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The Rosenthal Report - September 2018

Rosenthal Reports

In the September issue of the Rosenthal Report, we examine data confirming 2017 as the worst year yet for the opioid epidemic, explore the looming legal showdown over safe injection sites, and urge caution as the legalization and commercialization of marijuana accelerates.

Drug overdose deaths at record high

Latest data from the Centers for Disease Control confirm forecasts that 2017 would be the worst year yet for the opioid epidemic. According to nearly complete reporting from the states, more than 72,000 Americans died from drug overdose, an increase of 9.5 percent from 2016, and the highest death toll ever recorded. About two-thirds of those deaths are linked to opiods, especially the powerful synthetic opioid fentanyl that the CDC says is replacing less potent heroin and prescription opioid pills as the biggest killer.  

Overdose deaths rose sharply in some states already hit hard by the epidemic: 27 percent in New Jersey and 17 percent in Ohio as well as Indiana and West Virginia. But several states that introduced comprehensive public health campaigns and increased access to addiction treatment saw overdose deaths fall: 7.1 percent in Rhode Island, 5.8 percent in Vermont, and 1.1 percent in Massachusetts.

The epidemic continues to spread almost one year after President Trump declared a national health emergency - and then told Congress to figure out the details. While the House has passed dozens of bills, the Senate might not wrap up its version until the end of the year. In any event, there’s nothing in the legislation that would fundamentally change the current approach to treating addiction or allocate the massive funding needed to address a crisis that kills nearly 200 people a day. As some states have shown, there are effective strategies to bring this epidemic under control, but these would require leadership on a national level that is sorely lacking.

Safe injection sites v. the Department of Justice

A showdown is looming between cities that want to open safe injection sites for drug addicts and the Department of Justice, which says such facilities are not only illegal but also fail to curb drug use and drug-related crime. Currently, San Francisco is edging closer to opening what would be the nation’s first safe site, where substance abusers can shoot up under supervised conditions and obtain information about drug treatment. The mayors of New York, Philadelphia and Seattle are also planning safe sites, and remain defiant in the face of DOJ opposition. In August, Deputy Attorney General Rod Rosenstein published an op ed article in the New York Times warning he would take “swift and aggressive action” action against safe sites. As the rhetoric heats up, the Rosenthal Center proposes an alternative to the safe site concept: treatment transition centers that, rather than facilitating surrender to drugs, encourages addicts to enter life-changing treatment (see August Rosenthal Report.)

Mixed messages about marijuana

Cannabis-infused edibles are on the menu at many restaurants and pot-laced body wraps can be found at spas. The drug is touted on Wall Street as an investment opportunity, while Big Tobacco and Big Booze eye stakes in pot production. But as legalization and commercialization of the drug continues, there are also warnings about pot’s potential danger. A recent study found that low levels of THC, the psychoactive component of marijuana, linger in breast milk for up to six days after nursing mothers use the drug. In Colorado, drivers in fatal crashes increasingly test positive for marijuana. And a growing number of Americans report near-constant cannabis use, writes Annie Lowrey in her Atlantic column, “America’s Invisible Pot Addicts.” As a result, cannabis-use disorder is becoming far more common than many realize, Lowrey says, due in part to easier access and stronger pot.

With marijuana marketed as a lifestyle product and panacea for many ills, including depression and opioid addiction, we agree with Lowrey’s call for “reintroducing reasonable skepticism” into the national conversation. Caution is critical as commercial interests attempt to drive the legalization and regulatory debate.

6th September 2018
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The Rosenthal Report - August 2018

Rosenthal Reports

In the August issue of the Rosenthal Report, we look at renewed debate over safe injection sites for heroin and other opioid users and propose an experimental model for facilities that would provide a clear route into treatment rather than assistance for safe injection.

The Rosenthal Center proposes research to evaluate whether injection facilities can be designed to provide the essential bridge to treatment. Our model, Transition Treatment Centers, would include staffing by medical personnel and peer-based counselors, and be affiliated with a treatment network. They would offer a range of services, including medications and special assistance for safe injection. But most importantly, the Centers would provide an introduction to treatment on site, require participation by facility users, and limit the use of program facilities to no more than 60 days, in anticipation of a seamless passage to longer-term care by then. There are no easy solutions to the growing opioid epidemic. But sites that facilitate entry into life changing drug treatment - and not a surrender to a life of drug use – might prove to be a useful element of a comprehensive anti-opioid strategy.

Drug overdose deaths continue to climb in many U.S. cities, prompting politicians and policymakers in New York, Seattle, Philadelphia, San Francisco and elsewhere to advocate for the nation’s first safe injection sites. While many cities currently have needle exchange programs, where users receive a clean syringe, safe injection sites would allow addicts to shoot up under the supervision of health-care workers. Staff would not provide illegal drugs, but would administer overdose reversal medication and provide counseling and information about drug treatment options and programs.

Some 100 safe injection sites exist in Europe, Australia and Canada, but such facilities face legal and policy challenges in the U.S. Technically, they are illegal under federal law and there is ongoing controversy over their effectiveness. Supporters say supervised sites can prevent overdose deaths, reduce the transmission of HIV and hepatitis, and increase the number of people in treatment. But critics argue that by providing a safe space the sites encourage, rather than hinder, drug use and therefore perpetuate addiction. Moreover, they say that most addicts using the sites would be unlikely to enter treatment programs voluntarily.

In New York City, the plan recently unveiled by Mayor Bill de Blasio envisions four sites, called Overdose Prevention Centers, as pilot projects run by nonprofit groups and staffed by social workers and other trained professionals to administer medications and counsel addicts on treatment. Community outreach would precede the launch, encouraging public support for safe injections sites, which are generally opposed by their neighbors. A nationwide study in the June issue of Preventive Medicine found that among those surveyed only 29 percent supported legalized injection sites in their communities.

Some preliminary studies suggest that safe injections sites can reduce overdose deaths and increase the number of addicts in treatment. A report submitted by the New York City Health department with the mayor’s proposal estimated the four planned sites might prevent up to 130 overdose deaths a year (New York City had a record 1,441 last year). But more definitive, long-term studies are lacking, especially in the unique U.S. urban settings where sites are now being considered.

News briefs cover speculation about a possible Congressional slowdown on opioid legislation and an all too rosy view of pot.

 PLAYING POLITICS WHILE PEOPLE ARE DYING  

With nearly 200 Americans dying every day from drug overdose, bi-partisan legislation to combat the opioid epidemic should be winging its way through Congress. But so far only the House has passed bills; the Senate is dragging its feet. The Washington Post speculates that the purported Republican-led slowdown might be due to election year politics. Approving legislation before the upcoming midterm elections would play well for vulnerable incumbent Democratic senators in states hit hardest by the drug crisis, including West Virginia, Indiana and Missouri. While the initiatives and funding in the proposed bills don’t go far enough to fight the epidemic, politics should not stand in the way of providing more help to those suffering and dying from substance abuse.

MEMO TO AMERICANS: POT IS NOT A PANACEA

Americans have a much rosier view of marijuana than is backed up by science, according to a survey of more than 16,000 adults by the University of California, San Francisco. The study found that 36.9 percent of respondents believe that edible pot could prevent health problems, and 27.6 percent thought that driving under the influence of marijuana was safer than driving while drunk. The lead author of the study told Reuters that these relatively benign views of weed could be attributed to marijuana legalization – conflating legality and safety – as well as pot not being linked to the overdose deaths of the opioid epidemic.

1st August 2018
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The Rosenthal Report - July 2018

Rosenthal Reports

In the July issue of the Rosenthal Report, we examine new data showing an apparent increase in drug overdose deaths in 2017 as the opioid epidemic continues to spread across country, and outline the essential components of a nationwide strategy to tackle the crisis. In news briefs, marijuana legalization rolls on and Big Tobacco bets on Big Pot.

2017 might become the deadliest year yet of the national opioid epidemic.

Provisional data from the Centers for Disease Control through the 12-month period ending November 30, 2017 indicate that about 200 Americans are dying every day from drug overdose, up from roughly 175 per day in 2016. If the trend continues through the end of the year, the finalized figures would bring last year’s annual death toll to nearly 73,000, the CDC predicts, an increase of 13.2 percent over the previous year. It is a grim reminder of the epidemic’s tenacious grip on the country – as well as, hopefully, a call to action to address this crisis.

The data shows worrisome trends in some states. Overdose deaths spiked 36 percent in Nebraska, which had previously reported a low rate, while New Jersey, a state that has implemented a robust anti-opioid strategy under former governor Chris Christie, saw an increase of 36.8 percent.  The death rate rose 27 percent in Indiana and in Pennsylvania (there were declines in Utah and Montana, at 15.1 percent and 7.2 percent, respectively.)

As noted by the Rosenthal Report, a number of cities and states have introduced innovative initiatives to confront the crisis, such as Rhode Island’s prison treatment program. But we’re failing on the national level. President Trump declared a national public health emergency last October. His opioid commission issued a report with nearly 60 policy recommendations. Then the president left details to be worked out by Congress. Last month, the House debated more than 50 bills and eventually consolidated and approved bipartisan legislation that includes dozens of proposals. This measure now goes to the Senate.

Unfortunately, the House bill is a grab bag of narrowly tailored items that, on their own, fall short of the full bore initiative we desperately need. The bill calls for more research into non-addictive pain medications; permits nurse practitioners and physician assistants to prescribe addiction withdrawal medications; and provides grants to help law enforcement test for the presence of fentanyl. While there is some good policy among its many provisions, they do not constitute a coordinated nationwide strategy nor do they significantly expand access to addiction treatment.

What’s more, there’s no additional funding beyond the $6 billion already set out in the $1.3 trillion budget deal approved in March. As the Senate considers the opioid legislation, these are the issues that must be addressed:

LEADERSHIP

The federal government, perhaps through ONDCP (the office of the “drug czar”), should assume the role of national coordinator, overseeing development of state and city programs and funding across the country to ensure we are pursuing a comprehensive strategy, meeting goals and targets and exploring innovative approaches. 

TREATMENT

Because only a fraction of those suffering from addiction receive any kind of treatment, we need to expand access to a broad range of treatment services including medication-assisted treatment, (MAT), which combines medication with behavioral therapy, along with outpatient and residential programs that employ peer-based counseling and long-term residential treatment for the most vulnerable patients.  

FUNDING

Instead of the $6 billion in the budget deal for 2018 and 2019, what is needed is something closer to the proposal of Senator Warren of Massachusetts and Representative Cummings of Maryland for $100 billion over the next decade to put the country on a war footing and ensure sustained support for efforts that combat the opioid crisis, using as a model HIV/AIDS legislation that boosted money to cities, states and the hardest-hit communities.

Sadly, we lost ground in 2017. More people died from overdoses and thousands more continued to struggle with addiction, unable to receive treatment that could put them on the road to recovery. This epidemic could be effectively reversed; we know what to do. What’s missing is the leadership and commitment to a coordinated, well-funded national program focused on treatment to bring it under control.

NEWS BRIEFS
MARIJUANA LEGALIZATION ROLLS ON

Canada’s parliament approved a long-awaited bill to legalize weed, and across the border in Vermont the state legislature approved the sale of recreational pot – the ninth U.S. state to do so. Meanwhile, New York City mayor Bill de Blasio decriminalized pot smoking in public. It can be difficult, however, to get a clear picture of public sentiment as laws change and politicians shift positions. For example, a recent poll of New Yorkers by Emerson College for the organization Smart Approaches to Marijuana, found that only 22 percent and 24 percent of Latinos and African Americans, respectively, support legalization. The survey also found that 76 percent of New Yorkers do not support pot advertising and 58 percent do not want marijuana stores in their neighborhoods.  

BIG TOBACCO BETS ON BIG POT

The British-based tobacco giant Imperial Brands has taken a stake in the U.K. startup Oxford Cannabinoid Technologies to research medical uses of cannabis, the Wall Street Journal reported. Analysts described the $13.1 million investment   as “the most significant among the global tobacco players in the cannabis industry to date.” Imperial, which owns the Winston cigarette brand, said the company’s interest is limited to medical uses of marijuana.

 

 

 

9th July 2018
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The Rosenthal Report - June 2018

Rosenthal Reports

To fight the opioid epidemic, cities and states tweak the standard toolkit of addiction treatment – with promising results

 

In the June issue of the Rosenthal Report, we explore innovative approaches to the use of medication-assisted treatment in Baltimore and Virginia, as well as Rhode Island’s pioneering prison treatment program that has significantly reduced overdose deaths. In news briefs, we look at a spike in overdose deaths among black drug users in Massachusetts, and the movement to decriminalize magic mushrooms.

Medication-assisted treatment, MAT, is fast becoming the core strategy in our nationwide anti-opioid battle. It is endorsed by the Rosenthal Center as an effective addiction treatment when combined with behavioral therapy as well as with peer-based counseling and long-term residential treatment for the most vulnerable patients. In inner cities and Rust Belt towns, as well as correctional facilities, where this epidemic is so relentless and widespread, some policymakers are now implementing broad based services systems for opioid users anchored by MAT programs. 

Baltimore, for example, a city that recorded nearly 700 overdose deaths in 2016 compared to 167 in 2011, has launched a “levels of care” treatment program centered in hospital emergency rooms. Nearly all of the city’s 11 ERs now provide MAT “on demand” to addicts, in a program that includes overdose reversal drugs, drug screening, peer recovery specialists, support services and referrals to longer-term treatment. This “wrap-around” model integrates treatment into Baltimore’s existing healthcare system, and is designed to ensure that no patient “slips through the cracks,” according to Baltimore mayor Catherine E. Pugh. 

Virginia is getting more patients into MAT through Medicaid. Although the state only this week approved Medicaid expansion under the Affordable Care Act, it initiated a program in 2017 called Addiction and Recovery Treatment Services (ARTS). This provides financial incentives through Medicaid, such as higher reimbursement rates to addiction treatment providers, rewarding them for expanding services. Initial results are encouraging: in the first nine months of the program, opioid prescriptions and emergency room visits were down, and more than 16,000 Medicaid members received treatment for addiction, a two-thirds increase over the previous year.

Rhode Island’s prison program, which began in 2016, is also attracting attention. It offers a full range of MAT services – screening for all inmates, medications and peer counseling – and is the first such program for correctional facilities, which do not generally provide comprehensive treatment. Equally important, it ensures critical follow-up care so that former inmates continue to receive medications and therapy during the difficult post-release period, when addicts are most susceptible to relapse. One year into the program, the number of overdose deaths among recently released prisoners in Rhode Island plunged 61 percent.

The Rosenthal Center applauds such innovations. Tweaking the basic tenets of the MAT model to meet specific patient needs, budgets and healthcare delivery systems can substantially increase its effectiveness. Moreover, by mobilizing the national resource of persons in recovery – as these programs do – it is possible to vastly expand treatment strength and capacity. We must keep experimenting and moving forward, as there’s no one-size-fits-all solution to this deadly crisis. 

 

BRIEFS: 

Black overdose deaths in Massachusetts defy statewide decline 

Drug overdose deaths in Massachusetts fell in 2017, but not for every demographic: the death rate among whites dropped 13 percent and among Latinos 4 percent, but it surged 26 percent for blacks, a disturbing trend that mirrors a nationwide pattern in urban black populations. Researchers suspect the spike is due in part to increased use of cocaine that is laced (either intentionally or not) with the powerful synthetic opioid fentanyl. 

Magic mushrooms on the menu

Micro-dosing LSD and other hallucinogens is a thing now, receiving widespread coverage in the New York Timesand a new book by acclaimed author Michael Pollan that explores “the new science of psychedelics.” But as these drugs are still illegal, advocates in Denver are trying to mount ballot initiatives to do away with felony charges for possession of magic mushrooms, citing studies showing purported mental health – as well as spiritual - benefits. Activists are using the playbook from the fight to legalize recreational marijuana in Colorado, which means they just might succeed. 

 

 

4th June 2018
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The Rosenthal Report - May 2018

Rosenthal Reports

In this month’s Rosenthal Report, we examine a record decline in opioid prescriptions and an increase in the use of addiction medications, and explain what this means in the fight against the opioid epidemic. In news briefs: Rhode Island reduces overdose deaths among recently released prisoners; and politicians recalibrate their positions on marijuana legalization. 

Policies on Opioid Prescribing and Addiction Medications Yield Promising Results, But Must be Part of a Comprehensive Strategy

Efforts to limit the volume of opioid prescriptions and increase the use of addiction treatment medications are having an impact. According to newly released data, the volume of clinically prescribed opioids declined 10 percent in 2017. This was the steepest fall in 25 years, and included a16.1 percent reduction in high-dose prescriptions.  Meanwhile, new monthly prescriptions for three FDA-approved addiction drugs that relieve withdrawal symptoms and drug cravings - methadone, naltrexone and buprenorphine – nearly doubled to 82,000 over the past two years.

The new data illustrates the effectiveness of two critical strategies: more aggressive monitoring mechanisms and stricter clinical guidelines to limit opioid prescriptions, and expanded access to   medication-assisted treatment (MAT) programs that combine appropriate addiction medications with counseling and behavioral therapy.

These results are encouraging, but must be considered in the broader context of a deeply entrenched national epidemic. For example, the nation’s death toll from the drug crisis continues to rise. While 15 states lowered their rate of overdose fatalities, there were double-digit spikes in the other 35. This was largely due to the influx of the powerful synthetic opioid fentanyl, which is mixed with other drugs and is now the leading cause of overdose deaths, outpacing for the first time prescription opioids.

Any reduction in opioid prescriptions, which peaked in 2011, is welcome. Yet even with the latest decline opioids are still massively overprescribed. As the New York Times pointed out, the nation’s annual level of morphine prescriptions now totals 171 billion milligrams - enough for every American adult to have 52 pills. After clawing our back to 2006 prescribing levels, we must continue to reduce the availability of prescription painkillers while ensuring that those with legitimate needs for these drugs have access to their medications.

Expanding treatment and getting more addicts who need it into MAT programs is critical to slowing the epidemic. However, the latest data does not indicate how many new addiction medication prescriptions are filled for MAT patients who are not receiving concurrent therapy. This would be simply swapping one drug for another without providing support for life change. There are also significant gaps in access to addiction medications: an estimated 60 percent of rural counties do not have one doctor authorized to prescribe buprenorphine, which requires a waiver from the Drug Enforcement Agency.

We are making strides to bring the opioid crisis under control. But success depends on accelerating the pace by implementing comprehensive, coordinated, and well-funded strategies. Last month, Senator Elizabeth Warren of Massachusetts and Rep. Elijah Cummings of Maryland introduced a bill calling for $100 billion in funding over the next decade to address the opioid epidemic. Modeled on successful HIV/AIDS legislation, the bill is a major funding boost from Congress’s current $6 billion annual budget proposal. With nearly 64,000 Americans dead in 2016 from drug overdoses, $200 billion would be a more appropriate commitment.

BRIEFS:

SMALL STATE, BIG RESULTS: Rhode Island slashed the overdose mortality rate among recently released prisoners by 61 percent, according to a study in JAMA Psychiatry. Credit goes to a new program offering all inmates screening and MAT treatment while in jails and prisons as well as at outpatient facilities post-incarceration, when, as the study noted, they are more likely to relapse. 

SWITCHING SIDES: Former Republican House Speaker John Boehner, once a staunch opponent of marijuana legalization, has joined the advisory board of Acreage Holdings, a company that cultivates, processes and sells cannabis in 11 U.S. states. Explaining his new position, Boehner said his thinking had “evolved” after studying the criminal justice system and the needs of veterans to access the drug legally for disorders such as PTSD. Boehner joins the legalization bandwagon at a time when politicians from both parties are assessing voter sentiment on pot and recalibrating their positions accordingly, including New York Senator Chuck Schumer who now favors federal decriminalization of marijuana. Meanwhile, New York Governor Andrew Cuomo faces a spirited challenge for the gubernatorial nomination from actor Cynthia Nixon, who has made legalizing recreational pot a centerpiece of her campaign against the incumbent.

 

 

4th May 2018
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The Rosenthal Report - April 2018

Rosenthal Reports

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.

Briefs:

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.

4th April 2018
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The Rosenthal Report - SPECIAL REPORT

Rosenthal Reports

 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.

 

21st March 2018
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The Rosenthal Report - March 2018

Rosenthal Reports

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.

Disturbing trends

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.

BRIEFS

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.

2nd March 2018
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The Rosenthal Report - Special Report

Rosenthal Reports

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.

 

 


 

 

 

 

14th February 2018
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The Rosenthal Report - February 2018

Rosenthal Reports

 

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.

 

 

 

 

 

2nd February 2018
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The Rosenthal Report - January 2018

Rosenthal Reports

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.

 

2nd January 2018
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