“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
passionate pachyderms
Pharmacist Steve steve@steveariens.com 502.938.2414
Is state-level medical cannabis access mitigating or fueling America’s opioid crisis? Testifying before Congress last week, Drug Enforcement Agency (DEA) acting administrator Robert Patterson claimed the latter.
But when he prompted to provide evidence in support of the agency’s position, he acknowledged that he could not.
According to one recently published study, “National overall reductions in Medicare program and enrollee spending when states implemented medical marijuana laws were estimated to be $165.2 million per year.” In Canada, where medical cannabis access is legal federally, recently published data reports that over half of trial subjects were able to cease their use of opioids within six-months of enrolling in Health Canada’s cannabis access program.One might expect the administrator of the nation’s chief drug enforcement agency to be aware of at least some of this data. But Patterson’s testimony proved otherwise.
Specifically, when asked by Florida Republican Matt Gaetz if the DEA was aware of the landmark 2017 National Academy of Sciences study finding, “There is conclusive or substantial evidence that cannabis [is] effective for the treatment for chronic pain,” Patterson answered that he was not.
He further acknowledged that he was unfamiliar with several state-specific, longitudinal studies, such as those from Minnesota and New Mexico, finding that chronic pain patients who register to partake in cannabis therapy dramatically decrease their use of opioids and other pain-relieving drugs. (Separate assessments of state-authorized medical cannabis patients in Illinois, Michigan, New York, and elsewhere affirm these conclusions).
He further claimed ignorance with regard to the findings of a highly publicized study in the Journal of the American Medical Association finding that medical cannabis regulation is associated with year-over-year declines in overall opioid-related mortality, including heroin overdose deaths.
Moreover, when pressed to provide evidence — any evidence — in support of the DEA’s questionable position, Patterson readily admitted that he knew of none. In fact, upon further questioning, he acknowledged that the DEA has, to date, never even so much as reviewed the issue. He further suggested that those patients seeking an alternative to opioid analgesics may wish to try “Tylenol.”
The testimony concluded:
Rep. Gaetz: “You’re the acting administrator of the DEA. You cannot cite a single study that indicates that medical marijuana creates a greater challenge with opioids, and you’re unaware of the studies, including studies from the National Academies of Sciences, that demonstrate that medical marijuana can be an acceptable alternative to opioids. Is that what I’m understanding?”
Robert Patterson: “Yes.”
At a time when tens of thousands of Americans are dying annually from their use of opioids, it is almost inconceivable that the DEA would willfully and publicly maintain such a Flat Earth position with regard to the use of medical cannabis as a potential alternative. Their failure to acknowledge basic and readily available facts and science is once again indicative of the reality that the DEA, admittedly, is an agency that places political ideology above all else.
As a result, pundits and legislators — particularly those at the federal level — should no longer give deference to the DEA’s cannabis-specific public policy agenda. Rather, they should view the agency as an artifact of a bygone era, whose positions and opinions are increasingly out-of-touch with the emerging scientific, political, and cultural consensus.
Paul Armentano is the deputy director of the National Organization for the Reform of Marijuana Laws. He is the co-author of the book, Marijuana Is Safer: So Why Are We Driving People to Drink? and the author of the book, The Citizen’s Guide to State-By-State Marijuana Laws.
It has been a common question of frustration that hundreds and hundreds of chronic pain patients have commented on the National Pain Report stories we’ve done on the opioid issue in last several years.
Politico has been covering the issue and wants to hear more information from patients and providers. Their story, 5 unintended consequences of addressing the opioid crisis talked about both sides of the story—which pain patient advocates say has been rare in the coverage of the opioid issue.
They are interested in speaking with patients and providers about their experience. I filled out the form recently–identified myself as the editor of the National Pain Report and received a response email asking that we tell you about the opportunity to comment.
Their director of engagement, Annie Yu, sent me an email with the request.
“Our stories are read by some of the top health care policymakers in the country, and we want to make sure that we’re listening to many perspectives as we can and letting that shape and inform our reporting,” she wrote.
The frustration–and the increasing isolation-that permeate the chronic pain population are well documented in our readers’ reaction to our stories. This is a chance for you to talk with the media.
And it gives the health care providers–many of whom have expressed to us and others their frustration with the opioid crackdown which didn’t provide any alternative to the restrictions–a chance to tell their story about the treatment challenges this presents.
If you have time after you’ve given Politico your views and opinion, please share in our comment section the gist of what you shared.
This is also a good time to remind you of the survey that we are promoting in advance of the FDA meeting in July. The FDA is challenged with determining how to balance the need to ensure continued access to persons who rely on opioids for continuous pain relief while addressing the ongoing concerns about safe use, abuse and misuse. You are asked to comment before June 17.
ST. PAUL, Minn. – On the eve of Mother’s Day, one mother is trying to raise awareness about the high price of insulin.
It’s an issue for which she has paid much too high of a personal price.
“Last year our 26-year-old son passed away because he was rationing his insulin,” said Nicole Smith-Holt.
Her son, Alec, died from diabetic ketoacidosis after aging out of his parents’ insurance coverage on June 1.
“He was actually found dead in his apartment on June 27,” Smith-Holt said. “So he lasted 27 days not being covered.”
She said Alec’s medical costs would have been about $2,000 per month.
“Usually birthdays are a happy time, but it was actually a time when I became very, very afraid for his life,” she said. “I knew he couldn’t afford the options that were out there.”
So on Saturday, May 12, the day before Mother’s Day, Smith-Holt stood on the Minnesota Capitol steps with a group of other families who are rallying to lower the price of insulin. They also want to force big pharmaceutical companies to be transparent about how much the drugs cost to make – and how much of a profit they make.
According to the American Diabetes Association, nearly 7.5 million Americans need the drug. And a 2016 analysis showed the cost of insulin nearly tripled from 2002 to 2013.
This is the first Mother’s Day Smith-Holt will spend without her son.
“He was a mama’s boy,” she said. “He never let a Mother’s Day go by without spending time with me. He would show up at my job and bring me a bouquet of flowers, or take me out to dinner.”
She said this is a “heartbreaking” place to spend the holiday.
“I should be with my son,” she said. “I should not have had to bury him at such a young age. No parent should have to bury their children.”
Smith-Holt’s husband and Alec’s father, James Holt, Jr., agreed, “We should be planning a nice family barbecue. But that’s OK. We’re gonna keep fighting until we get this accomplished.”
Within the next two months, anyone who gets an acute opioid prescription filled at a Walmart will be limited to a seven-day supply of the medication, part of the company’s effort to curb the number of pills being sold illegally on the street.
Walmart announced last week it would join CVS Caremark, the nation’s largest pharmacy chain, to cap prescriptions, a move Walmart said put it in line with federal guidelines.
“We’re taking action in the fight against the nation’s opioid epidemic,” said Marybeth Hays, Walmart’s executive vice president of health and wellness.
But some doctors say policies such as Walmart’s intrude on the doctor-patient relationship and make it more inconvenient for patients to treat chronic pain, but do not prevent addicts from getting opioids.
Walmart’s policy, which will be put into effect within 60 days, also mirrors efforts by several states that limit acute opioid prescriptions to seven days, including a bill before Pennsylvania lawmakers that would impose the one-week limit.
The bill’s sponsor, Republican state Sen. Gene Yaw of Williamsport, said limits on opioids are necessary to prevent future addicts.
“There is no question about it — the way that doctors were told to eliminate pain is part of the problem we have today,” Yaw said. “Somewhere along the line, you need to pick a number and say this number of pills is enough to get by, but not get someone addicted.”
The bill passed the Senate in October and remains before a House committee.
Dr. Kenneth Choquette, a Coordinated Health pain management specialist and physician for three decades, said he learned of Walmart’s new prescription policy from patients who use opioids and were alarmed by it.
“This is a disturbing trend that is actually destroying those 95 percent or more of people who need this medication,” Choquette said. “This is a horrible policy that is going to greatly burden those who already are using walkers, canes and crutches to go out every week to get their medication.”
Each week at his practice, Choquette said, he works with ailing patients who are under more restrictions from insurance companies, both in the type and amount of medication those companies will cover.
“The addict is going to find pills or other methods no matter what,” Choquette. “But these limits by industries and insurance companies doesn’t fix anything other than to greatly inconvenience those who are already suffering and yet taking their medication properly under the care of a physician.”
Dr. John Gallagher, chairman of the Pennsylvania Medical Society’s opioid task force, said he’s open to any ideas that may help slow the opioid epidemic, but isn’t sure if limiting pain medication is the answer.
“The arbitrary refusal to fulfill a physician’s treatment plan while not cognizant of the complete clinical situation may not be appropriate,” Gallagher said. He said the better answer may be to develop clinical practical guidelines and consult with the prescribing physician.
There’s little doubt that opioids continue to kill in record numbers. For the third consecutive year, overdose deaths rose dramatically in 2017 in both Lehigh and Northampton counties, according to a Morning Call analysis of the annual coroner reports released at the end of January. A total of 306 people died of drug overdoses last year.
Northampton County had 109 drug-related deaths, an increase of 56 percent over 2016, while Lehigh County had 197 drug-related deaths, a rise of 25 percent.
Pennsylvania has the fourth highest rate of fatal drug overdoses, according to 2016 figures, the latest available from the Centers for Disease Control and Prevention.
In April, Gov. Tom Wolf extended a statewide disaster declaration intended to make getting treatment for opioid addiction faster and easier. The declaration, originally announced in January, waives 13 regulations or protocols in an effort to direct more resources to battling addiction.
The state also has a prescription drug monitoring program that flags those seeking opioid prescriptions at multiple pharmacies.
Another part of Walmart’s plan includes electronic prescriptions for narcotics in 2020, which would eliminate the possibility of a paper precription being altered to get more medicine. CVS Caremark announced restrictions in September to its 90 million plan members that imposes a seven-day limit on opioid pills and also puts limits on the quantities of some higher-dosage opioids.
Here is a chain pharmacy that has the fewest drive-thru windows that is creating a obstacle to those people dealing with acute pain and causing them to have to navigate thru their huge stores or find someone to drive them to the store and/or go by and pick up their C-II Rxs. Of course, sending someone in to pick up a C-II Rxs for someone else… may be a obstacles all in itself. What is a pt caught up in dealing with acute pain to do ?
So is the country’s LARGEST RETAILER… WALMART … discriminating against a protected class under the Americans with Disability Act ?
A voter-led initiative to implement a medical marijuana program in Utah has been facing opposition since it gained enough signatures to make it onto the ballot in November. Led by the state’s medical community, the opposition has now gained the support of a local division of the Drug Enforcement Administration, sparking controversy about whether federal employees are allowed to provide their backing to political campaigns.
Under federal election laws, government agencies and certain employees are prohibited from participating in partisan activities related to campaigns, though in this case, it’s not clear that one party is leading the effort since the organizations involved—the Utah Medical Association and Drug Safe Utah—are not associated with political parties.
Still, it’s questionable whether the DEA is meant to take sides in electoral politics at all, especially when it appears that the anti-ballot campaign has been using some ethically dubious tactics. Documents obtained by Marijuana Moment have shown that door to door canvassers from the opposition have been instructed to use misleading information and cater their message based on the age of the individuals they are speaking to.
The medical cannabis initiative qualified for the November 6th ballot in April, collecting a reported 200,000 signatures—tens of thousands more than it needed. But the complicated process by which a ballot measure qualifies to be placed before voters in Utah has the opposition looking for loopholes to get it removed.
In order to meet the state’s requirements, the initiative’s organizers had to collect more than 113,000 overall signatures across the state, but those signatures also had to make up at least 10 percent of voters who turned out in the last election in 27 of the state’s 29 districts.
It’s that 27 district loophole that the opposition is trying to exploit by canvassing door to door to get those who signed the petition to remove their signatures. If they are successful, the ballot initiative will not appear before voters in the fall. But their effort is a long shot since they have to convince hundreds of people in multiple districts by the May 15th deadline.
According to a report from the Salt Lake Tribune, the opposition’s campaign has also gained the support of the Drug Enforcement Administration’s Salt Lake City Metro Narcotics Task Force.
If approved in November, the ballot question would greatly expand Utah’s existing medical program allowing residents to apply for a medical cannabis license with a list of around 12 qualifying conditions. The initiative also covers labeling, inspection and distribution methods which include dispensaries, but still prohibits the smoking of cannabis flower. The ballot question runs counter to a pair of laws recently passed by the Utah legislature which allowed the Utah Department of Agriculture to oversee the production of cannabis for limited use by terminally ill patients.
According to recent polling, nearly 80 percent of Utah residents support the voter initiative, making it likely to pass if it appears on the ballot in the fall.
Governor Gary Herbert has voiced his opposition to the initiative in favor of the more restrictive program passed by lawmakers but has also said that voters ought to be allowed to decide what they want. “Let’s have the vote. Let’s have the debate,” Herbert said in a public address last month. “I think it’s good to have the people’s voice heard.”
Above is a link to the new Walmart Policy and below is what showed up on the web today from a pt in the NW trying to get a “routine opiate prescription filled at her “normal Walmart”
I sent you a message it’s a long one but it kind of has to do with the pharmacy business and it was very shocking today. I’ve been a patient at this Walmart with the same dose for two years the only thing that changed was my doctor retired and he was 90 well deserved and I got transferred to it to another physician and same amount of medicine the only thing that was different was it was not e-filed it was paper and I’m not used to that I brought it to the pharmacy and stupidly had them hold it because I thought it would be safe there I always do it with my daughters medication because it is a controlled substance to me the pharmacy is a safe place. Anyway I went to pick up my prednisone and he said we cannot fill these would not give me a reason I said I don’t believe this applies to me I said I’ve heard about the new law with Walmart I said that’s for new patients and I am a chronic pain patient and I have been a patient here for 2 years and he basically wouldn’t give me any explanation and gave me my prescriptions back and once I got home I looked at them and they had barcodes that they had apparently ripped off in a very rough manner you can almost see the back it’s so thin anyway I don’t know if a new Pharmacy will take them everyone there knows me by my first name except for this guy I probably seen twice and he’s young he’s probably in his twenties maybe early thirtie he gave me the 1 800 Walmart number, and I told the guy what happened I have to wait 3 days in the meanwhile I called the old Walmart that I went to for probably 6 years in a different area and question them what could have been the matter she said I’m going to call right away and find out for you they know me by first name as well and she said it was pharmacists digression. Well nothing has changed on my end he complained that it was a high dose well it’s the same dose I’ve taken for over 2 years and gotten filled there what changed he treated me like horrible. This totally reminds me I should have had my phone on the counter but never in my wildest dreams would this have ever happened I didn’t go there for that I went there for simple medications any other person would and I was treated like a criminal and I would have loved to have it on recording. Sorry but this reminded me of it.
States and treatment companies want to offer methadone clinics on wheels to reach more people with opioid addictions in remote and underserved areas. But the federal government is standing in their way.
From California to Vermont, mobile methadone vans have served people with opioid addiction in rural towns and underserved inner-city neighborhoods for nearly three decades.
But the U.S. Drug Enforcement Administration, which regulates dispensing of the FDA-approved addiction medicine, has refused to license any new methadone vans since 2007 over concerns about potential diversion of the medication.
Now, in an unrelenting opioid epidemic that is killing more than a hundred Americans every day, some state and local addiction agencies are asking the federal government to lift its moratorium as quickly as possible.
In Seattle and surrounding King County, for example, federal grant money has been set aside to deploy four new mobile methadone vans to provide treatment on demand in addiction hotspots around the city and county. But the project is on hold until the DEA lifts the ban.
“Mobile treatment vans are critical to addressing the opioid epidemic,” said King County behavioral health official Brad Finegood. “As this epidemic grows and changes, concentrations of people who are affected by it can be found in shifting locations within the city and county. If we’re going to be effective, we need to be nimble and bring the medication to them instead of asking everybody to trudge across town to get their daily dose at a fixed facility.”
Joining the chorus of state and local behavioral health agencies is another federal agency, the Substance Abuse and Mental Health Services Administration, which provides grants to King County and other locations to make it easier for people with dangerous opioid addictions to receive treatment with methadone and other evidence-based medications.
According to a spokesperson at SAMHSA, agency officials are urging the DEA to remove the ban.
At a recent New York City gathering of the methadone industry’s professional organization, the American Association for the Treatment of Opioid Dependence, DEA official James Arnold said a proposal for a new set of regulations that would permit new methadone vans to be licensed was months away from completion.
Mark Parrino, who heads the industry group, said no security breach in any of the mobile vans licensed before the moratorium has ever been reported, leading industry experts to question why the ban persists.
Treatment officials in Connecticut, Maryland, New Jersey, New York and Washington state have expressed interest in deploying new methadone vans to fight the epidemic but have been stymied by the DEA moratorium, Parrino said. The most urgent need for mobile methadone, he said, is in Puerto Rico, where Hurricane Maria destroyed much of the territory’s transportation infrastructure and medical facilities last year.
Logistical Constraints
More than 2 million Americans are addicted to opioid painkillers or heroin, but only 1 in 5 is receiving treatment for their disorder, according to SAMHSA. Of those, most are not receiving methadone or one of the two other approved medications considered by addiction specialists to be the standard of care.
Only about a third of all treatment facilities offer all three medications, according to Health and Human Services Secretary Alex Azar, and Medicaid and private insurance coverage of the medications varies widely from state to state.
Of the three available medications for opioid addiction, methadone is the oldest, most researched and most widely used. But it is also the most tightly regulated.
Taken daily under supervision as required by federal regulations, methadone is out of reach for many who do not live within a reasonable distance of the nation’s roughly 1,500 methadone dispensing locations. The two newer approved medications — buprenorphine and a time-release form of naltrexone called Vivitrol — can be prescribed by a physician and taken at home.
Similar to patients with other chronic diseases, people addicted to opioids typically respond better to one medication than to another. For many, methadone is the only addiction medicine that successfully reduces drug cravings and wards off relapse. But many people live far away from brick-and-mortar methadone clinics.
Although relapse is common in all types of drug treatment, research indicates that people who take any of the three approved medications have a greater shot at remaining sober compared to those who receive therapies without medication. But to remain in recovery, people with opioid addictions often must stay on what is known as maintenance therapy for years, or for life.
Expanding Treatment
In Washington state, Seattle-based Evergreen Treatment Services, which operates the only methadone van in the state, just received an $11 million grant from SAMHSA, part of which has been set aside to buy four new customized vans for about $200,000 each.
The vans — designed to provide space for counseling, urine drug screens and methadone dispensing — are slated to make daily visits to one or more hard-hit Seattle neighborhoods, as well as the city of Renton in surrounding King County, and two other underserved cities with high addiction rates outside of the county — Olympia and Hoquiam.
According to Evergreen director Molly Carney, Washington state’s substance abuse agency is working with SAMHSA to get DEA permission to purchase and outfit the vans. “We’re told they’re actively working on it,” she said, “but there’s no timeline and no promise of when it will get released.”
In New York, Democratic Gov. Andrew Cuomo has dedicated millions in state dollars to expanding access to treatment using all three medications — methadone, buprenorphine and naltrexone — and officials at the state’s alcohol and substance abuse agency are talking to the DEA about lifting the ban, a spokesperson said.
According to the agency, mobile addiction treatment and transportation services are a critical part of New York’s strategy to offer treatment to more people with addiction. “Location and access to transportation should never be a barrier for someone to receive the services they need to fight this disease,” said New York’s drug and alcohol commissioner Arlene González-Sánchez.
The Pew Charitable Trusts
Terrance Washington reviews his treatment schedule with nurse Stephen Wright in a treatment van parked at Baltimore’s central jail.
Working Vans
In Mays Landing, New Jersey, one of a handful of grandfathered methadone vans licensed prior to the DEA’s moratorium is parked outside the Atlantic County Jail and serves as a dispensing clinic for inmates. The program has proven so successful at keeping inmates in recovery from opioid addiction that another methadone program about 80 miles up the coast in Neptune City wants to do the same thing.
According to JSAS HealthCare’s administrative director Margaret Rizzo, incarcerated pregnant women on methadone maintenance who come into the nearby jail in Monmouth County are given daily “guest doses” of the addiction medication while they’re inside because of federal requirements. “But if you’re a male on medication assisted treatment when you come into the same jail, you’re out of luck,” she said.
If the DEA lifts its moratorium on mobile methadone, Rizzo said, her treatment facility plans to buy a van to provide methadone to up to 50 inmates at the county jail.
In 1990, opioid treatment centers in Baltimore and Boston became the first in the nation to expand their urban drug treatment operations by outfitting vans to serve high-demand neighborhoods.
The drug treatment program in Baltimore, the Institutes for Behavior Resources, operated a DEA-licensed van and a backup van to dispense methadone to hundreds of patients for about 10 years, and then purchased new vans and used them for another 10 years before parking the vehicles and letting their licenses expire.
Two years ago, Behavior Resources leased one of those vans to another nonprofit program, the Behavioral Health Leadership Institute, which is using the vehicle to provide buprenorphine instead of methadone. Although the DEA also has authority over buprenorphine, it has not banned licensed prescribers of the medication from working out of a van.
Equipped with a bathroom and private counseling rooms, the van allows Behavioral Health Leadership to offer low-income residents drug screenings, addiction assessments, counseling and pre-paid prescriptions for buprenorphine.
Parked outside the Baltimore Central Booking and Intake Center, the repurposed van recently offered an opportunity for Terrance Washington, 44, to start turning his life around. A heroin user for almost 20 years, he was released from the Baltimore jail in January.
“When I got out, I kept on going right past the van,” Washington said. “But later my friend told me he’d been going for treatment there, so I went back to check it out.”
Washington got counseling, a prescription for buprenorphine, and a makeshift ID to take to a nearby drugstore. Since then, he said, he’s been taking his addiction medication and stopping by the van every few days to talk to a nurse or doctor about his progress.
On a sunny March morning, Washington stepped into the van and shimmied sideways to sit in a tiny counseling booth and talk to the nurse on duty about his recovery.
As he left, Washington said finding the van and getting on medication for his drug cravings has been “a big relief.” Instead of breaking the law to pay for heroin again, he said, it’s allowed him to try to get caught up on his rent and take care of some outstanding legal issues.
ONE HUNDRED YEARS AGO ( 1917) our judicial system declared that opiate addiction was a CRIME and not a DISEASE and declared that any prescriber caught treating or maintaining a addict would be jailed. During the 60’s Methadone treatment programs were established in NY city by the Rockefeller Foundation… At this time, it is claimed that about HALF of all Heroin addicts in the country were living in NY city and average age of a Heroin OD was 29.
Of course, this was before the Controlled Substance Act (1970)… so the DEA did not exist.
Maybe the political influence of the Rockefeller Foundation got these Methadone clinics acceptable… who knows…
Somewhere along the line, the DEA/DOJ decided to license these addiction treatment centers… the same DOJ that declared that opiate addiction was a CRIME and not a DISEASE… is now licensing the entities to treat the CRIME OF ADDICTION with MEDICATION… BUT in 2007 the DEA has been been refusing to license any new mobile treatment van… that would be serving the most rural and under served addicts.
It is almost as if the DEA/DOJ wishes to keep a certain per-cent of the population being addicted to some opiate … committing crimes to fund their habit and continuing the spread of various diseases – most HIV, Hep B&C – because of the sharing of needles.
Is this how the DEA/DOJ is meeting their basic charge in the war on drugs ?
Attorney General Jeff Sessions says the Justice Department is striving to “bring down” both “opioid prescriptions” and “overdose deaths.” A study published the following day suggests those two goals may be at odds with each other, highlighting the potentially perverse consequences of trying to stop people from getting the drugs they want.
Columbia University epidemiologist David Fink and his colleagues systematically reviewed research on the impact of Prescription Drug Monitoring Programs, which all 50 states have established in an effort to prevent nonmedical use of opioid analgesics and other psychoactive pharmaceuticals. Reporting their results in the Annals of Internal Medicine, Fink et al. say the evidence that PDMPs reduce deaths involving prescription opioids is “largely insufficient,” adding that “implementation of PDMPs may have unintended negative outcomes — namely, increased rates of heroin-related overdose.”
The review covers 17 studies, 10 of which looked at the relationship between PDMPs and deaths involving narcotic pain relievers. Three studies “reported a decrease,” six “reported no change,” and one “reported an increase in overdose deaths.”
The picture looks worse when you take into account deaths involving illegally produced drugs, which now account for a large majority of opioid-related fatalities. Fink et al. found six studies that included heroin overdoses, half of which reported a statistically significant association between adoption of PDMPs and increases in such incidents.
To the extent that PDMPs succeed in making pain pills harder to obtain, they encourage nonmedical users to seek black-market substitutes. “Changes to either the supply or cost of prescription opioids after a PDMP is instituted,” Fink et al. observe, “might reasonably drive opioid-dependent persons to substitute their preferred prescription opioid with heroin or nonpharmaceutical fentanyl.”
Restricting access to pain pills also seems to be increasing the percentage of opioid users who begin with heroin. A 2015 survey of people entering treatment for opioid-use disorder found 33 percent had started with heroin, up from 9 percent in 2005.
If the aim is preventing drug-related deaths, this shift is counterproductive, to say the least. Because their purity and potency are inconsistent and unpredictable, illegally produced opioids are much more dangerous than pain pills.
Comparing deaths counted by the federal government to its estimates of users suggests that heroin is more than 10 times as lethal as prescription opioids. Policies that drive people toward more dangerous drugs help explain why deaths involving heroin and illicit fentanyl have skyrocketed in recent years, even as opioid prescriptions have declined.
A report published last month by the health care consulting firm IQVIA shows that the total volume of opioids prescribed in the United States fell by 29 percent between 2011 and 2017, from 240 billion to 171 billion morphine-milligram equivalents. According to data from the US Centers for Disease Control and Prevention, deaths involving pain pills nevertheless rose by 24 percent from 2011 to 2016, while total deaths involving opioids rose by 85 percent.
That trend includes a 252 percent increase in heroin-related deaths and an astonishing 628 percent increase in deaths involving the opioid category that consists mainly of fentanyl and its analogues. Final CDC figures for 2017 are not available yet, but the provisional numbers indicate there will be more increases.
In addition to magnifying the risks that nonmedical users face, the crackdown on pain pills is hurting patients. Many people who have successfully used opioids to treat severe chronic pain for years now find it difficult or impossible to obtain the medication they need to maintain a decent quality of life.
Since the current strategy is manifestly not working, drug warriors are, as usual, redoubling their efforts. The Drug Enforcement Administration, which sets annual quotas for opioid production, reduced the limit by 25 percent in 2017 and 20 percent this year.
Sessions plans to squeeze the supply even more, because “we are facing the deadliest drug crisis in American history.” He seems determined to make it deadlier.
LAS VEGAS – You’ve probably heard political figures make the claim that at least one Nevadan dies every day from an opioid overdose. That figure of more than 360 opioid deaths per year in our state has been repeated over and over, but is it true?
The answer — not really.
The I-Team obtained the records on which the claim is based.
In Nevada, statistics show that 99.98 percent of all opioid prescriptions do not result in overdoses, but the crackdown on pain medicine has continued to intensify anyway. Like most pain management physicians, Dr. Dan Laird has been overwhelmed by the rush of chronic pain patients who’ve essentially been abandoned by their doctors.
“Thousands of patients, their doctors have said, ‘I’m sorry, I can’t prescribe opiates anymore. You’re going to have to find somebody else,’ and there just isn’t anybody,” said Dr. Dan Laird, pain management physician.
When the CDC issued vague and unsubstantiated guidelines for opioids two years ago, it set off a nationwide panic among doctors, pharmacists, and regulators who simply said no. The result has been chaos.
A recent study shows opioid prescriptions dropped 29 percent from 2011-2017, but during that time opioid deaths rose 8 percent. Heroin and fentanyl deaths exploded. (Heroin deaths increased 252 percent. Fentanyl deaths increased 628 percent.)
Cutting back on legal pain meds not only failed to stop overdoses, it had the opposite effect. So, how can that be?
The coroner’s office keeps track of what it lists as all opioid related deaths.
“This information your team has been able to obtain is a game changer because it does confirm every suspicion I have had, and other doctors have had about the dishonesty of the publicity that surrounds this purported crisis,” Dr. Laird said.
The first fatality of 2017 lists heroin, hydromorphone and methadone, along with pneumonia. The second case lists methamphetamine and opiate intoxication. The third lists pneumonia, asthma tobacco, marijuana, and congestive heart failure along with methamphetamine and cocaine. All the way down the page, it’s the same picture over and over, multiple drugs, most of them illegal, often combined with alcohol, and the decedents also had serious underlying health issues. To label these as opioid deaths is a stretch.
It appears that if the toxicology showed an opioid in their system at the time of death, it’s counted as an opioid death, which is quite misleading. The records from 2018 — more of the same — heroin, heroin plus cardiovascular disease, inhalation injuries due to smoking methamphetamine or how about this one, multiple drugs along with cirrhosis, HIV and leukemia. Examples of pretty much every licit and illicit drug one could name.
Chronic pain patients like Rick Martin of Henderson are in pain management programs. They are tested, they follow the rules, but because of addicts taking deadly amounts of heroin or other drugs, the patients who follow the rules have been cast aside as collateral damage. Nevada is not yet as strict as many other states, but the political rhetoric is amping up in this election year, and the oft-cited figure of one Nevadan per day dying of opioids continues to resonate.
“Seventeen people a day die of heart disease. Fourteen people a day die of cancer. Four people per day die in Nevada of lung cancer. So, it’s important to keep these things in perspective. One person a day dies of an opioid but that includes everyone on the list, everyone who had an opioid in their system at the time of their death.
About one in every 40 of the deaths listed in the records involve a single, prescription opiate and there is no indication whether the decedent obtained the drugs through a legal prescription or other means.
For healthcare to improve, we need to look at the outcomes of our actions and activities, identify the source of our errors and do better. A few months ago, the Annals of Family Medicine reported on how “blame” is attributed; do we point at ourselves, others or the system?
The study was conducted based on records of the United Kingdom’s National Health Service’s National Reporting and Learning system which records all patient safety occurrences. Like many of these databases, it is required and captures much of the detail surrounding these bad outcomes – you might think of it as a paperwork version of the Transportation and Safety Boards investigations of plane and train crashes. The researchers found about 14,000 records about primary care’s poor outcomes and randomly selected about 2200 for the study [1] The defined “blame” as evidence in the free-text of these reports of judgments about “deficiency or fault by a person or people;” system failures were labeled no blame. Here is what they found:
System failures accounted for 55% of the outcomes – there were flaws in how the healthcare system was organized.
Forty-two percent of individuals writing these reports blamed others – termed “directed blame” by the authors.
Two percent of the report’s authors attributed the errors to themselves, acknowledging their personal responsibility.
The more often a poor outcome had multiple contributing factors, the more often there was directed blame.
Poor outcomes involving judgment and interactions with patients had higher percentages of directed blame.
The discussion mentions a classic theory in failure analysis [2] where human error is inevitable and poor outcomes are “the result of multiple smaller errors.” More importantly, improvement comes not from deciding who failed, “but how and why the defenses failed” – what about the system lead the individual astray? Blaming others is not conducive to that kind of analysis and is often the refuge of “cover one’s own back.” It also reflects how we believe the “system” made me do it when I bear responsibility, and when someone else can be held accountable, they are bad people. Blaming others may satisfy the soul, but does little to improve care.
The article is helpful in understanding the culture of patient safety; it came to mind because of the current Congressional hearings on the opioid crisis.
“But for hours on Tuesday, executives from five drug distributor companies largely parried questions from House members and attempted to shift blame to anyone but them — to the Drug Enforcement Administration, physicians, and pharmacies, among others.
“I just want you to feel shame,” Rep. David McKinley (R-W.Va.) told the executives at one point, suggesting that financial penalties were insufficient and alluding to jail time. “So what’s the proper accountability? …What’s the punishment that fits this crime?”
Many small and large errors contributed to the opioid epidemic, and we all bear responsibility for creating the situation and for correcting our mistakes. But attribution of blame and subsequent punishment is the role of the judiciary, not Congress. Congress makes the rules. For example, the Ensuring Patient Access and Effective Drug Enforcement Act of 2016 which among other provisions made it more difficult for the DEA to bring actions against drug distributors for the egregious behavior Representative McKinley is railing against – an act passed by the unanimous consent of the House, including Representative McKinley. This behavior sounds so much like the directed blame found in the study.
Congress should investigate the bad outcomes of their legislative efforts, but this staged theater of indignation and moral high ground serves us poorly. The current Congressional hearings on the opioid crisis reflects a culture of blame rather than reflection, just like those poor healthcare outcomes reports. Improving safety doesn’t come from photo ops and sound bites on the evening news any more than it comes from nurses and physicians blaming one another. Improving safety and our legislation comes from analysis and reflection that recognizes blame as an impediment, not a response. If Congress wishes to help and use its considerable powers then it should remember President Theodore Roosevelt’s initial phrase, speak softly.
[1] The survey size was selected to be confident in the statistical analysis of their results
