A new study of prescribing practices across all of California’s 1,760 ZIP codes found that between 2011 and 2015, residents of neighborhoods with the highest proportions of white people were more than twice as likely to be prescribed an opioid pain reliever than residents of neighborhoods where whites were scarce.
Across California, a blessing has become a curse for patients who dwell in overwhelmingly white communities: their ready access to opioid pain relievers.
A new study of prescribing practices across all of California’s 1,760 ZIP codes helps explain why opiates, some of medicine’s most addictive drugs, have wreaked more havoc on white communities than on communities of color.
Researchers found that between 2011 and 2015, residents of neighborhoods with the highest proportions of white people were more than twice as likely to be prescribed an opioid pain reliever than were residents of neighborhoods where whites were most scarce.
The answer, at least in part, appears to lie in unconscious physician biases about race, ethnicity and pain that more typically leave minority patients underserved and under medicated, authors of the new study said.
The findings from California were published Monday in the journal JAMA Internal Medicine. They appeared alongside a report chronicling the changing racial mix of opioid fatalities in New York City and an analysis from the Centers for Disease Control and Prevention showing that while doctors cut their rate of opioid prescribing by 20 percent between 2015 and 2017, current levels remain almost three times higher than they were in 1999.
“The resulting disparity in care may have briefly shielded minority communities from harm,” said study leader Joseph Friedman, a medical student at UCLA.
“But for far longer and in many more instances,” he said, “systematic racism within the healthcare system has led to … insufficient treatment of minority patients’ physical and psychic pain.”
In ZIP codes dominated by whites who were not of Latino or Asian heritage, opioid prescriptions flowed freely during the study period. And they were by far most generously offered in low-income white communities.
However, in ZIP codes with the highest proportion of minority residents, not even high income levels could close a yawning race and ethnicity gap in opioid prescribing.
The result is now all too familiar: an epidemic that has cut a swath of death and destruction through poor, rural white communities while largely sparing minorities.
The new research offers a revealing glimpse of how addiction to opioids may have gained a foothold first in California’s rural white communities while largely bypassing black, Latino and Asian neighborhoods.
Researchers found that in each of the five years they studied, roughly 24 percent of Californians left a doctor’s office at least once with a prescription for an opioid narcotic.According to Friedman, leaving a doctor’s office with a prescription for opioids is at least a key marker of a person’s risk for addiction and death.
Collectively, findings like these suggest that something more subtle is at work than just money, insurance coverage and access to healthcare, experts said.
Researchers concluded that the results of their study provide important insights when trying to understand the prescription drug epidemic that is occurring in mostly white communities and the reported disparities in untreated pain, anxiety, and ADHD that are simultaneously found in minority communities.
Authors include: Joseph Friedman, MPH; David Kim, MD; Todd Schneberk, MD, MS; Philippe Bourgois, PhD; Michael Shin, PhD; Aaron Celious, PhD; David L. Schriger, MD, MPH.
The “National Drug Control Strategy” report issued by the White House last week contains familiar hardline rhetoric, even while it undercuts claims by President Trump that building a Wall is crucial to blocking drug traffickers.
With the federal shutdown temporarily at bay, it’s back-to-school time for the White House, which recently released a drug policy report strikingly reminiscent of former President Reagan’s “Just Say No” response to the so-called “crack epidemic” of the 1980s—and of the hardline rhetoric of the Nixon administration.
The “National Drug Control Strategy” report issued last week by the White House Office of Drug Control Policy (ONDCP) asserts that the current opioid crisis is “unprecedented,” while seeming to undercut claims by President Trump and his advisers that the “Wall” is critical to stopping the flow of illicit drugs into the U.S.
According to some critics, the report is simplistic.
The 20-page report reads “like a book report from a student who may or may not have read the book, and who may or may not have wrote his report on the bus ride to school,” carped Reason.com.
The report’s “policy priorities” will surprise no one who has advocated for focusing policymakers’ attention on an epidemic held responsible for 130 overdose deaths a day.
Reduce the size of the drug-using population through education and prevention programs;
Remove barriers to long-term recovery programs; and
“Aggressively reducing the availability of illicit drugs in America’s communities.”
But it rachets up the rhetoric, noting that “the drug crisis our country faces today is unprecedented,” warning that it has “evolved over the past several decades and has steadily worsened with time,” directly affecting every state and county and “every socio-economic group.”
In fact, by the administration’s own admission, opioid deaths have begun to plateau. Speaking last October at the Milken Institute, Health Secretary Alex Azar said, “We are…far from the end of the epidemic, but we are perhaps at the end of the beginning.”
The report notes that in 2017, 68 percent of roughly 70,000 overdoses were primarily caused by synthetic opioids. Synthetic opioids have also seen a marked 413 percent increase in overdoses from 2014.
Heroin, cocaine, methamphetamines, and prescription opioids have also been responsible for increased overdose deaths since 2014, according to CDC figures cited in the administration’s report.
Combating Illicit Drug Supply
The report claims, without providing empirical evidence, that almost all the illicit drugs causing American overdose deaths are produced outside of the U.S. and trafficked across the nation’s borders.
But by its own implication, stopping the flow of drugs into the U.S. is more complicated than constructing a physical border wall, the centerpiece of President Trump’s immigration strategy.
“[T]raffickers continue to refine their methods and adopt new techniques for delivering potent illicit drugs to our communities,” the report said.
According to the paper, traffickers increasingly use international mail and express consignment carriers, a transport and delivery method which eliminates the risk of drug seizures during failed border crossings.
Traffickers are also increasing their use of cryptocurrency such as BitCoin, which allows participants throughout the drug supply chain to transact business virtually anonymously.
Furthermore, The Crime Reportcites US Customs and Border Protection data showing that the vast majority of fentanyl, methamphetamine, and other illicit drug seizures occur at official, rather than illicit, points of entry.
Echoing the rhetoric of the “War on Drugs” launched by the Nixon administration in the 1970s, the report asserts that “responding to the aggressive trafficking and distribution techniques of [drug trafficking organizations] is an urgent national security and law enforcement priority.”
The so-called “War,” which was one of the key factors that drove the rise in U.S. mass incarceration, has been discredited by critics on both the left and the right.
But the current administration has added some new wrinkles.
Focusing its attention on international coca production, the administration even blamed the Colombian peace process for the resurgence of cocaine in domestic drug markets.
The increased cultivation of coca and production of cocaine in Colombia, the source of more than 90 percent of the cocaine in the U.S. market, has once again reached record levels.
Moreover, the suspension of aerial eradication programs in Colombia during its peace process, from 2015 until today, has led to even greater yield from coca plants, resulting in increased production and purity levels. Cocaine use in the United States started rising again after many years of decline.
These passing comments on the Colombian peace process offer insight into the administration’s interest in “drastically curbing the supply of illegal drugs through […] cooperation with international partners to combat drug trafficking.”
Prevention and Recovery: Support for MAT
In other respects, the administration’s objectives tend toward less controversial methods.
The ONDCP plans to implement a nationwide mass media campaign, primarily using social media to warn youth about the harmful consequences of opioid use, and will work to strengthen CDC guidelines regarding safe opioid prescription practices.
The administration will also work to expand the use of prescription drug monitoring programs, which ensure that patients receive safe, non-toxic combinations of medicine from a consistent provider. These and other programs can help state, local, and tribal communities to prevent substance abuse from over-prescription, the White House said.
For those recovering from opioid addiction, the administration went as far as to endorse the use and expansion of Medication-Assisted Treatment (MAT), even for incarcerated individuals.
MAT is a harm reduction program that provides barbiturates to individuals suffering from Opioid Use Disorder (OUD) to gradually ease them into treatment and recovery.
The administration also acknowledged that it must expand treatment insurance coverage and ease the process of reimbursement, moves which it believes will encourage individuals with OUD on the margins of financial stability to initiate treatment that was previously not financially viable.
Finally, the report advocates for the expanded use of drug courts and pre-arrest diversion programs for individuals arrested for non-violent drug-related offenses, which it argues “will foster entrance into treatment programs and away from the cycle of destructive and self-defeating behaviors that is the hallmark of the disease of addiction.”
A study by the National Safety Council concludes the worsening opioid crisis now tops the list of the causes of “preventable deaths” for Americans.
An American is more likely to die from an accidental opioid overdose than from a motor vehicle crash, according to the National Safety Council (NSC).
The odds─one in 96─surpass the one-in-103 odds of dying in a car crash for the first time in history, the NSC said in its analysis of “unintentional, preventable injuries” released Monday.
“The nation’s opioid crisis is fueling the Council’s grim probabilities, and that crisis is worsening with an influx of illicit fentanyl,” the NSC said in a statement accompanying the data.
Ken Kolosh, manager of statistics at the National Safety Council, added that the opioid figures underlined the rise in accidental deaths from all causes, averaging 466 lives lost every day.
Americans are dying from accidents “at rates we haven’t seen in half a century,” despite the general increase in U.S. longevity, he said. “This new analysis reinforces that we must consistently prioritize safety at work, at home and on the road to prevent these dire outcomes.”
NSC analysis of data compiled by the Centers for Disease Control and Prevention also shows that falls – the third leading cause of preventable death behind drug overdose and motor vehicle crashes – are more likely to kill someone than ever before.
The lifetime odds of dying from an accidental fall are one in 114 – a change from one in 119 just a year ago.
Preventable injuries are the third leading cause of death, claiming an unprecedented 169,936 lives in 2017 and trailing only heart disease and cancer, the NSC said.
Allowing nurse-practitioners more “independence” in prescribing opioids to treat patients could play a key role in curbing the opioid epidemic, according to a University of Alabama study.
Allowing nurse-practitioners more “independence” in prescribing opioids to treat patients could play a key role in curbing the opioid epidemic, according to a University of Alabama study.
Scope of Practice (SOPs) laws in many states restrict nurse practitioners— often the primary providers of health care in rural and under-served communities—from prescribing opioids for treatment of patients without the supervision of a physician.
But such laws are counter-productive and may even “undermine patient safety,” concluded the study by Benjamin J. McMichael, an assistant law professor at the University of Alabama’s Hugh F. Culverhouse Jr. School of Law.
McMichael analyzed over 1.3 billion individual opioid prescriptions, representing about 90 percent cent of all opioid prescriptions filled at outpatient pharmacies between 2011 and 2017, to examine the impact SOP laws have on the quantity of opioids prescribed by both physicians and NPs.
Although SOP laws are strongly backed by the American Medical Association, among other groups, as a way to ensure patient safety, McMichael said he found no evidence to suggest that opioid patients’ health was compromised by NPs in states where such laws were not in existence.
In fact, he argued, the tendency of NPs to prescribe smaller doses or fewer prescriptions when they were not bound by what doctors ordered may be a significant factor in the successful treatment of addiction.
According to the data, the overall amount of morphine “milligram equivalents” prescribed by all providers during that period actually decreased slightly—by 1.2 percent— during that period.
“The clear majority of evidence demonstrates that granting NPs independence reduces the use of prescription opioids across three different measures of opioid prescribing,” wrote McMichael, in a working paper, entitled “Scope-of-Practice Law and Patient Safety: Evidence from the Opioid Crisis.”
He added: “Allowing NPs to practice independently, if anything, reduces the use of opioids, consistent with an improvement in patient safety, given the demonstrated harms associated with recent levels of opioid prescriptions.”
NPs are registered nurses who have undergone additional training to provide healthcare services historically provided by physicians, the study noted. In general, NPs may evaluate patients, provide diagnoses, offer treatment, and prescribe medications.
State scope-of-practice (SOP) laws—a subset of the occupational licensing laws that govern NPs and many other professionals—determine what services NPs may provide and the conditions under which they may provide those services.
Another significant effect of granting NPs more independence is lowering healthcare costs, McMichael noted.
McMichael cited other studies that have demonstrated that granting NPs more autonomy “can result in lower healthcare prices, increased access to care, and improved quality of care.”
“While SOP laws are not generally mentioned in the debate over the opioid crisis, the results… suggest that changing how the healthcare workforce is regulated via SOP laws could play a role in mitigating the effects of this crisis,” he wrote.
According to the Centers for Disease Control and Prevention, an estimated 40 Americans died each day from a drug overdose involving a prescription opioid during 2017.
The nation seems to be emerging from the “long tunnel” of the opioid crisis, but substituting medical marijuana as an alternative form of care may land us in a “fog of extensive, additional public health repercussions,” warn Arizona researchers.
While medical marijuana has emerged as an alternative for the treatment of opioid abuse, its effect on public health needs more study before pot is widely used in palliative care, according to a forthcoming paper in the Kansas Law Review.
“Promoting marijuana over opioids is risky, given substantial uncertainties over short- and long-term impacts of its widespread use,” the paper warned.
“Even as the nation slowly exits the long tunnel of the opioid crisis, it may be heading into a fog of extensive, additional public health repercussions.”
The co-authors, James G. Hodge, Walter Johnson and Drew Hensley, observed that while opioids are effective “pain killers,” marijuana is more like a “pain distracter.”
Hodge is law professor at Sandra Day O’Connor School of Law at Arizona State University (ASU). Johnson and Hensley are law students and legal researchers at ASU.
Last year, the White House issued a statement declaring opioid abuse a “public health emergency.” More than 300,000 Americans have died from overdoses involving opioids since 2000, and in 2016 alone, opioids killed more Americans than breast cancer.
But as local, state and federal officials work to lessen the impact of opioids, “public health interventions to curb opioids consequentially mean fewer patients are gaining regular access to opioids to control their pain,” said the paper.
The authors noted that some caregivers and substance abusers are turning to medical marijuana as an alternative form of care, since other treatments, such as ibuprofen or physical therapy, can be ineffective or prohibitively expensive.
Though as of September, 2018, medical marijuana was legal in 30 states and the District of Columbia (additional states approved medical marijuana in ballots during the midterm elections), the authors caution there is only a “thin proof of [its] efficacy for treating many conditions.”
The authors don’t dispute the benefits of medical marijuana for many patients in need.
But they note that although medical marijuana can be effective for patients suffering from HIV/AIDS, epilepsy, multiple sclerosis, and others, “the efficacy of marijuana as a palliative drug is not fully proven.”
Before medical providers exchange opioid prescriptions with medical marijuana prescriptions, the study argued the public needs more substantive research that balances its potential palliative effects against the public health and safety risks of long-term marijuana use.
Justice Department officials say they will prosecute any city or state that opens a safe injection site for opioid addicts, but a law professor argues in the Boston College Law Review that a clause in the federal Controlled Substance Act already makes such sites legal.
An “obscure” provision of the 1970 Controlled Substances Act protects states or cities who establish safe injection sites from federal prosecution, claims a forthcoming paper in the Boston College Law Review.
Safe injection sites, where substance abusers can self-administer drugs in a controlled environment under medical supervision, are recommended by some experts as a way to save lives in the opioid epidemic, and help individuals get supervised counseling.
At least 13 cities and states are considering them, and four cities—New York, Philadelphia, San Francisco, and Seattle—have announced plans to open sites. But the Department of Justice, reflecting the view of critics who claim they will encourage drug use and crime, has pledged “swift and aggressive action” against any jurisdiction that tries to start one.
In a New York Times op ed last August, Deputy Attorney General Rod Rosenstein warned such sites would be prosecuted under federal laws that make it a felony to “maintain any location for the purpose of facilitating illicit drug use.”
“Proponents of injection sites say they make drug use safer, but they actually create serious public safety risks,” wrote Rosenstein in his opinion column, entitled, “Fight Drug Abuse, Don’t Subsidize It.”
“Additionally, injection sites destroy the surrounding community. When drug users flock to a site, drug dealers follow, bringing with them violence and despair, posing a danger to neighbors and law-abiding visitors. ”
The feds say that government-run injection sites violate the so-called “crack house statute” passed in the mid-1980s making it a crime to make property available to others “for the purpose of unlawfully manufacturing, storing, distributing, or using a controlled substance.”
However, Alex Kreit, a visiting professor at the Drug Enforcement and Policy Center at the Ohio State University Moritz College of Law, claims the Act also contains an “obscure provision that immunizes officials” who violate federal drug laws in the course of “the enforcement of any law or municipal ordinance relating to controlled substances.”
“This provision was almost surely intended to protect state and local police officers who possess and distribute drugs in connection with undercover operations,” Kreit wrote in his forthcoming Boston College Law Review article.
“But, I argue, the text of the immunity provision and the little case law that exists interpreting it suggests it could shield government-run safe injection sites from federal interference.”
Photo courtesy Vancouver Insite.
According to Kreit, safe injection sites are the “next battlefield” in the ongoing conflict between state and federal drug laws.
Kreit observed that the debate about safe injection sites so far has largely been over whether federal prosecutors would overlook the “crack house” statute, in the same way that they have been asked to turn a blind eye to marijuana use in states that have legalized it.
But he says the loophole in existing law may make the debate irrelevant.
“Indeed, it is even possible that the provision could immunize a privately run facility, if the operators were formally deputized as “duly authorized officer[s]” in connection with a state or local safe injection law,” he wrote.
He conceded that Trump administration is unlikely to be persuaded, but he noted there was already widespread bipartisan support for finding alternatives to the nation’s failed “war on drugs.”
“It is possible, of course, that the political winds will shift again, especially since the Trump administration has taken steps to revive the drug war,” he added. “But, if support for replacing the war on drugs with a new strategy does continue to grow, a lingering question is what the new strategy will look like.
“Safe injection sites may provide a perfect test case.”
Safe injection sites have been operating for decades in other countries, including Canada, and a wealth of evidence suggests they can reduce overdose deaths and the spread of blood-borne diseases among injection drug users, said Kreit.
The site operated on the east side of Vancouver, Canada, called Insite, claims nearly 16,000 people have safely used its facilities since it opened in 2006, and is currently visited by an average 720 individuals daily.
A new program that provides opioid-dependent inmates with small drug doses to help ease their withdrawal when they leave prison shows promising results in Philadelphia. So why do so many U.S. corrections authorities resist medication-assisted treatment?
During more than a decade of IV drug use, 34-year-old Ana Vasquez, a homeless IV drug user, has kicked heroin nearly a dozen times in Philadelphia jails, most recently in late November 2017 after she was arrested during a buy-and-bust operation with a single $5 bag of powder cocaine in her possession.
The crime is considered so minor that, even prior to the election of Philadelphia’s new reformist District Attorney Larry Krasner—who ended cash bail for most low-grade misdemeanors this year―Vasquez would have been processed through police headquarters and released to the street on her own recognizance not more than 72 hours after her arrest.
But under Philadelphia’s unique and controversial “detainer” system―which requires that defendants on probation who violate the terms of their supervised release be held without bond until they’ve had a hearing before the judge who originally sentenced them―it would be the middle of January before Vasquez was finally released from Riverside Correctional Facility (RCF), Philadelphia County’s only exclusively female jail.
From there, she hitched a ride seven miles south, back to her home in the city’s Kensington neighborhood, where she spent her first night of freedom braving the frigid weather by getting high on heroin and cocaine.
“No matter how many times you detox in jail, it never gets any easier,” she said, in an interview shortly after her release. “It’s horrible. No one wants to leave their cell [and] you got at least half of the people on the block going through it, vomiting, diarrhea, not eating or sleeping.
“Sometimes they would give us ‘comfort meds’ as they call it, but in reality they don’t do shit.”
So it was a surprise when I got a call from Vasquez last month, a few days after she’d been arrested once again—this time on a more serious felony charge of possession with intent to deliver heroin—and she sounded, well, buoyant.
“They got us on subs,” she said, referring to the drug buprenorphine (an opioid agonist sold under the brand name Subutex). “You believe that? They dose us every day. It took a couple days to get adjusted to it but really, I feel great.
“This is a great program.”
The program Vasquez is referring to provides the option of medical detox from opioids or maintenance using genetic buprenorphine to every incoming inmate suffering from opioid dependency. It was quietly launched as a pilot in February at RCF; and on Aug. 13 it was expanded to encompass all inmates entering the Philadelphia prison system.
“We make such an investment to help people while they are in the system,” said Bruce Herdman, the Chief of Medical Operations for the county’s Department of Prisons.
“It doesn’t make sense not to help them after their release.”
Evidence has long demonstrated that treatment using opioid agonists like buprenorphine and methadone are the best way to do that. Agonists stimulate the same receptors in the brain as illicit opioids. But their long half-life makes them suitable for replacement therapy because they attenuate cravings for 24-36 hours (compared to just four to six hours from the combination of heroin and fentanyl commonly sold in Philadelphia).
Among other things, this reduces the compulsion that comes from the need to constantly redose.
It also keeps people alive long enough to benefit from recovery. Just a week in jail without opioids can reduce a dependent individual’s tolerance enough that the dosage they were accustomed to when they were arrested could be fatal.
Herdman says that research shows inmates kept on agonist therapy in jail are two-thirds less likely to die of an overdose in the early weeks of their release than those who lose their tolerance while incarcerated..
Under Philly’s new program, inmates with opioid dependencies are given a single 8 mg dose of buprenorphine once a day (half the average recommended dose in most outpatient programs). The drug is dispensed as a crushed tablet to make it harder to divert.
Prior to release, those who choose to continue treatment are assigned to a clinic or physician in the community, ideally with minimal, if any, gap between doses. When the program started, it avoided that issue by providing a few days of medication or providing a short-run prescription to hold patients over. But the jail had to put that policy on hold because of limited resources.
Herdman acknowledges his team is still working up the learning curve.
“We found that we could not scale that practice, the logistics are so difficult,” he said. “The volume here is the biggest challenge, the sheer burden of the size. We send 200-some people to court each day and people are released 24 hours a day seven days a week.
“We had to train eight additional doctors to qualify for the federal waiver [needed to prescribe buprenorphine] just to keep up with intakes.”
Dr. Jon Lepley, Chief Medical Officer of Corizon—which is contracted to provide health care services to Philadelphia’s jails—helped pioneer the program in partnership with the prison system after learning about the disproportionate number of inmates who overdosed and died soon after leaving jail.
“Historically, when someone came in they would receive a nursing assessment and if they presented with opioid withdrawal symptoms they would be detoxed with ‘comfort meds,’ like clonidine, promethazine [an antihistamine] and loperamide [Imodium],” said Lepley.
“But attitudes really started changing after Mayor Jim Kenney’s Opioid Commission released its report last year recommending that county inmates be offered the option of medication-assisted treatment. That was a turning point.”
Before launching the program, Herdman and Lepley consulted with officials at Rikers Island in New York City, which started offering heroin-addicted inmates methadone maintenance in 1986. The jail added buprenorphine as an option in 2008.
According to Jonathan Giftos, the Clinical Director of Substance Use Treatment at Rikers, the jail treated 4,000 inmates using methadone or bupe last year, and 70 percent of program participants are on long-term maintenance.
Unlike Philadelphia, Rikers (which has had plenty of time for trial and error) has no dosage cap—inmates are provided an individualized dose and can choose which medication works for them. When they are released they receive either seven days of medication or a 14-day prescription until they see a physician.
It’s also the only jail with a federally licensed Outpatient Treatment Facility onsite, meaning that it prescribe and dispense methadone without needing to contract with one of the city’s already overburdened clinics.
“It’s really rewarding to provide people with evidence-based treatment while they are at such a vulnerable point in their lives,” said Giftos. “For decades the standard of care at other jurisdictions was to provide no medication.
“But now I think we are seeing a new standard of care emerge as more jails are looking at the data and success rates of methadone or bupe provided in a correctional setting.”
However, that needle is moving extremely slowly—given the number of victims who come in contact with the criminal justice system. Despite their proven effectiveness, demand for opioid agonist therapies by jails is virtually nonexistent.
In one randomized study, researchers reviewed 81 requests for proposals (RFPs) for contracted jail healthcare services in 28 states and found that only 11 requested MAT; and all but three limited its use to pregnant women—who can suffer severe complications from improperly managed detox.
As I’ve previously reported, it’s estimated that two-thirds of inmates entering jail have a diagnosable substance abuse disorder, yet few jails even provide basic medical care for managing withdrawal, let alone allow for ongoing maintenance treatment.
Fewer than 10 percent of America’s 3,300 jails offer any medication-assisted treatment at all, let alone long-term agonist maintenance. Instead the roughly 200 jails, that provide MAT to inmates opt for the opioid antagonist naltrexone (sold under the brand name Vivitrol), which simply prevents individuals from feeling the effect of opioid drugs.
There is little data on the effectiveness of naltrexone for long-term success at preventing a relapse on illicit opioids (and to be fair, there’s not a whole lot on buprenorphine either, which wasn’t even an option for heroin addicts until 2002).
Although, a recent study found naltrexone is as effective as a daily oral dose of buprenorphine at preventing relapse after six month, the accuracy of that conclusion is undermined by the fact that more than a quarter of participants were unable to endure the required period of abstinence (up to four days) to even start taking Vivitrol.
But even if the data were sound, relapse prevention is just one measure of success.
Tens of thousands of human beings suffer needlessly through painful withdrawal while incarcerated in county jails, including people like Vasquez, whose entire criminal history is a reflection of a DSM-classified medical disorder. An untold number of them die in the process.
All of them would have a chance to be alive and in recovery today, if the municipalities where they perished had the political will and compassion to spend a fraction of the money treating their symptoms that they’ve shelled out in wrongful death lawsuits.
Philadelphia’s program will provide the option of treatment to thousands of potential inmates this year for just $500,000 out of the prison budget, according to Herdman.
As I recently reported, the ACLU is currently suing jails in three states—Washington, Massachusetts and Maine—for failing to provide appropriate treatment to detoxing inmates.
Dr. Lepley says Corizon will begin including medication-assisted treatment with buprenorphine as a standard protocol in its jail contracts. But that does not mean the facilities will be required to employ it. And the Pennsylvania Department of Corrections told The Crime Report that it will begin piloting SUBLOCADE, the first once-monthly injectable buprenorphine formulation for the treatment of opioid use disorder, with a target date of November 2018.
According to DOC spokesperson Susan McNaughton, the immediate goal will be to use the drug to detox incoming inmates, but the long-term goal is to offer ongoing maintenance.
Christopher Moraff is a freelance writer who covers the intersection of policing, drug use and civil liberties for The Crime Report and other publications. He welcomes comments from readers.
A new report by the American Bar Association’s Senior Lawyers Division makes nine recommendations and suggests 45 “action items” that it says can advance public health efforts to confront the opioid epidemic. One recommendation calls for promoting policies and laws that support families and caregivers struggling with opioid and substance misuse disorders.
The legal profession can play a “critical” role in combating the growing opioid crisis in America, says the American Bar Association (ABA).
“The legal profession’s voice is critical to advancing public health efforts to confront the opioid epidemic, including efforts focused on prevention, intervention, and treatment,” the ABA said.
According to the report, lawyers can provide alternatives to criminal sentencing, mandate education and training, strengthen data tracking and reporting requirements, and aid and support collaboration across agencies focused on developing family-friendly policies and resources–to name a few.
The report and its recommendations will be used to collaborate with other ABA entities to develop specific policy resolutions that address the opioid crisis.
“The epidemic is shortening American life expectancy, impacting local government budgets, straining family resources and relationships, and challenging all of us to find solutions,” said Jack Young, chair of the ABA Senior Lawyers Division.
“It affects all of us.”
Notably, the Senior Lawyers Division plans to have a resolution approving the report’s recommendations and action items reviewed by the ABA House of Delegates as early as the ABA Midyear Meeting in January 2019.
The report made the following recommendations:
Invest in multidisciplinary education and training opportunities for individuals, families, vulnerable populations, professionals, and community stakeholders.
Expand access to treatment and recovery for individuals with opioid and substance misuse disorders and aggressively address stigmatism.
Establish comprehensive treatment and outreach efforts tailored to the diverse needs of individuals and families struggling with opioid and substance misuse disorders.
Increase the legal profession’s capacity to respond to and meet individual and family needs through partnerships, collaboration, and dissemination of information and resources in support of individual and family needs.
Promote policies and laws that support families and caregivers struggling with opioid and substance misuse disorders.
Support policies and laws that support families in crisis and strengthen the family unit.
Identify state laws and initiatives that have been shown to decrease opioid and substance misuse while ensuring access to pain medications for those with chronic pain.
Expand research and understanding of litigation and policy issues with the aim of addressing the sometimes indirect yet complex issues affected by the opioid crisis.
Recognize the inconsistent response and action to the opioid crisis versus other forms of substance misuse and advocate for policies that address underlying health and socioeconomic disparities.
The opioid crisis has very little to do with prescription drugs, says a leading researcher. Patients treated for chronic pain with opioids–many of them elderly—are not dying from overdoses, and they shouldn’t be treated like addicts.
Anyone who watches TV news will know that America has a major public health problem concerning drug addiction and opioid overdose deaths. In this context, we sometimes hear terms like “prescription opioid epidemic” and “over-prescribing” thrown about indiscriminately.
Hidden inside the hype and misinformation are several inconvenient truths. Public policy on the drug crisis cannot be remotely effective until we embrace such truths and act on them.
The largest and most ignored truth is that our present opioid crisis has very little to do with prescription drugs─and data published by the CDC prove it. People with addiction disorders and patients treated by doctors for chronic pain with opioid pain relievers are largely separate demographic groups.
This is worth saying again. As recently noted in The Crime Report, when medical opioid prescribing rates per hundred population are plotted against opioid-related deaths per hundred thousand, we get what is a “splatter pattern.”
There is no trend in this data, no correlation, and certainly no cause-and-effect relationship. None.
The contribution of medically managed opioid analgesics to opioid mortality is lost in the noise. Our death toll is instead dominated by street drugs─heroin, imported fentanyl, diverted methadone and morphine─not prescriptions written by doctors for their patients.
The number of opioid prescriptions written in 2016 was the lowest it has been in 10 years, while overdose deaths continued to climb.
[SEE TABLE 1]
Table 1 courtesy Richard Lawhern
If over-prescribing of opioid analgesics was a major cause of our ever-increasing overdose-related deaths, then we would expect demographic groups with the highest rate of prescriptions to also display the highest mortality. But this is clearly not happening.
The next chart [TABLE 2] is a plot of US national prescribing rates per hundred population versus age group, using data from the Centers for Disease Control and Prevention (CDC) 2017 Annual Surveillance Report of Drug Related Risks and Outcomes. Predictably, the data show us that opioid prescribing rates among minors and young adults are lowest among all age groups, while prescribing among seniors is highest.
TABLE 2 courtesy Richard Lawhern
Now compare opioid prescribing rates with overdose mortality over time, extracted from the CDC Wonder database and aggregated by age group. Mortality for youth and young adults has soared since 1999 and is now six times the mortality in seniors over age 50.
After an initial rise in 1999 to 2006, mortality in people of middle age (36-50) leveled off into a narrow range. Tellingly, overdose death among people over age 50 remained stable throughout this 17-year period. The group most often exposed to medical opioids and who benefitted most during the 1990s from easing of prescription policy and treatment of pain as “the fifth vital sign” has shown no increase in mortality risk.
But you will almost never hear this inconvenient truth from anti-opioid partisans.
TABLE 3 courtesy Richard Lawhern
The US Congress is currently debating hundreds of bills which claim to “solve” various aspects of our opioid crisis. But much of this frenetic activity is a mad dash down an “Alice in Wonderland” rabbit hole that will solve nothing and instead make conditions much worse for both addicts and people in pain.
Most of the proposed legislation derives from the false narrative that “the problem” was caused by over-prescription and can be solved by reducing medical opioid supply. This narrative is untrue, and the medical evidence of the charts above confirms that it is untrue.
What is actually occurring in our public life is that misdirected opioid policy is killing thousands of patients by driving them into disability, medical collapse, and increasingly suicide.
Richard A. Lawhern
Public policy has become a war against pain patients, not against drugs.
It is time to declare a ceasefire in this phony war, and to reexamine the medical evidence on cause and effect in addiction and opioid-related deaths, before our legislators do even more harm.
Richard A. Lawhern, PhD, is co-founder and corresponding secretary of the Alliance for the Treatment of Intractable Pain. A non-physician patient advocate and writer with 20 years of volunteer public service, he has written for The Journal of Medicine, National Pain Report, Pain News Network, and other online media. His wife and daughter are pain patients. He welcomes comments from readers.
Most Americans seem willing to accept that opioid addiction should be treated as a disease rather than a criminal offense. But the wide variety and quality of treatment and rehab facilities in the US means we should now double down on efforts to investigate which ones really perform, says an addiction expert.
When most people think of rehab they think of Alcoholics Anonymous (AA) and its Twelve Steps, a quasi-religious, incremental process in which addicts must accept that they are helpless in their addiction; accept God and ask him to remove their addiction and other related flaws; make a list of those they have wronged and try to make amends to them; and live their life according to this message and carry it to other addicts.
Judges have continued to order people into AA, Narcotics Anonymous, and similar 12-step programs, despite two major objections.
First, multiple courts have ruled that such an order violates the Establishment Clause of the First Amendment because of the explicit mentions of God (sometimes camouflaged as a “higher power”).
Second, 12-step programs are not really rehabs. They are not evidence-based or scientific, and there are no trained professionals directing therapy or treatment. They are more like support groups—a fellowship of addicts—sharing personal stories and camaraderie to help each other avoid relapsing.
Because of their anonymity, their success rate is hard to determine, but it may be as low as five percent.
It is laudable that judges want to save money and avoid sending addicts to prison, but CAAIR programs, according to the Center for Investigative Reporting’s Reveal, are “little more than lucrative work camps for private industry.”
CAAIR is being sued by three of its former “Chicken Farm” inmates in effect for slave labor (the addict workers are not paid, seemingly in violation of at least Arkansas state law). CAAIR was an alternative to a traditional prison sentence, and if an addict couldn’t work due to factory-related injury, they were sent to prison after all.
Clearly, AA, NA, and CAAIR are not rehabs, but even treatments considered as traditional rehab don’t have an official definition. Most rehabs do share some conventions, however.
There are at least two kinds of rehabs: residential, or inpatient, and non-residential, or outpatient. In residential rehabs, the patient with an addiction is expected to remain in the facility for a set period of time—usually a week, a month, or three months—depending on the severity of addiction and ability to pay. Non-residential treatment takes place for a certain period during the day, but the patient returns home at night.
Ideally, an evidence-based rehab for substance abuse should offer medically monitored detoxification, medical staff, behavioral therapists and counselors trained in addiction medicine, medication-assisted treatment (MAT)—drugs such as methadone or buprenorphine to help wean addicts off other, harmful drugs such as heroin—and follow-up monitoring and therapy known as aftercare.
Rehab also can offer many other non-evidence-based alternative treatments as additions or alternatives, from spiritual to philosophical, exercise to meditation, even yoga and so-called equine therapy (basically riding a horse).
In some states, such as Florida, anybody qualified to be a landlord can open a sober home, a residence for recovering addicts receiving outpatient addiction treatment elsewhere.
$35 Billion Industry
The rapid increase in drug rehab facilities and insurance coverage—it has become a $35 billion industry—has led to what even the National Association of Addiction Treatment Providers (NAATP) admits are “bad actors” who attempt to take advantage of the addicted, their families, the insurance companies, and the federal and state governments by engaging in practices such as “patient brokering”, paying fees or “kickbacks” for referrals regardless of the appropriateness of the rehab. With that much money in play, it is inevitable.
The problem is that this new way of looking at addiction, as something more like a disease than a lack of willpower or a moral failing, is new to the nation as a whole. Addiction medicine is a relatively new specialty. Law enforcement and the courts seem to favor punishment; it’s in their natures.
How much of addiction is a choice, if it should be treated instead of punished, is still a new concept to a populace more conditioned to send problem drinkers to Alcoholics Anonymous and drug addicts to prison.
Even worse are “body brokers” who recruit addicts to fill a rehab bed to bilk the insurance company. Far from trying to help addicts into recovery, body brokers actively maintain their addiction, supplying them with drugs and milking them for frequent and unnecessary laboratory tests of their urine (which, because of insurance reimbursement, is sometimes known as “liquid gold”). Some of these addicts were even used for prostitution. Not surprisingly, some of these addicts overdose and die.
Florida sober home operator Kenneth Chatman has been convicted, but there are many more. Rehabs with warm weather, ocean views and other vacation resort-type amenities are the major culprits, such as in Florida and California, but questionable rehab clinics have been found in other locations, such as New York and Massachusetts.
NAATP endorses (“values”) “a comprehensive model of care that addresses the medical, bio-psycho-social and spiritual needs of individuals and families impacted by the disease of addiction” using “research-driven, evidence-based treatment interventions that integrate the sciences of medicine, therapy and spirituality.”
NAATP seems to favor inpatient or residential care, or at least says nothing about outpatient care (naturally), although the success rate seems to be about the same for both.
One Size Doesn’t Fit All
Drug rehab is not one size fits all. The treatment that works for one person won’t necessarily work for another. Most people who become addicted to a substance don’t require help to stop—you don’t hear much about them because they don’t become a societal problem—but “no help” isn’t a solution that will work for all addicts. (Some, such as AA, don’t even consider such individuals addicts because they were able to stop.)
The problem of catching and shutting down “bad actors” is another matter. Some politicians and courts want to rely too heavily on abstinence-only (“Just Say No”) or the Twelve Steps or forced labor such as CAAIR (it gives them a “work ethic”). Studies show MAT works better, but “that’s just exchanging one addiction or drug for another”, say these critics.
No, not any more than diabetics are exchanging one drug (insulin) for another (sugar). Addiction is a chronic brain condition like a disease that is caused by many factors, including a genetic predisposition. If medications such as methadone or buprenorphine will keep an addiction under control, allow the person with an addiction to keep a job and function in society without getting high, then it won’t hurt if they are on the medication for a week or 10 years.
Other harm reduction solutions, such as needle exchanges and safe-shooting sites (with testing to make sure that the drugs aren’t contaminated or laced with fentanyl), also save more lives than prison.
There also aren’t enough rehabs or qualified people to staff them. If every addict wanted help, they couldn’t find it. Doctors must be encouraged to add addiction medicine to their training.
Law enforcement, too, must be trained in recognizing and dealing with addicts. Drug Recognition Experts are a start, but they’re only focused on arresting someone who they perceive is intoxicated.
Vigilance by the friends and family of the addicts also is required. Warning signs of a bad actor, according to law enforcement, include offers to pay for travel to a faraway rehab or to waive fees, co-pays and sober home rent. If it sounds too good to be true, it might be. Give that gift horse a thorough oral exam.
Increased scrutiny of the drug addiction treatment industry is needed, according to West Palm Beach attorney Susan Ramsey, by law enforcement—she’s already seen it cause some bad actors to close—the insurance companies who are being defrauded—Chatman was under investigation by the Federal Bureau of Investigations for two years because of a tip about insurance fraud but was caught because someone OD’d—and by the industry itself.
NAATP may be trying better self-regulation now. At its annual meeting last month it announced its new Quality Assurance Initiative “designed to confront abuses in the treatment field, establish operational competence, and restore public trust in addiction treatment.”
It’s about time. In 2016, Marvin Ventrell, then executive director of NAATP, warned that “If our procedures for self-policing and transparency aren’t improved, the industry is going to be seriously harmed.”
Those chickens may have come home to roost.
Stephen Bitsoli, a Michigan-based freelancer, writes about addiction, politics and related matters for several blogs. He welcomes readers’ comments.