The Blackfeet Nation’s Plight Underscores the Fentanyl Crisis on Reservations

The deadly synthetic opioid has spread across the nation during the pandemic, and the problem is disproportionately affecting Native Americans.

BROWNING, Mont. — As the pandemic was setting in during summer 2020, Justin Lee Littledog called his mom to tell her he was moving from Texas back home to the Blackfeet Indian Reservation in Montana with his girlfriend, stepson, and son.

They moved in with his mom, Marla Ollinger, on a 300-acre ranch on the rolling prairie outside Browning and had what Ollinger remembers as the best summer of her life. “That was the first time I’ve gotten to meet Arlin, my first grandson,” Ollinger said. Another grandson was soon born, and Littledog found maintenance work at the casino in Browning to support his growing family.

But things began to unravel over the next year and a half. Friends and relatives saw Littledog’s 6-year-old stepson walking around town alone. One day, Ollinger received a call from her youngest son as one of Littledog’s children cried in the background. He was briefly unable to wake Littledog’s girlfriend.

Ollinger asked Littledog whether he and his girlfriend were using drugs. Littledog denied it. He explained to his mom that people were using a drug she had never heard about: fentanyl, a synthetic opioid that is up to 100 times as potent as morphine. He said he would never use something so dangerous.

Then, in early March, Ollinger woke up to screams. She left her grandchildren sleeping in her bed and went into the next room. “My son was laying on the floor,” she said. He wasn’t breathing.

She followed the ambulance into Browning, hoping that Littledog had just forgotten to take his heart medication and would recover. He was pronounced dead shortly after the ambulance arrived at the local hospital.

Littledog was among four people to die from fentanyl overdoses on the reservation that week in March, according to Blackfeet health officials. An additional 13 people who live on the reservation survived overdoses, making a startling total for an Indigenous population of about 10,000 people.

Fentanyl has taken root in Montana and in communities across the Mountain West during the pandemic, after formerly being prevalent mostly east of the Mississippi River, said Keith Humphreys of the Stanford-Lancet Commission on the North American Opioid Crisis.

Montana law enforcement officials have intercepted record numbers of pale-blue pills made to look like prescription opioids such as OxyContin. In the first three months of 2022, the Montana Highway Patrol seized over 12,000 fentanyl pills, more than three times the number from all of 2021.

Nationwide, at least 103,000 people died from drug overdoses in 2021, a 45% increase from 2019, according to data from the Centers for Disease Control and Prevention. About 7 of every 10 of those deaths were from synthetic opioids, primarily fentanyl.

Overdose deaths are disproportionately affecting Native Americans. The overdose death rate among Indigenous people was the highest of all racial groups in the first year of the pandemic and was about 30% higher than the rate among white people, according to a study co-authored by UCLA graduate student and researcher Joe Friedman.

In Montana, the opioid overdose death rate for Indigenous people was twice that of white people from 2019 to 2021, according to the state Department of Public Health and Human Services.

The reason, in part, is that Native Americans have relatively less access to health care resources, Friedman said. “With the drug supply becoming so dangerous and so toxic, it requires resources and knowledge and skills and funds to stay safe,” he said. “It requires access to harm reduction. It requires access to health care, access to medications.”

The Indian Health Service, which is responsible for providing health care to many Indigenous people, has been chronically underfunded. According to a 2018 report from the U.S. Commission on Civil Rights, IHS per patient expenditures are significantly less than those of other federal health programs.

“I think what we’re seeing now is deep-seated disparities and social determinants of health are kind of bearing out,” Friedman said, referring to the disproportionate overdose deaths among Native Americans.

Blackfeet Tribal Business Council member Stacey Keller said she has experienced the lack of resources firsthand while trying to get a family member into treatment. She said just finding a facility for detoxing was difficult, let alone finding one for treatment.

“Our treatment facility here, they’re not equipped to deal with opioid addiction, so they’re usually referred out,” she said. “Some of the struggles we’ve seen throughout the state and even the western part of the United States is a lot of the treatment centers are at capacity.”

The local treatment center doesn’t have the medical expertise to supervise someone going through opioid withdrawal. Only two detox beds are available at the local IHS hospital, Keller said, and are often occupied by other patients. The health care system on the reservation also doesn’t offer medication-assisted treatment. The nearest locations to get buprenorphine or methadone — drugs used to treat opioid addictions — are 30 to 100 miles away. That can be a burden to patients who are required by federal rules to show up each day at the approved dispensaries to receive methadone or must make weekly treks for buprenorphine.

Keller said tribal leaders have requested assistance from IHS to build out treatment and other substance use resources in the community, with no results.

The IHS’ Alcohol and Substance Abuse Program consultant, JB Kinlacheeny, said the agency has largely shifted to appropriating funds directly to tribes to run their own programs.

The Rocky Mountain Tribal Leaders Council, a consortium of Montana and Wyoming tribes, is working with the Montana Healthcare Foundation on a feasibility study for a treatment center operated by tribes to build capacity specifically for tribal members. Tribes across both states, including the Blackfeet, have passed resolutions supporting the effort.

Blackfeet political leaders declared a state of emergency in March after the fentanyl overdoses. A short time later, some of the tribal council chairman’s children were arrested on suspicion of selling fentanyl out of his home. The council removed Chairman Timothy Davis from his position as tribal leader in early April.

The tribe has created a task force to identify both the short- and long-term needs to respond to the opioid crisis. Blackfeet tribal police investigator Misty LaPlant is helping lead that effort.

Driving around Browning, LaPlant said she plans to train more people on the reservation to administer naloxone, a medication that reverses opioid overdoses. She also wants the tribe to host needle exchanges to reduce infections and the spread of diseases like HIV. There’s also hope, she said, that a reorganization of the tribal health department will result in a one-stop shop for Blackfeet Nation residents to find drug addiction resources on and off the reservation.

However, she said resolving some of the underlying issues — such as poverty, housing, and food insecurity — that make communities like the Blackfeet Nation vulnerable to the ongoing fentanyl crisis is a massive undertaking that won’t be completed anytime soon.

“You could connect historical trauma, unresolved traumas in general, and grief into what makes our community vulnerable,” she said. “If you look at the impact of colonialism and Indigenous communities and people, there’s a correlation there.”

Marla Ollinger is happy to see momentum building to fight opioid and fentanyl addiction in the wake of her son’s death and other people’s. As a mother who struggled to find the resources to save her son, she hopes no one else has to live through that experience.

“It’s heartbreaking to watch your children die unnecessarily,” she said.

This story is part of a partnership that includes Montana Public RadioNPR 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.

USE OUR CONTENT

This story can be republished for free (details).

El nuevo movimiento MADD: padres toman acción contra las muertes por drogas

Siguiendo el modelo de Mothers Against Drunk Driving, que generó un movimiento en la década de 1980, organizaciones como Victims of Illicit Drugs y Alexander Neville Foundation buscan aumentar la conciencia pública e influir en las políticas sobre drogas.

La vida tal como la conocía terminó para Matt Capelouto dos días antes de Navidad en 2019, cuando encontró a su hija de 20 años, Alexandra, muerta en la habitación de su infancia en Temecula, California. La ira superó al dolor cuando las autoridades dictaminaron que su muerte fue accidental.

La estudiante de segundo año de la universidad, que estaba pasando las vacaciones en casa, había tomado media pastilla que compró a un dealer a través de Snapchat. Resultó ser fentanilo, el poderoso opioide sintético que ayudó a que las muertes por sobredosis de drogas en los Estados Unidos ascendieran a más de 100,000 el año pasado.

“La envenenaron y a la persona que lo hizo no iba a pasarle nada”, dijo. “No pude soportarlo”.

Capelouto, quien se describe a sí mismo como políticamente moderado, dijo que la experiencia lo volvió cínico sobre la renuencia de California a imponer sentencias severas por delitos de drogas.

Así que el padre suburbano que una vez dedicó todo su tiempo a administrar su imprenta y criar a sus cuatro hijas, lanzó un grupo llamado Drug Induced Homicide y viajó a Sacramento en abril para cabildear por una legislación conocida como “Alexandra’s Law”.

El proyecto de ley habría facilitado que los fiscales de California condenaran a los vendedores de drogas letales por cargos de homicidio.

La organización de Capelouto es parte de un movimiento nacional de padres que se convirtieron en activistas, que luchan contra la cada vez más mortal crisis de las drogas, y están desafiando la doctrina de California de que las drogas deben ser tratadas como un problema de salud en lugar de ser procesadas por el sistema de justicia penal.

Siguiendo el modelo de Mothers Against Drunk Driving, que generó un movimiento en la década de 1980, organizaciones como Victims of Illicit Drugs y Alexander Neville Foundation buscan aumentar la conciencia pública e influir en las políticas sobre drogas. Un grupo, Mothers Against Drug Deaths, rinde homenaje a MADD tomando prestadas sus siglas.

Estos grupos presionan a los legisladores estatales para que impongan sanciones más estrictas a los distribuidores y a las empresas de tecnología de cabildeo para permitir que los padres controlen las comunicaciones de sus hijos en las redes sociales.

Colocan cartels en las calles que culpan a los políticos por la crisis de las drogas y organizan protestas de “muerte” contra los mercados de drogas al aire libre en Venice Beach, en Los Ángeles y el vecindario Tenderloin de San Francisco.

“Este problema se resolverá con los esfuerzos de base de las familias afectadas”, dijo Ed Ternan, quien lidera el grupo Song for Charlie, con sede en Pasadena, que se enfoca en educar a los jóvenes sobre los peligros de las píldoras falsificadas.

Muchos padres se movilizaron después de una ola de muertes que comenzó en 2019. A menudo, se trataba de estudiantes de secundaria o universitarios que pensaban que estaban tomando OxyContin o Xanax comprados en las redes sociales, pero en realidad estaban tomando pastillas que contenían fentanilo.

La droga llegó por primera vez a la costa este hace casi una década, en gran parte a través del suministro de heroína, pero desde entonces los cárteles mexicanos han introducido productos farmacéuticos falsificados mezclados con el polvo altamente adictivo en California y Arizona para atraer nuevos clientes.

En muchos casos, las víctimas de sobredosis son estudiantes sobresalientes o atletas estrella de los suburbios, lo que da lugar a un ejército de padres educados y comprometidos que desafían el silencio y el estigma que rodea a las muertes por drogas.

Ternan no sabía casi nada sobre el fentanilo cuando su hijo de 22 años, Charlie, murió en el dormitorio de la casa de su fraternidad en la Universidad de Santa Clara unas semanas antes de que se graduara en la primavera de 2020.

Los familiares determinaron a partir de los mensajes en el teléfono de Charlie que había tenido la intención de comprar Percocet, un analgésico recetado que había tomado después de una cirugía de espalda dos años antes. Los socorristas dijeron que el estudiante universitario de 6 pies y 2 pulgadas, y 235 libras, murió media hora después de tomar una píldora falsificada.

Ternan descubrió una serie de muertes similares en otras comunidades de Silicon Valley. En 2021, 106 personas murieron por sobredosis de fentanilo en el condado de Santa Clara, frente a las 11 de 2018. Las muertes incluían a un estudiante de segundo año de la Universidad de Stanford y a una niña de 12 años en San José.

Con la ayuda de dos ejecutivos de Google que perdieron a sus hijos a causa de las píldoras mezcladas con fentanilo, Ternan convenció a Facebook, Instagram, TikTok, YouTube y otras plataformas de redes sociales para que donaran espacios publicitarios para mensajes de advertencia sobre medicamentos falsificados.

La presión de los grupos de padres también ha impulsado a Snapchat, con sede en Santa Mónica, a implementar herramientas para detectar la venta de drogas y restricciones diseñadas para dificultar que los traficantes se dirijan a los menores.

Desde los primeros días de la epidemia de opioides, las familias de las personas que se enfrentan a la adicción y de las que han muerto por sobredosis se han apoyado mutuamente en los sótanos de las iglesias y en las plataformas en línea desde Florida hasta Oregon. Ahora, las organizaciones familiares que surgieron de la crisis del fentanilo en California han comenzado a cooperar entre sí.

Recientemente se formó una red de padres y otros activistas que se hace llamar la California Peace Coalition liderada por Michael Shellenberger, un autor y activista de Berkeley que se postula para gobernador como independiente.

Una crítica de las políticas progresistas de California es Jacqui Berlinn, una empleada de procesamiento legal en East Bay que inició Mothers Against Drug Deaths, un nombre que eligió como homenaje a los logros de la fundadora de Mothers Against Drunk Driving, Candace Lightner, ama de casa de Fair Oaks cuya hija de 13 años fue asesinada en 1980 por un conductor ebrio.

El hijo de Berlinn, Corey, de 30 años, ha consumido heroína y fentanilo durante siete años en las calles de San Francisco. “Mi hijo no es basura”, dijo Berlinn. “Se merece recuperar su vida”.

Berlinn cree que la decisión de la ciudad de no acusar a los traficantes ha permitido que florezcan los mercados de narcóticos al aire libre en ciertos vecindarios y el consumo de drogas, en lugar de alentar a las personas que enfrentan adicciones a buscar ayuda.

En abril, el grupo de Berlinn gastó $25,000 para erigir una valla publicitaria en el exclusivo distrito comercial de Union Square. Sobre una resplandeciente toma nocturna del puente Golden Gate, el letrero dice: “Famosos en todo el mundo por nuestros cerebros, belleza y, ahora, fentanilo sucio muy barato”.

Este mes, el grupo instaló un letrero a lo largo de la Interestatal 80 en dirección a Sacramento que apunta al gobernador demócrata Gavin Newsom.

Reproduciendo la señalización utilizada en los parques nacionales, la cartel presenta un saludo de “Bienvenido al Campamento Fentanyl” contra una toma de un campamento para personas sin hogar. El grupo dijo que una valla publicitaria móvil también rodeará el Capitolio estatal por un período no revelado.

Mothers Against Drug Deaths está pidiendo más opciones y fondos para el tratamiento de drogas y más arrestos de traficantes. Este último marcaría un giro brusco del evangelio de la “reducción de daños”, un enfoque de salud pública adoptado por funcionarios estatales y locales que considera que la abstención es poco realista.

En cambio, esta estrategia exige ayudar a las personas que enfrentan adicciones a mantenerse seguras a través de intercambios de agujas y naloxona, un fármaco para revertir la sobredosis que ha salvado miles de vidas.

Los fiscales progresistas Chesa Boudin en San Francisco y George Gascón en Los Ángeles han evitado encarcelar a los traficantes callejeros, a lo que llaman un juego sin sentido que castiga a las minorías pobres.

Los legisladores de California temen repetir los errores de la era de la guerra contra las drogas y han bloqueado una serie de proyectos de ley que endurecerían las sanciones por la venta de fentanilo. Dicen que la legislación lograría poco además de llenar las cárceles y prisiones del estado.

“Podemos encarcelar a la gente por mil años, y no evitará que la gente consuma drogas, y no evitará que mueran”, dijo el senador estatal Scott Wiener (demócrata de San Francisco). “Lo sabemos por experiencia”.

Algunos padres están de acuerdo. Después de ver a su hijo entrar y salir del sistema de justicia penal por cargos menores de drogas en la década de 1990, Gretchen Burns Bergman se convenció de que acusar a las personas por delitos menores de drogas, como la posesión, era contraproducente.

En 1999, la productora de desfiles de moda de San Diego inició A New Path, que ha abogado por la legalización de la marihuana y el fin de la ley de los “tres strikes” de California. Una década más tarde, formó Moms United to End the War on Drugs, una coalición nacional. Hoy, sus dos hijos se han recuperado de la adicción a la heroína con la ayuda de un “apoyo compasivo” y trabajan como consejeros de drogas, dijo.

“He estado en esto el tiempo suficiente para ver el movimiento pendular”, dijo Burns Bergman sobre las opiniones cambiantes del público sobre la aplicación de la ley.

En diciembre, Brandon McDowell, de 22 años, de Riverside, fue arrestado y acusado de vender la tableta que mató a la hija de Matt Capelouto. McDowell fue acusado de distribuir fentanilo con resultado en muerte, lo que conlleva una sentencia mínima obligatoria de 20 años en una prisión federal.

Aunque Alexandra’s Law no logró salir del comité, Capelouto señaló que años se dedicaron años de cabildeo hasta que se aprobaron leyes más estrictas sobre conducir en estado de ebriedad. Prometió no renunciar al proyecto de ley que lleva el nombre de su hija, que escribía poesía y amaba a David Bowie.

“Voy a estar de nuevo frente a ellos”, dijo, “Cada año”.

Esta historia fue producida por KHN, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

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.

USE OUR CONTENT

This story can be republished for free (details).

The New MADD Movement: Parents Rise Up Against Drug Deaths

People who have lost children to pills laced with fentanyl are demanding that lawmakers adopt stricter penalties and are pressuring Silicon Valley for social media protections. The movement harks back to the 1980s, when Mothers Against Drunk Driving activated a generation of parents.

Life as he knew it ended for Matt Capelouto two days before Christmas in 2019, when he found his 20-year-old daughter, Alexandra, dead in her childhood bedroom in Temecula, California. Rage overtook grief when authorities ruled her death an accident.

The college sophomore, home for the holidays, had taken half a pill she bought from a dealer on Snapchat. It turned out to be fentanyl, the powerful synthetic opioid that helped drive drug overdose deaths in the U.S. to more than 100,000 last year. “She was poisoned, and nothing was going to happen to the person who did it,” he said. “I couldn’t stand for that.”

The self-described political moderate said the experience made him cynical about California’s reluctance to impose harsh sentences for drug offenses.

So Capelouto, the suburban dad who once devoted all his time to running his print shop and raising his four daughters, launched a group called Drug Induced Homicide and traveled from his home to Sacramento in April to lobby for legislation known as “Alexandra’s Law.” The bill would have made it easier for California prosecutors to convict the sellers of lethal drugs on homicide charges.

Capelouto’s organization is part of a nationwide movement of parents-turned-activists fighting the increasingly deadly drug crisis — and they are challenging California’s doctrine that drugs should be treated as a health problem rather than prosecuted by the criminal justice system. Modeled after Mothers Against Drunk Driving, which sparked a movement in the 1980s, organizations such as Victims of Illicit Drugs and the Alexander Neville Foundation seek to raise public awareness and influence drug policy. One group, Mothers Against Drug Deaths, pays homage to MADD by borrowing its acronym.

The groups press state lawmakers for stricter penalties for dealers and lobby technology companies to allow parents to monitor their kids’ communications on social media. They erect billboards blaming politicians for the drug crisis and stage “die-in” protests against open-air drug markets in Los Angeles’ Venice Beach and San Francisco’s Tenderloin neighborhood.

“This problem is going to be solved by the grassroots efforts of affected families,” said Ed Ternan, who runs the Pasadena-based group Song for Charlie, which focuses on educating youths about the dangers of counterfeit pills.

Many parents mobilized after a wave of deaths that began in 2019. Often, they involved high school or college students who thought they were taking OxyContin or Xanax purchased on social media but were actually ingesting pills containing fentanyl. The drug first hit the East Coast nearly a decade ago, largely through the heroin supply, but Mexican drug cartels have since introduced counterfeit pharmaceuticals laced with the highly addictive powder into California and Arizona to hook new customers.

In many cases, the overdose victims are straight-A students or star athletes from the suburbs, giving rise to an army of educated, engaged parents who are challenging the silence and stigma surrounding drug deaths.

Ternan knew almost nothing about fentanyl when his 22-year-old son, Charlie, died in his fraternity house bedroom at Santa Clara University a few weeks before he was scheduled to graduate in spring 2020. Relatives determined from messages on Charlie’s phone that he had intended to buy Percocet, a prescription painkiller he had taken after back surgery two years earlier. First responders said the strapping 6-foot-2-inch, 235-pound college senior died within a half-hour of swallowing the counterfeit pill.

Ternan discovered a string of similar deaths in other Silicon Valley communities. In 2021, 106 people died from fentanyl overdoses in Santa Clara County — up from 11 in 2018. The deaths have included a Stanford University sophomore and a 12-year-old girl in San Jose.

With the help of two executives at Google who lost sons to pills laced with fentanyl, Ternan persuaded Facebook, Instagram, TikTok, YouTube, and other social media platforms to donate ad space to warnings about counterfeit drugs. Pressure from parent groups has also spurred Santa Monica-based Snapchat to deploy tools to detect drug sales and restrictions designed to make it harder for dealers to target minors.

Since the earliest days of the opioid epidemic, the families of people dealing with addiction and of those who have died from overdoses have supported one another in church basements and on online platforms from Florida to Oregon. Now, the family-run organizations that have sprung from California’s fentanyl crisis have begun cooperating with one another.

A network of parent groups and other activists that calls itself the California Peace Coalition was formed recently by Michael Shellenberger, a Berkeley author and activist running for governor as an independent.

One critic of California’s progressive policies is Jacqui Berlinn, a legal processing clerk in the East Bay who started Mothers Against Drug Deaths — a name she chose as an homage to the achievements of Mothers Against Drunk Driving founder Candace Lightner, a Fair Oaks housewife whose 13-year-old daughter was killed in 1980 by a driver under the influence.

Berlinn’s son, Corey, 30, has used heroin and fentanyl for seven years on the streets of San Francisco. “My son isn’t trash,” Berlinn said. “He deserves to get his life back.”

She believes the city’s decision not to charge dealers has allowed open-air narcotics markets to flourish in certain neighborhoods and have enabled drug use, rather than encouraged people dealing with addiction to get help.

In April, Berlinn’s group spent $25,000 to erect a billboard in the upscale retail district of Union Square. Over a glowing night shot of the Golden Gate Bridge, the sign says: “Famous the world over for our brains, beauty and, now, dirt-cheap fentanyl.”

This month, the group installed a sign along Interstate 80 heading into Sacramento that targets Democratic Gov. Gavin Newsom. Playing off signage used at parks, the billboard features a “Welcome to Camp Fentanyl” greeting against a shot of a homeless encampment. The group said a mobile billboard will also circle the state Capitol for an undisclosed period.

New Billboards from Mothers Against Drug Deaths on I-80 in Sacramento. @StopDrugDeaths pic.twitter.com/3UdXh9BUq5

— Mothers Against Drug Deaths (@JacquiBerlinn) May 12, 2022

Mothers Against Drug Deaths is calling for more options and funding for drug treatment and more arrests of dealers. The latter would mark a sharp turn from the gospel of “harm reduction,” a public health approach embraced by state and local officials that holds abstention as unrealistic. Instead, this strategy calls for helping people dealing with addiction stay safe through things like needle exchanges and naloxone, an overdose reversal drug that has saved thousands of lives.

The parent movement echoes recall efforts happening in two major cities. Progressive prosecutors Chesa Boudin in San Francisco and George Gascón in Los Angeles have veered away from throwing street dealers in jail, which they call a pointless game of whack-a-mole that punishes poor minorities.

California lawmakers are wary of repeating the mistakes of the war-on-drugs era and have blocked a series of bills that would stiffen penalties for fentanyl sales. They say the legislation would accomplish little apart from packing the state’s jails and prisons.

“We can throw people in jail for a thousand years, and it won’t keep people from doing drugs, and it won’t keep them from dying,” said state Sen. Scott Wiener (D-San Francisco). “We know that from experience.”

Some parents agree. After watching her son cycle in and out of the criminal justice system on minor drug charges in the 1990s, Gretchen Burns Bergman became convinced that charging people with minor drug offenses, such as possession, is counterproductive.

In 1999, the San Diego fashion show producer started A New Path, which has advocated for marijuana legalization and an end to California’s “three strikes” law. A decade later, she formed Moms United to End the War on Drugs, a nationwide coalition. Today, both her sons have recovered from heroin addiction with the help of “compassionate support” and work as drug counselors, she said.

“I’ve been at this long enough to see the pendulum swing,” Burns Bergman said of the public’s shifting views on law enforcement.

In December, Brandon McDowell, 22, of Riverside, was arrested and accused of selling the tablet that killed Matt Capelouto’s daughter. McDowell was charged with distributing fentanyl resulting in death, which carries a mandatory minimum sentence of 20 years in federal prison.

Although Alexandra’s Law failed to make it out of committee, Capelouto pointed out that years of lobbying went into the passage of stricter drunken driving laws. He vowed not to give up on the bill named for his daughter, who wrote poetry and loved David Bowie.

“I’m going to be back in front of them,” he said, “every year.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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.

USE OUR CONTENT

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.

USE OUR CONTENT

This story can be republished for free (details).

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.

USE OUR CONTENT

This story can be republished for free (details).

Never-Ending Costs: When Resolved Medical Bills Keep Popping Up

A bill one family considered paid wrongfully resurfaced, resurrecting painful memories. It’s a scenario that’s not uncommon but grievously unsettling.

Every now and then, Suzanne Rybak and her husband, Jim, receive pieces of mail addressed to their deceased son, Jameson. Typically, it’s junk mail that requires little thought, Suzanne said.

But on March 5, an envelope for Jameson came from McLeod Health.

Jim saw it first. He turned to his wife and asked, “Have you taken your blood pressure medication today?”

He knew showing her the envelope would resurface the pain and anger their family had experienced since taking Jameson to McLeod Regional Medical Center two years ago.

As KHN previously reported, Jameson was experiencing withdrawal symptoms from quitting opioids. Suzanne feared for her son’s life and took him to the emergency room near their home in Florence, South Carolina, on March 11, 2020.

There, they encountered a paucity of addiction treatment and the potential for high medical costs — two problems that plague many families affected by the opioid crisis and often lead to missed opportunities to save lives.

Jameson was not offered medications to treat opioid use disorder in the ER, nor was he given referrals to other treatment facilities, Suzanne said. The hospital wanted to admit him, but, being uninsured, Jameson feared a high bill. The hospital didn’t inform him of its financial assistance policy, Suzanne said. And he decided to leave.

Three months later, Jameson, 30, died of an overdose in his childhood bedroom.

In the following months, the Rybaks received bills from the McLeod Health system addressed to Jameson. He owed $4,928, it said. Suzanne called and wrote to hospital administrators until September 2020, when the bill was resolved under the system’s financial assistance program.

That was the last they had heard from McLeod Health until the new envelope arrived March 5 — one week before the two-year anniversary of his ER visit. That visit was what Suzanne calls “the beginning of the end for my son.”

When the Rybaks opened the envelope, they found a strikingly familiar bill for $4,928.

“I can’t even describe my anger and sadness,” Suzanne said. “It’s always present, but when we received that statement, we were just stunned.”

There’s no national data to indicate how often patients or their families receive medical bills that were previously paid or forgiven, but hospital billing experts say they frequently see it happen. Patients receive bills for claims their insurers already paid. A reminder statement arrives even after a patient submitted payment.

Unlike “surprise bills,” which often result from policy gaps when a provider is out of network, these are bills that were resolved but continue to pop up anyway. They can carry financial consequences — patients wind up paying for something they don’t truly owe or bills get passed on to debt collection agencies, triggering more phones calls and red tape. But often it’s the emotional toll that wears on patients most, spending hours on the phone with customer service each time the bill resurfaces or reliving the situations that led to the bill in the first place. For families like the Rybaks, the cost can feel never-ending.

Suzanne Rybak refused to engage with the McLeod hospital again but told KHN about the new bill.

In response to questions from KHN, McLeod Health determined the bill the Rybaks received was a mistake.

“Unfortunately our software system regenerated this statement due to a technical issue,” wrote spokesperson Jumana Swindler. “We are checking to ensure that it has not happened to any other patients and we are sorry this family was impacted by the error.”

A week after KHN’s inquiry, the Rybaks received a letter from the hospital explaining and apologizing for the error.

Many medical billing cases like this “boil down to human error,” said Michael Corbett, director of health care consulting for LBMC, a Tennessee-based firm that consults with health systems nationally on issues like billing and revenue. “Facilities don’t have a lack of tools [to avoid this]. It’s a breakdown in their processes.”

A billing agent may forget to mark the account as paid, he said. Or the hospital might contract its billing to an outside company and fail to inform them that this bill was covered under the hospital’s financial assistance program.

As hospitals and medical practices increasingly consolidate under large health systems, the chances for errors increase. Even hospitals and clinics within the same system may have different backend software, and within each hospital there can be separate programs for billing and electronic health records, Corbett explained.

Larger health systems may also have more people processing any given bill. If responsibilities are not clearly defined, multiple employees could unknowingly act on the same patient account.

The covid-19 pandemic has exacerbated potential errors, Corbett said. New medical billing employees may have received quick, virtual training and are working remotely with little interaction with team members or oversight. Some billing departments are understaffed, leading to delays in patients receiving bills or follow-up notices, he added.

To curb mistakes, Corbett said, hospitals need to invest in more comprehensive training and supervision for billing employees; enact consistent processes for anything from how patients’ financial information is collected at registration to when they’re sent bills; and, perhaps most important, track whether those processes are being followed.

For patients who find themselves in a situation like the Rybak family’s, Corbett advises calling the hospital billing department and asking to speak with a senior leader in its revenue cycle division. Unlike an account representative, this person could make decisions, Corbett said.

At the end of the conversation, ask to get the explanation in writing, he added.

“You’d anticipate and hope those notes are being recorded,” Corbett said, but that may not be the case. Or notes might get recorded in a section of hospital files that are excluded from a patient’s legal medical record, making it difficult for patients to access later.

For Suzanne Rybak, the idea of calling McLeod Health to straighten out yet another bill was too much. Instead, she added the statement to a binder of paperwork, in which she’s documented all her billing struggles with McLeod Health over the past two years.

Still, out of sight hardly means out of mind. The binder sits in her craft room, where she remembers Jameson encouraging her as she made beach bags and other items. He’d say to use “fruity colors,” Suzanne recalled — his way of describing tropical colors. Now she makes candles in that room, focusing on tropical fragrances she knows Jameson would have loved.

“I want hospitals to realize that you’re not just sending this bill to an address,” Suzanne said. “There are people who live in that house, who are going to open that mail and have feelings. … It’s a disaster to bring all that up again.”

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.

USE OUR CONTENT

This story can be republished for free (details).

$11M for North Carolina Work-Based Rehab Raises Concerns

As overdoses surge and opioid settlement dollars flow, funding to North Carolina rehab foreshadows national discussion about the best approaches to treatment.

DURHAM, N.C. — An addiction treatment facility, highly regarded by North Carolina lawmakers, sits in a residential neighborhood here and operates like a village in itself. Triangle Residential Options for Substance Abusers, better known as TROSA, hosts roughly 400 people a day on a campus with rows of housing units, cafeterias, a full gym, and a barbershop.

The program, which began in 1994, is uniquely designed: Treatment, housing, and meals are free to participants. And TROSA doesn’t bill insurance. Instead, residents work for about two years in TROSA’s many businesses, including a moving company, thrift store, and lawn care service. Program leaders say the work helps residents overcome addiction and train for future jobs. Of those who graduate, 96% of individuals remain sober and 91% are employed a year later, the program’s latest report claims.

Impressed with such statistics, state lawmakers recently allotted $11 million for TROSA to expand its model to Winston-Salem. It’s the largest amount in the state budget targeted to a single treatment provider and comes on the heels of $6 million North Carolina previously provided for its expansion, as well as $3.2 million TROSA has received in state and federal funds annually for several years.

This latest influx of taxpayer dollars — coming at a time when overdose deaths are surging and each dollar spent on treatment is crucial — is drawing criticism. Advocates, researchers, and some former employees and participants of TROSA say the program takes advantage of participants by making them work without pay and puts their lives at risk by restricting the use of certain medications for opioid use disorder. Although those who graduate may do well, only 25% of participants complete the program — a figure TROSA leaders confirmed.

“If I had known about this funding, I would have been the first person on the mic to [tell lawmakers], ‘I don’t think you all should do this,’” said K.C. Freeman, who interned at TROSA in 2018 and later spent two months on staff in the medical department. “You can’t look at the small number of people who had success and say this works. It’s not the majority.”

The dispute over TROSA’s funding comes amid national conversations about how to allocate billions of dollars available after landmark opioid settlements with drug companies. Two flashpoints in the North Carolina debate may provide a window into heated conversations to come. First: Are work-based rehabs legal or ethical? And second: Should every facility that receives public funding allow participants to use all medications for opioid use disorder?

Work as Treatment

Work-based rehabs are widespread across the country. The investigative news outlet Reveal identified at least 300 such facilities, including some that place participants in dangerous jobs at oil refineries or dairy farms with no training and exploit workers to bolster profits.

Many of these programs use a portion of their revenue to sustain the rehab and offer residents free housing or meals. That can make them attractive to state legislators, said Noah Zatz, a UCLA law professor who specializes in employment and labor law.

“Because essentially they’re running businesses off of people’s uncompensated labor, there is a built-in funding mechanism,” he said. “If the state doesn’t have to pay full freight to run a program … that might be a reason to like it.”

TROSA’s annual reports indicate more than half of its multimillion-dollar budget is funded through its businesses at which residents work, as well as goods and services that are donated to the program. About 30% of its funding comes from government grants and contracts.

Although TROSA and its leaders report no significant campaign donations, they spend upward of $75,000 a year on lobbying. In presentations, they often share a 2017 study — conducted by an independent research institute at TROSA’s request — which found TROSA saves the state nearly $7.5 million annually in criminal justice and emergency care costs.

The program’s self-financing aspect is part of its appeal for North Carolina Sen. Joyce Krawiec, a Republican who represents part of Forsyth County, where TROSA is building its new site.

“The good thing about TROSA: They raised most of their own funds,” she said in a phone interview.

It’s reasonable that residents don’t get paid for their work, she added, since they’re already receiving free treatment and housing. Other rehabs can be prohibitively expensive for many families, so TROSA provides a much-needed option.

But being a bargain doesn’t necessarily make it legal, Zatz and other labor experts said. A previous U.S. Supreme Court ruling suggests nonprofits that run businesses without paying employees could violate the Fair Labor Standards Act.

But TROSA administrators say they are not an employer; they are a therapeutic community. Clear policies guard against the exploitation of anyone, said Keith Artin, president and CEO. The jobs provide residents with structure and an opportunity to change their behaviors.

“The work-based element is essential to recovery,” Artin said. “We’re teaching people how to live.”

Toward the end of residents’ two-year stays, TROSA assists them in job-hunting and allows them to live on campus for several months while they work at a newfound job and build savings.

Diverging Work Experiences

TROSA’s model has widespread support among lawmakers and families affected by addiction. Benjamin Weston said it was “a blessing.”

Weston said he started using cocaine as a teenager and struggled with addiction for years. At 22, he entered TROSA. He said he was grateful for two years of free treatment.

After brief assignments in TROSA’s thrift store and moving company, Weston transitioned to the development office, where he solicited donations from local businesses. “It was meaningful work that also taught me a lot of good job skills,” he said.

Since graduating in 2016, Weston has worked in development for Hope Connection International, a nonprofit his mother started to support survivors of abuse and addiction.

Other graduates interviewed for this article talked about using the moving skills or commercial driving licenses they gained to obtain full-time jobs. Some said they’re buying houses and starting families — successes they credit to their experience in the program.

But not every resident finds the work model therapeutic. Several described working 10 to 16 hours a day, six days a week, in physically demanding moving or lawn care businesses. Several said there was little time for therapy and, with only a handful of counselors for hundreds of residents, wait times for a session could span weeks.

Freeman, the former TROSA employee who has a master’s in social work, said he thought residents rarely had an opportunity to process the trauma that made them use drugs in the first place. Although Freeman did not counsel clients — his role at TROSA focused on ordering and stocking medications — he said he noticed many graduates returned repeatedly to the program, struggling to stay away from substances once they left campus.

Richard Osborne first heard of TROSA while incarcerated on drug and theft-related charges. Like 38% of TROSA residents, he chose to attend the program as a condition of his probation.

One day in 2017, Osborne and other residents working with the moving company were unloading large boards of plywood from a trailer, when a board fell and smashed him against the trailer, he said. His vision became blurry and he worried about having a concussion, he said.

As he remembers it, no one suggested medical care. “The next day, they told me I had to get back to work,” he claimed.

That’s when Osborne said he decided to leave.

Today, Osborne, 31, said he has not used drugs in about four years, holds a steady job, and has a loving family. But it’s no thanks to TROSA, he said.

“They’re taking advantage of people at their low points in life,” he said. The moving company brings in $4 million a year, yet residents who work for it are not even allowed to keep tips, he added.

TROSA leaders confirmed the tips policy but said they could not comment on an individual residents’ experience. In general, CEO Artin wrote in an email, “when a resident is injured we ensure that they receive immediate medical attention and would never knowingly put a resident at risk.”

As a nonprofit, TROSA funnels revenue from its businesses back into the treatment program, he added.

The program’s 2020 tax documents show its top five employees combined earned over $750,000 in salary and benefits.

Medication Hesitancy

TROSA provides psychiatric care through a contract with Duke Health and offers group or individual counseling to residents who request it. The program employs four full-time counselors and partners with local providers who donate physical therapy, dental care, and other medical services.

But TROSA does not provide access to some of the most effective treatments for opioid use disorder: methadone and buprenorphine. Both medications activate opioid receptors in the brain and reduce opioid withdrawal and cravings. It’s been well documented that these medications greatly reduce the risk of opioid overdose death, and the FDA-approved drugs are considered the “gold standard” for treatment.

Right now, TROSA leaders say the only medication for opioid use disorder the program offers is naltrexone, an injectable medication that works differently than the other two because it requires patients to fully detox to be effective. Because of this, some experts are hesitant to use it, saying it puts people at higher risk of overdose death.

About one-third of TROSA participants report opioids are their primary drug of choice.

TROSA leaders said they’ve discussed adding the other addiction treatment medications but face logistical barriers. All medications at TROSA are self-administered, and leaders worry about diversion of oral methadone and buprenorphine, which are classified as controlled substances. They say they’d consider injectable buprenorphine, but it’s costly for their mostly uninsured participants.

“People choose to come here because it is a behavior modification program,” said Lisa Finlay, lead clinical counselor at TROSA. “They know that we don’t offer buprenorphine or those medications. We have people who have tried those medications in the past and believe that they actually led them back to using.”

Evidence suggests that people using medications for opioid use disorder have the best outcomes when they have access to other recovery support services, such as housing, employment, counseling, and a community. But while clinicians across the country have embraced these medications, leaders of residential treatment programs founded in the more traditional 12-step, abstinence-based recovery model have pushed back.

Some old-school recovery leaders claim the use of medications is simply replacing one drug with another, which has created stigma around this form of treatment.

A 2020 study found that about 40% of residential programs surveyed in the U.S. didn’t offer opioid use disorder medications and 20% actively discouraged people from using them. In North Carolina, there are 62 licensed long-term residential treatment facilities, according to the SAMHSA treatment locator, and fewer than half accept patients who take these medications. Only 12 facilities are licensed to prescribe buprenorphine.

This has resulted in tough conversations with patients for Kate Roberts, a clinical social worker on a UNC Health team that treats people with severe IV drug-related infections. Once patients are stabilized, many start buprenorphine, she said. Some say they want to go to a residential program for structure, job training, and to learn coping skills. Roberts recalled one patient saying to her: “I need to go to residential treatment and I need this medication because I fear I’ll die.”

“That’s really heartbreaking to hear a patient clearly articulate what it is that they need … which is in line with the [research] literature,” she said. “And that you know there are very few places in the state that offer that.”

Doctors and public health experts nationwide are pushing for lawmakers to fund rehab facilities that allow these medications, saying they’re the best way to combat the opioid crisis. Some medical and legal experts have said it’s in violation of the Americans with Disabilities Act to deny recovery services such as housing to people using medications for opioid use disorder. Health experts say that funding abstinence-based addiction programs could also inadvertently cause more overdoses if people leave the program and return to using drugs with a much lower tolerance, especially as fentanyl is rampant in the street drug supply.

These conversations will become only more important as opioid settlement funds arrive, said Bradley Stein, director of the national Rand Opioid Policy Center.

“The goal isn’t just to get people into treatment; it’s to get people doing better,” he said. “You want to make sure that you’re using the money effectively.”

The conversations have begun in North Carolina. When Rep. Graig Meyer (D-Durham) tweeted his support for TROSA late last year, clinicians reached out to him explaining their concerns about the program not allowing participants to use methadone or buprenorphine.

Although Meyer still believes it’s an effective program, he said, “I also have concerns from what I learned about TROSA’s approach to treating opioid addiction in particular. I’d like to see TROSA consider what their current practices are.”

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.

USE OUR CONTENT

This story can be republished for free (details).

At a Tennessee Crossroads, Two Pharmacies, a Monkey, and Millions of Pills

Prosecutors say opioid-seeking patients drove hours to get their prescriptions filled in Celina, Tennessee, where pharmacies ignored signs of substance misuse and paid cash — or “monkey bucks” — to keep customers coming back.

CELINA, Tenn. — It was about 1 a.m. on April 19, 2016, when a burglary alarm sounded at Dale Hollow Pharmacy in Celina, a tiny town in the rolling, wooded hills near the Kentucky border.

Two cops responded. As their flashlights bobbed in the darkness, shining through the pharmacy windows, they spotted a sign of a break-in: pill bottles scattered on the floor.

The cops called the co-owner, Thomas Weir, who arrived within minutes and let them in. But as quickly as their flashlights beamed behind the counter, Weir demanded the cops leave. He said he’d rather someone “steal everything” than let them finish their search, according to a police report and body camera footage from the scene.

“Get out of there right now!” Weir shouted, as if shooing off a mischievous dog. “Get out of there!”

The cops argued with Weir as he escorted them out. They left the pharmacy more suspicious than when they’d arrived, triggering a probe in a small town engulfed in one of the most outsize concentrations of opioids in a pill-ravaged nation.

Nearly six years later, federal prosecutors have unveiled a rare criminal case alleging that Celina pharmacy owners intentionally courted opioid seekers by filling dangerous prescriptions that would have been rejected elsewhere. The pharmacies are accused of giving cash handouts to keep customers coming back, and one allegedly distributed its own currency, “monkey bucks,” inspired by a pet monkey that was once a common sight behind the counter. Two pharmacists admitted in plea agreements they attracted large numbers of patients from “long distances” by ignoring red flags indicating pills were being misused or resold. In their wake, prosecutors say, these Celina pharmacies left a rash of addiction, overdoses, deaths, and millions in wasted tax dollars.

“I hate that this is what put us on the map,” said Tifinee Roach, 38, a lifelong Celina resident who works in a salon not far from the pharmacies and recounted years of unfamiliar cars and unfamiliar people filling the parking lots. “I hate that this is what we’re going to be known for.”

Celina, an old logging town of 1,900 people about two hours northeast of Nashville, was primed for this drug trade: In the shadow of a dying hospital, four pharmacies sat within 1,000 feet of each other, at the crux of two highways, dispensing millions of opioid pills. Before long, that intersection had single-handedly turned Tennessee’s Clay County into one of the nation’s pound-for-pound leaders of opioid distribution. In 2017, Celina pharmacies filled nearly two opioid prescriptions for every Clay County resident — more than three times the national rate — according to the Centers for Disease Control and Prevention.

Visitors once came to Celina to tour its historical courthouse or drop their lines for smallmouth bass in the famed fishing lake nearby. Now they came for pills.

Soon after Weir’s police encounter in 2016, the Drug Enforcement Administration set its sights on his two Celina pharmacies, three doors apart — Dale Hollow Pharmacy and Xpress Pharmacy. Separately, investigators examined the clinic of Dr. Gilbert Ghearing, which sat directly between Dale Hollow and Xpress and leased office space to a third pharmacy in the same building, Anderson Hometown Pharmacy. Its owners and operators have not been charged with any crime.

In December, a federal judge unsealed indictments against Weir and the other owners of Dale Hollow and Xpress pharmacies, Charles “Bobby” Oakley and Pamela Spivey, alleging they profited from attracting and filling dangerous and unjustifiable opioid prescriptions. Charges were also filed against William Donaldson, the former pharmacist and owner of Dale Hollow, previously convicted of drug dealing, who allegedly recruited most of the customers for the scheme.

The pharmacists at Dale Hollow and Xpress, John Polston and Michael Griffith, pleaded guilty to drug conspiracy and health care fraud charges and agreed to cooperate with law enforcement against the other suspects.

Ghearing was indicted on drug distribution charges for allegedly writing unjustifiable opioid prescriptions in a separate case in 2019. He pleaded not guilty, and his case is expected to go to trial in September.

‘An American Tragedy’

The Celina indictment comes as pharmacies enter an era of new accountability for the opioid crisis. In November, a federal jury in Cleveland ruled pharmacies at CVS, Walgreens, and Walmart could be held financially responsible for fueling the opioid crisis by recklessly distributing massive amounts of pain pills in two Ohio counties. The ruling — a first of its kind — is expected to reverberate through thousands of similar lawsuits filed nationwide.

Criminal prosecutions for such actions remain exceedingly rare. The Department of Justice in recent years increased prosecutions of doctors and pain clinic staffers who overprescribed opioids but files far fewer charges against pharmacists, and barely any against pharmacy owners, who are generally harder to hold directly responsible for prescriptions filled at their establishments.

In a review of about 1,000 news releases about legal enforcement actions taken by the Department of Health and Human Services since 2019, KHN identified fewer than 10 similar cases involving pharmacists or pharmacy owners being criminally charged for filling opioid prescriptions. Among those few similar cases, none involved allegations of so many opioids flowing readily through such a small place.

The Celina case is also the first time the Department of Justice sought a restraining order and preliminary injunction against pharmacies under the Controlled Substances Act, said David Boling, a spokesperson for the U.S. Attorney’s Office for the Middle District of Tennessee. DOJ used the civil filing to shut down Dale Hollow and Xpress pharmacies quickly in 2019, allowing prosecutors more time to build a criminal case against the pharmacy owners.

Former U.S. Attorney Don Cochran, who oversaw much of the investigation, said the crisis in Celina was so severe it warranted a swift and unique response.

Cochran said it once made sense for small pharmacies to be clustered in Celina, where a rural hospital served the surrounding area. But as the hospital shriveled toward closure, as have a dozen others in Tennessee, the competing pharmacies turned to opioids to sustain themselves and got hooked on the profits, he said.

“It’s an American tragedy, and I think the town was a victim in this,” Cochran said. “The salt-of-the-earth, blue-collar folks that lived there were victimized by these people in these pharmacies. I think they knew full well this was not a medical necessity. It was just a money-making cash machine for them.”

And much of that money came from taxpayers. In its court filings, DOJ argues the pharmacies sought out customers with Medicaid or Medicare coverage — or signed them up if they didn’t have it. To keep these customers coming back, the pharmacies covered their copays or paid cash kickbacks whenever they filled a prescription, prosecutors allege. The pharmacies collected more than $2.4 million from Medicare for opioids and other controlled substances from 2012 to 2018, according to the court filings.

Prosecutors say the pharmacies also paid kickbacks to retain profitable customers with non-opioid prescriptions. In one case, Dale Hollow gave $100 “payouts” to a patient whenever they filled his prescription for mysoline, an anti-seizure drug, then used those prescriptions to collect more than $237,000 from Medicare, according to Polston’s plea agreement.

Attorneys for Weir, Oakley, Donaldson, Spivey, Polston, and Griffith either declined to comment for this article or did not respond to requests for comment.

Ronald Chapman, an attorney for Ghearing, defended the doctor’s prescriptions, saying he’d done “the best he [could] with what was available” in a rural setting with no resources or expertise in pain management.

Chapman added that, while he does not represent the other Celina suspects, he had a theory as to why they drew the attention of federal law enforcement. As large corporate pharmacies made agreements with the federal government to be more stringent about opioid prescriptions, they filled fewer of them. Customers then turned to smaller pharmacies in rural areas to get their drugs, he said.

“I’m not sure if that’s what happened in this case, but I’ve seen it happen in many small towns in America. The only CVS down the street, or the only Rite Aid down the street, is cutting off every provider who prescribes opioids, leaving it to smaller pharmacies to do the work,” Chapman said.

Donaldson, reached briefly at his home in Celina on March 9, insisted the allegations levied against Dale Hollow and Xpress could apply to many pharmacies in the region.

“It wasn’t just them,” Donaldson said.

The Monkey and the Monkey Bucks

Long before it was called Dale Hollow Pharmacy, the blue-and-white building that moved millions of pills through Celina was Donaldson Pharmacy, and Donaldson was behind the counter doling out pills.

Donaldson owned and operated the pharmacy for decades as the eccentric son of one of the most prominent families in Celina, where a street, a park, and many businesses bear his surname. Even now, despite Donaldson’s prior conviction for opioid crimes and his new indictment, an advertisement for “Donaldson Pharmacy” hangs at the entrance of a nearby high school.

“Bill has always had a heart of gold, and he would help anyone he could. I just think he let that, well …” said Pam Goad, a neighbor, trailing off. “He’s always had a heart of gold.”

According to interviews with about 20 Celina residents, including Clay County Sheriff Brandon Boone, Donaldson is also known to keep a menagerie of exotic animals, at one point including at least two giraffes, and a monkey companion, “Carlos,” whom he dressed in clothing.

The monkey — a mainstay at Donaldson Pharmacy for years — both attracted and deterred customers. Linda Nelson, who owns a nearby business, said Carlos once escaped the pharmacy and, during a scrap with a neighbor’s dogs, tore down her mailbox by snapping its wooden post in half.

But the monkey wasn’t the only reason Donaldson Pharmacy stood out.

According to a DEA opioid database published by The Washington Post, Donaldson Pharmacy distributed nearly 3 million oxycodone and hydrocodone pills from 2006 to 2014, making it the nation’s 20th-highest per capita distributor during that period. It retained its ranking even though the pharmacy closed in 2011, when Donaldson was indicted for dispensing hydrocodone without a valid prescription.

Donaldson confessed to drug distribution and was sentenced to 15 months in prison. The pharmacy’s name was changed to Dale Hollow and ended up with Donaldson’s brother-in-law, Oakley. In 2014, Oakley sold 51% of the business to Weir, who also bought a majority stake of Xpress Pharmacy, three doors away, according to the DOJ’s civil complaint.

Under Weir’s leadership, these two pharmacies became an opioid hub with few equals, prosecutors say. From 2015 to 2018, Dale Hollow and Xpress pharmacies were the fourth-and 11th-highest per capita opioid purchasers in the nation, according to the DOJ, citing internal DEA data.

Many of these prescriptions were for Subutex, an opioid that can be used to treat addiction but is itself prone to abuse. Unless the patient is pregnant or nursing or has a documented allergy, Tennessee law requires doctors instead to prescribe Suboxone, an alternative that is much harder to abuse.

But at the Celina pharmacies, prescriptions for Subutex outnumbered those for Suboxone by at least 4-to-1, prosecutors say. In their plea agreements, pharmacists from Dale Hollow and Xpress described stores that thrived on the trade in Subutex, and said Weir set “mandates” for how many Subutex prescriptions to fill and instructed them to “never run out.”

Griffith, the head pharmacist at Xpress, said the pharmacy in 2015 created flyers specifically advertising Subutex, then delivered them on trays of cookies to practices throughout Tennessee, including some hours away. In the following two years, the amount of Subutex dispensed by Xpress increased by about eightyfold, according to his plea agreement.

Dale Hollow didn’t need flyers or cookies. It had Donaldson.

After getting out of prison in 2014, Donaldson was hired by the pharmacy he once owned, where he “recruited and controlled” about 50% to 90% of customers, according to the indictment filed against him. The pharmacy also enticed customers by distributing a Monopoly-like currency called “monkey bucks” — an apparent callback to Carlos — that could be spent at the pharmacy like cash, the indictment states.

Prosecutors also allege that, from a desk inside Dale Hollow, Donaldson would sign customers up for Medicare or Medicaid, then use a vehicle provided by the pharmacy to drive them to a doctor’s office to get opioid prescriptions, then back to Dale Hollow where he’d offer to cover their copays himself if they kept their business at the pharmacy. Sometimes, he would text the Dale Hollow pharmacist with instructions to fill specific prescriptions, or just to fill more of them, according to federal court records.

“Y’all have got to get your numbers up. Fill fill,” Donaldson texted Polston in 2018, according to his plea agreement.

By then, however, all those prescriptions had drawn unwanted attention.

In August 2018, Dale Hollow and Xpress pharmacies were raided by DEA agents, who brought with them Fox News’ Geraldo Rivera and a television crew. Six months later, DOJ filed its civil complaint, persuading a federal judge to immediately close both pharmacies.

Today, Dale Hollow Pharmacy sits shuttered, as it has been for the past three years, and a paper sign taped to the door says animals are not allowed inside by order of the DEA. The building that was once Xpress Pharmacy reopened this year as an unrelated pharmacy with a fresh coat of paint. Ghearing’s clinic and Anderson Hometown Pharmacy are closed.

Most of Celina’s opioid prescriptions are gone, too. According to the latest available CDC data, Clay County reported about 32 opioid prescriptions per 100 residents in 2020 — one-sixth the rate of 2017’s.

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.

USE OUR CONTENT

This story can be republished for free (details).

Money Flows Into Addiction Tech, But Will It Curb Soaring Opioid Overdose Deaths?

Experts are concerned that flashy Silicon Valley technology won’t reach those most in need of treatment for substance use disorders.

David Sarabia had already sold two startups by age 26 and was sitting on enough money to never have to work another day in his life. He moved from Southern California to New York City and began to indulge in all the luxuries his newly minted millionaire status conveyed. Then it all went sideways, and his life quickly unraveled.

“I became a massive cocaine addict,” Sarabia said. “It started off just casual partying, but that escalated to pretty much anything I could get my hands on.”

At one particularly low point, Sarabia was homeless for three months, sleeping on public transportation to stay warm. Even with plenty of money in the bank, Sarabia said, he’d lost the will to live. “I’d given up,” he said.

He got back on his feet, sort of, and for the next three years lived as a “functional cocaine addict” until his best friend, Jay Greenwald, died after a night of partying. Finally, Sarabia checked himself into a rehab in Southern California — ostensibly a luxurious one, although Sarabia didn’t find it to be so.

Still, the place saved his life. The clinicians really cared, he recalled, although their efforts were hampered by clunky technology and poor management. He had the feeling that the owners were more interested in profits than in helping people recover.

Just days off cocaine, the tech entrepreneur was scribbling designs for his next startup idea: a digital platform that would make clinician paperwork easier, combined with a mobile app to guide patients through recovery. After he left treatment in 2017, Sarabia tapped his remaining wealth — about $400,000 — to fund an addiction tech company he named inRecovery.

With the nation’s opioid overdose epidemic hitting a record high of more than 100,000 deaths in 2021, effective ways to fight addiction and expand treatment access are desperately needed. Sarabia and other entrepreneurs in the realm they call addiction tech see a $42 billion U.S. market for their products and an addiction treatment field that is, in techspeak, ripe for disruption.

It has long been torn by opposing ideologies and approaches: medication-assisted treatment versus cold-turkey detox; residential treatment versus outpatient; abstinence versus harm reduction; peer support versus professional help. And most people who report struggling with substance use never manage to access treatment at all.

Tech is already offering help to some. Those who can pay out-of-pocket, or have treatment covered by an employer or insurer, can access one of a dozen addiction telemedicine startups that allow them to consult with a physician and have a medication like buprenorphine mailed directly to their home. Some of the virtual rehabs provide digital cognitive behavior treatment, with connected devices and even mail-in urine tests to monitor compliance with sobriety.

Plentiful apps offer peer support and coaching, and entrepreneurs are developing software for treatment centers that handle patient records, personalize the client’s time in rehab, and connect them to a network of peers.

But while the founders of for-profit companies may want to end suffering, said Fred Muench, clinical psychologist and president of the nonprofit Partnership to End Addiction, it all comes down to revenue.

Startup experts and clinicians working on the front lines of the drug and overdose epidemic doubt the flashy Silicon Valley technology will ever reach people in the throes of addiction who are unstably housed, financially challenged, and on the wrong side of the digital divide.

“The people who are really struggling, who really need access to substance use treatment, don’t have 5G and a smartphone,” said Dr. Aimee Moulin, a professor and behavioral health director for the Emergency Medicine Department at UC Davis Health. “I just worry that as we start to rely on these tech-heavy therapy options, we’re just creating a structure where we really leave behind the people who actually need the most help.”

The investors willing to feed millions of dollars on startups generally aren’t investing in efforts to expand treatment to the less privileged, Moulin said.

Besides, making money in the addiction tech business is tough, because addiction is a stubborn beast.

Conducting clinical trials to validate digital treatments is challenging because of users’ frequent lapses in medication adherence and follow-up, said Richard Hanbury, founder and CEO of Sana Health, a startup that uses audiovisual stimulation to relax the mind as an alternative to opioids.

There are thousands of private, nonprofit, and government-run programs and drug rehabilitation centers across the country. With so many bit players and disparate programs, startups face an uphill battle to land enough customers to generate significant revenue, he added.

After conducting a small study to ease anxiety for people detoxing off opioids, Hanbury postponed the next step, a larger study. To sell his product to the country’s sprawling array of addiction treatment providers, Hanbury decided, he would need to hire a much larger sales team than his budding company could afford.

Still, the immense need is feeding enthusiasm for addiction tech.

In San Francisco alone, more than twice as many people died from drug overdoses as from covid over the past two years. Employers, insurers, providers, families, and those suffering addiction themselves are all demanding better and affordable access to treatment, said Unity Stoakes, president and managing partner of StartUp Health.

The investment firm has launched a portfolio of seed-stage startups that aim to use technology to end addiction and the opioid epidemic. Stoakes hopes the wave of new treatment options will reduce the stigma of addiction and increase awareness and education. The emerging tools aren’t trying to remove human care for addiction, but rather “supercharge the doctor or the clinician,” he said.

While acknowledging that underserved populations are hard to reach, Stoakes said tech can expand access and enhance targeted efforts to help them. With enough startups experimenting with different types of treatment and delivery methods, hopefully one or more will succeed, he said.

Addiction telehealth startups have gained the most traction. Quit Genius, a virtual addiction treatment provider for alcohol, opioid, and nicotine dependence, raised $64 million from investors last summer, and in October, $118 million went to Workit Health, a virtual prescriber of medication-assisted treatment. Several other startups — Boulder Care, Groups Recover Together, Ophelia, Bicycle Health, and Wayspring, most of which have nearly identical telehealth and prescribing models — have landed sizable funding since the pandemic started.

Some of the startups already sell to self-insured employers, providers, and payers. Some market directly to consumers, while others are conducting clinical trials to get FDA approval they hope to parlay into steadier reimbursement. But that route involves a lot of competition, regulatory hurdles, and the need to convince payers that adding another treatment will drive down costs.

Sarabia’s inRecovery plans to use its software to help treatment centers run more efficiently and improve their patient outcomes. The startup is piloting an aftercare program, aimed at keeping patients connected to prevent relapse after treatment, with Caron Treatment Centers, a high-end nonprofit treatment provider based in Pennsylvania.

His long-term goal is to drive down costs enough to offer his service to county-run treatment centers in hopes of expanding care to the neediest. But for now, implementing the tech doesn’t come cheap, with treatment providers paying anywhere from $50,000 to $100,000 a year to license the software.

“Bottom line, for the treatment centers that don’t have consistent revenue, those on the lower end, they will probably not be able to afford something like this,” he said.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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.

USE OUR CONTENT

This story can be republished for free (details).

Money Flows Into Addiction Tech, But Will It Curb Soaring Opioid Overdose Deaths?

Experts are concerned that flashy Silicon Valley technology won’t reach those most in need of treatment for substance use disorders.

David Sarabia had already sold two startups by age 26 and was sitting on enough money to never have to work another day in his life. He moved from Southern California to New York City and began to indulge in all the luxuries his newly minted millionaire status conveyed. Then it all went sideways, and his life quickly unraveled.

“I became a massive cocaine addict,” Sarabia said. “It started off just casual partying, but that escalated to pretty much anything I could get my hands on.”

At one particularly low point, Sarabia was homeless for three months, sleeping on public transportation to stay warm. Even with plenty of money in the bank, Sarabia said, he’d lost the will to live. “I’d given up,” he said.

He got back on his feet, sort of, and for the next three years lived as a “functional cocaine addict” until his best friend, Jay Greenwald, died after a night of partying. Finally, Sarabia checked himself into a rehab in Southern California — ostensibly a luxurious one, although Sarabia didn’t find it to be so.

Still, the place saved his life. The clinicians really cared, he recalled, although their efforts were hampered by clunky technology and poor management. He had the feeling that the owners were more interested in profits than in helping people recover.

Just days off cocaine, the tech entrepreneur was scribbling designs for his next startup idea: a digital platform that would make clinician paperwork easier, combined with a mobile app to guide patients through recovery. After he left treatment in 2017, Sarabia tapped his remaining wealth — about $400,000 — to fund an addiction tech company he named inRecovery.

With the nation’s opioid overdose epidemic hitting a record high of more than 100,000 deaths in 2021, effective ways to fight addiction and expand treatment access are desperately needed. Sarabia and other entrepreneurs in the realm they call addiction tech see a $42 billion U.S. market for their products and an addiction treatment field that is, in techspeak, ripe for disruption.

It has long been torn by opposing ideologies and approaches: medication-assisted treatment versus cold-turkey detox; residential treatment versus outpatient; abstinence versus harm reduction; peer support versus professional help. And most people who report struggling with substance use never manage to access treatment at all.

Tech is already offering help to some. Those who can pay out-of-pocket, or have treatment covered by an employer or insurer, can access one of a dozen addiction telemedicine startups that allow them to consult with a physician and have a medication like buprenorphine mailed directly to their home. Some of the virtual rehabs provide digital cognitive behavior treatment, with connected devices and even mail-in urine tests to monitor compliance with sobriety.

Plentiful apps offer peer support and coaching, and entrepreneurs are developing software for treatment centers that handle patient records, personalize the client’s time in rehab, and connect them to a network of peers.

But while the founders of for-profit companies may want to end suffering, said Fred Muench, clinical psychologist and president of the nonprofit Partnership to End Addiction, it all comes down to revenue.

Startup experts and clinicians working on the front lines of the drug and overdose epidemic doubt the flashy Silicon Valley technology will ever reach people in the throes of addiction who are unstably housed, financially challenged, and on the wrong side of the digital divide.

“The people who are really struggling, who really need access to substance use treatment, don’t have 5G and a smartphone,” said Dr. Aimee Moulin, a professor and behavioral health director for the Emergency Medicine Department at UC Davis Health. “I just worry that as we start to rely on these tech-heavy therapy options, we’re just creating a structure where we really leave behind the people who actually need the most help.”

The investors willing to feed millions of dollars on startups generally aren’t investing in efforts to expand treatment to the less privileged, Moulin said.

Besides, making money in the addiction tech business is tough, because addiction is a stubborn beast.

Conducting clinical trials to validate digital treatments is challenging because of users’ frequent lapses in medication adherence and follow-up, said Richard Hanbury, founder and CEO of Sana Health, a startup that uses audiovisual stimulation to relax the mind as an alternative to opioids.

There are thousands of private, nonprofit, and government-run programs and drug rehabilitation centers across the country. With so many bit players and disparate programs, startups face an uphill battle to land enough customers to generate significant revenue, he added.

After conducting a small study to ease anxiety for people detoxing off opioids, Hanbury postponed the next step, a larger study. To sell his product to the country’s sprawling array of addiction treatment providers, Hanbury decided, he would need to hire a much larger sales team than his budding company could afford.

Still, the immense need is feeding enthusiasm for addiction tech.

In San Francisco alone, more than twice as many people died from drug overdoses as from covid over the past two years. Employers, insurers, providers, families, and those suffering addiction themselves are all demanding better and affordable access to treatment, said Unity Stoakes, president and managing partner of StartUp Health.

The investment firm has launched a portfolio of seed-stage startups that aim to use technology to end addiction and the opioid epidemic. Stoakes hopes the wave of new treatment options will reduce the stigma of addiction and increase awareness and education. The emerging tools aren’t trying to remove human care for addiction, but rather “supercharge the doctor or the clinician,” he said.

While acknowledging that underserved populations are hard to reach, Stoakes said tech can expand access and enhance targeted efforts to help them. With enough startups experimenting with different types of treatment and delivery methods, hopefully one or more will succeed, he said.

Addiction telehealth startups have gained the most traction. Quit Genius, a virtual addiction treatment provider for alcohol, opioid, and nicotine dependence, raised $64 million from investors last summer, and in October, $118 million went to Workit Health, a virtual prescriber of medication-assisted treatment. Several other startups — Boulder Care, Groups Recover Together, Ophelia, Bicycle Health, and Wayspring, most of which have nearly identical telehealth and prescribing models — have landed sizable funding since the pandemic started.

Some of the startups already sell to self-insured employers, providers, and payers. Some market directly to consumers, while others are conducting clinical trials to get FDA approval they hope to parlay into steadier reimbursement. But that route involves a lot of competition, regulatory hurdles, and the need to convince payers that adding another treatment will drive down costs.

Sarabia’s inRecovery plans to use its software to help treatment centers run more efficiently and improve their patient outcomes. The startup is piloting an aftercare program, aimed at keeping patients connected to prevent relapse after treatment, with Caron Treatment Centers, a high-end nonprofit treatment provider based in Pennsylvania.

His long-term goal is to drive down costs enough to offer his service to county-run treatment centers in hopes of expanding care to the neediest. But for now, implementing the tech doesn’t come cheap, with treatment providers paying anywhere from $50,000 to $100,000 a year to license the software.

“Bottom line, for the treatment centers that don’t have consistent revenue, those on the lower end, they will probably not be able to afford something like this,” he said.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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.

USE OUR CONTENT

This story can be republished for free (details).

Calls to Overhaul Methadone Distribution Intensify, but Clinics Resist

The pandemic has shown that loosening the strict regulations on distributing methadone helps people recovering from addiction stay in treatment. But clinics with a financial stake in keeping the status quo don’t want to make permanent changes.

Days typically start early for patients undergoing opioid addiction treatment at Denver Recovery Group’s six methadone clinics in Colorado. They rise before dawn. Some take three buses to get to a clinic by 5 a.m. for a 15-minute conversation with a counselor and their daily dose of methadone, all before they go to work or take their kids to school. Some drive more than an hour each way from Longmont or Steamboat Springs.

“They’re coming from a billion miles away,” said Dr. Andreas Edrich, the clinics’ chief medical officer, noting their strong motivation to get care compared with other patients who struggle to stick to a simple medication regimen. “Most people can’t take their blood pressure to save their life, and that’s in their kitchen cabinet.”

Patients who take methadone, a synthetic narcotic used to treat opioid addiction, must jump through more hoops than perhaps any other patient group in the U.S. due to rules dating back five decades. Proponents for easing the rules say the pandemic has shown certain constraints serve more as barriers to care than protections. And consensus is growing among clinicians, patients, and regulators that it’s time for change.

“There’s probably very few folks who work in the field who feel like we should continue the status quo,” said Dr. Shawn Ryan, a board member for the American Society of Addiction Medicine.

Now officials at the Substance Abuse and Mental Health Services Administration are considering permanent changes to federal methadone rules. A National Academy of Medicine workshop on methadone regulations on March 3 and 4 may signal an inflection point.

Additionally, Sens. Ed Markey (D-Mass.) and Rand Paul (R-Ky.) have introduced a bill that would codify the rules loosened during the pandemic, which allowed flexibility on take-home doses, telehealth, and treatment vans. It would also allow pharmacies to dispense methadone for opioid use treatment.

Any changes to federal rules, however, could face significant resistance from methadone clinics — many of them for-profit — whose financial models are built on daily patient encounters, counseling, and regular drug tests.

“There are some entities who have a financial interest in keeping things the way that they are,” Ryan said. “Change costs money.”

Currently, methadone can be dispensed only through federally regulated opioid treatment centers. Patients, at least initially, have had to show up in person each day to get their dose until they had proven themselves stable, primarily out of concern that they would sell the methadone or take more than their daily dose, risking overdose.

But the covid-19 pandemic prompted federal authorities to loosen methadone regulations, allowing more patients to take doses home and rely on telehealth consultations instead of in-person visits. Studies have found the flexibility didn’t result in any increases in overdoses, illicit sales of methadone doses, or people dropping out of treatment. Instead, patients have reported greater satisfaction and a higher willingness to follow their regimens.

“From that standpoint, the pandemic was an absolute blessing in disguise,” Edrich said.

One study found that the number of methadone take-home doses nearly doubled during the pandemic.

“We really couldn’t see any differences in terms of treatment adherence,” said Ofer Amram, an assistant professor studying health disparities at Washington State University.

That real-world experiment showed that many of the methadone rules might not be needed.

“In most other countries in the West, including Canada, it’s much easier to get access to methadone treatment,” Amram said. “You can get it in most pharmacies.”

But an Oregon Health & Science University survey of 170 methadone clinics found that fewer than half permitted new patients to take home a 14-day supply despite the loosened guidelines, and about two-thirds allowed existing, stable patients to receive the full 28-day allotment allowed.

“At the end of the day, patients with opioid use disorder want to be treated like everybody else,” said Dr. Ximena Levander, an assistant professor of medicine at OHSU and a co-author of the study. “There are a lot of other high-risk medications we dispense in medicine, but it’s only this one medication where it’s required for patients to go to this specific place to get treatment.”

Opioid treatment programs generally get reimbursed on a fee-for-service model: The more services they provide and the more tests they run, the more they get paid. A shift to a model in which a person comes to the clinic only once a month could severely restrict their revenue. According to a federal survey of methadone clinics, 41% were run by private for-profit companies in 2020, up from 30% in 2010.

“Most of these patients pay cash,” said Taleed El-Sabawi, an addiction and public policy professor at Georgetown University. “So if you are requiring urine tests often, if you’re requiring patients come in, if you’re requiring that they go through other hoops, they’re paying for that.”

And with cash payments, she said, no health plans are involved to question whether the services are medically necessary.

Denise Vincioni, regional director for Denver Recovery Group and a former director of Colorado’s State Opioid Treatment Authority, defended the existing regulatory framework.

“The rules and regulations protect our patients, give us parameters to work within, and also keep us safe as providers,” she said. “It’s a very risky business because you’re managing people’s lives with narcotics.”

Many patients, she said, end up appreciating the routine that creates the good habit of taking their methadone at the same time every day. Patients who haven’t put in the time or shown they’re not using illicit substances “haven’t demonstrated some of that entitlement,” Vincioni said. “Loose structure has been to their detriment.”

Vincioni suggested the clinics should have more leeway to decide when somebody is ready for take-home doses and to rely on their clinical judgment rather than strict parameters. Currently, if doses are diverted or the patient overdoses, the clinic could face repercussions.

“If something happens, it’s your butt,” she said. “That’s part of what has prevented us from doing a lot of that loosening up.”

Within the addiction treatment world, methadone patients are treated differently from patients who use other opioid addiction treatments, such as buprenorphine or Suboxone. Generally, buprenorphine is considered safer than methadone, with less risk of overdose, but methadone may be a better option for patients with chronic pain or who have been exposed to high amounts of fentanyl.

There’s also a racial-equity component. It’s often said that Black patients get methadone, which carries a stigma, while their white counterparts get Suboxone, a drug that prevents cravings for opioids. Part of that is because methadone clinics are often located in minority neighborhoods.

Levander said the recent focus on racial justice is driving momentum for changes to methadone rules.

“A lot of the federal regulations have a very racist history and undertone,” she said. “One of the things that is helping to catalyze this change is that motivation to try to right a wrong.”

Christopher Garrett, a SAMHSA spokesperson, said the agency can make some changes to methadone regulations on its own and is currently reviewing the flexibility granted during the pandemic. The agency has indicated that it plans to extend the flexibility for take-home doses another year, regardless of when the public health emergency ends.

Advocates caution that federal and state rules often conflict with each other, and sometimes are poorly aligned with the payment structure from Medicare, Medicaid, and other health plans. A Pew Charitable Trusts analysis, for example, found that in many states fewer than half of the opioid treatment providers accept Medicaid.

The two-day National Academy of Medicine workshop this month is expected to culminate in a report with possible policy change recommendations.

“I’m hoping that the momentum is now finally here,” said Dr. Gavin Bart, director of addiction medicine at Hennepin Healthcare in Minneapolis. “This is now being taken quite seriously.”

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.

USE OUR CONTENT

This story can be republished for free (details).

KHN’s ‘What the Health?’: Why Health Care Is So Expensive, Chapter $22K

Congress is making slow progress toward completing its ambitious social spending bill, although its Thanksgiving deadline looks optimistic. Meanwhile, a new survey finds the average cost of an employer-provided family plan has risen to more than $22,000. That’s about the cost of a new Toyota Corolla. Alice Miranda Ollstein of Politico, Anna Edney of Bloomberg News and Rebecca Adams of CQ Roll Call join KHN’s Julie Rovner to discuss these issues and more. Also this week, Rovner interviews Rebecca Love, a nurse academic and entrepreneur, about the impending crisis in nursing.

Can’t see the audio player? Click here to listen on Acast. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

Congress appears to be making progress on its huge social spending bill, but even if it passes the House as planned the week of Nov. 15, it’s unlikely it can get through the Senate before the Thanksgiving deadline that Democrats set for themselves.

Meanwhile, the cost of employer-provided health insurance continues to rise, even with so many people forgoing care during the pandemic. The annual KFF survey of employers reported that the average cost of a job-based family plan has risen to more than $22,000. To provide what their workers most need, however, this year many employers added additional coverage of mental health care and telehealth.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Anna Edney of Bloomberg News and Rebecca Adams of CQ Roll Call.

Among the takeaways from this week’s episode:

  • Moderate Democrats who were worried about the price tag of the social spending bill said during negotiations last week that they wanted to see the full analysis of spending and costs from the Congressional Budget Office. But members of the House probably won’t get that score before voting on the bill. CBO instead is releasing its assessments piecemeal as analysts go through specific sections of the huge bill.
  • If the House passes the bill next week, which leadership is pledging, the legislation could still undergo major revisions in the Senate. Some provisions will be subject to the Byrd Rule, which says items in this type of bill must be related to the budget. Republicans are expected to challenge parts of the bill, and the parliamentarian will have to rule on whether their objections are valid.
  • Among the provisions that some moderate Democratic senators might object to are the paid family leave and the mechanism for lowering Medicare drug prices.
  • Congress is looking at a very busy end of the year, which could complicate passage of the social spending bill. Leaders already postponed a bill to raise the debt ceiling and the annual federal spending bills until early December.
  • A federal judge has blocked Texas Republican Gov. Greg Abbott’s order prohibiting mask mandates in schools. But a final resolution is likely some time away as the case is appealed. Disability rights groups, which had sued to stop the governor’s order, argued that the ban was keeping children with health problems who are at high risk from covid from coming to school.
  • Despite opposition from conservative leaders to vaccine mandates, the vast majority of workers have had their shots, either because they wanted them or their employer mandated it. Lawsuits brought against those workplace requirements may not signal a broad opposition among the population.
  • In its survey of employers’ health plans, KFF found that premiums are still increasing faster than wages as health costs continue to rise. Leaders of both political parties say they would like to reduce the cost of care, but no magic pill appears likely. Instead, lawmakers generally are more inclined to have the government pick up a bigger portion of the country’s health care costs when not finding a way to cut that spending.
  • One key challenge in addressing rising health care spending in Congress is the power of the health care industry. With the close political party margins on Capitol Hill, it is fairly easy for the industries to use their contributions to pick off a couple of members and keep major reform from passing.
  • The KFF survey also documented the wide expansion of telehealth coverage during the pandemic. Although employers and the government have been concerned that telehealth adds to spending because it duplicates services or allows doctors to charge for services they once performed over the phone without billing, it will be hard to put this genie back in the bottle. Consumers like the convenience. And some services, such as mental health therapy or medical consultations for rural residents, are much easier.

Also this week, Rovner interviews Rebecca Love, a nurse, academic and entrepreneur who has thought a lot about the future of the nursing profession and where it fits into the U.S. health care system

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: Washington Monthly’s “The Doctor Will Not See You Now,” by Merrill Goozner.

Alice Miranda Ollstein: NPR’s “Despite Calls to Improve, Air Travel Is Still a Nightmare for Many With Disabilities,” by Joseph Shapiro and Allison Mollenkamp.

Rebecca Adams: KHN’s “Patients Went Into the Hospital for Care. After Testing Positive There for Covid, Some Never Came Out,” by Christina Jewett.

Anna Edney: Bloomberg News’ “All Those 23andMe Spit Tests Were Part of a Bigger Plan,” by Kristen V Brown.

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

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.

USE OUR CONTENT

This story can be republished for free (details).

Watch: Going Beyond the Script of ‘Dopesick’ and America’s Real-Life Opioid Crisis

KHN teamed up with Hulu for a discussion of America’s opioid crisis, following the Oct. 13 premiere of the online streaming service’s new series “Dopesick.”

KHN and policy colleagues at our parent organization KFF teamed up with Hulu for a discussion of America’s opioid crisis, following the Oct. 13 premiere of the online streaming service’s new series “Dopesick.”

The discussion explored how the series’ writers worked with journalist Beth Macy, author of the book “Dopesick: Dealers, Doctors, and the Drug Company That Addicted America,” and showrunner Danny Strong to create and fact-check scripts and develop characters. It quickly moved on to a deeper discussion of how the fictionalized version of the opioid epidemic portrayed in the Hulu series dovetailed with the broader reality KFF’s journalists and analysts have been documenting in their work for the past few years.

Providing perspective on the role of public health and treatment were KHN correspondent Aneri Pattani, who has reported extensively on opioid policy, substance use and mental health, and KFF senior policy analyst Nirmita Panchal, whose analytical work focuses on mental health and substance use.

The forum was moderated by Chaseedaw Giles, audience engagement editor and digital strategist at KHN who has written about hip-hop music’s relationship with opioid abuse. It was filmed in KFF’s Washington, D.C., conference center to an audience of no one (courtesy of covid-19).

You can read a transcript of the forum by clicking here.

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.

USE OUR CONTENT

This story can be republished for free (details).

KHN’s ‘What the Health?’: The Politics of Vaccine Mandates

Like almost everything else associated with the covid-19 pandemic, partisans are taking sides over whether vaccines should be mandated. Meanwhile, Democrats on Capitol Hill are still struggling to find compromise in their effort to expand health insurance and other social programs. Alice Miranda Ollstein of Politico, Jen Haberkorn of the Los Angeles Times and Mary Ellen McIntire of CQ Roll Call join KHN’s Julie Rovner to discuss these issues and more. Also this week, Rovner interviews best-selling author Beth Macy about her book “Dopesick,” and the new Hulu miniseries based on it.

Can’t see the audio player? Click here to listen on Acast. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

Should covid vaccines be mandated? The answer to that question has become predictably partisan, as with almost everything else associated with the pandemic. Even as the federal government prepares to issue rules requiring large employers to ensure their workers are vaccinated, GOP governors are trying to ban such mandates, leaving employers caught in the middle.

Meanwhile, on Capitol Hill, Democrats are still working to reach a consensus on a package of social-spending improvements, the size of which will depend largely on how much they can cut prices for prescription drugs.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Jen Haberkorn of the Los Angeles Times and Mary Ellen McIntire of CQ Roll Call.

Among the takeaways from this week’s episode:

  • Congressional Democrats’ struggle to find a compromise on a $3.5 trillion spending package for health and other social programs looks likely to push them past their self-imposed deadline of the end of October to pass a bill. Leaders are wrestling with what to cut as they meet demands from moderates in the party to bring the spending down.
  • Everything in that package appears vulnerable at this stage in the negotiations. Party leaders are considering a variety of strategies, including throwing out some proposals or setting up the new benefits over a shorter time frame to test whether they work and the public appreciates them.
  • It appears that Democrats’ priorities will include proposals to enhance benefits for children. But the health programs at stake — new benefits for Medicare, providing insurance to low-income residents of states that have not expanded their Medicaid programs, and extending the enhanced premium subsidies for the Affordable Care Act — each have strong constituencies and will be hard for leaders to settle on.
  • The proposal to add billions of dollars to long-term care programs may draw the short straw. However, it does have some strong allies in Congress, including Sens. Ron Wyden (D-Ore.) and Bob Casey (D-Pa.).
  • Democratic leaders hope to fund some of the initiatives in this package by cutting Medicare’s drug spending. A poll by KFF this week showed that is a very popular notion, even among Republicans. But drugmakers are fighting that strategy with major ad campaigns and political donations. They need to pick off only a couple of vulnerable lawmakers to thwart the effort since Democrats have razor-thin majorities in both the House and Senate. House Speaker Nancy Pelosi, however, appears determined to get some sort of provision on drug price negotiations in the bill, even without the full effect of her original plan.
  • The Department of Labor reportedly has sent a proposed rule requiring large employers to have their workforce vaccinated to the Office of Management and Budget for review. That means the rule could be coming soon. But it is bound to run headlong into opposition in conservative states, like Texas, where Republican Gov. Greg Abbott has banned mandates. The issue will likely end up in federal court.
  • The fight over vaccine mandates highlights a divide in the Republican Party between the business-oriented faction that wants to move past the pandemic and the more libertarian wing of the party. Some of the most conservative political leaders lean toward that libertarian wing and see the vaccine mandate as a way to excite the base. The experience of some major companies, however, suggests that businesses and many workers don’t object to mandates. One example is United Airlines, where 99% of workers have been vaccinated.
  • As the federal courts bat the Texas abortion law back and forth, it appears headed for a review by the Supreme Court. Some analysts suggest that the urgency of the issue could push the court to take on the Texas issue before they hear a case in December about a different law seeking to limit abortion in Mississippi. But the Supreme Court generally likes to have cases fully debated in lower courts before coming to the justices, so a decision on the Texas law may have to wait.
  • The issue of abortion is getting a good bit of advertising time in the Virginia gubernatorial race. Democratic candidate Terry McAuliffe is telling voters he will work to keep abortions legal in the state and suggesting his opponent, Glenn Youngkin, will not. It’s a strategy that California Gov. Gavin Newsom used as he successfully fought a recall in an election last month.

Also this week, Rovner interviews Beth Macy, author of the best-selling “Dopesick: Dealers, Doctors and the Drug Company That Addicted America” and an executive producer of a miniseries of the same name now streaming on Hulu.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: KHN’s “6 Months to Live or Die: How Long Should an Alcoholic Liver Disease Patient Wait for a Transplant,” by Aneri Pattani

Jen Haberkorn: The Washington Post’s “Covid and Cancer: A Dangerous Combination, Especially for People of Color,” by Laurie McGinley

Mary Ellen McIntire: NPR’s “Judging ‘Sincerely Held’ Religious Belief Is Tricky for Employers Mandating Vaccines,” by Laurel Wamsley

Alice Miranda Ollstein: The 19th’s “Kansas Has Become a Beacon for Abortion Access. Next Year, That Could Disappear,” by Shefali Luthra

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

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.

USE OUR CONTENT

This story can be republished for free (details).

KHN’s ‘What the Health?’: Abortion Politics Front and Center

The polarizing abortion issue threatens to tie up Congress, the Supreme Court and the states for the coming year. Meanwhile, Congress kicks the can down the road to December on settling its spending priorities. Joanne Kenen of Politico and the Johns Hopkins School of Public Health, Yasmeen Abutaleb of The Washington Post and Sarah Karlin-Smith of the Pink Sheet join KHN’s Julie Rovner to discuss these issues and more.
Also this week, Rovner interviews KHN’s Aneri Pattani, who delivered the latest KHN-NPR “Bill of the Month” episode about a covid test that cost as much as a luxury car.

Can’t see the audio player? Click here to listen on Acast. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

Abortion, an issue that has mostly been simmering under the surface lately, is taking center stage in fights at the Supreme Court, in Congress and in the states, as the fate of legalized abortion in the United States hangs in the balance.

Meanwhile, Congress flirted with disaster as it appeared unlikely to meet deadlines to approve a series of budget bills, including an extension of the federal government’s lending authority. But lawmakers found ways to extend programs long enough to continue negotiating through the fall.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico and Johns Hopkins, Yasmeen Abutaleb of The Washington Post and Sarah Karlin-Smith of the Pink Sheet.

Among the takeaways from this week’s episode:

  • As Democratic lawmakers seek to reduce the cost of the president’s $3.5 trillion plan to boost health and other domestic programs, they are wrestling with whether to cut the number of programs they fund but still give them full support or to keep a wider range of initiatives but fund them for fewer years or at lower levels. Supporters of the latter proposal contend that getting the programs started is important and, if they have a constituency, it will be hard for Congress in the future to cut the programs.
  • Sen. Joe Manchin (D-W.Va.), who has been at the center of the negotiations because he was refusing to support the package if it stayed at $3.5 trillion, has called for new initiatives to be means-tested so that benefits don’t go to higher-income Americans. Past experience suggests that can lower the popularity of the programs because it creates more bureaucracy to oversee the benefits and sometimes creates problems with getting voters to buy into the need.
  • As the negotiations drag on, it seems less likely that the Democrats will agree on a plan to rein in prescription drug prices. Leaders haven’t come to terms on how they would like to address the issue, and drugmakers have beefed up their advertising campaign to oppose any action that could threaten their profits.
  • Manchin may also throw a wrench into the negotiations if he goes forward with plans to seek a provision in the legislative package that makes the so-called Hyde Amendment permanent. The Hyde Amendment, which is commonly added to annual health spending legislation, bars most federal dollars from being spent on abortions. Progressive Democrats strongly oppose the Hyde Amendment, and they would like to remove it from the annual spending bill for the Department of Health and Human Services.
  • Pfizer on Thursday announced it is seeking authorization from the Food and Drug Administration for a covid vaccine for children ages 5 to 11. The agency has scheduled an advisory committee meeting already and a decision could come around Halloween. A decision on vaccines for children under 5, however, seems unlikely before the end of the year.
  • The recent controversy over whether the U.S. should authorize so-called vaccine boosters has focused attention on the lack of good national data on covid’s effects. Much of the argument for those additional shots was based on studies from Israel and Britain because U.S. health officials have not been collecting the same level of data about covid cases and outcomes. That is partly a reflection of the decentralization of the U.S. health system.
  • The Biden administration announced this week it is reversing a federal Title X rule that denied funding to organizations that counseled people about abortion or referred them to abortion providers. Planned Parenthood left the program after the Trump administration implemented that rule.
  • Abortion is teeing up to be a big issue before the Supreme Court this term. The justices had already agreed to hear a case opposing a Mississippi law restricting most abortions after 15 weeks, but cases involving a controversial Texas law that denies abortions after six weeks appear bound for the high court soon, too.
  • Abortion opponents are hoping the court will overturn the landmark Roe v. Wade decision legalizing the procedure. But that could also set the court up for a major backlash and complaints about its politicization.
  • Biden has another key health opening in his administration: the director of the National Institutes of Health. But it doesn’t seem likely to be as difficult to fill as the head of the FDA, which the White House has still not offered a nominee for.

Also this week, Rovner interviews KHN’s Aneri Pattani, who reported the latest KHN-NPR “Bill of the Month” feature about two similar jaw surgeries with two very different price tags. If you have an outrageous medical bill, you’d like to send us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: The New York Times’ “A ‘Historic Event’: First Malaria Vaccine Approved by W.H.O.,” by Apoorva Mandavilli

Joanne Kenen: Vox.com’s “Why Merck’s Covid-19 Pill Molnupiravir Could Be So Important,” by Umair Irfan

Yasmeen Abutaleb: The Wall Street Journal’s “Why It’s So Hard to Find a Therapist Who Takes Insurance,” by Andrea Petersen

Sarah Karlin-Smith: The Washington Post’s “70 Years Ago, Henrietta Lacks’s Cells Were Taken Without Her Consent. Now, Her Family Wants Justice,” by Emily Davies

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

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.

USE OUR CONTENT

This story can be republished for free (details).

As Holdout Missouri Joins Nation in Monitoring Opioid Prescriptions, Experts Worry

Missouri is the last state to create a monitoring program to help spot the misuse of prescription drugs. But some public health experts warn that the nation’s programs are forcing people addicted to opioids to seek deadlier street options.

Kathi Arbini said she felt elated when Missouri finally caught up to the other 49 states and approved a statewide prescription drug monitoring program this June in an attempt to curb opioid addiction.

The hairstylist turned activist estimated she made 75 two-hour trips in the past decade from her home in Fenton, a St. Louis suburb, to the state capital, Jefferson City, to convince Republican lawmakers that monitoring how doctors and pharmacists prescribe and dispense controlled substances could help save people like her son, Kevin Mullane.

He was a poet and skateboarder who she said turned to drugs after she and his dad divorced. He started “doctor-shopping” at about age 17 and was able to obtain multiple prescriptions for the pain medication OxyContin. He died in 2009 at 21 from a heroin overdose.

If the state had had a monitoring program, doctors might have detected Mullane’s addiction and, Arbini thinks, her son might still be alive. She said it’s been embarrassing that it’s taken Missouri so long to agree to add one.

“As a parent, you would stand in front of a train; you would protect your child forever — and if this helps, it helps,” said Arbini, 61. “It can’t kill more people, I don’t think.”

But even though Missouri was the lone outlier, it had not been among the states with the highest opioid overdose death rates. Missouri had an average annual rank of 16th among states from 2010 through 2019, as the country descended into an opioid epidemic, according to a KHN analysis of Centers for Disease Control and Prevention data compiled by KFF.

Some in public health now argue that when providers use such monitoring programs to cut off prescription opiate misuse, people who have an addiction instead turn to heroin and fentanyl. That means Missouri’s new toll could cause more people to overdose and leave the state with buyer’s remorse.

“If we can take any benefit from being last in the country to do this, my hope would be that we have had ample opportunity to learn from others’ mistakes and not repeat them,” said Rachel Winograd, a psychologist who leads NoMODeaths, a state program aimed at reducing harm from opioid misuse.

Before Missouri’s monitoring program was approved, lawmakers and health and law enforcement officials warned that the absence made it easier for Missouri patients to doctor-shop to obtain a particular drug, or for providers to overprescribe opiates in what are known as pill mills.

State Sen. Holly Rehder, a Republican with family members who have struggled with opioid addiction, spent almost a decade pushing legislation to establish a monitoring program but ran into opposition from state Sen. Rob Schaaf, a family physician and fellow Republican who expressed concerns about patient privacy and fears about hacking.

In 2017, Schaaf agreed to stop filibustering the legislation and support it if it required that doctors check the database for other prescriptions before writing new ones for a patient. That, though, sparked fresh opposition from the Missouri State Medical Association, concerned the requirement could expose physicians to malpractice lawsuits if patients overdosed.

The new law does not include such a requirement for prescribers. Pharmacists who dispense controlled substances will be required to enter prescriptions into the database.

Dr. Silvia Martins, an epidemiologist at Columbia University who has studied monitoring programs, said it’s important to mandate that prescribers review a patient’s information in the database. “We know that the ones that are most effective are the ones where they check it regularly, on a weekly basis, not just on a monthly basis,” she said.

But Stephen Wood, a nurse practitioner and visiting substance abuse bioethics researcher at Harvard Law School, said the tool is often punitive because it cuts off access to opioids without offering viable treatment options.

He and his colleagues in the intensive care unit at Carney Hospital in Boston don’t use the Massachusetts monitoring program nearly as often as they once did. Instead, he said, they rely on toxicology screens, signs such as injection marks or the patients themselves, who often admit they are addicted.

“Rather than pulling out a piece of paper and being accusatory, I find it’s much better to present myself as a caring provider and sit down and have an honest discussion,” Wood said.

When Kentucky in 2012 became the first state to require prescribers and dispensers to use the system, the number of opioid prescriptions and overdoses from prescription opioids initially decreased slightly, according to a state study.

But the number of opioid overdose deaths — with the exception of a slight dip in 2018 and 2019 — has since consistently ticked upward, according to a KFF analysis of CDC data. In 2020, Kentucky was estimated to have had the nation’s second-largest increase in drug overdose deaths.

When efforts to establish Missouri’s statewide monitoring program stalled, St. Louis County established one in 2017 that 75 local jurisdictions agreed to participate in, covering 85% of the state, according to the county health department. The county now plans to move its program into the state one, which is scheduled to launch in 2023.

Dr. Faisal Khan, director of the county department, said he has no doubt that the St. Louis program has “saved lives across the state.” Opioid prescriptions decreased dramatically once the county established the monitoring program. In 2016, Missouri averaged 80.4 opioid prescriptions per 100 people; in 2019, it was down to 58.3 prescriptions, according to the CDC.

The overall drug overdose death rate in Missouri has steadily increased since 2016, though, with the CDC reporting an initial count of 1,921 people dying from overdoses of all kinds of drugs in 2020.

Khan acknowledged that a monitoring program can lead to an increase in overdose deaths in the years immediately following its establishment because people addicted to prescription opioids suddenly can’t obtain them and instead buy street drugs that are more potent and contain impurities.

But he said a monitoring program can also help a physician intervene before someone becomes addicted. Doctors who flag a patient using the monitoring program must then also be able to easily refer them to treatment, Khan and others said.

“We absolutely are not prepared for that in Missouri,” said Winograd, of NoMODeaths. “Substance use treatment providers will frequently tell you that they are at max capacity.”

Uninsured people in rural areas may have to wait five weeks for inpatient or outpatient treatment at state-funded centers, according to PreventEd, a St. Louis-based nonprofit that aims to reduce harm from alcohol and drug use.

For example, the waiting list for residential treatment at the Preferred Family Healthcare clinic in Trenton is typically two weeks during the summer and one month in winter, according to Melanie Tipton, who directs clinical services at the center, which mostly serves uninsured clients in rural northern Missouri.

Tipton, who has worked at the clinic for 17 years, said that before the covid-19 pandemic, people struggling with opioid addiction mainly used prescription pills; now it’s mostly heroin and fentanyl, because they are cheaper. Fentanyl is a synthetic opioid that is 50 to 100 times more potent than morphine, according to the National Institute on Drug Abuse.

Still, Tipton said her clients continue to find providers who overprescribe opiates, so she thinks a statewide monitoring program could help.

Inez Davis, diversion program manager for the Drug Enforcement Administration’s St. Louis division, also said in an email that the program will benefit Missouri and neighboring states because “doctor shoppers and those who commit prescription fraud now have one less avenue.”

Winograd said it’s possible that if the state had more opioid prescription pill mills, it would have a lower overdose death rate. “I don’t think that’s the answer,” she said. “We need to move in the direction of decriminalization and a regulated drug supply.” Specifically, she’d rather Missouri decriminalize possession of small amounts of hard drugs, even heroin, and institute regulations to ensure the drugs are safe.

State Rep. Justin Hill, a Republican from St. Charles and former narcotics detective, opposed the monitoring program legislation because of his concerns over patient privacy and evidence that the lack of a program has not made Missouri’s opioid problem any worse than many other states’. He also worries the monitoring program will lead to an increase in overdose deaths.

“I would love the people that passed this bill to stand by the numbers,” Hill said. “And if we see more deaths from overdose, scrap the monitoring program and go back to the drawing board.”

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.

USE OUR CONTENT

This story can be republished for free (details).

KHN’s ‘What the Health?’: Delta Changes the Covid Conversation

With covid cases on the upswing again around the country, partisan division remains over how to address the pandemic. Meanwhile, the Biden administration proposes bigger penalties for hospitals that fail to make their prices public as required. Stephanie Armour of The Wall Street Journal, Alice Miranda Ollstein of Politico and Tami Luhby of CNN join KHN’s Julie Rovner to discuss these issues and more. Also, for “extra credit,” the panelists suggest their favorite stories of the week they think you should read, too.

Can’t see the audio player? Click here to listen on SoundCloud. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

The resurgence of covid cases in the U.S. — largely attributable to the much more contagious delta variant — has given policymakers the jitters. The Biden administration is redoubling efforts to get people vaccinated, and even some Republicans who had been silent or skeptical of the vaccines are encouraging the unvaccinated to change their status.

Meanwhile, it’s not just covid that’s shortening U.S. life expectancy. Nearly 100,000 people died of drug overdoses in 2020, according to the Centers for Disease Control and Prevention. This week a multibillion-dollar settlement among states, drugmakers and distributors could funnel funding to fight the opioid scourge.

This week’s panelists are Julie Rovner of KHN, Stephanie Armour of The Wall Street Journal, Alice Miranda Ollstein of Politico and Tami Luhby of CNN.

Among the takeaways from this week’s episode:

  • If lawmakers fail to craft a bipartisan deal on Capitol Hill on traditional infrastructure spending, Democrats’ plans for a second bill that incorporates significant health care programs may need to be scaled back. That’s because the Democrats have pledged to fund major improvements in infrastructure and they would need to add that to the second bill, which is being moved through a special procedure that keeps it from being stalled in the Senate by a Republican filibuster. Some Democrats are nervous about making that second bill too broad.
  • The momentum toward vaccinating the public has stalled abruptly in the past month or so, and reports of rising cases is causing concern among conservatives. Some high-profile Republicans — including Senate Minority Leader Mitch McConnell, Rep. Steve Scalise (La.) and Florida Gov. Ron DeSantis — have been out during the past week touting the vaccines’ successes.
  • The agreement reached this week between state officials and companies that made or distributed opioids will send billions of dollars to the states to fund prevention and treatment programs for people with addiction problems. Some advocates worry, however, that the funding — much like the landmark tobacco settlement of past years — will instead be absorbed by cash-strapped states for other uses.
  • The Biden administration proposed significantly increasing the fines for hospitals that do not make their prices easily seen online and understood for patients. Despite the widespread eagerness to establish transparency, there is little indication consumers are using such tools.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: NPR’s “The Life Cycle of a COVID-19 Vaccine Lie,” by Geoff Brumfiel

Stephanie Armour: The Washington Post’s “Biden Administration, Workers Grapple With Health Threats Posed by Climate Change and Heat,” by Eli Rosenberg and Abha Bhattarai

Tami Luhby: The Los Angeles Times’ “Same Hospitals but Worse Outcomes for Black Patients Than White Ones,” by Emily Alpert Reyes

Alice Miranda Ollstein: The 19th’s “Courts Block Laws Targeting Transgender Children in Arkansas and West Virginia,” by Orion Rummler

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

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.

USE OUR CONTENT

This story can be republished for free (details).

How ERs Fail Patients With Addiction: One Patient’s Tragic Death

Two intractable failings of the U.S. health care system — addiction treatment and medical costs — come to a head in the ER, where patients desperate for addiction treatment arrive, only to find the facility may not be equipped to deal with substance use or, if they are, treatment is prohibitively expensive.

Jameson Rybak tried to quit using opioids nearly a dozen times within five years. Each time, he’d wait out the vomiting, sweating and chills from withdrawal in his bedroom.

It was difficult to watch, said his mother, Suzanne Rybak, but she admired his persistence.

On March 11, 2020, though, Suzanne grew worried. Jameson, 30 at the time, was slipping in and out of consciousness and saying he couldn’t move his hands.

By 11 p.m., she decided to take him to the emergency room at McLeod Regional Medical Center in Florence, South Carolina. The staff there gave Jameson fluids through an IV to rehydrate, medication to decrease his nausea and potassium supplements to stop his muscle spasms, according to Suzanne and a letter the hospital’s administrator later sent her.

But when they recommended admitting him to monitor and manage the withdrawal symptoms, Jameson said no. He’d lost his job the previous month and, with it, his health insurance.

“He kept saying, ‘I can’t afford this,’” Suzanne recalled, and “not one person [at the hospital] indicated that my son would have had some financial options.”

Suzanne doesn’t remember any mention of the hospital’s financial assistance policy or payment plans, she said. Nor does she remember any discussions of providing Jameson medication to treat opioid use disorder or connecting him to addiction-specialty providers, she said.

“No referrals, no phone numbers, no follow-up information,” she later wrote in a complaint letter to the hospital.

Instead, ER staff provided a form saying Jameson was leaving against medical advice. He signed and Suzanne witnessed.

Three months later, Jameson Rybak died of an overdose in his childhood bedroom.

Missed Opportunities

That March night in the emergency room, Jameson Rybak had fallen victim to two huge gaps in the U.S. health care system: a paucity of addiction treatment and high medical costs. The two issues — distinct but often intertwined — can come to a head in the ER, where patients and families desperate for addiction treatment often arrive, only to find the facility may not be equipped to deal with substance use. Or, even if they are, the treatment is prohibitively expensive.

Academic and medical experts say patients like Jameson represent a series of missed opportunities — both medical and financial.

“The emergency department is like a door, a really important door patients are walking through for identification of those who might need help,” said Marla Oros, a registered nurse and president of the Mosaic Group, a Maryland-based consulting firm that has worked with more than 50 hospitals nationwide to increase addiction treatment services. “We’re losing so many patients that could be identified and helped,” she said, speaking generally.

A spokesperson for McLeod Regional Medical Center, where Jameson went for care, said they would not comment on an individual’s case and declined to answer a detailed list of questions about the hospital’s ER and financial assistance policies. But in a statement, the hospital’s parent company, McLeod Health, noted that the hospital adhered to federal laws requiring that hospital ERs provide “immediate stabilizing care” for all patients, regardless of their ability to pay.

“Our hospitals attempt to manage the acute symptoms, but we do not treat chronic, underlying addiction,” the statement added.

Suzanne said her son needed more than stabilization. He needed immediate help breaking the cycle of addiction.

Jameson had been in and out of treatment for five years, ever since a friend suggested he try opioids to manage his anxiety and insomnia. He had insurance through his jobs in the hotel industry and later as an electrical technician, Suzanne said. But the high-deductible plans often left him paying out-of-pocket: $3,000 for a seven-day rehab stay, $400 for a brief counseling session and a prescription of Suboxone, a medication to treat opioid use disorder.

After he lost his job in February 2020, Jameson tried again to detox at home, Suzanne said. That’s what led to the ER trip.

Treating Addiction in the ER

Hospital ERs across the nation have become ground zero for patients struggling with addiction.

A seminal study published in 2015 by researchers at Yale School of Medicine found that giving patients medication to treat opioid use disorder in the ER doubled their chances of being in treatment a month later, compared with those who were given only referrals to addiction treatment.

Yet providing that medication is still not standard practice. A 2017 survey found just 5% of emergency medicine physicians said their department provided medications for opioid use disorder. Instead, many ERs continue to discharge these patients, often with a list of phone numbers for addiction clinics.

Jameson didn’t even get that, Suzanne said. At McLeod Regional, he was not seen by a psychiatrist or addiction specialist and did not get a prescription for Suboxone or even a referral, she said.

After Jameson’s death, Suzanne wrote to the hospital: “Can you explain to me, especially with the drug crisis in this country, how the ER was not equipped with personnel and/or any follow-up for treatment?”

Hospital administrator Will McLeod responded to Suzanne, in a letter she shared with KHN, that per Jameson’s medical record he’d been evaluated appropriately and that his withdrawal symptoms had been treated. Jameson declined to be admitted to the hospital, the letter said, and could not be involuntarily committed, as he “was not an imminent danger to himself or others.”

“Had he been admitted to our hospital that day, he would have been assigned to social workers and case managers who could have assisted with referrals, support, and follow-up treatment,” McLeod wrote.

Nationwide, hospitals are working to ramp up the availability of addiction services in the ER. In South Carolina, a state-funded program through the Medical University of South Carolina and the consulting firm Mosaic Group aims to help hospitals create a standardized system to screen patients for addiction, employ individuals who are in recovery to work with those patients and offer medication for opioid use disorder in the ER.

The initiative had worked with seven ERs as of June. It was in discussions to work with McLeod Regional hospital too, program staffers said. However, the hospital backed out.

The hospital declined to comment on its decision.

ER staffs around the country often lack the personnel to launch initiatives or learn about initiating addiction treatment. Sometimes affordable referral options are limited in the area. Even when the initial prescribing does occur, cost can be a problem, since Suboxone and its generic equivalent range in price from $50 to over $500 per prescription, without insurance.

In South Carolina, which has not expanded Medicaid, nearly 11% of the population is uninsured. Among patients in the state’s program who have been started on medications for opioid use disorder in ERs, about 75% are uninsured, said Dr. Lindsey Jennings, an emergency medicine physician at MUSC who works on the statewide initiative.

Other parts of the country face similar concerns, said Dr. Alister Martin, an emergency medicine physician who heads a national campaign to encourage the use of these medications in the ER. In Texas, for example, hundreds of doctors have gotten certified to provide the medications, he said, but many patients are uninsured and can’t pay for their prescriptions.

“You can’t make it effective if people can’t afford it,” Martin said.

Too Late for Charity Care

Throughout the night at McLeod Regional hospital’s ER, Jameson worried about cost, Suzanne said.

She wanted to help, but Jameson’s father and younger brother had recently lost their jobs, and the household was running on her salary as a public school librarian.

Suzanne didn’t know that nonprofit hospitals, like McLeod, are required by the federal government to have financial assistance policies, which lower or eliminate bills for people without the resources to pay. Often called charity care, this assistance is a condition for nonprofit hospitals to maintain their tax-exempt status.

But “nonprofits are actually doing less charity care than for-profits,” said Ge Bai, an associate professor at Johns Hopkins University who published a study this year on the level of charity care provided by different hospitals.

That’s in part because they have wide leeway to determine who qualifies and often don’t tell patients they may be eligible, despite federal requirements that nonprofit hospitals “widely publicize” their financial assistance policies, including on billing statements and in “conspicuous public displays” in the hospital. One study found that only 50% of hospitals regularly notified patients about eligibility for charity care before initiating debt collection.

McLeod Regional’s most recent publicly available tax return states that “uninsured patients are screened at the time of registration” and if they’re unable to pay and ineligible for governmental insurance, they’re given an application.

Suzanne said she doesn’t remember Jameson or herself receiving an application. The hospital declined to comment on the Rybaks’ case and whether it provides “conspicuous public displays” of financial assistance.

“Not once did anybody tell us, ‘Let’s get a financial person down here,’ or ‘There are grant programs,’” Suzanne said.

Mark Rukavina, with the nonprofit health advocacy group Community Catalyst, said most hospitals comply with the letter of the law in publicizing their assistance policy. But “how effective some of that messaging is may be a question,” he said. Some hospitals may bury the policy in a dense packet of other information or use signs with vague language.

A KHN investigation in 2019 found that, nationwide, 45% of nonprofit hospital organizations were routinely sending medical bills to patients whose incomes were low enough to qualify for charity care. McLeod Regional hospital reported $1.77 million of debt from sending bills to such patients, which ended up going unpaid, for the fiscal year ending in 2019.

Believing they couldn’t afford in-patient admission, the Rybaks left the hospital that night.

After the ER

Afterward, Jameson’s withdrawal symptoms passed, Suzanne said. He spent time golfing with his younger brother. Although his application for unemployment benefits was denied, he managed to defer payments on his car and school loans, she said.

But, inside, he must have been struggling, Suzanne now realizes.

Throughout the pandemic, many people with substance use disorder reported feeling isolated and relapsing. Overdose deaths rose nationwide.

On the morning of June 9, 2020, Suzanne opened the door to Jameson’s room and found him on the floor. The coroner determined he had died of an overdose. The family later scattered his ashes on Myrtle Beach — Jameson’s favorite place, Suzanne said.

In the months following Jameson’s death, hospital bills for his night in the ER arrived at the house. He owed $4,928, they said. Suzanne wrote to the hospital that her son was dead but received yet another bill addressed to him after that.

She shredded it and mailed the pieces to the hospital, along with a copy of Jameson’s death certificate.

Twelve days later, the health system wrote to her that the bill had been resolved under its charity care program.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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.

USE OUR CONTENT

This story can be republished for free (details).

Opioids like ‘Lean’ Permeate Hip-Hop Culture, but Dangers Are Downplayed

In big cities and small towns, opioid use among some young hip-hop fans is about emulating their favorite rap star’s image — while paying little attention to the serious consequences.

Nykerrius Williams knows about the close relationship between hip-hop and opioid use. Williams, 27, an independent rapper from Gibsland, Louisiana, who goes by the name Young Nyke, took oxycodone pills for the first time when he was 16 and has continued patterns of misuse of those pills, as well as Lortabs, Xanax and codeine cough syrups, until recently. To him, it’s part of the business.

Use Our Content

It can be republished for free.

“If you ain’t rapping about being on no drugs, or you out here in the streets selling some drugs,” he said of his chosen profession, “you ain’t got some of that going on — like, don’t nobody wanna hear what you talking about.”

This snapshot of Williams’ hip-hop life doesn’t seem all that different from that of musicians of other genres for whom the mix of drugs and addiction is a recurring storyline, claiming the lives of artists like Janis Joplin, found dead of a heroin overdose in 1970, and rapper DMX, who died last month.

But drug use in the hip-hop community has an ever increasing presence that is intertwined with the music – and one with dire consequences. The catchy lyrics suggest that opioid misuse is part and parcel with fame and wealth, just a normal, and innocuous, component of that life.  

Coverage on the abuse of hard drugs in the community usually focuses on tragedy surrounding certain popular rappers rather than the lyrics and the culture they create. And while public health experts take great pains, for example, to criticize and curtail the promotion of vaping to young people, little attention is paid to the dangerous effects that hip-hop is having on vulnerable listeners by normalizing popping Percocets or drinking cough syrup.

From big cities like Los Angeles to rural towns like Gibsland — population 878 — opioid misuse among some young, hopeful listeners is about emulating their favorite rap star’s enviable image. For others, it is not all about the high life. It’s self-medication.

“Let’s talk about pain,” said Mikiel Muhammad, 38, aka King Kong Gotcha, a member of the rap trio The Opioid Era in Virginia. “The pain is so deep. They ain’t got money to go see a psychiatrist, but they got money to go get a Perc-10. They got $10, $15 for that,” Gotcha said, referencing the street value of a 10-milligram Percocet tablet.

According to a February KFF report, anxiety, depression and thoughts of suicide have increased for young adults in the past year.

Artists like Young Nyke sometimes confront neighborhood and family violence, as well as a general lack of opportunities and resources in their communities — circumstances amplified by the covid pandemic. The poetic words detailing the rappers’ experience offer some support. But these phrases can also be fraught.

It’s not just the drug use that is worrisome, said Naa-Solo Tettey, an associate professor of public health at William Paterson University in Wayne, New Jersey. Often these songs promote using opioids while engaging in high-risk activities like unprotected sex or speeding and, while she is a hip-hop fan, “from a public health perspective, it’s just dangerous,” she said.

That toxicity reaches into populations already plagued by perpetual cycles of poverty, poor health and lowered life expectancy. There is a need for “culturally relevant interventions” to educate and raise awareness within the hip-hop music audience, which Tettey’s research categorizes as primarily composed of youth from “vulnerable and socially disadvantaged” groups.

It is time to turn a critical eye to how opioid misuse permeates hip-hop’s lyrics, creating an entryway for Black young adults into the American opioid epidemic, said Tettey.

In 2017 that epidemic was declared a national public health emergency, with over 47,000 opioid-related overdose deaths reported. Researchers at the Centers for Disease Control and Prevention say fatal drug overdoses nationwide have surged roughly 20% during the covid pandemic, killing more than 83,000 people in 2020. Within this grim statistic the Substance Abuse and Mental Health Services Administration has found inequities.

According to a 2020 report from the Department of Health and Human Services’ Office of Behavioral Health Equity and SAMHSA, attention to this crisis has focused more on white suburban and rural communities, even though Black communities are experiencing similar dramatic increases in opioid misuse and death. The report also found that synthetic opioids, like fentanyl, are affecting opioid death rates among Black people more severely than other populations.

A 2020 SAGE journal research paper found a large increase in prescription opioid overdose deaths among Black people. The paper also found the rate of death almost tripling between 1999 and 2017. In February 2018 the U.S. surgeon general tweeted a warning that trends in opioid misuse “may be a precursor to even more opioid overdose fatalities in the black community in coming years.”

“The music industry, all it does is perpetuate whatever’s going on outside,” said Jarrell Gilliard, 40, explaining the pharmaceutical drug presence he’s encountered and how it’s reflected in popular lyrics. “How they pump these pills and all these prescribed medicines through the streets. Once the streets got ’em …” said Gilliard, whose hip-hop alias is Grunge Gallardo.

Grunge is also a member of The Opioid Era, named for their gritty, raw imagery and lyrics. Songs such as “Suboxones,” “Sackler Oath” and “Overdose,” which opens with a haunting 911 recording of a woman frantically pleading for help with one, contrast sharply with the pill-laced tunes of hip-hop’s mainstream.

“I think that’s the most dangerous thing about it,” said Richard Buskey, 42, who completes The Opioid Era trio as Ambassador Rick. “It’s a disconnect between the youth and them realizing that they’re in the same category as what they would consider a junkie or a fiend.”

Tettey said that’s partly because mainstream artists represent a lifestyle many young adults want for themselves, which can translate into modeling behaviors like opioid misuse.

Feeling the ‘Lean’

Patrick Williams, 26, an independent rapper from Orange, Texas, with the stage name PatvFoo, is no stranger to addiction.

He was 21 when he first sipped “lean” — a drink made from mixing prescription cough syrup containing the antihistamine promethazine and the opioid codeine with soda, Jolly Rancher candies and ice, served in doubled-up Styrofoam cups. “It’s a variety of colors that you have,” PatvFoo said, referencing the various formulations of codeine cough syrups. Purple syrup ranks as most potent. PatvFoo learned about lean through the Texas rap scene and artists like DJ Screw and then became a user.

“At first, there’s a mellowing high,” said Stevie Jones, 23, also known as Prophet J, an independent rapper in Louisville, Kentucky. He has similar recollections from his first time misusing codeine syrups. He and his friends drizzled some on a blunt — the slang term for a hollowed-out cigar filled with pot. “It just makes it burn slower — like, get you a little bit higher, I guess,” Prophet J said.

Things can take a bad turn quickly. Although lean is one of the weaker opioids, experts say it is highly addictive, and often in a short time. “The day you go without it you get bad, bad stomach cramps. You feel like you got to just throw up all the time. You sweating. It’s like you got a bad flu,” PatvFoo said.

That flu-like feeling is opioid withdrawal, said Dr. Edwin C. Chapman, a Howard University College of Medicine alum who has practiced internal and addiction medicine in Washington, D.C., for more than 40 years. The symptoms range from runny nose and eyes to diarrhea and usually can be stopped with a gulp of cough syrup or lean, he said.

And there’s a harsh reality in that. Whether it’s Percocet pills or lean, “it’s all in the same class as heroin and fentanyl,” Chapman said.

But learning that opioid use is promoted in popular music came as a revelation to Chapman. “That’s not the music that I listened to,” said the 75-year-old doctor. The medical community, he said, has been focused on curbing the overprescribing of pain medication. “But it’s never talked about … that it’s being advertised overtly to young folks through music or through the media.”

Indeed, abuse of lean, also known as “purple drank” and “sizzurp,” has managed to evade the regulatory spotlight while remaining popular and recognizable — so much so that vaping companies distributed nicotine-containing e-liquids resembling the drink and even mimicked the slang term “double cup” in their labeling. These products triggered a 2019 Food and Drug Administration crackdown on the vaping juices. The drugs themselves, however, still pump through the streets, just like the hip-hop lyrics.

And it has altered the market, moving it beyond the street options of heroin and opioids, said hip-hop artist Buskey. “We living in the times where they’re getting it out of the medicine cabinet.”

Phillip Coleman, 34, a rapper in Rochester, New York, who goes by the name GodclouD, started using at age 15 after being prescribed 5-milligram tablets of Percocet following wisdom tooth extraction. That set him on a path to misusing prescription painkillers, which led to cocaine and then a heroin addiction that eventually landed him in prison.

Fortunately, Coleman was able to overcome his addictions in rehab and refocus on family and music. He cautions that people buying Percocet or other prescription pills on the street have no way of knowing if they are legitimate or “just pressed fentanyl.” He said the reward for opioid addiction isn’t the lifestyles of the rich and famous you see portrayed by some hip-hop artists. “You don’t get to trade in your empty bags like the box tops and get, like, a bike or whatever. Like, you don’t get no hat; you don’t get no fentanyl swag,” he chuckled. “Like, you just die.”

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.

USE OUR CONTENT

This story can be republished for free (details).

KHN’s ‘What the Health?’: 100 Days of Health Policy

It’s 100 days into Joe Biden’s presidency and a surprisingly large number of health policies have been announced. But health is notably absent from the administration’s $1.8 trillion spending plan for American families, making it unclear how much more will get done this year. Meanwhile, the Centers for Disease Control and Prevention loosens its mask-wearing recommendations for those who have been vaccinated, but the new rules are confusing. Joanne Kenen of Politico, Mary Ellen McIntire of CQ Roll Call and Sarah Karlin-Smith of the Pink Sheet join KHN’s Julie Rovner to discuss these issues and more. Plus, Rovner interviews KHN’s Julie Appleby, who reported the latest KHN-NPR “Bill of the Month” episode.

Can’t see the audio player? Click here to listen on SoundCloud.

It’s been a busy 100 days for the Biden administration on health policy. The promise Joe Biden made as president-elect to get 100 million covid vaccinations in arms was doubled, healthcare.gov reopened to those without insurance, and steps were taken to undo a raft of health policies implemented by President Donald Trump. The covid relief bill passed by Congress in March also boosted subsidies for those who buy their own coverage and provided incentives for the 12 states that have yet to expand their Medicaid programs under the ACA.

But those actions may prove the high point for health policy this year. Administration officials initially promised that health would be a major part of the president’s $1.8 trillion American Families Plan, but major changes, particularly those addressing prescription drug costs, were nowhere to be seen when the plan was unveiled Wednesday.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico, Mary Ellen McIntire of CQ Roll Call and Sarah Karlin-Smith of the Pink Sheet

Here are some takeaways from this week’s podcast:

  • Among the Trump administration health policies the Biden administration has moved to reverse are those on women’s reproductive health and Medicaid work requirements. Some experts suggest that Democratic officials pushed forward on this with good speed because the past administration’s health policies were easier to disentangle than its rules on environment, where Biden also wants to make changes.
  • Democratic lawmakers had seemed eager to use Biden’s family plan to expand Medicare or drive down prescription drug prices. It likely signals that while health care is a key issue for Democrats on Capitol Hill, it is not as big a priority in the White House. Biden, who did mention those policies favored by progressive lawmakers in his speech to Congress on Wednesday, seems to be putting his emphasis on strengthening the Affordable Care Act.
  • Right now, the pharmaceutical industry is scoring high with voters and politicians because of the successes of the covid vaccines. So, getting Senate approval of a bill to allow Medicare to negotiate drug prices is likely to be difficult. Those odds get even tougher without pressure from the White House.
  • Biden may also have shied away from the drug pricing initiative in his formal plan for helping families because he was concerned that it could divide the Democratic caucus and imperil the overall initiative.
  • The administration is gearing up to provide India with help to fight the pandemic. Public health officials point out that although the vaccination effort in the U.S. is going well, it is imperative to tamp down the virus in other countries so variants that could evade the vaccines don’t develop. However, there is already a debate about how much U.S. vaccine to ship abroad before authorities determine how to vaccinate children here.
  • Federal health officials have lifted the pause on using the Johnson & Johnson covid vaccine, but that decision has been controversial and some scientists question whether there was enough study or it was the right move.
  • The Centers for Disease Control and Prevention loosened its mask-wearing recommendations for people who have been vaccinated, but the new rules are confusing and even sparked some jokes among late-night TV comedians.
  • As the vaccination efforts in the U.S. gain steam, interest is growing among people with long-term cases of covid-19. A hearing on Capitol Hill this week looked at some of the issues, such as what sorts of disabilities these patients face and what workplace accommodations are necessary.
  • The National Institutes of Health is beginning major studies of “long covid” and its myriad symptoms. Although health officials do not yet have a clear definition of long covid, they are generally not dismissing patients’ complaints about the disorder. That differs from some mysterious ailments in the past.
  • The Biden administration has loosened the rules governing who can prescribe the drug buprenorphine, a controversial but effective treatment for opioid addiction. The policy eliminates a training requirement and seeks to allow medical professionals other than doctors to prescribe the drug. But hurdles to its use remain, leading some to question how much more widely the drug will be used as a result of the new policy.

Also this week, Rovner interviews KHN’s Julie Appleby, who reported the latest KHN-NPR “Bill of the Month” feature — about the intersection between car insurance and health insurance. If you have an outrageous medical bill you’d like to share with us, you can do it here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: This American Life’s “The Herd,” by Ira Glass, Anna Maria Barry-Jester and David Kestenbaum. Also, KHN’s “We’re Coming for You’: For Public Health Officials, a Year of Threats and Menace,” by Anna Maria Barry-Jester.

Joanne Kenen: The New Yorker’s “How Vaccine Hesitancy Is Driving Breakthrough Infections in Nursing Homes,” by Masha Gessen.

Mary Ellen McIntire: CQ Roll Call’s “FEMA’s Tasks Pit COVID-19 Vaccinations Against Hurricane Prep,” by Emily Kopp.

Sarah Karlin-Smith: The Pink Sheet’s “Conflicts Galore: Upcoming Accelerated Approval Cancer Panel Includes Many Industry Relationships,” by Sarah Karlin-Smith.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

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.

USE OUR CONTENT

This story can be republished for free (details).

Doctors More Likely to Prescribe Opioids to Covid ‘Long Haulers,’ Raising Addiction Fears

Chronic pain from covid can linger for months after patients appear to recover from the disease.

Covid survivors are at risk from a possible second pandemic, this time of opioid addiction, given the high rate of painkillers being prescribed to these patients, health experts say.

Use Our Content

It can be republished for free.

A new study in Nature found alarmingly high rates of opioid use among covid survivors with lingering symptoms at Veterans Health Administration facilities. About 10% of covid survivors develop “long covid,” struggling with often disabling health problems even six months or longer after a diagnosis.

For every 1,000 long-covid patients, known as “long haulers,” who were treated at a Veterans Affairs facility, doctors wrote nine more prescriptions for opioids than they otherwise would have, along with 22 additional prescriptions for benzodiazepines, which include Xanax and other addictive pills used to treat anxiety.

Although previous studies have found many covid survivors experience persistent health problems, the new article is the first to show they’re using more addictive medications, said Dr. Ziyad Al-Aly, the paper’s lead author.

He’s concerned that even an apparently small increase in the inappropriate use of addictive pain pills will lead to a resurgence of the prescription opioid crisis, given the large number of covid survivors. More than 3 million of the 31 million Americans infected with covid develop long-term symptoms, which can include fatigue, shortness of breath, depression, anxiety and memory problems known as “brain fog.”

The new study also found many patients have significant muscle and bone pain.

The frequent use of opioids was surprising, given concerns about their potential for addiction, said Al-Aly, chief of research and education service at the VA St. Louis Health Care System.

“Physicians now are supposed to shy away from prescribing opioids,” said Al-Aly, who studied more than 73,000 patients in the VA system. When Al-Aly saw the number of opioids prescriptions, he said, he thought to himself, “Is this really happening all over again?”

Doctors need to act now, before “it’s too late to do something,” Al-Aly said. “We must act now and ensure that people are getting the care they need. We do not want this to balloon into a suicide crisis or another opioid epidemic.”

As more doctors became aware of their addictive potential, new opioid prescriptions fell, by more than half since 2012. But U.S. doctors still prescribe far more of the drugs — which include OxyContin, Vicodin and codeine — than physicians in other countries, said Dr. Andrew Kolodny, medical director of opioid policy research at Brandeis University.

Some patients who became addicted to prescription painkillers switched to heroin, either because it was cheaper or because they could no longer obtain opioids from their doctors. Overdose deaths surged in recent years as drug dealers began spiking heroin with a powerful synthetic opioid called fentanyl.

More than 88,000 Americans died from overdoses during the 12 months ending in August 2020, according to the Centers for Disease Control and Prevention. Health experts now advise doctors to avoid prescribing opioids for long periods.

The new study “suggests to me that many clinicians still don’t get it,” Kolodny said. “Many clinicians are under the false impression that opioids are appropriate for chronic pain patients.”

Hospitalized covid patients often receive a lot of medication to control pain and anxiety, especially in intensive care units, said Dr. Greg Martin, president of the Society of Critical Care Medicine. Patients placed on ventilators, for example, are often sedated to make them more comfortable.

Martin said he’s concerned by the study’s findings, which suggest patients are unnecessarily continuing medications after leaving the hospital.

“I worry that covid-19 patients, especially those who are severely and critically ill, receive a lot of medications during the hospitalization, and because they have persistent symptoms, the medications are continued after hospital discharge,” Martin said.

While some covid patients are experiencing muscle and bone pain for the first time, others say the illness has intensified their preexisting pain.

Rachael Sunshine Burnett has suffered from chronic pain in her back and feet for 20 years, ever since an accident at a warehouse where she once worked. But Burnett, who first was diagnosed with covid in April 2020, said the pain soon became 10 times worse and spread to the area between her shoulders and spine. Although she was already taking long-acting OxyContin twice a day, her doctor prescribed an additional opioid called oxycodone, which relieves pain immediately. She was reinfected with covid in December.

“It’s been a horrible, horrible year,” said Burnett, 43, of Coxsackie, New York.

Doctors should recognize that pain can be a part of long covid, Martin said. “We need to find the proper non-narcotic treatment for it, just like we do with other forms of chronic pain,” he said.

The CDC recommends a number of alternatives to opioids — from physical therapy to biofeedback, over-the-counter anti-inflammatories, antidepressants and anti-seizure drugs that also relieve nerve pain.

The country also needs an overall strategy to cope with the wave of post-covid complications, Al-Aly said

“It’s better to be prepared than to be caught off guard years from now, when doctors realize … ‘Oh, we have a resurgence in opioids,’” Al-Aly said.

Al-Aly noted that his study may not capture the full complexity of post-covid patient needs. Although women make up the majority of long-covid patients in most studies, most patients in the VA system are men.

The study of VA patients makes it “abundantly clear that we are not prepared to meet the needs of 3 million Americans with long covid,” said Dr. Eric Topol, founder and director of the Scripps Research Translational Institute. “We desperately need an intervention that will effectively treat these individuals.”

Al-Aly said covid survivors may need care for years.

“That’s going to be a huge, significant burden on the health care system,” Al-Aly said. “Long covid will reverberate in the health system for years or even decades to come.”

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.

USE OUR CONTENT

This story can be republished for free (details).

KHN’s ‘What the Health?’: Open Enrollment, One More Time

Keeping a campaign promise, President Joe Biden has reopened enrollment for health coverage under the Affordable Care Act on healthcare.gov — and states that run their own health insurance marketplaces followed suit. At the same time, the Biden administration is moving to revoke the Trump administration’s permission for states to impose work requirements for some adults on the Medicaid health insurance program. Alice Miranda Ollstein of Politico, Kimberly Leonard of Business Insider and Rachel Cohrs of Stat join KHN’s Julie Rovner to discuss these issues and more. Also, Rovner interviews medical student Inam Sakinah, president of the new group Future Doctors in Politics.

Can’t see the audio player? Click here to listen on SoundCloud.

An estimated 9 million Americans eligible for free or reduced premium health insurance under the Affordable Care Act have a second chance to sign up for 2021 coverage, since the Biden administration reopened enrollment on healthcare.gov and states that run their own marketplaces followed suit.

Meanwhile, Biden officials took the first steps to revoke the permission that states got from the Trump administration to require many adults on Medicaid to work or perform community service in exchange for their health coverage. The Supreme Court is scheduled to hear a case on the work requirements at the end of March.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Kimberly Leonard of Business Insider and Rachel Cohrs of Stat.

Among the takeaways from this week’s podcast:

  • The Biden administration said it will promote the special enrollment period, a stark change from the Trump administration, which dramatically limited funding for outreach. But navigator groups, whose workers help individuals find and sign up for coverage, say they haven’t yet heard whether the federal government will be offering to pay them to help people during this three-month sign-up period.
  • The House appears poised to pass a bill next week that would fund the covid relief measures President Joe Biden is seeking, as well as major changes to the ACA. Senate staffers are working with the House to align legislation from both chambers as much as possible. With little or no Republican support and only razor-thin majorities in both the House and Senate, Democrats will need to find common ground among their caucus to push the bill through.
  • Congress has a firm deadline on the covid relief bill since many current programs, such as the expanded unemployment funding, expire March 14.
  • CVS announced this week that its insurance subsidiary, Aetna, will be participating in the ACA marketplaces in the fall, another sign that those exchanges are growing in acceptance.
  • The Biden administration’s effort to walk back Medicaid work requirements appears to be an effort to head off the arguments at the Supreme Court. Democrats fear that even if they stop the program through administrative action now, a high-court ruling saying the effort was legal could open the door for future Republican administrations to restore work requirements.
  • The federal government is pushing hard to get more covid vaccine shots in arms around the country and last week reported that 1.7 million doses had been distributed. But it is a race against the emerging threat of covid virus variants, which are even more contagious than the original coronavirus.
  • Among hurdles in the vaccination effort is hesitancy among certain groups to get the shot. There have been reports that 30% of military personnel refused to accept the vaccine and some high-profile athletes in the NBA don’t want to be in public service announcements promoting it. Groups opposed to vaccines in general are posting misinformation online that may also be a source of concern.
  • The latest controversy over New York Gov. Andrew Cuomo’s policies on counting deaths among nursing home residents with covid-19 has consumed Albany and led to inquiries by legal authorities. It also raises questions about whether politics — Cuomo, a Democrat, and President Donald Trump regularly sparred about covid policies — influenced public health decisions.

Also this week, Rovner interviews medical student Inam Sakinah, president of the new group Future Doctors in Politics.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: Stat’s “Hospitals’ Covid-19 Heroics Have Them Poised for Power in the New Washington,” by Rachel Cohrs

Rachel Cohrs: KHN’s “As Drug Prices Keep Rising, State Lawmakers Propose Tough New Bills to Curb Them,” by Harris Meyer; and Stat’s “States Still Can’t Import Drugs From Canada. Now, Many Are Seeking to Import Canadian Prices,” by Lev Facher

Alice Miranda Ollstein: Politico’s “How Covid-19 Could Make Americans Healthier,” by Joanne Kenen

Kimberly Leonard: The New Republic’s “The Darker Story Just Outside the Lens of Framing Britney Spears,” by Sara Luterman

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

USE OUR CONTENT

This story can be republished for free (details).

Are Public Health Ads Worth the Price? Not if They’re All About Fear

Public service announcements about drug use or other public health problems often fall short, public health marketing experts say, because they incite people’s worst fears rather than giving people solutions.

ST. LOUIS — The public service announcement showed a mother finding her teenage son lifeless, juxtaposed with the sound of a ukulele and a woman singing, “That’s how, how you OD’d on heroin.”

It aired locally during the 2015 Super Bowl but attracted national attention and has been viewed more than 500,000 times on YouTube.

“You want to tap into a nerve, an emotional nerve, and controversy and anger,” said Mark Schupp, whose consulting firm created the ad pro bono. “The spot was designed to do that, so we were happy with it.”

But like other ads and PSAs seeking to move the needle on public health, it went only so far.

Marketing experts say public health advertising often falls short because it incites people’s worst fears rather than providing clear steps viewers can take to save lives. They say lessons from opioid messaging can inform campaigns seeking to influence behavior that could help curb the coronavirus pandemic, such as wearing masks, not gathering in big groups and getting a covid-19 vaccine.

The Super Bowl ad was produced and aired by the St. Louis chapter of the National Council on Alcohol and Drug Abuse using $100,000 from an anonymous donor. Then-director Howard Weissman said a top priority for his group was for Missouri to start a prescription drug monitoring program.

Five years later, Missouri remains the only state without a statewide program. And the number of opioid deaths has steadily increased in that time, state data shows, up from 672 in all of 2015 to 716 deaths in just the first six months of 2020.

The national council, now called PreventEd, is one of many nonprofits and government agencies that invest millions in messaging aimed at curbing the opioid epidemic. People who study such advertisements said it’s difficult to measure their impact, but if the metric is the number of overdose deaths, they have not yet succeeded. The country set a record for overdose deaths in 2019 that it was on pace to break in 2020.

“You have to give them a solution, especially in a health context, like with opioids, because similar to with cigarette smoking, if you increase fear and don’t give a solution, they are just going to abuse more because that’s their coping mechanism,” said Punam Anand Keller, a Dartmouth College professor who studies health marketing.

To address public health issues, marketers often use images of diseased lungs to discourage smokers or the bloody aftermath of car crashes to prevent drunken driving. But these can provoke “defensive responses” that may be avoided by giving people ways to take action, said a 2014 International Journal of Psychology review of campaigns that use fear to persuade people.

Missouri’s state health and mental health departments, with the help of federal funds, spent at least $800,000 on advertising in 2019 to curb the opioid epidemic through their Time 2 Act and NoMODeaths campaigns, according to data from advertising agencies and partner organizations.

Mac Curran, a 34-year-old social media influencer, described his struggles with opioid addiction in a number of videos for Time 2 Act, one of which was viewed more than 100,000 times on Facebook. In another recent video, Curran used storytelling to highlight the benefits of getting treatment for his addiction. He talked about strangers cheering for him when he returned to a friend’s streetwear store after getting out of the recovery program, and discussed how he learned coping skills he could use throughout life.

Jay Winsten, a Harvard University scientist who spearheaded the U.S. designated-driver campaign to combat drunken driving, described Curran’s videos as “really excellent because he comes across as genuine and well spoken. People remember stories more than they do someone simply lecturing at them.”

Still, Winsten emphasized the importance of including actionable steps and would like to see Missouri and other groups focus on teaching friends of users “how to intervene and what language to use and not to use.”

Others, including the libertarian Cato Institute, argue that PSAs on drug use just don’t work and point to the history of failed campaigns to discourage teen marijuana use.

Yet agencies keep trying. Missouri’s mental health department and the Missouri Institute of Mental Health at the University of Missouri-St. Louis convened focus groups in 2019 with drug users and their families and captured their words on billboards for the NoMODeaths campaign. One said, “Don’t give up on treatment. It’s worth the work,” and gave a number to text for help with heroin, fentanyl or pill misuse.

In addition to giving information, the goal was “to let people who use drugs know that other people care if they live or die,” said Rachel Winograd, a psychologist who leads the NoMODeaths group aimed at reducing harm from opioid misuse.

She said she understands the argument that PSAs are a waste of money, given that organizations like hers have limited funds and also try to provide housing for those in recovery and naloxone, used to revive people after overdoses.

But, Winograd said, some of the advertisements appeared to work. The organization saw a big increase after the ads ran in the number of people who visited its website or texted a number for information on treatment or obtaining naloxone.

Although federal funding rose for fiscal years 2021 and 2022, Winograd’s team and state officials decided to cut NoMODeaths’ advertising budget in half and instead spend the money on direct services like naloxone, treatment and housing.

Now health agencies are consumed by the coronavirus pandemic and are trying to craft messages that cut through politically charged discourse and get the public to adopt safety measures such as wearing masks, staying physically distanced and getting vaccinated.

Convincing people to wear masks has been difficult because messages have been mixed. Missouri’s health department has tried to depoliticize mask-wearing and get people to view it as a public health solution, said spokesperson Lisa Cox.

But Missouri Gov. Mike Parson has appeared without a mask at public events and has declined to enact a statewide mask mandate. He also said at a Missouri Cattlemen’s Association event in July, “If you want to wear a dang mask, wear a mask.”

Cox would not comment on whether Parson’s approach undermined the state’s public health efforts, but Keller said it did.

Missouri’s messaging about vaccines has been much more straightforward and clear. A website provides facts and answers to common questions as it encourages people to “make an informed choice” on whether to get the shots.

Keller praised the “unemotional, not-fear-arousing” approach to the vaccine messaging issued so far.

“It needs the right messengers: well-known individuals who have high credibility within specific population groups that currently are hesitant about taking the vaccine,” Winsten said.

This time, Parson has been one of those messengers. When he announced the launch of the vaccine website in November, he said in a news release: “Safety is not being sacrificed, and it’s important for Missourians to understand this.”

In spite of the politicization of the virus crisis, Winsten, who serves on the board of advisers of the Ad Council’s $50 million covid vaccine campaign, has “guarded optimism” that enough people will get vaccinated to curb the pandemic.

And he remains hopeful that PSAs could eventually help reduce the number of people who die from opioids.

“Look at the whole anti-smoking movement. That took over two decades,” he said. “These are tough problems. Otherwise, they would be solved already.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

USE OUR CONTENT

This story can be republished for free (details).

San Francisco Wrestles With Drug Approach as Death and Chaos Engulf Tenderloin

Covid-19, distrust of police and cheap narcotics have turned parts of the wealthy city into cesspools of filth and drug overdose. City officials and residents profoundly disagree on what needs to be done.

This story also ran on Los Angeles Times. It can be republished for free.

SAN FRANCISCO — In early 2019, Tom Wolf posted a thank-you on Twitter to the cop who had arrested him the previous spring, when he was homeless and strung out in a doorway with 103 tiny bindles of heroin and cocaine in a plastic baggie at his feet.

“You saved my life,” wrote Wolf, who had finally gotten clean after that bust and 90 days in jail, ending six months of sleeping on scraps of cardboard on the sidewalk.

Today, he joins a growing chorus of people, including the mayor, calling for the city to crack down on an increasingly deadly drug trade. But there is little agreement on how that should be done. Those who demand more arrests and stiffer penalties for dealers face powerful opposition in a city with little appetite for locking people up for drugs, especially as the Black Lives Matter and Defund the Police movements push to drastically limit the power of law enforcement to deal with social problems.

Drug overdoses killed 621 people in the first 11 months of 2020, up from 441 in all of 2019 and 259 in 2018. San Francisco is on track to lose an average of nearly two people a day to drugs in 2020, compared with the 178 who had died by Dec. 20 of the coronavirus.

As in other parts of the country, most of the overdoses have been linked to fentanyl, the powerful synthetic opioid that laid waste to the eastern United States starting in 2013 but didn’t arrive in the Bay Area until about five years later. Just as the city’s drug scene was awash with the lethal new product — which is 50 times stronger than heroin and sells on the street for around $20 for a baggie weighing less than half a gram — the coronavirus pandemic hit, absorbing the attention and resources of health officials and isolating drug users, making them more likely to overdose.

The pandemic is contributing to rising overdose deaths nationwide, according to the Centers for Disease Control and Prevention, which reported last month that a record 81,000 Americans died of an overdose in the 12 months ending in May.

“This is moving very quickly in a horrific direction, and the solutions aren’t matching it,” said Supervisor Matt Haney, who represents the Tenderloin and South of Market neighborhoods, where nearly 40% of the deaths have occurred. Haney, who has hammered City Hall for what he sees as its indifference to a life-or-death crisis, is calling for a more coordinated response.

“It should be a harm reduction response, it should be a treatment response — and yes, there needs to be a law enforcement aspect of it too,” he said.

Tensions within the city’s leadership came to a head in September, when Mayor London Breed supported an effort by City Attorney Dennis Herrera to clean up the Tenderloin by legally blocking 28 known drug dealers from entering the neighborhood.

But District Attorney Chesa Boudin, a progressive elected in 2019 on a platform of police accountability and racial justice, sided with activists opposing the move. He called it a “recycled, punishment-focused” approach that would accomplish nothing.

People have died on the Tenderloin’s needle-strewn sidewalks and alone in hotel rooms where they were housed by the city to protect them from covid-19. Older Black men living alone in residential hotels are dying at particularly high rates; Blacks make up around 5% of the city’s population but account for a quarter of the 2020 overdoses. Last February, a man was found hunched over, ice-cold, in the front pew at St. Boniface Roman Catholic Church.

The only reason drug deaths aren’t in the thousands, say health officials, is the outreach that has become the mainstay of the city’s drug policy. From January to October, 2,975 deaths were prevented by naloxone, an overdose reversal drug that’s usually sprayed up the nose, according to the DOPE Project, a city-funded program that trains outreach workers, drug users, the users’ family members and others.

“If we didn’t have Narcan,” said program manager Kristen Marshall, referring to the common naloxone brand name, “there would be no room at our morgue.”

The city is also hoping that this year state lawmakers will approve safe consumption sites, where people can do drugs in a supervised setting. Other initiatives, like a 24-hour meth sobering center and an overhaul of the city’s behavioral health system, have been put on hold because of pandemic-strained resources.

Efforts like the DOPE Project, the country’s largest distributor of naloxone, reflect a seismic shift over the past few years in the way cities confront drug abuse. As more people have come to see addiction as a disease rather than a crime, there is little appetite for locking up low-level dealers, let alone drug users — policies left over from the “war on drugs” that began in 1971 under President Richard Nixon and disproportionately punished Black Americans.

In practice, San Francisco police don’t arrest people for taking drugs, certainly not in the Tenderloin. On a sunny afternoon in early December, a red-haired young woman in a beret crouched on a Hyde Street sidewalk with her eyes closed, clutching a piece of foil and a straw. A few blocks away, a man sat on the curb injecting a needle into a thigh covered with scabs and scars, while two uniformed police officers sat in a squad car across the street.

Last spring, after the pandemic prompted a citywide shutdown, police stopped arresting dealers to avoid contacts that might spread the coronavirus. Within weeks, the sidewalks of the Tenderloin were lined with transients in tents. The streets became such a narcotics free-for-all that many of the working-class and immigrant families living there felt afraid to leave their homes, according to a federal lawsuit filed by business owners and residents. It accuses City Hall of treating less wealthy ZIP codes as “containment zones” for the city’s ills.

The suit was settled a few weeks later after officials moved most of the tents to designated “safe sleeping sites.” But for many, the deterioration of the Tenderloin, juxtaposed with the gleaming headquarters of companies like Twitter and Uber just blocks away, symbolizes San Francisco’s starkest contradictions.

Mayor Breed, who lost her younger sister to a drug overdose in 2006, has called for a crackdown on drug dealing.

The Federal Initiative for the Tenderloin was one such effort, announced in 2019. It aims to “reclaim a neighborhood that is being smothered by lawlessness,” U.S. Attorney David Anderson said at a recent virtual news conference held to announce a major operation in which the feds arrested seven people and seized 10 pounds of fentanyl.

Law enforcement agencies have blamed the continued availability of cheap, potent drugs on lax prosecutions. Boudin, however, said his office files charges in 80% of felony drug cases, but most involve low-level dealers whom cartels can easily replace in a matter of hours.

He pointed to a 2019 federal sting that culminated in the arrest of 32 dealers — mostly Hondurans who were later deported — after a two-year undercover operation involving 15 agencies.

“You go walk through the Tenderloin today and tell me if it made a difference,” said Boudin.

His position reflects a growing “progressive prosecutor” movement that questions whether decades-old policies that focus on putting people behind bars are effective or just. In May, the killing of George Floyd by the Minneapolis police energized a nationwide police reform campaign. Cities around the country, including San Francisco, have promised to redirect millions of dollars from law enforcement to social programs.

“If our city leadership says in one breath that they want to defund the police and are for racial and economic justice and in the next talk about arresting drug dealers, they’re hypocrites and they’re wrong,” said Marshall, the leader of the DOPE Project.

But Wolf, 50, believes a concerted crackdown on dealers would send a message to the drug networks that San Francisco is no longer an open-air illegal drug market.

Like hundreds of thousands of other Americans who’ve succumbed to opiate misuse, he began with a prescription for the painkiller oxycodone, in his case following foot surgery in 2015. When the pills ran out, he made his way from his tidy home in Daly City, just south of San Francisco, to the Tenderloin, where dealers in hoodies and backpacks loiter three or four deep on some blocks.

When he could no longer afford pills, Wolf switched to heroin, which he learned how to inject on YouTube. He soon lost his job as a caseworker for the city and his wife threw him out, so he became homeless, holding large quantities of drugs for Central American dealers, who sometimes showed him photos of the lavish houses they were having built for their families back home.

Looking back, he wishes it hadn’t taken six arrests and three months behind bars before someone finally pushed him toward treatment.

“In San Francisco, it seems like we’ve moved away from trying to urge people into treatment and instead are just trying to keep people alive,” he said. “And that’s not really working out that great.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

USE OUR CONTENT

This story can be republished for free (details).

Patients Struggle to Find Prescription Opioids After NY Tax Drives Out Suppliers

The tax was touted as a way to generate funding for treatment programs across the state. But to avoid paying, scores of manufacturers and wholesalers stopped selling opioids in New York.

NEW YORK — Mike Angevine lives in constant pain. For a decade the 37-year-old has relied on opioids to manage his chronic pancreatitis, a disease with no known cure.

But in January, Angevine’s pharmacy on Long Island ran out of oxymorphone and he couldn’t find it at other drugstores. He fell into withdrawal and had to be hospitalized.

“You just keep thinking: Am I going to get sick? Am I going to get sick?” Angevine said in a phone interview. “Am I going to be able to live off the pills I have? Am I going to be able to get them on time?”

His pharmacy did not tell him the reason for the shortage. But Angevine isn’t the only pain patient in New York to lose access to vital medicine since July 2019, when the state implemented an excise tax on many opioids.

The tax was touted as a way to punish major drugmakers for their role in the opioid epidemic and generate funding for treatment programs. But to avoid paying, scores of manufacturers and wholesalers stopped selling opioids in New York. Instead of the anticipated $100 million, the tax brought in less than $30 million in revenue, two lawmakers said in interviews. None of it was earmarked for substance abuse programs, they said.

The state’s Department of Health, which has twice this year delayed an expected report on the impact of the tax, did not respond to questions for this story.

The tax follows strong efforts by federal and New York officials to tamp down the use of prescription opioids, which had already cut back some supply. Now, with some medications scarce or no longer available, pain patients have been left reeling. And the law appears to have missed its target: Instead of taking a toll on manufacturers, the greater burden appears to have fallen on pharmacies that can no longer afford or access the painkillers.

Among the companies that no longer sell opioids in New York is Epic Pharma. Independent Pharmacy Cooperative, a wholesaler, confirmed it no longer sells medications subject to the tax, but still sells those that are exempt, which are treatments for opioid addiction methadone and buprenorphine and also morphine. AvKARE and Lupin Pharmaceuticals said they do not ship opioids to New York anymore. Amneal Pharmaceuticals, which manufactures Angevine’s oxymorphone, declined to comment, as did Mallinckrodt.

Since the tax went into effect, Cardinal Health, which provides health services and products, published an extensive 10-page list of opioids it does not expect to carry. Cardinal Health declined to comment.

The New York tax is slowly gaining attention in other states. Delaware passed a similar tax last year. Minnesota is assessing a special licensing fee between $55,000 and $250,000 on opioid manufacturers. New Jersey Gov. Phil Murphy proposed such a tax this year but was turned down by the legislature.

The company that makes the first point of sale within New York pays the tax. That isn’t always the drugmaker. It can mean wholesalers selling to pharmacies here are assessed, explained Steve Moore, president of the Pharmacists Society of the State of New York.

Independent Pharmacy Cooperative said about half its revenue from opioid sales in New York would have gone to taxes.

Mark Kinney, the company’s senior vice president of government relations, said the law is putting companies in a very difficult position.

When wholesalers like IPC left the opioid market, competitive prices went with them.

Without these smaller wholesalers, it’s hard for pharmacies to go back to other wholesalers “and say, ‘Hey, your prices aren’t in line with the rest of the market,’” Moore said.

Indeed, nine independent pharmacies told KHN that when they can get opioids they are more expensive now. They have little choice but to eat the cost, drop certain prescriptions or pass the expense along.

“We can trickle that cost down to the patient,” said a pharmacist at New London Pharmacy in Manhattan, “but from a moral and ethics point of view, as a health care provider, it just doesn’t seem right to do that. It’s not the right thing to ask your patient to pay more.”

In addition, Medicare drug plans and Medicaid often limit reimbursements, meaning pharmacies can’t charge them more than the programs allow.

Stone’s Pharmacy in Lake Luzerne was losing money “hand over fist,” owner Leigh McConchie said. His distributor was adding the tax directly to his pharmacy’s cost for the drugs. That helped drive down his profit margins from opioid sales between 60% and 70%. Stone’s stopped carrying drugs like fentanyl patches and oxycodone, and though that distributor now pays the tax itself, the pharmacy is still feeling the effects.

“When you lose their fentanyl, you generally lose all their other prescriptions,” he said, noting that few customers go to multiple pharmacies when they can get everything at one.

If pharmacies have few opioid customers, those price hikes have less impact on their business. But being able to manage the costs is not the only problem, explained Zarina Jalal, a manager at Lincoln Pharmacy in Albany. Jalal can no longer get generic oxycodone from her supplier Kinray, though she can still access brand-name OxyContin. New York’s Medicaid Mandatory Generic Drug Program requires insurers to provide advance authorization for the use of brand-name prescriptions, delaying the approval process. Sometimes patients wait several days to get their prescription, Jalal explained.

“When I see them suffer, it hurts more than it hurts my wallet,” she said.

One of Jalal’s customers, Janis Murphy, needs oxycodone to walk without pain. Now she is forced to buy a brand-name drug and pays up to three times what she did for generic oxycodone before the tax went into effect. She said her bill since the start of this year for oxycodone alone is $850. Lincoln Pharmacy works with Murphy on a payment plan, without which she would not be able to afford the medication at all. But the bill keeps growing.

“I’m almost in tears because I cannot get this bill down,” she said in a phone interview.

Several pharmacists raised concerns that patients who lose access to prescription opioids may turn to street drugs. High prescription prices can drive patients to highly addictive and inexpensive heroin. McConchie of Stone’s Pharmacy said he now dispenses twice as many heroin treatment drugs as he did a year ago. Former opioid customers now come in for prescriptions for substance use disorder.

Trade groups and some physicians and state legislators opposed the tax before it went into effect, voicing concerns about a slew of potential consequences, including supply problems for pharmacists and higher consumer prices.

New London Pharmacy said one of its regular distributors stopped shipping Percocet, a combination of oxycodone and acetaminophen. Instead, the pharmacy orders from a more expensive company. The pharmacist estimated that a bottle of Percocet for which it used to pay $43 now costs up to $92.

“Even if we absorb the tax, we’re not getting a break from reimbursements either,” a pharmacist who spoke on the condition of anonymity explained, adding that insurance reimbursements have not increased in proportion to rising drug costs. “We’re losing.”

Latchmin Raghunauth Mondol, owner of Viva Pharmacy & Wellness in Queens, has also seen that problem. The pharmacy used to be able to purchase 100 15-milligram tablets of oxycodone for $15, but that’s now $70, she said, and the pharmacy is reimbursed only about $21 by insurers.

Other opioids are just not available.

Mondol said she has been unable to obtain certain doses of two of the most commonly prescribed opioids, oxycodone and oxymorphone — the drug Angevine was on.

After Angevine lost access to oxymorphone, his doctor put him on morphine, but it does not give him the same relief. He’s been in so much pain that he stopped going to physical therapy appointments.

“It’s a marathon from hell,” he said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

USE OUR CONTENT

This story can be republished for free (details).

Pandemic Presents New Hurdles, And Hope, For People Struggling With Addiction

Relaxed regulations in response to the pandemic means more access to addiction treatment medications. But recovery programs are accepting fewer people, and the danger of overdose remains high.

Before Philadelphia shut down to slow the spread of the coronavirus, Ed had a routine: most mornings he would head to a nearby McDonald’s to brush his teeth, wash his face and — when he had the money — buy a cup of coffee. He would bounce between homeless shelters and try to get a shower. But since businesses closed and many shelters stopped taking new admissions, Ed has been mostly shut off from that routine.

He’s still living on the streets.

“I’ll be honest, I don’t really sleep too much,” said Ed, who’s 51 and struggling with addiction. “Every four or five days I get a couple hours.”

KHN agreed not to use his last name because he uses illegal drugs.

Philadelphia has the highest overdose rate of any big city in America — in 2019, more than three people a day died of drug overdoses there, on average. Before the coronavirus began spreading across the United States, the opioid overdose epidemic was the biggest health crisis on the minds of many city officials and public health experts. The coronavirus pandemic has largely eclipsed the conversation around the opioid crisis. But the crisis still rages on despite business closures, the cancellation of in-person treatment appointments and the strain on many addiction resources in the city.

When his usual shelter wasn’t an option anymore, Ed tried to get into residential drug treatment. He figured that would be a good way to try to get back on his feet and, if nothing else, get a few good nights of rest. But he had contracted pinkeye, a symptom thought to be associated with the virus that leads to COVID-19, so the evaluation center didn’t want to place him in an inpatient facility until he’d gotten the pinkeye checked out. But he couldn’t see a doctor because he didn’t have a phone for a telehealth appointment.

“I got myself stuck, and I’m trying to pull everything back together before it totally blows up,” he said.

Rosalind Pichardo wants to help people in Ed’s situation. Before the pandemic, Pichardo would hit the streets of her neighborhood, Kensington, which has the highest drug overdose rate in Philadelphia. She’d head out with a bag full of snack bars, cookies and Narcan, the opioid overdose reversal drug.

She’d hand Narcan out to people using drugs, and people selling drugs — anyone who wanted it. Pichardo started her own organization, Operation Save Our City, which initially set out to work with survivors of gun violence in the neighborhood. When she realized that overdoses were killing people too, she began getting more involved with the harm reduction movement and started handing out Narcan through the city’s syringe exchange.

When Pennsylvania’s stay-at-home order went into effect, Pichardo and others worried that more people might start using drugs alone, and that fewer first responders would be patrolling the streets or nearby and able to revive them if they overdosed.

So, Pichardo and other harm reduction activists gave out even more Narcan. A representative for Prevention Point Philadelphia, the group that operates a large syringe exchange program in the city, said that during the first month of the city’s stay-at-home order, they handed out almost twice as much Narcan as usual.

After the lockdowns and social distancing began, Pichardo worried that more people would be using drugs alone, leading to more overdoses. But Philadelphia’s fatal overdose rate during the pandemic remains about the same as it was this time last year. Pichardo said she thinks that’s evidence that flooding the streets with Narcan is working — that people are continuing to use drugs, and maybe even using more drugs, but that users are utilizing Narcan more often and administering it to one another.

That is the hope. But Pichardo said users don’t always have a buddy to keep watch, and during the pandemic first responders have seemed much more hesitant to intervene. For example, she recently administered Narcan to three people in Kensington who overdosed near a subway station, while two police officers stood by and watched. Before the pandemic, they would often be right there with her, helping.

To reverse the overdoses, Pichardo crouched over the people who she said had started turning blue as their oxygen levels dropped. She injected the Narcan into their noses, using a disposable plastic applicator. Normally, she would perform rescue breathing, too, but since the pandemic began she has started carrying an Ambu bag, which pumps air into a person’s lungs and avoids mouth-to-mouth resuscitation. Among the three people, she said, it took six doses of Narcan to revive them. The police officers didn’t step in to help but did toss several overdose-reversal doses toward Pichardo as she worked.

“I don’t expect ’em to give ’em rescue breaths if they don’t want to, but at least administer the lifesaving drug,” Pichardo said.

In her work as a volunteer, she has reversed almost 400 overdoses, she estimated.

“There’s social distancing — to a limit,” Pichardo said, “I think when someone’s life is in jeopardy, they’re worth saving. You just can’t watch people die.”

Even before Philadelphia officially issued its stay-at-home order, city police announced they would stop making low-level arrests, including for narcotics. The idea was to reduce contact overall, help keep the jail population low and reduce the risk of the virus getting passed around inside. But Pichardo and other community activists said the decreased law enforcement emboldened drug dealers in the Kensington neighborhood, where open-air drug sales and use are common.

“You can tell they have everything down pat, from the lookout to the corner boys to the one actually holding the product — the one holding the product’s got some good PPE gear,” said Pichardo.

More dealers working openly on the street has led to more fights over territory, she added, which in turn has meant more violence. While overall crime in Philadelphia and other major cities has declined during the pandemic, gun violence has spiked.

Police resumed arrests at the beginning of May.

Now when she goes out to offer relief and hand out Narcan, Pichardo packs a few extra things in her bag of supplies: face masks, gloves and gun locks.

“It’s like the survival kit of the ’hood,” she said.

For those struggling with addiction who are ready to start recovery, newly relaxed federal restrictions have made it easier to get medications that curb opioid cravings and stem withdrawal. Several efforts are underway among Philadelphia-based public health groups and criminal justice advocacy organizations to give cellphones to people who are homeless or coming out of jail, so they can make a telehealth appointment and get quicker access to a prescription for those medicines.

During the pandemic, people taking medication-assisted treatment can renew their prescription every month instead of every week, which helps decrease trips to the pharmacy. It is too soon to know if more people are taking advantage of the new rules, and accessing medication-assisted treatment via telehealth, but if that turns out to be the case, many addiction medicine specialists argue the new rules should become permanent, even after the pandemic ends.

“If we find that these relaxed restrictions are bringing more people to the table, that presents enormous ethical questions about whether or not the DEA should reinstate these restrictive policies that they had going in the first place,” said Dr. Ben Cocchiaro, a physician who treats people with substance-use disorder.

Cocchiaro said the whole point of addiction treatment is to facilitate help as soon as someone is ready for it. He hopes if access to recovery can be made simpler during a pandemic, it can remain that way afterward.

This story is part of a partnership that includes WHYY, NPR and Kaiser Health News.

Vaping, Opioid Addiction Accelerate Coronavirus Risks, Says NIDA Director

Dr. Nora Volkow, who heads the National Institute on Drug Abuse, details how emerging science points to added challenges for these patient populations and the public health system.

In 2018, opioid overdoses claimed about 47,000 American lives. Last year, federal authorities reported that 5.4 million middle and high school students vaped. And just two months ago, about 2,800 cases of vaping-associated lung injuries resulted in hospitalizations; 68 people died.

Until mid-March, these numbers commanded attention. But as the coronavirus death toll climbs and the economic costs of attempting to control its spread wreak havoc, the public health focus is now dramatically different.

In the background, though, these other issues — the opioid epidemic and vaping crisis — persist in heaping complications on an overwhelmed public health system.

It is creating a distinctly American problem, said Dr. Nora Volkow, who heads the National Institute on Drug Abuse.

Volkow spoke with Kaiser Health News about the emerging science around COVID-19’s relationship to vaping and to opioid use disorder, as well as how these underlying epidemics could increase people’s risks. Her remarks have been edited for length and clarity.

Q: We’ve already been experiencing two epidemics at once — vaping and the opioid crisis — and now we’re in the midst of a third. Does that change the nature of addressing the coronavirus in the United States?

It makes a different kind of situation than we see abroad. It forces us as a country to be urgently multitasking, to focus on the urgent needs of COVID while not ignoring the other epidemics devastating America. That’s certainly challenging.

Q: What is the evidence around the relationship between vaping and the coronavirus?

Because of the recency, there’s no data to show if there are differences in outcomes between people who vape and people who do not vape. There’s no reported scientific evidence. We will start seeing it.

We know from all the cases of acute lung injury that vaping, particularly certain combinations of chemicals that were related to vaping of THC, actually led to death. The cause of death was pulmonary dysfunction. We know from animal experiments that vaping itself — not even giving any drugs with it — can produce inflammatory changes in the lung.

We already know for COVID that, with comorbid conditions — particularly those that affect the lungs, the heart, the immune system — [patients] are more likely to have negative outcomes.

One can predict an association. In the meantime, because of the data that already exist, we should be very cautious. The prudent thing is to strongly advise individuals who are vaping to stop.

Q: Young people so far appear to have lower risks of COVID complications. Does vaping change that?

We know there have been fatalities among young people. One very important area of research is to try to understand the specific vulnerabilities among young people.

Why would you want to risk it when you already know vaping produces inflammatory changes in the lungs? We know in medicine, a tissue that has suffered harm is more vulnerable.

The big centers where you are observing the rise in COVID-19 cases, that’s where you are more likely to see the comorbidity of vaping.

It’s young people that are mostly vaping, but also older people, many of whom otherwise would be smoking tobacco. [Smoking] also raises the risk. Even though the samples have not been large enough, overall, smokers have done worse than nonsmokers when they have COVID.

Q: Let’s talk about opioid use disorder. What kind of comorbidities are we starting to see between opioid use disorder and COVID-19?

People who have opioid use disorder are also likely to be smokers. Smoking itself increases harm to your lungs.

We do know that opioids actually are immunosuppressants. This has been extensively studied. Nicotine also can disrupt immunity and actually impair the capacity of the cell to respond to viral infections.

One of the things opioids do is they depress your respiration. If it’s severe enough, they stop breathing. That’s what leads to death.

Whether you overdose or not, when you are taking opioids, the frequency of your breathing is down, and the oxygen in your blood tends to be lower.

The [COVID] infection targets the respiratory tissues in the lungs. It interferes with the capacity to transfer oxygen into the blood.

If you get COVID and you are taking opioids, the physiological consequences are going to be much worse. You’re not only going to have the effects of the virus itself, but you’ll have the depressive effects of opioids in the respiratory system [and] in the brain that lead to much less circulation in the lungs.

Q: What about other supports for people in recovery?

Community support systems like syringe exchange programs are closing. Methadone clinics are closing. If they’re not closing, they’re unable to process the same number of patients — because the staff is getting sick or the place where the methadone clinic was does not allow for so many people. Public transportation is not available for people to attend their methadone clinics.

We’re also hearing from our investigators they have observed a significant reduction in the capacity of the health care system to initiate people on medication for opioid use disorder — especially buprenorphine. Many of the buprenorphine initiations were done in health care facilities that are saturated with COVID.

Q: What’s happening to address those problems?

If in the past, if you were a physician or a nurse practitioner and you wanted to initiate someone on buprenorphine, the laws were that you needed to see that person physically. That’s changed. It’s now possible you can initiate someone on buprenorphine through telehealth. That’s incredibly valuable.

There’s extended reimbursement for telehealth, which expands access to treatment. There are also apps that have been created that provide individuals who have addiction [access] to mentors or coaches, as well as access to therapies and group therapies.

That is one of the aspects that has actually been accelerated by the COVID crisis. These may facilitate treatment into the future, even when COVID’s no longer there.

Coronavirus Crisis Opens Access To Online Opioid Addiction Treatment

Under the national emergency, the government has waived a law that required patients to have an in-person visit with a physician before they could be prescribed drugs that help quell withdrawal symptoms, such as Suboxone. Now they can get those prescriptions via a phone call or videoconference with a doctor. That may give video addiction therapy a kick-start.

[UPDATED on April 28]

Opioid addiction isn’t taking a break during the coronavirus pandemic.

But the U.S. response to the viral crisis is making addiction treatment easier to get.

Under the national emergency declared by the Trump administration in March, the government has suspended a federal law that required patients to have an in-person visit with a physician before they could be prescribed drugs that help quell withdrawal symptoms, such as Suboxone. Patients can now get those prescriptions via a phone call or videoconference with a doctor.

Addiction experts have been calling for that change for years to help expand access for patients in many parts of country that have shortages of physicians eligible to prescribe these medication-assisted treatments. A federal report in January found that 40% of U.S. counties don’t have a single health care provider approved to prescribe buprenorphine, an active ingredient in Suboxone.

A 2018 law called for the new policy, but regulations were never finalized.

“I wish there was another way to get this done besides a pandemic,” said Dr. David Kan, chief medical officer of Bright Heart Health, a Walnut Creek, California, company. It has recently started working with insurers and health providers to help addicted patients get therapy and medications without having to leave their homes. He said he hopes the administration will make the changes permanent after the national emergency ends.

For years before the emergency regulations, Bright Heart — along with several other telemedicine counseling providers — began offering opioid addiction treatment and counseling via telemedicine, even if they couldn’t prescribe initial medication for addiction. Patients can renew prescriptions for drugs to deal with withdrawal symptoms, get drug-tested and meet with counselors for therapy.

When Nathan Post needed help overcoming a decade-long drug addiction, he went online in 2018 and used Bright Heart Health to connect to a doctor and weekly individual and group counseling sessions. He said the convenience is a big benefit.

“As an addict, it was easy to have excuses not to do stuff, but this was easy because I could just be in my living room and turn on my computer, so I had no reason to blow it off,” he said.

Post, 38, a tattoo artist who recently moved from New Mexico to Iowa City, Iowa, was addicted to Suboxone, the drug he was prescribed in 2009 to deal with an addiction to opioid pills.

Officials with the insurer Anthem said using Bright Heart’s telemedicine option has helped increase medication-assisted treatment for members with opioid drug abuse issues from California and nine other states from 16% to more than 30%. While fewer than 5% of Anthem patients seeking addiction treatment use telemedicine, the company expects the option to become more common.

Bright Heart Health officials say one barometer of the effectiveness of the care is that 90% of patients are still in treatment after 30 days and 65% after 90 days — far higher than with traditional treatment.

Several insurers — including Aetna, and Blue Cross and Blue Shield companies like Anthem across the country — have begun covering the telemedicine addiction service.

Dr. Miriam Komaromy, medical director of Boston Medical Center’s Grayken Center for Addiction, said there are some downsides to virtual care.

“I think therapists and providers do worry whether it provides the same level of engagement with the patient and whether it’s possible to gauge someone’s sincerity and level of motivation as easily over a camera as in person,” she said.

But she predicted telemedicine service will grow because of the tremendous need to broaden access to mental health and addiction counseling. “Too often the default is no counseling for patients,” she said. “This gives us another set of tools.”

Patients can also have trouble finding a doctor who is eligible to prescribe medication to help treat addiction. Physicians are required to get a federal license to prescribe Suboxone and other controlled substances that help patients with opioid addictions and can write only limited numbers of prescriptions each month. Many doctors hesitate to seek that qualification.

A few small studies have found that patients are as likely to stay with telemedicine treatment as with in-person care for drug addiction. But no studies have determined whether one type of therapy is more effective.

Telemedicine does have its limits — and is not right for everyone, particularly patients who require more intensive inpatient care or who lack easy internet access, Komaromy said.

Premera Blue Cross and Blue Shield officials said they are partnering with Boulder Care, a digital recovery program based in Portland, Oregon, to help customers in rural Alaska. “Telemedicine is a unique way for someone to go through treatment in a discreet manner,” said Rick Abbott, a Premera vice president.

Nathan Post, a tattoo artist living in Iowa City, Iowa, used a telemedicine service to help overcome his addiction to Suboxone. “This was easy because I could just be in my living room and turn on my computer, so I had no reason to blow it off,” he says. (Courtesy of Nathan Post)

While telemedicine has been growing in popularity for physical medicine, some people may still be reluctant to use it for drug addiction.

There are also concerns that allowing providers to prescribe controlled substances without meeting patients in person could increase the risks of fraud.

“There is a fear around this that there may be some rogue providers who make a lot of money off addiction and will do it stealthily on the internet,” said Dr. Alyson Smith, an addiction medical specialist with Boulder Care. “While that is a small risk, we have to compare it to the huge benefit of expanding treatment that will save lives.”

Smith said she doesn’t notice a big difference in treating patients for drug addiction in her office compared with on a video screen. She can still see patients’ pupils to make sure they are dilated and ask them about how they are feeling — which can determine whether it’s appropriate to prescribe certain drugs. Dilated pupils are a sign of patients suffering from withdrawal from heroin and other drugs.

Dr. Dawn Abriel, who treated Post and previously directed a methadone clinic in Albuquerque, New Mexico, said she can diagnose patients over video without issue.

“I can pick up an awful lot on the video,” particularly a patient’s body language, she said. “I think people open up to me more because they are sitting in their homes and in their place of comfort.”

In West Virginia, one of the states hardest hit by the opioid addiction epidemic, Highmark, a Blue Cross and Blue Shield company, started offering telehealth addiction coverage with Bright Heart Health in January. Highmark officials say a lack of providers, particularly in rural parts of the state, meant that many of the insurer’s members had difficulty finding the help they need.

Dr. Caesar DeLeo, vice president and executive medical director of strategic initiatives for Highmark, said the insurer was having problems getting customers into care. Only about a third of members with addiction issues were receiving treatment, he said.

“We needed to address the crisis with a new approach,” DeLeo said. “This will give people more options and give primary care doctors who do not want to prescribe Suboxone another place to refer patients.”

DeLeo said patients will also be referred to Bright Heart in hospital emergency rooms.

Dr. Paul Leonard, an emergency doctor and medical director for Workit Health, an Ann Arbor, Michigan, company offering telemedicine treatment and counseling programs, said many patients who turn to ERs for addiction treatment get little help finding counseling. With online therapy, patients can sign up while still in the ER.

“We’ve built a better mousetrap,” Leonard said.

Telemedicine addiction providers said they and their patients are getting more accustomed to virtual care.

“There are always times you wish you could reach out and hold someone’s hand, and you can’t do that,” said Boulder’s Smith. “But we feel like we are more skilled at a virtual hand-holding and really connect with people and they feel well supported in return.”

California’s New Attack On Opioid Addiction Hits Old Roadblocks

State officials in California have achieved some success in promoting the use of medication-assisted treatment for people with opioid addictions, but they are bumping up against familiar resistance and constraints.

Jennifer Stilwell, a 30-year-old mother of two young children, kicked heroin cold turkey five years ago, but she got hooked again last fall.

Stilwell, an accountant in Placerville, California, tried to quit a second time, but she couldn’t tolerate the sickening withdrawal symptoms. She resisted going to the emergency room because “I thought they’d treat me like a drug addict and not a patient in pain,” she said.

Instead, she kept smoking heroin to keep the agony at bay. Then, in February, a county mental health worker told her about a new program that promised stigma-free treatment for her addiction.

She went to the ER at Marshall Medical Center in Placerville, where a doctor put her on buprenorphine, one of three drugs approved by the Food and Drug Administration for medication-assisted treatment (MAT) of people with opioid dependency.

Her ongoing treatment includes intensive counseling and social support, providing what is known in the recovery field as “whole person” therapy.

“It’s still early in my battle,” Stilwell said. “But my withdrawals are gone. Now I can concentrate on being a mother.”

Marshall is one of a growing number of health care institutions across California that offer medication-assisted treatment with funding and support from the state’s MAT Expansion Project, which started in 2018 and is financed by $265 million in federal grants.

Numerous studies have shown that relapse and overdose rates are lower among opioid users who get MAT than those who don’t. From 2016 to 2018, for example, the overdose death rate in Humboldt County — one of California’s highest ― dropped by about half, which officials attributed in large part to the MAT Expansion Project.

In February, California’s Department of Health Care Services, which administers the project, touted its success, reporting that it has provided care for 22,000 previously untreated Californians with opioid addictions and created 650 new locations where patients can receive MAT.

But the number of new people brought into treatment is only a small fraction of those who need it. In 2019, more than half a million Californians with an opioid use disorder lacked access to treatment, according to a study by the Urban Institute.

The state effort faces many of the same obstacles that have hindered wider acceptance of MAT for years: the stigma of addiction, federal regulations that depress the number of MAT providers, and hostility in some corners of the treatment community to the very notion of using drugs to combat drug addiction.

Moreover, the addiction treatment industry has become a magnet in recent years for unscrupulous operators who aggressively recruit clients, eyes fixed on the dollar signs rather than on evidence-based treatments such as MAT.

Now there’s another, hopefully temporary, challenge. The COVID-19 crisis and related social-distancing measures are forcing MAT practitioners to scramble for new ways to accommodate patients, said Eric Hill, a “substance navigator” at Marshall Medical Center who helps guide patients through their MAT treatment.

Hill said MAT patients entering the program through emergency rooms are now given prescriptions for up to a month, rather than a week. He said he is following up with clients by phone rather than in person, and he and others are trying to arrange video calls between doctors and patients for prescription renewals.

The state program seeks to broaden access to MAT by launching or enhancing treatment programs at ERs, hospitals, primary care clinics, residential treatment programs, county mental health centers, jails and drug courts. Training more doctors to provide MAT is also a pillar of the campaign.

But patients who take anti-addiction drugs can have difficulty finding housing and recovery therapy, which are integral to their treatment. They are often shunned by groups adhering to traditional 12-step theories of sobriety that require participants to be free of drugs — including MAT drugs.

“MAT patients will say that the treatment was working. They were just starting to feel better, going to support groups, back at their jobs, but they had a hard time finding a place to live,” said Hill.

Many patients who stop taking their MAT drugs in order to get a roof over their heads have relapsed, Hill said.

Marlies Perez, a division chief at the state health care department, said the agency “is taking a strong stand against such stigma that prevents patients from their continued recovery.” Through its media campaign, Choose Change California, it seeks to alter perceptions within the recovery community and persuade more doctors and patients to embrace MAT.

The state expansion project puts a strong emphasis on building MAT capacity in emergency rooms, where opioid users often face suspicion.

Of the 320 acute care hospitals with emergency rooms statewide, 52 currently offer MAT. In those hospitals, staff members like Hill help patients get the care they need, including the psychological and social dimensions. Health care department officials say they plan to quadruple the number of participating hospitals to more than 200 over the next few years.

(Photo Courtesy of Jennifer Stilwell)

Opioid misuse is not nearly as deadly in California as in the rest of the U.S., even though the rise of fentanyl has begun to cause bigger problems in the Golden State.

In 2018, the rate of opioid overdose deaths in California stood at 5.8 per 100,000 residents, far below the national average of 14.6 per 100,000. In some rural counties of California, however, opioid death rates exceed the national average. The two states with the highest rates were West Virginia, at 42.4 per 100,000, and Delaware at 39.3.

Another obstacle to MAT expansion, one squarely in the sights of California health authorities, is that many doctors are hesitant to participate because they must undergo federally mandated training for a waiver that allows them to prescribe buprenorphine.

“Doctors can prescribe OxyContin with abandon but not buprenorphine, which has been shown to be helpful to opioid addicts,” said Dr. Aimee Moulin, a director at the California Bridge Program, which helps administer the state’s MAT program.

Buprenorphine is less powerful and less likely to cause fatal overdoses than methadone, another drug commonly used to fight opioid addiction. And doctors who get the waiver for buprenorphine can prescribe it in their offices, while methadone must be administered in federally certified treatment programs.

The state’s health care department said the expansion project has thus far trained 395 new MAT prescribers. But as of July 2019, just 3.2% of prescribers in the state were authorized to prescribe buprenorphine, according to the Urban Institute study.

Dr. Peter Liepmann, a Pasadena-based family physician with an interest in addiction medicine, said it can be difficult to find a buprenorphine prescriber. Not long ago, when he was thinking about opening a practice in Glendale, California, he consulted the Substance Abuse and Mental Health Services Administration’s (SAMHSA) listings of physicians who offer MAT.

“If you were looking for somebody to dispense buprenorphine and you called people on that list, you would have come up with one doctor who ran a cash-only, no-insurance practice, and he was very expensive,” Liepmann said.

The state’s Perez said some doctors may not fully understand the benefits of MAT because medical schools devote little time to addiction training. Another element of the MAT project, she said, is to fund a substance-use-disorder curriculum at training hospitals.

Perez counseled patience: “We didn’t get into this opioid dependency situation overnight, and we’re not going to find a total solution overnight either.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Must-Reads Of The Week From Brianna Labuskes

Newsletter editor Brianna Labuskes wades through hundreds of health care policy stories each week, so you don’t have to.

Happy Friday! Where yours truly has parsed approximately 4,346,276,986 coronavirus stories to bring you the most important ones — such as the fact that 38% of Americans won’t buy Corona beer “under any circumstances” because of the outbreak; that apparently dog masks are now all the rage, despite the fact that health professionals say even healthy humans don’t need them; and that if you need of a cheat sheet on what facial hairstyles are officially called you can head over to the CDC for a nifty graphic. (The “walrus” might be my favorite.)

More seriously, here’s what you need to know about the outbreak dominating global attention, sending stocks plunging and creating a booming demand for hand sanitizer. I can tell you one common thread running through coverage about experts’ advice: Keep calm, carry on and wash your hands.

President Donald Trump cracked jokes about his germophobia and downplayed the severity of the coronavirus outbreak at a press conference this week, in which he put Vice President Mike Pence in charge of the country’s coronavirus response. This raised immediate eyebrows, considering that under Pence’s watch Indiana weathered a major HIV outbreak largely attributed to decisions he made as governor.

By contrast, you have the CDC’s Dr. Nancy Messonnier, who has become a leading player in the crisis, saying it’s not a question of if but when the coronavirus will sweep into the U.S. She also said that she’s been talking with her kids about how to prepare and that “the disruption to everyday life might be severe.”

Not surprisingly, after all that whiplash, the administration decided all information released to the public must first get the OK from Pence.

Politico: Coronavirus Gets a Trumpian Response

The New York Times: Pence Will Control All Coronavirus Messaging From Health Officials

The New York Times: What Has Mike Pence Done in Health?

The New York Times: C.D.C. Officials Warn of Coronavirus Outbreaks in the U.S.

Meanwhile, a new case out of California put a harsh spotlight on the deep flaws of the CDC’s original testing parameters. The patient — who may be the first in the U.S. with no link to traveling abroad — was in the hospital for more than 10 days before the CDC approved a coronavirus test. The delay exposed about 100 health workers to the virus as well as set back any attempts to contain people she’d been in contact with.

Stat: A Single Coronavirus Case Exposes a Bigger Problem: The Scope of Undetected U.S. Spread Is Unknown

ProPublica: Key Missteps at the CDC Have Set Back Its Ability to Detect the Potential Spread of Coronavirus

If a whistleblower is to be believed, those testing missteps weren’t the only ones made by the government in the early days of the response: New allegations have come to light that HHS workers who were sent to help with the U.S. evacuees weren’t given proper medical training or gear before being exposed to the patients.

The Washington Post: U.S. Workers Without Protective Gear Assisted Coronavirus Evacuees, HHS Whistleblower Says

Meanwhile, for a president who has tied his fate to the health of the stock markets, the global financial turmoil is more worrisome than ever.

Politico: Trump Faces ‘Black Swan’ Threat to the Economy and Reelection

One of the few good things about the coronavirus is that the vast majority of cases are mild. However, that’s also one of the things that might tip it into a pandemic. For more extreme illnesses (like Ebola), it’s far easier to isolate patients. But for those with symptoms that are essentially presenting as a mild cold, it’s harder to contain the spread.

On that note, it’s hard to tell just how lethal the disease is (and anyone who tells you otherwise, question their motives). Because so many cases are mild, some experts say we’re seeing only the tip of the iceberg, and the mortality rate would drop if we had a better sense of how many people are actually infected. Others argue that there’s no evidence that officials don’t have an accurate count.

Right now, from what’s available, it seems the death rate outside the epicenter in China was 0.7%. That’s still soberingly high, but also a long way away from SARS’ 10%.

The New York Times: Most Coronavirus Cases Are Mild. That’s Good and Bad News.

Stat: New China Coronavirus Data Buttress Fears About High Fatality Rate

As someone who has little kiddos in their life (and who affectionately calls them Typhoid Marys), I can’t help but include this story. Are kids innocent bystanders in this outbreak, getting infected if someone brings the virus into their households? Or are they, in fact, a population that is stealthily driving this epidemic, as they can do with the flu?

Stat: Key Question for Coronavirus Response: What’s Kids’ Role in Spreading It?

Globally, cases are climbing, with patients showing up in Lithuania, the Netherlands, Iran, Kuwait, the United Kingdom … you get the gist. Although we’re not really seeing it yet in Latin or South American countries beyond a Brazilian patient who had traveled to Italy, where cases skyrocketed 45% in one day.

In China, officials are tapping their tried-and-true propaganda playbook, but the anger that has boiled up over the government’s handling of the outbreak may be cracking the party’s stronghold. Meanwhile, authorities, in an ongoing attempt to contain the spread, are offering people more than $1,400 to self-report if they have coronavirus symptoms.

The New York Times: Coronavirus Weakens China’s Powerful Propaganda Machine

Reuters: China City Offers $1,400 Reward for Virus Patients Who Report to Authorities

And South Korea gets a shoutout for implementing a very cool idea to create “drive-thru” testing for potential patients.

Reuters: South Korea Launches ‘Drive-Thru’ Coronavirus Testing Facilities As Demand Soars

Remember, there are plenty more stories were those came from. If you’re interested in the full scope of coronavirus coverage, check out all our Morning Briefings from the week.


Believe it or not, there was other news this week! Democrats held a rowdy debate in South Carolina ahead of Super Tuesday, where Sen. Bernie Sanders (I-Vt.) fielded the inevitable attacks that come with being a front-runner. He was put on the hot spot about topics ranging from the cost of his “Medicare for All” plan to his past stance on guns.

Reuters: At Rowdy Debate, Democratic Rivals Warn Sanders Nomination Would Be ‘Catastrophe’

The New York Times: Fact-Checking the Democratic Debate in South Carolina

Sanders (after releasing a plan on how he was going to pay for his ambitious agenda) said that “‘Medicare for All’ will lower health care costs in this country by $450 billion a year and save the lives of 68,000 people who would otherwise have died.” But experts are skeptical of the findings.

KHN: Sanders Embraces New Study That Lowers ‘Medicare For All’s’ Cost, But Skepticism Abounds


A federal appeals court upheld a Trump administration ban on federally funded family planning centers referring women for abortions, arguing that the rule is slightly less restrictive than a 1988 version upheld by the Supreme Court. What’s interesting to note is that the court was the California-based U.S. Court of Appeals for the 9th Circuit. Trump has now named 10 judges to the 9th Circuit — more than one-third of its active judges — compared with seven appointed by President Barack Obama over eight years.

The Washington Post: Appeals Court Upholds Trump Ban on Abortion Referrals by Family Planning Clinics

Los Angeles Times: Trump Has Flipped the 9th Circuit — and Some New Judges Are Causing a ‘Shock Wave’

WBUR: Looking at Changes Happening Within the Nation’s Largest Federal Appeals Court

Beyond fighting for survival in the courts, abortion clinics are often faced with so many fees and unexpected costs that they can face closure from their financial burdens alone. Among those are: security to protect staff and patients; airfare to get doctors to areas lacking trained physicians willing to perform abortions; higher rates for contractors concerned about protesters and boycotts; more stringent loan terms; insurance that can be canceled unexpectedly; and, for some clinic owners, legal fees for defending the constitutionality of the procedure.

Bloomberg: Abortion Clinics Are the Most Challenging Small Business in America


Vocal opposition continues to pour in about the arcane Medicaid rule change that could reduce Medicaid spending by 6% to 8%, or $37 billion to $49 billion, a year. The Trump administration says the change would increase transparency and prevent abuses that enable states to draw down more federal money than they’re entitled to. But, so far, more than 4,200 organizations or individuals from both parties are sounding alarm bells about it.

Stateline: Medical Groups Slam Trump Medicaid Rule


In the miscellaneous file for the week:

— The Sacklers, under fire over allegations about their role in the opioid crisis, turned to Mike Bloomberg to help them manage their reputation. Will that haunt him in his presidential bid?

ProPublica: When the Billionaire Family Behind the Opioid Crisis Needed PR Help, They Turned to Mike Bloomberg

— Are some people immune to Alzheimer’s? Scientists studying donated brains have identified patients who have all the markers for the debilitating disease but didn’t seem to have any symptoms when alive. The findings offer hope that the seemingly inherent protection could be replicated by a drug.

Stat: They Have ‘Alzheimer’s Brains’ But No Symptoms. Why?

— America is facing an autopsy crisis: Large swaths of the country don’t have a medical examiner. Bodies are even having to be shipped across state lines if an autopsy is needed. At one point the problem was so bad that Oklahoma’s overloaded medical examiner declined to perform autopsies on people over 40 who died of unexplained causes.

The New York Times: Piled Bodies, Overflowing Morgues: Inside America’s Autopsy Crisis

— Colorado is continuing to move forward with plans for its public option, this week unveiling reimbursement rates that officials say would keep hospitals profitable under the system. Hospitals were … uh … a little skeptical of those claims.

The Denver Post: Colorado Consumers Could Save Up to 20% Under State Health Insurance Option, Polis Says

— In this terrifying story, a student died after calling 911 because the responders couldn’t locate him.

The Washington Post: College Student Yeming Shen Died of Flu in Troy, N.Y., After 911 Couldn’t Track His Location.


That’s it from me! Have a great weekend.

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

They Fell In Love Helping Drug Users. But Fear Kept Him From Helping Himself.

Sarah and Andy fell in love while working to keep drug users from overdosing. But when his own addiction reemerged, Andy’s fear of returning to prison kept him from the best treatment.

She was in medical school. He was just out of prison.

Sarah Ziegenhorn and Andy Beeler’s romance grew out of a shared passion to do more about the country’s drug overdose crisis.

Ziegenhorn moved back to her home state of Iowa when she was 26. She had been working in Washington, D.C., where she also volunteered at a needle exchange — where drug users can get clean needles. She was ambitious and driven to help those in her community who were overdosing and dying, including people she had grown up with.

“Many people were just missing because they were dead,” said Ziegenhorn, now 31. “I couldn’t believe more wasn’t being done.”

She started doing addiction advocacy in Iowa City while in medical school — lobbying local officials and others to support drug users with social services.

Beeler had the same conviction, born from his personal experience.

“He had been a drug user for about half of his life — primarily a longtime opiate user,” Ziegenhorn said.

Beeler spent years in and out of the criminal justice system for a variety of drug-related crimes, such as burglary and possession. In early 2018, he was released from prison. He was on parole and looking for ways to help drug users in his hometown.

He found his way to advocacy work and, through that work, found Ziegenhorn. Soon they were dating.

“He was just this really sweet, no-nonsense person who was committed to justice and equity,” she said. “Even though he was suffering in many ways, he had a very calming presence.”

People close to Beeler describe him as a “blue-collar guy” who liked motorcycles and home carpentry, someone who was gentle and endlessly curious. Those qualities could sometimes hide his struggle with anxiety and depression. Over the next year, Beeler’s other struggle, with opioid addiction, would flicker around the edges of their life together.

Eventually, it killed him.

People on parole and under supervision of the corrections system can face barriers to receiving appropriate treatment for opioid addiction. Ziegenhorn said she believes Beeler’s death is linked to the many obstacles to medical care he experienced while on parole.

About 4.5 million people are on parole or probation in the U.S., and research shows that those under community supervision are much more likely to have a history of substance use disorder than the general population. Yet rules and practices guiding these agencies can preclude parolees and people on probation from getting evidence-based treatment for their addiction.

A Shared Passion For Reducing Harm

From their first meeting, Ziegenhorn said, she and Beeler were in sync, partners and passionate about their work in harm reduction — public health strategies designed to reduce risky behaviors that can hurt health.

After she moved to Iowa, Ziegenhorn founded a small nonprofit called the Iowa Harm Reduction Coalition. The group distributes the opioid-overdose reversal drug naloxone and other free supplies to drug users, with the goal of keeping them safe from illness and overdose. The group also works to reduce the stigma that can dehumanize and isolate drug users. Beeler served as the group’s coordinator of harm reduction services.

“In Iowa, there was a feeling that this kind of work was really radical,” Ziegenhorn said. “Andy was just so excited to find out someone was doing it.”

Meanwhile, Ziegenhorn was busy with medical school. Beeler helped her study. She recalled how they used to take her practice tests together.

“Andy had a really sophisticated knowledge of science and medicine,” she said. “Most of the time he’d been in prison and jails, he’d spent his time reading and learning.”

Beeler was trying to stay away from opioids, but Ziegenhorn said he still used heroin sometimes. Twice she was there to save his life when he overdosed. During one episode, a bystander called the police, which led to his parole officer finding out.

“That was really a period of a lot of terror for him,” Ziegenhorn said.

Beeler was constantly afraid the next slip — another overdose or a failed drug test — would send him back to prison.

An Injury, A Search For Relief

A year into their relationship, a series of events suddenly brought Beeler’s history of opioid use into painful focus.

It began with a fall on the winter ice. Beeler dislocated his shoulder — the same one he’d had surgery on as a teenager.

“At the emergency room, they put his shoulder back into place for him,” Ziegenhorn said. “The next day it came out again.”

She said doctors wouldn’t prescribe him prescription opioids for the pain because Beeler had a history of illegal drug use. His shoulder would dislocate often, sometimes more than once a day.

“He was living with this daily, really severe constant pain — he started using heroin very regularly,” Ziegenhorn said.

Beeler knew what precautions to take when using opioids: Keep naloxone on hand, test the drugs first and never use alone. Still, his use was escalating quickly.

A Painful Dilemma 

The couple discussed the future and their hope of having a baby together, and eventually Ziegenhorn and Beeler agreed: He had to stop using heroin.

They thought his best chance was to start on a Food and Drug Administration-approved medication for opioid addiction, such as methadone or buprenorphine. Methadone is an opioid, and buprenorphine engages many of the same opioid receptors in the brain; both drugs can curb opioid cravings and stabilize patients. Studies show daily maintenance therapy with such treatment reduces the risks of overdose and improves health outcomes.

But Beeler was on parole, and his parole officer drug-tested him for opioids and buprenorphine specifically. Beeler worried that if a test came back positive, the officer might see that as a signal that Beeler had been using drugs illegally.

Ziegenhorn said Beeler felt trapped: “He could go back to prison or continue trying to obtain opioids off the street and slowly detox himself.”

He worried that a failed drug test — even if it was for a medication to treat his addiction — would land him in prison. Beeler decided against the medication.

A few days later, Ziegenhorn woke up early for school. Beeler had worked late and fallen asleep in the living room. Ziegenhorn gave him a kiss and headed out the door. Later that day, she texted him. No reply.

She started to worry and asked a friend to check on him. Not long afterward, Beeler was found dead, slumped in his chair at his desk. He’d overdosed.

“He was my partner in thought, and in life and in love,” Ziegenhorn said.

It’s hard for her not to rewind what happened that day and wonder how it could have been different. But mostly she’s angry that he didn’t have better choices.

“Andy died because he was too afraid to get treatment,” she said.

Beeler was services coordinator for the Iowa Harm Reduction Coalition, a group that works to help keep drug users safe. A tribute in Iowa City after his death began, “He died of an overdose, but he’ll be remembered for helping others avoid a similar fate.”(Courtesy of Sarah Ziegenhorn)

How Does Parole Handle Relapse? It Depends

It’s not clear that Beeler would have gone back to prison for admitting he’d relapsed and was taking treatment. His parole officer did not agree to an interview.

But Ken Kolthoff, who oversees the parole program that supervised Beeler in Iowa’s First Judicial District Department of Correctional Services, said generally he and his colleagues would not punish someone who sought out treatment because of a relapse.

“We would see that that would be an example of somebody actually taking an active role in their treatment and getting the help they needed,” said Kolthoff.

The department doesn’t have rules prohibiting any form of medication for opioid addiction, he said, as long as it’s prescribed by a doctor.

“We have people relapse every single day under our supervision. And are they being sent to prison? No. Are they being sent to jail? No,” Kolthoff said.

But Dr. Andrea Weber, an addiction psychiatrist with the University of Iowa, said Beeler’s reluctance to start treatment is not unusual.

“I think a majority of my patients would tell me they wouldn’t necessarily trust going to their [parole officer],” said Weber, assistant director of addiction medicine at the University of Iowa’s Carver College of Medicine. “The punishment is so high. The consequences can be so great.”

Weber finds probation and parole officers have “inconsistent” attitudes toward her patients who are on medication-assisted treatment.

“Treatment providers, especially in our area, are still very much ingrained in an abstinence-only, 12-step mentality, which traditionally has meant no medications,” Weber said. “That perception then invades the entire system.”

Attitudes And Policies Vary Widely

Experts say it’s difficult to draw any comprehensive picture about the availability of medication for opioid addiction in the parole and probation system. The limited amount of research suggests that medication-assisted treatment is significantly underused.

“It’s hard to quantify because there are such a large number of individuals under community supervision in different jurisdictions,” said Michael Gordon, a senior research scientist at the Friends Research Institute, based in Baltimore.

A national survey published in 2013 found that about half of drug courts did not allow methadone or other evidence-based medications used to treat opioid use disorder.

A more recent study of probation and parole agencies in Illinois reported that about a third had regulations preventing the use of medications for opioid use disorder. Researchers found the most common barrier for those on probation or parole “was lack of experience by medical personnel.”

Faye Taxman, a criminology professor at George Mason University, said decisions about how to handle a client’s treatment often boil down to the individual officer’s judgment.

“We have a long way to go,” she said. “Given that these agencies don’t typically have access to medical care for clients, they are often fumbling in terms of trying to think of the best policies and practices.”

Increasingly, there is a push to make opioid addiction treatment available within prisons and jails. In 2016, the Rhode Island Department of Corrections started allowing all three FDA-approved medications for opioid addiction. That led to a dramatic decrease in fatal opioid overdoses among those who had been recently incarcerated.

Massachusetts has taken similar steps. Such efforts have only indirectly affected parole and probation.

“When you are incarcerated in prison or jail, the institution has a constitutional responsibility to provide medical services,” Taxman said. “In community corrections, that same standard does not exist.”

Taxman said agencies may be reluctant to offer these medications because it’s one more thing to monitor. Those under supervision are often left to figure out on their own what’s allowed.

“They don’t want to raise too many issues because their freedom and liberties are attached to the response,” she said.

Richard Hahn, a researcher at New York University’s Marron Institute of Urban Management who consults on crime and drug policy, said some agencies are shifting their approach.

“There is a lot of pressure on probation and parole agencies not to violate people just on a dirty urine or for an overdose” said Hahn, who is executive director of the institute’s Crime & Justice Program.

The federal government’s Substance Abuse and Mental Health Services Administration calls medication-assisted treatment the “gold standard” for treating opioid addiction when used alongside “other psychosocial support.”

Addiction is considered a disability under the Americans with Disabilities Act, said Sally Friedman, vice president of legal advocacy for the Legal Action Center, a nonprofit law firm based in New York City.

She said disability protections extend to the millions of people on parole or probation. But people under community supervision, Friedman said, often don’t have an attorney who can use this legal argument to advocate for them when they need treatment.

“Prohibiting people with that disability from taking medication that can keep them alive and well violates the ADA,” she said.

This story is part of a partnership between NPR and Kaiser Health News.

Must-Reads Of The Week From Brianna Labuskes

Newsletter editor Brianna Labuskes wades through hundreds of health care policy stories each week, so you don’t have to.

Happy Friday! The gloves came off and the knives came out at the debate this week, so let’s jump right into the fray.

Sen. Elizabeth Warren (D-Mass.) came out swinging on Wednesday night in an all-around livelier debate than most we’ve seen this primary season. When it came to health care, few were safe from Warren’s jabs — South Bend, Indiana, Mayor Pete Buttigieg’s plan was deemed “paper-thin,” Minnesota Sen. Amy Klobuchar’s was so short it could fit on a Post-it note. Even Vermont Sen. Bernie Sanders (whose plan Warren supports) was criticized as not being realistic or a team player.

Warren wasn’t the only one on the attack. Former Vice President Joe Biden hit at new-comer and billionaire Mike Bloomberg for once upon a time labeling the Affordable Care Act “a disgrace.” But Biden left out some context in that particular attack — such as the fact that Bloomberg was commenting that the law wasn’t enough to fix the deeply flawed health system.

Meanwhile, Midwestern Nice was put to the test as tensions between Buttigieg and Klobuchar boiled over. “You voted to confirm the head of Customs and Border Protection under Trump, who was one of the architects of the family-separation policy,” Buttigieg pointed out. At one point, Klobuchar shot out: “Are you trying to say that I’m dumb? Or are you mocking me here, Pete?”

The Washington Post: A Guide to the Most Biting Brawls of the Contentious Las Vegas Presidential Debate

The Washington Post: Fact-Checking the Ninth Democratic Debate

Buttigieg also tried to get Sanders to take some responsibility for his supporters’ social media behavior. The issue was top of mind this week after a powerful culinary union in Nevada condemned the “vicious attacks” its members were receiving following the union’s criticism of Sanders’ “Medicare for All” plan.

The Wall Street Journal: Democratic Debate in Nevada: The Moments That Mattered

The incident between the union and Sanders’ supporters is the tip of the iceberg of a larger Medicare for All civil war roiling organized labor. On one side, you have liberal unions who argue a government-run plan would free them up to refocus and allow them to concentrate on other important matters. The other side of the coin says there’s no way the health care provided under such a system would be as good as the hard-earned plans they have now.

Politico: Labor’s Civil War Over ‘Medicare For All’ Threatens Its 2020 Clout


I was overly optimistic last week in everyone’s desire to adopt an official name for the coronavirus outbreak. Sorry scientists, “COVID-19” does not seem to have taken off, and, at least colloquially, you might be stuck with “coronavirus.” But no matter what it’s called, it is still demanding the world’s attention. Here’s a look at some of the more noteworthy and interesting stories from the week:

— The number of cases in China keeps dropping, in a sign that the outbreak might be stabilizing, at least in the epicenter. But that doesn’t mean anyone should be optimistic (heaven forbid!), because it’s likely cases outside China are on the cusp of blooming into a pandemic.

The New York Times: Coronavirus Epidemic Keeps Growing, But Spread in China Slows

— The Washington Post peels back the curtain on a fight between the State Department and the CDC over whether infected cruise ship passengers should be flown back to America without telling the other people on the plane. Guess who won …

The Washington Post: Diamond Princess: State Department Flew Coronavirus-Infected Americans to the US Against CDC Advice

— Who in our cast of characters holds the responsibility of steering the world through this crisis? (All I keep thinking is: “Responders…Assemble!” Anyone else? Or only your resident Marvel geek here?)

Stat: The Responders: Who Is Leading the Charge in the Coronavirus Outbreak

— Why is a hospital in Omaha, Nebraska, making news? Because in the early 2000s a group of doctors and scientists came up with the idea of creating a biocontainment unit there. Not everyone was on board at the time, calling it “overkill.” But nearly two decades of epidemics have proved the skeptics wrong.

The Associated Press: Why Treat People Exposed to Virus in Omaha? Why Not?

The New York Times: First Ebola, Now Coronavirus. Why an Omaha Hospital Gets the Toughest Cases.

— Are computers better at spotting an outbreak before humans’ puny minds can? Well, they’re quicker, certainly, but they lack our finesse. AI is more like an overly anxious car alarm, and disease fighters are still needed to come in and tease out the complexities of the situation.

The Associated Press: Can AI Flag Disease Outbreaks Faster Than Humans? Not Quite

— More men than women are falling victim to the coronavirus, and that might have something to do with smoking rates.

The New York Times: Why the Coronavirus Seems to Hit Men Harder Than Women

— The prejudice that tagged along with this outbreak is nothing new. Experts warn that there’s a long history of this kind of reaction, and that if we don’t heed warnings about the consequences of such behavior we’ll just be repeating mistakes of the past again.

Undark: Coronavirus Spurs Prejudice. History Suggests That’s No Surprise.

— The vast majority of coronavirus cases are mild. But in 2% of cases, it’s brutally lethal. So what’s happening?

The Washington Post: How the New Coronavirus Can Kill People or Sicken Them

— Is COVID-19 here to stay or will it disappear like its coronavirus brethren?

Los Angeles Times: SARS Killed Hundreds and Then Disappeared. Could This Coronavirus Die Out?

— And, something I had not considered, but with the Olympics coming up, experts say the world needs to have a better grip on the virus before countries should think about attending.

The Associated Press: Virologist: Tokyo Olympics Probably Couldn’t Be Held Now


As the Trump administration pushes to increase patients’ access to their electronic health records, tech companies wait hungrily in the wings for the data to slip out from under the protection of HIPAA. Supporters of the administration’s moves say that Big Tech will be mindful of their own brands and reputations and treat the potential of (lucrative, sweeping) health data responsibly. Critics are a little less sure about that rose-colored-glasses view of an industry mired in data-privacy scandals.

Politico: Trump’s Next Health Care Move: Giving Silicon Valley Your Medical Data


Covered California enrollment numbers gave health law supporters something to be smug about this week: Thanks to a state-level individual mandate and more subsidies, the marketplace saw a 41% jump in new sign-ups. Covered California officials were pretty much, like, “See what can be done when you support this model?”

Sacramento Bee: Covered California Health Insurance Sign-Ups Rise in 2020

Speaking of California, Gov. Gavin Newsom made a big statement by devoting the entirety of his State of the State address to the homelessness crisis. “Let’s call it what it is. It’s a disgrace,” he said. A main focus for Newsom was the intersection of mental health and homelessness, and what the state can be doing to better help those who need it.

Los Angeles Times: California Homelessness Crisis ‘A Disgrace,’ Newsom Says in State of the State


In the miscellaneous file for the week:

— Pharma used to rule the roost on Capitol Hill. But those days are looking more and more like a thing of the past. The WSJ dissects the once-ironclad relationship between the industry and Republicans, and what went wrong for the drugmakers.

The Wall Street Journal: How the Drug Lobby Lost Its Mojo in Washington

— These days we’re used to courts demanding scientific evidence, to jurors being presented with experts in the field when having to make a decision about the medical ramifications of something like a pesticide or other chemical. But that wasn’t always the case. Undark looks back on when that changed, and the family that’s cited so often in court cases their name has become a verb.

Undark: For Science in the Courts, the Daubert Name Looms Large

— Ever wonder why things are priced to the 99 cents? That’s because of the way people perceive numbers and the greater likelihood you’ll buy something priced at $4.99 versus $5.00. When it comes to pennies, that might seem inconsequential. But it turns out the same kind of thinking can be applied to age — and, thus, decisions about where the cutoff should be on procedures like open-heart surgery.

Stat: How Psychology of a $4.99 Price Tag May Affect Doctors’ Decisions

— Everyone went into the opioid lawsuits with high hopes, buzzing about the possibility of the reckoning (and settlement) being akin to that of Big Tobacco’s in the 1990s. But the reality is likely to be a letdown.

The New York Times: Payout From a National Opioids Settlement Won’t Be As Big As Hoped


And that’s it from me! Have a great weekend.

Listen: Missouri Efforts Show How Hard It Is To Treat Pain Without Opioids

KHN Midwest correspondent Lauren Weber was interviewed by KBIA’s Sebastián Martínez Valdivia to discuss the challenges Missouri faces in managing patients’ pain amid the opioid epidemic.

KHN Midwest correspondent Lauren Weber speaks with KBIA’s Sebastián Martínez Valdivia about the challenges Missouri faces in trying to treat chronic pain without opioids. Weber had reported that only about 500 of Missouri’s roughly 330,000 adult Medicaid beneficiaries used a new, alternative pain management plan to stem opioid overprescribing in the program’s first nine months. Meanwhile, 109,610 Missouri Medicaid patients received opioid prescriptions last year.

You can listen to the conversation on the KBIA website.

No Quick Fix: Missouri Finds Managing Pain Without Opioids Isn’t Fast Or Easy

In the first nine months of an alternative pain management program in Missouri, only a small fraction of the state’s Medicaid recipients have accessed the chiropractic care, acupuncture, physical therapy and cognitive-behavioral therapy meant to combat the overprescription of opioids.

ST. LOUIS — Missouri began offering chiropractic care, acupuncture, physical therapy and cognitive-behavioral therapy for Medicaid patients in April, the latest state to try an alternative to opioids for those battling chronic pain.

Yet only about 500 of the state’s roughly 330,000 adult Medicaid users accessed the program through December, at a cost of $190,000, according to Josh Moore, the Missouri Medicaid pharmacy director. While the numbers may reflect an undercount because of lags in submitting claims, the jointly funded federal-state program known in the state as MO HealthNet is hitting just a fraction of possible patients so far.

Meanwhile, according to the state, opioids were still being doled out: 109,610 Missouri Medicaid patients of all age groups received opioid prescriptions last year.

The going has been slow, health experts said, because of a slew of barriers. Such treatments are more time-consuming and involved than simply getting a prescription. A limited number of providers offer alternative treatment options, especially to Medicaid patients. And perhaps the biggest problem? These therapies don’t seem to work for everyone.

The slow rollout highlights the overall challenges in implementing programs aimed at righting the ship on opioid abuse in Missouri — and nationwide. To be sure, from 2012 to 2019, the number of Missouri Medicaid patients prescribed opioid drugs fell by more than a third — and the quantity of opioids dispensed by Medicaid dropped by more than half.

Still, opioid overdoses killed an estimated 1,132 Missourians in 2018 and 46,802 Americans nationally, according to the latest data available. Progress to change that can be frustratingly slow.

“The opioids crisis we got into wasn’t born in a year,” Moore said. “To expect we’d get perfect results after a year would be incredibly optimistic.”

Despite limited data on the efficacy of alternative pain management plans, such efforts have become more accepted, especially following a summer report of pain management best practices from the U.S. Department of Health and Human Services. States such as Ohio and Oregon see them as one part of a menu of options aimed at curbing the opioid crisis.

St. Louis chiropractor Ross Mattox, an assistant professor at chiropractic school Logan University, sees both uninsured patients and those on Medicaid at the CareSTL clinic. He cheered Missouri’s decision to expand access, despite how long it took to get here.

“One of the most common things I heard from providers,” he said, “is ‘I want to send my patient to a chiropractor, but they don’t have the insurance. I don’t want to prescribe an opioid — I’d rather go a more conservative route — but that’s the only option I have.’”

And that can lead to the same tragic story: Someone gets addicted to opioids, runs out of a prescription and turns to the street before becoming another sad statistic.

“It all starts quite simply with back pain,” Mattox said.

Practical Barriers

While Missouri health care providers now have another tool besides prescribing opioids to patients with Medicaid, the multistep approaches required by alternative treatments create many more hoops than a pharmacy visit.

The physicians who recommend such treatments must support the option, and patients must agree. Then the patient must be able to find a provider who accepts Medicaid, get to the provider’s office even if far away and then undergo multiple, time-consuming therapies.

“After you see the chiropractor’s for one visit, it’s not like you’re cured from using opioids forever — it would take months and months and months,” Moore said.

The effort and cost that go into coordinating a care plan with multiple alternative pain therapies is another barrier.

“Covering a course of cheap opioid pills is different than trying to create a multidisciplinary individualized plan that may or may not work,” said Leo Beletsky, a professor of law and health sciences at Northeastern University in Boston, noting that the scientific evidence of the efficacy of such treatments is mixed.

And then there’s the reimbursement issue for the providers. Corry Meyers, an acupuncturist in suburban St. Louis, does not accept insurance in his practice. But he said other acupuncturists in Missouri debate whether to take advantage of the new Medicaid program, concerned the payment rates to providers will be too low to be worthwhile.

“It runs the gamut, as everyone agrees that these patients need it,” Meyers stressed. But he said many acupuncturists wonder: “Am I going to be able to stay open if I take Medicaid?”

Structural Issues 

While helpful, plans like Missouri’s don’t address the structural problems at the root of the opioid crisis, Beletsky said.

“Opioid overutilization or overprescribing is not just a crisis in and of itself; it’s a symptom of broader structural problems in the U.S. health care system,” he said. “Prescribers reached for opioids in larger and larger numbers not just because they were being fooled into doing so by these pharmaceutical companies, but because they work really well for a broad variety of ailments for which we’re not doing enough in terms of prevention and treatment.”

Fixing some of the core problems leading to opioid dependence — rural health care “deserts” and the impact of manual labor and obesity on chronic pain — requires much more than a treatment alternative, Beletsky said.

And no matter how many alternatives are offered, he said, opioids will remain a crucial medicine for some patients.

Furthermore, while alternative pain management therapies may lessen opioid prescriptions, they do not address exploding methamphetamine addiction or other addiction crises leading to overdoses nationwide — even as a flood of funds pours in from the national and state level to fight these crises.

The Show-Me State’s refusal to expand Medicaid coverage to more people under the Affordable Care Act also hampers overall progress, said Dr. Fred Rottnek, a family and addiction doctor who sits on the St. Louis Regional Health Commission as chair of the Provider Services Advisory Board.

“The problem is we relatively cover so few people in Missouri with Medicaid,” he said. “The denominator is so small that it doesn’t affect the numbers a whole lot.”

But providers like Mattox are happy that such alternative treatments are now an option, even if they’re available only for a limited audience.

He just wishes it had been done sooner.

“A lot of it has to do with politics and the slow gears of government,” he said. “Unfortunately, it’s taken people dying — it’s taken enough of a crisis for people to open their eyes and say, ‘Maybe there’s a better way to do this.’”