“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
In yet another negative decision of a new cancer drug, the medicines cost-effectiveness watchdog for England and Wales has issued new draft guidance that has also come in for criticism from the Institute for Cancer Research, though the latter sees a role for Pharma to reduce the cost of drug development.
The National Institute for Health and Care Excellence (NICE) said today that it does not recommend US pharma major Bristol-Myers Squibb’s (NYSE: BMY) Opdivo (nivolumab) for the treatment of head and neck cancer. The anticipated marketing authorization for nivolumab is for treating squamous cell carcinoma of the head and neck which has progressed during or after platinum-based chemotherapy.
The NICE appraisal committee found that the evidence showed a significant improvement in overall survival rates in the short term after nivolumab. However, its value for money was considerably above that which is usually a cost-effective use of National Health Service resources.
“The committee heard that treatment options for patients in this area are limited, and it’s important to patients that treatment extends their life and improves the quality of life,” noted Professor Carole Longson, director of the Health Technology Evaluation Centre at the NICE, adding: “But the additional costs of nivolumab were considered to be very high in relation to its benefit to be recommended for routine NHS use at present.”
Consultees, including the company, healthcare professionals and members of the public are now able to comment on the draft recommendations via the NICE website until Thursday 4 May. All comments received during this consultation will be fully considered by the committee and a second draft of the guidance will be published.
If there are no objections at that stage, NICE will publish final guidance to the NHS. Until then, NHS bodies should make decisions locally on the funding of specific treatments.
Although the NICE draft guidance does not recommend nivolumab for treating head and neck cancer, it does state that people already receiving the drug may continue until they or their doctor thinks it’s appropriate to stop.
“Disappointing and frustrating,” says ICR expert
“It is disappointing and frustrating that today’s decision means doctors will not be able to offer this game-changing immunotherapy to patients with advanced head and neck cancer. Once it has relapsed or spread, the disease is extremely difficult to treat and options, including surgery and radiotherapy, are very limited,” said Kevin Harrington, Professor of Biological Cancer Therapies at The Institute of Cancer Research (ICR), London, and Consultant Clinical Oncologist at The Royal Marsden NHS Foundation Trust, who led the UK arm of the phase III clinical trial of nivolumab for advanced head and neck cancer.
He continued: “Nivolumab is an expensive drug but it is also the only treatment shown in a Phase III trial to improve survival for this group of patients – and it did so without worsening patients’ quality of life, and with fewer side-effects than other options. It’s crucial that talks on the drug’s availability continue and ultimately that this decision is reversed, since otherwise patients face missing out on a genuinely effective treatment simply because of cost.”
ICR chief executive Prof Paul Workman added: “This decision denies patients a genuine breakthrough treatment that makes a real difference for people with relapsed of metastatic head and neck cancer. It is another example, and a particularly stark one, of an innovative cancer therapy not being made available on the NHS because of cost. I’d urge NICE and the manufacturer to work together to reach an agreement on price so that this decision can be overturned as soon as possible.
“We need to recognize that the price of cancer drugs is much too high, and that’s particularly the case with the exciting new wave of immunotherapies. We need pharmaceutical companies to bring down the cost of drug development through smaller, more targeted trials, and to do much more to pass on the savings to patients. NICE for its part must take much greater account of innovation in its appraisal processes, to give exciting treatments like nivolumab a better chance of reaching patients.”
ICER and QALY of Opdivo
The appraisal committee concluded that the incremental cost effectiveness ratios (ICERs) for nivolumab would be above the range of £66,000 to £75,000 ($81,774-$92,925; ERG) per quality-adjusted life-year (QALY) gained compared to other treatments – considerably above that usually considered to be a cost-effective use of NHS resources (£20,000 to £30,000 per QALY gained).
The committee concluded that nivolumab met all the criteria to be considered a life-extending end-of-life treatment. The committee considered that the most plausible ICER was likely to be above £50,000 per QALY gained, and concluded that the amount of additional weight that would need to be assigned to the QALY benefits in this patient group would be too great for nivolumab to be considered a cost-effective use of NHS resources. The company has agreed a patient access scheme with the Department of Health.
GALVESTON – A Texas family has filed a wrongful death lawsuit in connection with the 2015 death of their son in the Galveston County Jail.
Jesse R. and Diane Jacobs filed the lawsuit in the Galveston Division of the Southern District of Texas in the death of their son, Jesse C. Jacobs.
The lawsuit names Mary Johnson, Boon-Chepman Benefit Administrators Inc., Soluta Inc. Soluta Health Inc., Care Here, the estate of Dr. Teresa Becker, Dr. Harry Louis Faust, Dr. Linea McNeel, Dr. Gary Beech, Kathy White (also known as Kathy Jean Jordan), Will George, Robin Bartholomew, Mellissa Faulk, Joe Lloreda, Monica McCray, Josephine Irogbu and Deborah Wiggins as defendants.
The Jacobs family is represented by the Lewis Law Group PLLC of Houston. They are seeking a jury trial.
According to court records, Jesse Jacobs, 32, died in police custody in March 2015 after his Xanax prescription was withheld from him.
The lawsuit states that he did not receive adequate medical care while he was held in the Galveston County Jail for eight days.
Jacobs reported to the jail on March 6, 2015, after pleading guilty a month earlier to DWI charges. He had received a 30-day sentence.
Court records indicate that Jacobs informed jail officials that he was prescribed and had been taking Xanax for a severe panic disorder. He also presented his bottle of prescription, with pills and a letter from his treating physician.
According to court records, the letter from Dr. Don LaGrone stated that it was “imperative” that he take the medications everyday.
The lawsuit notes that intake officer Joe Lloreda “made the decision to abruptly discontinue Jacobs’s Alprazolam (Xanax) medication without any tapering orders and failed to take steps to prevent any foreseeable withdrawal symptoms. He further failed to contact any physician regarding his possible withdrawals before denying him of his medication resulting in Alprazolam (Xanax) withdrawals.”
Three physicians that also worked at the jail – Faust, Becker and McNeel – each signed off on Lloreda’s intake order detailing the detoxification protocol and withdrawals, the suit states.
The suit also notes that on March 9, Jacobs called home and spoke to his mother on a recorded jail call. He noted that he had not seen a doctor yet, even though Faust maintained that he had. His medical chart indicates that he was feeling “irritable, difficulty concentrating, heart racing, anxious, sweating, and moisture on forehead,” with not one symptom noted to be addressed by medical personnel.
According to court records, during his detention in the jail, Jacobs’ symptoms worsened. He suffered panic attacks, including sweating, disorientation, palpitations, nausea, panic, anxiety, and terrible seizures day after day without any emergency medical attention to prevent these symptoms, until his final day in the Galveston County Jail, when he was found on the floor of his jail cell drooling and unresponsive.
After Wiggins found Jacobs in this emergency state, and before CPR emergency services were performed, or a call was made to 911 for emergency services, Wiggins left Jacobs with the deputy to return to the clinic, the suit states.
The lawsuit contends that she “retrieved ammonia caps to use on Jacobs, despite his having difficulty breathing, in an effort to confirm Jacobs was not faking, pursuant to jail policy, and summoned another nurse, Monica McCray, who also worked overnight to return with her to Jacobs’ cell,” according to the suit.
Jacobs had stopped breathing in his cell and court records note that 911 emergency services were summoned to revive him. In the interim, the suit notes that Wiggins vegan low effort chest compressions.
The suit further noted that McCray brought a crash cart, with an automatic defibrillation and attached it to Jacobs. The cart was attached and his vitals were captured. No pulse was detected and no shock was administered.
Jacobs was transported to a local hospital where he died one day later.
The suit states that jail officials and Boon-Chapman’s Soluta Health Medical Personnel refused to treat Jacobs for his seizures, except for documenting some of the seizures.
It also alleges that Jacobs suffered from withdrawal symptoms, as a result of the abrupt disruption of the medication that his body became physically dependent upon, and needed.
Moreover, court records indicate that jail officials and medical personnel ignored Jacobs’ complaints, “intentionally failed to provide medical treatment him by abruptly discontinuing his long term high dose alprazolam, and had wanton disregard, and deliberate indifference for Jesse C. Jacobs’ serious medical needs.”
Their decisions and a delay of outside emergency treatment, according to the suit, resulted in Jacobs’ death.
The lawsuit also claims that the Galveston County and Galveston County Sheriff and other defendants required the detoxification protocol action against inmates entering the jail facility by intake personnel, on a basis and standard of just “knowing it” or admission by an inmate that they are on a substance, as Jacobs did, without considering whether the individual is using the substance legally as a prescribed medication.
Further, the lawsuit claims that Jacobs’ civil rights, under the Eighth and 14th amendment of the United States Constitution “to be free from cruel and unusual punishment, to receive proper medical care, and to receive adequate medical care, while incarcerated and under the custody and control of Galveston County, at the Galveston County Jail under the supervision and control of the Galveston County Sheriff, Galveston County John Doe Jailers 1-20 and Galveston County Jail’s contracted medical providers.”
The lawsuit also contends that more than 28 medical individuals came into contact with Jacobs, and “each individual failed to address his withdrawals symptom at all, other than document them and the other two medical personnel individuals failed to adequately address the withdrawals symptoms.” It notes that the medical personnel also knew the dangers of failing to ensure that Jacobs received his medication or a suitable substitute.
The lawsuit also contends that Jacobs was placed in a violent solitary cell, where he remained until he died, and had to be revived placed on life support, only to be pronounced dead the following day.
It also claims that Jacobs was discriminated against because of his disability, anxiety disorder and was denied reasonable accommodations in the jail by Soluta Health and Boone Chapman.
The suit also claims medical negligence under the Texas Healthcare Liability Act and supervisor liability. It seeks punitive and exemplary damages against each defendant as well as compensatory general damages.
In filing the lawsuit, Jacobs’ parents, as representatives of his estate, are seeking fair compensation and also hope to prevent another the occurrence of a similar incident in any Texas jail.
Had something happen today you may want to know about and not sure how the media will spin it tomorrow in the news. A short time ago Benefis fired all their PA’s who were mostly responsible for doing the things doctor don’t have time for or want to do, like refill pain meds. So lately, all these legitimate patients who need their pain meds filled are withdrawing, desperate, and told by their doctors “I don’t refill pain meds.” Will today I saw at least 20 Sheriff’s, Police, and Fire trucks race by my house. Apparently, one of Dr. Duby’s (in my opinion an arrogant orthopedic asshole) patients was so desperate they went to his house to ask for a pain med script. He obviously wasn’t home so the patient burned Duby’s house down and as as he was leaving the house saw a sheriff’s vehicle, ran into another house and shot himself in the head (DOA).
Last week, the acting director of the federal Drug Enforcement Administration was asked whether his agents ever intentionally allow drug shipments into communities in the interest of making a bigger bust later on.
RICHMOND: This committee held many hearings, and was furious about the Fast and Furious program. At least from my knowledge of DEA and other drug agencies, oftentimes part of a bigger sting is letting transactions and other things go through. Now, it’s a very specific question. In DEA’s past, present, future, any times do you let drugs hit communities to get the bigger fish?
ROSENBERG: We’re not supposed to, no, sir.
RICHMOND: Okay. Are you aware of any instances where it may happen?
ROSENBERG: I’ll have to check and get back to you on that.
Rosenberg’s demurral isn’t entirely surprising, given the framing. “Fast and Furious” was the name of an ATF operation that allowed illegal gun sales to proceed to track their buyers and sellers. Roughly 1,400 of the guns were lost, two of which turned up at the scene of a Border Patrol agent’s murder in 2010.
But it’s notable that Rosenberg didn’t deny his agency conducts similarly structured operations and likely wasn’t being entirely forthcoming, as there is considerable evidence that DEA does allow drugs to enter communities in the hopes of bringing down major players in drug dealing and distribution.
In 2015, the DOJ’s Inspector General criticized the DEA for how it tracked and approved the illegal activity of its sources: “These inadequate DEA policies and procedures related to OIA greatly increase the risk to the DEA, the U.S. government, and the public from the involvement of DEA confidential sources in OIA.”
Federal law allows informants, like those employed by the DEA, to engage in “otherwise illegal activity” as part of an investigation. Those activities include “trafficking in what would be considered as large quantities of controlled substances” — 450 kilos of cocaine, for instance, or more than 90,000 kilos of marijuana.
“DEA undercover agents or DEA confidential sources of information commonly pose as buyers or sellers of controlled substances,” explained DEA spokesman Russell Baer in an email. Those informants are permitted to engage in all manner of illegal activities, even the large-scale trafficking of drugs.
Baer added that “as a general rule, DEA does not sell drugs. This type of activity is not a normal investigative technique, and is not commonplace.” Moreover, any illegal activity undertaken by confidential sources must be approved by supervising agents, Baer said.
But we don’t know how often such large-scale trafficking might happen under DEA supervision because the agency doesn’t release this information. Outside experts say that DEA-approved drug sales are “routine.”
“In my experience dealing with hundreds of drug war prisoners this behavior is embedded in DEA practices,” said Tony Papa of the Drug Policy Alliance, a reform group.
Papa knows better than others: Down on his luck in the Bronx in the 1980s, he agreed to deliver an envelope containing cocaine on behalf of a friend for $500. The friend was actually an informant cooperating with the DEA to get out of his own drug troubles.
Papa was busted and given a sentence of 15 years to life under New York state’s harsh drug laws. “Something like this is routine,” he said.
The DEA maintains its confidential sources “provide invaluable contributions and assistance in furtherance of DEA investigations against major domestic and transnational criminal organizations.” But the use of confidential sources in drug investigations has come under fire in recent years, particularly after several high-profile deaths of young people who critics say were coerced into becoming informants after being arrested for low-level offenses involving marijuana and other drugs.
Aside from direct involvement in drug deals, law enforcement officials may also allow drugs to flow into communities because they’re interested in seizing the cash proceeds from the sale of those drugs. Investigations have revealed that drug task force authorities working the nation’s highways often focus on the routes where cash from drug transactions travels, rather than the routes the drugs themselves flow through.
That’s been the case, for instance, in Oklahoma, according to an ACLU report. “We are deliberately letting the drugs get to their final destination, get sold, get used, and in some cases letting someone die of an overdose,” said Brady Henderson of the Oklahoma ACLU last year.
We should all be dead,” said Jonathan Goyer one bright morning in January as he looked across a room filled with dozens of his coworkers and clients. The Anchor Recovery Community Center, which Goyer helps run, occupies the shell of an office building in Pawtucket, Rhode Island. Founded seven years ago, Anchor specializes in “peer-to-peer” counseling for drug addicts. With state help and private grants, Anchor throws everything but the kitchen sink at addiction. It hosts Narcotics Anonymous meetings, cognitive behavioral therapy sessions, art workshops, and personal counseling. It runs a telephone hotline and a hospital outreach program. It has an employment center for connecting newly drug-free people to sympathetic hirers, and banks of computers for those who lack them. And all the people who work here have been in the very pit of addiction—shoplifting to pay for a morning dose, selling their bodies, or dragging out their adult lives in prison. Some have been taken to emergency rooms and “hit” with powerful anti-overdose drugs to bring them back from respiratory failure.
That is how it was with Goyer. His father died of an overdose at forty-one, in 2004. His twenty-nine-year-old brother OD’d and died in 2009. When he was shooting heroin he slept on the floor of a public garage. He would pick up used hypodermic needles if they were new enough that the volume gauges inked on the outside hadn’t been rubbed off with use. He OD’d several times before getting clean in 2013. Now he visits people after overdoses and tells them, “I was right where you’re at.”
There have always been drug addicts in need of help, but the scale of the present wave of heroin and opioid abuse is unprecedented. Fifty-two thousand Americans died of overdoses in 2015—about four times as many as died from gun homicides and half again as many as died in car accidents. Pawtucket is a small place, and yet 5,400 addicts are members at Anchor. Six hundred visit every day. Rhode Island is a small place, too. It has just over a million people. One Brown University epidemiologist estimates that 20,000 of them are opioid addicts—2 percent of the population.
Salisbury, Massachusetts (pop. 8,000), was founded in 1638, and the opium crisis is the worst thing that has ever happened to it. The town lost one young person in the decade-long Vietnam War. It has lost fifteen to heroin in the last two years. Last summer, Huntington, West Virginia (pop. 49,000), saw twenty-eight overdoses in four hours. Episodes like these played a role in the decline in U.S. life expectancy in 2015. The death toll far eclipses those of all previous drug crises.
And yet, after five decades of alarm over threats that were small by comparison, politicians and the media have offered only a muted response. A willingness at least to talk about opioid deaths (among other taboo subjects) surely helped Donald Trump win last November’s election. In his inaugural address, President Trump referred to the drug epidemic (among other problems) as “carnage.” Those who call the word an irresponsible exaggeration are wrong.
Jazz musicians knew what heroin was in the 1950s. Other Americans needed to have it explained to them. Even in the 1960s and 1970s, with bourgeois norms and drug enforcement weakening, heroin lost none of its terrifying underworld associations. People weren’t shooting it at Woodstock. Today, with much of the discourse on drug addiction controlled by medical bureaucrats, it is common to speak of addiction as an “equal-opportunity disease” that can “strike anyone.” While this may be true on the pharmacological level, it was until quite recently a sociological falsehood. In fact, most of the country had powerful moral, social, cultural, and legal immunities against heroin and opiate addiction. For 99 percent of the population, it was an adventure that had to be sought out. That has now changed.
America had built up these immunities through hard experience. At the turn of the nineteenth century, scientists isolated morphine, the active ingredient in opium, and in the 1850s the hypodermic needle was invented. They seemed a godsend in Civil War field hospitals, but many soldiers came home addicted. Zealous doctors prescribed opiates to upper-middle-class women for everything from menstrual cramps to “hysteria.” The “acetylization” of morphine led to the development of heroin. Bayer began marketing it as a cough suppressant in 1898, which made matters worse. The tally of wrecked middle-class families and lives was already high by the time Congress passed the Harrison Narcotics Tax Act in 1914, threatening jail for doctors who prescribed opiates to addicts. Americans had had it with heroin. It took almost a century before drug companies could talk them back into using drugs like it.
If you take too much heroin, your breathing slows until you die. Unfortunately, the drug sets an addictive trap that is sinister and subtle. It provides a euphoria—a feeling of contentment, simplification, and release—which users swear has no equal. Users quickly develop a tolerance, requiring higher and higher amounts to get the same effect. The dosage required to attain the feeling the user originally experienced rises until it is higher than the dosage that will kill him. An addict can get more or less “straight,” but approaching the euphoria he longs for requires walking up to the gates of death. If a heroin addict sees on the news that a user or two has died from an overly strong batch of heroin in some housing project somewhere, his first thought is, “Where is that? That’s the stuff I want.”
Tolerance ebbs as fast as it rises. The most dangerous day for a junkie is not the day he gets arrested, although the withdrawal symptoms—should he not receive medical treatment—are painful and embarrassing, and no picnic for his cellmate, either. But withdrawals are not generally life-threatening, as they are for a hardened alcoholic. The dangerous day comes when the addict is released, for the dosage he had taken comfortably until his arrest two weeks ago may now be enough to kill him.
The best way for a society to avoid the dangers of addictive and dangerous drugs is to severely restrict access to them. That is why, in the twentieth century, powerful opiates and opioids (an opioid is a synthetic drug that mimics opium) were largely taboo—confined to patients with serious cancers, and often to end-of-life care. But two decades ago, a combination of libertarian attitudes about drugs and a massive corporate marketing effort combined to instruct millions of vulnerable people about the blessed relief opioids could bring, if only mulish oldsters in the medical profession could get over their hang-ups and be convinced to prescribe them. One of the rhetorical tactics is now familiar from debates about Islam and terrorism: Industry advocates accused doctors reluctant to prescribe addictive medicines of suffering from “opiophobia.”
In 1996, Purdue Pharmaceuticals brought to market OxyContin, an “extended release” version of the opioid oxycodone. (The “-contin” suffix comes from “continuous.”) The time-release formula meant companies could pack lots of oxycodone into one pill, with less risk of abuse, or so scientists claimed. Purdue did not reckon with the ingenuity of addicts, who by smashing or chewing or dissolving the pills could release the whole narcotic load at once. That is the charitable account of what happened. In 2007, three of Purdue’s executives pled guilty to felony misbranding at the time of the release of OxyContin, and the company paid $600 million in fines. In 2010, Purdue brought out a reformulated OxyContin that was harder to tamper with. Most of Purdue’s revenues still come from OxyContin. In 2015, the Sackler family, the company’s sole owners, suddenly appeared at number sixteen on Forbes magazine’s list of America’s richest families.
Today’s opioid epidemic is, in part, an unintended consequence of the Reagan era. America in the 1980s and 1990s was guided by a coalition of profit-seeking corporations and concerned traditional communities, both of which had felt oppressed by a high-handed government. But whereas Reaganism gave real power to corporations, it gave only rhetorical power to communities. Eventually, when the interests of corporations and communities clashed, the former were in a position to wipe the latter out. The politics of the 1980s wound up enlisting the American middle class in the project of its own dispossession.
OxyContin was only the most commercially successful of many new opioids. At the time, the whole pharmaceutical industry was engaged in a lobbying and public relations effort to restore opioids to the average middle-class family’s pharmacopeia, where they had not been found since before World War I. The American Pain Foundation, which presented itself as an advocate for patients suffering chronic conditions, was revealed by the Washington Post in 2011 to have received 90 percent of its funding from medical companies.
“Pain centers” were endowed. “Chronic pain” became a condition, not just a symptom. The American Pain Society led an advertising campaign calling pain the “fifth vital sign” (after pulse, respiration, blood pressure, and temperature). Certain doctors, notoriously the anesthesiologist Russell Portenoy of the Beth Israel Medical Center, called for more aggressive pain treatment. “We had to destigmatize these drugs,” he later told the Wall Street Journal. A whole generation of doctors was schooled in the new understanding of pain. Patients threatened malpractice suits against doctors who did not prescribe pain medications liberally, and gave them bad marks on the “patient satisfaction” surveys that, in some insurance programs, determine doctor compensation. Today, more than a third of Americans are prescribed painkillers every year.
Very few of them go on to a full-blown addiction. The calamity of the 1990s opioid revolution is not so much that it turned real pain patients into junkies—although that did happen. The calamity is that a broad regulatory and cultural shift released a massive quantity of addictive drugs into the public at large. Once widely available, the supply “found” people susceptible to addiction. A suburban teenager with a lot of curiosity might discover that Grandpa, who just had his knee replaced, kept a bottle of hydrocodone on the bedside table. A construction boss might hand out Vicodin at the beginning of the workday, whether as a remedy for back pain or a perquisite of the job. Pills are dosable—and they don’t require you to use needles and run the risk of getting AIDS. So a person who would never have become a heroin addict in the old days of the opioid taboo could now become the equivalent of one, in a more antiseptic way.
But a shocking number of people wound up with a classic heroin problem anyway. Relaxed taboos and ready supply created a much wider appetite for opioids. Once that happened, heroin turned out to be very competitively priced. Not only that, it is harder to crack down on heavily armed drug gangs that sell it than on the unscrupulous doctors who turned their practices into “pill mills.” Addicts in Maine complain about the rising price of black-market pharmaceutical pills: They have risen far above the dollar-a-milligram that used to constitute a kind of “par” in the drug market. An Oxy 30 will now run you forty-five bucks. But you can shoot heroin when the pills run out, and it will save you money. A lot of money. Heroin started pouring into the eastern United States a decade ago, even before the price of pills began to climb. Since then, its price has fallen further, its purity has risen—and, lately, the number of heroin deaths is rising sharply everywhere. That is because, when we say heroin, we increasingly mean fentanyl.
Fentanyl is an opioid invented in 1959. Its primary use is in transdermal patches given to people for end-of-life care. If you steal a bunch of these, you can make good money with them on the street. Addicts like to suck on them—an extremely dangerous way to get a high. Fentanyl in its usual form is about fifty times as strong as street heroin. But there are many different kinds of fentanyl, so the wallop it packs is not just strong but unpredictable. There is butyrfentanyl, which is about a quarter the strength of ordinary fentanyl. There is acetylfentanyl, which is also somewhat weaker. There is carfentanil, which is 10,000 times as strong as morphine. It is usually used as an animal tranquilizer, although Russian soldiers used an aerosol version to knock out Chechen hostage-takers before their raid on a Moscow theater in 2002. A Chinese laboratory makes its own fentanyl-based animal tranquilizer, W-18, which finds its way into Maine through Canada.
China manufactures a good deal of the fentanyl that comes to the U.S., one of those unanticipated consequences of globalization. The dealers responsible for cutting it by a factor of fifty are unlikely to be trained pharmacists. The cutting lab may consist of one teenager flown up from the Dominican Republic alone in a room with a Cuisinart and a box of starch or paracetamol. It takes considerable skill to distribute the chemicals evenly throughout a package of drugs. Since a shot of heroin involves only the tiniest little pinch of the substance, you might tap into a part of the baggie that is all cutting agent, no drug—in which case you won’t get high. On the other hand, you could get a fentanyl-intensive pinch—in which case you will be found dead soon thereafter with the needle still sticking out of your arm. This is why fentanyl-linked deaths are, in some states, multiplying year on year. The federal CDC has lagged in reporting in recent years, but we can get a hint of the nationwide toll by looking at fentanyl deaths state by state. In Maryland, the first six months of 2015 saw 121 fentanyl deaths. In the first six months of 2016, the figure rose to 446.
Sometimes arrested or hospitalized users are surprised to find that what they thought was heroin was actually fentanyl. But there are addicts who swear they can tell what’s in the barrel of their needles. One in Rhode Island, whom we’ll call Gilberto, says heroin has a pleasant caramel brown tint, like the last sip of Coca-Cola in a glass. Fentanyl is clear. And many addicts claim they can recognize the high. “Fentanyl just hits you. Hard,” Gilberto says. “But it’s got no legs on it. It lasts about two hours. Heroin will hold you.” This makes fentanyl a distinctly inconvenient drug, but many addicts prefer it. All dealers, at least around Rhode Island, describe their heroin as “the fire,” in the same way all chefs describe their ribs as so tender they just fall off the bone.
“I knew we were screwed, as a state and as a country,” Jonathan Goyer says, “when I had a conversation with a kid who was going through withdrawals.” Although he had enough money to get safer drugs, the kid was going to wait through the sweats and the diarrhea and the nausea until his dealer came in at 5 p.m. That would allow him to risk his life on fentanyl.
Those in heroin’s grip often say: “There are only two kinds of people—the ones I get money from and the ones I give money to.” A man who is dead to his wife and his children may be desperate to make a connection with his dealer. They don’t buy much besides heroin—perhaps a plastic cup of someone else’s drug-free urine on a day when they need to take a drug test for a hospital or employer. This will set them back twenty or thirty dollars. In addiction, as in more mainstream endeavors, the lords of hedonism are the slaves of money. Gilberto in Rhode Island claims to have put a million dollars into each of his needle-pocked arms, at the rate of three fifty-bag “bricks” of heroin a day.
Dealers are businessmen and behave like businessmen, albeit heavily armed ones. They may “throw something” to a particularly reliable customer—that is, give him enough heroin from time to time to allow him to deal a bit on his own account and stay solvent. An addict who discovers that the 10mg pills he is paying $18 each for in Maine are available for $10 in Boston, a three-hour drive away, may be tempted to sell them to support his own habit. The line between users and pushers blurs, rendering impractical the policy that most people prefer—be merciful to drug users, but come down hard on dealers.
Addicts wake up “sick,” which is the word they use for the tremulous, damp, and terrifying experience of withdrawal. They need to “make money,” which is their expression for doing something illegal. Some neighborhood bodegas—the addicts know which ones—will pay 50 cents on the dollar for anything stolen from CVS. That is why razor blades, printer cartridges, and other expensive portable items are now kept under lock and key where you shop. Addicts shoplift from Home Depot and drag things from the loading docks. They pull off scams. They will scavenge for thrown-out receipts in trash cans outside an appliance store, enter the store, find the receipted item, and try to return it for cash. On the edge of the White Mountains in Maine, word spread that the policy at Hannaford, the dominant supermarket chain, was not to dispute returns of under $25. For a while, there was a run on the big cans of extra virgin olive oil that sold for $24.99, which were brought to the cash registers every day by a succession of men and women who did not, at first sight, look like connoisseurs of Mediterranean cuisine. Women prostitute themselves on Internet sites. Others go into hospital emergency rooms, claiming a desperately painful toothache that can be fixed only with some opioid. (Because if pain is a “fifth vital sign,” it is the only one that requires a patient’s own testimony to measure.) This is generally repeated until the pain-sufferer grows familiar enough to the triage nurses to get “red-flagged.”
The population of addicts is like the population of deer. It is highest in rustic places with access to urban supplies. Missouri’s heroin problem is worst in the rural counties near St. Louis. New Hampshire’s is worst in the small cities and towns an hour or so away from the drug markets of Massachusetts: Lawrence, Lowell, and Boston. But the opioid epidemic of the past decade is unusually diverse. Anchor’s emergency room clients are 82 percent white, 9 percent Hispanic, and 6 percent black. The state of Rhode Island is 85 percent white, 9 percent Hispanic, and 5 percent black. “I try to target outreach,” Goyer says, “but the demographics are too random for that.”
Drug addiction used to be a ghetto thing. Now Oxycodone has joined shuttered factories and Donald Trump as a symbol of white working-class desperation and fecklessness. The reaction has been unsympathetic. Writes Nadja Popovich in The Guardian: “Some point to this change in racial and economic demographics as one reason many politicians have re-evaluated the tough ‘war on drugs’ rhetoric of the past 30 years.”
The implicit accusation is that only now that whites are involved have racist authorities been roused to act. This is false in two ways. First, authorities have not been roused to act. Second, when they do, they will have epidemiological, and not just tribal, grounds for doing so. A plague afflicting an entire country, across ethnic groups, is by definition more devastating than a plague afflicting only part of it. A heroin scourge in America’s housing projects coincided with a wave of heroin-addicted soldiers brought back from Vietnam, with a cost peaking between 1973 and 1975 at 1.5 overdose deaths per 100,000. The Nixon White House panicked. Curtis Mayfield wrote his soul ballad “Freddie’s Dead.” The crack epidemic of the mid- to late 1980s was worse, with a death rate reaching almost two per 100,000. George H. W. Bush declared war on drugs. The present opioid epidemic is killing 10.3 people per 100,000, and that is without the fentanyl-impacted statistics from 2016. In some states it is far worse: over thirty per 100,000 in New Hampshire and over forty in West Virginia.
In 2015, the Princeton economists Angus Deaton and Anne Case released a paper showing that the life expectancy of middle-aged white people was falling. Prominent among the causes cited were “the increased availability of opioid prescriptions for pain” and the falling price and rising potency of heroin. Census figures show that Case and Deaton had put the case mildly: Life expectancy was falling for all whites. Although they are the only racial group to have experienced a decline in longevity—other races enjoyed steep increases—there are still enough whites in the United States that this meant longevity fell for the country as a whole.
Bill Clinton alluded to the Case-Deaton study often during his wife’s presidential campaign. He would say that poor white people are “dying of a broken heart.” Heroin has become a symbol of both working-class depravity and ruling-class neglect—an explosive combination in today’s political climate.
Maine’s politicians have taken the opioid epidemic as seriously as any in the country. Various new laws have capped the maximum daily strength of prescribed opioids and limited prescriptions to seven days. The levels are so low that they have led some doctors to warn that patients will go onto the street to get their dosages topped off. “We were sad,” State Representative Phyllis Ginzler said in January, “to have to come between doctor and patient.” She felt the deadly stakes of Maine’s problem gave her little alternative.
Paul LePage, the state’s garrulous governor, has been even more direct. Speaking of drug dealers at a town hall in rural Bridgton in early 2016, he said: “These are guys with the name D-Money, Smoothie, Shifty, these types of guys. They come from Connecticut and New York, they come up here, they sell their heroin, they go back home. Incidentally, half the time they impregnate a young white girl before they leave.” This is what the politics of heroin threatens to become nationwide: To break the bureaucratic inertia, one side will go to any rhetorical length, even invoking race. To protect governing norms, the other side will invoke decency, even as the damage mounts. It is what the politics of everything is becoming nationwide. From town to town across the country, the correlation of drug overdoses and the Trump vote is high.
The drug problem is already political. It is being reframed by establishment voices as a problem of minority rights and stigmatization. A documentary called The Anonymous People casts the country’s 20 million addicts as a subculture or “community” who have been denied resources and self-respect. In it, Patrick Kennedy, who was Rhode Island’s congressman until 2011 and who was treated for OxyContin addiction in 2006, says: “If we can ever tap those 20 million people in long-term recovery, you’ve changed this overnight.” What’s needed is empowerment. Another interviewee says, “I refuse to be ashamed of what I am.”
This marks a big change in attitudes. Difficult though recovery from addiction has always been, it has always had this on its side: It is a rigorously truth-focused and euphemism-free endeavor, something increasingly rare in our era of weasel words. The face of addiction a generation ago was that of the working-class or upper-middle-class man, probably long and intimately known to his neighbors, who stood up at an AA meeting in a church basement and bluntly said, “Hi, I’m X, and I’m an alcoholic.”
The culture of addiction treatment that prevails today is losing touch with such candor. It is marked by an extraordinary level of political correctness. Several of the addiction professionals interviewed for this article sent lists of the proper terminology to use when writing about opioid addiction, and instructions on how to write about it in a caring way. These people are mostly generous, hard-working, and devoted. But their codes are neither scientific nor explanatory; they are political.
The director of a Midwestern state’s mental health programs emailed a chart called “‘Watch What You Call Me’: The Changing Language of Addiction and Mental Illness,” compiled by the Boston University doctor Richard Saltz. It is a document so Orwellian that one’s first reaction is to suspect it is a parody, or some kind of “fake news” dreamed up on a cynical website. We are not supposed to say “drug abuse”; use “substance use disorder” instead. To say that an addict’s urine sample is “clean” is to use “words that wound”; better to say he had a “negative drug test.” “Binge drinking” is out—“heavy alcohol use” is what you should say. Bizarrely, “attempted suicide” is deemed unacceptable; we need to call it an “unsuccessful suicide.” These terms are periphrastic and antiscientific. Imprecision is their goal. Some of them (like the concept of a “successful suicide”) are downright insane. This habit of euphemism and propaganda is not merely widespread. It is official. In January 2017, less than two weeks before the end of the last presidential administration, drug office head Michael Botticelli issued a memo called “Changing the Language of Addiction,” a similarly fussy list of officially approved euphemisms.
Residents of the upper-middle-class town of Marblehead, Massachusetts, were shocked in January when a beautiful twenty-four-year-old woman who had excelled at the local high school gave an interview to the New York Times in which she described her heroin addiction. They were perhaps more shocked by her description of the things she had done to get drugs. A week later, the police chief announced that the town had had twenty-six overdoses and four deaths in the past year. One of these, the son of a fireman, died over Labor Day. At the burial, a friend of the dead man overdosed and was rushed to the hospital. One fireman there said to a mourner that this was not uncommon: Sometimes, at the scene of an overdose, they will find a healthy- and alert-looking companion and bring him along to the hospital too, assuming he might be standing up only because the drug hasn’t hit him yet. In communities like this, concerns about “hurtful” words and stigma can seem beside the point.
Former Bush administration drug czar John Walters and two other scholars wrote last fall, “There is another type of ‘stigma’ afflicting drug users—that their crisis is somehow undeserving of the full resources necessary for their rescue.” Walters is talking largely about law enforcement. As he said more recently: “If someone were getting food poisoning from cans of tuna, the whole way we’re doing this would be more aggressive.”
Which is not the direction we’re going. In state after state, voters have chosen to liberalize drug laws regarding marijuana. If you want an example of mass media–induced groupthink, Google the phrase “We cannot arrest our way out of the drug problem” and count the number of politicians who parrot it. It is true that we cannot arrest our way out of a drug problem. But we cannot medicate and counsel our way out of it, either, and that is what we have been trying to do for almost a decade.
Calling addiction a disease usefully describes certain measurable aspects of the problem—particularly tolerance and withdrawal. It fails to capture what is special and dangerous about the way drugs bind with people’s minds. Almost every known disease is something people wish to be rid of. Addiction is different. Addicts resist known cures—even to the point of death. If you do not reckon with why addicts go to such lengths to continue suffering, you are unlikely to figure out how to treat them. This turns out to be an intensely personal matter.
Medical treatment plays an obvious role in addressing the heroin epidemic, especially in the efforts to save those who have overdosed or helping addicts manage their addictions. But as an overall approach, it partakes of some of the same fallacies as its supposed opposite, “heartless” incarceration. Both leave out the addict and his drama. Medicalizing the heroin crisis may not stigmatize him, but it belittles him. Moral condemnation is an incomplete response to the addict. But it has its place, because it does the addict the compliment of assuming he has a conscience, a set of thought processes. Those thought processes are what led him into his artificial hell. They are his best shot at finding a way out.
In 1993, Francis F. Seeburger, a professor of philosophy at the University of Denver, wrote a profound book on the thought processes of addicts called Addiction and Responsibility. We tend to focus on the damage addiction does. A cliché among empathetic therapists, eager to describe addiction as a standard-issue disease, is that “no one ever decides to become an addict.” But that is not exactly true, Seeburger shows. “Something like an addiction to addiction plays a role in all addiction,” he writes. “Addiction itself . . . is tempting; it has many attractive features.” In an empty world, people have a need to need. Addiction supplies it. “Addiction involves the addict. It does not present itself as some externally imposed condition. Instead, it comes toward the addict as the addict’s very self.” Addiction plays on our strengths, not just our failings. It simplifies things. It relieves us of certain responsibilities. It gives life a meaning. It is a “perversely clever copy of that transcendent peace of God.”
The founders of Alcoholics Anonymous thought there was something satanic about addiction. The mightiest sentence in the book of Alcoholics Anonymous is this: “Remember that we deal with alcohol—cunning, baffling, powerful!” The addict is, in his own, life-damaged way, rational. He’s too rational. He is a dedicated person—an oblate of sorts, as Seeburger puts it. He has commitments in another, nether world.
That makes addiction a special problem. The addict is unlikely ever to take seriously the counsel of someone who has not heard the call of that netherworld. Why should he? The counsel of such a person will be, measured against what the addict knows about pleasure and pain, uninformed. That is why Twelve Step programs and peer-to-peer counseling, of the sort offered by Goyer and his colleagues, have been an indispensable element in dragging people out of addiction. They have authority. They are, to use the street expression, legit.
The deeper problem, however, is at once metaphysical and practical, and we’re going to have a very hard time confronting it. We in the sober world have, for about half a century, been renouncing our allegiance to anything that forbids or commands. Perhaps this is why, as this drug epidemic has spread, our efforts have been so unavailing and we have struggled even to describe it. Addicts, in their own short-circuited, reductive, and destructive way, are armed with a sense of purpose. We aren’t. It is not a coincidence that the claims of political correctness have found their way into the culture of addiction treatment just now. This sometimes appears to be the only grounds for compulsion that the non-addicted part of our culture has left.
Missouri retailers of alcohol may currently offer discounts and specials just like other businesses. But unlike other businesses, they cannot publicly advertise actual truthful retail prices through newspapers, radio and TV.
It’s a bizarre example of government censorship that dates to the repeal of Prohibition in the 1930s – and it conflicts with the last 40 years of U.S. Supreme Court rulings protecting commercial free speech.
House Bill 433 would fix this constitutional issue, upholding free speech in Missouri’s free marketplace and strengthening truth in advertising for consumers.
HB433, which has been voted do-pass by the House General Laws and Rules committees, would allow retailers to truthfully advertise their actual prices for alcohol.
HB433 is a pro-active approach to benefit consumers and free-marketplace competition while shedding unconstitutional language from Missouri laws and regulations. It allows retailers to “Purchase, publish, and display advertisements that list the amount of the rebate or discount and the retail price after the rebate or discount.”
This allows consumers to compare prices through truthful advertising. Courts have consistently ruled that is how free speech in the free marketplace is supposed to work.
In 1976, the Supreme Court ruled that “the free flow of commercial information is indispensable” in a free market system. (Va. State Board of Pharmacyv. Va. Citizens Consumer Council, Inc.). And in 2011, the nation’s highest court declared, “The fear that people would make bad decisions if given truthful information cannot justify content-based burdens on speech” (Sorrell v. IMS Health, Inc.).
Citing Supreme Court decisions protecting First Amendment rights, the 8th U.S. Circuit Court of Appeals in January reversed a lower court and reinstated a lawsuit alleging Missouri’s alcohol laws and regulations violate the constitutional guarantee of free speech.
The judges said Missouri’s restrictions are too broad, irrational and do “little, if anything” to “directly advance the interest in promoting responsible drinking.” For example, the judges noted the state’s censorship of ads with truthful alcohol prices means consumers must physically go into a store or bar to learn actual prices. That is just absurd.
The judges also wrote: “A theoretical increase in demand for alcohol based on a lower price does not necessarily mean any consumption of that alcohol is irresponsible.”
Missouri should not wait on the courts to throw out our laws and regulations, an outcome that seems certain based on this 8th Circuit declaration: “The multiple inconsistencies within the regulations poke obvious holes in any potential advancement of the interest in promoting responsible drinking, to the point the regulations do not advance any interest at all.”
HB433 does not affect Missouri’s strict laws against underage sales of alcohol, or selling alcohol to obviously intoxicated persons, or driving while intoxicated. HB433 also does not affect Missouri’s strong ‘Three Tier” alcohol regulatory system for manufacturers, distributors and retailers of alcohol.
The legislation simply allows advertising of truthful alcohol prices on TV, radio and newspapers by all retail sellers of alcohol.
Why would anyone oppose this? It’s pretty simple: They are afraid of free marketplace competition.
The loudest opponents are certain large-volume retailers who claim they have no fear of competition – but they oppose truthful advertising for consumers about prices. They are fine with restricting truthful consumer advertising in spite of the First Amendment, because they want to keep pocketing more money from consumers who cannot compare prices through public advertising.
I am writing on behalf of the Missouri Retailers Association and the Missouri Grocers Association, comprised of retailers with hundreds of Missouri locations and tens of thousands of employees. We are not afraid of competition – we welcome it because it’s good for consumers.
We join the Missouri Broadcasters Association, the Missouri Press Association and other advocates for truthful consumer advertising, free speech and a free marketplace in urging passage of HB433.
I am not normally a fan of Dr Oz… but this article seems poignant
America’s best-known physician, Mehmet Oz, came to Philadelphia’s rail-side heroin encampments Monday for the kind of medical education seen by few doctors, let alone his daytime television audience.
“I just walked into hell,” said Oz, wearing jeans and hiking boots, as he picked his way along big piles of discarded syringes along the Conrail tracks in West Kensington.
He appeared genuinely shocked at what he found along the Gurney Street corridor, a stretch of squalor that extends two-thirds of a mile along a busy freight rail line. An estimated 150 people who use heroin live along the rails that sit in a filthy gulch.
Accompanied by law enforcement and city officials, Oz was shown the highlights, including a makeshift shack known as the “doctor’s office” because it’s where people go who need help shooting up. A hand-written sign on the way announced in English and Spanish: “Attention! Service must be payed (sic) before any is given! No exceptions!”
“Just like a real doctor’s office,” quipped Oz, a cardiothoracic surgeon before becoming a best-selling author and TV host. “Is the doctor around?”
The “doctor” seemed to have left in a hurry. Needles, still primed with heroin, lay abandoned on a makeshift table.
Nearby, the syndicated TV host saw a small mirror propped against a tree, and asked what it was for. It’s there so heroin users can more easily find an available neck vein, explained Gary Tuggle, special agent in charge of U.S. Drug Enforcement Administration operations in Philadelphia.
Tuggle led Oz, his crew, city officials, and reporters under the Mascher Street bridge, where newly posted “No Trespassing” signs were nailed to trees and hung on utility poles every 10 yards.
Tuggle told Oz that heroin addicts from as far away as Maine and Florida converge on the area near the railroad line.
“Why here?” Oz asked.
“Purity and price,” Tuggle replied. “It’s a matter of economics, that’s what drives them in. It’s pure and cheap.”
Oz shook his head.
“What if you built two large walls on either side of the tracks?” Oz asked. “Would that solve the problem?”
It was Tuggle’s turn to shake his head.
“That would only push it someplace else,” Tuggle said.
The city has been negotiating with Conrail for the last nine months over cleaning out the area and building a fence to keep people from getting to the gulch, which is largely concealed by trees and scrub. The two sides have been at an impasse over who is responsible for the squalor.
“If both sides are going to spend millions of dollars to clean this up, we have to make sure this is secure, or we’re going to be doing this all over again in a few months,” said city Managing Director Mike DiBerardinis, who was later interviewed by Oz on camera. “They have to take responsibility.”
The railroad has said it would pay for a massive cleanup and a fence along the worst section of the drug corridor. “We stand ready to resume productive good faith discussions with the City of Philadelphia to help us accomplish this shared goal,” Conrail said in a statement Monday.
As Oz spoke to city Health Commissioner Thomas Farley for the cameras, a Conrail representative chatted briefly with DiBerardinis near a pile of discarded needles.
Oz, a professor of surgery at Columbia University, has been sharply rebuked in recent years by his professional peers. He has been accused of endorsing unproven treatments and hosting celebrities who have promoted questionable health practices for profit. The episode shot Monday, Oz said, will be broadcast the first week of May. The syndicated Dr. Oz Show is shown at 1 p.m. weekdays locally on Fox29.
Steve Johnson, 49, came to the tracks earlier Monday to score his morning fix. Seeing the crowd, he walked two blocks up the hill and bought a $10 bag of heroin.
Learning the crowd was there with Oz, he went back to ask for help to straighten out his life.
Johnson said he once made a good living as a contractor in South Jersey, where he built commercial buildings and fancy homes.
“I thought I was rich and powerful,” Johnson said. Five years ago, he said, his girlfriend shared a needle with him. One hit and he was hooked. He lost his family, his house, and his business.
Now he panhandles to pay for his habit.
Johnson told Oz he feels safe in the encampment.
“I can cop and get high right here,” he said. “It’s governed down here.”
He said other drug users carry naloxone, the easy-to-use antidote for overdoses. There’s an unofficial code of conduct in the gulch, he said.
“At other places, if you nod off [become unconscious] people will steal needles right out of your arm,” Johnson told Oz.
Oz walked Johnson down to the tracks, looked into his eyes, and asked how he protects himself.
Johnson pulled a box cutter out of his pocket and flashed the tiny blade.
“You’re going to have to kill me before you steal my dope,” Johnson said.
Oz told Johnson he would get him help finding work and a home if he could get clean.
Johnson said he has gone through treatment dozens of times.
“I’m homeless. I spend 30 days in treatment and I’m back out on the street,” Johnson said. “They help you get clean and then they throw you right back on the street. Nobody helps you after.
“Each person is addicted for a different reason,” Johnson told Oz. “Treating people in a large group, one on 30, doesn’t do it.”
After Oz went to speak with city officials, Johnson went back under the bridge. As the doctor’s camera crew gathered around, the former builder prepared his dose and shot it into his arm.
“I don’t know why they want us out of here,” Johnson said minutes later, looking relieved as the drug took effect. “We’re out of the way. You’d think they’d want to herd us here.”
Contact Sam Wood at samwood@phillynews.com, 215-854-2796 or @samwoodiii
An employee at the embattled Veterans Affairs hospital in Arizona is facing a punishment ranging from “reprimand to removal,” Fox News has learned, for publicly revealing the name of a colleague he claims harassed him after the whistle-blower exposed exceedingly long wait times for patients at the Phoenix facility.
In a letter dated March 30, the VA accused scheduling manager Kuauhtemoc Rodriguez of violating “privacy standards you are expected to enforce [and] breaching your responsibilities as a supervisor,” by sending the media a copy of an email he wrote to the hospital director that detailed alleged harassment and included the name of a colleague as one of the top offenders.
The VA claims divulging the name of a fellow employee violates its policy prohibiting release of “Sensitive Personal Information” (SPI) without permission. This includes “education, financial transactions, medical history, criminal or employment history, and information that can be used to distinguish or trace the individual’s identity.”
Rodriguez acknowledged his email named an assistant as someone who had criticized him in front of veterans and others — but said he didn’t disclose any personal information.
“Just reporting someone’s name shouldn’t be secret — we are government employees,” Rodriguez told Fox News. “They are trying to twist anything they can to punish me.”
The Phoenix VA hospital was the epicenter of allegations ranging from lax care to misconduct in 2014 when a scheduling clerk became the first whistle-blower to disclose that a secret appointment wait list existed and dozens of would-be patients had died.
In a report released in October 2016, the VA Inspector General’s Office (OIG) found that 215 deceased patients had open appointments at the Phoenix facility on the day they died.
Rodriguez complained to the VA inspector general last November that 90 veterans still were waiting more than 400 days for care and five had died without seeing a doctor. In February, he filed another complaint alleging more than 4,000 veterans had their appointments inexplicably canceled by the Phoenix VA after they already had waited more than 180 days, documents show.
Whistle-blowers across the nation started reporting their own VA horrors, including Brandon Coleman, a Phoenix counselor who told the inspector general that many suicidal veterans were not getting timely care.
Being a whistle-blower comes with a price: many say they have endured a hostile work environment while waiting for their complaints to be remedied. Coleman and Rodriguez are two who went public with allegations and later claimed they received continued harassment at work.
Rodriguez detailed his alleged mistreatment in lengthy memos to the Office of Special Counsel, a department that reports directly to the president and is charged with protecting whistle-blowers. He said incidents included his desk being moved into a closet with no air conditioning; his promotion being halted; being told he was better suited for a rural outpost because “you have native blood”; and facing an increased workload.
The VA stood by the warning sent to Rodriguez.
“The Department of Veterans Affairs is obligated to ensure the confidentiality of its beneficiaries’ and employees’ personal identifying information,” the VA said in a statement regarding Rodriguez’s pending discipline. “Employees are expected to act in a manner that is consistent with VA’s core values of Integrity, Commitment, Advocacy, Respect and Excellence. Leadership should take action to ensure the safety of our patients and staff and preserve the integrity of our mission within applicable laws and regulations.”
The agency has given Rodriguez until April 13 to respond to its claims, and then an assistant chief said he would impose discipline ranging from “reprimand to removal.”
Rep. Phil Roe, R-Tenn., chairman of the House Committee on Veterans Affairs, has taken a dim view of the VA’s actions.
“It is unacceptable that any law-abiding whistle-blower would be punished for bringing the issues within VA to light,” Roe said in a statement, adding he has introduced legislation to enhance whistle-blower protections and allow for easier suspension, demotion or firing of bad employees.
That bill, the VA Accountability First Act of 2017, recently passed the House and forbids the VA from suspending or firing any employee without permission from the Special Counsel. It also shortens the amount of time the VA takes to investigate alleged misconduct, such as in Rodriguez’s case.
The First Amendment Coalition, a free speech advocacy group that aids the public in battles against government secrecy, also said the VA’s use of a privacy statute is overly broad if it claims names of employees should not be divulged.
“To threaten discipline up to and included firing seems at the very least heavy-handed; it’s not like the Social Security or bank account numbers were released,” said David Snyder, the coalition’s executive director.
Snyder said there could be instances where Rodriguez’s reprimand may be technically correct, such as if he knowingly violated an agency guideline. But where the general public is concerned, most federal employee names do not fall under a category of “secret.”
“Is the mere existence of an employee’s name secret or to be withheld from the public? Certainly not,” Snyder said. “The mere existence of a name isn’t something they are entitled to redact” in document requests.
The media often uses the Freedom of Information Act (FOIA) to obtain documents, which often include emails naming the sender and recipient.
“What is redactable is medical, personnel or similar files,” Snyder said. “As a general matter, that is understood to mean sensitive private information. Just a name by itself does not fall into that category.”
Frier Levitt announced today a search for Medicare beneficiaries with Part D coverage through SilverScript Insurance Company (“SilverScript”) that may have paid excessive copayments for a possible class action lawsuit. Medicare beneficiaries with Part D benefits that pay more than $200 out of pocket for covered medications may have claims against SilverScript for overpaying for medications year after year and may be able to serve as a class action representative. Upon success, class action representatives are not only compensated for their loss, but also receive payment for their service as a class action representative.
Medicare beneficiaries that participate in SilverScript may have overpaid for the drug benefit copayment. SilverScript, the largest Medicare-approved Part D prescription drug plan provider, is a wholly owned subsidiary of CVS Health, Inc., which also owns and operates CVS Caremark, a Pharmacy Benefit Manager. SilverScript calculates Medicare beneficiary out of pocket copayments based in part on the amount of money that Caremark, who processes prescription drug claims, pays to the participating pharmacy at the point of sale. Through utilization of Direct and Indirect Remuneration Fees (“DIR Fees”), SilverScript and Caremark may have inflated the initial costs of medication paid to the pharmacy at the point of sale, only to reduce the amount paid to pharmacies months later, well after patients have received their medications.
The damage to Medicare beneficiaries occurs because SilverScript does not re-calculate the Medicare beneficiaries’ copayment and is believed to not refund the excess copayment made by patients. Patients paid a copayment at the point of sale based on a price set by SilverScript and Caremark that may not have been accurate. Patients may have paid hundreds or thousands of dollars more than they should have over the course of a single year. Frier Levitt is looking to file a class action against SilverScript challenging the over payment by patients.
Medicare beneficiaries with Part D coverage through SilverScript who pay more than $200 out of pocket for covered medications are encouraged to contact attorney Steven L. Bennet, Esq. at sbennet@frierlevitt.com or (973) 618-1660. Beneficiaries have the right to express concerns with their Part D coverage and doing so does not put their coverage at risk.
About Frier Levitt, LLC
Frier Levitt is a national boutique healthcare law firm. Our 27 healthcare attorneys include pharmacist-lawyers, class action attorneys, trial attorneys and those whose practice concentrates in Medicare law. Our breadth of experience in the health care field provides a unique perspective to bring relief to Medicare beneficiaries unfairly charged excessive out of pocket costs to obtain drug benefits under Medicare. For additional information, visit www.FrierLevitt.com.
Media Contact:
Adam Toris Marketing Director Frier Levitt, LLC Phone: 973.618.1660 Email: atoris@frierlevitt.com
Members of the Alabama Pharmacy Association are fighting a decision to impose additional regulations on alprazolam -commonly known as Xanax – which will place the drug into the most tightly-controlled group of medications.
Alabama would become the first state in the nation to move alprazolam into the same category as the powerful opioids methadone, oxycodone and fentanyl.
“The State Committee of Public Health received a request from the Alabama Board of Medical Examiners to reschedule alprazolam from Schedule IV to Schedule II due to concerns about patient safety in the midst of the substance abuse epidemic that Alabama and the nation are facing,” according to a statement released by the Alabama Department of Public Health. “This epidemic is marked by overdose deaths including those from opioids and benzodiazepines. After consideration of the criteria outlined in SS 20-2-20 of the Alabama Code, it was determined that alprazolam has a high potential for abuse, which may lead to severe psychological or physical dependence, thereby warranting the rescheduling.”
If legislators approve the reclassification at a committee meeting later this week, patients receiving the drug could no longer receive refills without a doctor’s visit. Under current regulations, doctors can provide up to six refills in six months for patients taking alprazolam.
Alprazolam is used to treat anxiety and panic disorders. It works more quickly than similar drugs and has a higher potential for abuse.
According to a 2014 federal report, emergency room visits for non-medical use of alprazolam more than doubled from 2005 to 2010. Drug abusers often combine alprazolam with other sedating drugs including opioids and muscle relaxants, increasing the potential for overdose and death, according to the U.S. Centers for Disease Control and Prevention..
Michael Hogue, pharmacy professor and assistant dean for the Center for Faith and Health at Samford University, said the reclassification of alprazolam won’t solve the serious problem of overdoses, but could cause many problems for patients taking the drug to treat anxiety.
Alabama has a shortage of psychiatric providers, Hogue said, which will make it difficult for patients who need to schedule a visit to refill a prescription.
“By changing alprazolam to schedule two, we are going to put incredible pressure on the psychiatric system in this state,” Hogue said.
The U.S. Drug Enforcement Agency classifies some prescription drugs with the potential for abuse, imposing more restrictions on the most dangerous and addictive substances. The DEA currently groups alprazolam with other anxiety drugs such as Valium and Klonopin. For the most part, Alabama follows federal classification, but state law allows public health officials to move drugs into more highly-regulated categories if there is evidence of widespread injury.
Hogue said he hasn’t seen any evidence to support the state’s effort to impose tighter restrictions on alprazolam.
Alabama ranks near the top in prescriptions per capita of anxiety medications and opioid painkillers, according to the CDC. Overdose deaths linked to those drugs rose after 2001, but have leveled off in recent years. The DEA put the painkiller hydrocodone in the most highly-restricted category in 2014, but Alabama physicians still prescribe it frequently, Hogue said.
“The only thing that changed was that the rate of heroin addiction skyrocketed after they changed the classification,” Hogue said.
Why the DEA intentionally lets drugs into communities
