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.

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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.

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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

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

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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.

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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.

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“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.

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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.

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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.

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

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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.

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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.

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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

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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.

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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.

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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.

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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.

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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.

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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.’”