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.
The Rosenthal Report - December 2017
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.
The Rosenthal Report - November 2017
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.
The Rosenthal Report - October 2017
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.
TO SENATORS: REJECT OBAMACARE REPEAL, SAVE DRUG TREATMENT PROGRAMS
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.
The Rosenthal Report - September 2017
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.
The Rosenthal Report - August 2017
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.
The Rosenthal Report - July 2017
“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.
The Rosenthal Report - June 2017
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.
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.
President Trump: don’t gut the budget of the White House Office of National Drug Control Policy!
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!
The Rosenthal Report - May 2017
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.”
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.
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.
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.
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.
The Rosenthal Report - April 2017
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
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.
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.
The Rosenthal Report - March 2017
Can the Feds Delegalize Marijuana—and Should They?
Yes, they can, but not easily. So it came as something of a surprise last month when White House press secretary Sean Spicer was asked about the federal ban on pot and told reporters “I do believe you’ll see greater enforcement of it.” Not for medical use, he explained “That’s very different than the recreational use, which is what the Department of Justice will be further looking into.”
Recreational use, now legal in eight states, has achieved quasi legitimacy under the past three presidents. An Obama administration memo agreed not to challenge state marijuana laws so long as the drug did not cross state lines, reach children, or benefit drug cartels. Although a federal crackdown on marijuana would appear to be inconsistent with the Trump administration’s embrace of states’ rights, Attorney General Jeff Sessions has long been an opponent of legalized pot and declared during his confirmation hearing “I won’t commit to never enforcing federal law.”
There’s a case to be made for the status quo, and it has been made by Washington’s Governor Jay Inslee and Attorney General Bob Ferguson who wrote to Sessions earlier in the month, arguing that Washington State’s tightly regulated, tax paying marijuana industry was plainly preferable to illegal trafficking that enriched criminals. Inslee and Ferguson are prepared to take the issue to court. (They’ve won against the new administration twice already.) But, while there are state sovereignty claims they can raise and officials in other states consider any administration action now “federal overreach” most lawyers would agree that the federal supremacy clause of the Constitution trumps all and state laws must defer to federal.
And that’s for the best. Despite the benefits of legalization (and there are some), the downside can be grim indeed. In Washington, the state’s Traffic Safety Commission found the number of DUI arrestees testing positive for THC rose from 19 percent to 33 percent in the two-and-a-half years since legalization in 2012, and the number of traffic fatalities involving marijuana rose 48 percent between 2013 and 2014. In Colorado, marijuana use among both adolescents and adults has steadily increased since legalization stretching well beyond the national average.
Kevin Sabet, who heads Smart Approaches to Marijuana (SAM) welcomes federal intervention “The current situation is unsustainable,” he says. “States that have legalized marijuana continue to see a black market for the drug, increased rates of youth drug use, continued high rates of alcohol sales, and interstate trafficking, with drug dealers taking advantage of non-enforcement.”
Bear in mind that marijuana, particularly the high-test products of today, are far from the relatively benign substance that aging baby boomers recall from their youth. Outside the legalized states, teen use has remained relatively stable, while adult use has been rapidly rising.
What researchers are now finding among adult users are low levels of risk awareness, increased incidence and severity of cannabis use disorder, and higher risk of death and psychosis. Risk of psychosis also exists for adolescent users, along with impaired learning, judgment, and memory. Teens have a greater vulnerability to marijuana addiction, and a new and frightening discovery is the risk to pot-smoking teens of lasting harm to the brain.
All things considered, a federal crackdown on state legalized recreational marijuana may not be a bad idea.
Drugs and the Elderly
Rising Number of Seniors Now Use Three or More Psychoactive Drugs
Popping “a pill for every ill” has become the American way. Encouraged by the pharmaceutical industry, we have abiding faith in medication to keep us comfortable and content, especially as our minds and bodies age and we face the multiple infirmities of our later years. So it is alarming but not surprising that researchers at the University of Michigan found the number of seniors using three or more mind or mood altering drugs have more than doubled over the past decade. Data collected by the Center for Disease Control showed there were 3.38 million doctor visits in 2013 by patients over 65 taking three or more psychoactive drugs—up from 1.5 million such patients in 2004. The sharpest increase was in rural areas where the number of these patients tripled.
Nearly half the heavy consumers of psychoactive drugs found by the study had no formal diagnosis of a mental health disorder, insomnia, or chronic pain, the three conditions for which most of these drugs—antidepressants, painkillers, tranquilizers, and sleeping pills—are usually prescribed. One quarter of the prescriptions were for antidepressants and 10 percent for opioids. Among patients with ongoing prescriptions for a benzodiazepine tranquilizer, only 16 percent had a diagnosed mental health condition and almost none was referred for behavior therapy.
Mixing mind-altering substances poses considerable risks for seniors. Dizziness and confusion are common side effects and make falling a major concern, while the combination of opioid painkillers and benzodiazepine tranquilizers can prove fatal.
Medical Marijuana for the Retired: Benefit or Hazard?
More and more, seniors are turning to marijuana to relieve a host of ailments, including neuropathic pain, arthritis, the muscle spasms of multiple sclerosis, and the appetite loss and nausea of chemotherapy. A report in the New York Times noted that much of this consumption takes place in nursing homes and retirement communities. Although most nursing homes do not openly allow it, an increasing number are developing programs to regulate how residents in the 29 states that sanction medical marijuana can take their daily dose.
Professional opinion is divided. A number of academic researchers see medical use by elders as an important and growing field of study. Others, including Dr. Thomas Strouse at UCLA, view medical marijuana for the aged with alarm. “There’s no evidence that it is particularly helpful to older people”, he says, and points to the possible harm of older marijuana users becoming dizzy, confused, and more likely to fall.
Drug Firm Accused of Price Gouging for Opioid Overdose Injector
As the nation’s opioid epidemic continues to spiral, Kaleo Pharma is under fire for dramatically raising the price of its popular injector device that delivers the opioid overdose-reversing drug naloxone. Kaleo hiked the price to $4,500 for a twin pack of the Evzio device, which cost $690 when it was introduced in 2014. This increase of more than 500 percent prompted more than 30 U.S. senators to ask Kaleo for an explanation.
The firm maintains the list price issue is largely “moot” because Kaleo gives away many devices, insurance covers the cost for many patients, and the Veterans Administration has negotiated a lower price. But it’s clear that if you can’t pay, the price surge hurts. For example, Vermont’s health department says Evzio isn’t an option due to its high cost, so the state’s first responders will use a less expensive nasal spray that might not prove as effective.
First responders prefer Evzio because it comes in pre-filled dosages and provides a unique “intelligent system” with voice and visual guidance to help administer the drug. The rate of opioid overdoses is accelerating. Over a span of just 32 hours in early February, emergency workers in Louisville, Kentucky reportedly responded to almost two overdose cases an hour. Facing this kind of pressure, devices like Evzio can be critical to saving lives. But Kalẻo’s sky-high prices may put them out of reach for many healthcare providers struggling to contain a worsening crisis.
Warnings about Using Pot for Children with Autism
Doctors at Boston’s Children’s Hospital and the Department of Pediatrics at Harvard University Medical School strongly advise against using marijuana to treat children and adolescents with marijuana, autism, ADHD or other developmental and behavioral disorders. Although this practice is being advanced by some parent advocacy groups, the doctors clearly state that “good evidence is almost entirely lacking” to support it. The doctors voice concern that efforts to use pot for this purpose, coupled with the push to legalize medical marijuana, may result in medical marijuana permits being issued for developmental and behavioral conditions “for which no data on efficacy, safety or tolerability exist.”
Marijuana Treatment for Veterans Linked to Suicide
New doubts have been raised about pot-based treatments for veterans with PTSD. A report in the Journal of Psychiatric Research cited evidence that marijuana-dependent military veterans face an increased risk of suicidal thoughts and suicide attempts, not a diminished one. The study looked at more than 3,000 veterans of the Afghanistan and Iraq wars, many of whom have turned to pot to treat symptoms of PTSD. Concerned about a suicide rate among these veterans of nearly 20 a day, the authors call for further study of the relationship between cannabis use disorder (CUD) and suicidal ideation among men and women who served in those wars.
Republican healthcare proposal to replace Obamacare could threaten Medicaid-related mental health and substance abuse treatment programs!
In its current form, GOP plan would fundamentally change Medicaid funding for 74 million low income Americans: one-third of those on Medicaid rolls receive treatment for a mental health of substance abuse disorder.
As the opioid crisis deepens and devastates families and communities, Congress must stand up for vulnerable patients and not jeopardize funding to states and patients who need drug programs!
Tell the President:
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
The Rosenthal Report - February 2017
The High Cost of Not Knowing
With the launch of its new website, the Rosenthal Center makes available key findings of its initial survey. The Survey of Perceptions of Drug Use in America, now in the website library, studied how drug abuse (the use of illicit drugs and illicit use of prescription drugs) has remained a critically negative aspect of American life for more than half a century despite the efforts of law enforcement, the healthcare community, and the full spectrum of social services. What has kept drug abuse alive and well, we learned, is in large measure how little and how poorly average men, women, and their children understand drugs, drug use, and addiction.
What do Americans know and, more importantly, what do they believe? These are the questions that prompted the Perceptions Survey, conducted for us by Schoen Consulting, since what people know and what they believe profoundly influence behavior. They are also the raw material of public opinion, shape public policy, and largely determine how drug abuse is regarded and how drug abusers are served by society.
Two Families in Five Must Deal with Drug Abuse
Focusing sharply on drugs and the family, the survey found two in five Americans have dealt with drug abuse within their families, but barely one in three sought outside help or support. Most striking was the disparity between what parents recall about drug use by their children and what today’s young adults recall doing in their teens. Twenty one percent of parents reported their children had used drugs, while nearly half as many young adults (30 percent) remembered using drugs as adolescents.
Parents were generally aware that their children smoked cigarettes, less aware of marijuana use, and surprisingly unaware of how many of their children drank alcohol. The greatest disparity, however, was between parental awareness of non-medical use of opioid painkillers and the actual level of teen use. Just 8 percent of parents believed their children had used these life-threatening drugs but 28 percent of young adults said they indeed had done so.
Most Parents Disregard Marijuana’s Greatest Dangers
Most discouraging was discovering how lightly parents take marijuana use by their teenage children. There is growing evidence that regular use of marijuana during the adolescent years can have profoundly damaging consequences later in life. Although two out of three parents agree that teen marijuana is a real concern, barely one in five (22%) claimed to be “very familiar” with the greater vulnerability of teens to marijuana addiction and the threat of lasting brain damage. So, it was not surprising that, when asked which toxic substance—cigarettes, alcohol, or marijuana—they would rather their children indulged in, it was marijuana, at 44 percent, that was chosen by the greatest number of parents.
In a set of clearly conflicting opinions about addiction: survey participants split almost evenly over whether or not addicts were “powerless before their addiction;” slightly more than half (53 percent) believed relapse was a part of the addiction disorder; more than two out of three (67 percent) called addiction “chronic;” and yet a shade short of three out of four (74 percent) said addiction was curable.
Little of what we learned was surprising. In the age of the Internet and 24/7-news cycle, there is no shortage of information, facts, factoids, and opinions. But what the military call “intelligence,” the hard, cold, indisputable facts that commanders count on, is difficult to find among the welter of material on the Internet and in the increasingly partisan press and parochial media. This reality defines the mission of the Rosenthal Center. It is the search for truth and revelation of error in what Americans believe about issues that influence behavior, public opinion, public policy, and what we do and fail to do to arrest the spread of addiction and care for its victims.
Physicians Deeply Divided over Opioid Prescribing Practices
In the face of the nation’s opioid addiction crisis, there is a growing debate within the medical and substance abuse treatment communities over the prescribing of painkilling drugs. At issue are both federal agency guidelines and state government efforts to control opioid use through prescription monitoring programs and legislation limiting how much, how often and for whom opioid medication should be prescribed.
“There’s a civil war in the pain community,” according to Daniel B. Carr, M.D., president of the American Academy of Pain Medicine. “One group believes the primary goal of pain treatment is curtailing opioid prescribing,” he says. “The other group looks at the disability, the human suffering, the expense of chronic pain.”
Dr. Carr makes the case for compassion and the physician’s obligation to alleviate suffering. Reducing the nation’s extraordinary level of prescriptions for opioid painkillers (e.g. Vicodin, Percocet, Oxycontin) is the agenda of Physicians for Responsible Opioid Prescribing, (PROP) who contend that today’s addiction crisis is the result of:
- The promotion of a high-potency, time release opioid painkiller (OxyContin) in the late 1980s and early 1990s;
- The notion that addiction due to prescribed opioid pain management is rare;
- The then guiding principle of pain management, which was “titrate to effect” or keep raising dosage until the medication provides sufficient relief as measured on a pain intensity scale.
Rules for Opioid Use Now: “Go Slow and Low”
What replaced this approach, in addition to state legislated limits, are the guidelines for pain management issued by the Centers for Disease Control and backed by the surgeon general. The CDC guidelines encourage such alternatives to opioids as exercise, cognitive behavioral therapy or the use of aspirin, ibuprofen and other anti-inflammatory medications. (Other sources also recommend acupuncture and meditation). When opioids are to be used, the rule is go slow and low—low dosage, and a strictly limited number of pills—only immediate release pills and, not the extended release, long-acting kind.
The guidelines are voluntary, intended primarily for primary care physicians and aimed specifically at non-cancer chronic pain. But a recent article on STATNews, the health news website of the Boston Globe, reported how emergency room doctors across the country are cutting back on narcotic painkillers for acute pain and prescribing them only as a last resort. The effort, says Dr. Jay Bhatt, chief medical officer of the American Hospital Association, is “to stem the tide of the opioid epidemic.”
So far, there is no evidence that this is occurring. Opioid prescribing was in decline well before the guidelines were issued last March, yet overdose deaths continued to rise. Heroin has replaced more expensive and harder to find prescription painkillers pills for many addicted users, and the Drug Enforcement Administration warned this summer of high-powered fentanyl in counterfeit painkiller pills flooding the black market. A counterfeit fentanyl-laden pill was responsible for the death last year of the singer/record producer, Prince.
Opioid Restriction Lobby Discounts the Severity of Pain
PROP justifies wholesale reduction of opiate use not only because the use of prescribed narcotics can lead to addiction and a host of other distressing consequences—from depression and anxiety to respiratory impairment and sleep apnea—but also, they contend, because too much attention is given to how severely a patient’s chronic condition hurts. This perception of pain was described most vividly in a 2015 commentary in the New England Journal of Medicine by the organization’s president Dr. Jane C. Ballantyne and Dr. Mark D. Sullivan, titled “Intensity of Chronic Pain—The Wrong Metric?” the commentary asked, “Is a reduction in pain intensity the right goal for the treatment of chronic pain?” Their answer was “No.” They maintained that, “Willingness to accept pain, and engagement in valued life activities despite pain, may reduce suffering and disability without necessarily reducing pain intensity.”
PROP’s position on pain is not without support within the pain treatment community. “The American culture has grown intolerant of pain,” psychiatrist Anna Lembke of Stanford University’s medical school told STATNews. Lempke, who practices at the school’s pain clinic and heads Stanford’s Addiction Medicine Dual Diagnosis Clinic, feels we just make too much of a fuss about pain. “Whether it’s surgery or women going into childbirth, there’s an almost alarmist reaction to pain, and it’s contagious and makes people more anxious, which makes the pain worse,” she said.
The Institute of Medicine’s latest estimate is that that roughly 100 million adult Americans suffer incurable pain from disease, injury or nervous system malfunction. They use a broad array of medications and therapies to find relief, and opioids are only one option—and not necessarily the first one.
“Opioids absolutely harm some patients, but they absolutely help some patients”
“Opioids absolutely harm some patients,” Dr. Daniel P. Alford told the Boston Globe, “but they absolutely help some patients.” An addiction specialist at Boston University’s School of Medicine, Alford directs the school’s Safe and Competent Prescribing Education program. He is no fan of what he called “opioid phobia” or “blanket regulatory changes that treat everybody the same.” Many of the patients he knows, who function well on opioids and can safely use them for years, no longer can get the medication they have been using or get enough of it.
At Stanford, Dr. Sean Mackey, who heads the pain management program, is no happier with blanket regulations. “The thing is we all want black and white,” he told STATNews. “We don’t do well with nuance. And this is an incredibly nuanced issue.” He described a patient on opioids whose foot was crushed in an accident and had undergone surgery ten times for “the burning, terrible pain” of the injury. “People will say, ‘this guy’s on way too much opioid medication,” Mackey said. “But guess what: He gets up every morning and goes to work and does his job, and he’s been on the same regimen for years and years and tried everything else first.
“There’s almost a McCarthyism on This, Silencing so Many people”
The schism in the pain management field is deeply troubling to authorities like Mackey. He finds physicians being trained at the Stanford pain center increasingly fearful of prescribing opioids. “There’s almost a McCarthyism on this, that’s silencing so many people who are simply scared.”
Dr. Carr is neither silenced nor scared. The Academy president says only about 10 percent of patients using opioid drugs are at risk of addiction. He finds CDC’s guidelines dictate dosages or limits that ignore the needs of the individual patient, “Many appropriate and compliant patients, already stigmatized and marginalized by virtue of having pain and using opiates to treat it, are finding it impossible to continue therapy from which they derive benefit.” Indeed victims of chronic pain, who came to opiate pain management after every other medical intervention failed, now find themselves, as they will tell you, “being treated like addicts or criminals.”
In his first President’s Message, Dr. Carr focused on the victims of today’s guidelines, regulations, and physician monitoring programs. The patients who are “now denied treatment that has long worked for them,” he called, “collateral damage in the war on opioid abuse.”
Weed Market Grows
Marijuana legalization and the introduction of new pot products are having a broad impact on the marijuana market. Cannabis sales totaled $53.3 billion in 2016 across legal, medical, and illicit markets in North America, according to Arcview Market Research. Most of those sales – 87 percent – were from illegal channels. Still, legal market sales climbed 34 percent over 2015 to $6.9 billion, due to the easing of state regulations prohibiting medical or recreational use. The report forecasts legal cannabis sales growing 26 percent annually to $21.6 billion by 2021, as more states approve legalization. Meanwhile, consumers’ buying habits are changing, and concentrated marijuana products with high levels of THC are now more popular than traditional dried leaf. In Colorado, according to Arcview, concentrate sales quadrupled to $80 million by the third quarter of 2016 compared to $20 million in 2014, when legalized adult-use was launched in the state.
Doubts on Pot for Anxiety and Depression
For those suffering depression and anxiety, using cannabis for relief may not be an effective long-term solution. Colorado State University researchers found that, while marijuana can initially help relieve symptoms of anxiety and depression, chronic use may prove detrimental, according to a report published in PeerJ. The CSU study examined the relationship between pot users’ habits and neurological activity, including the processing of emotions. “There is a common perception that using cannabis relieves anxiety,” study co-author Jeremy Andrzejewski said, but so far research has yet to fully support this claim.
More Cases of Marijuana “Mystery Illness”
Emergency room doctors in Colorado have seen an influx of patients suffering from cannabinoid hyperemesis syndrome, or CHS, a little known disease associated with regular and prolonged marijuana use. A 2015 study published in the journal Academic Emergency Medicine found that ER admissions for CHS at two urban Colorado hospitals nearly doubled between 2009 – the year medical marijuana was legalized – and 2011. CHS symptoms include severe abdominal pain and intense cyclical vomiting, which ER doctors say can be controlled by hot baths and showers – or, of course, by reducing or stopping the use of pot.
Rise in Pot Use During Pregnancy
More pregnant women in the U.S. are using marijuana than did a decade ago, JAMA reported. The rate of use rose 62 percent, from 2.37 to 3.85, between 2002 and 2014, among 200,000 women ages 18 to 44 in the data group. The rate was even higher for younger women ages 18 to 25, with 7.47 of them using the drug within the preceding month. Preliminary research on pot use during pregnancy - ostensibly for morning sickness - shows a spectrum of potential risks to the fetus, including anemia and low birth weight that often requires neonatal intensive care. In addition, maternal pot use is linked to such developmental problems as impaired impulse control and attention loss during school years. Laws legalizing medical marijuana do not list pregnancy-related conditions among allowed uses, but also don’t prohibit use or carry warning labels. “Doctors must be aware of the risks involved and err on the side of caution by not recommending the drug for pregnant patients,” Dr. Nora Volkow, director of the National Institute on Drug Abuse, wrote in a JAMA editorial.
Survey on Perceptions of Drug Use in America
What do Americans know about drugs, drug use, and addiction? More importantly, what do they believe? And how does this influence their behavior, the behavior of their children, and the parent-child relationship? What is the impact of drug use on families, on communities, and on society?
Click below to download PDF of Full Survey
The Rosenthal Report - January 2017
21st Century Cures Act:
A Boon to Mainstream Medicine; A Threat to Drug Treatment*
In December, President Obama signed the 21st Century Cures Act authorizing $6.3 billion for an array of medical research and healthcare initiatives. The National Institute of Health gets $4.8 billion over 10 years – including $1.8 billion for its cancer “moonshot” – and the FDA secures $500 million to accelerate development of new medicines and medical devices. Finally, the Act earmarks $1 billion to combat the nation’s escalating epidemic of opioid addiction. Recall that earlier, Congress passed the Comprehensive Addiction and Recovery Act (CARA), which featured similar anti-opioid strategies but lacked the Cures Act’s funding commitments. Here are the highlights:
• States receive $1 billion in new funding for existing and supplemental programs to expand access to abuse prevention programs, improve treatment facilities and services, and train healthcare professionals.
• The money, distributed in block grants of $500 million for the 2017 and 2018 fiscal year, targets states, underserved communities and vulnerable populations hardest hit by the opioid crisis.
• Congress must approve appropriations each fiscal year, but funds for the opioid epidemic are already authorized from approved cuts in the Prevention and Public Health Fund and sales from the Strategic Petroleum Reserve.
That’s the good news, but other provisions of the act threaten the future of free-standing substance abuse programs and the very nature of drug abuse treatment as it has evolved over the past fifty years.
• The ACT will advance a key feature of CARA, the prioritization of medically assisted treatment (MAT) for drug abuse, which is increasingly implemented during today’s crisis either with none of the behavioral therapies required by SAMHSA guidelines or with only minimal behavioral services.
• Echoing the surgeon general’s recent call to merge substance abuse treatment with mainstream medicine, a stated goal of the Cure Act is to “heal the fracture” and “bridge the gap” between physical and behavioral healthcare.
• In this union, substance abuse is considered a mental health issue and not the unique challenge that we who treat it recognize it to be. Although treatment for substance abuse seeks self-awareness, as does mental health treatment, treating drug abusers requires not only the active participation of patients, but also the insight, trust, and support that patients give each other.
• In its effort to strengthen the mental health workforce, the Act provides support for recruitment and training of mental health practitioners at almost every level and venue. But the Act singles out for inquiry “peer support specialists” in drug treatment programs, calling for a study of federally-funded peer support programs, focused on the qualifications of specialists.
• As for to what has become federally mandated destigmatizing nomenclature, the Act dictates the use of “mental health and substance use disorder” in place of the simple, straightforward description of “substance abuse.”
The Opioid Epidemic and:
Rural White Women
No population group has been harder hit by the opioid epidemic than white, middle-aged women in rural areas of the country. The Washington Post crunched national health and mortality statistics, finding that death rates for this group spiked an alarming 48 percent between 1990 and 2014. It’s part of a broader trend of “decaying health” for white women across the country, but is much more pronounced for white women aged 30 to 44 who live in small towns and less urbanized areas, the Post reported. By comparison, the death rates for women in the same age group in urban areas remained flat or grew by only 1 to 3 percent.
For white men in the same rural demographic, the death rate rose between 9 and 12 percent. While that is also unexpectedly high, the increase is still below what the paper called “the most extreme changes in mortality” for white rural women. Multiple factors are to blame for the rising death rates, the paper says, including an increase in alcoholism, suicide and obesity. But the biggest risk factor was clearly the scourge of opioid and heroin overdoses that has been “particularly devastating in working-class and rural communities.”
As the opioid epidemic sweeps through rural areas of the country, hospital neonatal units are struggling to treat the growing number of drug-dependent newborns, the New York Times reported at the end of 2016. Quoting JAMA Pediatrics, the paper noted a sevenfold increase in the number of drug-dependent newborns in rural hospitals between 2004 and 2013 compared to a fourfold rise in drug-dependency among urban infants during this time period (7.5 per 1,000 newborns in rural areas compared to 1.2 per 1,000 previously; and an uptick in cities to 4.8 per 1,000 from 1.4 per 1,000).
The rising rates mirror the widening use of opioids among pregnant women, the researchers reported. In Utah, for instance, nearly 42 percent of pregnant women on Medicaid were prescribed opioids, mostly to treat back or abdominal pain. Maternal use and misuse of drugs such as oxycodone and illegal narcotics leads to neonatal abstinence syndrome, including breathing problems, seizures and difficulties breastfeeding. The problem of drug dependent newborns, the paper grimly concluded, has “grown more quickly than realized and shows no sign of abating.”
The number of youngsters removed from parental custody and placed in foster care or with relatives is increasing in tandem with opioid-related drug use and deaths across the country. More than 80,000 first-time foster care cases were related to parental drug abuse in 2015, the Wall Street Journal reported. Not surprisingly, the numbers are rising in states worst hit by the crisis, including a 19 percent increase in Ohio; 40 percent in Vermont; and 24 percent in West Virginia. Several states, such as New Hampshire and Vermont, have changed laws to make it possible to take children out of homes where parents are addicted and are budgeting more for social workers to help deal with the crisis, according to a Pew Charitable Trusts report.
Teen Drug Use Falls- But Not Pot
The good news from monitoring the Future’s latest school survey is the overall drop in 8th, 10th , and 12th grade drug use this past year. Use of tobacco and alcohol also hit new lows. Among other positive finding of the survey conducted annually by the University of Michigan for NIDA is declining use of amphetamines like Ritalin and Adderall and non-medical use of prescription narcotics. Use of these opioids fell from 9.5 percent among 12th graders in 2004 to 4.8 percent in 2016 with no corresponding increase in heroin use. The bad news, however, is the absence of marijuana from the general decline. Although 8th grade use did fall, 10th grade use showed no significant change, and past month use for 12th graders rose from 21.3 percent to 22.5 percent (up from 18.7 over the past decade).
What may be the most troubling finding of the latest survey is the dramatic decline in student awareness of marijuana dangers. Long before current research revealed the drug’s threat to the adolescent brain, the overwhelming majority of teens recognized the danger of regular marijuana use. In the early Nineties, roughly 80 percent of students in all three secondary school grades saw great risk in regular use. But the latest survey found just 57.5 percent of 8th graders now see great risk, only 44 percent of 10th graders do, and no more than 31 percent of seniors.
According to the 2016 survey, past year use of marijuana by 12th graders in states with medical marijuana continues to be higher than it is in states without such those laws—38.3 percent of seniors in states that have medical marijuana used the drug during the past year compared to 33.3 percent of seniors in states that do not have it. As for teens in states that have legalized recreational use, they are more likely to eat their pot than teens in states that have not legalized—40.2 percent of legalized state seniors reported using edibles, while only 28.1 percent of non-legalized state seniors are snacking on pot.
The Rosenthal Report - December 2016
The Surgeon General Has Solid Facts But A Flawed Plan To Combat Opioid Addiction
In a fact-packed and ambitious document titled Facing Addiction in America, The Surgeon General’s Report on Alcohol, Drugs, and Health, Dr. Vivek H. Murthy declares, “It is time to change how we as a society address alcohol and drug misuse and substance use disorders,” and indeed it is. But, while the report released last month is filled with useful information about drug use, treatment, and recovery, the public health strategy at the heart of Dr. Murthy's scenario for addressing rising levels of substance misuse and a nationwide epidemic of opioid addiction is fatally flawed.
What made headlines when the report was released were the statistics—one in seven Americans at risk of addiction and the one in ten lacking the treatment they need. More Americans now use prescription opioids than use tobacco, according to the surgeon general, and more suffer from substance use disorders than from cancer.
Dr. Murthy boils down the recommendations of his 412-page report to a five-point prescription. Three points are clear and predictable:
• Expand access to evidence-based treatment;
• Add more community-based prevention programs;
• Undertake research that advances development of strategies for treatment, prevention, and support of recovery.
A fourth point—utilizing health reform and parity measures to increase access to substance misuse services—becomes questionable after last month’s election. Nevertheless, as Dr. Murthy says, “Whatever happens, continuing to expand coverage will remain key to addressing addiction.”
It is at the fifth point that the surgeon general’s plan goes off the rails, for he proposes the integration of treatment for substance use disorders with the rest of mainstream health care, which, as detailed in his report, would mean the virtual elimination of today’s network free-standing programs for substance abuse and other behavioral healthcare services.
The rationale for this proposal derives in part from Dr. Murthy’s own professional experience as a hospitalist (an internist treating hospitalized patient exclusively) and a medical services manager. But it mostly reflects the orthodoxies that now guide federal substance abuse policy:
• The alleged ability of “substance use” to “hijack” the normal function of brain circuits;
• The perception of substance use disorders as a “chronic relapsing condition” no different than such other chronic disorders as diabetes or hypertension; and
• The attempt to destigmatize addiction, including such efforts as banning use of the words “abuse, abuser, or addict.”
Please note that:
• While addiction skews choice it does not eradicate free will.
• There is more than adequate evidence that, as Dr. Sally Satel puts it, “addiction is an activity that can be altered by its foreseeable consequences”
• Shame and stigma are among the most useful of social mechanisms and society’s chief means of modifying negative behaviors. If it’s okay to employ stigma against smoking, why not against illicit drug use?
“Addiction,” says Dr. Murthy, “isn’t evidence of a character flaw or a moral failure, it’s a chronic disease of the brain that deserves the same compassion that any other chronic illness does, like diabetes or heart disease.” This perception of addiction appears throughout the report. “A substance use disorder is a medical illness,” the report says and, “The primary goal and general management methods of treatment for substance used disorders are the same as those for the treatment of other chronic illnesses.”
Separation of substance abuse services from the rest of health care, the surgeon general contends, “has contributed to the lack of understanding of the medical nature of these conditions…and the slow adoption of scientifically supported medical treatments by addiction treatment providers.”
Under Murthy’s plan, state funding and licensing policies would be employed to bring about the shotgun marriage of behavioral and general healthcare.
The fatal flaw in all of this is the politically correct but therapeutically absurd notion that there is truly no difference between substance abuse and other chronic disorders. Nor is there compelling evidence that, save for a few black swans, addiction is in fact a chronic (i.e. incurable) condition. Chronic or not, the behavioral component of addiction goes far beyond the need for compliance in managing diabetes or hypertension. Bad behavior is a fundamental component of addiction and the past fifty years of treatment experience has taught us that changing behavior is not what mainstream medicine does.
Medication helps, and the Murthy plan calls not only for the expansion of medication assisted treatment (MAT)—the use of methadone, buprenorphine, and naltrexone—but elimination or reduction of “restrictions on how these drugs may be prescribed or dispensed” that he maintains, “have reduced their availability for many people who could benefit from them.”
Those of us who actually treat addiction recognize that medication is, by itself, not treatment. It is a useful adjunct for the behavioral therapies that help our patients find their way to sustained recovery. But the most powerful ingredient by far in the treatment of addiction is the joint effort of patients, together with each other and peer counselors in recovery to take control of their own lives.
Consistent with his call for a public health approach, the surgeon general’s plan includes “harm reduction” programs for those users “who may not be ready to stop substance use,” sanctioning needle exchange programs, overdose prevention education, and access to naloxone. These strategies, he says, “reduce substance misuse and its negative consequences… such as transmission of HIV and other infectious diseases.” They also, as the surgeon general acknowledges, “seek to help individuals engage in treatment to reduce, manage, and stop their substance use when appropriate.”
When it comes to “the treatment gap” the difference between those substance users who need treatment and those who receive it, the report allows that, “Many factors contribute to this,” and goes on to list “the inability to access or afford care, fear of shame and discrimination, and lack of screening for substance misuse and substance use disorders in general health care settings.” In addition, the report notes that roughly forty percent of those “who know they have an alcohol or drug problem are not ready to stop using, and many others simply feel they do not have a problem or a need for treatment.”
Although it may appear somewhere in the report’s 412 pages, there is no mention in the executive summary or in any of the surgeon general’s interviews of what is surely a critical factor in the inability of our society to bring substance misuse under control. As the number of drug and alcohol users has risen over the past decade, the number of treatment admissions for substance use disorders has fallen.
The report shows illicit drug use rising from 8.3 percent of the population to 10.2 percent between 2002 and 2014. In roughly the same time frame, between 2004 and 2014, as the U.S. population increased by 10 percent, the number of treatment admissions fell by 11 percent, from 1,808,469 to 1,616,358.
Most critical was the precipitous decline of close to 50 percent in teen treatment. “The earlier people try alcohol or drugs, the more likely they are to develop a substance use disorder,” says the surgeon general’s report. But what it does not say is that adolescents are much less likely than adults to find effective treatment. Although the report cites one million adolescents (12 to 17) who need but lack treatment, teen admissions plummeted between 2004 and 2014 from 146,423 to 78,018. How or why this has occurred is an issue the demands investigation.
The Rosenthal Report - November 2016
Victory, Defeat, and Uncertainty for Recreational Marijuana
Pro-pot forces outspent and overwhelmed opponents of recreational marijuana use in California, Massachusetts, Nevada, and Maine, but failed to win in Arizona. Meanwhile, in Alaska, where voters approved recreational use close to two years ago, the first pot shops just opened in Valdez and Fairbanks. These five join Colorado and Washington, states with recreational marijuana already on the books, in the shops, and growing in the fields. This year’s election also saw medical use of marijuana approved by voters in Florida, North Dakota, and Arkansas, making medical use the law in a majority of states.
Legalization champion Ethan Nadelmann, executive director of the Soros-funded Drug Policy Alliance, called the election results “a monumental victory for the marijuana reform movement.” The Washington Post speculated that adoption of legal marijuana by California, home to roughly 12 percent of nation’s population, might “prompt the federal authorities to rethink their decades-long prohibition on the use of marijuana.” This thought has clearly not escaped President Obama who said, in a recent interview with Bill Mahr, that passage of the legalization proposals could make “untenable” the current federal “hands-off” policy towards legalization efforts at the state level.
It is not likely, however, that the incoming Trump administration, strong for law and order and skeptical of drug reform, would be enthusiastic about keeping their hands off. “The prospect of Rudy Giuliani or Chris Christie as attorney general,” Nadelmann allowed in an interview, “does not bode well. There are various ways in which a hostile White House could trip things up.”
The battle against legalization is clearly not over on the state by state level. “We were outspent greatly in both California and Massachusetts, so this loss is disappointing, but not wholly unexpected,” says Kevin Sabat, president of SAM (Smart Approached to Marijuana), a leader in the fight against legalization. "This is the beginning of the conversation, not the end,” he adds, for SAM will be working with localities within the legalizing states, he says, “to ensure they know their rights and obligations to protect their citizens from pot shops, candies, and advertising."
What Was Lost With Hillary
There was no mention of the nation’s opioid epidemic in the Presidential Debates and Donald Trump’s sole reference to the problem went no farther than the Mexican border where, he declared, “We’re going to build a wall and we’re going to stop that heroin from pouring in.” But Hillary Clinton had a carefully thought out plan to spend ten billion dollars over the next ten years on just about everything other than a wall.
It would have boosted the Substance Abuse Block Grant, (money that regularly goes to the states for drug abuse services), provided blanket provision of naloxone for overdose victims, funded prevention initiatives, promoted prescription monitoring programs, and prioritized treatment over incarceration.
When it came to treatment, Hillary’s plan was committed to comprehensive, ongoing care, and, according to the Associated Press, would promote greater use of medication assisted treatment (MAT).
The Problem with Medication Assisted Treatment (MAT)
Hillary is not alone in promoting medication assisted treatment. President Obama’s plan, authorized by Congress before the summer recess, also increases funding for MAT programs.
But, at what point does “medication assisted” treatment become “the medication alternative” to treatment, for federal regulations define MAT as “the use of medication in combination with counseling and behavioral therapies.” This is an issue that troubles health care officials in areas hard hit by the opioid addiction, where the priority has been getting buprenorphine step-down medications to patients in new opioid treatment clinics where they are unlikely to be getting much, if anything, in the way of the “whole patient approach” that federal guidelines say should provide, “a range of services to eliminate, reduce, or prevent the use of illicit drugs.”
Prescription by Decree
When it comes to medically assisted treatment for Medicaid patients, no state is more generous than Vermont. A number of states demand that Medicaid patients “fail first” at a less costly intervention or, as Kelly Clark, M.D., president-elect of the American Society of Addiction Medicine points out, “require patients to wean off their addiction medication” (which she considers akin to telling a heart patient to taper off of his medication after a year). But not Vermont, where the state’s Medicaid program pays for 68 percent of all the retail prescriptions for buprenorphine, more than any other state in the nation.
Governor Peter Shumlin, who chose not to run for a fourth term this year, has been determined to end the state’s opioid crisis and is proposing to limit the number of painkilling pills a physician can prescribe for a patient. The issue of setting prescription rules was passed on to the governor and the Vermont State Department when legislators approved an omnibus bill designed to curb the opioid crisis.
“Limits would be based”, says the governor, “on severity and duration of pain, the complication of the procedure, and the particular medication prescribed.” He contends that rationing the number of pills will reduce the incidence of addiction, “We didn’t have a heroin crisis in America before OxyContin was approved and started being handed out like candy.”
According to the state’s health commissioner, Harry Chen, M.D., the proposal would cap prescriptions for some minor procedures at between nine and twelve pills. The plan, he explained would impose consistency on opioid prescription. “There is a clear pattern of over-prescribing,” he said, and “tremendous disparity between different doctors on how many painkillers are prescribed for the same surgery.”
Critics of the plan warn that limiting access to legal pain medication was most likely to drive patients to seek illicit drugs. It should also be recalled that over-prescription of pain medication in the recent past was not due entirely to aggressive marketing. It reflected as well the under-treatment of pain that preceded today’s concern about patient satisfaction.
Adderall: Not Just for Kids
After last month’s report on A.D.H.D., Casey Schwartz’s article, “Generation Adderall,” appeared in the Sunday Times Magazine.
Casey wasn’t an A.D.H.D. adolescent. She came to Adderall on her own as a young adult, a sophomore student at Brown University. It was when she was stuck for a five-page report due the next day on a book she’d only just begun to read that Casey took two Adderall pills from a friend. She spent the rest of the night, she recalls, “in a state of peerless ecstasy. The world fell away; it was only me, locked in a passionate embrace with the book I was reading and the thoughts I was having about it, which tumbled out of nowhere and built into what seemed an amazing pile of riches.”
She was hooked. It was an experience she was going to have and seek to have repeatedly over the years that followed. Casey was not unique. As she points out, adults made up the fastest growing group of Adderall users in the mid-2000s. And, once she realized she needn’t buy overpriced pills from A.D.H.D. kids, and conned her own prescription from an easily hoodwinked psychiatrist, she had access to pills for life.
Does Adderall actually enhance cognitive performance? Is it, as Casey asks “a smart drug?” She calls the evidence “more than a little ambiguous.”
In time, she came to realize, she writes, that “I lived in a paradox, believing that the drug was indispensible to my very survival while also knowing that it was nothing short of toxic, poisonous to art, love, and life.” Periodically, she tried to get off Adderall and eventually succeeded. But she found the drug infinitely more difficult to relinquish than various experts assured her it was supposed to be. She also found evidence in the message boards of websites devoted to giving up the drug that she was far from alone in her struggles to quit.
The Rosenthal Report - October 2016
The Good News
The good news isn't all that good. The initial report from SAMHSA (Substance Abuse and Mental Health Services Administration) on findings of the National Survey of Drug Use and Health for 2015 shows a sharp decline in adolescent use of cigarettes and alcohol. Teen cigarette use has fallen by more than two-thirds since 2002 and alcohol use by nearly half. But at 7.0 percent, current (past month) use of marijuana by adolescents has remained at much the same level over the past decade.
A slight dip in teen use from the previous year and a significant decline from a peak in 2009, along with recent levels of adolescent heroin use, encourage agency officials to describe the current data as offering, "hope that marijuana and heroin use may be slowing down." What has clearly slowed down is the prevalence of adolescents with marijuana use disorders—either dependence on the drug or abuse of it—for the survey found this number falling from 4.3 percent of adolescents to 2.6 percent since 2002.
The Bad News
That's the increase in adult use. For young adults (18 to 25), the level of current (past month) use—now stands at just under 20 percent (19.8)—and has been creeping up from l6.6 percent since 2008. The level of current use for older adults increased by more than half again as much during the same seven-year period from 4.2 percent to 6.5 percent. Should the increase in adult use concern us? You bet it should. Recent articles and editorials in the American Journal of Psychiatry point to the increase in adult use, with low levels of risk awareness, increased incidence and severity of cannabis use disorder, higher risk of death and psychosis (including schizophrenia), and a troubling low rate of treatment.
Our friends at Smart Approaches to Marijuana (SAM) flagged a new study by Quest Diagnostics, a major drug testing firm that found the rate of workers testing positive for marijuana has increased by 47 percent since 2011. This increase over the past three years followed a long period of declining drug use in the workplace and is clearly a reflection not simply of legalization and the quasi-legalization of medicalized marijuana, but also of what the author of a Journal of Psychiatry article calls "the increasingly accepting social attitudes toward marijuana use."
The Scary News
Psychiatrists are well aware that a connection exists between adolescent marijuana use and psychosis. The article “Concurrent and Sustained Cumulative Effects of Adolescent Marijuana Use on Subclinical Psychotic Symptoms” in the recent American Journal of Psychiatry nailed down some of the specific in a five-year study of more than a thousand teen-age boys.
Researchers at the University of Pittsburgh and Arizona State found that for each year the boys smoked marijuana 52 or more times they increased the risk of persistent subclinical psychotic symptoms by 21 percent. For each year of weekly use the chance of experiencing paranoia rose 133 percent and experiencing hallucinations rose 92 percent. All in all, the study should put "paid" to the notion that pot is pretty harmless stuff.
Risk Raising Synthetics
Complicating the already complex opioid overdose epidemic is the increasing use of powerful synthetic narcotics to boost the potency of heroin. From New England to California, authorities are finding growing numbers of overdose victims dosing themselves with heroin cut with fentanyl, a fast acting, short lasting synthetic painkiller widely used in medicine and 100 times stronger than morphine. In Ohio, the number of fentanyl overdose cases rose from 84 in 2013 to close to 1,500 in 2015.
Recently, carfentanil, a brawny cousin of fentanyl, showed around Cincinnati and in southern Indiana along the Kentucky border. A synthetic opioid used by veterinarians to sedate large animals (including elephants), carfentanil has 10,000 times the strength of morphine. During just one week this past August, it was responsible for close to 200 overdose cases and at least four deaths in the Cincinnati area. The DEA has issued a nationwide warning about carfentanil and NIDA has alerted authorities in both Ohio and Florida.
The danger low-cost, high-powered synthetics pose isn’t only increasing the overdose potential of drugs sold as heroin. They also are being used in counterfeit painkilling pills. The death of singer, songwriter, and musical icon Prince was caused by fentanyl in a counterfeit pill labeled Watson 36 that allegedly contained only hydrocodone and acetaminophen.
Our Medicated Kids
Pioneers in the study of attention deficit hyperactivity disorder (A.D.H.D.) have long decried the growing number of children now being diagnosed with A.D.H.D. That number grew from six hundred thousand in 1990 to six million by 2014. It is still growing, although there are no laboratory tests to confirm the diagnosis, which is based on subjective evaluation and screening for symptoms of inattention, hyperactivity, and impulsive behavior. Medication has become the standard response, and the great majority of the diagnosed are prescribed Ritalin, Adderall, or similar stimulants.
Fewer than one in three receives the behavior therapy that should accompany medication. And only half the diagnosed preschoolers receive the behavior therapy recommended as the first line of treatment by the American Academy of Pediatrics.
Now, New York Times reporter Alan Schwarz tells how all this came about, blowing the whistle on what he describes as one of the world’s most aggressive marketing campaigns. His book ADHD Nation tells how an alliance of drug companies, academic psychiatrists, policy makers, and celebrity pitchmen (what he calls “the A.D.H.D. industrial complex”) has sold the nation and the world, not on drugs, but—in the guise of awareness—on A.D.H.D. itself.
“Attention deficit hyperactivity is real,” says Schwarz, who opens his book with that sentence. But disorders of attention, once thought to be relatively rare (affecting only about three percent of preadolescents) have come to be routinely diagnosed, affecting more than 14 percent of American boys. And who is it that is diagnosed? In the classroom it’s most often the youngest children in a class. In the pediatrician’s office it’s likely to be allegedly under-achieving children of parents who believe the right pills will turn them into academic champions. Moreover, the drugs are now being prescribed for two-and-three year olds, which one pediatric critic of practice calls no more than “a quick fix for an unruly child.”
O.D. Fatalities as a Campaign Issue
Under the headline “Why It Matters: Issues at Stake in the Election,” the Associated Press recently listed and briefly described 17 pressing issues facing the nation, putting Iran first on the list and free trade agreements last. In thirteenth place was the article’s capsule summary of the “Opioid Epidemic,” leading with a single sentence citing the nation’s 28,000 opioid overdose deaths in 2014. The cause, according to AP, was the quadrupling of prescription painkiller sales since the start of the millennium. What is needed now are more dollars for “prevention, treatment and recovery services.”
Although the addiction epidemic was prominently featured in the Republican’s early and overcrowded nomination debates, it hasn’t surfaced much since the party conventions and wasn’t mentioned by either candidate in the first of the presidential debates. Summarizing where the candidates stand on the issue, AP cited Donald Trump’s wall along our southern border, which he contends is essential to stopping the flow of illegal drugs into the country, and Hillary Clinton’s pledge to spend ten billion dollars on addiction services.
The Rosenthal Report - September 2016
A Proper Place for Pot
When the Drug Enforcement Administration (D.E.A.) turned down petitions to drop marijuana from the Schedule 1 of the Controlled Substances Act last month, there were cries of anguish and outrage from the pro-pot crowd, plus a plea from The New York Times to “Stop Treating Marijuana Like Heroin.” But this was no hard-hearted rejection of the current reality—widespread decriminalization and quasi-legalization by prescription, plus actual legalization in two states (with upcoming votes in five more come November). It was simple recognition that, no matter how prevalent the acceptance of toking becomes, pot is still a mind altering substance and, as such, falls under the Controlled Substance Act.
So, legislators clamoring for a category change are stuck with the strictures of the Act’s “eight factor analysis.” It’s not the degree of “actual or potential abuse” that keeps pot in the top category. It’s the lack of any “approved medical use.” That's what's required of drugs in the lower categories.
Although a downgrade of marijuana to a lower category is not in the cards, the D.E.A.—in an even-handed action by the Obama administration—opened wide the doors to marijuana research, allowing universities and even private companies to secure agency approval to grow their own pot for research purposes. Only the University of Mississippi now enjoys this privilege.
Marijuana’s current clinical credentials, however, are not too impressive. Despite a plethora of anecdotal reports and reputable work on the drug’s ability to alleviate nausea, improve appetite, and ease painful spasms, there is little in the way of hard scientific data to support prescription of smokable marijuana for all the many maladies now being treated with pot in the medical marijuana states. Serious research on components of marijuana, however, is now under way, and the new regulations should accelerate this process. The Food and Drug Administration has already approved two drugs—Marinol and Casamet that contain synthetic versions of a substance found in marijuana. Both are prescribed for the nausea and vomiting of cancer patients and Marinol is given to aid the appetite of AIDS patients.
It’s true that marijuana is no heroin, but it’s no benign indulgence either. While most—but far from all—adult users appear to avoid serious consequence, the same is not true of kids. Adolescents are twice as likely as adults to become addicted to marijuana (and, yes, pot is addictive). More significantly marijuana impairs perception and judgment, shrinks attention span and compromises the ability to learn, all of which impedes the maturation and socialization that should be occurring throughout the adolescent years.
The most recent and disturbing discoveries about marijuana have found heavy use in adolescence resulting in lasting changes to “working memory,” altering brain structures critical to memory and reasoning, impeding problem solving and the retention of information needed for everyday tasks.
What I find particularly troubling, if predictable, is how casually many parents now regard marijuana use. Our recent survey of public perceptions of drug abuse found that more parents would rather see their children smoking pot than smoking cigarettes.
Today, it is legalization that gets the headlines, but the real issue is society’s increasing acceptance of marijuana use and the burden this places on families. Parents now, more than ever, need be aware of just how dangerous and damaging marijuana can be for their kids and must deal with the threat without the level of support from law, society, and the community that they once enjoyed.
Take the Pledge & Turn the Tide
That’s the message that Vivek H. Murthy, M.D., the U.S. Surgeon General, sent to 2.4 million physicians and other health care professionals at the end of August, urging them to go online to the Turn the Tide website, sign up, and commit themselves to the campaign’s three-point program:
There’s no doubting the impact of the opioid addiction epidemic that has been growing since the start of the current millennium. Between 1999 and 2014, as prescription of opioid medications (such as Percocet, Vicodin, and OxyContin) quadrupled, more than 165,000 Americans died from opioid-related overdoses. And today, more and more addicted men and women who can no longer secure the drugs they crave by prescription are turning to the more accessible and less costly option of heroin.
The surgeon general is hardly the first to sound the alarm. By 2008 more Americans were dying from drug overdose than from motor vehicle accidents. The Center for Disease Control designated the spread of addiction as “epidemic” in 2010 and issued guidelines for a far more restrained approach to the prescription of opioids this past March. (The surgeon general’s letter includes a pocket card copy of the CDC guidelines). It was also in 2010 that my colleague Andrew Kolodny, M.D. and his Physicians for Responsible Opioid Prescribing organization began advocating for restraint and controls in the use of opioids.
Although I don’t argue with the need to respond aggressively to the addiction epidemic and to address the over-prescription of potent painkillers, I am concerned about over-responding. After all, much of the problem we face today came about because of over-responding to the under-treatment of pain. It was not only aggressive marketing of prescription opioids that led to over-prescription. It was also a newfound concern about patient satisfaction in the 1980s. That’s, when patient pain came to matter, as patients were recognized as “health care consumers,” physicians as “providers,” and the federal government started keeping track of patient satisfaction. When I turned to the Turn the Tide website I was struck by one of the factoids that crossed the screen in the site’s numerical display. It read: “As many as 1 in 4 receiving long-term opioid therapy (in primary care settings) struggle with opioid addiction.”
What, I wondered, about the other three? What, for that matter, about all the patients with chronic pain whose caregivers will now feel pressure to follow the CDC guidelines that encourage such alternatives to opioids as exercise, cognitive behavioral therapy or the use of aspirin, ibuprofen and other anti-inflammatory medications. (Other sources also recommend acupuncture and meditation). When opioids are to be used, the rule is go slow and low—low dosage, and a strictly limited number of pills—only immediate release pills too, not the extended release, long-acting kind. Will this reduce the incidence of addiction and overdose? It certainly should, but I suspect there’ll be a world of hurt that goes untreated as well.
There is a wry twist to one aspect of Surgeon General’s pledge. It’s the requirement of those who sign up to connect patients with opioid use disorders with evidence based treatment. Since the overwhelming majority of new treatment capacity authorized by Congress (but yet to be funded) is specifically for medically assisted treatment (MAT), we can be fairly certain that these patients will have ready access to buprenorphine, suboxone and similar semi-synthetic opioid derivatives.
When the Enemy is Us
Yes, former drug users are stigmatized. That’s true. It is also true that stigma flourishes, in part, because of efforts by the very folks who protest most ardently against it. Whether or not it inhibits addicts from seeking treatment, stigma has profound and negative effects on the lives of men and women in recovery. A recent survey of public perceptions of addiction and drug abuse conducted by Schoen Consulting for the Rosenthal Center, found that three quarters of Americans find social drinkers trustworthy enough to hire, while barely half consider recovering addicts that trustworthy. When it comes to approving a potential husband or wife for their children, our survey respondents put the totally abstinent at the top of their list, with social drinkers close behind. Barely 30 percent would bless the union of their son or daughter to an addict in recovery.
What the survey also revealed was widespread misunderstanding of addiction. Seventy percent of respondents agreed that addiction was a disease, 67 percent that it was a chronic condition, and slightly more than half that relapse was a built-in aspect of the disorder. They split almost evenly over whether or not addicts were powerless to resist their addiction (with a slight edge on the pro-powerless side). Nevertheless three out of four maintained that this chronic relapsing condition is curable.
As for stigma, close to two-thirds of Americans hold it to be a useful social tool, and stigmatization they agree might well reduce the use of marijuana, as it has the use of cigarettes. A key finding about stigma, however, is the belief by better than two thirds of respondents that defining relapse as integral to addiction contributes to stigmatizing people in recovery. There is a lesson in this for those vested most firmly in the “chronic relapsing” disease model. Rather than bowdlerizing the language of addiction (banning the use of “addicts,” “abuse,” or “abusers”) what is more likely to destigmatize recovery is ceasing to insist that addiction is incurable, and indeed the evidence is mounting that, for most (if not all) addicts, this is not necessarily true.
The Rosenthal Report - August 2016
What Congress Didn’t Do
Before it broke camp for its seven-week summer recess, Congress passed legislation to address the nation’s epidemic of opioid addiction. With more than 28,600 overdose deaths in 2014, an army of addicts uncovered or insufficiently covered by health care insurance, and a health system that lacks adequate capacity to meet today’s substance abuse treatment needs, President Obama had pressed Congress to provide $1.1 billion in new money, most of which would go to the states to support medically-assisted treatment (MAT) of opioid addiction.
After painful compromises had been worked out in both houses and the conference committee, the measure was passed and sent to the President. It authorizes the federal government to make grants to the states for addiction treatment and prevention programs, but fails to appropriate the funds for them. Although there was strong pressure—and clearly need—for an immediate appropriation, the summer recess began without it. House Republicans say they will appropriate $581 million (far less than the $1.1 billion requested by the administration) when they return to Washington, but there is no guarantee that this promise will survive the haggling over appropriations that comes as the government’s fiscal year winds down at the end of September.
What Congress and HHS Did Do
As part of the addiction treatment measure, Congress has made it possible for physician assistants and nurse practitioners to prescribe buprenorphine for patients in opioid treatment programs (OTPs). In a more significant move, the Department of Health and Human Services (HHS) increased the number of patients for whom authorized physicians (and now their surrogates) can prescribe buprenorphine step-down medications (such as Suboxone) from 100 patients to 275.
Threatened to be lost in the shuffle is the federal requirement that opioid treatment programs offering medically assisted treatment (MAT) provide “a range of services to reduce, eliminate, or prevent the use of illicit drugs, potential criminal activity and/or the spread of infectious disease.”
Bear in mind that the key word in medically assisted treatment is “assisted.” Medication itself is not treatment. SAMHSA (Substance Abuse and Mental Health Services Administration) defines medically assisted treatment as “the use of medications, in combination with counseling and behavioral therapies to provide a ‘whole patient approach’ to substance use disorders.” HHS requires physicians seeking to increase their patient limit to “attest” that they will “adhere to evidence-based treatment guidelines.”
It is not likely, however, that much in the way of behavioral healthcare services will be available at the “Suboxone clinics” now proliferating in states hit hard by the opioid abuse epidemic. And the prescription of buprenorphine’s step-down (and addictive) medications to an expanding list of patients troubles a good many health officials there. As the medical director of Tennessee’s Department of Mental Health and Substance Abuse Services warns, “I think the focus has been so much on expanding treatment and getting treatment out to people, that they really haven’t focused on some of the unintended consequences.”
High Risk Munchies
Pot is all too often good for a giggle, but news about marijuana edibles from the National Poison Data System is anything but humorous. Reporting on “single substance exposure calls” for marijuana cookies, candies and the like between January 2013 and December 2015, the poison service found 430 calls nationally with more than half from the two states that have legalized recreational marijuana use. There were 166 calls from Colorado and 96 from Washington, with the number of calls increasing over the course of the study. The age group found most at risk were children under five, who were the subjects of 109 calls. Lethargy, rapid heartbeat, and agitation were the most common symptoms. Three exposed patients (including a four-year-old) had to be intubated, half were hospital treated and released, and three admitted to a critical care unit. Our friends at NFIA (National Families in Action) and SAM (Smart Approaches to Marijuana) alerted us to the Poison Center’s report and also to news about Défoncé Chocolatier’s high end marijuana chocolates (see below).
High Test Bonbons
The high style, high powered inaugural bar of Défoncé chocolate comes in 18 pyramid-shaped detachable segments and 180 milligrams of THC. With concentrated cannabis extract alleged to spread evenly throughout the bar, each pyramid section should deliver a ten-milligram hit of THC, believed to be roughly equivalent to several good pipe puffs. Défoncé (it’s French for “stoned”) is the creation of a former production manager at Apple set on delivering a fashionable product with predictable high-making capacity. Available now in California dispensaries, the Défoncé bar comes in such flavors as coffee, vanilla bean, dark, mint, and hazelnut. The obvious question is how hard is it for consumers to stop munching after a pot-laden pyramid or two.
The Rosenthal Report - July 2016
Drug Abuse by Any Other Name
It made headlines when Michael Botticelli, the White House drug czar blamed “terms like abuser and addict” for discouraging people with drug use disorders from seeking treatment. The head of the Office of National Drug Control policy was hardly setting a trend. The words “abuse” and “abuser” no longer appear in publications and communications of the Substance Abuse and Mental Health Administration and “abuse” has been replaced by “substance use disorder” in psychiatry’s latest Diagnostic and Statistical Manual of Mental Disorders. Government and the treatment field in general seem bent on expunging language they see as contributing to the stigmatization of addiction, and they would rename the National Institute on Drug Abuse if this didn’t require action by Congress.
Stigma, it seems, has a bad name. It has—to make perhaps too fine a point—been stigmatized and unfairly so, for stigma has served for centuries as one of the most useful of social mechanisms. It is the most civil means of sanctioning behavior that threatens the community, violates community mores or norms, or is simply unattractive. This is not at all a bad thing when you consider the alternative. Without informal social controls communities turn to power to modify behavior they find sufficiently frightening, repugnant, or aberrant. We call the cops to curb the negative behaviors we cannot shame. We criminalize it, as we did with substance misuse.
Now that we are in the process of decriminalizing drug use it is no time to abandon stigma as well. If stigma is cool enough to use against smokers, why decide it’s too cruel to turn on heroin addicts? Shame works, argues psychiatrist Sally Satel in an article that answers positively the question “Can Shame Be Useful?” Although repeated drug use may indeed alter the brain, especially the regions that mediate self-control, “A vast literature,” she points out, “shows that addiction is an activity that can be altered by its foreseeable consequences.” As for the notion that drugs hold captive (or highjack) the drug user’s brain, see below.
Doubting the Disease Model
A slowly growing wave of dissent appears to be challenging the conviction put forth in the New England Journal of Medicine at the start of the year by Nora Volkow, the head of NIDA, and her co-authors. Their article celebrated increasing acceptance of addiction as “a chronic relapsing brain disease” and resulting neurobiological advances due to acceptance of the brain disease model.
In June, the neuroscientist Marc Lewis challenged the disease model in The Guardian. If addiction is a disease, he wrote, “We might wonder how the disease of addiction could be overcome as a result of willpower, changing perspective, changing environments, or emotional growth. There is evidence that each of these factors can be crucial in beating addiction, yet none of them is likely to work on cancer, pneumonia, diabetes, or malaria.” Further, Lewis reasons, “Once they recover, as most addicts eventually do, it is confusing and debilitating to be told they are chronically ill.”
Before the month ended, writer Maia Szalavitz put forth her own case in the Sunday Times that “addiction is neither a sin nor a progressive disease.” It is, she contends, a learning disorder. Addiction, she allows, “skews choice—but doesn’t completely eliminate free will.”
Moreover, belief in the disease model is nowhere near as widespread as the Volkow article suggests. A recent survey of public perceptions of drugs, drug use, and addiction, commissioned by the Rosenthal Center and conducted by the Schoen Consulting group, found three out of four Americans reject the notion that addiction is incurable. As for the hard held conviction of most brain scientists that addicts are powerless before their addiction, only 16 percent of the population strongly agrees and 44 percent flatly reject it.
Making Overdoses Safer—Not Necessarily Fewer
It could hardly have been any cuter. Adorable nine-year-old Audrey Stepp was practicing injecting her stuffed lamb with naloxone. The scene was shown on an ABC “20/20” broadcast interview with Audrey and her mother and was picked up by other evening news broadcasts. It wasn’t make-believe. Audrey was practicing how to inject her older brother Sammy who has struggled with heroin addiction for the past six years.
Naloxone is now available, without a prescription, (in nasal spray and hand-held automatic injector) at most pharmacies across the country. NIDA has just created a web section providing “how to” information about the overdose reversal medication for families like Audrey’s. According to the Institute, Naloxone is now “a front line tool used by first responders in preventing opioid overdose deaths”—a laudable goal, when overdose killed some 18 thousand users of opioid painkillers and more than 10 thousand heroin users in 2014.
But what then? What follows? As U.S. News & World Report reported on June 6th, a recent study of prescriptions filled for overdose patients during the thirty days following their hospital release found only 16.7 percent filled prescriptions for addiction treatment medication, and 22.4 percent got opioid painkillers.
While we clearly need to reduce the horrendous incidence of opioid overdose deaths, let’s not mistake a decline in fatalities as a victory over our society’s epidemic of drug misuse.
The Rosenthal Report - June 2016
Good News and Bad
Good news for kids comes from the Journal of Clinical Child & Adolescent Psychology, reporting research findings that show children with attention-deficit problems improve faster when they first receive behavioral treatment (i.e. talk therapy) rather than the current standard practice of starting with prescription stimulants such as Adderall or Ritalin (which more than four million children and adolescents now receive). The bad news comes from Washington where $920 million of the $1.1 billion President Obama wants to fight the nation’s opioid addiction epidemic is earmarked specifically for medication-assisted treatment. Resorting to drugs (methadone, buprenorphine, LAAM, and naltrexone)—not as aids to treatment but more often as treatment itself and subsequent maintenance—means that we will create an ever-growing population of permanently addicted men and women.
More News Good and Bad
Here the good news comes from the DEA crediting tighter control of hydrocodone prescriptions for reducing the prescription rate for this highly addictive opioid painkiller by 26.3% and reducing the number of pills consumed by roughly one billion. The bad news however, is the simultaneous rise in overdose deaths reported in just about every one of the nation’s counties as former oxycodone addicts turned to heroin. Looking ahead, it is not unreasonable to expect the CDC’s “Start Low and Go Slow” guidelines, recommending nonopioid alternatives for chronic pain to be accompanied by similar boosts in heroin consumption and overdose deaths.
Keeping Pot at Arm’s Length—Not Quite
Marijuana may be legal in Colorado, but not within 1,000 feet of a school. That’s the law. But it’s not the practice. Reporters for the Denver Post have found 25 marijuana shops operating well within the thousand-foot exclusion zone.
Heroin Injection Sites: Good Intentions Often Go Awry
What should thoughtful policy makers make of proposals to open legally sanctioned heroin injection sites in San Francisco, New York City, and Ithaca? While the sites can provide access to treatment, direct evidence of harm reduction is scant. Studies of legal injection sites in Vancouver, Sydney, and throughout Europe have found no significant reductions in HIV or hepatitis infection or the sharing of syringes. More significantly, the evaluations found no solid evidence of overdoses being averted. As Toronto, Ottawa, and Montreal, plan to follow Vancouver’s example with programs of their own, one journalist for the Toronto Star reported on the program in Oslo, Europe’s overdose capital with the continent’s highest overdose death rate. In Oslo, he writes, “the existence of safe injection sites has neither discouraged users to take it off the streets nor significantly persuaded users to avail themselves of rehabilitation.’ Ten years after the Oslo program began, the overall mortality rate is just where it was a decade ago. “Good intentions,” he writes, “can lead to bad consequences. One need look no further than the Slab, an area leading from the Oslo train station directly to the city’s main street. Emaciated addicts gather in the area every day, every night, slumping against the walls of derelict warehouses around the docks, openly injecting heroin, knowing police won't move in unless it becomes necessary to quell a significant public disturbance.”