Category: Doctors

NY Docs Are Now Required to Prescribe Naloxone to Some Patients on Opioid Painkillers

This strategy — now in place in at least 10 states — is part of an effort to curb accidental opioid overdose deaths by patients who take these powerful medications.

Without opioid painkillers to dull the ache in his knees and other joints, Arnold Wilson wouldn’t be able to walk half a block. The 63-year-old former New York City nurse has crippling arthritis for which he takes OxyContin twice a day and oxycodone when he needs additional relief.

For the past several years, he’s kept another drug on hand as well: naloxone, an overdose reversal drug often referred to by the brand name Narcan.

Although overdose deaths from illicit drugs sold on the street make headlines, the risk of overdose is just as real for patients who take opioids prescribed by their doctors.

“It gives me a sense of relief and security,” said Wilson, who keeps Narcan nasal spray in his car and at home. His pain management doctor at Montefiore Medical Center in the Bronx prescribed the opioids in 2013, after a bout with meningitis exacerbated joint problems Wilson had as a result of two brain aneurysms and several strokes. His doctor urged him to start carrying Narcan in 2017.

Naloxone, which begins to reverse an overdose within minutes, is typically administered by others. Though he’s never needed it, Wilson’s 18-year-old daughter knows how to use it. “I’ve instructed her how to do it, in case I’m lethargic,” he said. His girlfriend and friends know what to do, too.

A recently enacted New York law aims to ensure that naloxone is available if needed by people like Wilson who take prescription opioids.

Under the law, which took effect this summer, doctors must co-prescribe naloxone to certain patients who are at risk of an overdose when writing the patients’ first opioid prescription each year. Risk factors that would trigger the requirement include taking a high daily dose of an opioid (at least 90 morphine milligram equivalents, or MME); taking certain other drugs, like sedative hypnotics; or having a history of substance use disorder.

At least 10 other states have similar laws, according to research by the Network for Public Health Law.

“Sometimes patients, especially if they’ve been taking opioids for a long time, don’t understand the risks,” said Dr. Laila Khalid, co-director of the chronic pain clinic at Montefiore Medical Center. The clinic provides free naloxone to patients through the state’s opioid overdose prevention program.

Someone may forget the timing of their last dose and inadvertently take too much, for example, or have a few extra drinks at a party, Khalid said. Alcohol and some medications, like benzodiazepines, amplify opioids’ effects.

“Drug overdose deaths continue to climb, as they have nearly every year for more than two decades,” said Emily Einstein, chief of the Science Policy Branch at the National Institute on Drug Abuse. In 2021, Einstein noted, overdose deaths in the United States topped an estimated 100,000 for the first time, according to provisional data from the Centers for Disease Control and Prevention. According to this provisional data, Einstein said, the vast majority of those deaths — over 80,000 — involved opioids. While most opioid overdose deaths were attributable to illicit fentanyl, approximately 17,000 deaths involved prescription opioids, including methadone.

Naloxone, available as either a nasal spray or injection, is considered safe and causes few side effects. It’s not addictive. The CDC recommends that people at risk of overdose carry it with them so that a family member or bystander can administer it if necessary.

Experts in drug policy point to a key statistic that laws like the one in New York aim to address: In nearly 40% of overdose deaths, another person is present, according to the CDC.

If bystanders had had naloxone, “most of those people wouldn’t have died,” said Corey Davis, director of the Harm Reduction Legal Project at the Network for Public Health Law.

In every state, including New York, pharmacists are authorized to dispense naloxone, often under “standing orders” that allow dispensing without a prescription, typically to people who are at risk of overdose or are in a position to help someone at risk.

So then why require physicians to write scripts?

Mandating is more effective than recommending, experts said. By requiring physicians to prescribe the drug, more people who might need naloxone would have it on hand — if they fill the prescription. But there’s no guarantee they will.

A prescription can also help remove the lingering stigma of asking for an overdose drug at the pharmacy counter.

“It removes friction points,” said Davis. “You just drive through the window and pick it up.”

In a 2019 analysis, pharmacists in states that required co-prescribing naloxone with opioids filled nearly eight times as many naloxone prescriptions per 100,000 people as those in states that didn’t require it.

Missouri doesn’t have a co-prescribing law, but Danielle Muscato’s pain management doctor recently suggested she carry Narcan. The 38-year-old civil rights activist, who lives in Columbia, takes the prescription opioid tramadol and several other drugs to keep her chronic severe lower back pain in check. She’s glad to have the nasal spray tucked in her purse, just in case.

“I think it’s a wonderful thing” that people carry it and know how to use it, she said. “I wish this was standard everywhere.”

Since the New York law went into effect, “I have definitely seen an uptick of prescribers adding naloxone to opioids, especially if it’s a large order,” said Ambar Keluskar, pharmacy manager at Rossi Pharmacy in Brooklyn.

Patients don’t always understand why they’re getting it, though, said Toni Tompkins, supervising pharmacist at Phelps Hometown Pharmacy in the upstate New York town of Phelps.

A two-dose package of naloxone spray typically costs about $150. The medication is now available in generic form, which may reduce the out-of-pocket cost. Most insurers cover it, although patients typically owe a copayment. The uninsured can generally get naloxone through state programs.

In New York, private insurers are required to cover naloxone, and Medicaid also covers it, said Monica Pomeroy, a spokesperson for the state health department. The state’s Naloxone Co-Payment Assistance Program (N-CAP) covers the cost of copays up to $40 for those with insurance, Pomeroy said. Uninsured people or those with unmet deductibles can get it free at one of the state’s opioid overdose prevention sites.

In November, the FDA announced it is considering making naloxone available without a prescription.

Although offering it over the counter would make the drug easier to get, some people are concerned that insurance might not cover it. Further, “if a patient is just picking it up somewhere without getting any guidance on how to use it, that could be a downside,” said Anne Burns, vice president of professional affairs at the American Pharmacists Association.

Some professionals believe naloxone should be dispensed with every opioid prescription, regardless of risk factors. In Rochester, New York, and surrounding Monroe County, that’s what happens. In 2021, the county executive, Adam Bello, signed Maisie’s Law, named after a local 9-month-old girl who died after swallowing a methadone pill she found on a neighbor’s kitchen floor.

“It’s horrible what happened,” said Karl Williams, a pharmacy law professor and chair of the board of the Pharmacists Society of the State of New York. “Maybe it’s a next-level standard that should become law.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Hospitals Have Been Slow to Bring On Addiction Specialists

Hospitals have specialists ready to offer consult and care for concerns from cancer to childbirth but often no one with expertise in addiction medicine. Patients with a history of substance use — who are discharged without care — are at risk for overdose.

In December, Marie, who lives in coastal Swampscott, Massachusetts, began having trouble breathing. Three days after Christmas, she woke up gasping for air and dialed 911.

“I was so scared,” Marie said later, her hand clutched to her chest.

Marie, 63, was admitted to Salem Hospital, north of Boston. The staff treated her chronic obstructive pulmonary disease, a lung condition. A doctor checked on Marie the next day, said her oxygen levels looked good, and told her she was ready for discharge.

We are not using Marie’s last name because she, like 1 in 9 hospitalized patients, has a history of addiction to drugs or alcohol. Disclosing a diagnosis like that can make it hard to find housing, a job, and even medical care in hospitals, where patients with an addiction might be shunned.

But talking to the doctor that morning, Marie felt she had to reveal her other medical problem.

“‘I got to tell you something,’” Marie recalled saying. “‘I’m a heroin addict. And I’m, like, starting to be in heavy withdrawal. I can’t — literally — move. Please don’t make me go.’”

At many hospitals in Massachusetts and across the country, Marie would likely have been discharged anyway, still in the pain of withdrawal, perhaps with a list of local detox programs that might provide help.

Discharging a patient without specialized addiction care can mean losing a crucial opportunity to intervene and treat someone at the hospital. Most hospitals don’t have specialists who know how to treat addiction, and other clinicians might not know what to do.

Hospitals typically employ all sorts of providers who specialize in the heart, lungs, and kidneys. But for patients with an addiction or a condition related to drug or alcohol use, few hospitals have a clinician — whether that be a physician, nurse, therapist, or social worker — who specializes in addiction medicine.

That absence is striking at a time when overdose deaths in the U.S. have reached record highs, and research shows patients face an increased risk of fatal overdose in the days or weeks after being discharged from a hospital.

“They’re left on their own to figure it out, which unfortunately usually means resuming [drug] use because that’s the only way to feel better,” said Liz Tadie, a nurse practitioner certified in addiction care.

In fall 2020, Tadie was hired to launch a new approach at Salem Hospital using $320,000 from a federal grant. Tadie put together what’s known as an “addiction consult service.” The team included Tadie, a patient case manager, and three recovery coaches, who drew on their experiences with addiction to advocate for patients and help them navigate treatment options.

After Marie asked her doctor to let her stay in the hospital, he called Tadie for a bedside consultation.

Tadie started by prescribing methadone, a medication to treat opioid addiction. Although many patients do well on that drug, it didn’t help Marie, so Tadie switched her to buprenorphine, with better results. After a few more days, Marie was discharged and continued taking buprenorphine.

Marie also continued seeing Tadie for outpatient treatment and turned to her for support and reassurance: “Like, that I wasn’t going to be left alone,” Marie said. “That I wasn’t going to have to call a dealer ever again, that I could delete the number. I want to get back to my life. I just feel grateful.”

Tadie helped spread the word among Salem’s clinical staff members about the expertise she offered and how it could help patients. Success stories like Marie’s helped make the case for addiction medicine — and helped unravel decades of misinformation, discrimination, and ignorance about patients with an addiction and their treatment options.

The small amount of training that doctors and nurses get is often unhelpful.

“A lot of the facts are outdated,” Tadie said. “And people are trained to use stigmatizing language, words like ‘addict’ and substance ‘abuse.’”

Tadie gently corrected doctors at Salem Hospital, who, for example, thought they weren’t allowed to start patients on methadone in the hospital.

“Sometimes I would recommend a dose and somebody would give pushback,” Tadie said. But “we got to know the hospital doctors, and they, over time, were like, ‘OK, we can trust you. We’ll follow your recommendations.’”

Other members of Tadie’s team have wrestled with finding their place in the hospital hierarchy.

David Cave, one of Salem’s recovery coaches, is often the first person to speak to patients who come to the emergency room in withdrawal. He tries to help the doctors and nurses understand what the patients are going through and to help the patients navigate their care. “I’m probably punching above my weight every time I try to talk to a clinician or doctor,” Cave said. “They don’t see letters after my name. It can be kind of tough.”

Naming addiction as a specialty, and hiring people with specific training, is shifting the culture of Salem Hospital, said social worker Jean Monahan-Doherty. “There was finally some recognition across the entire institution that this was a complex medical disease that needed the attention of a specialist,” Monahan-Doherty said. “People are dying. This is a terminal illness unless it’s treated.”

This approach to treating addiction is winning over some Salem Hospital employees — but not all.

“Sometimes you hear an attitude of, ‘Why are you putting all this effort into this patient? They’re not going to get better.’ Well, how do we know?” Monahan Doherty said. “If a patient comes in with diabetes, we don’t say, ‘OK, they’ve been taught once and it didn’t work, so we’re not going to offer them support again.’”

Despite lingering reservations among some Salem clinicians, the demand for addiction services is high. Many days, Tadie and her team have been overwhelmed with referrals.

Four other Massachusetts hospitals added addiction specialists in the past three years using federal funding from the HEALing Communities Study. The project is paying for a wide range of strategies across several states to help determine the most effective ways to reduce drug overdose deaths. They include mobile treatment clinics; street outreach teams; distribution of naloxone, a medicine that can reverse an opioid overdose; rides to treatment sites; and multilingual public awareness campaigns.

It’s a new field, so finding staff members with the right certifications may be a challenge. Some hospital leaders say they’re worried about the costs of addiction treatment and fear they’ll lose money on the efforts. Some doctors report not wanting to initiate a medication treatment while patients are in the hospital because they don’t know where to refer patients after they’ve been discharged, whether that be to outpatient follow-up care or a residential program. To address follow-up care, Salem Hospital started what’s known as a “bridge clinic,” which offers outpatient care.

Dr. Honora Englander, a national leader in addiction specialty programs, said the federal government could support the creation of more addiction consult services by offering financial incentives — or penalties for hospitals that don’t embrace them.

At Salem Hospital, some staffers worry about the program’s future. Tadie is starting a new job at another hospital, and the federal grant ended June 30. But Salem Hospital leaders say they are committed to continuing the program and the service will continue.

This story is part of a partnership that includes WBUR, NPR and KHN.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Journalists Dig In on the Fiscal Health of the Nation and Hospital Closures in Rural Missouri

KHN and California Healthline staff made the rounds on national and local media this week to discuss their stories. Here’s a collection of their appearances.

KHN chief Washington correspondent Julie Rovner discussed health care costs and the fiscal health of Medicare and Social Security on C-SPAN’s “Washington Journal” on Sept. 28. She also discussed President Joe Biden’s comments about the covid-19 pandemic being “over,” as well as health inflation, the government funding bill, and other domestic news on WAMU/NPR’s “1A” on Sept. 23.

KHN senior correspondent Sarah Jane Tribble discussed the collapse of two rural Missouri hospitals on The Eagle 93.9-KSSZ’s “Wake Up Mid-Missouri” on Sept. 26.

KHN senior correspondent Julie Appleby discussed the legal challenge to the Affordable Care Act provision that guarantees free preventive care benefits on Texas Public Radio’s “The Source” on Sept. 21.

KHN correspondent Brett Kelman discussed a recent Supreme Court ruling that may affect doctors charged with overprescribing opioids on Apple News’ “Apple News Today” on Sept. 30.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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This story can be republished for free (details).

¿Puede una inyección mensual frenar la adicción a opioides? Expertos dicen que sí

Una opción inyectable mensual para el tratamiento de la adicción a opioides no logra llegar a todos los que la necesitan por las trabas burocráticas para obtener el medicamento.

Oakland, California.- El doctor Andrew Herring tiene un objetivo claro con los pacientes que buscan medicamentos para tratar la adicción a opioides: persuadirlos de que reciban una inyección de buprenorfina de liberación prolongada.

En su clínica de adicciones en el Hospital Highland, un centro público en el corazón de Oakland, Herring promueve la administración de una inyección de buprenorfina en la barriga para proporcionar un mes de tratamiento, en lugar de recetar versiones orales que deben tomarse a diario.

Asegura que esta opción es un “cambio de juego” y que puede ser su única oportunidad de ayudar a un paciente vulnerable en riesgo de sobredosis.

En California, donde las muertes por sobredosis han estado aumentado, expertos en adicciones dicen que administrar un mes de medicamento tiene un gran potencial, particularmente para las personas sin vivienda o que luchan contra otras formas de inestabilidad.

Sin embargo, el uso de buprenorfina inyectable sigue siendo bastante limitado, especialmente en comparación con otras formas de medicación para la adicción. Los investigadores aún tienen que publicar estudios que comparen diferentes formas de administrar buprenorfina.

La buprenorfina, uno de los tres medicamentos aprobados en los Estados Unidos para tratar el trastorno por uso de opioides, funciona uniéndose a los receptores de opioides en el cerebro y reduciendo las ansias y los síntomas de abstinencia.

Así, si un paciente toma una dosis alta de una droga como la heroína o el fentanilo, es menos probable que sufra una sobredosis. Los pacientes a menudo usan buprenorfina durante años.

Si Herring receta un suministro de buprenorfina en forma de tableta o de una tira que se coloca debajo de la lengua, el paciente debe comprometerse a tomar el medicamento al menos una vez al día, y muchos dejan de hacerlo.

“Es como algo religioso: tienes que levantarte cada mañana y repetir tus votos”, dijo Herring. “En realidad, hay muchas personas que merecen un tratamiento y que no pueden cumplir con ese requisito”.

Las formas orales de buprenorfina han estado disponibles para tratar la adicción desde 2002 y se pueden comprar como genéricos por menos de $100 al mes.

La buprenorfina inyectable, vendida bajo la marca Sublocade, recibió la aprobación de la FDA en 2017. Tiene un precio de lista alto, de $1,829.05 por una inyección mensual. El fabricante Indivior reportó ganancias de $244 millones por la venta de la droga, solo el año pasado, y pronostica alcanzar los $1,000 millones. No hay disponible una versión genérica o competidora del medicamento.

La mayoría de los pacientes no pagarán el precio completo, dice Indivior, su fabricante, porque la mayoría de los planes de salud cubren el medicamento. Los médicos, sin embargo, dicen que el alto costo puede ser una barrera para los pacientes con planes privados, que a veces se resisten a cubrir el medicamento.

Medi-Cal, el programa de seguro médico de California para personas de bajos ingresos, cubre Sublocade sin autorización previa, lo que hace que el tratamiento sea accesible para la mayoría de los pacientes de Herring.

Aún así, expertos en adicciones dicen que el uso de Sublocade sigue siendo limitado debido a los obstáculos normativos necesarios para administrarlo.

Los proveedores deben registrarse en la Administración de Control de Drogas (DEA) y obtener una exención para recetar buprenorfina porque se considera una sustancia controlada. Además, las clínicas deben completar un programa de certificación de seguridad de la FDA para dispensar el medicamento. Y solo puede pedirse a través de una farmacia especializada, aprobada por la FDA.

“En muchos hospitales, eso significará un retraso en la obtención de este medicamento o simplemente optar por no recibirlo”, dijo el doctor Rais Vohra, director regional de California Bridge Network, un programa financiado por el estado que apoya a los hospitales para que ofrezcan tratamiento para adicciones, incluida la clínica de Herring.

Vohra dijo que el Centro Médico Regional Comunitario en Fresno, donde trabaja como médico de emergencia, todavía está revisando los requisitos para ver si la farmacia del hospital puede distribuir el medicamento, lo que lo convertiría en uno de los pocos proveedores del Valle Central.

La buprenorfina oral, por el contrario, es una receta simple que la mayoría de las farmacias locales tienen en stock.

“Todos los obstáculos que los médicos y los pacientes tienen que superar para obtener este medicamento son una locura. No hacemos eso para ninguna otra enfermedad”, dijo la doctora Hannah Snyder, quien dirige la clínica de adicciones en el Hospital General Zuckerberg de San Francisco.

Varios médicos señalaron que el acceso sigue siendo un problema incluso con formas orales de buprenorfina. A pesar de una cascada de estudios que prueban la eficacia del tratamiento asistido por medicamentos, muchos médicos se resisten a recetarlo, especialmente en comunidades de color.

“La pregunta más importante no es si la bupre inyectable de acción prolongada es una mejor solución”, dijo el doctor Michael Ostacher, profesor de la Escuela de Medicina de la Universidad de Stanford, que compara las versiones inyectables y orales de buprenorfina a través de Veteran Affairs. “La pregunta más importante es cómo aumentamos el acceso al tratamiento para todas las personas que lo necesitan”.

Angela Griffiths se encuentra entre los pacientes que dicen que Sublocade ha cambiado sus vidas. Griffiths, de 41 años, de San Francisco, usó heroína durante 18 años. Cuando estaba embarazada de su hija en 2016, los médicos le recetaron metadona, lo que la hizo sentir “miserable”. Hace tres años cambió a tiras de buprenorfina, pero llevar las tiras a todas partes todavía la hacía sentir atada a su adicción.

Cuando los médicos de la clínica general de SF la cambiaron a inyecciones mensuales de Sublocade, describió el cambio como “extraordinario”.

En los estados donde los planes de Medicaid aún pueden requerir autorización previa, las esperas para Sublocade pueden extenderse a meses. Al otro lado de la frontera, en la clínica Northern Nevada Hopes en Reno, Nevada, por ejemplo, la doctora Taylor Tomlinson dijo que les dice a los pacientes que, entre las batallas por la cobertura y los retrasos en las farmacias, es posible que tengan que esperar dos meses para recibir una inyección.

“El tiempo de espera crea una barrera para la atención”, opinó Tomlinson

El programa de Medicaid de California no requiere autorización previa, pero proporcionar Sublocade sigue siendo un desafío. Herring ha podido reducir parte de la burocracia en su clínica de Oakland trabajando con la farmacia de Highland para almacenar y distribuir Sublocade.

Tan pronto como un paciente acepta una inyección, Herring simplemente llama a la farmacia al final del pasillo y se la administra en el acto.

Herring ve la urgencia de aumentar el uso de buprenorfina inyectable a medida que aumenta el uso de fentanilo en California. Durante años, el mortal opioide sintético se concentró principalmente en la costa este; en 2018, el 88% de estas muertes ocurrieron en los 28 estados al este del río Mississippi.

Pero más recientemente, el fentanilo ha comenzado a infiltrarse en los estados occidentales. De 2018 a 2020, las muertes por sobredosis de fentanilo en California se quintuplicaron, según datos estatales.

“Nadie entiende a lo que se enfrenta”, dijo Herring sobre la potencia del fentanilo. “Este es el momento en el que ocurrirán un mayor número de muertes”.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Can a Monthly Injection Be the Key to Curbing Addiction? These Experts Say Yes

In California, where overdose deaths are on the rise, physicians say administering anti-addiction medication as a monthly injection holds tremendous potential. So, why aren’t more patients getting it?

OAKLAND, Calif. — Dr. Andrew Herring has a clear goal walking into every appointment with patients seeking medication to treat an opioid use disorder: persuade them to get an injection of extended-release buprenorphine.

At his addiction clinic at Highland Hospital, a bustling public facility in the heart of Oakland, Herring promotes administering a shot of buprenorphine in the belly to provide a month of addiction treatment rather than prescribing oral versions that must be taken daily. For him, the shots’ longer-acting protection is a “game changer” and may be his only chance to help a vulnerable patient at risk of overdose.

“At any point in time, they’re just a balloon that’s going to go,” Herring said. “You might only have this one interaction. And the question is, how powerful can you make it?”

In California, where overdose deaths have been rising for years, addiction experts say administering a month’s worth of anti-addiction medication holds great potential, particularly for people without housing or who struggle with other forms of instability. Yet despite its promise, the use of injectable buprenorphine remains fairly limited, especially compared with other forms of addiction medication. Researchers have yet to publish studies comparing different ways to administer buprenorphine.

Buprenorphine, one of three medications approved in the U.S. to treat opioid use disorder, works by binding to opioid receptors in the brain and reducing cravings and withdrawal symptoms. And because it occupies those receptor sites, buprenorphine keeps other opioids from binding and ensures that if a patient takes a high dose of a drug like heroin or fentanyl, they are less likely to overdose. Patients often stay on buprenorphine for years.

If Herring prescribes a supply of buprenorphine as a tablet or film that is placed under the tongue, the patient must commit to taking the medication at least once a day, and many fall out of treatment. He said this is especially true for his patients experiencing homelessness and those who also use methamphetamine.

“It’s like a religious thing — you have to wake up every morning and repeat your vows,” said Herring. “In reality, there are a lot of people who deserve treatment who can’t meet that requirement.”

Oral forms of buprenorphine have been available to treat addiction since 2002 and can be purchased as a generic for less than $100 a month. Injectable buprenorphine, sold under the brand name Sublocade, received FDA approval in 2017. It has a hefty list price of $1,829.05 for a monthly injection. The drugmaker Indivior reported $244 million in revenue from Sublocade last year alone, with a company goal to eventually make $1 billion in annual sales. No generic or competing version of the drug is available.

Most patients won’t pay full price, Indivior says, because most health plans cover the drug. Physicians, however, say the high cost can be a barrier for patients with private health plans, which sometimes resist covering the medication. Medi-Cal, California’s health insurance program for low-income people, covers Sublocade without prior authorization, making the treatment accessible to the majority of Herring’s patients.

Still, addiction experts say, Sublocade use remains limited because of the regulatory hurdles required to dispense it.

Providers must register with the U.S. Drug Enforcement Administration and obtain a waiver to prescribe buprenorphine because it’s considered a controlled substance. In addition, clinics must complete an FDA safety certification program to dispense the medication. And Sublocade can be ordered only by a specialty pharmacy, which must also pass the FDA program.

“At many hospitals, that will mean either a delay in getting this medication on our shelves or just opting out,” said Dr. Rais Vohra, regional director for the California Bridge Network, a state-funded program that supports hospitals in offering treatment for substance use disorders, including Herring’s clinic.

Vohra said Community Regional Medical Center in Fresno, where he works as an emergency physician, is still looking through the documentation requirements to see if the hospital’s pharmacy can distribute the medication — which would make it one of the few Central Valley providers to do so.

Oral buprenorphine, by contrast, is a simple prescription that most local drugstores keep in stock.

“All the hoops that clinicians and patients have to jump through to get this medication is crazy. We don’t do that for any other disease,” said Dr. Hannah Snyder, who runs the addiction clinic at Zuckerberg San Francisco General Hospital across the bay.

Several clinicians noted that access remains a problem even with oral forms of buprenorphine. Despite a cascade of studies proving the effectiveness of medication-assisted treatment, many patients across the country struggle to find a provider willing to prescribe buprenorphine in any form — especially in communities of color.

“The most important question isn’t whether long-acting injectable bupe is a better solution than sublingual buprenorphine for opioid use disorder,” said Dr. Michael Ostacher, a professor at Stanford University School of Medicine, who is comparing injectable and oral versions of buprenorphine through Veterans Affairs. “The bigger question is how we increase access to treatment for all people who need [the medication].”

Angela Griffiths is among the patients who say Sublocade has changed their lives. Griffiths, 41, of San Francisco, used heroin for 18 years. When she was pregnant with her daughter in 2016, doctors put her on methadone, which made her feel “miserable.” Three years ago, she said, she switched to buprenorphine films, but carrying the strips with her everywhere still made her feel tied to her addiction.

“The ritual of taking something every day plays something in your mind,” Griffiths said.

When doctors at the SF General clinic switched her to monthly Sublocade injections, she described the change as “extraordinary.”

“I’m not reaching for my drawer anymore for a fix,” she said. “I have the freedom to wake up and start my day however I want, whether it’s to go to the patio and drink a cup of coffee or to snuggle with my daughter in bed a little longer. It’s there; I don’t have to take anything.”

In states where Medicaid plans may still require prior authorization, waits for Sublocade can stretch into months. Across the border at the Northern Nevada Hopes clinic in Reno, Nevada, for example, Dr. Taylor Tomlinson said she tells patients that between battles for coverage and pharmacy delays, they might have to wait two months for an injection.

“I’m always going to offer it to a patient who I think would be a good candidate, but in the time they have to wait, they get interested in other things,” said Tomlinson. “It creates a barrier to care.”

California’s Medicaid program does not require prior authorization but providing Sublocade is still a challenge. At the Placerville clinic supported by the California Bridge Network, Dr. Juliet La Mers, the director, said a quarter of her buprenorphine patients get injections. Still, they often wait two weeks before Sublocade arrives from the specialty pharmacy.

Herring has been able to cut through some of that red tape at his Oakland clinic by working with the Highland pharmacy to stock and distribute Sublocade. As soon as a patient agrees to an injection, Herring simply calls the pharmacy down the hall and administers it on the spot.

Herring sees urgency — and opportunity — to increase the use of injectable buprenorphine as fentanyl use rises across California. For years, the deadly synthetic opioid was concentrated mostly on the East Coast; in 2018, 88% of deaths from synthetic opioids occurred in the 28 states east of the Mississippi River. But more recently, fentanyl has begun to infiltrate Western states. From 2018 to 2020, deaths from fentanyl overdoses in California quintupled, according to state data.

“No one understands what they’re dealing with,” Herring said of fentanyl’s potency. “This is the time where our greatest deaths are going to occur.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Readers And Tweeters Dive Into Debate Over ‘Medicare For All’

Kaiser Health News gives readers a chance to comment on a recent batch of stories.

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

Savings For All?

Your criticism about former Vice President Joe Biden’s “Medicare for All” cost estimates is spot-on but leaves out important savings (“KHN & PolitiFact HealthCheck: Would ‘Medicare For All’ Cost More Than U.S. Budget? Biden Says So. Math Says No,” Feb. 14). Under Biden’s plan, private insurance stays intact, meaning there are premiums and point-of-service costs that do not appear as taxes but are added to the nation’s health care expense. Medicare for All, on the other hand, is zero at the point of service, meaning Americans would have no financial qualms seeking comprehensive care. Public options add bureaucratic costs, are subject to personal income fluctuations and have deductibles and copays. We depend on organizations like yours to present the full picture. Here’s hoping you will, in the public’s interest.

― Dr. Donald Green, Pennington, New Jersey

— Manuel Freire, Fort Lauderdale, Florida

For Alzheimer’s Patients Like Me, Knowing Is Half The Battle

I want to thank Judith Graham for her piece discussing the uncertainty and fear patients feel when faced with the potential onset of Alzheimer’s disease or dementia (“Stalked By The Fear That Dementia Is Stalking You,” Feb. 21).

As an Alzheimer’s patient with a confirmed diagnosis, I know all too well how unsettling it can be to suffer from cognitive decline without knowing the nature of your condition. For me, it started with little things like forgetting a name or misplacing a set of house keys. Still, it wasn’t until I applied to participate in an Alzheimer’s clinical trial and received a PET scan identifying amyloid protein buildup in my brain did I definitively know I had the disease.

Like many of the patients discussed in the article, dealing with these early warning signs can be an enormous source of anxiety — especially when it’s unclear whether or not the cause is Alzheimer’s or another cognitive issue. That’s why getting a precise diagnosis was such a critical step for myself and my husband, Jim.

As mentioned in the article, amyloid PET scans are not fully covered by Medicare, a critically important detail, which I believe must be remedied. As the prevalence of Alzheimer’s continues to grow as our population ages, expanding access to diagnostic tools that can identify this disease will become ever more critical. I remain optimistic that our representatives in Washington can come together and address this issue ― so more patients like me don’t have to live under a cloud of uncertainty.

— Geri Taylor, New York City

An Infusion Of Debt

Glad you are pointing this out (“Patients Stuck With Bills After Insurers Don’t Pay As Promised,” Feb. 7). It’s happening again, post-Affordable Care Act. For us, it’s my husband’s battle with multiple sclerosis, but more the battle with his insurer. It approved his treatment cost for a new drug, sent a letter saying everything was covered. Then, lo and behold, we get a bill for $4,000 that it said we had to pay. No reason or rationale given. So now we are on a payment plan with the hospital that gave him his infusion. Not sure why we even bother with paying our premiums in the first place, considering the out-of-pocket expense and worthlessness of preapprovals; it doesn’t really matter. Please keep writing these articles ― it helps.

― Margaret Paez, Los Angeles

When Choice Of Hospitals Is A Life-Or-Death Choice

Thanks so much for your coverage of death-with-dignity situations (“Terminally Ill, He Wanted Aid-In-Dying. His Catholic Hospital Said No,” Jan. 29). We all need to know as much as possible about the institutions and structures that may prevent patients from choosing a dignified death. Please consider linking to the Catholic ethics rules so readers can read them for themselves. Please make us a map of Colorado showing the hospitals that are abiding by these rules. Please explain that emergency services in rural areas may have no choice but to take patients to the nearest (possibly non-law-abiding) hospital. Rewired has written about Eastern hospitals where serious pregnancy issues were poorly treated by Catholic hospitals.

Many of us do not understand that hospital choice may become a life choice and doctor choice may also become a life choice. And, please, also feature regularly and loudly all the practitioners and organizations being formed to protect patients’ legal right to die. Thanks so much for the good work that you do.

― Diane Curlette, Boulder, Colorado

Taking Pains Over Statistics

In stories about the opioid crisis (“No Quick Fix: Missouri Finds Managing Pain Without Opioids Isn’t Fast Or Easy,” Feb. 13), I always see total death statistics but never a breakdown of how many of the fatalities represent responsible legal users vs. illegal users.

A lot of us elderly folks have a very hard time getting our pain meds nowadays. Thirty used to last me five to seven months, and I took them only when I couldn’t get to sleep due to pain throughout my body. We have discussed it on our seniors’ webpage in our rural area and many of us used to get them. Overdoses and addiction aren’t the norm and aren’t even in the realm of our experiences. Why do we have to pay for others’ mistakes? They don’t outlaw cars even though many people die from wrecks caused by bad drivers!

― William Scriven, Valley Springs, California

— Nicolas Terry, Indianapolis

Collateral Damage From Insurers’ Dispute

When I read Brian Krans’ article about the Dignity-Cigna dispute (“Patients Caught In Crossfire Between Giant Hospital Chain, Large Insurer,” Feb. 6), I was reminded of my own situation: In California, Oscar dropped coverage for all UCLA care facilities in its Covered California (Affordable Care Act) plans, as of this year. I don’t know how many people use Oscar, but the UCLA system is a major health care provider here in West L.A. There’s no indication that there’s a dispute — this is represented as a final decision. UCLA is gone!

I figured I could get similar care from the Providence network, but my first choice for a primary care physician proved a bit odd: On our first visit, he presented at least four ideas that seem outside the medical mainstream. With some embarrassment, I asked for a different PCP. That physician ordered lab work but said no one in the building was authorized by Oscar to do blood draws, so I was sent to a facility in another city … which turned out to be out of business. I was finally referred to a third facility, which turned out to be more convenient than the last ― but the inconvenient run-around for something as simple as a blood draw and the penny-pinching by my insurance company do not bode well for the future of American medicine.

This is the second disruption I’ve had in insurance providers since the ACA began, and another indication that our current health care system is still very broken.

— Gary Davis, Los Angeles

— Scott Gordon, Fennimore, Wisconsin

Raising A Red Flag On Animal Rights Group

As a registered dietitian, I do not promote the keto diet. Mentioned in the article “As VA Tests Keto Diet To Help Diabetic Patients, Skeptics Raise Red Flags” (Feb. 3) is the group Physicians for Responsible Medicine, which is an extreme animal rights group with ties to PETA. About 3% of its members are physicians. Attending a seminar on nutrition for cardiovascular disease, I was dismayed to see the speaker had ties to Physicians for Responsible Medicine. After hearing about all the terrible effects of eating animal products, when the speaker could no longer contain himself and shouted out, “You don’t eat dead animals, do you?” I walked out and called my professional association to complain. Please do not give credibility to this organization.

― Mary Lucius, Beavercreek, Ohio

— Nancy Coney, South Bend, Indiana

Price-Gouging At Its Core

I read your most recent story on surprise medical billing (“When Your Doctor Is Also A Lobbyist: Inside The War Over Surprise Medical Bills,” Feb. 12) and found it to be largely one-sided against physicians and, somewhat, hospitals. Although private equity certainly is an influence in the conversation, very little to any time was spent discussing the efforts of insurance companies to continually drive down reimbursements. Furthermore, when we look at Medicare rates, which insurance companies rates are based on, the actual reimbursement has not significantly increased over the past few decades when you account for inflation or the consumer price index. So to paint the picture that physicians are trying to gouge patients does not seem very fair. While there are always a few bad apples and opportunists, the majority of physicians simply want to be paid fairly. Remember: Over the past few years, insurance companies have reported record profits — billions per fiscal quarter. Why are we not talking about why more of our premiums are not going to the provision of health care and instead to shareholders? I think the article fails to paint the entire picture for a lay audience. Nowhere does it report the amount of money spent on lobbying by the insurance industry.

― Dr. Shamie Das, Atlanta

— Gene Christian, Memphis, Tennessee

Health Care’s High-Cost Formula Goes Beyond Drug Prices

What patients care about more than drug prices is how much they have to pay out-of-pocket for their critical medications (“Watch: Let’s Talk About Trump’s Health Care Policies,” Feb. 4). Because of high-deductible health plans and tiered formularies, what patients pay at the pharmacy counter often has less to do with the list price of the drugs they need and more to do with the design of their health benefits. It is especially troubling that high-value drugs for chronic conditions like diabetes are often subject to unaffordable cost sharing that hits disproportionately at the beginning of the benefit year. Employers and health plans need to exempt these drugs from high deductibles as now permitted by the IRS. The same goes for Medicare Part D, which hugely penalizes seriously ill patients at the start of each year when they have yet to reach the catastrophic threshold.

Clearly, the problem of high drug prices needs to be addressed, but this will require a systematic and comprehensive approach that is certain to be resisted by one vested interest or another. In the meantime, patients need immediate relief from unaffordable out-of-pocket costs. Some steps that should be taken immediately include exempting high-value care from plan deductibles and capping and smoothing out-of-pocket costs in Medicare Part D. Much, if not all, of the cost associated with these measures can be offset by not paying for low- and no-value care that costs billions per year.

― Daniel Klein, president & CEO of the Patient Access Network (PAN) Foundation, Washington, D.C.

Cause For Investigation

The example you give presents an illegal activity by the home health agency (“Why Home Health Care Is Suddenly Harder To Come By For Medicare Patients,” Feb. 3). At a minimum, that agency should have a complaint registered against them, if not investigated by the Office of the Inspector General. The agency lied about Medicare not covering the patient’s needs. And they should have had the patient sign an ABN/NOMNC (Advance Beneficiary Notice/Notice of Medicare Non-Coverage) and explained it to the patient as required, so he could choose to appeal with the Quality Improvement Organization (QIO) for coverage of medically necessary care.

Kaiser Health News needs to provide education for the elderly and families to make sure they don’t fall prey to this type of behavior. If the agency simply says “I don’t have the staff to cover you,” they are responsible to assist the patient in finding another agency. But they cannot elect to just stop providing a medically necessary service, just as they cannot keep seeing someone when it is not medically necessary. Key here is to get people to know their rights as a Medicare beneficiary.

― Edward Dieringer, Salt Lake City

— Tom Cassels, Arlington, Virginia

— Peg Graham, Washington, D.C.

Privacy Concern: I Lack Seamless Access To My Own Records

I work in a medical center and have taken HIPAA training repeatedly over the years. I have also noted the staggering amount of money spent on medical electronic records. Yet in four attempts over a 20-year period, I have yet to get my medical records sent from one doctor or practice to another. I could not get records of my husband’s hospital stay sent to his primary physician, dental records sent from one dentist to another and, this fall, the pertinent records when my rheumatologist changed practices. My insurance paid for blood tests four times a year and X-rays over a five-year period. I have contacted the facilities and submitted a complaint to HHS Office for Civil Rights, which appears to be the correct office.

I find it unacceptable that, with all the talk about how expensive medical care is, tests over time are not easily available to patients when requested. I read Kaiser Health News regularly and at least I feel informed about what can go wrong. Thank you.

— Susan Klimley, New York City

— Dr. Sarah Nguyen, Los Angeles