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The Rosenthal Report - November 2017

Rosenthal Reports

The Government Mobilizes to Fight the Opioid Epidemic

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

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

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

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

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

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

3rd November 2017
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The Rosenthal Report - October 2017

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

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

 Mapping technology helps pinpoint gaps in addiction treatment

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

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

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

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

Opioid makers face barrage of legal actions

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

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

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

 

 

 

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

Rosenthal Reports

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

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

20th September 2017
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The Rosenthal Report - September 2017

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

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

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

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

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

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

What we need to do: 

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

5th September 2017
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The Rosenthal Report - August 2017

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

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

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

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

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

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

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

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

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

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

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

3rd August 2017
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The Rosenthal Report - July 2017

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

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

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

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

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

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

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

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

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

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

6th July 2017
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The Rosenthal Report - June 2017

Rosenthal Reports

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

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

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

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

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

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

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

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

The States Take Action: Kentucky

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

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

 

COMMENTARY

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

6th June 2017
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The Rosenthal Report - May 2017

Rosenthal Reports

MAINSTREAMING MARIJUANA

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

 

CANADA OPTS FOR POT LEGALIZATION

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

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

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

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

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

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

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

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

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

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

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

Commentary  

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

 

TRADING PLACES: POT OR PAINKILLERS?

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

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

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

 

THE STATES TAKE ACTION: VERMONT AND NEW HAMPSHIRE

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

Vermont

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

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

New Hampshire

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

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

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

Commentary

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

4th May 2017
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The Rosenthal Report - April 2017

Rosenthal Reports

CONFRONTING THE OPIOID EPIDEMIC

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

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

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

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

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

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

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

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

 

First of a series: The States Take Action

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

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

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

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

 

COMMENTARY

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

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

A CLOSER LOOK: The Risks and Rewards of Opioid Rationing 

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

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

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

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

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

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

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

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

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

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

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

4th April 2017
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The Rosenthal Report - March 2017

Rosenthal Reports


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.

Marijuana Update

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.    

3rd March 2017
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Republican healthcare proposal to replace Obamacare could threaten Medicaid-related mental health and substance abuse treatment programs!

Rosenthal Reports

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!

1st March 2017
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The Rosenthal Report - February 2017

Rosenthal Reports

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.
 

RP chart feb 17.png


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.

RP Chart feb 17 2.png
 
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.”

Marijuana Update


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. 

2nd February 2017
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The Rosenthal Report - January 2017

Rosenthal Reports

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.”

Addicted Babies

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.” 


Traumatized Children

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. 
 


Marijuana Update
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.

18th January 2017
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