Dr. Mitch Rosenthal Proposes Changes to Safe Injection Sites
The Rosenthal Report - November 2019
Supervised injection sites for drug users must focus on facilitating movement to treatment
Supervised injection sites providing a controlled and safe environment for drug use are again on the national agenda. A federal court ruling last month removed a legal obstacle to opening the first such U.S. facility, in Philadelphia, which is struggling with the opioid epidemic and a skyrocketing rate of overdose, as are other American cities. While it’s not certain when this might happen, questions remain regarding how such sites will help move users into drug treatment.
These sites do not provide drugs to addicts, but rather offer access to clean needles, and health professionals are on hand to administer anti-overdose drugs as well as provide counseling. Supervised sites have operated for years in Canada, Australia and Europe and some studies show they can reduce overdose fatalities as well as the transmission of infectious diseases through injection and drug-related criminality.
Yet, while the goal is to save lives, such harm-reduction strategies fall short when it comes to ensuring that users opt for treatment. My experience suggests that after a user injects drugs or is rescued from an overdose at a safe site, there is insufficient engagement to end the cycle of drug abuse.
Safehouse, the Philadelphia nonprofit sponsoring the supervised site, would do this by counseling users and promoting medication-assisted treatment (MAT), which combines withdrawal drugs and behavioral therapy. But it leaves the final decision up to the patient, believing that by establishing a trusting relationship with the user, he or she will more likely agree to give treatment a try.
As noted in a previous Rosenthal Report (August, 2018), what is missing from this approach is a mindset that all patients can be helped to enter treatment. We also propose to limit the time and access to the facility to 60 days to discourage continued drug use without agreeing to treatment. By the end of this time, and after extensive interaction with peer-based counselors and addiction professionals, there would be an expectation that the patient is ready to enter treatment to become drug free.
We encourage the safehouse project in Philadelphia, but it must have a research protocol. And at the same time, they should also run a pilot project along the lines I have suggested that can transform a supervised injection center into a treatment induction center. We need to know which will work better and prove to be more beneficial as part of a comprehensive anti-opioid strategy.
Dr. Mitch Rosenthal on the Need to Support a FDA Ban on Flavored E Cigarettes
Dr Mitch Rosenthal on the Need to Ban Vaping Across the Entire Country
Dr. Mitchell Rosenthal on Upcoming Opioid Litigation Cases this Month
Dr. Mitchell Rosenthal on the Need to Stop Vaping Nationally
Dr. Mitch Rosenthal on the Need to Follow Massachusetts' Lead on Banning All Vaping Products
The Rosenthal Report - October 2019
Amid growing alarm about vaping-related illnesses, states should immediately ban e-cigarettes
At the end of September, the number of cases of respiratory illness linked to vaping rose sharply—to 805 from 530 in a single week—and 12 persons had died, the Centers for Disease Control and Prevention reported. With the mysterious disease now present in 46 states and territories and nearly 11 million Americans vaping on a regular basis, the problem of vaping-related illnesses has become a national health emergency that requires urgent action—and this is most easily accomplished on the state level.
Massachusetts has taken the lead on this issue by placing a four-month ban on sales of e-cigarettes. This includes online and in-store sales of all vaping products and devices as well as the pods that contain nicotine or THC—the psychoactive component of marijuana which might play some role in the illnesses. The Rosenthal Center urges all states to enact a comprehensive ban along the lines of the Massachusetts restrictions as the most effective way to safeguard public health in the face of a baffling dilemma and slow federal action to contain it.
Doctors first recognized some linkages between acute respiratory distress and e-cigarettes as early as 2012. But only recently have health officials begun comparing data and patient histories to better understand the connections to vaping. While the cause is still unknown, there are some patterns: The ailments mostly strike young men with a median age of 19 who have used e-cigarettes with THC or nicotine, and the lung damage many of them suffer is so severe that many end up in the ICU or on ventilators. The epidemic also coincides with a surge in popularity of e-cigarettes among teenagers, as a recent survey found that 21 percent of 12th-graders vaped in 2018—almost double the number who had in 2017.
City, state and federal health agencies—as well as the $2.6 billion e-cigarette industry—are belatedly responding to the escalating crisis. The Food and Drug Administration (which has yet to conduct safety tests or trials on vaping products) has proposed a ban on the flavored e-cigarettes preferred by young people, and the CDC has urged teens and other consumers to stay away from bootleg vaping devices and street cannabis. Walmart has stopped selling e-cigarettes and Juul Labs, the industry leader in e-cigarettes, has pulled controversial advertising that was clearly targeting young people.
Unfortunately, these efforts are a patchwork solution to an extremely complex problem. To truly protect the public, we need a tough crackdown on e-cigarette sales across the board in every state, to allow time for doctors and other medical experts to determine the cause (or causes) of the illnesses and for policymakers to `cigarette ban might pose difficulties for those who use these products as a smoking-cessation aid, it is absolutely necessary to confront this problem. Eventually, we must also enact strong legal measures to curb teenage vaping—such as establishing a nationwide legal age of 21 to buy e-cigarettes—to prevent a new generation from being addicted to vaping nicotine or marijuana.
Dr. Mitch Rosenthal on the Dangers and Risks Associated with Vaping
Dr. Mitch Rosenthal on the Dangers of Vaping
Dr. Mitch Rosenthal on the Federal Government's Move to Ban Flavored E Cigarettes
Dr. Mitch Rosenthal on the Dangers of New & Powerful Marijuana that is Available
Dr. Mitch Rosenthal on the Need for Any Opioid Crisis Settlement to Focus on Treatment
The Rosenthal Report - September 2019
AS AN OPIOID SETTLEMENT NEARS, WE MUST ENSURE ANY WINDFALL SETTLEMENT GOES TOWARD DESPERATELY NEEDED DRUG TREATMENT
Nationwide opioid litigation appears to be entering a decisive phase, with one of the main defendants—the opioid maker Purdue Pharma—in settlement talks valued at as much as $12 billion. Purdue is among some two-dozen prescription opioid manufacturers, drug distributors and pharmacy chains being sued by state and local governments in roughly 2,000 lawsuits. The companies are accused of fueling the epidemic that has led to hundreds of thousands of opioid-related overdose deaths during the last two decades.
While the terms of a Purdue deal remains in flux, it is clear that these companies acted in a vile and immoral way. Any settlement should reflect the magnitude of the misery they have inflicted on families and communities across the country. Equally important, the ultimate outcome of this entire wave of lawsuits will determine how we combat the epidemic over the next decade—and what resources are available to end this public health crisis.
THE Johnson & Johnson case
Momentum in the Purdue lawsuits follows last month’s resolution of an opioid case in Oklahoma against Johnson & Johnson (the only such case to go to trial). The healthcare giant—which was the leading supplier of the chemical ingredient used to make prescription opioid painkillers—was ordered to pay the state $572 million in damages for aggressive marketing tactics similar to those employed by Purdue and others. Separately, out-of-court opioid settlements ranging from $10 million to $270 million have also been reached ahead of a planned October court date in Cleveland for consolidated cases.
These numbers are important, because a Purdue agreement could pave the way for a master opioid settlement on a scale similar to the 1998 Master Tobacco Agreement, in which cigarette companies agreed to pay $246 billion over 25 years for anti-tobacco initiatives. As such, many of the opioid plaintiffs are already disagreeing over the terms of the proposed settlement and how to divvy up the money they stand to be awarded.
Money for drug treatment, not repairing potholes
The Johnson & Johnson decision, which the company is appealing, stipulates in vague language that the money should go to “abate the opioid crisis.” With pressure mounting to reach a deal, we must ensure that any agreement includes adequate compensation for the crime. In addition, there must be ironclad guarantees the money is used for addiction treatment—and not siphoned off by cities and states for general operating expenses, which is what happened following the tobacco settlement.
As the opioid epidemic continues to rage on while other drug crises are escalating, the need for this money only becomes more urgent. Although 2018 saw a slight decrease in prescription opioid misuse and cases of opioid use disorder, according to the latest findings from the National Survey on Drug Use and Health, an estimated 70,000 Americans died of drug overdose last year, three-fourths of which were opioid-related. The survey also noted troubling increases in methamphetamine use and marijuana-use disorders among young people.
Stumbling blocks to reaching a deal
The price that defendants should pay for their role in flooding America with more than 76 billion opioid painkillers while misleading patients about the addictive nature of the drugs is difficult to calculate. Some state attorneys general say the proposal in its current form falls short (prosecutors in the Johnson & Johnson case, for example, had sought $17 billion for a 30-year anti-opioid effort). Purdue sold $36 billion of OxyContin since introducing the drug in 1996 and the firm’s founding Sackler family has profited handsomely.
The proposed settlement would see the family cede its ownership stake in Purdue and contribute $3 billion of its own money for damages, which some say is not enough and would leave the Sackler fortune largely intact. Another possible sticking point: the proposed deal is tied to potential profits that Purdue—which would be restructured as a “public beneficiary trust”—continues to earn from selling OxyContin, the prescription painkiller that contributed to the epidemic. Purdue would also donate a number of addiction treatment drugs it is developing but are not yet approved by the Food and Drug Administration.
Whether the other parties chose to fight in court or make a deal is unclear, as is any final estimate of damages. Regardless, we need to establish a national action plan to ensure any settlement windfall—however much that ends up being—isn’t diverted. By significantly expanding a wide range of affordable and accessible drug treatment options, including long-term residential and medication-assisted treatment, we can help all those struggling with substance abuse and begin to close this tragic chapter of our history.
Dr. Mitch Rosenthal on the Risks of Overprescribing Opioids to Children for Tonsillectomy
Dr. Mitch Rosenthal on the Lack of Attention to the Opioid Crisis in the Current Political Discussion
Dr Mitch Rosenthal on the Need for Comprehensive Action Plans to Combat the Opioid Crisis
The Rosenthal Report - August 2019
AN AMERICAN OPIOID SCANDAL: HOW THE DRUG INDUSTRY FUELED THE OPIOID EPIDEMIC WITH 76 BILLION PAIN PILLS
As the opioid epidemic escalated, the broad outlines of the crisis became generally well known. Pharmaceutical companies marketed highly habit-forming drugs as non-addictive, pharmacies filled prescriptions without question, and doctors wrote excessive opioid prescriptions even for minor ailments such as a sprained ankle. Yet while the trajectory of the epidemic was clear, the full extent of the complicity shared by drug makers, drug distributors and pharmacies has not been entirely transparent—until now.
According to newly released federal data, the major players in the drug industry flooded the nation with roughly 76 billion prescription painkiller pills between 2006 and 2012, fueling an epidemic that led to 100,000 overdose fatalities during these years. This data and related documents reveal the greed and negligence of these companies—while also serving as a warning we must heed if we are to prevent another epidemic.
Pumping pills to America
The previously undisclosed Drug Enforcement Agency (DEA) data that has come to light as part of opioid-industry lawsuits reveal the unprecedented scale of the pill pushing. Enough oxycodone and hydrocodone painkillers were distributed to supply every adult and child in the country with 36 pills per year. In small towns such as Norton, Virginia, the equivalent of 306 pills for each of the 3,900 residents were distributed. As fast as opioid manufacturers produced the pills, pharmacies obligingly handed them out: At one point, a Walgreens in Port Richey, Florida—with a population of only 2,831 residents—was ordering 3,271 bottles of oxycodone each month (or nearly one bottle of painkiller pills per person.)
The system fails, and death rates spiral
Not surprisingly, the death rates from opioids soared in areas saturated with those billions of pills. An analysis by the Washington Post—which, along with the Charlotte Post-Gazette in West Virginia fought to release the DEA data against drug company objections—found that the most fatalities occurred in rural communities in West Virginia, Kentucky and Virginia. But despite the spike in opioid-related deaths, the drug makers, distributors and pharmacies—including such national chains as CVS and Walgreens as well as Walmart superstores—did little to intervene. Compliance and monitoring systems required by law and designed to flag suspicious orders and prescription flows, were routinely overlooked. Company emails suggest that executive were unconcerned about the massive outflows of pills and the number of overdose deaths as they pursued greater profits.
Lawsuits target key drug industry firms
The disturbing data and documents were unsealed as part of roughly 2,000 lawsuits brought by towns and counties against more than two-dozen firms—including Purdue Pharma, which introduced OxyContin in 1990—that have since been consolidated into one case in Cleveland. Meanwhile, another lawsuit filed last month argues that the drug distributors and pharmacies are also to blame for helping move all those pills, opening a new frontline in the legal battle. (The drug companies, for their part, say the epidemic was the result of doctors overprescribing the drugs and customers abusing them.)
As assessed in previous Rosenthal Reports, the lawsuits might end in a master settlement on the same scale as the $206 billion tobacco industry agreement of 1998. Should that come to pass, I will continue to urge all parties involved in the lawsuits to guarantee sufficient funding be allocated directly to substance-abuse initiatives and drug treatment.
However, with an estimated 70,000 overdose deaths in 2018 alone—two-thirds of which were linked to opioids—we cannot rely solely on a potential legal settlement for future funding of substance abuse services. Regardless of what results from with those lawsuits, the federal government should immediately allocate $100 billion over the next decade for programs to expand education, prevention and most importantly, treatment.
Based on what we have recently learned about the inner workings of the drug industry, we must also take the following steps:
-Ensure that prescription-monitoring regimes imposed over the past few years remain in place and are strengthened, if needed. These strict, statewide controls successfully track the number of painkiller prescriptions, and alert officials to possible abuses by doctors, pharmacies and/or patients.
-Improve addiction-medicine education in medical schools, providing students with a solid grounding and practice in the field, and broader awareness of patient issues and concerns. Doctors must continue to speak openly and frankly with patients about all aspects of pain medication if they are to secure informed consent.
-Give the DEA the resources, manpower and authority to effectively enforce the rules that pertain to the manufacture, distribution and dispensing of legally produced controlled substances, such as painkillers.
As these latest revelations have helped blow the lid off the American opioid scandal and expose for the first time the depth of the drug industry’s involvement in this deadly public health crisis, it is time to bring this hideous chapter in our history to a close. With the knowledge and information available to us now, and with the proper regulations and oversight in place, we can end the current crisis and be well positioned to prevent the next.
Dr Mitch Rosenthal on the Susceptibility of the Adolescent Brain to Drugs and Addiction
Dr Mitch Rosenthal on the Overprescription of Opioid Medication in the United States
Dr. Mitch Rosenthal on the Need to Emulate Effective Overdose Prevention Programs from Dayton, Ohio
The Rosenthal Report - July 2019
SPECIAL REPORT: TEENS AND THE NEW ERA OF POWERFUL, LEGAL MARIJUANA
Cannabis is now legal in 43 states plus Washington, D.C., including 33 for medical marijuana use alone and 11 for recreational. Polling shows strong public support and politicians increasingly endorse legalization based largely on the widespread belief that marijuana and other pot-related products are relatively benign—or even beneficial for a host of ailments—with few, if any, potential risks. But what, in fact, has been the impact of this new era of easily accessible, highly potent pot—especially on such vulnerable groups as teenagers?
To find out, we spoke to a dozen teens between the ages of 14 and 17 at Outreach, an adolescent treatment center on Long Island. What the youngsters told us—about how they started using, the constant peer pressure they face, their progression to stronger drugs, and their struggles trying to stop—painted a disturbing portrait of a younger generation caught up in a new and dangerous level of substance abuse.
For the young people at the Outreach facility, their first exposure came as early as middle school, where they would, for example, gather in bathrooms to use e-cigarettes and vape nicotine as well as cannabis. “You easily get pulled into something new because everyone is doing it,” one girl recalled. In addition to the nicotine cartridges that come in such wildly popular e-cigarette brands such as Juul, the students would vape pre-packaged, liquid-filled pods containing up to 90 percent THC (the psychoactive component of cannabis). These products are currently illegal in New York State but can be easily obtained through intermediaries in states where recreational marijuana has been legalized, the teens said.
The impact of vaping today’s stronger pot is immediate. “You get really high, really fast, and you just want to stay high,” one teen said. And as tolerance builds, users turn to any number of new cannabis offerings that pack an even stronger punch. These include wax or dabs, as well as Moon Rocks—a potent strain of cannabis dipped in hash oil and sprinkled with cannabis resin. Noted one boy, “If the drugs don’t work anymore you move on to the next strongest thing—to whatever messes you up.”
The teens at Outreach talked about what it’s like to get high using these more concentrated marijuana products, with symptoms including blackouts, racing heartbeat and difficulty breathing. One girl stole money from her parents to buy the drugs, and many withdrew from their normal teenage routines and friendships, and eventually even gave up going to school. Teens are brought to Outreach by their parents, by referral from the juvenile justice system, or by their school—both institutions are becoming more and more concerned about teen marijuana use.
Research confirms what the young people at Outreach described. Vaping nicotine is surging in popularity in this age group, with more than one-third of 12th graders reporting having vaped in 2018, up 10 percent from the previous year, according to the Monitoring the Future Survey. In addition, more than 13 percent of these 12th graders vaped cannabis compared to 9.5 percent in 2017. As legalized marijuana becomes more accessible and new products flood the market, “[the drug] is increasingly the first substance in the sequence of adolescent drug use,” a 2018 Columbia University study reported in the journal Drug and Alcohol Dependence.
John Venza, vice president of residential and adolescent services at Outreach, said the teens’ experience with marijuana follows a new pattern of earlier onset and faster progression. “There is a quick introduction through vaping nicotine and then THC and then a comfortable progression to products that hit like a ton of bricks,” Venza explained. These include edibles such as Pot Tarts, a pot-filled version of the popular packaged pastry, or candies with wrappers designed to look like such common confections as Snickers bars or Reese’s peanut butter cups.
Parents have traditionally been the first line of defense against teen drug addiction. Today, however, many of them take a more hands-off approach. “They think it’s just pot and so not a big problem, and that sets the tone for not getting involved,” Venza said. What’s more, many parents underplay the difference between what drugs are now and what they were when they were adolescents. With legalization, according to Venza, ”pot has been normalized.”
Listening to these remarkably smart and self-aware young people is moving and provides hope they will succeed.
It is now our responsibility to take action. While pro-marijuana legislation has recently stalled in New York and New Jersey, the legalization trend is likely to continue. The Rosenthal Center supports a comprehensive strategy to deal with the availability of new cannabis products and the resultant uptick in teen marijuana use:
Education and Prevention Programs:
Focused on students, parents, teachers, school officials, social workers, therapists, and anyone who regularly interacts with young people, these programs must make people fully aware of the risks and dangers of today’s more-powerful marijuana and its impact on the developing brain, the warning signs of drug use, as well as the specific harms from vaping cannabis.
As legalization moves ahead, we must insist on strict rules and regulations for how and where marijuana is sold, including what products are available; age limits; clear and concise warning labels and information about dosage and interactions. We will need adequate safeguards to prevent it from being explicitly marked to young people.
While our main focus today has largely been on the devastating opioid epidemic, we must now allocate additional financial resources and manpower to significantly expanding access to specialized treatment options for teenagers. And because it is unlikely we will be able to prevent the legalization of marijuana in New York State, we should also aim to educate parents, teachers, young people and the general public on how teen drug use remains a real and critical problem—one that would be tragic to ignore.
The Rosenthal Report - June 2019
THE OPIOID EPIDEMIC ENTERS THE 2020 PRESIDENTIAL RACE
In 2017, there were a record 70,000 drug overdose deaths in the United States, two-thirds of which were linked to opioids—and data for both 2018 and this year shows no significant reduction in fatalities. Yet as the 2020 Presidential race kicks into high gear, only two of the 24 Democratic candidates—Senators Elizabeth Warren and Amy Klobuchar—have announced comprehensive strategies to fight the opioid epidemic. Given the Trump administration’s lackluster response to the crisis, the Democrats are missing an opportunity to both raise greater awareness of the drug crisis and build political momentum to find and fund solutions.
Sen. Warren’s proposal is based on the Comprehensive Addiction Resources Emergency (CARE) Act, a bill she and Rep. Elijah Cummings introduced in Congress in 2018. It calls for $100 billion to be spent over 10 years to boost substance-abuse treatment and other anti-drug initiatives—a scale and scope of funding supported by the Rosenthal Center. Money would go to both increase access to drug treatment and the use of overdose-reversal drugs, as well as such measures as research into innovative treatments and training for health care staff, among other measures. To fund the program, Warren proposed instituting a new wealth tax on the super rich.
Sen. Klobuchar’s plan also allocates $100 billion over a decade to address the opioid epidemic as well as alcohol misuse and mental health services. It includes smart initiatives in prevention, treatment and recovery such as better training for doctors to recognize the early warning signs of addiction, transitional housing for recovering addicts, and treatment instead of incarceration for nonviolent drug offenders. Funding would come from charging opioid manufacturers a fee for every milligram of drugs they sell—similar to a recently approved opioid tax in New York State—and reaching a “master settlement agreement” from the nearly 2,000 lawsuits that have been filed against pharmaceutical companies and distributors.
For the most part, both proposals are thoughtful and incorporate many of the best practices of addiction care. Most importantly, they aim to get more individuals with substance use disorder intro treatment.
Today, only one in five addicts receive specialty treatment and fewer than half of all treatment facilities offer medication assisted treatment (MAT), which combines addiction-withdrawal medications and peer-based counseling. Compared with the Trump administration’s failed attempts at curbing the epidemic, the Democratic proposals would likely have more impact than anything the government has previously attempted.
Whether these strategies are ever enacted, however, is as uncertain as the election itself. The ambitious CARE Act never gained much traction in either the House or Senate. Lacking strong leadership from the White House, Congress opted instead to boost prescription-drug monitoring and law enforcement, allocating overall around $6 billion in short-term funding—a fraction of what would be appropriate.
While it’s still early days in the campaign, I urge other Democratic candidates to take a forceful stand as well. Elevating the opioid epidemic onto the high profile platform of a presidential campaign—and taking the message to areas of the country hardest hit by the opioid epidemic, as Warren has done—will ensure the issue remains at the forefront of public debate and policymaking.
New Opioid Taxes & Employer-based Solutions to the Opioid Epidemic
The Rosenthal Report - May 2019
Can taxes help combat the opioid epidemic? New York State intends to find out
New York State is addressing the opioid epidemic with a first of its kind opioid tax on manufacturers and distributors of prescription opioids, as well as a tax credit for businesses that employ drug users who are either in recovery or have completed treatment. The measures were enacted in the most recent budget to raise additional funding for treatment programs, and encourage more people to enter treatment, and could also serve as a model for other states at a time when substantial federal funding is lacking.
Taxing the opioid makers and distributors that are largely responsible for this crisis is the right thing to do, and could yield up to $100 million annually for anti-drug programs. However, because budget language stipulates this money is “intended” for drug treatment programs, there’s no guarantee opioid tax revenues will actually be used to help those struggling with addiction and opioid abuse. Instead, the revenues go into the state’s general fund, which legislators will haggle over how to spend at a later date. The likely result is allocation of only a portion of the $100 million to anti-drug programs through the state Office of Alcoholism and Substance Abuse (OASAS).
With neither Governor Cuomo nor state legislators able to do anything about this now, we are stuck in the frustrating position of having no assurance the revenue being generated specifically for drug services will ultimately reach the people most in need. This is especially disturbing when considering that more than 4,100 New York State residents died from drug overdose in 2017, up from 3,638 in 2016. The Rosenthal Center urges the political leadership in Albany to close this loophole in the budget’s language to ensure opioid tax revenue is eventually allocated solely to drug treatment.
The second budget measure – a $2,000 employer tax credit for each new or existing employee in a state-certified recovery program - is a winner. For substance abusers, the promise of a real job is a powerful incentive and an attainable goal to strive for while getting off drugs. The tax credit is particularly important for smaller firms, including many in upstate regions hit hard by the opioid crisis that have trouble finding drug-free workers. Backed by an initial $2 million in state funding, this initiative will certainly gain a foothold across New York – as it is a win-win for companies, communities and individuals who are determined to rebuild their lives and stay clean.
This program is similar to a successful one I helped design for Belden, an international manufacturing company. Known as Pathways to Employment, it was also structured around such addiction-care best practices as early detection and evaluation, free treatment, social support and incentives – including a job that can lead to stability.
At this early stage, New York’s tax reforms might seem like just a footnote to bigger efforts underway to fight the opioid epidemic and reduce overdose fatalities. But if adopted on a wider scale, including by the federal government, the results would likely have an extraordinary impact. Although these taxes alone won’t end the opioid epidemic, they will help plug gaps in funding due to insufficient federal allocations, expand treatment options and enable more people to enter treatment as part of a comprehensive anti-drug strategy.
The Rosenthal Report - April 2019
DRUG TREATMENT FUNDING ENDANGERED AS TRUMP SEEKS TO DISMANTLE AFFORDABLE CARE ACT
In a disturbing development, President Trump is backing a Texas lawsuit that would invalidate the Affordable Care Act (ACA), slashing funds for substance abuse treatment and leaving more than 30 million Americans without health insurance. That includes those who purchased insurance plans through ACA marketplaces, and low-income beneficiaries covered under ACA’s Medicaid expansion. Even more troubling, as we grapple with the opioid epidemic, rescinding ACA would end the requirement that insurance companies cover substance abuse treatment.
ACA and the Medicaid expansion have had a substantial impact on treating addiction at a time when more than 70,000 Americans are expected to die this year from drug overdose. Medicaid pays for a quarter of all addiction treatment in the U.S., including prescriptions for two medications used to treat opioid withdrawal. This has led to a welcome increase in the number of treatment programs and primary care doctors who are able to prescribe withdrawal medications, an essential component of medication-assisted treatment (MAT) which combines anti-craving drugs with behavioral therapy and peer-based counseling.
So, more than two years into the Trump administration, we are still looking into the abyss – without strong leadership and massive funding for an anti-drug effort – and are now facing the threat to dismantle the ACA. Some believe funds might be forthcoming from a settlement of the opioid lawsuits now underway in many states against opioid makers. But in the only settlement so far, Purdue Pharma agreed to pay $270 million to Oklahoma for opioid addiction research and treatment, a fraction of the $20 billion in damages the state had sought.
We cannot wait for lawsuits when, on average, 130 Americans die every day from drug overdose. The Trump administration is ignoring a national crisis when we have the resources to launch a national campaign to help those suffering from substance abuse, and to stop the tragic loss of life.
Dr. Mitch Rosenthal's Good Day NY Addiction and Best Treatment Practices Segment
East Hampton Star: Medical Marijuana
March 7, 2019
To the Editor:
Your article “Suffolk County Debates Legalized Marijuana” (Feb. 26) covered the County Legislature’s hearing on Gov. Cuomo’s plan for marijuana legalization very well. It provided valuable insights on the arguments to be made for and against legalization, and on the right of local governments to opt out of the statewide plan and retain local prohibition of the marijuana trade.
As a psychiatrist who has been treating addiction for more than half a century and an East Hampton homeowner and part-time resident, I found the debate deeply troubling. It highlights the current dilemma of making decisions about the use of marijuana when so much about modern marijuana and its impact on users and communities is still not known. Equally troubling is what we now do know about the drug and the likely effects of legalization, to which the partisans of legalization are either unaware or indifferent.
The general public believes marijuana is a benign psychoactive drug, while today’s marijuana is powerful and dangerous, especially to the developing brain of adolescents and users vulnerable to mental illness. Consumers can already buy marijuana products with no idea of how much T.H.C., pot’s psychoactive component, it contains. Medical marijuana marketers claim that salves, oils, and even cosmetics and beverages made with C.B.D., a non-psychoactive marijuana component, can relieve stress and anxiety and aches and pains — even help Alzheimer’s disease. But there is, in fact, only one drug derived from the cannabis plant approved by the F.D.A. and it is for a rare childhood epilepsy.
With so much research now underway and so much risk in the rush to legalize, the most rational response to the governor’s proposal is not to opt out, but to oppose it.
MITCHELL S. ROSENTHAL, M.D.
Dr. Rosenthal was the founder of the national Phoenix House programs and today is the president of the Rosenthal Center for Addiction Studies. Ed.
President Trump Lacks Opioid Crisis Strategy
Gottlieb's Disappointing Departure from FDA
The Rosenthal Report - March 2019
IF THE OPIOID LAWSUITS PRODUCE A FUNDING WINDFALL, WE MUST BE PREPARED TO SPEND THE MONEY WISELY
We are fighting the opioid epidemic on many fronts, with prevention, education, law enforcement and treatment. The battle is also being waged in state and federal courts, for drug overdose is now the leading cause of death for Americans under the age of 50. Some 37 states and more than 1,500 cities and counties are currently suing the makers and distributors of prescription painkillers for contributing to an epidemic that kills more than 70,000 Americans a year. The cases might well end with an agreement on the magnitude of the massive 1998 financial settlement against tobacco companies, considering that the opioid industry could be worth as much as $35 billion annually by 2025. Such a result could provide funding on a scale needed to help bring the epidemic under control - but only if we have the right strategy and legal agreement.
Prosecutors say pharmaceutical firms including OxyContin-maker Purdue Pharma, played down the addictive risks of these drugs. These false marketing practices duped doctors and patients into believing that opioids were relatively benign, and failed to monitor excessive prescribing and distributions (the companies have denied any wrongdoing). As details of the lawsuits emerge, and the scope of alleged negligence is revealed, these cases resemble those against cigarette makers. In exchange for ending all legal liability, those defendants agreed in 1998 to pay the states a minimum $206 billion over 25 years for lifesaving tobacco control efforts, and continue making annual payments in perpetuity that correlate to the market share of each company.
As we look toward a possible opioid settlement, we’d best recall what happened to all that tobacco money. Unfortunately, the states were not legally required to use the funds for anti-tobacco initiatives. And as a result the vast majority of states diverted the windfall to public works and other projects (funds were even used to subsidize tobacco farmers in North Carolina.) An analysis by the American Lung Association on the 20th anniversary of the agreement found that states today are spending less than 3 cents of every settlement dollar per year on anti-tobacco programs. Only one state funded these programs in 2018 at levels recommended by the Centers for Disease Control. While tobacco use has fallen dramatically since the settlement, much more could have been accomplished.
We must not repeat that mistake. If the opioid cases end with substantial and continuing funding for anti-drug programs, the settlement should contain language that guarantees payments are used for substance abuse initiatives. Programs must focus on prevention, education and early intervention strategies. They must substantially expand access to a broad range of treatment options including long-term residential and behavioral therapy, along with medication-assisted treatment (MAT). The money could be used to establish community-based clinics and treatment facilities in hard hit rural areas, and also in prisons. Funding might also support treatment programs to help private companies provide treatment to job applicants who fail drug tests like the program I helped design for Belden.
The Rosenthal Center has long advocated $100 billion in government funding over the next decade to fight the opioid epidemic, but Congress has only appropriated a fraction of that amount. A substantial opioid settlement might reach the level I believe is appropriate, with those drug makers accused of contributing to the crisis and tragic loss of life paying for a comprehensive and well-organized nationwide effort to end the suffering.
To ensure public health and The Hill: Safety, Impose a Two-Year Moratorium On Marijuana Legalization
Reckless Pursuit of Marijuana Legalization and Commercialization
We Need Treatment Funding, Not a Border Wall, to Solve Drug Crisis
The Rosenthal Report - February 2019
Mr. President: Stop Politicizing the Opioid Epidemic
More than 140,000 Americans have died from drug overdose since President Trump took office more than two years ago. Now the president is exploiting the crisis in his battle with Congressional Democrats over funding for a wall along the southern border. The president, ignoring or misconstruing the government’s drug trafficking data, said last month that drugs including meth, heroin, cocaine and fentanyl are coming over the border in a “vast pipeline” but could be “stopped cold” by a wall.
In fact, an estimated 35 percent of overdose deaths are due to legal prescription opioids manufactured by U.S. companies; they are not brought over the border by drug mules. The Drug Enforcement Agency’s 2018 Threat Assessment stated that while the majority of heroin and cocaine does enter the country along the southwest border with Mexico, those drugs are transported in cars, trucks and tractor-trailers at legal ports of entry and official crossing points, not at remote desert locations. Meanwhile, much of the fentanyl responsible for the spike in U.S. overdose is manufactured in labs in China and shipped here by mail.
The Trump administration has a poor record of responding to the opioid epidemic, aside from declaring it a public health emergency in 2017, which was largely a formality. At a time when innovative programs in many cities and states are starting to show positive results, it is wrong to divert attention from the most important needs: increasing education and prevention, reducing overdose fatalities, and expanding access to treatment. Instead of politicizing the opioid crisis, what we really need in Washington is strong leadership and a federal commitment to providing more resources, manpower and funding. Last year Congress appropriated around $9 billion for the epidemic, but a more appropriate amount would have been $100 billion to address this national tragedy over the next decade.
Big Pot sets up shop
For some time now, the Rosenthal Center has been concerned about the evolution of the legal marijuana market into a powerful industry known as Big Pot. Backed by politicians, investors, growers, marketers and retailers, Big Pot is here and open for business. As noted in the Wall Street Journal’s Heard on the Street column, “serious money is now flooding into marijuana,” with $7.9 billion raised by cannabis companies globally in just the fourth quarter of 2018, double the amount raised in all of 2017. Tobacco and liquor companies are particularly keen to establish a foothold in what could be a $50 billion U.S. market by 2025.
That forecast seems plausible: In 2018 consumers in California placed an order for a cannabis product every 8 seconds, according to an analysis of first year medical and recreational sales in the state. Women and baby boomers are driving growth, the report by cannabis platform Eaze found. Products with CBD – the non-psychoactive component of marijuana – are especially popular due to purported “wellness benefits” such as relief from anxiety, stress and pain. Users of these products might truly believe they work. But other than the one FDA-approved, CBD-based drug for a rare form of epilepsy, there’s no definitive scientific evidence that CBD oils, creams and chocolates really accomplish what is claimed. Posing even more uncertainty and risk are potent marijuana products with up to 25 percent THC, the drug’s psychoactive component, which are also popular.
Unlike tobacco and alcohol products and pharmaceuticals, legally purchased marijuana does not carry warning labels, dosage recommendations or information about potential side effects – about which we still lack sufficient information. More research is needed, and that is why I am renewing my call for a two-year moratorium on legalization to provide the opportunity to study the impact so far on health and social behavior. Complete legalization of marijuana across the country may be inevitable. That’s why consumers – especially parents of adolescents – need to know more about what Big Pot is selling.
VIDEO on Alex Berenson's Book, Tell Your Children
Marijuana Is More Dangerous Than You Think
Marijuana Is More Dangerous Than You Think
As legalization spreads, more Americans are becoming heavy users of cannabis, despite its links to violence and mental illness
By Alex Berenson
January 4, 2019
Over the past 30 years, a shrewd and expensive lobbying campaign has made Americans more tolerant of marijuana. In November 2018, Michigan became the 10th state to legalize recreational cannabis use; New Jersey and others may soon follow. Already, more than 200 million Americans live in states that have legalized marijuana for medical or recreational use. Yet even as marijuana use has become more socially acceptable, psychiatrists and epidemiologists have reached a consensus that it presents more serious risks than most people realize.
Contrary to the predictions of both advocates and opponents, legalization hasn’t led to a huge increase in people using the drug casually. About 15% of Americans used cannabis at least once in 2017, up from 10% in 2006, according to the federal government’s National Survey on Drug Use and Health. By contrast, almost 70% of Americans had an alcoholic drink in the past year.
But the number of Americans who use cannabis heavily is soaring. In 2006, about 3 million Americans reported using the drug at least 300 times a year, the standard for daily use. By 2017, that number had increased to 8 million—approaching the 12 million Americans who drank every day. Put another way, only one in 15 drinkers consumed alcohol daily; about one in five marijuana users used cannabis that often.
And they are consuming cannabis that is far more potent than ever before, as measured by the amount of THC it contains. THC, or delta-9-tetrahydrocannabinol, is the chemical responsible for the drug’s psychoactive effects. In the 1970s, most marijuana contained less than 2% THC. Today, marijuana routinely contains 20-25% THC, thanks to sophisticated farming and cloning techniques and to the demand of users to get a stronger high more quickly. In states where cannabis is legal, many users prefer extracts that are nearly pure THC.
Cannabis advocates often argue that the drug can’t be as neurotoxic as studies suggest because otherwise Western countries would have seen population-wide increases in psychosis alongside rising marijuana use. In reality, accurately tracking psychosis cases is impossible in the U.S. The government carefully tracks diseases such as cancer with central registries, but no such system exists for schizophrenia or other severe mental illnesses.
Some population-level data does exist, though. Research from Finland and Denmark, two countries that track mental illness more accurately, shows a significant increase in psychosis since 2000, following an increase in cannabis use. And last September, a large survey found a rise in serious mental illness in the U.S. too. In 2017, 7.5% of young adults met the criteria for serious mental illness, double the rate in 2008.
None of these studies prove that rising cannabis use has caused population-wide increases in psychosis or other mental illness, although they do offer suggestive evidence of a link. What is clear is that, in individual cases, marijuana can cause psychosis, and psychosis is a high risk factor for violence. What’s more, much of that violence occurs when psychotic people are using drugs. As long as people with schizophrenia are avoiding recreational drugs, they are only moderately more likely to become violent than healthy people. But when they use drugs, their risk of violence skyrockets. The drug they are most likely to use is cannabis.
The most obvious way that cannabis fuels violence in psychotic people is through its tendency to cause paranoia. Even marijuana advocates acknowledge that the drug can cause paranoia; the risk is so obvious that users joke about it, and dispensaries advertise certain strains as less likely to do so. But for people with psychotic disorders, paranoia can fuel extreme violence. A 2007 paper in the Medical Journal of Australia looked at 88 defendants who had committed homicide during psychotic episodes. It found that most of the killers believed they were in danger from the victim, and almost two-thirds reported misusing cannabis—more than alcohol and amphetamines combined.
The link between marijuana and violence doesn’t appear limited to people with pre-existing psychosis. Researchers have studied alcohol and violence for generations, proving that alcohol is a risk factor for domestic abuse, assault and even murder. Far less work has been done on marijuana, in part because advocates have stigmatized anyone who raises the issue. Still, there are studies showing that marijuana use is a significant risk factor for violence.
A 2012 paper in the Journal of Interpersonal Violence, examining a federal survey of more than 9,000 adolescents, found that marijuana use was associated with a doubling of domestic violence in the U.S. A 2017 paper in the journal Social Psychiatry and Psychiatric Epidemiology, examining drivers of violence among 6,000 British and Chinese men, found that drug use was linked to a fivefold increase in violence, and the drug used was nearly always cannabis.
Before states legalized recreational cannabis, advocates predicted that legalization would let police focus on hardened criminals rather than on marijuana smokers and thus reduce violent crime. Some advocates even claim that legalization has reduced violent crime: In a 2017 speech calling for federal legalization, Sen. Cory Booker (D., N.J.) said that “these states are seeing decreases in violent crime.”
But Mr. Booker is wrong. The first four states to legalize marijuana for recreational use were Colorado and Washington in 2014 and Alaska and Oregon in 2015. Combined, those four states had about 450 murders and 30,300 aggravated assaults in 2013. In 2017, they had almost 620 murders and 38,000 aggravated assaults—an increase far greater than the national average.
Knowing exactly how much of that increase is related to cannabis is impossible without researching every crime. But for centuries, people all over the world have understood that cannabis causes mental illness and violence—just as they’ve known that opiates cause addiction and overdose. Hard data on the relationship between marijuana and madness dates back 150 years, to British asylum registers in India.
Yet 20 years ago, the U.S. moved to encourage wider use of cannabis and opiates. In both cases, we decided we could outsmart these drugs—enjoying their benefits without their costs. And in both cases, we were wrong. Opiates are riskier than cannabis, and the overdose deaths they cause are a more imminent crisis, so public and government attention have focused on them. Soon, the mental illness and violence that follow cannabis use also may be too widespread to ignore.
—Mr. Berenson is a former New York Times reporter and the author of 12 novels. This essay is adapted from his new book, “Tell Your Children: The Truth About Marijuana, Mental Illness and Violence,” which will be published by Free Press on Jan. 8.
What Advocates of Legalizing Pot Don’t Want You to Know
NY Times: Opinion
What Advocates of Legalizing Pot Don’t Want You to Know
The wave toward legalization ignores the serious health risks of marijuana.
By Alex Berenson
January 4, 2019
The Rosenthal Report - January 2019
2018: THE YEAR IN REVIEW
At the start of 2018 there was little hope that the opioid epidemic could be brought under control. A record 72,000 Americans had died from drug overdose the previous year, and legislation aimed at curbing the crisis was stalled in Congress. Yet by year’s end the number of fatalities appeared to be leveling off in a few states and cities that had introduced comprehensive prevention and treatment initiatives. One dramatic success story was Dayton, Ohio, which reduced by more than half the rate of overdose deaths. The beleaguered city, once the epicenter of the opioid epidemic, implemented a program that included expanding long-term treatment options, establishing a community support network and utilizing peer-based counseling. All of these approaches are components of the Rosenthal Center’s anti-drug strategy.
The news is certainly encouraging, but we must build on this first sign of progress with an infusion of new funding. And by that I mean significantly more than the $8 billion over the next 5 years included in the opioid bill signed in October by President Trump. It will also require strong leadership on a national level that has so far been lacking. And we must learn from Dayton and other successful programs in Rhode Island, Vermont and Virginia. Currently only one in five Americans in need of treatment for drug abuse receives care, a tragic situation when, as a nation, we have the resources to ensure that every individual struggling with addiction could have access to effective treatment.
During the year, the Center continued to make its voice heard on a range of addiction issues. We responded to the renewed debate over safe injection sites – where addicts use drugs in a supervised setting – proposing alternative facilities that would instead transition addicts to treatment. I worked with a forward-thinking Indiana company, Belden, to design an innovative, corporate-sponsored treatment program for job candidates who had failed a drug test but were willing to enter treatment. And with methamphetamine use resurgent, I made the case in an opinion piece for The Hill that it’s time to shift the focus of national drug policy to the substance abusers – rather than the ever-changing substance of the moment.
A highly disturbing feature of the past year was the acceleration of the movement to legalize and commercialize marijuana. The pot lobby wooed politicians and the public, promoting the fiction that marijuana is totally benign despite strong scientific evidence indicating otherwise. New pot products flooded the market with dubious medical claims. And companies including Coca-Cola and the tobacco giant Altria eyed marijuana startups. Amid this frenzy, I proposed a two-year moratorium on legalization to study the drug’s impact on health and social behavior in legalized states as well as in Canada. It’s too late now to stop legalization. But a brief pause would give us time to assess and evaluate how to regulate the soon-to-boom marijuana industry and better protect such vulnerable groups as teenagers.
We approach 2019 with a sense of guarded optimism for further evidence of a slowing opioid epidemic if the appropriate policies, funding and leadership are provided. Our research will concentrate on the needs of vulnerable adolescents and other overlooked population groups. We will continue to voice concerns about Big Pot and the risks posed by an uncontrolled marijuana market. As always, the Center will advocate thoughtful solutions to challenging addiction issues, always putting the individual first and supporting policies that help people achieve rewarding lives without drugs.