St. Louis Post-Dispatch: Drug Treatment and Pathways to Employment
NY Times: Letter to the Editor
The Rosenthal Report - May 2018
In this month’s Rosenthal Report, we examine a record decline in opioid prescriptions and an increase in the use of addiction medications, and explain what this means in the fight against the opioid epidemic. In news briefs: Rhode Island reduces overdose deaths among recently released prisoners; and politicians recalibrate their positions on marijuana legalization.
Policies on Opioid Prescribing and Addiction Medications Yield Promising Results, But Must be Part of a Comprehensive Strategy
Efforts to limit the volume of opioid prescriptions and increase the use of addiction treatment medications are having an impact. According to newly released data, the volume of clinically prescribed opioids declined 10 percent in 2017. This was the steepest fall in 25 years, and included a16.1 percent reduction in high-dose prescriptions. Meanwhile, new monthly prescriptions for three FDA-approved addiction drugs that relieve withdrawal symptoms and drug cravings - methadone, naltrexone and buprenorphine – nearly doubled to 82,000 over the past two years.
The new data illustrates the effectiveness of two critical strategies: more aggressive monitoring mechanisms and stricter clinical guidelines to limit opioid prescriptions, and expanded access to medication-assisted treatment (MAT) programs that combine appropriate addiction medications with counseling and behavioral therapy.
These results are encouraging, but must be considered in the broader context of a deeply entrenched national epidemic. For example, the nation’s death toll from the drug crisis continues to rise. While 15 states lowered their rate of overdose fatalities, there were double-digit spikes in the other 35. This was largely due to the influx of the powerful synthetic opioid fentanyl, which is mixed with other drugs and is now the leading cause of overdose deaths, outpacing for the first time prescription opioids.
Any reduction in opioid prescriptions, which peaked in 2011, is welcome. Yet even with the latest decline opioids are still massively overprescribed. As the New York Times pointed out, the nation’s annual level of morphine prescriptions now totals 171 billion milligrams - enough for every American adult to have 52 pills. After clawing our back to 2006 prescribing levels, we must continue to reduce the availability of prescription painkillers while ensuring that those with legitimate needs for these drugs have access to their medications.
Expanding treatment and getting more addicts who need it into MAT programs is critical to slowing the epidemic. However, the latest data does not indicate how many new addiction medication prescriptions are filled for MAT patients who are not receiving concurrent therapy. This would be simply swapping one drug for another without providing support for life change. There are also significant gaps in access to addiction medications: an estimated 60 percent of rural counties do not have one doctor authorized to prescribe buprenorphine, which requires a waiver from the Drug Enforcement Agency.
We are making strides to bring the opioid crisis under control. But success depends on accelerating the pace by implementing comprehensive, coordinated, and well-funded strategies. Last month, Senator Elizabeth Warren of Massachusetts and Rep. Elijah Cummings of Maryland introduced a bill calling for $100 billion in funding over the next decade to address the opioid epidemic. Modeled on successful HIV/AIDS legislation, the bill is a major funding boost from Congress’s current $6 billion annual budget proposal. With nearly 64,000 Americans dead in 2016 from drug overdoses, $200 billion would be a more appropriate commitment.
SMALL STATE, BIG RESULTS: Rhode Island slashed the overdose mortality rate among recently released prisoners by 61 percent, according to a study in JAMA Psychiatry. Credit goes to a new program offering all inmates screening and MAT treatment while in jails and prisons as well as at outpatient facilities post-incarceration, when, as the study noted, they are more likely to relapse.
SWITCHING SIDES: Former Republican House Speaker John Boehner, once a staunch opponent of marijuana legalization, has joined the advisory board of Acreage Holdings, a company that cultivates, processes and sells cannabis in 11 U.S. states. Explaining his new position, Boehner said his thinking had “evolved” after studying the criminal justice system and the needs of veterans to access the drug legally for disorders such as PTSD. Boehner joins the legalization bandwagon at a time when politicians from both parties are assessing voter sentiment on pot and recalibrating their positions accordingly, including New York Senator Chuck Schumer who now favors federal decriminalization of marijuana. Meanwhile, New York Governor Andrew Cuomo faces a spirited challenge for the gubernatorial nomination from actor Cynthia Nixon, who has made legalizing recreational pot a centerpiece of her campaign against the incumbent.
There Are No Easy Medical Solutions to the Opioid Crisis
The Rosenthal Report - April 2018
In this month’s report, we examine the administration’s highly controversial, get-tough strategy for the national opioid epidemic and look at new studies that raise questions about drugs routinely used for pain management and fighting opioid addiction. In news briefs: soaring nationwide consumption of cocaine and tranquilizers and New York City ups its anti-opioid budget.
Trump’s “new” anti-opioid strategy recycles failed policies of the past
President Trump unveiled his administration’s long-awaited anti-opioid strategy, but if anyone were expecting a balanced approach they would have been disappointed. The focus on law enforcement – harsher sentences for drug crimes, building a southern border wall, and the death penalty for drug dealers – not only ignores history (the failed “war on drugs” in the 80s) but also research proven addiction treatment solutions. In editorials, Trump’s get-tough solutions were roundly criticized as “alarming” (Houston Chronicle) as well as “preposterous” and “insane” (New York Times). The Rosenthal Center would add: troubling, even dangerous.
Executing drug dealers, as Iran and the Philippines do, won’t end the opioid epidemic or curtail drug consumption. A border wall won’t curb letter-sized shipments of deadly fentanyl from China, purchased over the dark web. A recent study by the Pew Charitable Trusts found “no statistically significant relationship” between state drug imprisonment rates and overall drug use, drug overdose deaths and drug arrests. The President may believe that such bluster plays well with his base, but it ignores the plight of millions of Americans struggling with substance abuse.
Law enforcement should be one element of a comprehensive strategy. But what is more important is the need for greater access to treatment – in particular, long-term residential treatment for the most vulnerable drug users. We also need more education, prevention and outreach programs. Everyone who requires help must be able to receive it (now only around 10 percent of those with substance abuse disorder receive treatment).
President Trump hinted at these priorities but failed to provide any details or specific proposals. Now it’s up to Congress to figure out what to do; dozens of bills are being discussed and there’s $6 billion in the budget. The Rosenthal Center supports boosting funding to expand treatment and establishing a secure funding pipeline to the states. Politico reported that many states have left untouched hundreds of millions of dollars from the 2016 21st Century Cures Act because of the lack of ongoing commitments, which make it difficult for them to start programs and hire a workforce. This money is being lost – and so then are lives.
New studies raise questions about both prescription opioid use and addiction medications
Opioids are still prescribed for pain management, while the standard drug arsenal for addiction medicine includes Naloxone to reverse overdoses and Suboxone to curb drug craving. But now, a slew of recent studies suggest that our assumptions about all of these drugs may need revising.
A JAMA report, for example, found that opioids are no more effective against common forms of chronic back pain or hip or knee arthritis than are over the counter painkillers such as acetaminophen. When it comes to Suboxone, John Hopkins University researchers found fully two thirds of the patients in their study, who received that drug in treatment, were filling prescriptions for opioid medications in the year after treatment and nearly half were doing so while still in treatment. As for Naloxone, a controversial report noted that the drug “led to more opioid-related emergency room visits and more opioid-related theft, with no reduction in opioid-related mortality.”
While such studies are important to our understanding of these drugs and the impact they have, we shouldn’t stop using them in clinical practice. As the national opioid epidemic evolves we must continually re-evaluate the necessity of drugs used to fight pain and the efficacy of adjunctive drugs used in addiction treatment. If anything, the Naloxone findings underscore the Rosenthal Center’s belief that reviving addicts from an overdose is only the first step to recovery. We must then provide immediate evaluation, assessment and comprehensive treatment options, and have the ability to use compassionate coercion, if needed, to compel addicts to start this process.
BIG APPLE BUDGET: New York City upped its anti-opioid spending by $22 million to a total of $60 million in 2018; the money will toward improving drug overdose response times by emergency workers and more programs to connect patients at public hospitals with substance abuse treatment.
COCAINE COMEBACK: After falling by 50 percent between 2006 and 2010, cocaine consumption and cocaine-related deaths have soared, especially among African-Americans, making the drug the nation’s Nr. 2 killer among illicit drugs.
AMERICA’S NEXT BIG DRUG PROBLEM: In the shadow of the opioid crisis, there have been dramatic increases in prescriptions for benzodiazepines - tranquilizers better known as Xanax, Valium and Klonopin – and quantities of the drugs taken by adults as well as teenagers have increased as well. While overdose deaths involving benzodiazepines are much fewer than opioids, the drugs are sometimes mixed with fentanyl for a stronger high, posing a heightened risk of overdose.
To End the Opioid Epidemic, We Must Expand Substance Abuse Treatment - Thrive Global
The Rosenthal Report - SPECIAL REPORT
Trump’s Troubling “Get-Tough” Opioid Strategy
President Trump unveiled his long-awaited anti-opioid strategy, but much of what he said was disappointing.
Instead of focusing on expanding treatment – especially long-term residential treatment for the most vulnerable addicts – the President proposed a “get-tough” law-enforcement approach as a way to end this national epidemic.
But harsher drug sentences, building a wall on the southern border and advocating the death penalty for certain drug-related crimes won’t stop the surge in drug overdoses.
We must be tough on crime, to be sure. But let’s also be tough (and thoughtful) on treatment. The urgent need is for greater access to treatment once an addict has been revived from an overdose and starts a drug regime to reduce cravings.
The president also mentioned advancing medication-assisted treatment (MAT), wider use of overdose-reversal drugs, reducing opioid prescriptions and helping vets and prisoners stay off drugs.
All good ideas – yet that requires more money. Congress has already allocated $6 billion in new funding to fight the epidemic. That’s not enough. We need to immediately double the block grants to the states to $3.8 billion annually over the next decade. Let the states take the lead so more troubled Americans get the treatment they desperately need.
For Many Drug Addicts, Compassionate Coercion May Be the Best Medicine - Thrive Global
The Rosenthal Report - March 2018
In this month’s Rosenthal Report, we present an in-depth look at the widespread use of marijuana wax, a highly potent marijuana product that has become popular among adolescents, and propose an action plan to increase awareness of this potentially dangerous drug. In news briefs, drug overdose deaths decline in some states but spike in others; the White House convenes an opioid summit; and the U.S. has a new drug czar.
Marijuana Wax Poses New Risks
The marijuana concentrate known as wax is a powerful and potentially dangerous drug, and its use today appears to be more widespread, especially among adolescents, than had been previously known. At a time when teen use of tobacco, alcohol and drugs has been in steady decline, the rapid spread of wax poses new risks for this vulnerable age group and underscores the need for more large-scale studies of the drug.
Marijuana wax, also called dabs, shatter or honey, is derived from marijuana leaf by dousing the ground buds with a solvent such as flammable butane to extract the tetrahydrocannabinol (THC), the psychoactive chemical component in cannabis. The yellowish, sticky substance that remains is wax. It is heated – sometimes with a blowtorch, or in an e-cigarette - and the vapor inhaled for a potent hit of between 60 percent and 90 percent concentrated THC, compared to between 10 percent and 20 percent from smoking plain marijuana leaf.
Interviews with wax users and clinicians suggest several disturbing trends. Wax can be purchased at medical marijuana dispensaries in states were it is legal. Young people underestimate the intense, often hallucinogenic high the drug delivers; instead, they view it more casually as an alternative to smoking leaf marijuana. Finally, there appears to be only limited awareness of the drug and its possible harmful effects among parents, addiction specialists and educators.
“Wax was uncommon a few years ago, but now kids are all over it as part of early experimental drug use,” says John Venza, vice president of adolescent services at Outreach, a nonprofit treatment provider for adolescents in New York City and Long Island. Chinling Chen, regional vice president of youth services at Phoenix House in California, says the drug wasn’t initially on their radar screen, but a recent survey of residents at the program’s Los Angeles facility indicated that wax is “widely available and many kids are well versed in its use.”
Increased wax use parallels medical marijuana legalization: the drug is part of the product line of THC-based concentrates, the fastest growing sector of the legal marijuana industry. In non-legal states, wax is manufactured with a do-it-yourself contraption - known as a dab rig - that can cause fires or personal injury (the city of Los Angeles considered banning “volatile cannabis manufacturing” but settled on restricting it to outside residential areas). Today, companies that sell medical marijuana produce wax in their own facilities and users can safely vape the product in e-cigarette devices, which are very popular with teenagers.
Seeking a ”really strong high”
Jade, a 16-year old high school student, currently in drug treatment, could be regarded as a typical teenage wax user. Jade [not her real name] told us that she heard about the drug from friends – “all of them are using it,” she says. Jade would buy wax herself in a dispensary, despite age restrictions, or get someone of age to buy it for her. She kept a portable vape pen handy, and because wax is odorless and smokeless, she could inhale the drug undetected in her bedroom or in a school bathroom with friends to get a “really strong high.” Another teenage user described it as a “numbing body high.” Both said they would switch between wax and marijuana leaf or sometimes mix the two.
Preliminary studies have identified potential risks associated with wax. A 2017 Portland State University report found that wax contained cancerous toxins such as benzene. A 2014 study in Addictive Behaviors concluded that a majority of users preferred wax to smoking traditional cannabis due to its potency, and that extremely high THC levels may lead to higher tolerance - suggesting a more rapid progression to chronic marijuana dependency. However, these studies have been limited in scope and therefore lack critical evidence and data.
What we can do
As the use of wax proliferates, we must begin large-scale longitudinal studies to answer questions about its potency and toxicology as well as the long-term impact on users – especially teenagers. At the same time, we should initiate an extensive public education and awareness campaign to ensure that users, parents and educators are alert to wax’s dangers and that clinicians ask questions about wax and other powerful THC products when they evaluate patients.
Overdose deaths decline in some states, spike in others
Provisional data from the Centers for Disease Control suggests that drug overdose deaths declined in 14 states in the 12-month period ending July 2017, an encouraging sign that efforts to slow the opioid epidemic might be working. But in five states - Delaware, Florida, New Jersey, Ohio and Pennsylvania – overdose deaths rose by more than 30 percent, most likely due to the increased presence of the powerful synthetic opioid fentanyl.
White House Opioid Summit
At a special White House opioid summit, cabinet secretaries, policymakers and members of the public affected by the opioid crisis discussed ways to combat the epidemic, from stricter law enforcement to more education, prevention and treatment. Health and Human Services secretary Alex Azar focused on expanding medication-assisted treatment (MAT) and speeding up Medicaid waivers to allow more facilities to provide substance abuse treatment. For his part, President Trump floated the idea of imposing the death penalty for drug dealing, suggesting that countries with capital punishment for this crime
have a better record that the U.S. in combating drug abuse. He did not outline any specific proposals to combat the epidemic as Congress considers how to appropriate $6 billion for the crisis allocated in its recent bipartisan budget deal.
Meet the nation’s new “drug czar”
Making his first public appearance at the summit was the nation’s new acting drug czar James Carroll, the White House deputy chief of staff who was nominated by President Trump to fill a post that has been vacant since December 2017. The position, officially known as Director of the Office of National Drug Control Policy, helps coordinate U.S. drug policy.
The Rosenthal Report - Special Report
CONGRESSIONAL BUDGET DEAL COMMITTS $ 6 BILLION TO FIGHT THE OPIOID CRISIS: HOW TO SPEND IT?
The recently approved two-year Congressional budget deal includes $6 billion to fight the opioid epidemic, a desperately needed influx of funding for this national drug crisis. According to the plan, $3 billion would be available in 2018 and the remainder in 2019, while keeping intact the existing $1 billion in funding from the 21st Century Cures Act that covered 2017 and 2018. What’s missing from the Congressional deal, however, is how the new money will be spent. Senate Majority leader Mitch McConnell has said the $6 billion will go toward “new grants, prevention programs and law enforcement in vulnerable communities across the country,” without offering any specific details.
By any measure, the additional $6 billion is still a drop in the bucket considering the scope of the crisis: drug overdose deaths for 2017 are expected to exceed the nearly 64,000 who died in 2016. President Trump’s 2019 budget proposal, released a few days after the Congressional agreement, proposed $13 billion for the opioid crisis, with much of that funding being diverted from the office of the White House “drug czar” to the Department for Health and Human Services. As this is highly unlikely to win Congressional approval, the Rosenthal Center has compiled a wish list of priorities for the $6 billion commitment:
- Ensure that all the money allocated by Congress goes toward education, prevention and treatment rather than law enforcement, as the “tough on crime” approach favored by Attorney General Jeff Sessions has little or no impact on drug use.
- $3.8 billion in new money to double the size of the current federal Substance Abuse Prevention and Treatment Block Grants to the states with the entire amount set aside for prevention, treatment and recovery services. Such grants are quick and easy to implement, and would give the states on the front line of the crisis a secure pipeline for programs already underway, including those that are starting to reduce the overdose death rate.
*Distribute the remaining funds to support the following:
- expanding existing programs and launching new initiatives to increase overall availability of Medication-Assisted Treatment (MAT), with required behavioral therapy and access to long-term residential treatment when needed.
- initiatives focused on education, prevention and treatment programs focused on the highly vulnerable adolescent age group, in order to prevent the next generation of adult addicts.
- establishing a new workforce development program in the addiction services sector to alleviate the scarcity and rapid turnover of personnel, including education loan forgiveness if grantees serve in addiction facilities in high need areas.
The Rosenthal Report - February 2018
THE TRUMP ADMINISTRATION IS AWOL ON THE OPIOID EPIDEMIC
- No new funding proposals forthcoming in the State of the Union
- National health emergency renewed without clear strategy or leadership
- The Rosenthal Center proposes a long-term action plan to end the epidemic
At a time when 175 Americans die every day from a drug overdose, it was discouraging that President Trump’s State of the Union on January 30th touched only briefly on the opioid crisis and failed to include any proposal for additional funding to fight this national epidemic. The president said he was committed to helping get treatment “for those who have been so terribly hurt” by addiction, but offered neither a clear strategy nor more money. Instead, he signaled approval of the law-and-order approach being pursued by attorney General Jeff Sessions, vowing to “get much tougher on drug dealers and pushers if we are going to succeed in stopping this scourge.”
Trump’s declaration of an opioid public health emergency in October was a promising but ultimately empty gesture, as no significant resources or major initiatives followed. While a few important steps have been taken – including the crackdown on illegal shipments of the deadly synthetic opioid fentanyl, and relaxing restrictions on reimbursements to large substance abuse treatment facilities - the administration has largely ignored the excellent recommendations of the White House special opioid commission.
Moreover, the post of permanent “drug czar” at the Office of National Drug Control Policy (ONDCP) remains vacant and the administration has threatened to drastically reduce the agency’s budget. Grants from the $1 billion 21st Century Cures Act failed to prioritize states hit hardest by the epidemic. Law enforcement and border controls are important, of course, but they are not the solution to this crisis: 40 percent of drug overdose deaths in 2016 involved a prescription opioid, according to the CDC.
The opioid crisis status as national public health emergency was recently renewed for another 90 days, providing a window of opportunity to end policy paralysis. The Rosenthal Center believes the administration should now set out an aggressive national agenda with the following achievable goals:
- Appoint a qualified “drug czar” and support the existing senior staff at ONDCP and increase its budget to ensure this important office can properly coordinate drug policy across the many federal agencies engaged in drug control activities. Maintain ONDCP control over appropriate funds in other federal agencies.
- Immediately allocate a 50 percent to 100 percent increases in the federal Substance Abuse Prevention and Treatment Block Grants to the states, to support their anti-drug programs.
- Implement such recommendations of the White House opioid commission as wider use of drug courts, stricter prescription drug monitoring, improving doctor and professional training, and making overdose reversal drugs more available.
- Work with Congress to approve a $100 billion long-term spending bill over the next decade with a focus on education, prevention and appropriate treatment, including the expansion of Medication-Assisted Treatment (MAT) with behavioral therapy and long-term residential treatment as essential components.
President Trump concluded his brief remarks about the opioid epidemic by saying, “the struggle will be long and it will be difficult – but, as Americans always do, in the end, we will succeed, we will prevail.” This is true. There is hope. But only if we have the commitment, consensus and the willingness to take action – and pay for it.
The Rosenthal Report - January 2018
2017: A Year of Challenges and Missed Opportunities
The opioid epidemic continued to plague the nation last year, despite renewed efforts by cities, states and the Trump administration—which declared a public health emergency in October—to address the crisis. Urban and rural, white and black, rich and poor, young and old: no community or demographic was immune to the scourge of addiction and the unrelenting rise in overdose deaths. As the New York Times concluded in an article at the end of the year, the country’s addiction crisis “ranks among the great epidemics of our age.”
Drug overdose data for 2016, released by the CDC last year, confirmed the unrelenting advance of the epidemic: more than 63,000 people died, mostly adults between 25 and 54 and more men than women. There was a surprising uptick in deaths among African-Americans in urban counties, which shifted perceptions of the epidemic as a predominantly white and rural phenomenon. Deaths caused by the highly potent synthetic opioid fentanyl surged, as did overdoses from cocaine mixed with opioids. West Virginia, New Hampshire and Pennsylvania remained among the hardest hit states, as did the District of Columbia. But New York City also reported a record 1,374 drug overdose deaths, a nearly 47 percent spike over the previous year.
There were a few glimmers of hope. Many states implemented ambitious and well thought out anti-drug programs: the strategy in Massachusetts includes tougher prescription drug monitoring, wider use of overdose reversal drugs, and increasing the number of addiction treatment beds, which together is expected to drive down the number of deaths by 10 percent. The Trump health emergency announcement was a positive step that drew media attention to the epidemic. The White House special commission on opioids, to which I contributed expert testimony, produced an extensive report with recommendations that included an increase in medication-assisted treatment (MAT) which combines behavioral therapies with drugs to reduce withdrawal symptoms and drug cravings.
Unfortunately, the administration missed an opportunity to back the report and the emergency declaration with additional funding for drug treatment programs and services. At a time when drug overdoses are the leading cause of death among Americans under the age of 50, the GOP-controlled Congress tried but failed to repeal Obamacare and Medicaid expansion, which would have undermined programs that provide a critical share of addiction treatment dollars. Attorney General Sessions, for his part, signaled approval of maximum sentencing and incarceration for even minor drug offenses – tactics that we know do not address the underlying causes of addiction.
As the year unfolded, the Rosenthal Report tracked many of the issues that had an impact on the opioid epidemic. These included mandatory treatment for addiction; a barrage of lawsuits against opioid makers; the economic consequences of the crisis; treatment innovations; and new studies purporting to show that marijuana could be used as a safe alternative painkiller to opioids.
Most importantly, the Rosenthal Center continued to advocate for immediate emergency funding to the states. We proposed a 50 percent to 100 percent increase in the federal Substance Abuse Prevention and Treatment Block Grant, as well as a massive increase in funding, totaling $100 billion over the next decade, for a bold national plan to tackle this crisis. This money would be used to expand access to long-term residential treatment, which offers the best hope of recovery to vulnerable drug users most at risk of overdose; ensure that behavioral therapy is an essential component of MAT; and provide states with the ability to implement more education and prevention programs and the tools to get more addicts into comprehensive treatment.
Provisional data suggests that drug-related deaths continued to climb in 2017. And yet I still believe we can overcome this crisis. We have the knowledge, resources and expertise to treat the more than 20 million Americans with addiction problems, only a fraction of whom now receive help. We need the money and the political will to get the job done. This is the message of optimism I voiced last year - in the Rosenthal Report, in talks and media appearances, at professional conferences and in videos on our website – and will continue to do so in 2018.