pharmacies.
“You really go back to the inability for us to know how things are costing,” said Barb Sears, director of the Department of Medicaid, which is in the process of evaluating confidential pricing data from CVS and Ohio’s other Medicaid pharmacy benefit manager, OptumRx. “So the first line of defense is, ‘OK, you say this is how much I can buy it for, then show me.’”
Burke said last year’s dramatic dip in what CVS paid pharmacists is just an example of a broader pattern — one that could drive out pharmacies that are the health-care system’s most-frequent point of contact for Medicaid patients and others.
“Who the hell would go into business when you lose $100 on everything you do?” he asked. “I don’t care if you’re mowing yards or selling drugs, you’re going to stop doing that.”
JOHNSON CITY, TN (WJHL) – A renowned author and addiction psychiatrist says the efforts of the Department of Veterans Affairs and other institutions across the country to taper people off opioids without their consent is “an outrage.”
“To take a patient who’s doing well off of medication abruptly and without their permission is not unfair. I actually think it’s malpractice,”
Dr. Sally Satel said. “I think it is an outrage when you have a person who’s doing well on a dose of medication, highly functional and their pain is under good control. This is what you want. This is the clinical outcome.”
Dr. Satel is a resident scholar at the American Enterprise Institute and a lecturer at Yale University. She’s a vocal opponent of the involuntary tapering of controlled opioids.
“It shouldn’t be done without their permission,” she said. “Without the patient’s consent, the results are often disasterous.”
Mountain Home VA Medical Center is prescribing half as many opioids as it did in 2012, according to recently released federal data. Since December 2016, several veterans have voiced their frustration over what they’ve said is a mandate to taper their pain medications.
Dr. Satel says many institutions have misinterpreted the Centers for Disease Control’s pain management guidelines as mandates rather than recommendations.
“It doesn’t say anything about taking people off their medications if they don’t want to go off of it,” Dr. Satel said. “Of course, it’s frustrating, especially when it’s misinterpreted in the direction of poor patient care. It’s very frustrating.”
For decades, VA and other doctors have prescribed pain medications because they thought, at the time, that’s what patients needed. However, in recent years, they changed their approach when new research found opioids can be dangerous and ineffective.
“I understand their fear, their anxiety and their anger, but I want them to understand this is driven by our concern for their safety,” Mountain Home VA Opiate Safety Initiative Chairman Dr. Martin Eason said in December 2016.
Most recently, Mountain Home VA Chief of Staff Dr. David Hecht said the facility is proud of its 49% decrease in opioid prescriptions since 2012. He added, doctors consider every patient’s need on a case-by-case basis and taper veterans off opioids in a safe way.
“Many veterans have really understood and bought into it and it has helped us,” Dr. Hecht said. “Any time we reduce these medications, we want to reduce them in a safe environment.”
The VA maintains it has taken patients off opioids gradually and given veterans the opportunity to appeal their tapering decisions. The agency adds while opioids may help with short-term pain, they are not approved to treat chronic pain in non-cancer patients. Mountain Home is now encouraging veterans to try safer and more effective alternatives.
As we reported earlier this month, VA representatives plan to discuss preliminary data that show a link between opioid discontinuation and suicides at an upcoming summit. Dr. Satel has authored several published works alongside one of those speakers.
At this very moment, more than 110,000 people across the United States are lingering on organ transplant waiting lists. The ravages of the opioid epidemic have created an unforeseen opportunity – an increase in the availability of organs for donation.
New research led by investigators at University of Utah Health and Brigham and Women’s Hospital shows that an increase in drug-overdose related deaths has boosted the number of organs available for transplantation. They found a more than 10-fold increase in the proportion of donors who died from drug intoxication between the years 2000 and 2016 in the United States, from 1.2% (59) to 13.7% (1,029).
“We were surprised to learn that almost all of the increased transplant activity in the United States within the last five years is a result of the drug overdose crisis,” said Mandeep R. Mehra, MD, medical director of the Heart and Vascular Center at Brigham and Women’s Hospital and first author on the study.
But are these organs safe?
The researchers examined 17 years of transplantation records andfound no significant change in the recipients’ chance of survival when the organ donation came from victims of drug intoxication. The study publishes online on in the New England Journal of Medicine.
The researchers examined survival rate of 2,360 patients one year after receiving a heart or lung transplant from donors who died from drug intoxication compared to recipients of organs from donors who died from other causes, including gunshot wound, asphyxiation, blunt head injury and intracranial hemorrhage or stroke.
According to Josef Stehlik, MD, MPH, medical director of the Heart Transplant Program at the U of U Health and senior author on the research, the team examinedheart and lung data because these organs are the more sensitive to reduced oxygen supply that may occur during a drug overdose. They focused on survival in the first year, because these concerns would manifest shortly after the transplant. The fact that transplant patients who received these organs had similar survival as other transplant patients relieves the concerns of irreversible organ damage from drug overdose death.
“In the unfortunate circumstances where opioid deaths happen, organ donation can extend life of many patients in need of transplant,” said Stehlik. “Yet, these organs are often not considered suitable for organ donation.”
Clinicians have traditionally been conservative when identifying organs from drug intoxication deaths for procurement. During an overdose, a person may experience prolonged episodes of low blood pressure that can reduce the supply of oxygen throughout the body. There are also considerations that include infection risk, such as Hepatitis B and C and HIV, but this risk can be minimized with modern testing.
“I feel hopeful that doctors across the country will read this and feel confident that organs that pass the required tests are safe for transplant,” Stehlik said. “This awareness is especially important when organ procurement professionals have to decide on use of potential donors with this high-risk history.”
This study can also serve to better inform patients. The United Network for Organ Sharing policy requires patients are made aware of the circumstances of higher risk donations and can decide whether or not to accept it.
As the government invests millions to combat the opioid epidemic, the transplant community does not plan to rely on drug-intoxication deaths as a long-term source of donations.
“We must look to new ways to increase organ donor recovery by concentrating on greater use of marginal organs or by expanding the suitable donor pool by using new technologies to improve organ function before the transplant takes place,” Mehra said.
The research team also examined the Eurotransplant data that tracked transplantation in eight European countries during the same period. They found the number of organ donors dying from drug intoxication in Europe has remained low (less than 1 percent). Stehlik attributes these low numbers to policies in Europe that have kept opioid drug prescriptions low.
Along with Stehlik and Mehra, John Jarcho, MD, and Muthiah Vaduganathan, MD, MPH, at Brigham and Women’s Hospital in Boston, Wida Cherikh, PhD, and Rebecca Lehman, PhD, with the United Network for Organ Sharing and Jacqueline Smits, PhD, with the Eurotransplant International Foundation contributed to this analysis.
Vice News from the TV Channel Viceland has reported some stories that are on our side as far as the “opioid epidemic.” I would love to see them do a full show on our cause. This is where you come in! They have a phone number where you can call and leave a message, essentially about anything…this is what we would like you to do.
Call 646-851-0347 and leave a message. Please choose option 1. I suggest you write down what you want to say instead of winging it, that way you know you cover the information that is important. Below is a suggestion of what you should include in your message.
1. Your name and number number (if you are not comfortable leaving your number that is okay, but hopefully they will contact some of us back.
2. State that you are calling as a chronic pain patient and want to dispute the false narrative that the mainstream media is propagating about opioids in America.
3. Explain why you need opioids and how the current hysteria over opioids is affecting your life and report if you have had your meds cut or discontinued. Be specific but do not ramble. try to be concise.
4. Ask them to please do a show sharing the plight of chronic pain patients because no one is telling our side of the story.
This is an easy call to action and imagine the impact if they get 500 calls from us……or 1000. PLEASE participate. No one has the right to complain about the situation if they are not actively trying to change it. No one will fight for us, WE have to fight for ourselves. Please try to do this within the next two weeks. It will make a stronger impression if all the calls come at once. Help make our voices heard!
As the opioid epidemic rages on, many still have misconceptions about what heroin really does – and how we can end the crisis
The War on Drugs Expanded the Ways People Use Heroin – and Set the Stage for the Opioid Crisis
Spencer Platt/Getty Images
There is nothing new about heroin: What has changed is the way that we consume, dispense and talk about it. Despite the rising rate of opioid abuse and overdose in this country, we continue to mischaracterize heroin, thereby neglecting to understand the indelible hold it has on users. Here’s an attempt to clear up some of the most common misconceptions.
Heroin Isn’t Always White Powder
Heroin generally comes in three different forms in the United States: powder heroin – which falls into two subcategories, brown and off-white – tar heroin and heroin pills. Historically, the Mississippi River has been the line of demarcation between the tar and powder markets. Off-white powder heroin, which originates in Southeast and Southwest Asia, is generally considered the most desirable kind. Powder, with its origins in Mexico, often carries a deeper, browner hue, and is usually less powerful. On the West Coast, heroin comes almost exclusively from Mexico and South America and is most often sold in tar form; little balls of goo that look like black earwax. The third, least common form of heroin is “pill” form. “Pills” refer to heroin often sold in gel capsules and mixed with other powders – be it cocaine, methamphetamine or the more common heroin adulterants like powdered lactose, quinine and baby laxative. Pills are usually the cheapest and lowest-quality form of the drug.
What Might Look Like an Opioid High Is Actually the Symptoms of Withdrawal
Outsiders often confuse withdrawal symptoms for the effects of the drug, because the effects of withdrawal are far more noticeable than the euphoria the drug produces. Dilated pupils, sweating, shaking, slurring and vomiting aren’t signs of being high; they’re signs of opioid withdrawal. Quitting heroin is often called “kicking” in reference to the tendency to kick out one’s legs in attempt to stretch away the discomfort.
The War on Drugs Expanded the Ways People Use Heroin – and Set the Stage for the Opioid Crisis
In the Sixties and Seventies, just about all heroin addicts were intravenous users, but as the purity of the drug increased, so did potential methods for use.
During the 1960s, heroin use rose, in part, due to soldiers returning from Vietnam who were exposed to the drug overseas, and drug dealers in urban centers seized on this opportunity. Then, in the summer of 1969, when Nixon declared his war on drugs, he cited New York City’s heroin trade as the core of the problem. The speech apparently roused the NYPD, who proceeded to arrest some of the city’s biggest dealers.
Meanwhile, suppliers in Asia became concerned that they would lose their distribution. In response, they began setting up their own networks in America’s cities to establish a more discrete trade. Heroin sold in the U.S. saw a bump in purity around this time as a result of this more direct supply line. However, purity levels would soon skyrocket as the heroin market was about to become competitive.
Though Nixon targeted heroin in his speech, in practice the drug war mainly targeted toward marijuana.
With cocaine, heroin and marijuana all categorized as Schedule I drugs, DEA agents opted to pursue the smelliest, bulkiest and most conspicuous of those three substances.
Colombian and Mexican drug cartels, who had previously trafficked mainly in marijuana, switched to a product that was less noticeable and carried more value by weight. Ironically, it was the drug war itself that pushed the cartels into the heroin business.
Additionally, in the Eighties, crack appeared almost overnight – and authorities suddenly deprioritized heroin. Meanwhile, as a result of the tenfold rise in heroin purity between 1970 and 1990, nasal administration became a viable option for users. Mexican and Colombian cartels introduced the drug to suppliers and users who previously had only dealt with cocaine. The new, more socially acceptable method of use endeared the drug to an entirely new demographic of trendy, wealthy and often white cocaine users.
The demographic that had previously been most afflicted by heroin addiction took a deliberate step away from the drug. In low-income urban centers, the fallout of the 1970s heroin explosion became a cautionary tale. A generation came up witnessing the long-term effects of the drug, which had hardly existed as a threat in rural and suburban America. “Young African Americans and young Latinos were not going into heroin because they saw the destruction that occurred in their families and in their neighborhoods and they didn’t want to go down that road,” says Philippe Bourgois, a cultural anthropologist and author of the book Righteous Dope Fiend. “It was seen as a loserly thing to do.”
Meanwhile, he says, working-class white people in rural areas – which in the past had not been as affected by drug epidemics – found themselves beset by poverty due to the shifting nature of the American economy. The groundwork was laid for a potential drug crisis.
The Pharmaceutical Companies Made it Worse
For a true public health crisis to occur, there first had to be an influx of opioids into the country, the likes of which no drug cartel could muster. Enter the major American pharmaceutical companies. In the late 1990s, the pharmaceutical companies successfully lobbied the Joint Commission, an organization responsible for accrediting American health care programs thereby essentially setting the standard for American health care programs, to accept the concept of pain as a vital sign. Before that, pain was a secondary consideration. But now, physicians would be required to ask about and treat their patients’ pain. In the decade that followed, sales of prescription opioids in the U.S. quadrupled. Roughly during the same time period, the overdose rates quadrupled as well.
And as they made public attempts to reform, it only took the crisis in new directions. Take “abuse-proof” OxyContin. In 2010, OxyContin producer Purdue Pharma introduced a new version of the pill that they claimed was “crush-proof,” turning into a jelly if you tried to crush it into a powder, therefore making it impossible to inject or snort. Almost immediately, though, Internet forums lit up with collective solutions for overcoming the newly implemented safeguards. Meanwhile, anecdotes of addicts visiting the emergency room as a result of injecting the binders contained within the abuse-proof pills began to spread. Other users opted for a better workaround: switching to heroin.
Naloxone Is No Party
The existence of more opioid-dependent citizens continues to benefit the pharmaceutical industry. Naloxone, often sold under the brand name Narcan, counteracts the effects of an opioid overdose. Since 2014, there’s been a near 500 percent increase in sales of the drug. Meanwhile, over the last three years, pharmaceutical companies have steadily raised the price by as much as 50 percent. Now, with first responders throughout the country needing a steady supply of naloxone on hand, Big Pharma doesn’t only see several billion dollars per year off opioids themselves, but they see a growing profit from the sale of anti-opioids.
Thus far, 46 U.S. states have opted to make naloxone available over the counter. Despite this progress, a vocal minority has expressed concern that increased access to naloxone might have dangerous repercussions. The hysteria generated by those who oppose naloxone access may be responsible for the creation of a relatively new heroin myth.
In August 2017, a report from Boston’s Fox News 25 claimed to have identified a new trend where partygoers were intentionally overdosing on opioids so they could take Naloxone, thereby “giving the drug user a rush.” Several similar reports described the practice, dubbed “Narcan Parties.” The supposed trend was touted by Pennsylvania State Senator Lisa Boscola and State Representative Dan McNeil as a reason not to expand access to naloxone in the state. However, there’s no evidence that these parties are actually happening. “I have not been able to verify a single case of this,” Bill Stauffer, Executive Director at the Pennsylvania Recovery Organization, told The Outline. “I suspect it to be an urban legend.”
Replacement and Maintenance Therapies Gets Results Maintenance therapies like methadone and subutex have shown better results than non-medication-assisted treatments, both in cases of addicts seeking abstinence from opioids, and for those seeking simply to carry on living relatively normal lives. Replacement therapy with drugs like methadone, subutex, kratom and even cannabis have also shown major promise in helping addicts get clean.
The success rate of addicts getting clean without the help of replacement therapies has been stated to be as low as 3 to 5 percent and as high as 20 to 30 percent. Success rates amongst those using drugs like methadone and buprenorphine to help them taper off opioids have been cited as high as 60 to 90 percent. According to the California Society of Addiction Medicine, addicts who go cold turkey are significantly more likely to relapse than those who taper off with drugs like methadone or Suboxone.
Though Attorney General Jeff Sessions recently shared his opinion that most heroin addiction starts with marijuana “and other drugs too,” the benefits of marijuana as a potential treatment for opioid addiction have become the cornerstone of several controversial treatment modalities. Researchers also believe that painkillers derived from chemicals found in marijuana such as CBD could provide an effective and far less dangerous alternative to prescription opioids.
Safe-injection Sites Reduce Risk, Too
A 2005 study in Switzerland found greater reductions in opioid use and greater rates of complete abstinence among subjects who were given injectable heroin while supervised, over those who were given methadone over the same 12-month period. With the number of supervised injection sites around the world nearing 100, and showing promise in major cities like Sydney, Vancouver and Amsterdam, activists in major cities like New York have begun the fight to bring supervised injection sites to the U.S.
The Cure Could be in Hallucinogens
If anything like a “cure” for opioid addiction ever emerges, it will likely come from outside the medical establishment. For example, many consider Ibogaine, a hallucinogenic plant, to be one of the most promising opioid-dependence treatments on the horizon. The anti-addictive potential of the drug was discovered in the 1960s by Howard Lotsoff, an opioid-addicted beatnik who would spend the rest of his life championing the drug as a treatment for addiction.
The mantle for Ibogaine advocacy has since been taken up by people like Dimitri Mugianis, who after getting clean with Ibogaine put his life and freedom on the line to help suffering addicts with guerilla-style treatments in hotels across New York City. After a DEA sting landed Mugianis in jail in 2011, he became an icon of the harm reduction movement, a movement many consider integral to improving the state of addiction in this country. (After a years-long court battle, he was eventually convicted of a misdemeanor drug charge and served 45 days house arrest.)
While scientists see promise in drugs like 18MC, a new chemical compound that attempts to make use of the anti-addictive properties of Ibogaine without the hallucinogenic effects, Mugianis believes that too much emphasis is put on chemical solutions.
Mugiainis insists that the only way forward is to begin changing our outlook on those addicted to opioids. “We need to start treating drug users well, like human beings,” he tells Rolling Stone. “We must offer a menu of choices as varied and complex as humans are, and addiction is.”
Addicts Aren’t So Easily Pegged
Mugianis believes that the biggest misconception about heroin addicts is that they are non-functional. During his time treating addicts, Mugianis says he’s seen heroin users with careers and families living what many would consider successful, fulfilling lives. The harm for them mainly came when they didn’t have access to the drug. “To say that people are totally dysfunctional on opiates as Americans, we’d have to discount all that active users have given to this culture, from Billie Holliday to Edgar Allan Poe to Jimi Hendrix; people who not only functioned but excelled and enriched our culture,” he says. “The people who made our culture were high.”
HAMILTON, Mont. — The Florence doctor convicted last year of 22 felony drug counts including two negligent homicides is back in jail.
Dr. Chris Christensen had been free pending his appeal with the Montana Supreme Court. He was sentenced to 10 years in prison. But his bail has been revoked.
According to court documents, Christensen failed to file a timely appeal with the state Supreme Court.
Christensen has been arrested and is currently in the Ravalli County Detention Center.
The report said that it is the court’s judgment that Christensen’s stay should be “lifted immediately” and that he should begin serving his sentence “without further delay.”
A whistleblower with Aetna who accused CVS Caremark of gouging Medicaid and Medicare customers with high prescription-drug costs has been placed on paid administrative leave by the insurance company.
The move comes after the whistleblower’s lawsuit was unsealed in federal court in early April. It also comes as CVS Caremark, one of the country’s largest pharmacy benefit managers, pursues the acquisition of Aetna for a reported $69 billion.
Sarah Behnke, at the time the chief Medicare actuary for Aetna, filed the whistleblower lawsuit, which is pending. Her attorney told The Dispatch that the decision by Aetna to send her home is “retaliatory and inappropriate.”
Behnke said her internal investigation found that CVS Caremark was billing the federal government significantly higher prices for seniors’ drugs than was appropriate.
The scheme has been used by CVS Caremark since 2007, Behnke said, and has cost the federal government more than $1 billion in fraudulent charges, according to her lawsuit.
Some pharmacists say the same practice is happening in Ohio. CVS Caremark is the pharmacy benefit manager for four of Ohio Medicaid’s five managed-care companies.
A pharmacy benefit manager, or PBM, is the middleman entity that negotiates with drug manufacturers and then sets the prices for insurance companies and pharmacies. Those prices are what the public pays for prescription drugs.
State legislators in Ohio have requested that CVS provide pricing lists to see whether so-called “spread pricing” is happening in Ohio. Spread pricing is when the PDM negotiates a lower or discounted price with a drug manufacturer and then negotiates another price with the pharmacy. PBMs also negotiate different payments to pharmacies to make money. Those discounts typically are not passed on to the health-insurance provider.
CVS Caremark officials, who have rejected allegations of spread pricing or wrongdoing, say they will turn over documents by June 1. They say they were not aware of who filed the lawsuit until after announcing the plan to buy Aetna.
“We believe this complaint is without merit, and we intend to vigorously defend ourselves against these allegations,” CVS Health spokesman Michael DeAngelis said in an email response. Should CVS Caremark acquire Aetna, he said, “CVS Health policy prohibits the taking of punitive action against a whistleblower.”
Aetna officials declined to comment.
The lawsuit and CVS Caremark’s planned acquisition of Aetna both have significant implications for taxpayers, who fund Medicare and Medicaid programs.
Aetna would be the first health-care provider owned by CVS. If the purchase is approved by the U.S. Department of Justice, it would give the pharmacy giant a health-care conglomerate of managed-care and pharmacy benefit management operations.
That control of the entire chain of health care by CVS would, in effect, create a vertical monopoly and directly affect how much customers end up paying for health care, including prescription drugs.
The Trump administration has heavily criticized these types of conglomerations as being “monopolies” that allow companies in the prescription-drug chain to conceal prices. Last week, President Donald Trump’s Food and Drug Administration chief called it a “rigged system” against the public.
PBMs such as CVS Caremark were created to lower prescription-drug costs in the marketplace. During the past five years, prescription-drug costs have been the fastest growing facet of the health care chain, according to a recent study by U.S. News and World Report.
Three PBMs control between 80 and 90 percent of the prescription drugs in the marketplace, with an estimated $400 billion in gross sales, according to the IMS Institute for Healthcare Informatics. PBMs conceal how they affect drug prices from insurance providers and the public.
Behnke filed a federal False Claims Act lawsuit in 2014 under seal. Whistleblower lawsuits are sometimes filed under seal to allow federal prosecutors time to review the allegations and get involved.
Behnke’s attorney, Susan Schneider Thomas, said the government deferred participation for now. That allowed the judge to unseal the lawsuit in April.
That meant that CVS officials didn’t formally know the allegations or who filed the lawsuit until April.
Whistleblower advocates expressed concern that the acquisition by CVS could be bad for Behnke and affect the lawsuit. They said it’s unlikely, though, that CVS pursued the acquisition to choke off the lawsuit.
“I think if there is an acquisition by CVS, she has a reason to be concerned,” said James Mowery Jr., a Dublin-based lawyer whose firm specializes in whistleblower lawsuits. “She needs to be sure that her employer will always be Aetna, and she needs to be keeping a diary of everything that happens up until the acquisition.”
Mowery said the proposed acquisition makes the lawsuit a “significantly complex piece of litigation.”
Whistleblower Advocates, a whistleblower-lawyers firm based in Chicago, said that until the federal government demands to be a party in the suit, CVS will not feel pressure to address Behnke or her accusations.
Behnke said she took her concerns to corporate executives for Aetna and CVS Caremark in 2013, according to court records. Nothing happened.
Thomas said in the complaint she filed against CVS Caremark that the company was charging Aetna 25 to 40 percent more for drugs than its competitors.
Behnke also said that during meetings in February of 2013 with CVS officials to present her findings, CVS Vice President Allison Brown said Caremark had negotiated lower prices for those drugs but was not contractually obligated to show Aetna those prices.
Thomas called the exchange a “virtual admission of liability,” according to court records.
attrib? CVS Caremark officials also confirmed at those meetings that they had re-created Behnke’s analysis of drug prices and confirmed that she was accurate, according to court records. Behnke asked whether CVS Caremark could use the information to negotiate better prices for Aetna’s policyholders.
“Caremark defendants … stated that improving or increasing the discounts Aetna received would adversely impact” CVS Caremark’s profits due to “retail contracting methodology,” according to court records.
In an email sent in July of 2013, Aetna’s head of its Medicare division marveled at how much money CVS Caremark was making on the “hidden spread.”
By September of 2013, Aetna indicated it would shop around for another PBM to see whether it could find better rates, according to the lawsuit.
CVS Caremark officials immediately offered to lower the costs of drugs for Aetna. When Aetna started shopping for a better deal, CVS Caremark offered an even steeper discount, according to the lawsuit.
Attorneys for CVS Caremark filed a motion April 20 to permanently seal the case again, saying the lawsuit would cause significant financial harm. The company’s attorney said Behnke provided sensitive information.
“These details concern the financial guarantees and pricing terms to which Caremark and Aetna agreed as well as financial terms allegedly offered during negotiations and data allegedly revealing specific prices paid by Aetna as well as Caremark’s performance on financial guarantees,” the motion read.
Behnke’s attorneys have until Friday to respond to the request to seal the case.
