We Need to Consider Involuntary Treatment for Heroin Overdose

www.epmonthly.com/article/need-consider-involuntary-treatment-heroin-overdose/#comment-270064

For too long we have waiting for drug addicts to hit rock bottom before intervening. But the costs to individuals, and to society, are simply too high. We must take firm, compassionate action, and it starts in the emergency department.

How many times have we reversed a heroin overdose only to have the patient leave the ED to OD again? Maybe it’s time to change that cycle. Here in Maryland, I am spearheading a subtle yet radical new approach, and a growing coalition of medical professionals, social workers and politicians are beginning to show their support. I’d like to share it with you, my colleagues, because it’s an approach that often begins in the emergency department.   

Let’s consider a common scenario. A family brings in their grandfather who is depressed and suicidal. They found him sitting on the side of the bed with a shotgun in his mouth. With such evidence, you have the legal authority to commit the patient to a locked psychiatric ward – essentially incarcerate him – for up to three days or until such time that a judge can examine him to see if he is a “danger to himself.” If evidence of such is submitted to the judge, she can further commit/incarcerate him until such time that the “danger to self” has subsided.

Now let’s change the scenario slightly. Instead of a grandfather with a gun in the mouth, it’s a young adult with a needle in his arm. Both “weapons” are life threatening. The difference is that in the second scenario, the young adult is clearly not intending to commit intentional suicide. But it is reasonable, even obvious, to the rational person that the risk of death is so great that he is exhibiting a knowing and willful gross indifference to his own personal safety. And that is where we hope to change the law, to expand the definition of “danger to self” to include heroin addiction, to allow health care professionals, you and I, to involuntarily commit addicts to treatment. Before you start the push back let’s unpack this a little.

First and foremost, I’m not suggesting we mandate in-patient treatment. We don’t have enough psychiatric beds now. Patients can spend weeks in the ER waiting for such beds to open up. Furthermore, with people failing in-patient rehab multiple times, there simply will never be enough in the nations coffers to cover such a program. We could break the bank overnight.

But the cost of mandatory out-patient therapy is within reach, especially considering the savings over doing nothing. But how would mandatory out-patient therapy work? Maryland is already in the process of building its first “stabilization units” dedicated to substance abuse. After the catastrophes of the old drunk tanks, people picked up by ambulance and police with no other complaint but drunkeness could no longer be brought to jail, but had to go to the ER for clearance. Now we will have a place for such patients to be evaluated and stabilized before disposition. Such units could have an assigned judge that could hear emergency cases of “danger to self” resulting from drugs. A tracking ankle bracelet could be attached to the patient before being released to follow up the next day with an outpatient detox unit. If the patient failed to show up for medically assisted outpatient detox and therapy, a warrant for their arrest would be issued, and the standard punishment for this misdemeanor would be four days of incarceration. This just happens to be the standard time required for unassisted withdrawal. Cold turkey withdrawal is absolutely miserable, with its nausea, vomiting, muscle aches, and “goose flesh.” But it’s not life threatening. It’s a simple matter of “We can do this the easy way or the hard way.” After a few times of going through involuntary withdrawal, the patient will finally realize that outpatient therapy with medical assistance is not so bad.

For the patient with a tracking device and a mobile phone, telemedicine programs could help encourage follow up with therapy while letting them know when they are in dangerous areas of known drug dealing. Such tracking could also help alert law enforcement to areas where drugs are being sold.

I know what you’re thinking. Whoa, isn’t this a little over the top? A little big brother? Some civil libertarians might even argue in the abstract that “there is no law against stupid”. If there were, we might incarcerate smokers or extreme sport enthusiasts or even jaywalkers. But the heroin epidemic is a national disaster of historic proportions. It dwarfs the death toll of hurricanes, terrorist attacks, even recent wars. The Vietnam War cost America over 50,000 lives and untold injuries over the course of about 10 years. We will lose that many Americans to overdoses next year alone. And the body count continues to accelerate. Moreover, the secondary cost to society in health care, crime, cultural damage, and loss of productive lives in simply incalculable. A crisis of this proportion deserves a fundamental shift in culture and law. Our approach is to broaden the definition of “danger to self” with very narrow and specific language.  The courts will always be leary of infringements on personal rights and will fight hard to uphold the right to due process. But I believe laws can be drafted narrowly that rise to the danger without introducing more risk to our personal constitutional right to be left alone.

Some argue that you can’t really help the addict until they want help. They say that you can’t see improvement until the patient “hits rock bottom.” But there is a lot of physical and social carnage that occurs as the patient free falls to the “bottom.” Besides the obvious risk of death, there is the risk of disease, HIV, heart disease, trauma, and many other expensive disorders. And society ends up picking up the tab for most of it. Further, all of us have seen the secondary fall out of the addict’s behavior, family destruction, spousal and childhood abuse, and violent crime. Society has an interest in preventing such damage and cannot stand by as though we have no dog in this fight. We do. And we have the right and responsibility to act, for the benefit of the patient and ourselves.

Yes, such a law would require an expansion of the courts along with a loss in some aspect of personal freedom. But I think these problems are not insurmountable. The larger question is whether we currently have the infrastructure to handle the influx of patients, even in an outpatient setting. And the answer is a resounding NO. After retiring from emergency medicine I have taken a position as the Chief Medical Officer of the largest methadone treatment facility in the nation, treating over 3,000 patients daily. (I know, that’s jumping from the frying pan to the fire! More on that another time.) But it is estimated that there are over ten times that many heroin addicts in Baltimore alone. Can we build the capacity to serve that many patients? Not overnight, for sure. But this is a pathway that is both rationale and eventually doable. As they say, Rome wasn’t built in a day. We can start laying a foundation for a better future.

I’d love to hear your thoughts, your criticisms, and your suggestions. As ER docs we have been living with this problem for decades. I think it’s time that emergency physicians lead the charge in 50 states to do something to change it. You can reach me at mplaster@epmonthly.com.

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Trump opioid panel will recommend nationwide drug courts, tightened requirements for prescribers

www.statnews.com/2017/10/30/opiod-commission-draft-recommendations/

WASHINGTON — President Trump’s commission on combating the opioid epidemic plans to encourage the federal government to establish drug courts in every federal judicial district, adjust reimbursement rates for addiction treatment, and streamline federal funding used by state and local governments to implement drug treatment and prevention programs, according to a draft of the panel’s final report.

Those steps are among the 53 recommendations laid out in the draft, a copy of which was obtained by STAT. The final report is set to be released on Wednesday.

The highlights:

Drug courts in all federal judicial districts

As of 2015, according to the commission, less than one-third of federal judicial districts and 44 percent of U.S. counties operated drug courts, which serve as alternatives to the traditional court system and have been shown to increase engagement in addiction treatment and reduce recidivism rates. The commission will recommend the Department of Justice establish drug courts in every federal district, and that individuals with substance use disorder who violate probation terms be diverted to a drug court as opposed to prison.

Drug courts combine elements of criminal justice and addiction treatment to help those with substance use disorder avoid criminal sentencing, provided participants comply with a treatment course that can include counseling and medication-assisted treatment.

Staffers in nearly nearly every governor’s office, according to the report, expressed concern about opioid-related funding from the federal government being “fragmented.

The commission will recommend a system for distributing federal funding that expands and mirrors the process for obtaining block grants offered by the Substance Abuse and Mental Health Services Administration. That process should require only one application and result in states receiving at least equivalent funding while allowing them to redirect resources currently used for paperwork toward program implementation.

Changes to reimbursement rates set by federal addiction treatment providers

The commission will recommend that the Centers for Medicare and Medicaid Services review policies that incentivize the prescription of opioids over more expensive non-opioid treatments.

It will also urge the Department of Health and Human Services to review its rates to more adequately measure and cover the “true costs” of treating substance use disorder, including use of inpatient psychiatric facilities.

The report recommends lowering barriers to substance use disorder treatment, including those that impose limits on access to any of the three forms of medication-assisted treatment approved by the Food and Drug Administration. Separately, the report recommends increasing access to recovery coaches.

A best-practices guide issued by the National Highway Traffic Safety Administration — which oversees the federal Office of Emergency Medical Services — currently recommends that paramedics and advanced medical technicians be allowed by local communities to administer naloxone, the overdose-reversal drug. The report recommends the those guidelines be reviewed to allow emergency medical technicians to also administer the medication, and in higher doses.

Several states currently prohibit some classifications of emergency responders from administering naloxone.

Tighten requirements for prescribers

The report will recommend the Drug Enforcement Administration require prescribers seeking to renew licenses to prescribe opioids first demonstrate they have participated in an education program regarding the drugs’ prescription. The report also recommends that HHS develop a “national curriculum and standard of care for opioid prescribers,” and that pharmacists receive training “on best practices to evaluate the legitimacy of opioid prescriptions.”

Eliminating patient pain evaluations from surveys

The commission will recommend that CMS eliminate questions about pain levels from patient satisfaction surveys, thereby ensuring that providers are not incentivized to prescribe opioids in order to increase measured patient approval.

Steps to ensure parity

The draft report says federal and state regulators should have better ways of measuring health providers’ compliance with parity laws, which require providers to provide and fund services for mental health and addiction on an equal basis to other health conditions.

Media camaign

The White House, the commission will recommend, should fund and coordinate with private-sector and nonprofit groups to implement a “wide-reaching, national multi-platform media campaign addressing addiction stigma and the danger of opioids.” The report likens the effort to a similar initiative launched during the HIV/AIDS epidemic of the 1980s and 1990s.

In another prevention initiative, the report recommends a collaboration between states and the Department of Education to implement student assessment programs to identify at-risk youth in middle school, high school, and college in need of treatment.

The report will also recommend implementing policies that ensure patients are adequately educated about the “risks, benefits, and alternatives of taking opioids” before receiving an opioid prescription for chronic pain.

Expand compliance with the Prescription Drug Monitoring Act

The report will push the White House to endorse the Prescription Drug Monitoring Act, legislation currently before Congress that would require states receiving federal grant money to comply with regulations for prescription drug monitoring programs and share data with a national hub to be established by the Department of Justice.

Separately, the commission recommended integrating PDMP data with electronic health records systems, and that the DEA and the Office of National Drug Control Policy increase electronic prescribing to prevent forgery and drug diversion.

Better data on overdose deaths

“We do not have sufficiently accurate data from medical examiners around the country to determine overdose deaths,” the report reads. It directs the federal government to develop forensic and toxicology procedures for use while investigating drug-related deaths.

Leveraging Public Health Service personnel

The report recommends the White House deploy health care workers from the Public Health Service Commissioned Corps to administer treatment and care in areas with above-average opioid use.

Bolstering research money

The director of the National Institutes of Health, Francis Collins, has acknowledged already that while he hopes the agency will continue to play a major role in addressing the drug crisis, it will be unable to significantly do so by merely redirecting some of its current funding. The commission agrees, and cited three institutes within NIH it deems worthy of increased research funding: the National Institute on Drug Abuse, National Institute of Mental Health, and National Institute on Alcohol Abuse and Alcoholism. It did not specify recommended funding levels.

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Surgeons are worried overweight patients and smokers in England and Wales are being denied surgery to save money

http://www.bbc.com/news/health-36101302

A report by the Royal College of Surgeons found a third of local NHS health bosses in England put restrictions on access to surgery.

But it says this goes against official guidance and can prolong patient pain.

However, some local NHS groups criticised in the report say their polices are based on good evidence.

The Royal College of Surgeons has been increasingly alarmed about the rationing of surgery in the NHS in the tough financial climate.

Its report is based on freedom of information returns from nearly all of the 209 clinical commissioning groups in England and all seven health boards in Wales.

While some CCGs have voluntary policies in place, where patients are encouraged to stop smoking or lose weight, others have introduced mandatory policies, which means patients have to meet fixed criteria before surgery.

‘Soft targets’

The college says mandatory policies are “a cause for concern” and it fears patients with a high body mass index (BMI) or who smoke are becoming “soft targets” for NHS savings.

The report reveals 31% of CCGs and one health board in Wales have at least one policy requiring people to lose weight or stop smoking before they can be referred for routine surgery.

Local NHS groups which compel patients to meet fixed criteria before surgery include:

• Luton CCG – has a BMI cut-off of 30 for any planned surgical procedure
• East and North Hertfordshire CCG – requires a patient’s BMI to be under 30 or for them to lose 10% of their bodyweight before surgery
• North East Essex CCG – requires patients who smoke to stop and attend smoking cessation programmes before referral to surgery

• iWonder: Should the NHS always foot the bill?

Dr Hari Pathmanathan, who chairs East and North Hertfordshire Clinical Commissioning Group, said there were good reasons why they asked some patients to lose weight and stop smoking before being given an anaesthetic.

“These patients are much more likely to suffer serious breathing problems, get infections and have heart, kidney and lung complications,” he said.

“It also takes them longer to recover, and they have a higher risk of dying under anaesthetic.

“It is for these health reasons that patients who have a higher risk because of their weight are not be booked for routine surgery until they have lost enough weight to improve the outcomes of their surgery, although no-one would be asked to wait for more than nine months.”

Dr Pathmanathan added that every patient’s case was considered individually, based on their health needs, and the restrictions were for planned surgery only.

The report suggests one in five CCGs has mandatory policies on BMI levels before hip and knee replacement surgery, while 4% have mandatory policies on getting patients to stop smoking before hip and knee replacement surgery.

Of the CCGs that responded, 22% reported having at least one “voluntary” policy in place.

‘Case-by-case basis’

The Royal College of Surgeons said any blanket ban on surgery based on a patient’s weight or whether they smoked was wrong and not supported by national guidance.

Instead, president Clare Marx said, patients should be encouraged to sign up to programmes to help them stop smoking and manage their weight while awaiting surgery.

“NHS surgical treatment should be based on clinical guidance and patients should be dealt with on a case-by-case basis,” she said.

“In some instances, a patient might need surgery in order to help them to do exercise and lose weight.

“While it is difficult to categorically prove such policies are aimed at saving money, it is unlikely to be a coincidence that many financially challenged CCGs are restricting access to surgery.”

She added National Institute for Health and Care Excellence (NICE) guidance did not support these mandatory bans for routine surgery.

No justification

British Orthopaedic Association president Tim Wilton said there was no clinical or financial justification for refusing to fund hip or knee replacements.

“Good outcomes can be achieved for patients regardless of whether they smoke or are obese, even at BMIs of over 50, and these surgeries are highly cost effective, typically delivering sustained pain relief for a cost that equates to just £7.50 a week,” he said.

“Hard-and-fast rules also undermine the NHS’s ability to involve patients in decisions about their own care, and are a distraction from the task at hand: making sure patients receive the best possible advice and care, to enable them to make the best possible decisions for their health – including losing weight and stopping smoking where appropriate.”

However, Dr Anita Ray-Chowdhury, clinical director of system change at Luton CCG, defended their approach.

“We do everything we can to ensure that patients who need urgent or life saving surgery get the help they need quickly, irrespective of their weight or if they smoke.

“For less urgent surgery there is strong clinical evidence showing that being overweight and smoking can have an adverse effect to the outcome, so we advise that clinicians work with the patients to take a holistic approach by addressing lifestyle factors that may improve the outcome of surgery.”

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The Myth of an Opioid Prescription Crisis

https://www.cato.org/policy-report/septemberoctober-2017/myth-opioid-prescription-crisis

According to the New York Times, drug overdoses are now the leading cause of death for Americans under age 50. Opioid overdoses, in particular, have been on the rise in recent years, killing over 30,000 people in 2015. In response, many have called for stricter regulations on prescription opioids. But are doctor-prescribed drugs truly the cause of the increase in overdoses? At a Capitol Hill Briefing in June, Arizona surgeon and Cato senior fellow Jeffrey A. Singer argued that regulators, in their rush to interfere in the patient-doctor relationship, are actually causing more problems than they’re solving.

THE SCIENCE OF OPIOIDS
Many people in the policy world really don’t understand the science of opioids, so let’s begin by clearing up a few myths. First, it’s important to understand that the long-term use of opioids, unlike alcohol, really doesn’t have deleterious effects on the body. That’s why we place people on methadone maintenance, for example, sometimes for their whole lives.

And so far there’s no conclusive evidence that long-term use of opioids has any effect on cognitive faculties or on the brain itself. Second, I want to clear up misconceptions about heroin. Heroin is a brand name. The chemical name is diacetylmorphine. Its generic name is diamorphine. It was invented by Bayer in the late 1800s and given the brand name of heroin, which is a derivation of a German word that has to do with “strength.” It’s still on the formulary and used by doctors and pain patients in a lot of developed nations, including the United Kingdom, Canada, and others. It was banned in this country in 1924 because the head of the Narcotics Bureau at the time was convinced that it corrupted moral character. And despite appeals by the physicians at the time to leave it legal because there weren’t that many pain medications available, it was banned. So of course, as any economist will tell you, within a very short period of time heroin became the number one substance for opioid addicts — because what would you rather sell on the black market: something that’s totally banned, or something there are other ways to get?

Heroin is about three times more potent than morphine; and methadone, which we give people on methadone maintenance — we’ll get more into that later — is also two and a half to three times more potent than morphine. Dilaudid, which is legal and which we give to patients for whom morphine is not working, is three to four times more potent than heroin. And fentanyl, also legal, is 50 times more potent than morphine.

Another commonly held misconception is that if you take one hit of heroin, you’re hooked. That’s absolutely not true. If it is, then why isn’t that the case with morphine or Dilaudid or any other legal opioids we give people? In fact, as early as the 1960s, studies done in the New England Journal of Medicine and International Journal of Group Psychotherapy identified heroin users who were true recreational users. They used it on occasion, on weekends. They had productive lives and were not addicted, just occasional users.

And although we often hear the words “addiction” and “physical dependence” used interchangeably, there is a difference. A recent article in the New England Journal of Medicine by Nora D. Volkow points out that, on the molecular level, physical dependence is when you actually develop withdrawal symptoms when the drug is taken away, so you need to be tapered off — as opposed to addiction, which is a behavioral disorder, in which you actually seek the drug. You will make major sacrifices in your lifestyle that have negative consequences for you because it’s so important to you to take the drug.

That’s a lot different from physical dependence. I’m a surgeon, and most of our patients who come to the office dependent on opioids want to be off them, so we help them slowly taper off. An addict, on the other hand, doesn’twant to be off them, which is why you have a high recidivism rate when you’re treating drug addicts.

ARE OVERDOSES A PRESCRIPTION PROBLEM?
The National Survey on Drug Use in Health has found that the nonmedical use of prescription opioids such as oxycodone and hydrocodone actually peaked in 2012. Total opioid use was actually lower in 2014 than in 2012. Despite that, opioid overdose deaths have increased. There were 33,000 deaths in 2015.

An overwhelming majority of those deaths, however, are people who used mixtures of drugs. In 2013, New York City found that 94 percent of the people who died from heroin or other opioids had mixed drugs in their system. These were not necessarily chronic pain patients. And also, for the first time, this year more people died from heroin overdoses than from prescription opioid overdoses.

According to Chinazo Cunningham at Albert Einstein College of Medicine, who helped develop the 2016 Centers for Disease Control and Prevention (CDC) guidelines, the number of prescription opioid overdoses is actually stabilizing, but opioid overdose rates have not plateaued because heroin use is dramatically increasing. So that’s important to understand — that the big cause of overdose problems now is heroin. We’re also seeing heroin use become much more prevalent in people in upper socioeconomic groups, and among suburban and rural white individuals.

According to the National Survey on Drug Use and Health, only one-quarter of people who take opioids for nonmedical reasons get them by obtaining a prescription. So the sequence that everybody thinks exists, in which a patient gets narcotics for pain, gets hooked, and then eventually dies from an overdose, is not your typical story. In fact, a 2014 JAMA (Journal of the American Medical Association) study of 136,000 patients treated for opioid overdoses in emergency rooms found that just 13 percent of them were chronic pain patients. And the CDC cites a study showing that the opioid-related overdose rate for people who are on chronic pain medicine under the guidance of a doctor is 0.2 percent.

New addictions in people who take opioids for pain, in general, are uncommon. The most rigorous comprehensive review, from the Cochrane Library, found that the addiction rate of people put on prescription opioids was about 1 percent. It’s very rare that a doctor prescribes a painkiller for a patient in pain who then gets hooked and becomes a heroin addict.

THE TRUE CAUSE OF THE PROBLEM
Both the CDC and the Texas A&M College of Pharmacy report that what they areseeing, however, is that as pain patients who are physically dependent and are in pain are gradually cut off pain medicine by their doctors, who are getting pressured to stop prescribing, a lot of them go on to seek pain medicine through the illicit drug market. And of course when they go to the illicit drug market, they often buy counterfeit opioids, and they don’t know what they’re laced with. Oftentimes they’re laced with fentanyl. And many of them are buying heroin, because heroin is, according to the CDC, about one-fifth the price of streetobtainable prescription opioids.

Also driving the opioid problem is the promotion of tamper-resistant opioids. The Food and Drug Administration (FDA) is encouraging pharmaceutical companies to develop drugs that are tamper-resistant — in other words, you can’t use them for anything other than the medicinal use for which they were prescribed.

Mark Twain has been quoted as saying that history may not repeat itself, but it rhymes. Many people may be aware that back during the days of alcohol prohibition, ethanol was still allowed to be produced for industrial use. But the government required that the manufacturers put in what was called denatured alcohol — they put ingredients in it to make it unpalatable, so that bootleggers couldn’t steal vats of ethanol and sell it on the black market. But bootleggers are pretty resourceful people, and they soon found out how to distill those impurities out and still sell it. So in 1926, the government required industrial ethanol manufacturers to add methyl alcohol, or methanol, also called wood alcohol, which can make you blind when you drink it. (That’s where the expression “drinking himself blind” comes from.)

So they put methyl alcohol and benzene in the ethanol, and that, despite attempts, could not be distilled out. At least 10,000 deaths are documented since 1926 from people who were drinking bootlegged alcohol that contained methanol and benzene.

That was the alcohol prohibition years’ version of tamper-resistant alcohol, and it resulted in unintended consequences. I’m sure nobody wanted to see people die. But the same thing is happening today with tamperresistant drugs.

For example — in 2010, OxyContin was converted to a tamper-resistant package. And when people couldn’t crush it any more to snort it, they figured out how to boil it, turn it into an injectable form, and then inject it. A study published in the Canadian Medical Journal in 2015 found that “In Ontario and the US, overall rates of opioid-related deaths have continued to rise since the long-acting formulation of oxycodone (OxyContin) was replaced with a tamper-resistant formulation… . Rather, there is increasing evidence that individuals shift to other opioids, including uncontrolled formulations such as heroin.” In JAMA Psychiatry in 2015, Cicero and Ellis found that nonmedical users of OxyContin switched to other opioids, or to heroin, after the tamper resistant reformulation of OxyContin replaced regular OxyContin in 2010.

In June, the FDA asked the manufacturer of Opana ER to pull it off the market. Opana is the brand name for oxymorphone, stronger than oxycodone. It used to be very popular, when it was obtained in the black market, to crush it and snort it. The manufacturers then made it so that it was not crushable, so people figured out how to boil it and inject it. And then an outbreak of HIV was reported in the Indianapolis area from people sharing dirty needles to inject Opana ER. I understand what tamper-resistant measures are trying to do, but instead they’re actually creating a lot of these problems.

At the same time, all but one state (Missouri) have adopted PDMPs, or prescription drug monitoring programs. These programs give us doctors a report card — in the case of Arizona, it’s every quarter — of where you stand with respect to all of your colleagues in your specialty as to how many prescriptions you wrote for oxycodone, hydrocodone, and so forth. It is not broken down by how many patients you saw, just how many prescriptions you wrote. And it ranks you in ranges from normal to outlier, to extreme outlier.

That casts a chilling effect on doctors. Nobody wants to be seen as an outlier. It pressures doctors to cut back on prescribing, and then their legitimately suffering patients are driven to the illegal market where they get laced opioids, or they go to cheaper heroin and, of course, that is where the overdoses occur. A study just came out in May from the University of Pennsylvania that examined the effect of PDMPs from 1999 to 2014, and they found that PDMPs were not associated with reductions in drug overdose mortality rates, and may be related to increasedmortality from illicit and other unspecified drugs.

So what can we do from a policy standpoint? I’m an advocate of what’s known as harm reduction: if we can’t stop people from using these drugs, at least let’s do what we can to make sure they don’t harm themselves. An example of harm reduction is methadone maintenance, which has been around for decades. You basically replace an addiction to heroin with an addiction to methadone in the form of a pill, which prevents withdrawal but doesn’t give you the euphoria. It’s sort of like the opioid version of a nicotine patch.

Another policy being used in several countries is — and this may sound weird — heroin maintenance programs. Now remember, heroin is diamorphine, which is a pharmaceutical that is available and used in many developed countries. In 1994, Switzerland started a heroin maintenance program.

There are criteria to join it to make sure you’re not trying to game the system, but you declare yourself a heroin addict; you come into a clinic in the morning; you’re given pharmaceutical-grade diamorphine with a clean needle and syringe; a nurse is there watching you; you inject yourself; and then you leave. You sign in and sign out. They’ve found that many addicts, once they aren’t spending their whole day looking for their connection, get a job, some get married and have a family, and as they resume a more conventional lifestyle a significant number of them actually detox themselves off. A smaller program like this in the United Kingdom has been going on for about 10 years. In Vancouver, British Columbia, one just began in December 2016. Since heroin is a banned substance in this country, we would need to pass legislation to allow a few heroin maintenance pilot programs.

Another form of harm reduction, from the clinician’s standpoint: Instead of pressuring doctors through things like these prescription drug monitoring boards to decrease the amount of prescriptions we give to our patients, why don’t you just let us be doctors? That’s our job. When I have a patient who has recovered from major trauma surgery, and I know he’s physically dependent, and he’s asking me for another refill of oxycodone, and I think this has been going on a little longer than it should be — what I do ethically, as part of my profession, is have a discussion with my patient and see if I can get the patient to go along with my tapering him off. Sometimes patients are in denial. If they’re addicted, I can refer them to someone who has more expertise in treating addiction.

But if I’m faced with the decision between giving this guy another prescription under the condition that he’ll see me in two weeks so we can talk about this again, or cutting him off and risking that he’ll go get some counterfeit Percocet and maybe die of an overdose because it contained fentanyl or carfentanil — I think you should leave that judgment call to me, the doctor. If we can keep people on methadone maintenance, why can’t I decide, under close supervision, to keep a person on oxycodone maintenance? There’s no difference, chemically. My advice would be to stop interfering in the patient-doctor relationship — you’re actually making it worse.

In summary, our opioid overdose problem is not a product of the patient-doctor relationship. It’s a product of drug prohibition, because it’s the illegal market that has led to all these impurities and to people getting substances that kill them. We need to address drug prohibition, not the patient-doctor relationship.

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The New Shingles Vaccine: What You Should Know About Shingrix

It offers better and longer-lasting protection. Should you get it?

https://www.consumerreports.org/shingles-vaccine/new-shingles-vaccine-shingrix-what-you-should-know/

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More than 100 million Americans live with chronic pain — more than cancer, diabetes and heart disease combined. Nationally syndicated health columnist and author Judy Foreman will share her experience with pain, how she came to write this easy-to-read book based on solid scientific evidence, what individuals can do to alleviate this most common of human miseries, and what our country needs to do to transform the way pain is perceived, judged and treated. The Center for Practical Bioethics will also introduce, “Relieving Pain in Kansas City,” a community-wide response to the issues Judy will discuss.

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Utah nurse reaches $500G settlement over violent arrest after blocking cop

http://www.foxnews.com/us/2017/11/01/utah-nurse-reaches-500g-settlement-over-violent-arrest-after-blocking-cop.html

A Utah nurse who was arrested for refusing to let a police officer draw blood from an unconscious patient settled Tuesday with Salt Lake City and the university that runs the hospital for $500,000.

Nurse Alex Wubbels and her lawyer, Karra Porter, announced the move nearly two months after they released police body-camera video showing Detective Jeff Payne handcuffing Wubbels. The footage drew widespread attention online amid the national debate about police use of force.

The settlement covers all possible defendants in a lawsuit, including individual police officers, university police and hospital security guards. The payout will be divided among the city and the University of Utah.

Wubbels plans to use part of the money to fund legal help for others trying to get similar body-camera video. She said that in cases like hers, video is essential to being heard and believed.

She said she also plans to give a portion of the $500,000 to a nurse’s union and help lead a campaign to stop physical and verbal abuse of nurses on the job.

University of Utah hospital officials said in a statement they support Wubbels and have changed their procedures and training on how police and health care workers interact to ensure nothing similar happens again.

A spokesman for Salt Lake City didn’t immediately return messages seeking comment.

Wubbel was following hospital policy when she told Payne he needed a warrant or the consent of the patient to draw blood after a July 26 car crash. The patient was not under arrest or suspected of wrongdoing.

Payne had neither. He eventually dragged Wubbels outside and handcuffed her as she screamed that she had done nothing wrong.

She was released without being charged but has said the incident left her feeling terrified and bullied. In a call for changes, Wubbel and her lawyer released the video they had obtained through a public records request.

Salt Lake City Police Chief Mike Brown has since apologized and fired Payne after an internal investigation found he violated department policies.

Brown said in a disciplinary letter that he was “deeply troubled” by Payne’s conduct, which he said brought “significant disrepute” on the department.

Payne is appealing that decision, saying the firing was an unfair reaction to the negative publicity.

The patient was an off-duty Idaho reserve police officer driving a semitrailer when he was hit by a man fleeing police in a pickup truck. He later died of his injuries.

Lt. James Tracy, a police supervisor who ordered the arrest of the nurse, was demoted to officer and also is appealing. He said he suggested Payne consider handcuffing the nurse and that his superiors had never informed him of the hospital’s blood-draw policy, according to appeal documents.

Wubbels said she was relieved at the discipline and would be disappointed if it’s overturned, though she stressed that decision is out of her control.

“The police have to police themselves,” she said. “This is something I never would have expected to happen, but I’m also honored by the weight of it.”

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Are Payers the Leading Cause of Death in the United States?

https://www.medpagetoday.com/blogs/revolutionandrevelation/68935

On September 17, 2017 The New York Times and ProPublica collaborated on an interesting story. You may have missed it.

As everyone knows, we are in the midst of a horrific opioid addiction epidemic. Physicians are prescribing opiates for pain relief, and patients are becoming addicted to them. One-fifth of patients who receive an initial 10-day prescription for opioids will still be using opiates a year later. That is simply extraordinary.

Physicians are prescribing opiate formulations that are highly addictive. But they do not need to do that.

There are several newer formulations that relieve pain and are far less addictive than older agents. But they are prescribed uncommonly. Why is that?

It is not because physicians are uninformed.

It is because payers will not pay for the alternatives. The less-addictive opiates are more expensive, so payers have declined to support them. Patients get addicted because paying for highly addictive opiates saves the payers money.

The New York Times also noted that the treatment of opiate addiction is expensive. It is far cheaper for payers if physicians continue to prescribe opiates than if physicians enrolled a person into a drug addiction program.

What does that look like? Patients get more prescriptions for opiates instead of getting the help they need.

The Payers Are in Charge

If you are looking for someone to blame for the opioid epidemic, you can certainly blame physicians. You can blame pharmaceutical companies. But while you are at it, don’t forget to include payers.

This conclusion should not be surprising. We live in a world where payers — not physicians — determine what drugs and treatments patients receive.

If patients have a life-threatening condition, it is not unusual for a payer to demand that a physician first prescribe a cheaper and less effective alternative. Physicians know that the drugs they are allowed to use may not work very well, but frequently, payers demand that they be tried first anyway.

What happens if the patient doesn’t respond to the cheap drug?

Often, the physician continues to prescribe it, because — to gain access to the more effective drug — physicians need to go through a painful process of preauthorization. For many practitioners, it isn’t worth it.

Don’t patients eventually get the drugs that they need?

No. All too often, physicians stop trying. Or patients get frustrated and give up. Often, payers says “No!” no matter how many times they are asked. And if the drug is for a life-threatening illness and enough time passes by, then the patient may no longer be alive to demand that they get the right drug.

So we spend more for healthcare than any other country in the world, but Americans do not get the care they need. There is a simple reason. Treatment decisions are not being driven based on a physician’s knowledge or judgment. They are being driven by what payers are willing to pay for.

How many people are affected by all of this?

Everyone.

That includes me and my family. That includes everyone that I know.

Medicine has made incredible progress in the last 20-30 years. But you are not likely to benefit from it.

Do you want to blame the high cost of drugs? You can do that, but if you do, you will be missing the point. We should expect better drugs to be more expensive than less effective ones. But we do not expect to have a company decide that we will get the inferior drug simply because they want to make a profit.

Are payers the leading cause of death in the United States? If you think this is a crazy question, please think again.

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Jurors hear opening arguments in Christensen trial

http://www.nbcmontana.com/news/keci/jurors-hear-opening-arguments-in-christensen-trial/644085796

HAMILTON, Mont. – Jurors heard opening arguments in the drug trial of Dr. Chris Christensen in Hamilton District Court Monday.

The Florence doctor is accused of causing the deaths of two patients, endangering the lives of nine other patients and of distributing dangerous drugs.

Christensen’s clinic was raided in 2014.

The prosecution and defense delivered impassioned arguments before District Court Judge Jeffrey Langton.

Prosecutor Thorin Geist showed photographs of two people he said died under Christensen’s care.

The first picture displayed was of Gregg Griffin.

“The defendant knew that Gregg was an addict,” said Geist. “He was an opiate addict when he put the methadone in his hands.”

The second picture he showed was of Kara Philbrick-Lenker, who went to Christensen for pain.

“Three days later she died of a drug overdose,” said Geist. “The defendant put the drugs in her hand.”

But Christensen’s attorney, Josh Van de Wetering, called the doctor a “compassionate” man who showed “respect” for his patients and understood the pain they were in.

Van de Wetering said what you will hear during the trial is that some didn’t follow Christensen’s prescriptions and others were desperate.

“If you’re not going to get treated by a doctor you’re probably going to buy it on the street,” said Van de Wetering. “That’s what Dr. Christensen knows.”

But Geist said Christensen has a history of over-prescribing.

After complaints in Idaho the doctor agreed to surrender his license for two years after prescribing controlled substances.

“And they told him that at least five of those patients had died of a drug overdose,” said Geist. “And at least another six had been hospitalized.

He said when Christensen moved his practice to Florence in less than six months his first patient had died.

Van de Wetering said the doctor is “not a criminal.” He said the Federal Drug Enforcement Administration is pushing pharmacists and doctors not to fill prescriptions and is scaring patients who are addicted and in pain.

“We don’t treat it like a medical condition the way we should,” said the defense attorney. “We judge those people.”

But Geist also showed pictures of the men and women who were patients of Christensen’s, whose lives he said were endangered by the doctor.

They are expected to testify.

“First, do no harm,” said Geist. “It’s one of the fundamental principles of medicine.” He said you will hear testimony that Christensen “ignored that principle.”

Geist said by writing prescriptions outside the accepted standards of professional practice it was the medical professionals of this state who took action to protect his patients.

The trial is expected to last 18 days.

His attorney said Christensen will take the stand.

800 chronic pain pts in this Dr’s practice can’t find a new doc because they all want previous medical records, but our judicial system (DEA) seized all the practice’s records … the same pt records that these same records that is needed for these pts need to get accepted by a new prescriber/practice. How many of these chronic pain pts end up committing suicide because of actions of the DEA ?

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Fentanyl’s ferocious proliferation

http://www.post-gazette.com/opinion/2017/10/31/Fentanyl-s-ferocious-proliferation/stories/201710310064

The face of America’s opioid crisis is shifting rapidly.

An emerging-threats report prepared by the Drug Enforcement Administration and marked “for official use only” notes that fentanyl — variants of which can be as much as 10,000 times stronger than morphine — made up 65 percent of the agency’s opioid identifications in the second quarter this year. The report, obtained by Foreign Policy, is based on seized drug evidence analyzed by DEA’s laboratory.

Furanyl fentanyl, the next most common compound, made up another 9 percent of opioid identifications.

These numbers reflect the escalation of a frightening trend already identified by public health officials. Data released this month by the Centers for Disease Control and Prevention note that fentanyl is now the leading cause of overdose deaths in the United States.

The rise of fentanyl underscores how hard it will be to solve the opioid epidemic. President Donald Trump last week declared the opioid epidemic a national public health emergency, saying that “overdoses are driven by a massive increase in addiction to prescription painkillers, heroin and other opioids.” Yet Mr. Trump’s long-awaited announcement comes months after he first promised to declare opioid abuse a “national emergency,” which would have freed up money from the federal Disaster Relief Fund. A “national public health emergency” does not automatically make more funding available.

The main issue, however, is how best to address the opioid crisis, whether through funding to help treat addiction or more emphasis on law enforcement, such as a border wall, the solution favored by Mr. Trump. A presidential commission, headed by New Jersey Gov. Chris Christie, is expected to submit its final report next week.

Clamping down on drug supply has proved difficult, since the opioid epidemic is so fluid. Even if law enforcement were to curtail heroin coming in from Mexico, this might simply open new avenues of supply. Much of furanyl fentanyl, for example, originates in China and comes through the mail.

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