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The Rosenthal Report - December 2017

Rosenthal Reports

In the Rosenthal Report for December, we look at:

  • The promise and risk of innovation to fight the opioid epidemic
  • How the drug industry is promoting “better” opioids with government help
  • Why we need to stay focused on addiction treatments that work

Innovation is the latest buzzword when addressing the opioid epidemic, backed by the Trump administration and the pharmaceutical industry as a silver bullet solution to the crisis. But as government and private companies increase investments in research and development, we risk losing sight of the many effective treatments and approaches already at our disposal, such as the residential care that is so hard to find by many who now need it. While innovation is critical to advance addiction treatment, we won’t find easy answers solely with technology and new medications.

Many new products are already coming to market. The FDA recently approved two: an electronic earpiece that blocks opioid withdrawal symptoms by sending an electronic pulse through four cranial nerves to reduce nausea, anxiety, and pain; and a “digital” pill equipped with sensors that lets doctors closely monitor a patient’s pain level and frequency of drug use through a small data-storage device attached to the abdomen.

Pharmaceutical companies are gearing up as well, developing new forms of supposedly “better” opioids – in many cases, with government help. In an unusual move, the administration is promising substantial funding for public-private partnerships with the drug industry to develop non-addictive painkillers as well as so-called abuse-deterrent opioids, which Big Pharma claims will help curb substance abuse.

This is a troubling approach. We need to change lives, not drugs. And we can’t depend on technology – for all its promise – to do the hard work of addiction recovery. More importantly, we need to make sure the treatments that do work are easily available to a growing addict population.

Overdose reversal drugs, for example, are highly effective. But many municipalities across the country can’t get them because of limited supply and rising prices (one brand, Evzio, now costs $4,500 for two doses, up from $690 in 2014). Evidence-based prevention programs can work, especially for children and teenagers, but they were given scant notice in the opioid commission report.

Promoting abuse-deterrent opioids, especially with taxpayer money, is “insanity,” as a New York Times editorial put it. Abuse-deterrent is a misleading term referring to pills that are harder to crush or alter for injection or snorting, but have the same addictive properties and therefore won’t prevent someone from ingesting opioids or becoming addicted.

The Rosenthal Center believes that residential therapy of varying lengths – therapy that treats the whole person, with proven clinical practices and peer-based counseling - offers the best chance of sustained recovery. Yet today there are many places in the country where residential facilities are not available or affordable for many people. Far too often we hear tragic stories of addicts’ lives lost during a desperate scramble to find treatment and the means to pay for it.

This is a failure of government policy and funding priorities. The Rosenthal Center will continue to strongly support increased funding to expand the treatments and programs that we know help save lives every day. 

4th December 2017
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The Rosenthal Report - November 2017

Rosenthal Reports

The Government Mobilizes to Fight the Opioid Epidemic

  • Trump declares a “public health emergency”
  • White House commission outlines 56 recommendations
  • No new funding request undercuts implementation

Federal efforts to address the opioid epidemic gained momentum in October. President Trump declared a public health emergency and a week later his special opioid commission issued its final report with 56 wide-ranging recommendations. Unfortunately, neither the administration nor the commission requested any additional funding to back up the proposals, raising questions about how and when they would be implemented. The commission did press Congress to “appropriate sufficient funds” but did not identify how much is needed.

This was a missed opportunity. We know that effective treatment, especially long-term residential treatment, can save lives – but it also requires money. The current $1 billion for anti-drug initiatives available under the 21st Century Cures Act is insufficient, given the widening scope of the crisis. In an interview on Fox television news, I repeated a Rosenthal Center proposal to immediately double the existing federal block grants to the states, which would free up $1.9 billion for critical state programs. But experts estimate that at least ten billion a year is needed to cope with what the administration recognized as “the worst drug crisis in American history.”

The commission’s recommendations included many effective strategies already in place. Some focus on harm reduction, others on prevention and education, as well as prescription monitoring, doctor training and making overdose reversal drugs more available.  It called for expanding drug courts and streamlining the way federal dollars are funneled to the states for anti-drug initiatives. To increase treatment capacity, the commission recommended lifting in all 50 states the regulation that limits the number of beds in treatment facilities that receive Medicaid support. The Center endorses this measure that would immediately open treatment to thousands of low-income Americans.

Otherwise, the report acknowledged the need for medication-assisted treatment (MAT) – which combines behavioral counseling with drugs to reduce withdrawal cravings – saying it was “underutilized” and should be expanded. But the report did not say how.

Given the scope of this crisis, we cannot make recommendations without committing more dollars. In its just released 2017 drug threat assessment report, the DEA found that overdose deaths, already at a high level, continue to rise due to the mixing of heroin with the highly potent synthetic opioid fentanyl, a drug more widely available than ever before. “It has never been a more important time to use all the tools at our disposal to fight this epidemic,” the report concluded. The Rosenthal Center will continue to send that message loud and clear to politicians, policymakers and the media.

3rd November 2017
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The Rosenthal Report - November 2017

Rosenthal Reports

The Government Mobilizes to Fight the Opioid Epidemic

  • Trump declares a “public health emergency”
  • White House commission outlines 56 recommendations
  • No new funding request undercuts implementation

Federal efforts to address the opioid epidemic gained momentum in October. President Trump declared a public health emergency and a week later his special opioid commission issued its final report with 56 wide-ranging recommendations. Unfortunately, neither the administration nor the commission requested any additional funding to back up the proposals, raising questions about how and when they would be implemented. The commission did press Congress to “appropriate sufficient funds” but did not identify how much is needed.

This was a missed opportunity. We know that effective treatment, especially long-term residential treatment, can save lives – but it also requires money. The current $1 billion for anti-drug initiatives available under the 21st Century Cures Act is insufficient, given the widening scope of the crisis. In an interview on Fox television news, I repeated a Rosenthal Center proposal to immediately double the existing federal block grants to the states, which would free up $1.9 billion for critical state programs. But experts estimate that at least ten billion a year is needed to cope with what the administration recognized as “the worst drug crisis in American history.”

The commission’s recommendations included many effective strategies already in place. Some focus on harm reduction, others on prevention and education, as well as prescription monitoring, doctor training and making overdose reversal drugs more available.  It called for expanding drug courts and streamlining the way federal dollars are funneled to the states for anti-drug initiatives. To increase treatment capacity, the commission recommended lifting in all 50 states the regulation that limits the number of beds in treatment facilities that receive Medicaid support. The Center endorses this measure that would immediately open treatment to thousands of low-income Americans.

Otherwise, the report acknowledged the need for medication-assisted treatment (MAT) – which combines behavioral counseling with drugs to reduce withdrawal cravings – saying it was “underutilized” and should be expanded. But the report did not say how.

Given the scope of this crisis, we cannot make recommendations without committing more dollars. In its just released 2017 drug threat assessment report, the DEA found that overdose deaths, already at a high level, continue to rise due to the mixing of heroin with the highly potent synthetic opioid fentanyl, a drug more widely available than ever before. “It has never been a more important time to use all the tools at our disposal to fight this epidemic,” the report concluded. The Rosenthal Center will continue to send that message loud and clear to politicians, policymakers and the media.

3rd November 2017
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The Rosenthal Report - October 2017

Rosenthal Reports
In the Rosenthal Report for October, we look at:
  • How the federal government can help states fight the opioid epidemic, following the failure to repeal ACA and cut Medicaid
  • Mapping technology to pinpoint drug treatment gaps on Staten Island
  • The impact of involuntary commitment in New Hampshire and neighboring Massachusetts
  • The barrage of lawsuits against opioid makers
Provide emergency federal funding to the states for drug addiction programs

The failure by Congress to repeal the Affordable Care Act ensures, for now, that millions of Americans will continue to receive drug addiction treatment (Medicaid pays for about one-fifth of all substance abuse services). But there’s much more to be done to help the states implement robust anti-opioid prevention and drug treatment programs. Among the states with programs underway is New Jersey, which announced a comprehensive $200 million plan that supports Medicaid-based recovery programs and peer coaching for recovering addicts. Yet many financially strapped statehouses need more money. The federal government could kick in $940 million by providing an emergency 50 percent increase in block grants (New York State, for instance, would get $54 million). This would prime the funding pipeline for state programs, while we develop longer-term nationwide strategies and funding resources.

 Mapping technology helps pinpoint gaps in addiction treatment

Why does the borough of Staten Island have the highest rate of drug overdose deaths in New York City? One factor, according to a new report by Columbia University and the Staten Island district attorney’s office, is that there are few treatment facilities available where the most drug overdoses occur. To reach this conclusion, researchers used mapping technology to match overdoses by ZIP code and treatment centers, a model that could be replicated in other locations to identify where treatment is most needed. The report, initiated by Bridget G. Brennan, the city’s special narcotics prosecutor, recommended expanding treatment options over law enforcement approaches, but mentioned only medically assisted treatment and the use of opioid withdrawal drugs like buprenorphine. This is only a first step to recovery, which must include behavioral therapy, and for those need it, long-term residential treatment for the best chance of success.  

A tale of two states: how involuntary commitment policies can save lives

New Hampshire does not allow involuntary commitment, which places drug addicts into treatment. But across the state line, Massachusetts does. A recent report by NPR New Hampshire highlighted the stark outcomes of this policy. It described the death of a young man in New Hampshire from a fentanyl overdose as his parents sought treatment for him; meanwhile, in nearby Massachusetts a young woman was able to enter treatment under pressure from her parents and a drug court, and is now in recovery. These stories support the conviction of the Rosenthal Center that mandatory treatment is at least as successful as voluntary.

Those with drug-use problems don’t usually volunteer for treatment, and require suasion from family members or an employer and the enforcement of the court system. Last year, New Hampshire’s legislature shelved a proposal to change the law on involuntary treatment, undermining efforts to bring that state’s high opioid overdose death rate under control.

Opioid makers face barrage of legal actions

Lawsuits against the drug industry for its role in the opioid epidemic are piling up - and there may be more to come. Dozens of suits have already been brought by cities, counties and states to recoup costs incurred from the surge of drug overdose deaths linked to opioids. In the latest move, the attorney generals of 41 U.S. states said they are investigating pharmaceutical firms to see whether deception was involved in marketing opioids to doctors and patients. The legal strategy is similar to the one used in successful litigation against tobacco companies, which brought a $246 billion settlement in 1998 from cigarette manufacturers. The Rosenthal Center supports legal efforts that may secure money for drug addiction services, but recognizes that lawsuits alone are not the solution to this complex public health problem.

SAM (Smart Approaches to Marijuana): New report on the link between marijuana and opioid 

Some preliminary studies have suggested that the use of medical marijuana in states where it is legal may reduce opioid use. But a new report published in the American Journal of Psychiatry found that cannabis use increased the risk of developing nonmedical prescription opioid use as well as opioid use disorder. Based on a survey of 30,000 Americans, the study demonstrated that marijuana users were more than twice as likely as non-users to move on to abuse prescription opioids, even when controlling for factors such as age, sex, race and ethnicity.

 

 

 

3rd October 2017
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The Rosenthal Report - October 2017

Rosenthal Reports
In the Rosenthal Report for October, we look at:
  • How the federal government can help states fight the opioid epidemic, following the failure to repeal ACA and cut Medicaid
  • Mapping technology to pinpoint drug treatment gaps on Staten Island
  • The impact of involuntary commitment in New Hampshire and neighboring Massachusetts
  • The barrage of lawsuits against opioid makers
Provide emergency federal funding to the states for drug addiction programs

The failure by Congress to repeal the Affordable Care Act ensures, for now, that millions of Americans will continue to receive drug addiction treatment (Medicaid pays for about one-fifth of all substance abuse services). But there’s much more to be done to help the states implement robust anti-opioid prevention and drug treatment programs. Among the states with programs underway is New Jersey, which announced a comprehensive $200 million plan that supports Medicaid-based recovery programs and peer coaching for recovering addicts. Yet many financially strapped statehouses need more money. The federal government could kick in $940 million by providing an emergency 50 percent increase in block grants (New York State, for instance, would get $54 million). This would prime the funding pipeline for state programs, while we develop longer-term nationwide strategies and funding resources.

 Mapping technology helps pinpoint gaps in addiction treatment

Why does the borough of Staten Island have the highest rate of drug overdose deaths in New York City? One factor, according to a new report by Columbia University and the Staten Island district attorney’s office, is that there are few treatment facilities available where the most drug overdoses occur. To reach this conclusion, researchers used mapping technology to match overdoses by ZIP code and treatment centers, a model that could be replicated in other locations to identify where treatment is most needed. The report, initiated by Bridget G. Brennan, the city’s special narcotics prosecutor, recommended expanding treatment options over law enforcement approaches, but mentioned only medically assisted treatment and the use of opioid withdrawal drugs like buprenorphine. This is only a first step to recovery, which must include behavioral therapy, and for those need it, long-term residential treatment for the best chance of success.  

A tale of two states: how involuntary commitment policies can save lives

New Hampshire does not allow involuntary commitment, which places drug addicts into treatment. But across the state line, Massachusetts does. A recent report by NPR New Hampshire highlighted the stark outcomes of this policy. It described the death of a young man in New Hampshire from a fentanyl overdose as his parents sought treatment for him; meanwhile, in nearby Massachusetts a young woman was able to enter treatment under pressure from her parents and a drug court, and is now in recovery. These stories support the conviction of the Rosenthal Center that mandatory treatment is at least as successful as voluntary.

Those with drug-use problems don’t usually volunteer for treatment, and require suasion from family members or an employer and the enforcement of the court system. Last year, New Hampshire’s legislature shelved a proposal to change the law on involuntary treatment, undermining efforts to bring that state’s high opioid overdose death rate under control.

Opioid makers face barrage of legal actions

Lawsuits against the drug industry for its role in the opioid epidemic are piling up - and there may be more to come. Dozens of suits have already been brought by cities, counties and states to recoup costs incurred from the surge of drug overdose deaths linked to opioids. In the latest move, the attorney generals of 41 U.S. states said they are investigating pharmaceutical firms to see whether deception was involved in marketing opioids to doctors and patients. The legal strategy is similar to the one used in successful litigation against tobacco companies, which brought a $246 billion settlement in 1998 from cigarette manufacturers. The Rosenthal Center supports legal efforts that may secure money for drug addiction services, but recognizes that lawsuits alone are not the solution to this complex public health problem.

SAM (Smart Approaches to Marijuana): New report on the link between marijuana and opioid 

Some preliminary studies have suggested that the use of medical marijuana in states where it is legal may reduce opioid use. But a new report published in the American Journal of Psychiatry found that cannabis use increased the risk of developing nonmedical prescription opioid use as well as opioid use disorder. Based on a survey of 30,000 Americans, the study demonstrated that marijuana users were more than twice as likely as non-users to move on to abuse prescription opioids, even when controlling for factors such as age, sex, race and ethnicity.

 

 

 

3rd October 2017
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TO SENATORS: REJECT OBAMACARE REPEAL, SAVE DRUG TREATMENT PROGRAMS

Rosenthal Reports

The Graham-Cassidy bill would cap Medicaid funding and let states drop mandatory drug treatment coverage.

We’re facing a massive opioid epidemic that will kill more than 60,000 Americans this year: now is the worst time to pull the rug from critical drug treatment funding.

20th September 2017
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The Rosenthal Report - September 2017

Rosenthal Reports
We need a national strategy to address teenage opioid use

After declining for seven years, teenage drug overdose deaths grew by nearly 20 percent in 2015 in a worrying sign that the opioid crisis is reaching a younger and more vulnerable segment of the American population. New data from the Centers for Disease Control (CDC) found that 772 teens aged 15-19 died in 2015 from drug overdoses, compared to 658 the year before. This reverses a 26 percent fall in the rate of overdose deaths between 2007 and 2014.

The uptick in teen overdose deaths in 2015 is troubling for many reasons. Digging into the data, we see that teen overdose deaths were linked to the growing use of both heroin and synthetic opioids such as fentanyl. There was also a sharp 34 percent spike in deaths among teenage girls in the two years between 2013 and 2015, and a 15 percent increase for boys from 2014 to 2015. For both males and females, the majority of deaths were unintentional.

For some perspective, consider that teens still represent a small percentage of the 64,000 Americans – up 22 percent over 2015  - who died from drug overdoses in 2016. Yet the increase in teenage overdoses suggests that young people now have easier access to deadly drugs as well as a growing interest in them, after many years in which they had largely stayed away from drugs, alcohol and tobacco. Overall, the number of overdose deaths involving fentanyl or fentanyl analogues doubled from 2015 to 2016, the CDC found.

These findings come at a time when there are insufficient treatment resources dedicated to teenagers and adolescents. Even as drug use and overdoses rise, teen admissions to treatment facilities are going down. This reflects a continuing trend in the drug abuse treatment field that has long underserved adolescents. Although the overall number of clients in treatment fell by 19 percent between 2005 and 2015, the number for teens plummeted by 56 percent over the same time period, according to SAMHSA data.

The sudden rise in teenage overdose deaths in 2015 may be an aberration. But as the opioid crisis continues unabated, it is clear that young people are increasingly susceptible to addiction. Therefore, we must develop a national strategy to close the glaring gap in services for this age group. This should include prevention programs and treatment facilities targeted to young people and their unique developmental considerations. Intervening early when teens first show signs of addiction is the best way to avert a lifetime of drug use.

What we need to do: 

Encourage federal, state and local authorities to increase funding to expand youth-oriented addiction programs, starting with prevention and outreach to stop or delay initiation of teen opioid use; provide more residential treatment programs of adequate duration and prioritize the involvement of families at all levels of treatment; and remove barriers to admission and broaden insurance coverage.

5th September 2017
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The Rosenthal Report - September 2017

Rosenthal Reports
We need a national strategy to address teenage opioid use

After declining for seven years, teenage drug overdose deaths grew by nearly 20 percent in 2015 in a worrying sign that the opioid crisis is reaching a younger and more vulnerable segment of the American population. New data from the Centers for Disease Control (CDC) found that 772 teens aged 15-19 died in 2015 from drug overdoses, compared to 658 the year before. This reverses a 26 percent fall in the rate of overdose deaths between 2007 and 2014.

The uptick in teen overdose deaths in 2015 is troubling for many reasons. Digging into the data, we see that teen overdose deaths were linked to the growing use of both heroin and synthetic opioids such as fentanyl. There was also a sharp 34 percent spike in deaths among teenage girls in the two years between 2013 and 2015, and a 15 percent increase for boys from 2014 to 2015. For both males and females, the majority of deaths were unintentional.

For some perspective, consider that teens still represent a small percentage of the 64,000 Americans – up 22 percent over 2015  - who died from drug overdoses in 2016. Yet the increase in teenage overdoses suggests that young people now have easier access to deadly drugs as well as a growing interest in them, after many years in which they had largely stayed away from drugs, alcohol and tobacco. Overall, the number of overdose deaths involving fentanyl or fentanyl analogues doubled from 2015 to 2016, the CDC found.

These findings come at a time when there are insufficient treatment resources dedicated to teenagers and adolescents. Even as drug use and overdoses rise, teen admissions to treatment facilities are going down. This reflects a continuing trend in the drug abuse treatment field that has long underserved adolescents. Although the overall number of clients in treatment fell by 19 percent between 2005 and 2015, the number for teens plummeted by 56 percent over the same time period, according to SAMHSA data.

The sudden rise in teenage overdose deaths in 2015 may be an aberration. But as the opioid crisis continues unabated, it is clear that young people are increasingly susceptible to addiction. Therefore, we must develop a national strategy to close the glaring gap in services for this age group. This should include prevention programs and treatment facilities targeted to young people and their unique developmental considerations. Intervening early when teens first show signs of addiction is the best way to avert a lifetime of drug use.

What we need to do: 

Encourage federal, state and local authorities to increase funding to expand youth-oriented addiction programs, starting with prevention and outreach to stop or delay initiation of teen opioid use; provide more residential treatment programs of adequate duration and prioritize the involvement of families at all levels of treatment; and remove barriers to admission and broaden insurance coverage.

5th September 2017
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The Rosenthal Report - August 2017

Rosenthal Reports
White House drug commission calls for Trump to declare a national drug emergency
Commission’s strategy lacks clear funding goals
What’s needed is a bold $100 billion plan to fight the opioid epidemic

The White House opioid commission’s call in July for President Trump to declare a “national health emergency” to fight the opioid epidemic is an important step forward. So too are the forward-thinking policy guidelines issued by the commission, which I addressed in June. Using stark language, the commission’s interim report urged the President and Congress to focus on funding and launching initiatives to combat a drug “scourge” that will eventually affect every American, the report warned.

Many of the commission’s proposals go to the heart of the crisis, and target policy areas important to the Rosenthal Center. These range from increasing treatment capacity – especially residential treatment – through Medicaid; expanding Medication-Assisted Treatment (MAT); providing overdose reversal drugs to all law enforcement; and disrupting the flow of the deadly synthetic opioid fentanyl, which the commission calls “the next grave challenge on the opioid front.”

While moving in the right direction, the report does not go far enough. It failed to commit a specific amount of money to the national emergency at a time when 142 Americans die every day from drug overdoses. And it does not address a number of specific policy ideas that are key to successfully confronting this epidemic.

As we go to press, it’s uncertain whether President Trump will declare a health emergency and if he will support a large funding commitment. After all, as the legislative showdown over healthcare reform recently demonstrated, President Trump and the GOP-led Congress were willing to gut Medicaid and scale back essential benefits that would have devastated drug treatment programs.

With this in mind, the Rosenthal Center calls for bipartisan leadership and a comprehensive $100 billion national action program that expands on the commission’s findings and sets more specific goals and explicit policy language as follows:

Immediately allocate $100 billion to the states. This will incentivize the states to match funding to expand existing programs and design and build up new initiatives that directly address the needs of their communities.

Ensure that behavioral therapy is an essential component of medication- assisted treatment (MAT). While the commission calls for expanding MAT, it does not specifically mention the importance of behavioral therapy and counseling. Under federal SAMHSA guidelines, MAT must include both medication and therapy as a way to help addicts reorder their lives and provide them with self-awareness and a new social network for sustained recovery.  

Expand access to long-term residential treatment. With resources strained by the fast moving epidemic, few states today have sufficient capacity to provide long-term treatment for the skyrocketing addict population. The commission is right to prioritize this goal, as long-term treatment can help break the cycle of serial short-term admissions that often result in subsequent relapse and in many cases, death.

Renewed focus on specific addict populations, including vulnerable adolescents. The commission did not specifically mention adolescents, even though the Surgeon General estimates that one million adolescents (12 to 17) are in need of drug treatment but routinely fail to receive it. Teen admissions to drug programs plummeted by almost 50 percent between 2004 and 2014 to just over 78,000, due in part to the closing of dedicated facilities. We must ensure that adolescents who are prey to opioid addiction receive treatment at an early stage of their drug misuse to prevent a new generation of young adult opioid addicts tomorrow.

Extend the Continuum of Care service model. The commission correctly proposed ensuring a continuum of care into the criminal justice system, noting that treatment during and after incarceration works to reduce recidivism and lowers mortality risk. We should also enlarge the model to include offsite services to homeless shelters, schools and addicts’ homes.  

3rd August 2017
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The Rosenthal Report - August 2017

Rosenthal Reports
White House drug commission calls for Trump to declare a national drug emergency
Commission’s strategy lacks clear funding goals
What’s needed is a bold $100 billion plan to fight the opioid epidemic

The White House opioid commission’s call in July for President Trump to declare a “national health emergency” to fight the opioid epidemic is an important step forward. So too are the forward-thinking policy guidelines issued by the commission, which I addressed in June. Using stark language, the commission’s interim report urged the President and Congress to focus on funding and launching initiatives to combat a drug “scourge” that will eventually affect every American, the report warned.

Many of the commission’s proposals go to the heart of the crisis, and target policy areas important to the Rosenthal Center. These range from increasing treatment capacity – especially residential treatment – through Medicaid; expanding Medication-Assisted Treatment (MAT); providing overdose reversal drugs to all law enforcement; and disrupting the flow of the deadly synthetic opioid fentanyl, which the commission calls “the next grave challenge on the opioid front.”

While moving in the right direction, the report does not go far enough. It failed to commit a specific amount of money to the national emergency at a time when 142 Americans die every day from drug overdoses. And it does not address a number of specific policy ideas that are key to successfully confronting this epidemic.

As we go to press, it’s uncertain whether President Trump will declare a health emergency and if he will support a large funding commitment. After all, as the legislative showdown over healthcare reform recently demonstrated, President Trump and the GOP-led Congress were willing to gut Medicaid and scale back essential benefits that would have devastated drug treatment programs.

With this in mind, the Rosenthal Center calls for bipartisan leadership and a comprehensive $100 billion national action program that expands on the commission’s findings and sets more specific goals and explicit policy language as follows:

Immediately allocate $100 billion to the states. This will incentivize the states to match funding to expand existing programs and design and build up new initiatives that directly address the needs of their communities.

Ensure that behavioral therapy is an essential component of medication- assisted treatment (MAT). While the commission calls for expanding MAT, it does not specifically mention the importance of behavioral therapy and counseling. Under federal SAMHSA guidelines, MAT must include both medication and therapy as a way to help addicts reorder their lives and provide them with self-awareness and a new social network for sustained recovery.  

Expand access to long-term residential treatment. With resources strained by the fast moving epidemic, few states today have sufficient capacity to provide long-term treatment for the skyrocketing addict population. The commission is right to prioritize this goal, as long-term treatment can help break the cycle of serial short-term admissions that often result in subsequent relapse and in many cases, death.

Renewed focus on specific addict populations, including vulnerable adolescents. The commission did not specifically mention adolescents, even though the Surgeon General estimates that one million adolescents (12 to 17) are in need of drug treatment but routinely fail to receive it. Teen admissions to drug programs plummeted by almost 50 percent between 2004 and 2014 to just over 78,000, due in part to the closing of dedicated facilities. We must ensure that adolescents who are prey to opioid addiction receive treatment at an early stage of their drug misuse to prevent a new generation of young adult opioid addicts tomorrow.

Extend the Continuum of Care service model. The commission correctly proposed ensuring a continuum of care into the criminal justice system, noting that treatment during and after incarceration works to reduce recidivism and lowers mortality risk. We should also enlarge the model to include offsite services to homeless shelters, schools and addicts’ homes.  

3rd August 2017
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The Rosenthal Report - July 2017

Rosenthal Reports
“We are facing an addiction crisis likely to be the most deadly drug epidemic in the nation’s history.”

In June, I testified in Washington, D.C. at the first meeting of the new Presidential Commission on Combating Drug Addiction and the Opioid Crisis, speaking on behalf of the Rosenthal Center and as deputy chairman of the National Council on Alcoholism and Drug Addiction.

I used the occasion to bluntly tell members we are facing an addiction crisis likely to be the most deadly drug epidemic in the nation’s history. The numbers tell a tragic story:  in 2016 nearly 60,000 Americans died from drug overdoses, mostly from opiates, a 20 percent increase over the year before. Over the next decade, opioids could kill between 500,000 and 650,000 Americans - nearly as many as HIV/AIDS killed in the 1980s, and equal to the number of those who will die from prostate and breast cancer - if the crisis of addiction and overdose accelerates, a STAT News report concluded.

The crisis is tearing at the fabric of our society, devastating families and communities as it spreads back to inner city neighborhoods, as well as to suburbs, from the rural areas hit hardest by the current epidemic. Addiction now touches almost every race, ethnicity and area of the country. According to recent data, drug overdoses are the leading cause of death for Americans under the age of 50; for the first time in a century the overall death rate for Americans in the prime of life is rising.  

The terrifying reality is that nothing we’re doing today has been able to stop the spread of opioid addiction, an observation I made that was quoted in US News & World Report’s coverage of the hearing. Despite prescription monitoring programs, new pain management guidelines, and a raft of prevention and education programs, deaths from heroin and super-potent synthetics like fentanyl have gone through the roof, overwhelming hospital emergency rooms and healthcare workers.

We are engulfed in a perfect storm of disabling forces. Drugs like fentanyl and its even more powerful analogue carafentanil (an elephant tranquilizer) can be easily purchased online over the “dark web,” which is difficult for law enforcement to detect and disrupt. Enough powdery fentanyl to get 50,000 users high – or, more likely, to kill them – can fit into a first-class size envelope and be shipped anywhere.

Yet we do have the ability and knowhow to manage addiction. With the right treatment most addicts can come back to a full and fulfilling life for their families and for society. 

Securing the future of Medicaid is critical to this goal. Cutting funding would severely endanger the lives of addicts, especially those with few social or economic resources. Medicaid is the largest payer for addiction services across the country, and to gut this entitlement program now would be “immoral and mean-spirited,” I said in a statement quoted by the New York Daily News.

If it does nothing else, the Commission should recommend the expansion of long-term residential treatment programs. Far too frequently, patients become trapped in a cycle of serial admissions and short-term treatment programs that are ineffective and inadequate, and often amount to merely postponing a fatal overdose, a comment that was mentioned in a PBS Newshour report on the hearing. For these patients, long-term residential treatment is most successful -although few states have sufficient long-term treatment capacity, and only one in ten addicts get the treatment they need. 

I would hope the Commission, chaired by New Jersey governor Chris Christie, along with the Trump administration, Congress and state and local officials, listen carefully to what I and other experts had to say – and more importantly, that they take action sooner rather than later to seriously address this national health emergency. 

6th July 2017
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The Rosenthal Report - July 2017

Rosenthal Reports
“We are facing an addiction crisis likely to be the most deadly drug epidemic in the nation’s history.”

In June, I testified in Washington, D.C. at the first meeting of the new Presidential Commission on Combating Drug Addiction and the Opioid Crisis, speaking on behalf of the Rosenthal Center and as deputy chairman of the National Council on Alcoholism and Drug Addiction.

I used the occasion to bluntly tell members we are facing an addiction crisis likely to be the most deadly drug epidemic in the nation’s history. The numbers tell a tragic story:  in 2016 nearly 60,000 Americans died from drug overdoses, mostly from opiates, a 20 percent increase over the year before. Over the next decade, opioids could kill between 500,000 and 650,000 Americans - nearly as many as HIV/AIDS killed in the 1980s, and equal to the number of those who will die from prostate and breast cancer - if the crisis of addiction and overdose accelerates, a STAT News report concluded.

The crisis is tearing at the fabric of our society, devastating families and communities as it spreads back to inner city neighborhoods, as well as to suburbs, from the rural areas hit hardest by the current epidemic. Addiction now touches almost every race, ethnicity and area of the country. According to recent data, drug overdoses are the leading cause of death for Americans under the age of 50; for the first time in a century the overall death rate for Americans in the prime of life is rising.  

The terrifying reality is that nothing we’re doing today has been able to stop the spread of opioid addiction, an observation I made that was quoted in US News & World Report’s coverage of the hearing. Despite prescription monitoring programs, new pain management guidelines, and a raft of prevention and education programs, deaths from heroin and super-potent synthetics like fentanyl have gone through the roof, overwhelming hospital emergency rooms and healthcare workers.

We are engulfed in a perfect storm of disabling forces. Drugs like fentanyl and its even more powerful analogue carafentanil (an elephant tranquilizer) can be easily purchased online over the “dark web,” which is difficult for law enforcement to detect and disrupt. Enough powdery fentanyl to get 50,000 users high – or, more likely, to kill them – can fit into a first-class size envelope and be shipped anywhere.

Yet we do have the ability and knowhow to manage addiction. With the right treatment most addicts can come back to a full and fulfilling life for their families and for society. 

Securing the future of Medicaid is critical to this goal. Cutting funding would severely endanger the lives of addicts, especially those with few social or economic resources. Medicaid is the largest payer for addiction services across the country, and to gut this entitlement program now would be “immoral and mean-spirited,” I said in a statement quoted by the New York Daily News.

If it does nothing else, the Commission should recommend the expansion of long-term residential treatment programs. Far too frequently, patients become trapped in a cycle of serial admissions and short-term treatment programs that are ineffective and inadequate, and often amount to merely postponing a fatal overdose, a comment that was mentioned in a PBS Newshour report on the hearing. For these patients, long-term residential treatment is most successful -although few states have sufficient long-term treatment capacity, and only one in ten addicts get the treatment they need. 

I would hope the Commission, chaired by New Jersey governor Chris Christie, along with the Trump administration, Congress and state and local officials, listen carefully to what I and other experts had to say – and more importantly, that they take action sooner rather than later to seriously address this national health emergency. 

6th July 2017
Read More

The Rosenthal Report - June 2017

Rosenthal Reports

In this month’s report, we explain why Attorney General Jeff Sessions’ tough sentencing directive for low-level drug crimes is the wrong way to fight drug abuse and underscores the Trump administration’s mixed messages on the opioid crisis. Our series on statewide initiatives examines Kentucky’s efforts to contain its opioid epidemic and one of the nation’s highest rates of overdose deaths.

Memo to Trump: Locking Up Drug Addicts Won’t End the Opioid Epidemic

U.S. Attorney General Jeff Sessions told federal prosecutors in May to impose harsh, mandatory minimum sentences for even low level and nonviolent drug crimes, scuttling Obama-era leniency toward offenders not associated with drug gangs or trafficking. Sessions’ policy reversal signals a return to the failed mass-incarceration strategies deployed during the “war on drugs” in the 1980s and 1990s, and is especially misguided as the nation grapples with a devastating opioid epidemic.

We are concerned about the potential consequences of a new dragnet of stricter enforcement and punishment for less serious drug offenses committed by substance abusers. This doesn’t mean we are soft on crime: by all means, put drug-dealing kingpins in prison.  Instead of locking addicts in prison, we can leverage the interaction with the criminal justice system to provide them with opportunities for recovery.

Tough, mandatory minimum sentencing removes the possibility for creative sentencing by judges to place addicts in programs as an alternative to incarceration. Following the Obama guidelines, more than 30 states have already overhauled sentencing laws, introducing limited prison terms, expanding drug treatment programs and drug courts, which place most offenders in treatment. 

Addicts require encouragement and most frequently coercion to enter treatment, and courts can help. Vanessa Vitolo, a recovering heroin addict who told her harrowing story to President Trump and his new opioid commission, is typical. As a young woman she got hooked on drugs, cycled in and out of jail and found herself homeless and feeling “lost in every aspect of the word,” she recalled. With help from her parents, and sentencing from a drug court, Vitolo finally received long-term treatment. Today, three years later, she is stable and in recovery, with a job and an apartment.

Vanessa’s story highlights the long road to recovery, and the role the criminal justice system can play.  Let’s use guidelines for sentencing to get more addicts into treatment.   It is also vital to create more treatment units within our prisons, and establish support systems outside prison so that recovering addicts are not just let on the street. This makes sense to maintain their health and safety as well as that of society.

President Trump’s opioid commission has a chance to be forward thinking and take advantage of decades of experience that the criminal justice system has had with treatment providers.  Sessions’ sentencing directive is regressive. Instead of pounding the table for law and order, we need to continue the integration of the criminal justice system and substance abuse treatment programs into a comprehensive life-enhancing strategy.

The States Take Action: Kentucky

Like other Central Appalachian states, Kentucky has been hit hard by the opioid epidemic. There were 1,248 fatal overdoses in 2015, a 16 percent increase over the year before; the death rate was 29.9 per 100,000 population, the nation’s third highest. Contributing factors include poverty, complex injuries suffered by coal minors, and lax prescribing practices. Kentucky is one of 13 states in which the annual number of opioid painkiller prescriptions exceeds the number of residents. In Clay County, for example, with a population of 21,000, pharmacies dispensed more than 2.8 million doses of opioid pain killers in 2016, or 150 doses for every man, woman and child in the area, according to a Kaiser Health News report.

In early 2017,Governor Matt Bevin outlined Kentucky’s anti-opioid strategy at the National Prescription Drug Use and Heroin Summit. The plan includes a new law limiting opioid painkiller prescriptions to a 3-day supply; education programs on neonatal abstinence syndrome (a massive problem in the state); and ensuring over the counter access to the overdose reversal drug naloxone. To address an acute lack of treatment beds, Kentucky has applied for a waiver from the Medicaid rule that prohibits federal dollars being used for addiction treatment facilities with more than 16 beds. A 2016 survey by television station WCPO found that in eight counties in northern Kentucky some 30,000 people needed substance abuse treatment, but that there was only capacity for one-third of them in the region.

 

COMMENTARY

Obtaining a Medicaid waiver to the 16-bed limit provision will eventually increase the number of desperately needed long-term treatment beds, but this will take time. Meanwhile, threatened cuts to Medicaid funding and the possible repeal of the Affordable Care Act (ACA) by Congress would have an immediate and devastating impact on the state’s large low-income population (nearly 440,000 residents joined the Medicaid rolls under ACA). While Medicaid expansion did make some opioid drugs more available legally, it also made treatment more accessible, a story in the Atlantic magazine pointed out. In Clay County, where 60 percent of residents receive Medicaid benefits, opioid overdose deaths fell from 27 in 2011 to 4 in 2016 due in part to increased treatment options and the wider availability of drugs like suboxone, which reduces symptoms of opiate addiction and withdrawal. Changes to Medicaid funding and eligibility would imperil these important gains as Kentucky addresses its opioid crisis.

6th June 2017
Read More

The Rosenthal Report - June 2017

Rosenthal Reports

In this month’s report, we explain why Attorney General Jeff Sessions’ tough sentencing directive for low-level drug crimes is the wrong way to fight drug abuse and underscores the Trump administration’s mixed messages on the opioid crisis. Our series on statewide initiatives examines Kentucky’s efforts to contain its opioid epidemic and one of the nation’s highest rates of overdose deaths.

Memo to Trump: Locking Up Drug Addicts Won’t End the Opioid Epidemic

U.S. Attorney General Jeff Sessions told federal prosecutors in May to impose harsh, mandatory minimum sentences for even low level and nonviolent drug crimes, scuttling Obama-era leniency toward offenders not associated with drug gangs or trafficking. Sessions’ policy reversal signals a return to the failed mass-incarceration strategies deployed during the “war on drugs” in the 1980s and 1990s, and is especially misguided as the nation grapples with a devastating opioid epidemic.

We are concerned about the potential consequences of a new dragnet of stricter enforcement and punishment for less serious drug offenses committed by substance abusers. This doesn’t mean we are soft on crime: by all means, put drug-dealing kingpins in prison.  Instead of locking addicts in prison, we can leverage the interaction with the criminal justice system to provide them with opportunities for recovery.

Tough, mandatory minimum sentencing removes the possibility for creative sentencing by judges to place addicts in programs as an alternative to incarceration. Following the Obama guidelines, more than 30 states have already overhauled sentencing laws, introducing limited prison terms, expanding drug treatment programs and drug courts, which place most offenders in treatment. 

Addicts require encouragement and most frequently coercion to enter treatment, and courts can help. Vanessa Vitolo, a recovering heroin addict who told her harrowing story to President Trump and his new opioid commission, is typical. As a young woman she got hooked on drugs, cycled in and out of jail and found herself homeless and feeling “lost in every aspect of the word,” she recalled. With help from her parents, and sentencing from a drug court, Vitolo finally received long-term treatment. Today, three years later, she is stable and in recovery, with a job and an apartment.

Vanessa’s story highlights the long road to recovery, and the role the criminal justice system can play.  Let’s use guidelines for sentencing to get more addicts into treatment.   It is also vital to create more treatment units within our prisons, and establish support systems outside prison so that recovering addicts are not just let on the street. This makes sense to maintain their health and safety as well as that of society.

President Trump’s opioid commission has a chance to be forward thinking and take advantage of decades of experience that the criminal justice system has had with treatment providers.  Sessions’ sentencing directive is regressive. Instead of pounding the table for law and order, we need to continue the integration of the criminal justice system and substance abuse treatment programs into a comprehensive life-enhancing strategy.

The States Take Action: Kentucky

Like other Central Appalachian states, Kentucky has been hit hard by the opioid epidemic. There were 1,248 fatal overdoses in 2015, a 16 percent increase over the year before; the death rate was 29.9 per 100,000 population, the nation’s third highest. Contributing factors include poverty, complex injuries suffered by coal minors, and lax prescribing practices. Kentucky is one of 13 states in which the annual number of opioid painkiller prescriptions exceeds the number of residents. In Clay County, for example, with a population of 21,000, pharmacies dispensed more than 2.8 million doses of opioid pain killers in 2016, or 150 doses for every man, woman and child in the area, according to a Kaiser Health News report.

In early 2017,Governor Matt Bevin outlined Kentucky’s anti-opioid strategy at the National Prescription Drug Use and Heroin Summit. The plan includes a new law limiting opioid painkiller prescriptions to a 3-day supply; education programs on neonatal abstinence syndrome (a massive problem in the state); and ensuring over the counter access to the overdose reversal drug naloxone. To address an acute lack of treatment beds, Kentucky has applied for a waiver from the Medicaid rule that prohibits federal dollars being used for addiction treatment facilities with more than 16 beds. A 2016 survey by television station WCPO found that in eight counties in northern Kentucky some 30,000 people needed substance abuse treatment, but that there was only capacity for one-third of them in the region.

 

COMMENTARY

Obtaining a Medicaid waiver to the 16-bed limit provision will eventually increase the number of desperately needed long-term treatment beds, but this will take time. Meanwhile, threatened cuts to Medicaid funding and the possible repeal of the Affordable Care Act (ACA) by Congress would have an immediate and devastating impact on the state’s large low-income population (nearly 440,000 residents joined the Medicaid rolls under ACA). While Medicaid expansion did make some opioid drugs more available legally, it also made treatment more accessible, a story in the Atlantic magazine pointed out. In Clay County, where 60 percent of residents receive Medicaid benefits, opioid overdose deaths fell from 27 in 2011 to 4 in 2016 due in part to increased treatment options and the wider availability of drugs like suboxone, which reduces symptoms of opiate addiction and withdrawal. Changes to Medicaid funding and eligibility would imperil these important gains as Kentucky addresses its opioid crisis.

6th June 2017
Read More

President Trump: don’t gut the budget of the White House Office of National Drug Control Policy!

Other

Slashing spending to just $24 million from $388 million will harm nation-wide efforts to fight the deadly opioid epidemic.

ONDCP oversees essential drug programs and integrates critical government resources. Don’t be penny wise and pound foolish!

11th May 2017
Read More

President Trump: don’t gut the budget of the White House Office of National Drug Control Policy!

Other

Slashing spending to just $24 million from $388 million will harm nation-wide efforts to fight the deadly opioid epidemic.

ONDCP oversees essential drug programs and integrates critical government resources. Don’t be penny wise and pound foolish!

11th May 2017
Read More

The Rosenthal Report - May 2017

Rosenthal Reports

MAINSTREAMING MARIJUANA

As the Trump administration signals support for hard line anti-drug policies, Canada is poised to legalize recreational marijuana nationwide – only the second country to do so.  Meanwhile, support is growing for more research into using pot as a painkiller to help patients avoid opioid addiction. This month’s Report looks at these developments and the potential impact on perceptions and marijuana use. Our series on statewide initiatives to confront the opioid crisis focuses on Vermont and New Hampshire.

 

CANADA OPTS FOR POT LEGALIZATION

Canadian Prime Minister Justin Trudeau has introduced legislation that would legalize recreational use of marijuana nationwide by July 2018, a move approved by seven out of ten Canadians and designed to keep marijuana out of the hands of young people. Canada now has the world’s highest rates of youth cannabis use—21 percent of teens 15 to 19 and 30 percent of young adults 20 to 24.

Bill Blair, who will shepherd the legislation through the Canadian Parliament, makes the case that, “Criminal prohibition has failed to protect our kids and our communities.” Ralph Goodale, the nation’s public safety minister concurs, saying, “If your objective is to protect public health and safety and keep cannabis out of the hands of minors, and stop the flow of illegal profits to organized crime, then the law as it stands today has been an abject failure.”

During his campaign, Trudeau promised to expand legalization to recreational marijuana from court mandated medical marijuana. Details of the new measure follow recommendations of a federal taskforce, and include federal control over licensing and production and provincial regulation of how it can be sold.

Pricing and taxation will be jointly decided, and, after the nation’s experience with tobacco—when high prices, rather than reducing consumption, created a black market in cigarettes—should be low enough to limit illicit sales—as should harsh penalties proposed by the legalization measure.

Giving or selling pot to teens or “using youth to commit a cannabis-related offense” could land you in prison for 14 years. Lesser cannabis-related felonies, such as creating, packaging or labeling “products that are appealing to youth” will carry fines and prison terms. Growing, importing, exporting, or selling marijuana without a federal license will remain serious federal offenses.

The federal minimum age to buy marijuana will be 18, but the provinces can set higher minimum ages. Adults can possess as much as 30 grams of pot in public and families are allowed to grow four marijuana plants (to a maximum height of one meter). Aggressive marketing will be discouraged, product information limited largely to brand name, ingredients, strain of marijuana, and the government may insist on plain packaging. Police would be allowed to administer a saliva test to motorists to screen for THC, the psychoactive ingredient in marijuana.

In the workplace, employees would not have the right to freely use marijuana and are still expected to show up sober and ready to work, an assessment in the Globe and Mail newspaper concluded. In the province of Ontario, specifically, restrictions on smoking tobacco in the workplace would apply equally to the smoking of marijuana. 

Given Trudeau’s Liberal Party majority, and support from the left-leaning New Democratic Party, recreational pot legalization is expected to pass easily. Conservative Party members voiced opposition, asserting that legalization would only increase adolescent marijuana use, while doctors – who have long had misgivings about medical marijuana – expressed grave concerns about the impact on youth.

The Canadian Pediatric Society warns that legalization does not mean the drug is safe. The doctors hold that one in seven teenagers who start using cannabis develop cannabis-use disorder and, though the adult brain seems able to recover from chronic pot use in just a few weeks, teens who smoke pot frequently can do long-lasting damage to their brains. Concerns about danger to the adolescent brain prompted the Canadian Medical Association to urge the government to ban the sale of marijuana to people under 21 and to restrict the amount and potency of the drug available to those under 25.

Protecting youth, Health Minister Jane Philpott maintains, is “at the center” of the legalization measure, and the government promises, “a robust public education campaign to inform youth of the risks and harms of cannabis use.” Clearly, one is needed, for Canadian Youth Perceptions on Cannabis, a study released at the end of January by the nonprofit Canadian Centre on Substance Abuse found “Young people think marijuana is neither addictive nor harmful.” 

Speaking in support of the marijuana measure, Blair maintains that legalization is not aimed at promoting use of the drug or to maximize tax revenues. “In every other jurisdiction that has gone down the road of legalization, they focused primarily on a commercial regulatory framework. In Canada, it’s a public-health framework.”

Commentary  

Canada’s plan for legalization contains much that is attractive to those who believe—as we do—that the paramount issue is limiting adolescent marijuana use. Legalization in the United States has, as opponents point out, led to increased teen use of the drug.  Advocates for the Canadian plan contend that what they propose should not raise the nation’s already sky-high rate of youthful use.  We doubt that any measure sanctioning adult use can prevent that.

 

TRADING PLACES: POT OR PAINKILLERS?

Researchers are becoming interested in how certain marijuana components could be used in controlled settings to help curb the opioid crisis. While U.S. Attorney General Jeff Sessions has mocked the idea as “stupid,” recent studies suggest that weed may be a safe substitute for opioid painkillers as well as an aid to curbing opioid abuse. “Epidemics require a paradigm shift in thinking about all possible solutions,” Yasmina Hurd, a neuroscientist at Mount Sinai Hospital in New York, argued in Trends in Neuroscience, explaining the growing interest in pot for these purposes. “We have to be open to marijuana because there are components of the plant that seem to have therapeutic properties.”

At this point, however, studies suggest only correlations between medical marijuana use and reducing chronic pain and opioid addiction. Preclinical animal models have demonstrated that CBD, a non-psychoactive element in marijuana, reduces the rewarding properties of opioid drugs and withdrawal symptoms. A small pilot study by Dr. Hurd mirrored these conclusions, as did research at the University of Michigan and a RAND Corporation paper with researchers at University of California, Irvine that compared states with and without medical marijuana dispensaries.

While intriguing, these initial findings are largely observational and anecdotal. They do not support changing current clinical practice towards cannabis, as the lead author of the Michigan study, Keith Boehnke, has stated. For one thing, these studies were conducted with patients at medical dispensaries who are more inclined to endorse the benefits of medicinal marijuana. Still, it is worthwhile exploring pot as an alternative to dangerous prescription opioid painkillers or to reduce opioid addiction. Research must be pursued in long-term, large-scale clinical studies that focus solely on the CBD component and not THC, a powerful psychoactive element in marijuana. 

 

THE STATES TAKE ACTION: VERMONT AND NEW HAMPSHIRE

These neighboring New England states are struggling to contain the opioid epidemic that has ravaged their communities. Drug overdose mortality rates in 2015 reached 16.7 per 100,000 inhabitants in Vermont, and 34.3 n New Hampshire - one of the nation’s highest, according to the Centers for Disease Control and Prevention.

Vermont

In 2014 Vermont’s then-governor Peter Shumlin sounded the alarm about his state’s intensifying opioid epidemic, declaring a “full-blown crisis” with a spiraling number of drug overdoses and persons seeking treatment.  The state legislature responded with measures to expand the use of overdose reversal drugs; introduce prescription rationing (as of January 2017); promote treatment options in lieu of prosecution and incarceration; and develop the state’s “spoke-and-hub” treatment infrastructure of centralized and local care.

After leveling off for a few years, the number of Vermonters who died from drug overdoses spiked in 2016 to 104, up from 66 the year before, almost evenly split between heroin and fentanyl overdoses. The victims represented a cross section of the state’s population: blue collar and professional class, rural and urban, old and young, and roughly 30 percent were women, the Vermont website Seven Days reported. Vermont’s anti-opioid efforts have had some impact. Indeed, the overdose numbers could have been worse if not for the widespread distribution of the overdose reversal drug Narcan, and the opening of more treatment facilities and a reduction in waiting times.

New Hampshire

Despite a relatively small population of 1.4 million, more than double neighboring Vermont, New Hampshire is often called “ground zero” of the rural opioid epidemic. In 2015, the state reported 439 drug overdose deaths - the second highest per capita rate in the nation after West Virginia – and 478 deaths are estimated for 2016.

The state response has focused on expanding access to treatment (New Hampshire ranked second to last nationwide in access to treatment), addressing a shortage of trained staff in recovery programs, and increasing the number of doctors licensed to prescribe Suboxone, a drug that eases withdrawal symptoms. Other measures include a drug crisis hotline; the Safe Station program, where addicts can seek help and referrals at fire stations; and stricter prescription monitoring rules that went into effect at the start of 2017. More than 10,000 persons have received addiction treatment after gaining coverage through the Medicaid expansion under the Affordable Care Act.

Holly Cekala, executive director of Hope for New Hampshire, a recovery community nonprofit, says the state is making strides to confront the epidemic and has come a long way from the “treatment apocalypse” it faced when the crisis first unfolded. But considering the high number of overdoses and waiting times for residential treatment – averaging four to six weeks – “there’s still a lot of work to be done,” she told the Rosenthal Report.

Commentary

Vermont and New Hampshire are taking the right steps to control the opioid epidemic, putting in place programs that will help save lives and get addicts into effective treatment. In both states, there is a range of options including outpatient and residential treatment lasting up to 90 days, including medication-assisted treatment (MAT) – especially in Vermont. Hard-hit New Hampshire needs to increase the number of residential treatment places and add more recovery housing; raise Medicaid reimbursement payments to allow more lower-income patients to enter treatment; and provide more prison-based drug treatment programs. It’s a resolutely stubborn public health crisis that will take time and determination to overcome.

4th May 2017
Read More

The Rosenthal Report - May 2017

Rosenthal Reports

MAINSTREAMING MARIJUANA

As the Trump administration signals support for hard line anti-drug policies, Canada is poised to legalize recreational marijuana nationwide – only the second country to do so.  Meanwhile, support is growing for more research into using pot as a painkiller to help patients avoid opioid addiction. This month’s Report looks at these developments and the potential impact on perceptions and marijuana use. Our series on statewide initiatives to confront the opioid crisis focuses on Vermont and New Hampshire.

 

CANADA OPTS FOR POT LEGALIZATION

Canadian Prime Minister Justin Trudeau has introduced legislation that would legalize recreational use of marijuana nationwide by July 2018, a move approved by seven out of ten Canadians and designed to keep marijuana out of the hands of young people. Canada now has the world’s highest rates of youth cannabis use—21 percent of teens 15 to 19 and 30 percent of young adults 20 to 24.

Bill Blair, who will shepherd the legislation through the Canadian Parliament, makes the case that, “Criminal prohibition has failed to protect our kids and our communities.” Ralph Goodale, the nation’s public safety minister concurs, saying, “If your objective is to protect public health and safety and keep cannabis out of the hands of minors, and stop the flow of illegal profits to organized crime, then the law as it stands today has been an abject failure.”

During his campaign, Trudeau promised to expand legalization to recreational marijuana from court mandated medical marijuana. Details of the new measure follow recommendations of a federal taskforce, and include federal control over licensing and production and provincial regulation of how it can be sold.

Pricing and taxation will be jointly decided, and, after the nation’s experience with tobacco—when high prices, rather than reducing consumption, created a black market in cigarettes—should be low enough to limit illicit sales—as should harsh penalties proposed by the legalization measure.

Giving or selling pot to teens or “using youth to commit a cannabis-related offense” could land you in prison for 14 years. Lesser cannabis-related felonies, such as creating, packaging or labeling “products that are appealing to youth” will carry fines and prison terms. Growing, importing, exporting, or selling marijuana without a federal license will remain serious federal offenses.

The federal minimum age to buy marijuana will be 18, but the provinces can set higher minimum ages. Adults can possess as much as 30 grams of pot in public and families are allowed to grow four marijuana plants (to a maximum height of one meter). Aggressive marketing will be discouraged, product information limited largely to brand name, ingredients, strain of marijuana, and the government may insist on plain packaging. Police would be allowed to administer a saliva test to motorists to screen for THC, the psychoactive ingredient in marijuana.

In the workplace, employees would not have the right to freely use marijuana and are still expected to show up sober and ready to work, an assessment in the Globe and Mail newspaper concluded. In the province of Ontario, specifically, restrictions on smoking tobacco in the workplace would apply equally to the smoking of marijuana. 

Given Trudeau’s Liberal Party majority, and support from the left-leaning New Democratic Party, recreational pot legalization is expected to pass easily. Conservative Party members voiced opposition, asserting that legalization would only increase adolescent marijuana use, while doctors – who have long had misgivings about medical marijuana – expressed grave concerns about the impact on youth.

The Canadian Pediatric Society warns that legalization does not mean the drug is safe. The doctors hold that one in seven teenagers who start using cannabis develop cannabis-use disorder and, though the adult brain seems able to recover from chronic pot use in just a few weeks, teens who smoke pot frequently can do long-lasting damage to their brains. Concerns about danger to the adolescent brain prompted the Canadian Medical Association to urge the government to ban the sale of marijuana to people under 21 and to restrict the amount and potency of the drug available to those under 25.

Protecting youth, Health Minister Jane Philpott maintains, is “at the center” of the legalization measure, and the government promises, “a robust public education campaign to inform youth of the risks and harms of cannabis use.” Clearly, one is needed, for Canadian Youth Perceptions on Cannabis, a study released at the end of January by the nonprofit Canadian Centre on Substance Abuse found “Young people think marijuana is neither addictive nor harmful.” 

Speaking in support of the marijuana measure, Blair maintains that legalization is not aimed at promoting use of the drug or to maximize tax revenues. “In every other jurisdiction that has gone down the road of legalization, they focused primarily on a commercial regulatory framework. In Canada, it’s a public-health framework.”

Commentary  

Canada’s plan for legalization contains much that is attractive to those who believe—as we do—that the paramount issue is limiting adolescent marijuana use. Legalization in the United States has, as opponents point out, led to increased teen use of the drug.  Advocates for the Canadian plan contend that what they propose should not raise the nation’s already sky-high rate of youthful use.  We doubt that any measure sanctioning adult use can prevent that.

 

TRADING PLACES: POT OR PAINKILLERS?

Researchers are becoming interested in how certain marijuana components could be used in controlled settings to help curb the opioid crisis. While U.S. Attorney General Jeff Sessions has mocked the idea as “stupid,” recent studies suggest that weed may be a safe substitute for opioid painkillers as well as an aid to curbing opioid abuse. “Epidemics require a paradigm shift in thinking about all possible solutions,” Yasmina Hurd, a neuroscientist at Mount Sinai Hospital in New York, argued in Trends in Neuroscience, explaining the growing interest in pot for these purposes. “We have to be open to marijuana because there are components of the plant that seem to have therapeutic properties.”

At this point, however, studies suggest only correlations between medical marijuana use and reducing chronic pain and opioid addiction. Preclinical animal models have demonstrated that CBD, a non-psychoactive element in marijuana, reduces the rewarding properties of opioid drugs and withdrawal symptoms. A small pilot study by Dr. Hurd mirrored these conclusions, as did research at the University of Michigan and a RAND Corporation paper with researchers at University of California, Irvine that compared states with and without medical marijuana dispensaries.

While intriguing, these initial findings are largely observational and anecdotal. They do not support changing current clinical practice towards cannabis, as the lead author of the Michigan study, Keith Boehnke, has stated. For one thing, these studies were conducted with patients at medical dispensaries who are more inclined to endorse the benefits of medicinal marijuana. Still, it is worthwhile exploring pot as an alternative to dangerous prescription opioid painkillers or to reduce opioid addiction. Research must be pursued in long-term, large-scale clinical studies that focus solely on the CBD component and not THC, a powerful psychoactive element in marijuana. 

 

THE STATES TAKE ACTION: VERMONT AND NEW HAMPSHIRE

These neighboring New England states are struggling to contain the opioid epidemic that has ravaged their communities. Drug overdose mortality rates in 2015 reached 16.7 per 100,000 inhabitants in Vermont, and 34.3 n New Hampshire - one of the nation’s highest, according to the Centers for Disease Control and Prevention.

Vermont

In 2014 Vermont’s then-governor Peter Shumlin sounded the alarm about his state’s intensifying opioid epidemic, declaring a “full-blown crisis” with a spiraling number of drug overdoses and persons seeking treatment.  The state legislature responded with measures to expand the use of overdose reversal drugs; introduce prescription rationing (as of January 2017); promote treatment options in lieu of prosecution and incarceration; and develop the state’s “spoke-and-hub” treatment infrastructure of centralized and local care.

After leveling off for a few years, the number of Vermonters who died from drug overdoses spiked in 2016 to 104, up from 66 the year before, almost evenly split between heroin and fentanyl overdoses. The victims represented a cross section of the state’s population: blue collar and professional class, rural and urban, old and young, and roughly 30 percent were women, the Vermont website Seven Days reported. Vermont’s anti-opioid efforts have had some impact. Indeed, the overdose numbers could have been worse if not for the widespread distribution of the overdose reversal drug Narcan, and the opening of more treatment facilities and a reduction in waiting times.

New Hampshire

Despite a relatively small population of 1.4 million, more than double neighboring Vermont, New Hampshire is often called “ground zero” of the rural opioid epidemic. In 2015, the state reported 439 drug overdose deaths - the second highest per capita rate in the nation after West Virginia – and 478 deaths are estimated for 2016.

The state response has focused on expanding access to treatment (New Hampshire ranked second to last nationwide in access to treatment), addressing a shortage of trained staff in recovery programs, and increasing the number of doctors licensed to prescribe Suboxone, a drug that eases withdrawal symptoms. Other measures include a drug crisis hotline; the Safe Station program, where addicts can seek help and referrals at fire stations; and stricter prescription monitoring rules that went into effect at the start of 2017. More than 10,000 persons have received addiction treatment after gaining coverage through the Medicaid expansion under the Affordable Care Act.

Holly Cekala, executive director of Hope for New Hampshire, a recovery community nonprofit, says the state is making strides to confront the epidemic and has come a long way from the “treatment apocalypse” it faced when the crisis first unfolded. But considering the high number of overdoses and waiting times for residential treatment – averaging four to six weeks – “there’s still a lot of work to be done,” she told the Rosenthal Report.

Commentary

Vermont and New Hampshire are taking the right steps to control the opioid epidemic, putting in place programs that will help save lives and get addicts into effective treatment. In both states, there is a range of options including outpatient and residential treatment lasting up to 90 days, including medication-assisted treatment (MAT) – especially in Vermont. Hard-hit New Hampshire needs to increase the number of residential treatment places and add more recovery housing; raise Medicaid reimbursement payments to allow more lower-income patients to enter treatment; and provide more prison-based drug treatment programs. It’s a resolutely stubborn public health crisis that will take time and determination to overcome.

4th May 2017
Read More

The Rosenthal Report - April 2017

Rosenthal Reports

CONFRONTING THE OPIOID EPIDEMIC

This month’s Rosenthal Report examines new efforts announced by New York City and the State of New Jersey to stem the escalating opioid crisis, as well as the impact of opioid rationing and monitoring programs. Both are urgently needed as the opioid death toll escalates: 52,401 Americans died from overdoses in 2015, including more than 20,000 from opioid pain relievers and nearly 13,000 from heroin or heroin synthetics.  

It would be unfair to directly compare the two initiatives, since states (mostly with federal funds) provide, by far, the greatest amount of substance abuse service. Both, however, are responding to mounting numbers of overdose fatalities in different ways: New York City with a limited, narrowly focused approach and New Jersey with a broader and more comprehensive one. Reducing the number of fatalities however will not necessarily reduce the number of overdoses, because it is only by successfully addressing addiction itself can we curb the crisis. 

New York City Mayor Bill de Blasio Announces Anti-Opioid Initiative

Faced with a surge of opioid overdose deaths, de Blasio outlined a new initiative to combat the crisis and pledged $38 million annually to reduce the number of opioid deaths by 35 percent over the next five years. An estimated 1,300 New Yorkers died of drug overdose in 2016—the highest number on record. More than 1,075 of those died from opioid pain pills or opiates like heroin and the powerful synthetic opioid fentanyl, which accounted for 90 percent of opiod drug deaths last year compared to fewer than 5 percent from fentanyl before 2015. 

The Mayor’s plan, called HealingNYC, includes a reliable mix of prevention, outreach, professional training and supply reduction. To reduce overdose deaths, the city will distribute 100,000 naloxone kits to treatment centers, homeless shelters and pharmacies. And, for the first time, all 23,000 NYC Police Department patrol officers will carry the overdose reversal drug and be trained to use it. 

Also on the agenda are public awareness campaigns; more mental health clinics in high-need schools with a disproportionate share of suspensions and mental health issues, which can be precursors to substance abuse.  According to a City Hall statement, education programs for clinicians to reduce overprescribing are part of the initiative, as are doubling to 600 the number of inmates receiving methadone on Rikers Island, and the creation of police “Overdose Response Squads” that will target dealers in high-risk neighborhoods and “disrupt the supply of opioids before they come into the city,” according to a City Hall statement.

Another key element is providing medication-assisted treatment (MAT) for addiction to an additional 20,000 New Yorkers by 2022. Ten NYC hospital emergency departments will establish buprenorphine induction (the first phase of treatment to find the patient’s ideal daily dose of the drug) and what is called “care management” through the stabilization and maintenance phases. 

A Health Department spokesperson told the Rosenthal Report that HealthyNYC intends to make “the full spectrum of evidence based drug treatment” available to New Yorkers, including rehab beds and counseling at overdose programs and outpatient clinics. Still, the Mayor’s initiative is intensely focused on “increasing the availability and use of buprenorphine,” the spokesperson said, noting that the drug is currently underutilized in the city’s drug programs. 

 

First of a series: The States Take Action

NEW JERSEY
Entering his last year in office, two-term governor Chris Christie announced a comprehensive opioid emergency plan this past January. It establishes a broad framework for tackling the epidemic from a patchwork of programs already in place, including equipping emergency responders with overdose reversal drugs and training former drug users as counselors to drug addicts admitted to hospital emergency rooms.  

Christie’s plan followed a grim year for drug deaths in the state: overdoses from heroin and other opiates, including the powerful synthetic opioid fentanyl, claimed the lives of 1,600 drug users in New Jersey—a 20 percent increase over the previous year’s total. The governor’s first step was to declare a public health emergency, which gives him additional resources to battle the epidemic, and launch a television ad—with himself as pitchman—urging viewers to use a new one-stop website and telephone hotline to learn about addiction resources. 

The initiative includes substantive measures covering education and prevention, opioid prescription monitoring, and insurance coverage. In addition, there are regulations that limit physician prescriptions of opioids to a five-day supply instead of a 30-day one; rule changes that consider 18- and 19-year olds to be children to reduce waiting lists for treatment beds; proposed legislation that would require private insurers to pay for at least six months of drug treatment; and expanded education programs, starting in kindergarten, about avoiding opioid abuse.  

Democratic lawmakers in the state generally embraced the plan, but it already faces resistance from a physicians lobbying group, the Medical Society, which said it would be “cruel” to patients to limit prescriptions as well as an “intrusion” on medical practice.  Christie’s initiative got a reprieve when the GOP’s healthcare plan, which would have jeopardized Medicaid funding to the states and substance abuse programs, was withdrawn. And with Christie named to lead an anti-opioid drug commission within the White House’s new Office of American Innovation, his influence may also be felt at the federal level – and with the backing of President Trump.

 

COMMENTARY

All efforts to address the opioid crisis ravaging America’s urban and rural communities are to be applauded. Both the New York City and New Jersey initiatives include excellent ideas and effective policies, but the blueprint they offer is incomplete. The orientation (especially in New York) on curbing overdose deaths represents a short term, medication-based emergency response plan rather than a comprehensive long-term strategy that would lead patients to full recovery. 

That approach would require more than Mayor de Blasio’s planned $38 million expenditure. By comparison, he has allocated $1.6 billion for the Vision Zero safe streets initiative to eliminate traffic injuries and deaths. “We have made a commitment to decisively confront the epidemic of traffic fatalities and injuries,” the Mayor has said. The same should hold true for substance abuse and drug addiction. What about a Vision Zero for the addiction epidemic? It’s time to think bigger and bolder about bringing this crisis under control.   

A CLOSER LOOK: The Risks and Rewards of Opioid Rationing 

In one form or another, rationing opioids is now a reality.  Every state except Missouri has special prescription limitations, and the Center for Disease Control (CDC) has issued voluntary pain management guidelines backed by the surgeon general intended mainly for primary care physicians treating patients for non-cancer chronic pain. 

The motivation for rationing and monitoring is clear: prescription painkillers can be a gateway to addiction and abuse.  A paper published in the current Annals of Surgery, reported that three out of four recent heroin users say they were introduced to opioids by prescription medications. Unconsumed opioid pills remained in four out of five filled prescriptions, and one out of every five “opioid-naïve” surgical patients “continue to require opioids long after their surgical care is complete.”

A recent CDC study found that that risk of addiction for a representative sample of “opioid-naïve” cancer-free patients increased with each day of medication – starting with day three. Only six percent of the 1.3 million patients in the sample who were given a one-day supply were using opioids a year after their initial prescription. That number doubled to 12 percent for those given a six-day supply and to 24 percent if that first supply was for 12 days. 

February’s Rosenthal Report told how ER doctors are cutting back on narcotic painkillers. Dentists are also heeding this advice. They prescribe about 8 percent of all opioid drugs—and more than 30 percent of those given to patients aged 10 to 19. Last year, the American Dental Association recommended that dentists consider over-the-counter pain relievers as “first-line therapy for acute pain management.”

Now, surgeons are testing painkiller rationing. A Washington Post story highlighted a study at Dartmouth-Hitchcock Medical Center in New Hampshire that limited opioid prescriptions to a specific number of pills for five of the most common outpatient surgical procedures (for example, five pills for a partial mastectomy, and ten for a lymph node biopsy.) In addition, patients were counseled in the use of non-narcotic, over the counter pain relievers such as ibuprofen to manage pain.

A follow-up survey confirmed the efficacy of rationing: the total number of pills fell to under 3,000 from more than 6,000 for the 224 patients in the study. Moreover, a smaller sample of 148 patients was found to have taken only about half of the pills that were prescribed. Although only one patient returned to the medical center for a refill prescription, others may have sought additional pain medication from their primary care physicians, who write close to half of all opioid prescriptions. 

For those in favor of opioid rationing, the definitive factor in the explosive over-prescription of pain medication was the promotion of a high-potency, time-release opioid painkiller (OxyContin) in the late 1980s and early 1990s as well as the notion that addiction due to prescribed opioid pain management is rare. But, while promotion of that new painkiller did indeed play a key role, so did the long-time under-treatment of pain that preceded today’s concern for patient satisfaction.

The organization, Physicians for Responsible Opioid Prescribing (PROP), is a leader in the rationing campaign. It argues that while prescribed narcotics can lead to addiction, too much attention is given to how severely a patient’s chronic condition hurts. Reducing the intensity of pain, PROP maintains, should not be the goal of treatment for chronic pain. “Willingness to accept pain, and engagement in valued life activities despite pain, may reduce suffering and disability without necessarily reducing pain intensity,” the organization insists.

While PROP’s position enjoys support within the medical community, many doctors find the rationing campaign and “opioid phobia” troubling because opioids also clearly help some patients. A previous Rosenthal Report cited the example of Dr. Sean Mackey, head of Stanford University’s pain management program, who described a patient on an opioid regime for a severe foot injury who was able to continue working. 

To be sure, physicians must carefully consider the risks and rewards.  The monitoring programs have had a significant impact on prescribing practices, and have reduced “doctor shopping” – when patients seek out doctors who will prescribe more opioids. Nevertheless, the number of opioid deaths continues to rise; many patients are driven to illicit drugs; and although the rate of fatalities from the use of commonly prescribed opioid medications has flattened, the rate of death from heroin and heroin synthetics is increasing.

Equally important, critics say the CDC guidelines ignore the needs of the individual patient and lack compassion for their pain. Many patients feel like addicts or criminals when they require more painkillers after other medical interventions have failed. The tragedy is that doctors cannot agree on an approach to pain medication that recognizes both the need to control levels of opioid prescribing and the obligation to relieve patient pain.

4th April 2017
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The Rosenthal Report - April 2017

Rosenthal Reports

CONFRONTING THE OPIOID EPIDEMIC

This month’s Rosenthal Report examines new efforts announced by New York City and the State of New Jersey to stem the escalating opioid crisis, as well as the impact of opioid rationing and monitoring programs. Both are urgently needed as the opioid death toll escalates: 52,401 Americans died from overdoses in 2015, including more than 20,000 from opioid pain relievers and nearly 13,000 from heroin or heroin synthetics.  

It would be unfair to directly compare the two initiatives, since states (mostly with federal funds) provide, by far, the greatest amount of substance abuse service. Both, however, are responding to mounting numbers of overdose fatalities in different ways: New York City with a limited, narrowly focused approach and New Jersey with a broader and more comprehensive one. Reducing the number of fatalities however will not necessarily reduce the number of overdoses, because it is only by successfully addressing addiction itself can we curb the crisis. 

New York City Mayor Bill de Blasio Announces Anti-Opioid Initiative

Faced with a surge of opioid overdose deaths, de Blasio outlined a new initiative to combat the crisis and pledged $38 million annually to reduce the number of opioid deaths by 35 percent over the next five years. An estimated 1,300 New Yorkers died of drug overdose in 2016—the highest number on record. More than 1,075 of those died from opioid pain pills or opiates like heroin and the powerful synthetic opioid fentanyl, which accounted for 90 percent of opiod drug deaths last year compared to fewer than 5 percent from fentanyl before 2015. 

The Mayor’s plan, called HealingNYC, includes a reliable mix of prevention, outreach, professional training and supply reduction. To reduce overdose deaths, the city will distribute 100,000 naloxone kits to treatment centers, homeless shelters and pharmacies. And, for the first time, all 23,000 NYC Police Department patrol officers will carry the overdose reversal drug and be trained to use it. 

Also on the agenda are public awareness campaigns; more mental health clinics in high-need schools with a disproportionate share of suspensions and mental health issues, which can be precursors to substance abuse.  According to a City Hall statement, education programs for clinicians to reduce overprescribing are part of the initiative, as are doubling to 600 the number of inmates receiving methadone on Rikers Island, and the creation of police “Overdose Response Squads” that will target dealers in high-risk neighborhoods and “disrupt the supply of opioids before they come into the city,” according to a City Hall statement.

Another key element is providing medication-assisted treatment (MAT) for addiction to an additional 20,000 New Yorkers by 2022. Ten NYC hospital emergency departments will establish buprenorphine induction (the first phase of treatment to find the patient’s ideal daily dose of the drug) and what is called “care management” through the stabilization and maintenance phases. 

A Health Department spokesperson told the Rosenthal Report that HealthyNYC intends to make “the full spectrum of evidence based drug treatment” available to New Yorkers, including rehab beds and counseling at overdose programs and outpatient clinics. Still, the Mayor’s initiative is intensely focused on “increasing the availability and use of buprenorphine,” the spokesperson said, noting that the drug is currently underutilized in the city’s drug programs. 

 

First of a series: The States Take Action

NEW JERSEY
Entering his last year in office, two-term governor Chris Christie announced a comprehensive opioid emergency plan this past January. It establishes a broad framework for tackling the epidemic from a patchwork of programs already in place, including equipping emergency responders with overdose reversal drugs and training former drug users as counselors to drug addicts admitted to hospital emergency rooms.  

Christie’s plan followed a grim year for drug deaths in the state: overdoses from heroin and other opiates, including the powerful synthetic opioid fentanyl, claimed the lives of 1,600 drug users in New Jersey—a 20 percent increase over the previous year’s total. The governor’s first step was to declare a public health emergency, which gives him additional resources to battle the epidemic, and launch a television ad—with himself as pitchman—urging viewers to use a new one-stop website and telephone hotline to learn about addiction resources. 

The initiative includes substantive measures covering education and prevention, opioid prescription monitoring, and insurance coverage. In addition, there are regulations that limit physician prescriptions of opioids to a five-day supply instead of a 30-day one; rule changes that consider 18- and 19-year olds to be children to reduce waiting lists for treatment beds; proposed legislation that would require private insurers to pay for at least six months of drug treatment; and expanded education programs, starting in kindergarten, about avoiding opioid abuse.  

Democratic lawmakers in the state generally embraced the plan, but it already faces resistance from a physicians lobbying group, the Medical Society, which said it would be “cruel” to patients to limit prescriptions as well as an “intrusion” on medical practice.  Christie’s initiative got a reprieve when the GOP’s healthcare plan, which would have jeopardized Medicaid funding to the states and substance abuse programs, was withdrawn. And with Christie named to lead an anti-opioid drug commission within the White House’s new Office of American Innovation, his influence may also be felt at the federal level – and with the backing of President Trump.

 

COMMENTARY

All efforts to address the opioid crisis ravaging America’s urban and rural communities are to be applauded. Both the New York City and New Jersey initiatives include excellent ideas and effective policies, but the blueprint they offer is incomplete. The orientation (especially in New York) on curbing overdose deaths represents a short term, medication-based emergency response plan rather than a comprehensive long-term strategy that would lead patients to full recovery. 

That approach would require more than Mayor de Blasio’s planned $38 million expenditure. By comparison, he has allocated $1.6 billion for the Vision Zero safe streets initiative to eliminate traffic injuries and deaths. “We have made a commitment to decisively confront the epidemic of traffic fatalities and injuries,” the Mayor has said. The same should hold true for substance abuse and drug addiction. What about a Vision Zero for the addiction epidemic? It’s time to think bigger and bolder about bringing this crisis under control.   

A CLOSER LOOK: The Risks and Rewards of Opioid Rationing 

In one form or another, rationing opioids is now a reality.  Every state except Missouri has special prescription limitations, and the Center for Disease Control (CDC) has issued voluntary pain management guidelines backed by the surgeon general intended mainly for primary care physicians treating patients for non-cancer chronic pain. 

The motivation for rationing and monitoring is clear: prescription painkillers can be a gateway to addiction and abuse.  A paper published in the current Annals of Surgery, reported that three out of four recent heroin users say they were introduced to opioids by prescription medications. Unconsumed opioid pills remained in four out of five filled prescriptions, and one out of every five “opioid-naïve” surgical patients “continue to require opioids long after their surgical care is complete.”

A recent CDC study found that that risk of addiction for a representative sample of “opioid-naïve” cancer-free patients increased with each day of medication – starting with day three. Only six percent of the 1.3 million patients in the sample who were given a one-day supply were using opioids a year after their initial prescription. That number doubled to 12 percent for those given a six-day supply and to 24 percent if that first supply was for 12 days. 

February’s Rosenthal Report told how ER doctors are cutting back on narcotic painkillers. Dentists are also heeding this advice. They prescribe about 8 percent of all opioid drugs—and more than 30 percent of those given to patients aged 10 to 19. Last year, the American Dental Association recommended that dentists consider over-the-counter pain relievers as “first-line therapy for acute pain management.”

Now, surgeons are testing painkiller rationing. A Washington Post story highlighted a study at Dartmouth-Hitchcock Medical Center in New Hampshire that limited opioid prescriptions to a specific number of pills for five of the most common outpatient surgical procedures (for example, five pills for a partial mastectomy, and ten for a lymph node biopsy.) In addition, patients were counseled in the use of non-narcotic, over the counter pain relievers such as ibuprofen to manage pain.

A follow-up survey confirmed the efficacy of rationing: the total number of pills fell to under 3,000 from more than 6,000 for the 224 patients in the study. Moreover, a smaller sample of 148 patients was found to have taken only about half of the pills that were prescribed. Although only one patient returned to the medical center for a refill prescription, others may have sought additional pain medication from their primary care physicians, who write close to half of all opioid prescriptions. 

For those in favor of opioid rationing, the definitive factor in the explosive over-prescription of pain medication was the promotion of a high-potency, time-release opioid painkiller (OxyContin) in the late 1980s and early 1990s as well as the notion that addiction due to prescribed opioid pain management is rare. But, while promotion of that new painkiller did indeed play a key role, so did the long-time under-treatment of pain that preceded today’s concern for patient satisfaction.

The organization, Physicians for Responsible Opioid Prescribing (PROP), is a leader in the rationing campaign. It argues that while prescribed narcotics can lead to addiction, too much attention is given to how severely a patient’s chronic condition hurts. Reducing the intensity of pain, PROP maintains, should not be the goal of treatment for chronic pain. “Willingness to accept pain, and engagement in valued life activities despite pain, may reduce suffering and disability without necessarily reducing pain intensity,” the organization insists.

While PROP’s position enjoys support within the medical community, many doctors find the rationing campaign and “opioid phobia” troubling because opioids also clearly help some patients. A previous Rosenthal Report cited the example of Dr. Sean Mackey, head of Stanford University’s pain management program, who described a patient on an opioid regime for a severe foot injury who was able to continue working. 

To be sure, physicians must carefully consider the risks and rewards.  The monitoring programs have had a significant impact on prescribing practices, and have reduced “doctor shopping” – when patients seek out doctors who will prescribe more opioids. Nevertheless, the number of opioid deaths continues to rise; many patients are driven to illicit drugs; and although the rate of fatalities from the use of commonly prescribed opioid medications has flattened, the rate of death from heroin and heroin synthetics is increasing.

Equally important, critics say the CDC guidelines ignore the needs of the individual patient and lack compassion for their pain. Many patients feel like addicts or criminals when they require more painkillers after other medical interventions have failed. The tragedy is that doctors cannot agree on an approach to pain medication that recognizes both the need to control levels of opioid prescribing and the obligation to relieve patient pain.

4th April 2017
Read More

Tell the President:

Other

DON’T dump the Drug Czar

DO save the ONDCP

Drug overdose kills more than 52,000 Americans a year—more than cancer, more than auto accidents.
A cohesive national anti-addiction policy is essential.
But the Office of Drug Control Policy (ONDCP), the part of your White House that oversees 
the nation’s anti-drug efforts, is on the hit list of the Budget Office, along with PBS, Americorps, and the National Endowments.
Eliminating ONDCP will save roughly $25 million for salaries, expenses, and policy research, and denyabout $350 million to critical drug control programs.
This is penny wisdom and pound folly at its worst.

-Mitchell S. Rosenthal, MD
President

 

1st March 2017
Read More

Tell the President:

Other

DON’T dump the Drug Czar

DO save the ONDCP

Drug overdose kills more than 52,000 Americans a year—more than cancer, more than auto accidents.
A cohesive national anti-addiction policy is essential.
But the Office of Drug Control Policy (ONDCP), the part of your White House that oversees 
the nation’s anti-drug efforts, is on the hit list of the Budget Office, along with PBS, Americorps, and the National Endowments.
Eliminating ONDCP will save roughly $25 million for salaries, expenses, and policy research, and denyabout $350 million to critical drug control programs.
This is penny wisdom and pound folly at its worst.

-Mitchell S. Rosenthal, MD
President

 

1st March 2017
Read More

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