- Voice Your Opinion on Funding changes for Michigan’s Addiction and Mental Health Services
- It’s beginning to feel like big tobacco all over again
- 30% Of Patients Prescribed Opioids For More Than A Month Still On Them A Year Later
- Bill White’s message to congress
- “the opioid epidemic is the new AIDS”
- Sentences to ponder
- Sentences to ponder
- Van Jones, Newt Gingrich and Patrick Kennedy opioid advocacy paid by drug maker
- In case you were wondering how Pharma’s faring
- the unintended consequences were, in retrospect, predictable
Do you recall the post about potential changes to Michigan's public funding for addiction treatment and mental health services? Well, the final report came in and it looked a lot like the interim report that my earlier post reported on. Basically, no major changes, but try some pilots to increase integration with physical health care. This seems sensible, given the uncertain future of medicaid expansion. But, it's not over yet. I received the following from the Michigan Association of Mental Health Boards.
Filed under: UncategorizedWe need you, within the next two weeks (prior to April 10, when any 298-related change to the FY18 budget will be nearly wrapped up), to contact the House and Senate Appropriations Committee members. We also need you to ask members of your Board of Directors, your staff, and your community partners to make those same contacts. These contacts are critical to support the solid recommendations contained in the 298 Report, and to counter the efforts by others opposed to the public management of the state's publicly sponsored behavioral health and intellectual/developmental disability services and supports system.Legislators are hearing from the private sector on this issue; see the attached Crain's Detroit Business article (March 9, 2017) where DHHS budget committee chairs raise questions about the lack of MHP pilots in the 298 process. We must raise our concerns to those suggestions.Click the link below to log in and send your message:
City officials in Everett - that's in western Washington state - are taking a bold step in their effort to control the opioid crisis. The city filed a lawsuit against the manufacturer of OxyContin, a leading opioid pain medication, claiming the manufacturer knew the drug was being illegally trafficked to residents and did not act to stop it. The suit accuses the manufacturer, Purdue Pharma, of gross negligence.And, this:
Attorneys in West Virginia, which has the highest opioid overdose rate in the nation, filed lawsuits in federal court Thursday on behalf of two counties and targeting some of the nation’s largest drug distribution companies. A dozen attorneys general in hard-hit states are considering similar suits against many of the same companies. “The purpose of these lawsuits is to make the economic cost of willfully violating the law so significant that we force the wholesalers to abide by the law,” said Paul Farrell Jr., who filed the lawsuits in West Virginia and plans to file lawsuits on behalf of five other counties in the state next week. The suits are among the first of their kind in the country. They accuse the companies of creating a hazard to public health and safety by shipping inordinate quantities of opioids into the state in violation of a West Virginia law. The law was originally designed to permit the demolition of run-down buildings that posed a public nuisance and threatened the safety of a community. The lawsuits name McKesson Corp., Cardinal Health and AmerisourceBergen — which distribute 85 percent of the nation’s drugs. Also named are Walgreens, CVS and others.And, this:
The County Legislature voted Thursday to have Schenectady County become the fourth New York county to sue large pharmacy companies over costs incurred by the county in fighting the epidemic of heroin and prescription opioid abuse. The lawsuit charges that some drug manufacturers promoted long-established opioid drugs for use as long-term painkillers -- despite knowing their addictive properties -- and that that has lead to overdose deaths and greater social services, law enforcement and jail costs for the county, as people become addicted and commit crimes to get or pay for drugs.And, this:
The Simmons Hanly Conroy firm has filed several lawsuits on behalf of New York counties against pharmaceutical manufacturers and physicians, alleging the counties have spent millions of dollars fighting an opioid drug epidemic they say was caused by aggressive marketing. “As a direct and foreseeable consequence of Defendants’ wrongful conduct, Plaintiff has been required to spend millions of dollars each year in its efforts to combat the public nuisance created by Defendants’ deceptive marketing campaign,” the suits state. The Simmons firm, based in Alton, has built its business on asbestos litigation. It filed its most recent suits on behalf of Erie County in Buffalo on the state's western border and Broome County in Binghamton in south central last month in those respective state courts.And, the Teamsters:
Newly focused on an issue that is ravaging its members, the International Brotherhood of Teamsters on Thursday plans to challenge one of the world’s biggest pharmaceutical wholesalers, demanding that AmerisourceBergen Corp. investigate its own sales practices and potential supply chain diversions, and factor compliance into its executives’ pay. The Chesterbrook-based company, ranked 12th by revenue on the Fortune 500, is holding its annual shareholder meeting in Philadelphia, and the union pension and benefits funds own an undisclosed share. But any shareholder can attend the closed meeting. Representatives said they will question the board and hold an afternoon rally outside.The response could be characterized as blaming the victim, claiming that the lawsuits are diverting attention from addressing the crisis. Filed under: Uncategorized
From a review of 1,294,247 patient records from a database of commercial health plan information from a large number of managed care plans and is representative of the U.S. commercially insured population.
The rate of long-term use was relatively low (6.0% on opioids 1 year later) for persons with at least 1 day of opioid therapy, but increased to 13.5% for persons whose first episode of use was for ≥8 days and to 29.9% when the first episode of use was for ≥31 days.(The study excluded patients with a substance abuse disorder diagnosis.) CORRECTION: The title of this post has been corrected. It originally read, "Almost Half Of Patients Prescribed Opioids For A Month Get Hooked For A Year". This is a good reminder of the Joint Commission's lesson to not trust other people's characterization of research and always read the source material. Filed under: Uncategorized
Bill White shares an open letter to congress:
Two of the most important responses to the opioid epidemic have been the ACA’s expansion of Medicaid in 31 states and the District of Columbia and the ACA requirement that states include mental health and addiction treatment as reimbursable services. Those critical responses will be turned back if the GOP health reform proposal is passed in its current form.Read the rest here. Filed under: Uncategorized
For the last couple of years, when trying to explain the experience of the opioid crisis, I've often said, "I imagine it's _KINDA_ like the AIDS epidemic in the late 1980s and early 1990s." However, I always qualify the statement by emphasizing "kinda" and saying something like, "I'm not saying it's that rough." Now, Andrew Sullivan, who survived the AIDS epidemic, says the following:
Those of us who lived through the AIDS epidemic retain one singular memory: The plague that ravaged our lives was largely invisible to others. The epidemic was so concentrated for a while in a gay male subculture — often itself veiled by various closet doors — that straight people without gay family members or friends couldn’t see it. There was blanket media coverage, of course. But in your everyday life, if you were straight, you could live quite easily in the 1990s without coming across someone with AIDS. While gay men were living in a medieval landscape of constant disease and death, many others carried on in safe, medical modernity, that elysian period in human history when most diseases can at least be treated, if not cured. It occurred to me reading this reported essay by Christopher Caldwell that _THE OPIOID EPIDEMIC IS THE NEW AIDS_ in this respect. Its toll in one demographic — mostly white, working-class, and rural — vastly outweighs its impact among urbanites. For many of us in the elite, it’s quite possible to live our daily lives and have no connection to this devastation. And yet its ever-increasing scope, as you travel a few hours into rural America, is jaw-dropping: 52,000 people died of drug overdoses in 2015. That’s more deaths than the peak year for AIDS, which was 51,000 in 1995, before it fell in the next two years. The bulk of today’s human toll is related to opioid, heroin, and fentanyl abuse. And unlike AIDS in 1995, there’s no reason to think the worst is now over.It's a very powerful statement. However, I'd need more information about the emphasis on the single demographic of "white, working-class, and rural." Especially since Sullivan's emphasis on this demographic ends up becoming a convenient vehicle for his pet arguments in support of Charles Murray. Sullivan also notes an important contrast between the opioid crisis and the AIDS epidemic:
There are major differences between the two health crises, of course, but none of them are very encouraging. AIDS was eventually overcome by innovation by pharmaceutical companies. The heroin epidemic is, in many ways, the creation of those very same companies, thanks to their cynical marketing of opioid products in the 1990s.He ends with these thoughts about policy and advocacy:
Worse: Funds for AIDS research kept rising and rising through the 1990s. Today, the Trump administration’s proposed cuts to Medicaid could drastically reduce treatment options in a spiraling crisis. Silence = Death, once again. But where, one wonders, is the ACT UP of the red states?Filed under: Uncategorized
grief by elycefelizFrom Atul Gawande:
We are running out of ways to emphasize how dire the opioid overdose crisis has become. In 2015, United States drug overdose deaths exceeded 50,000; 30,000 involved opioids. There were more deaths from opioid overdose than not only from motor vehicle accidents, but also than from HIV/AIDS at the peak of the epidemic in 1995.Filed under: Uncategorized
You may recall that Van Jones, Patrick Kennedy and Newt Gingrich have started engaging in advocacy around the opioid epidemic. Here's what I said at the time:
You may have heard that the unlikely crew of Newt Gingrich, Patrick Kennedy & Van Jones have taken interest in addressing the opioid crisis. More allies is a great thing.I then observed that: * they strongly advocated medication assisted treatment (buprenorphine in particular) as the standard of care, * they conflated recovery with access to MAT, * it was great that they provided sources, so we could look at their evidence. I examined the evidence and found it didn't speak to the goals of most families and people with addiction. Turns out, I was being pretty naive to think of them as altruistic allies. I thought these influential men had a common concern about a national crisis and decided to come together to use their power and influence to advocate for solutions. I disagreed with the emphasis of there solutions, but chalked that up to reasonable people disagreeing. I looks like I assumed too much. A new article in STAT describes them as paid advisers to the group and adds the following:
But the nonprofit group refuses to answer a simple question: Who is funding the campaign? Gingrich told STAT he had no idea who was supporting Advocates for Opioid Recovery, which was founded last year. Kennedy declined to be interviewed, as did Van Jones, the CNN commentator and former Obama aide who is another paid adviser. Jones has coauthored opinion pieces with the other two men and promoted the advocacy group on social media.Gingrich described Kennedy as the driving force and the article reports the following:
Kennedy has close ties to treatment centers that could benefit from wider use of the medications in opioid treatment and broader payment for the treatment by insurers. Several treatment centers that make use of medication-assisted treatment are sponsors of the Kennedy Forum, a nonprofit he founded to increase access to treatment for people suffering from mental illness and addiction and promoting research in the area. One of those organizations is CleanSlate Addiction Treatment Centers, where Kennedy has also been a board member since 2015. The organization paid $750,000 last year to settle government allegations that it was improperly prescribing Suboxone, one of the class of medications advocated by Kennedy and the other paid advisers to Advocates for Opioid Recovery.This begs all sorts of questions, right?
A spokesman for Advocates for Opioid Recovery declined to say how much the men are paid. He said the organization would not disclose information on who is funding it other than it is “a variety of organizations and people” that want to be anonymous. The spokesman, Peter Collins, declined to answer whether or not any of the funding is coming from manufacturers or suppliers of the medications, or facilities that base their treatment model on use of the drugs.And, no one is willing to talk about it. However, they've been all over TV and print media:
The three men, in opinion pieces and interviews, have called for increasing the number of patients a doctor can treat with the medicines as well as boosting government funding and insurance coverage for medication-assisted treatment.STAT reports that the directors all have ties to Kennedy and the executive director is a former Gingrich staffer. And, the group is operated from a public relations firm. WILL WE EVER KNOW WHO FUNDS THEIR GROUP? according to a filing with the Securities and Exchange Commission, is Braeburn Pharmaceuticals Inc. The private company, based in Princeton, N.J., won approval last year to market an implant that continuously dispenses the opioid addiction medicine buprenorphine. Braeburn is the maker of Probuphine. As my previous post on Probuphine indicated, STAT reports:
. . . some addiction experts have expressed skepticism that the Braeburn implant will be an effective treatment option. There are alternative opioid-addiction treatments that do not rely on medication, including abstinence-based and behavioral therapy programs.JUDGE FOR YOURSELF Earlier this week, I posted an article from the Joint Commission that reviewed their role in the opioid crisis and attempted to identify lessons to be learned. One of the lessons was "_carefully review the primary literature on issues of critical importance and do not simply repeat the claims of experts in previous articles_". Well, I reviewed the evidence for Gingrich's, Jones' and Kennedy's claims. You can see that, with links to sources, here. Filed under: Uncategorized
Yesterday, I posted about the Joint Commission's review of the unintended consequences of their emphasis on pain without the proper input, review and feedback systems. The opioid crisis that this has contributed to have been a disaster for families, communities and health care professionals who are trying to navigate the standards, untrustworthy standards of care, and their medical/social consequences. One might wonder how Pharma is faring in this crisis. Has there been regulatory, criminal, funding or popular backlash that has hurt their viability? It would appear not. * An opioid overdose medication/device was $575 when it was introduced. This seemed kind of expensive, but they had a novel delivery device and, hey, prices will come down once it's been on the market for a while. Not so fast. That same medication/device is now $4500. * The 21st Century Cures Act has been considered by many to be a gift to Pharma. * They are charging outrageous prices for treatment for hepatitis C (a common consequence of illicit opioid addiction) and hiring academic economists and health care experts to publish scholarly articles and convene academic conferences to make the case for their products and pricing. * The Senate Finance Committee has buried an investigative report on financial ties between drug manufacturers and medical organizations that were setting guidelines for opioid use. * The manufacturer of the most popular treatment medication has been getting assistance from the National Institute on Drug Abuse while _manipulating prices and engaging in aggressive tactics to maintain a monopoly_. * Even after litigation and massive fines, many of these manufacturers seem to be doing very well. For example, Purdue, the manufacturer of Oxycontin, was fined $635,000,000 for misrepresenting the risks of the drug and their business does not appear to have suffered in any way. Filed under: Uncategorized
JAMA just published an article on the history of the Joint Commission standards on pain and the lessons learned from the opioid crisis that followed. The article describes the impetus for the increased attention to pain.
In 1990, Max2 decried the lack of improvement in pain assessment and treatment over the previous 20 years and called for a different approach that included the following: make pain “visible”; give physicians and nurses bedside tools to guide use of analgesics; ensure patients a place in the communications loop; increase clinician accountability by developing quality assurance guidelines; improve care systems; assess patient satisfaction; and work with narcotics control authorities to encourage therapeutic opiate use. _MAX REITERATED THE CONVENTIONAL WISDOM OF THE DAY THAT “THERAPEUTIC USE OF OPIATE ANALGESICS RARELY RESULTS IN ADDICTION_,”2 although _THIS WAS BASED ON A SINGLE PUBLICATION_ from 1980 that lacked detail about the study methods.3In 2000, The Joint Commission introduced standards for pain management and began referring to pain as "the fifth vital sign." However . . .
The Joint Commission standards raised concerns that requiring all patients to be screened for the presence of pain and raising pain treatment to a patients’ rights issue could lead to overreliance on opioids.What were the real world consequences?
Signals appeared suggesting that some clinicians had become overzealous in treating pain. In a 2003 survey of 250 adults who had undergone surgical procedures, almost 90% of patients reported they were satisfied with their pain medications. Nevertheless, the authors concluded that “many patients continue to experience intense pain after surgery”7 and “[a]dditional efforts are required to improve patients’ postoperative pain experience.”7 Health care organizations implemented treatment policies and algorithms based on patients’ responses to numerical pain scales. Concerns about this practice increased after a report that the incidence of opioid oversedation increased from 11.0 to 24.5 per 100 000 inpatient hospital days after the hospitals implemented a numerical pain treatment algorithm.8 The ISMP linked overaggressive pain management to a substantial increase in oversedation and fatal respiratory depression events.Is that a little too jargon-ey for you? How about this?
Several conclusions from this history could serve as lessons for addressing the current prescription opioid epidemic. First, engage all stakeholders when creating standards and not just those who passionately favor action. Advocates may be less able to see the possible unintended consequences than other stakeholders. . . . Second, try to anticipate unintended consequences and have monitoring programs in place from the start. Many of the unintended consequences of The Joint Commission standards were, in retrospect, predictable, and the need for changes may have been identified earlier if there had been prospective monitoring of adverse consequences. . . . Third, pay close attention to what programs and procedures organizations implement to meet new requirements. For example, the algorithms organizations used to guide treatment based on numerical pain scores should have immediately raised concern. . . .Finally, they share a lesson that I emphasize over and over about addiction treatment research.
Fourth,_ CAREFULLY REVIEW THE PRIMARY LITERATURE ON ISSUES OF CRITICAL IMPORTANCE AND DO NOT SIMPLY REPEAT THE CLAIMS OF EXPERTS IN PREVIOUS ARTICLES_. The 1980 letter to the editor by Porter and Jick3 suggesting that addiction is rare in patients treated with narcotics has been cited almost 1000 times. Yet the report is so brief, methodologically vague, and unlikely to be generalizable to recent medical practice that its finding should never have been disseminated without cautionary notes and calls for research.The article does close with a worthwhile reminder.
Concerns about unintended consequences should not serve as a deterrent from pursuing “noble” goals.We should work hard to not pit the problems of pain patients and people with addict against each other. We can attentively and compassionately treat pain and be mindful of the limitations and risks of the drugs involved for the patient and the community. Filed under: Uncategorized