THE ROSENTHAL REPORT - NOVEMBER 2018

ROSENTHAL REPORTS

IMPOSE A MORATORIUM ON MARIJUANA LEGALIZATION

The Rosenthal Center proposes a two-year moratorium on the legalization of marijuana to study the drug’s impact on health and social behavior in legalized states. Over the past few years, the drive to legalization – led by the pot lobby, cannabis companies and politicians recently converted to the cause - has created a seemingly unstoppable rush to commercialization. This has raised concerns about shifting consumption patterns, the toxicity of new pot products, and market regulation for both medical and recreational marijuana. As legalization accelerates – voters in four states including conservative Utah will decide on marijuana ballot initiatives in the midterms – it is time to pause. A two-year moratorium will provide ample time to accomplish the following: review evidence from states where pot has been legalized as well as in Canada, which took the step last month; evaluate current studies that show marijuana is far from a benign substance; and establish an appropriate framework to control the drug’s use and sale in the future.

I am most concerned about teenagers having easier access to today’s much more powerful marijuana. Adolescents are highly susceptible to the slick packaging and rosy (if dubious) health benefits ascribed to these new pot products, including those laced with CBD. This non-psychoactive component of pot is said to alleviate everything from aching joints to anxiety. There is, in fact, only one drug derived from the cannabis plant approved by the FDA (for epilepsy), and only anecdotal evidence suggests that pot can relieve nausea and help people with symptoms of PTSD, among many other unsubstantiated claims.

In this new environment, teens are experimenting with smoking and vaping pot as well as consuming marijuana edibles. New studies indicate the following: chronic use in adolescent years leads to chronic use in adulthood and impaired cognitive development; marijuana poses a greater risk to the developing brains of teenagers than alcohol consumption; and quitting cannabis for just one week can significantly boost the memory of once-a-week adolescent and young adult users. 

A two-year moratorium isn’t likely to stop the runaway train of legalization, as 62 percent of Americans favor it and 94 percent support medical marijuana. But it will allow time to better assess and evaluate the potential risks of pot, and put in place regulations and restrictions to control the rapid commercialization and widespread use of the drug.

 

DRUG OVERDOSES DEATHS ARE DOWN, BUT WE’RE NOT OUT OF THE WOODS YET

Preliminary tracking data from the Centers for Disease Control indicate a 2.8 percent drop in overdose fatalities in the 12-month period ending in March 2018, providing a glimmer of hope that the opioid crisis might be ebbing. Wider use of overdose reversal drugs and prevention and treatment initiatives in such states as Vermont, Rhode Island and Massachusetts – all of which registered declines in overdose deaths – are probably responsible for the slight decrease. But it’s not clear yet whether this is a blip or a sustainable trend. Despite the overall drop, deaths linked to the synthetic opioid fentantyl as well as methamphetamines are still rising. And even if the current decline in overdose rate continues for the rest of the year, an estimated 70,000 people will die in 2018 compared to more than 72,000 in 2017. That remains a tragic and unacceptable toll.

THE ROSENTHAL REPORT - OCTOBER 2018

NEW OPIOID LEGISLATION UNLIKELY TO SLOW DRUG EPIDEMIC

 LONG-AWAITED BILL LACKS BOLD STRATEGY AND BOOST IN FEDERAL SPENDING

Opioid legislation approved last month by Congress is a wasted opportunity.  The bipartisan bill, hammered out over the past year, merely tinkers at the edges of the epidemic instead of setting out a coordinated national strategy. Most glaringly, it fails to allocate significant new long-term funding to expand access to drug treatment – our most effective means of curbing a surge in overdose deaths across the country.

To win support on both sides of the aisle, Congress adopted a scattershot approach when drafting the Opioid Crisis Response Act of 2018. The bill includes a number of worthy initiatives supported by the Rosenthal Center, such as grants for addiction and pain treatment research, stricter law enforcement to halt the flow of illicit drugs like fentanyl, and easier ways for addicts to obtain withdrawal medications. But the legislation, enacted one year after President Trump declared a national health emergency, does not contain an overall plan or a suitable increase in federal dollars for states, cities and organizations on the frontline of the crisis.

Early estimates suggest the bill will cost between $5 billion and $8 billion to implement over five years. A more appropriate allocation would be in the range of $100 billion over the next decade, a proposal made by Senator Elizabeth Warren and Representative Elijah Cummings that never got off the ground.

If such funds were available, I would direct the money to expanding a wide range of treatment options and redressing the severe shortage of long-term residential beds for the most vulnerable addicts. We must also support innovative programs in prisons and in poorly served rural areas, and provide targeted treatment programs for neglected teenage drug users. We should, in addition, address the growing problem of workplace addiction that is exacerbating the nationwide labor shortage (see story below).         

No doubt the opioid bill will make a good talking point for candidates in the coming midterm elections. They can boast about doing something about an epidemic that killed more than 72,000 Americans last year. In fact, a Wall Street Journal analysis found that, so far in 2018, campaign ads containing opioid messaging in congressional and gubernatorial races have aired more than 50,000 times across 25 states, including West Virginia and Ohio, states with closely contested races and increasing numbers of overdose fatalities.

Such messages might swing an election. But they won’t guarantee affordable and effective addiction treatment for those suffering and dying from substance abuse. Helping these people must now become a national priority.

INNOVATIVE CORPORATE-BACKED DRUG TREATMENT PROGRAM SHOWS PROGRESS

The drug treatment initiative I helped design a year ago for Belden, an international manufacturing corporation, is yielding positive results. During a recent follow up visit to the company’s factory in Richmond, Indiana, I learned that a number of employees who successfully completed the Pathways to employment program are now operating machinery on the factory floor. Pathways is unique because instead of turning away job applicants who fail a drug test, it promises permanent jobs to those who commit to drug treatment and random drug testing.

The U.S. Chamber of Commerce has praised the program. When I was there a delegation of federal officials came to see the program, including Surgeon General Dr. Jerome Adams, Secretary of Labor Alexander Acosta, the president's senior counselor, Kellyanne Conway, and Vice President Pence's wife, Karen Pence and the former first lady of Indiana.  They were excited by the potential of the model and the early positive results.

Corporate America can’t single-handedly solve this drug crisis. But for the growing number of companies like Belden that face similar challenges finding drug-free workers, Pathways to Employment serves as a model that addresses the labor shortage, fights addiction and supports communities.

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.

THE ROSENTHAL REPORT - AUGUST 2018

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.

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.

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. 

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.

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.

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.

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.

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.

THE ROSENTHAL REPORT - DECEMBER 2017

ROSENTHAL REPORTS

In the Rosenthal Report for December, we look at:

• The promise and risk of innovation to fight the opioid epidemic

• How the drug industry is promoting “better” opioids with government help

• Why we need to stay focused on addiction treatments that work

Innovation is the latest buzzword when addressing the opioid epidemic, backed by the Trump administration and the pharmaceutical industry as a silver bullet solution to the crisis. But as government and private companies increase investments in research and development, we risk losing sight of the many effective treatments and approaches already at our disposal, such as the residential care that is so hard to find by many who now need it. While innovation is critical to advance addiction treatment, we won’t find easy answers solely with technology and new medications.

Many new products are already coming to market. The FDA recently approved two: an electronic earpiece that blocks opioid withdrawal symptoms by sending an electronic pulse through four cranial nerves to reduce nausea, anxiety, and pain; and a “digital” pill equipped with sensors that lets doctors closely monitor a patient’s pain level and frequency of drug use through a small data-storage device attached to the abdomen.

Pharmaceutical companies are gearing up as well, developing new forms of supposedly “better” opioids – in many cases, with government help. In an unusual move, the administration is promising substantial funding for public-private partnerships with the drug industry to develop non-addictive painkillers as well as so-called abuse-deterrent opioids, which Big Pharma claims will help curb substance abuse.

This is a troubling approach. We need to change lives, not drugs. And we can’t depend on technology – for all its promise – to do the hard work of addiction recovery. More importantly, we need to make sure the treatments that do work are easily available to a growing addict population.

Overdose reversal drugs, for example, are highly effective. But many municipalities across the country can’t get them because of limited supply and rising prices (one brand, Evzio, now costs $4,500 for two doses, up from $690 in 2014). Evidence-based prevention programs can work, especially for children and teenagers, but they were given scant notice in the opioid commission report.

Promoting abuse-deterrent opioids, especially with taxpayer money, is “insanity,” as a New York Times editorial put it. Abuse-deterrent is a misleading term referring to pills that are harder to crush or alter for injection or snorting, but have the same addictive properties and therefore won’t prevent someone from ingesting opioids or becoming addicted.

The Rosenthal Center believes that residential therapy of varying lengths – therapy that treats the whole person, with proven clinical practices and peer-based counseling - offers the best chance of sustained recovery. Yet today there are many places in the country where residential facilities are not available or affordable for many people. Far too often we hear tragic stories of addicts’ lives lost during a desperate scramble to find treatment and the means to pay for it.

This is a failure of government policy and funding priorities. The Rosenthal Center will continue to strongly support increased funding to expand the treatments and programs that we know help save lives every day. 

THE ROSENTHAL REPORT - NOVEMBER 2017

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.

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.

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.

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.  

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. 

THE ROSENTHAL REPORT - JUNE 2017

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

MEMO TO TRUMP: LOCKING UP DRUG ADDICTS WON’T END THE OPIOID EPIDEMIC

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

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

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

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

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

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

THE STATES TAKE ACTION: KENTUCKY

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

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

 

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.

THE ROSENTHAL REPORT - MAY 2017

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.