Schools, Sheriffs, and Syringes: State Plans Vary for Spending $26B in Opioid Settlement Funds

The cash represents an unprecedented opportunity to derail the opioid epidemic, but with countless groups advocating for their share of the pie, the impact could depend heavily on geography and politics.

With more than 200 Americans still dying of drug overdoses each day, states are beginning the high-stakes task of deciding how to spend billions of dollars in settlement funds from opioid manufacturers and distributors. Their decisions will have real-world implications for families and communities across the country that have borne the brunt of the opioid crisis.

Will that massive tranche of money be used to help the people who suffered the most and for programs shown to be effective in curbing the epidemic? Or will elected officials use the money for politically infused projects that will do little to offer restitution or help those harmed?

Jacqueline Lewis, of Columbus, Ohio, is wondering exactly that. She lost her son this fall after his 20-year struggle with addiction.

After emptying her retirement account and losing her house to pay for his rehab, court fees, and debts to dealers, she’s now raising her 7-year-old granddaughter while also caring for her 95-year-old mother with dementia, on nothing more than Social Security payments.

When Lewis heard Ohio would receive $808 million in opioid settlement funds, she thought there’d finally be relief for thousands of families like hers.

She was eager to speak with members of the OneOhio Recovery Foundation, which was created to oversee the distribution of most of Ohio’s funds. As they determined priorities for funding, she wanted them to consider perspectives like hers, a mother and grandmother who’d faced addiction up close and saw the need for more treatment centers, addiction education in the workplace, and funding for grandparents raising grandkids as a result of the opioid epidemic.

But she couldn’t find anyone to listen. At an August foundation meeting she attended, board members excused themselves to go into a private session, she said. “They just left the room and left us sitting there.” When she attended another meeting virtually, audience members weren’t allowed to “voice anything or ask questions.”

A local group that advocates for people affected by the opioid epidemic has expressed similar concerns and is now suing the foundation for a lack of transparency, even though few decisions about funding priorities have been made yet.

The strife in Ohio highlights the tensions emerging nationwide as settlement funds start flowing. The funds come from a multitude of lawsuits, most notably a $26 billion settlement resulting from more than 3,000 cities, counties, and states suing manufacturer Johnson & Johnson and distributors McKesson, AmerisourceBergen, and Cardinal Health for their roles in the opioid crisis. Payments from that case began this summer and will continue for 18 years, setting up what public health experts and advocates are calling an unprecedented opportunity to make progress against an epidemic that has ravaged America for three decades.

But, they caution, each state seems to have its own approach to these funds, including different distributions between local and state governments and various processes for spending the money. With countless individuals and groups advocating for their share of the pie — from those dealing with addiction and their families to government agencies, nonprofits, health care systems, and more — the money’s impact could depend heavily on geography and politics.

“It sounds like a lot of money, but it’s going to a lot of places and going to be spread out over time,” said Sara Whaley, a researcher at Johns Hopkins Bloomberg School of Public Health who tracks state use of opioid funds. “It’s not going to magically end this crisis. But if it’s used well and used thoughtfully, there is an opportunity to make a real difference.”

And if not, it could be just another political boondoggle.

Avoiding the ‘Tobacco Nightmare’

The worst-case scenario, many say, is for the opioid settlement to end up like the tobacco master settlement of 1998.

States won $246 billion over 25 years, but less than 3% of the annual payouts are used for smoking prevention or cessation, according to the Campaign for Tobacco-Free Kids. Most has gone toward filling budget gaps, building roads, and subsidizing tobacco farmers.

But there are stronger protections in place for the opioid settlement dollars, said Christine Minhee, founder of a website that tracks the funds.

The arrangement specifies that states must spend at least 70% of the money for opioid-related expenses in the coming years and includes a list of qualifying expenses, like expanding access to treatment and buying the overdose reversal medication naloxone. Fifteen percent of the funds can be used for administrative expenses or for governments to reimburse past opioid-related expenses. Only the remaining 15% is a free-for-all.

If states don’t meet those thresholds, they could face legal consequences and even see their future payouts reduced, Minhee said.

“The kind of tobacco nightmare stuff where only 3% of funds were spent on what they were meant for is legally and technically impossible,” she said. Though, she added, “a different nightmare is still possible.”

Experts tracking the funds say transparency around who receives the money and how those decisions are made is key to a successful and useful distribution of resources.

In Rhode Island, for instance, public comment is a regular part of opioid advisory committee hearings. In North Carolina and Colorado, online dashboards show how much money each locality is receiving and will track how it is spent.

But other states are struggling.

In Ohio, the document that creates a private foundation to oversee most of the state’s funds says that “the Foundation shall operate in a transparent manner” and that meetings and documents will be public. Yet the OneOhio Recovery Foundation has since said it is not subject to open-meetings law. It has adopted a policy that meetings can be closed if the board decides the content is “sensitive or confidential material that is not appropriate for the general public.”

The contradiction between the board’s actions and how it was conceived led Dennis Cauchon, president of Harm Reduction Ohio, which distributes naloxone across the state, to sue the foundation. He said he wants the public to have more say in how the funding is spent.

“The board members are in a closed loop, and they’re having a hard time learning what the needs are,” Cauchon said.

The 29-member board includes representatives of local regions, as well as appointees from the governor, state attorney general, and legislative leaders. Many are city- and county-level politicians, and one is the wife of a U.S. senator. They are not paid for this role.

Nathaniel Jordan, executive director of the nonprofit Columbus Kappa Foundation, which distributes naloxone to Black communities in Ohio, has raised concerns about the board’s lack of racial diversity. Since 2017, Black men have had the highest rate of drug overdose deaths in the state, he said, but only one board member is Black. “What gives?”

Kathryn Whittington, chair of the OneOhio Recovery Foundation, said the board is being “very transparent in what we are doing.” The public can attend meetings in person or online. Recordings of past meetings are posted online, along with the agenda, board packet, and policies discussed — including a draft of the diversity and inclusion policy the board is considering.

People who want to provide input “can always reach out to me as the chair or any other board member,” said Whittington, who added that two of her children have struggled with addiction too. But the best option is to contact one of Ohio’s 19 regional boards, she said. Those groups can elevate local concerns to the foundation board.

“We are still at the very beginning,” Whittington emphasized. No money from the 18-year settlement has been spent yet. The board’s operational expenses — including a $10,000-per-month contract with a public relations firm — is being paid from $1 million from a previous opioid-related settlement.

But Lewis, the woman raising her granddaughter in Columbus, worries that the day for families to speak may never come.

“They keep saying it’s not ready, and before you know it, they’ll be handing out money and it’ll be too late,” she said.

Following the Money

Rhode Island is one of the states working fastest to distribute settlement dollars. Its Executive Office of Health and Human Services, which controls 80% of the funds and works with an opioid advisory committee, released a plan to use $20 million by July 2023.

Although the plan doesn’t specify funding for people raising grandchildren, it does allocate $900,000 to recovery supports, which will include community agencies that serve family members, the department said. The single largest allocation, $4 million, will go to school- and community-based mental health programs.

The investment that has sparked the most interest is $2 million for a supervised drug consumption site. Its location and opening date will be determined by organizations that respond to the state’s request for proposals, said Carrie Bridges Feliz, chair of the opioid settlement advisory committee. At a time when fentanyl, a synthetic opioid 50 times stronger than heroin, is infiltrating most street drugs and overdose rates are high, “we were anxious to make use of these funds.”

In contrast, the process of distributing settlement dollars in Louisiana has barely begun. State Attorney General Jeff Landry announced in July 2021 that Louisiana was expected to receive $325 million from the 18-year settlement but has not released any additional information. His office did not respond to repeated inquiries about the status of the funds.

The governor’s office and state health department said they could not answer specific questions about the funds and had not yet been contacted by the attorney general’s office, which negotiated the state’s settlement agreement. Multiple clinicians who treat substance use disorder and advocates who work with people who use drugs were similarly in the dark.

The state’s written plan says it will create a five-person task force to recommend how to spend the money. Kevin Cobb, president of the Louisiana Sheriffs’ Association, said the group had appointed its representative to the task force, but he didn’t know if other members had been selected or when they would meet.

One decision Louisiana has made so far is to give 20% of the settlement funds directly to sheriffs — a move that has made some people nervous.

“This plays into an increase in support for an authoritarian response to what are public health issues,” said Nadia Eskildsen, who has worked for syringe service programs and other such groups in New Orleans.

She worries that money will be funneled toward increasing arrests, rather than helping people find housing, work, or health care. Meanwhile, almost 1,400 Louisiana residents died of opioid-related causes last year.

K.P. Gibson, the Acadia Parish sheriff who will represent the sheriffs association on the state task force, said his focus is not on punishment, but on getting people into treatment. “My jail problem will resolve itself if we resolve the problem of opioid addiction,” he said.

Many health and policy experts say using settlement funds to pair mental health professionals with police officers or provide medications for opioid use disorder in prisons could reduce deaths.

States’ choices generally reflect a range of local priorities: While Louisiana has carved out funds for law enforcement, Maine is dedicating 3% of its statewide share for special education programs in schools, and Colorado has allocated 10% to addiction infrastructure, like workforce training, telehealth expansion, and transportation to treatment.

Maine requires that some funds be used for special education because school districts also sued the opioid companies, said state Attorney General Aaron Frey.

Patricia Hopkins said she signed on to the lawsuit because she’s seen the impact of the opioid crisis on students over the past decade as superintendent of school district 11, a rural part of central Maine’s Kennebec County with 1,950 students.

A report compiled by her staff in 2019 showed nearly 4% of students have a parent dealing with addiction.

Sixty miles north, in rural Penobscot County, school district 19 social worker Meghan Baker said she knows two siblings who were home when first responders arrived to revive their parents with naloxone, and another set of siblings who lost their mother to an overdose.

Students who experience this trauma often become angry, act out at school, and find it difficult to trust adults. When Baker refers them to counseling services in the community, they encounter waitlists that run six months to a year.

“If we could hire more guidance counselors and social workers, at least we can help some of those kids during the school day,” she said.

It’s clear that many have high hopes for the billions of dollars in opioid settlement funds arriving over the next two decades. But they have questions too, because effectively using this large pot of money requires planning and forethought.

For people like Jacqueline Lewis in Ohio, whose family has lost so much to an epidemic too long ignored, progress feels slow.

As she tries to make do on Social Security, Lewis focuses on the positives: Her granddaughter is a happy child, and her older brother lives with them to help out. But the financial worries gnaw at her. And what if her own health falters before her granddaughter is an adult?

“I might be OK right now, but tomorrow, I never know,” she said.

KHN correspondent Rae Ellen Bichell contributed to this report.

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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Médicos se apresuran a usar fallo de la Corte Suprema para liberarse de cargos por opioides

En una decisión de junio, el tribunal dijo que los fiscales no solo deben probar que una receta no estaba médicamente justificada sino también que el que la escribió sabía del riesgo de recetar opioides.

El doctor Nelson Onaro admitió el verano pasado que había escrito recetas ilegales, aunque dijo que solo pensaba en sus pacientes. Desde una pequeña clínica en Oklahoma, repartió cientos de pastillas de opioides y docenas de parches de fentanilo sin un propósito médico legítimo.

“Esos medicamentos fueron recetados para ayudar a mis pacientes, desde mi propio punto de vista”, dijo Onaro en la corte, mientras, a regañadientes, se declaraba culpable de seis cargos de tráfico de drogas. Al confesar, podría haber recibido una sentencia reducida de tres años o menos en prisión.

Pero Onaro cambió de opinión en julio. En los días previos a su sentencia, le pidió a un juez federal que desestimara su acuerdo de culpabilidad, enviando su caso a juicio. Para tener la oportunidad de ser exonerado, enfrentaría cuatro veces más cargos y la posibilidad de una sentencia más severa.

¿Por qué correr el riesgo? Un fallo de la Corte Suprema ha elevado el umbral para condenar en casos como el de Onaro. En una decisión de junio, el tribunal dijo que los fiscales no solo deben probar que una receta no estaba médicamente justificada sino también que el que la escribió sabía del riesgo.

De repente, el estado mental de Onaro tiene más peso en la corte. Los fiscales no se han opuesto a que el médico retire su declaración de culpabilidad de la mayoría de los cargos, admitiendo en una presentación judicial que enfrenta “un cálculo legal diferente” después de la decisión de la Corte Suprema.

El fallo unánime de la Corte complica los esfuerzos continuos del Departamento de Justicia para responsabilizar penalmente a los que recetan de manera irresponsable por alimentar la crisis de opioides.

Antes, los tribunales inferiores no habían considerado la intención del que recetaba. Hasta ahora, los médicos enjuiciados en gran medida no podían defenderse argumentando que estaban actuando de buena fe cuando emitían recetas incorrectas. Ahora pueden, aunque no es necesariamente una garantía para salir de la cárcel, dicen los abogados.

“Esencialmente, a los médicos se los esposaba”, dijo Zach Enlow, abogado de Onaro. “Ahora pueden quitarse las esposas. Pero eso no significa que van a ganar la pelea”.

La decisión de la Corte Suprema en Ruan vs. Estados Unidos, emitida el 27 de junio, fue eclipsada por la controversia nacional tres días antes, cuando el tribunal anuló los derechos federales del aborto.

Pero el fallo, menos conocido ahora, se está filtrando en silencio a través de los tribunales federales, fortaleciendo a los acusados ​​en los casos de abuso de recetas y puede tener un efecto escalofriante en futuros juicios a médicos bajo el Controlled Substance Act.

En los tres meses desde que se emitió, la decisión de Ruan se ha invocado en al menos 15 juicios en curso en 10 estados, según una revisión de KHN de los registros de la corte federal.

Los médicos citaron la decisión en las apelaciones posteriores a la condena, las mociones para absoluciones, nuevos juicios, reversiones de culpabilidad y un intento fallido de excluir el testimonio de un experto en prescripciones, argumentando que su opinión ahora era irrelevante. Otros acusados ​​han solicitado con éxito retrasar sus casos para que la decisión de Ruan pueda verse utilizarse en sus argumentos en los próximos juicios o audiencias de sentencia.

David Rivera, ex fiscal estadounidense de la era Obama, quien lideró juicios sobre abuso de prescripciones en Tennessee, dijo que cree que los médicos tienen una “gran oportunidad” de anular las condenas si se les prohibió discutir una defensa de buena fe o se instruyó a un jurado que ignorara este argumento.

Rivera dijo que los acusados ​​que movilizaban cientos de miles de pastillas aún serían condenados, incluso si finalmente se requiriera un segundo juicio. Pero la Corte Suprema ha extendido un “salvavidas” a un grupo pequeño de acusados ​​que “dispensaron con su corazón, no con su mente”, dijo.

“Lo que la Corte Suprema está tratando de hacer es dividir entre un médico malo y una persona que podría tener una licencia para practicar la medicina pero que no actúa como médico y es un traficante de drogas”, dijo Rivera. “Un médico que actúa bajo una creencia sinceramente sostenida de que está haciendo lo correcto, incluso si puede ser horrible en su trabajo y no se le deben confiar vidas, incluso eso no es criminal”.

La decisión de Ruan fue el resultado de las apelaciones de dos médicos, Xiulu Ruan y Shakeel Kahn, quienes fueron condenados por separado por recetar píldoras en Alabama y Wyoming, respectivamente, y sentenciados a 21 y 25 años de prisión. En ambos casos, los fiscales se basaron en una táctica común para mostrar que las recetas eran un delito: los testigos expertos revisaron las recetas de los acusados ​​y testificaron que estaban fuera de lugar con lo que un médico razonable haría.

Pero al escribir la opinión de la Corte Suprema, el entonces juez Stephen Breyer insistió en que la carga de la prueba no debería ser tan simple de superar, devolviendo ambas condenas a los tribunales inferiores para su reconsideración.

Debido a que a los médicos se les permite, y se espera, que distribuyan drogas, escribió Breyer, los fiscales no solo deben demostrar que escribieron recetas sin propósito médico, sino que también lo hicieron “a sabiendas o intencionalmente”. De lo contrario, los tribunales corren el riesgo de castigar “conductas que se encuentran cerca, pero en el lado permitido de la línea criminal”, escribió Breyer.

Para los abogados defensores, el fallo unánime envió un mensaje inequívoco.

“Este es un tiempo hiperpolarizado en Estados Unidos, y particularmente en la corte”, dijo Enlow. “Sin embargo, este fue un fallo de 9-0 que decía que el mens rea, o el estado mental del médico, es importante”.

Tal vez en ninguna parte la decisión de Ruan fue más apremiante que en el caso del doctor David Jankowski, un médico de Michigan que estaba en juicio.

Jankowski fue condenado por crímenes federales de drogas y fraude y enfrenta 20 años de prisión. En un anuncio del veredicto, el Departamento de Justicia dijo que el médico y su clínica suministraron a las personas “sin necesidad de drogas”, que se “vendían en las calles para alimentar las adicciones de los adictos a los opioides”.

La abogada defensora Anjali Prasad dijo que el fallo de Ruan llegٕó antes de las deliberaciones del jurado en el caso, pero después de que los fiscales pasaran semanas presentando el argumento de que el comportamiento de Jankowski no fue el de alguien que prescribe de manera razonable, un estándar legal que ya no es suficiente para convencer.

Prasad citó la decisión de Ruan en una moción para un nuevo juicio, que fue denegada, y dijo que tiene la intención de utilizar la decisión como base para una próxima apelación. La abogada también dijo que está discutiendo con otros dos clientes sobre apelar sus condenas en base a Ruan.

“Espero que los abogados de defensa penal como yo estén más fortalecidos para llevar sus casos a juicio y que sus clientes estén 100% listos para luchar contra los federales, lo cual no es una tarea fácil”, dijo Prasad.

Algunos acusados ​​lo están intentando. Hasta ahora, algunos han obtenido pequeñas victorias. Y al menos uno sufrió una derrota aplastante.

En Tennessee, la enfermera practicante Jeffrey Young, acusada de intercambiar opioides por sexo y notoriedad para ser parte de un piloto de un reality show, retrasó con éxito su juicio de mayo a noviembre para dar cuenta de la decisión de Ruan, argumentando que “alteraría drásticamente el paisaje de la guerra del gobierno contra los que hacen recetas”.

También en Tennessee, Samson Orusa, un médico y pastor que el año pasado fue condenado por entregar recetas de opioides sin examinar a los pacientes, presentó una moción para un nuevo juicio basado en la decisión de Ruan, luego persuadió a un juez reacio a retrasar su sentencia durante seis meses. para considerarlo.

Y en Ohio, el doctor Martin Escobar citó el fallo de Ruan en un argumento de 11 horas para evitar la prisión.

En enero, Escobar se declaró culpable de 54 cargos de distribución de sustancias controladas, incluidas las recetas que causaron la muerte de dos pacientes. Después de la decisión de Ruan, Escobar intentó retirar su petición, diciendo que habría ido a juicio si hubiera sabido que los fiscales tenían que demostrar intencionalidad.

Una semana después, el día en que Escobar fue sentenciado, un juez federal negó la moción.

Su declaración de culpabilidad permaneció.

Escobar fue condenado a 25 años.

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 Rush to Use Supreme Court Ruling to Escape Opioid Charges

After a unanimous ruling from the high court, doctors who are accused of writing irresponsible prescriptions can go to trial with a new defense: It wasn’t on purpose.

Dr. Nelson Onaro conceded last summer that he’d written illegal prescriptions, although he said he was thinking only of his patients. From a tiny, brick clinic in Oklahoma, he doled out hundreds of opioid pills and dozens of fentanyl patches with no legitimate medical purpose.

“Those medications were prescribed to help my patients, from my own point of view,” Onaro said in court, as he reluctantly pleaded guilty to six counts of drug dealing. Because he confessed, the doctor was likely to get a reduced sentence of three years or less in prison.

But Onaro changed his mind in July. In the days before his sentencing, he asked a federal judge to throw out his plea deal, sending his case toward a trial. For a chance at exoneration, he’d face four times the charges and the possibility of a harsher sentence.

Why take the risk? A Supreme Court ruling has raised the bar to convict in a case like Onaro’s. In a June decision, the court said prosecutors must not only prove a prescription was not medically justified ― possibly because it was too large or dangerous, or simply unnecessary ― but also that the prescriber knew as much.

Suddenly, Onaro’s state of mind carries more weight in court. Prosecutors have not opposed the doctor withdrawing his plea to most of his charges, conceding in a court filing that he faces “a different legal calculus” after the Supreme Court decision.

The court’s unanimous ruling complicates the Department of Justice’s ongoing efforts to hold irresponsible prescribers criminally liable for fueling the opioid crisis. Previously, lower courts had not considered a prescriber’s intention. Until now, doctors on trial largely could not defend themselves by arguing they were acting in good faith when they wrote bad prescriptions. Now they can, attorneys say, although it is not necessarily a get-out-of-jail-free card.

“Essentially, the doctors were handcuffed,” said Zach Enlow, Onaro’s attorney. “Now they can take off their handcuffs. But it doesn’t mean they are going to win the fight.”

The Supreme Court’s decision in Ruan v. United States, issued June 27, was overshadowed by the nation-shaking controversy ignited three days earlier, when the court erased federal abortion rights. But the lesser-known ruling is now quietly percolating through federal courthouses, where it has emboldened defendants in overprescribing cases and may have a chilling effect on future prosecutions of doctors under the Controlled Substances Act.

In the three months since it was issued, the Ruan decision has been invoked in at least 15 ongoing prosecutions across 10 states, according to a KHN review of federal court records. Doctors cited the decision in post-conviction appeals, motions for acquittals, new trials, plea reversals, and a failed attempt to exclude the testimony of a prescribing expert, arguing their opinion was now irrelevant. Other defendants have successfully petitioned to delay their cases so the Ruan decision could be folded into their arguments at upcoming trials or sentencing hearings.

David Rivera, a former Obama-era U.S. attorney who once led overprescribing prosecutions in Middle Tennessee, said he believes doctors have a “great chance” of overturning convictions if they were prohibited from arguing a good faith defense or a jury was instructed to ignore one.

Rivera said defendants who ran true pill mills would still be convicted, even if a second trial was ultimately required. But the Supreme Court has extended a “lifeline” to a narrow group of defendants who “dispensed with their heart, not their mind,” he said.

“What the Supreme Court is trying to do is divide between a bad doctor and a person who might have a license to practice medicine but is not acting as a doctor at all and is a drug dealer,” Rivera said. “A doctor who is acting under a sincerely held belief that he is doing the right thing, even if he may be horrible at his job and should not be trusted with human lives ― that’s still not criminal.”

The Ruan decision resulted from the appeals of two doctors, Xiulu Ruan and Shakeel Kahn, who were separately convicted of running pill mills in Alabama and Wyoming, respectively, then sentenced to 21 and 25 years in prison. In both cases, prosecutors relied on a common tactic to show the prescriptions were a crime: Expert witnesses reviewed the defendants’ prescriptions and testified that they were far out of line with what a reasonable doctor would do.

But in writing the opinion of the Supreme Court, then-Justice Stephen Breyer insisted the burden of proof should not be so simple to overcome, remanding both convictions back to the lower courts for reconsideration.

Because doctors are allowed and expected to distribute drugs, Breyer wrote, prosecutors must not only prove they wrote prescriptions with no medical purpose but also that they did so “knowingly or intentionally.” Otherwise, the courts risk punishing “conduct that lies close to, but on the permissible side of, the criminal line,” Breyer wrote.

To defense attorneys, the unanimous ruling sent an unambiguous message.

“This is a hyperpolarized time in America, and particularly on the court,” Enlow said. “And yet this was a 9-0 ruling saying that the mens rea ― or the mental state of the doctor ― it matters.”

Maybe nowhere was the Ruan decision more pressing than in the case of Dr. David Jankowski, a Michigan physician who was on trial when the burden of proof shifted beneath his feet.

Jankowski was convicted of federal drug and fraud crimes and faces 20 years in prison. In an announcement of the verdict, the DOJ said the doctor and his clinic supplied people with “no need for the drugs,” which were “sold on the streets to feed the addictions of opioid addicts.”

Defense attorney Anjali Prasad said the Ruan ruling dropped before jury deliberations in the case but after prosecutors spent weeks presenting the argument that Jankowski’s behavior was not that of a reasonable prescriber — a legal standard that on its own is no longer enough to convict.

Prasad cited the Ruan decision in a motion for a new trial, which was denied, and said she intends to use the decision as a basis for a forthcoming appeal. The attorney also said she is in discussion with two other clients about appealing their convictions with Ruan.

“My hope is that criminal defense attorneys like myself are more emboldened to take their cases to trial and that their clients are 100% ready to fight the feds, which is no easy task,” Prasad said. “We just duke it out in the courtroom. We can prevail that way.”

Some defendants are trying. So far, a few have scored small wins. And at least one suffered a crushing defeat.

In Tennessee, nurse practitioner Jeffrey Young, accused of trading opioids for sex and notoriety for a reality show pilot, successfully delayed his trial from May to November to account for the Ruan decision, arguing it would “drastically alter the landscape of the Government’s war on prescribers.”

Also in Tennessee, Samson Orusa, a doctor and pastor who last year was convicted of handing out opioid prescriptions without examining patients, filed a motion for a new trial based on the Ruan decision, then persuaded a reluctant judge to delay his sentencing for six months to consider it.

And in Ohio, Dr. Martin Escobar cited the Ruan ruling in an eleventh-hour effort to avoid prison.

Escobar in January pleaded guilty to 54 counts of distributing a controlled substance, including prescriptions that caused the deaths of two patients. After the Ruan decision, Escobar tried to withdraw his plea, saying he’d have gone to trial if he’d known prosecutors had to prove his intent.

One week later, on the day Escobar was set to be sentenced, a federal judge denied the motion.

His guilty plea remained.

Escobar got 25 years.

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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A Free-for-All From Readers and Tweeters, From Medical Debt to Homelessness

KHN 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.

It is appalling that an article like this even has to be written. Our "healthcare" system is broken.How to get rid of medical debt — or avoid it in the first place https://t.co/EIo7lHps8k

— Karin Wiberg (@kswiberg) July 1, 2022

— Karin Wiberg, Raleigh, North Carolina

Lifesaving Information

I just want to thank you from the bottom of my heart for the work you do that exposes the utter brokenness of America’s health system (“Diagnosis: Debt: How to Get Rid of Medical Debt — Or Avoid It in the First Place,” July 1). You are helping to fix it!

— Ruth Worley, Athens, Ohio

Recovering from being sick or caring for a sick loved one should not ruin any American’s finances. Here are some tactics to navigate the system. https://t.co/ykvDkUecj0

— Bayeté (@BayeteKenan) July 10, 2022

— Bayeté Ross Smith, Harlem, New York

Patients Left Holding the Bag

Your “Diagnosis: Debt” articles are interesting and serve as further examples of how the health care industry is set up for the health care system and not the people who use it.

In the USA, medical debt should not be an issue, but we don’t teach people how to save or understand how to navigate the system. I am a nurse blogger/advocate and see the repercussions of what people go through who have inadequate insurance and lack savings or the ability to understand what is happening to them when they are thrust into the complex health care system. But, in reality, none of us really think about our health or the health care system till we are in the middle of a crisis. If we are honest, none of us are really prepared for a catastrophic event, and this is what we need to work on going further through education and advocacy.

I will continue to educate the public in my small way so people can understand their role in our health care system so they are prepared for a medical event and know that they can use their voice to speak up and advocate for themselves.

— Anne Llewellyn, Plantation, Florida

Portland has become a wasteland! Where are the environmentalists at least? Oh yeah, they're all in their gated communities, worrying about climate change and plastic straws for the rest of us. (hope you can see this LA Times article)https://t.co/WrboM9vtPs

— Bob Beddingfield (@bobbeddingfield) June 23, 2022

— Bob Beddingfield, Houston

Destination: Disaster

We visited Portland, Oregon, a year ago for a vacation and we will never go back: stores that don’t give baskets because people use them to steal. Stores that put poles on carts to keep people from racing out of the store with them full of merchandise. Closed storefronts. Homeless people everywhere (“Sobering Lessons in Untying the Knot of a Homeless Crisis,” June 21).

It was like a Third World country. I’m not a Republican, very far from it, but accepting the idea that anyone who wants can live on the streets, dump their trash, and get subsidized by the city cannot end well. And this problem is not limited to Portland. San Francisco is in a very similar situation with crime, drug abuse, and homelessness.

There is no one-size-fits-all solution. Throwing money at the problem and then ignoring the continuing unresolved problem hasn’t worked and, I think, never will.

The idea that a city can host an unlimited number of drug and alcohol addicts at public expense won’t work.

The idea that shoplifting, car break-ins, robberies, etc. are allowed, not arrested, not prosecuted, not punished can never work out well.

And people wonder why the Democrats are in such deep, deep trouble in spite of the horrible ideas the Republicans promote.

This will not end well.

— David Alexander, Palo Alto, California

Quite possible the best news story about our local homeless challenges I have read recently. 'Not safe anymore': Portland confronts the limits of its support for homeless services #homless #Portland https://t.co/Ujr5KzhYAi

— Ben Brown Jr. (@BenBrownJunior) June 22, 2022

— Ben Brown Jr., Beaverton, Oregon

On Wheelchair Repairs, Steering Clear of Error

As the CEO of National Seating & Mobility (NSM), I applaud the work of KHN in providing in-depth reporting about important issues in health care, including the complex rehabilitation technology (CRT) industry.

However, the recent article “Despite a First-Ever ‘Right-to-Repair’ Law, There’s No Easy Fix for Wheelchair Users” (June 2) presented several inaccuracies, misrepresentations, and errors in its characterization of NSM and our work.

The article stated that NSM and other CRT providers have limited their investments in service and repair to increase profits. NSM leadership has continuously invested in our service and repair business, including establishing a career path and certification program to professionalize the service technician role, improving onboarding and ongoing training programs, reorganizing our funding team to introduce repair-specific funding specialists to better assist clients in the repair process, investing in market analysis on competitive wages that resulted in a 15%-20% hourly pay increase for technicians, and more. In 2022, NSM has almost 500 service technicians on staff, which is 22% more technicians per count of client-delivered orders versus 2019. Our investment in service and repair is long-standing and will continue.

The article also suggested that Medicare’s use of competitive bidding favors large companies, often at the expense of quality and customer service. NSM was not part of the previous bidding session for durable medical equipment (DME) to establish current rates and was not awarded any Medicare contracts as a result. Most of the products we provide are considered CRT and are exempt from the competitive bid process and pricing. Due to section 16005 of the 21st Century Cures Act and House Bill H.R. 1865, product codes that can be used for CRT or basic DME are paid at the normal rate for CRT instead of competitive pricing.

Finally, the article makes false assumptions about our company: that we keep a limited inventory of parts, and we have little incentive to hire technicians or pay for training because we lose money with repairs.

Each mobility solution — and therefore each repair—is highly customized to a client’s needs. This customization means parts that are replaced less frequently across our client population aren’t likely to be stocked versus those parts that are frequently replaced. The current global supply chain disruption has also affected our inventory; the amount of stock we have on hand is entirely dependent upon availability. Additionally, the labor shortage our country is experiencing has created a challenge across all industries, ours included.

Repair reimbursement is a loss-leader for the CRT industry, exacerbated recently due to inflation in the supply chain and labor markets. While other companies are forced to turn down repairs due to these challenges, NSM continues to provide repairs because it is the right thing to do.

NSM is a customer service business, earning our business in every client interaction. We recognize improvements are needed, and we are committed to investing in advocacy, programs, and collaborative industry efforts to lead our industry in a new direction to improve the lives of those we serve.

— Bill Mixon, CEO of National Seating & Mobility, Franklin, Tennessee

This needs to change! It should not be so complicated to get simple repairs made to #wheelchairs!https://t.co/MpTAyeBEms via @KHNews #DisabilityRights

— W. Ron Adams (@WRonAdams) June 11, 2022

— W. Ron Adams, Erlanger, Kentucky

These folks have also worked so hard to get landmark legislation passed across the country, including a really important first step in Colorado on the right to repair wheelchairs: https://t.co/xaZPRnaYDD

— Hayley Tsukayama (@htsuka) June 3, 2022

— Hayley Tsukayama, San Francisco

Clearing the Air on Vaping vs. Smoking

I just listened to your piece on the FDA banning Juul (“KHN’s ‘What the Health?’: The FDA Goes After Nicotine,” June 23). One of your panelists mentioned she’d read (actually, she said she’d read only the headline) about diacetyl (she didn’t want to even try to pronounce this) and popcorn lung.

I believe it is irresponsible for so-called scientific experts to comment on things they haven’t read properly and things they clearly have no knowledge about. Diacetyl is present in cigarette smoke in concentrations hundreds of times higher than in vape products and yet there hasn’t been a single case of popcorn lung attributed to smoking. Anything to do with the toxicity of a chemical present must surely make reference to the concentrations, putting it in context. The fact that a chemical is detectable obviously doesn’t mean that it’s harmful in the concentrations present.

There is a terrible misunderstanding among consumers and indeed health care professionals regarding the relative harms of vaping vs. smoking — given that the vast majority of vapers are ex- or current cigarette smokers, this is the relevant point.

I suggest that the scientific credibility of your program is compromised by such sloppy and inaccurate commentary.

— Mark Dickinson, Twickenham, Middlesex, United Kingdom

Be wary when big companies come in to "save" local institutions, whether it be the hometown newspaper, local education or the hospital.https://t.co/gV4ZJDkR71

— Dave Gragg (@DaveGragg) June 15, 2022

— Dave Gragg, Republic, Missouri

Shoring Up Rural Care

Since 2010, 138 rural hospitals have closed, leaving many communities without access to health care. In rural areas, this can create a domino effect of other hardships — a hospital often serves as the largest employer, and when these facilities shut down, the hardware store or restaurants often face similar fates. Put simply, when a rural hospital shutters, it becomes harder for the town itself to survive (“Patients for Profit: Buy and Bust: When Private Equity Comes for Rural Hospitals,” June 15).

Then there is the most critical aspect: Without hospitals, rural Americans lose timely access to lifesaving medical care. On average, the distance between a rural hospital and the closest facility with 100 or more acute care beds is 28.9 miles. Preserving access to care in our rural communities and ensuring hospitals remain the cornerstone of the economy is essential. This is why addressing the hospital closure crisis must be a top priority in Congress.

To determine what needs to be done, it can be helpful to examine the cause of the crisis. Multiple factors have contributed to the high number of rural hospital closures over the past decade, with two major factors being slim or negative hospital operating margins and workforce shortages. The covid-19 pandemic has further strained the health care industry, leading to increased levels of provider burnout and perpetuating the workforce shortage.

On top of this, rural providers continue to feel the strain of Medicare sequestration, which reduces eligible payments to rural hospitals from Medicare by 2%. Relief from Medicare sequestration during the pandemic expired on April 1, contributing to the financial burdens rural hospitals already face. With many rural hospitals already operating on negative margins, these decreased reimbursements could be disastrous.

Further, due to recent statutory changes, provider-based rural health clinics affiliated with small rural hospitals are not eligible for cost-based reimbursement as they historically were. Unless Congress addresses this shortcoming, it may not be financially feasible for small rural hospitals to provide primary care in these settings, and care gaps in rural communities may widen.

Reps. Sam Graves, a Republican from Missouri, and Jared Huffman, a Democrat from California, worked together to introduce the Save America’s Rural Hospital Act. This legislation will help rural health care providers keep their doors open and ensure rural communities have access to the care they need and deserve.

For example, it will permanently eliminate Medicare sequestration for rural hospitals, allowing these facilities to be reimbursed for the entirety of their eligible cost. It will make permanent increased Medicare payments for ground ambulance services in rural and super rural areas. Further, this bill will reauthorize the Medicare Rural Hospital Flexibility Program to provide new grants to help eligible rural providers transition to new models and evolve to meet community needs in their changing health care environments.

To address potential primary care shortages, it will also create a voluntary quality measure reporting program for provider-based rural health clinics. If these facilities choose to participate, they will receive increased reimbursement in exchange.

Health care access is critical to preserving the rural way of life for more than 60 million rural Americans. This legislation must be considered to ensure stability in our communities, which will ultimately benefit the country as a whole.

— Alan Morgan, CEO of NRHA, Kansas City, Missouri

In short, our system is not set up for the unique needs of rural hospitals, making them financially stretched. Private equity swoops in, buys the hospital, takes the COVID-19 relief money, closes the hospital, then runs. #ruralhealth https://t.co/qZBHG7yeeH

— Whitney Zahnd (@WhitneyZahnd) June 15, 2022

— Whitney Zahnd, Iowa City, Iowa

A Pitch for Integrated Behavioral Health

I am a clinical psychologist who works at a large, safety-net academic health center in Colorado. I am writing about your recent article “Patients Seek Mental Health Care From Their Doctor but Find Health Plans Standing in the Way” (June 8). I appreciate the focus of this article on some of the barriers patients face in trying to access mental health care in the U.S. However, I was a little concerned that your article did not mention the rapidly growing field of integrated behavioral health. Although I understand that not all primary care providers’ offices employ an integrated behavioral health clinician, the numbers are growing quickly across the country. For example, in the hospital where I work, there is at least one IBH clinician in every community primary care center, and in most of the specialty clinics (e.g. oncology, OB-GYN) as well.

While I think PCPs are certainly able to dispense basic-level mental health advice (e.g., abdominal breathing exercises for anxiety), I don’t think the answer is to turn over mental health care to medical professionals, any more than I believe it would be a good idea to turn over a patient’s diabetes management to a psychologist, even if that psychologist had some basic training in how to treat diabetes. Instead, I believe it is in patients’ best interests to continue to advocate and nurture a team-based approach that includes both medical and mental health specialists within the same clinic.

— Trina Seefeldt, Denver

This madness must stop. Most of us in primary care do address/treat mental health problems. #insurance #healthcare #SinglePayer would solve this. Patients Seek Mental Health Care From Their Doctor But Find Health Plans Standing in the Way https://t.co/YyAzJ0GylL via @khnews

— Andrea DeSantis DO (@adesantisb) June 10, 2022

— Dr. Andrea DeSantis, Charlotte, North Carolina

In Defense of Free Clinics

I was reading with interest — and then dismay — at your article published June 23 on the Hispanic insurance gap (“Trump’s Legacy Looms Large as Colorado Aims to Close the Hispanic Insurance Gap”). In the opening paragraphs, you reference a man who had symptoms that “free clinics told him were hemorrhoids but were actually colon cancer.”

In that one phrase, you single-handedly and forcefully implied that free clinics deliver poor care and are not to be trusted. With the next sentence about his tragic death, you solidify that implication.

As a charitable clinic with more than 26 years of serving the uninsured in our community, I take great exception to this careless mischaracterization of a sector that has delivered high-quality care to millions of people who have fallen through the cracks.

Most free and charitable clinics care for people with absolutely no insurance. This can significantly limit the amount of outside testing and diagnostics that can be done with patients, even if they are symptomatic. Up until this year, our clinic had absolutely no option for sending someone to a gastroenterologist for a colonoscopy unless they were willing to pay out-of-pocket — upward of $5,000. We have to regularly tell people that we do not have any good options for them because we cannot access certain specialists or tests. Do they need it? Yes. Can we provide it to them? No. Does this incredible inequity and frustration with the health care system that prevents our patients from getting the advanced care they need weigh on us every day? Absolutely.

Free and charitable clinics are not part of the problem. They are part of the solution. And the broad generalization you made impacts how the public perceives this incredibly important piece of the health care sector.

For more information on free and charitable clinics, I invite readers to learn about the National Association of Free and Charitable Clinics at https://nafcclinics.org/.

— Suzanne Hoban, executive director of Family Health Partnership Clinic, Crystal Lake, Illinois

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

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Readers and Tweeters Weigh In on America’s Medical Debt, Obesity Epidemic, and Opioid Battles

KHN 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.

So, you're American, you have a lousy health insurance plan, you get cancer. You survive cancer. But can you survive your massive medical $$$ debt?https://t.co/e6Jzw9W4SR

— Laurie Garrett (@Laurie_Garrett) June 17, 2022

— Laurie Garrett, New York City

Medical Debt as the Ultimate Medical Mystery

I read your investigation about health care and debt on NPR’s site (“Diagnosis: Debt: 100 Million People in America Are Saddled With Health Care Debt,” June 16). However, it seems the story’s focus is wrong. It shouldn’t be about how we pay for these astronomical medical bills but why are they so high to begin with? How do hospitals get away with their fees? For example, my daughter, who is 7, has been to the hospital/emergency room five times in her life. Each bill has been completely different with no rhyme or reason. The latest one was $7,000 for about a three-hour ER visit and for two IVs! It’s the highest bill we have ever seen, and that includes a two-night stay at a hospital. In addition to this bill, collections called us — and it hadn’t even been 60 days since our visit and had been only a few weeks since the hospital visit. So now our credit score could be affected, and we haven’t even had a chance to review or figure out how to pay this bill. Would love all this explained.

— Ilyssa Block, Kansas City, Missouri

A Hard-Learned History Lesson

Although I liked the article by Noam N. Levey and Aneri Pattani on people burdened by medical debt (“Diagnosis: Debt: Upended: How Medical Debt Changed Their Lives,” June 16), it uses the term “grandfathered in.” This term was used as a rule to prevent Black people from voting after the Civil War. Please make an effort to refrain from using this offensive term.

— MB Piccirilli, Portland, Oregon

Upended: How Medical Debt Changed Their Lives https://t.co/IbJwJoOt3N @khnews This has to stop! NFP healthcare systems destroying the lives of the people they are designed to serve?!? Unethical. STOP! #healthcare #UniversalHealthCare #MedicareForAll #bankruptcy

— Andrew Gallan PhD ⛳️🇺🇦 (@agallan) June 20, 2022

— Andrew Gallan, Boca Raton, Florida

Steering Clear of Predatory Billing

Every month I see and hear these “Bill of the Month” stories on NPR’s webpage or broadcast on the NPR affiliate station in my area (“Her First Colonoscopy Cost Her $0. Her Second Cost $2,185. Why?” May 31). Every month I pat myself on the back for having decided that there is no way I am ever going to put myself through so-called screenings, which are just one more avenue for the U.S. health delivery system to screw people over as that health delivery system is well aware that there is no oversight for this type of predatory billing. I can tell you at my age and with only Social Security retirement as sole income, I couldn’t ever hope to hire legal help to dispute a bill like those featured in “Bill of the Month” — a bill like that would either cause me to have an immediate heart attack or file bankruptcy or both. Nope. No screenings. I actually have decided that, if I have any choice in the matter, I will simply forgo any so-called medical care. Obviously, if I keel over and pass out and someone hauls my sorry self into the emergency room, I won’t have the choice (except to walk out once “revived”). Given the state of health care and the predatory behaviors of the bottom-lining money-hungry hospitals, clinics, and even just doctors, my choice is simply to opt out. KHN needs to use its voice to tell the U.S. medical community that people are so tired of the garbage that they simply refuse care.

— Jan Baldwin, Coburg, Oregon

First colonoscopy: $0Second colonoscopy: $2kAnother example of how the fine print can put patients on the hook for bills that should be covered, especially in this case of a preventative screening. Patients deserve better.https://t.co/v55XVdGAeB

— Terry Wilcox (@Terrilox) June 2, 2022

— Terry Wilcox, Vienna, Virginia

In Michelle Andrews’ story about unexpected costs after a polyp removal during a colonoscopy, she states the anesthesiologist “merely administers a sedative.” This is an understatement. Anesthesiologists perform a review of the patient’s chart, see the patient pre-procedure, monitor their vitals during the procedure, and assess them post-procedurally. Furthermore, anesthesiologists are prepared to manage unexpected emergencies, including unexpected aspiration, allergic reactions, cardiac arrest, etc. This is more than “merely administering a sedative.”

We keep folks from dying or having complications and train a long time to do so. The flippant manner in which our actions are framed in the article is unfortunate.

— Dr. Elizabeth Leweling, Chicago

Preventive care, like screening colonoscopies, are free of charge to patients under the Affordable Care Act. @DrLindaMD @AlexMMTri @EvanKirstel @FriedbergEric @nkagetsu @rstraxMDhttps://t.co/qLP9l5SSPl

— Ian Weissman, DO (@DrIanWeissman) June 1, 2022

— Dr. Ian Weissman, Milwaukee

As president of the American Society for Gastrointestinal Endoscopy, I listened with interest to a recent segment on “All Things Considered” regarding patient cost sharing for a screening colonoscopy. The segment featured patient Elizabeth Melville, who received a bill for her screening colonoscopy that involved a removal of a polyp.

I was dismayed by the segment, which included several factually incorrect and misleading statements by Dr. Elisabeth Rosenthal, and which were incredibly damaging to efforts to eliminate impediments and misinformation about screening colonoscopy. ASGE has been at the forefront of policy efforts to eliminate patient out-of-pocket costs for screening colonoscopy, including those screenings that involve the removal of a polyp or other tissue. As the segment correctly noted, the Affordable Care Act provides for coverage without patient cost sharing of preventive services that have an “A” or “B” rating from the U.S. Preventive Services Task Force, which includes colorectal cancer screening. Recognizing that colonoscopy is the only cancer screening modality that also allows for actual removal of precancerous lesions in real time (and thus preventing the cancer), it is particularly important that patients and consumers understand the facts.

Following passage of the ACA, legislative and regulatory corrective actions have been necessary to ensure that patients who undergo a screening colonoscopy that includes a polyp removal are not stuck with a surprise bill. As noted, screening colonoscopy is a unique preventive service in that it not only detects cancer, but it can prevent it through removal of suspicious or potentially precancerous polyps or lesions. In 2020, Congress passed legislation that would phase out by 2030 cost sharing for Medicare beneficiaries when a screening colonoscopy turns diagnostic during the screening encounter. That means, if a Medicare beneficiary has a screening colonoscopy today and a polyp is removed, that patient is likely to have an out-of-pocket payment obligation.

The difference in cost-sharing rules for commercially insured patients and Medicare beneficiaries has created confusion for patients, and the changes in regulation have created complex billing scenarios. Dr. Rosenthal referred to billing for colonoscopy as a “gray area.” This is not a gray area to ASGE, as coding rules are clear. But there are scenarios that could impact whether a patient has an out-of-pocket obligation for a colonoscopy. For example, often insurers will not cover a screening colonoscopy without cost sharing if the screening occurs less than 10 years after the patient’s previous colonoscopy. These shorter screening intervals typically occur when a patient is considered high-risk, or if there was a finding during the previous colonoscopy, such as a polyp, as used in your illustration. Many insurers regard these colonoscopies as “surveillance” or “high-risk” colonoscopies and will not cover them as a preventive screening without cost sharing. This is not the decision of the physician or hospital; this is a decision made by the insurance company.

I was particularly struck by Dr. Rosenthal’s comment that “it is not OK to change the game in the middle of the test,” which leads to a patient getting a bill. I want to be very clear that when a patient is scheduled for a screening colonoscopy, the physician performing the colonoscopy has no idea whether a polyp or tissue will be found and will need to be removed. This is not a “gotcha” game that physicians are playing with patients, as insinuated by Dr. Rosenthal’s remarks; there are coding and billing rules that must be followed when facilities and physicians are submitting claims to insurance companies. ASGE continually works to ensure that we educate and promulgate coding rules and updated guidance for our 15,000 members worldwide.

The cost-sharing policy for colorectal cancer screening, and screening colonoscopy specifically, is complex and confusing. We are disappointed that NPR did not use the segment as an opportunity to work through the complexity to provide consumers with a better guide of questions to ask their insurance company before scheduling a colonoscopy, including whether a screening colonoscopy performed at an interval of less than 10 years will be covered under their health plan without cost sharing.

— Dr. Bret T. Petersen, ASGE president, Rochester, Minnesota

Great Bill of the Month reporting today by @mandrews110 for @KHNews. Nobody likes getting a colonoscopy. Patients shouldn't be penalized for doing the right thing and getting recommended cancer screenings: https://t.co/cNlEj85IZ4

— Ryan Holeywell (@RyanHoleywell) May 31, 2022

— Ryan Holeywell, Washington, D.C.

Taking the Doctor’s Advice

Dr. Taison Bell was wonderful to listen to (“Watch: UVA Doctor Talks About the State of the Pandemic and Health Equity,” May 26). I really appreciated his presentation and the valuable things he had to say. Thanks for including it in your KHN mailing!

— Jan McDermott, San Francisco

I spoke with ⁦@hnorms⁩ from ⁦@KHNews⁩ about the state of the pandemic and health equity. There is still a lot to be done to movement smart policies that help high risk communities of color. https://t.co/LAf2WCIN0X

— Dr. Taison Bell (@TaisonBell) May 26, 2022

— Dr. Taison Bell, Charlottesville, Virginia

Mad Over ‘New MADD’ Coverage

This article is grossly inaccurate and insulting (“The New MADD Movement: Parents Rise Up Against Drug Deaths,” May 23). Most fentanyl users are not all-star athletes or honor students. Their parents are not more educated than the parents of addicts. And the parents of addicts have been mobilized for years, with many feeling that the fentanyl movement has distracted attention away from needed health care. The article says that the drugs are being introduced by Mexican cartels that seek vengeance against low-level dealers, many of whom are just friends getting things for one another. The article distinguishes between drug users and fentanyl “victims,” creating and reinforcing the stigma these groups claim to be trying to eliminate. It does a great disservice to those of us who lost children to addiction and overdose, and is insulting to our children and to us as parents. Thank you.

— Susan Elamri, Detroit

Interesting read detailing the lack of accountability for drug dealers selling fentanyl laced counterfeit pills resulting in death/overdoses. Consequences and rehabilitation should not be mutually exclusive solutions, we can do both. https://t.co/KlvBH3O1kq

— Chief Paco Balderrama (@BalderramaPaco) May 23, 2022

— Paco Balderrama, chief of police, Fresno, California

When ‘Overweight’ Is ‘Normal’

Quoting from the article “‘Almost Like Malpractice’: To Shed Bias, Doctors Get Schooled to Look Beyond Obesity” (May 24): “Research has long shown that doctors are less likely to respect patients who are overweight or obese, even as nearly three-quarters of adults in the U.S. now fall into one of those categories.”

Perhaps the answer is to change the scale of weight. Why do 25% of adults get to be called “normal” and 75% of adults are “overweight”? Let’s base the decision on reality-based observation!

— Leslie Rigg, Lake Worth Beach, Florida

1) Anti-fat bias is real and certainly an issue. For physicians and others who treat people with #obesity, the question becomes where to draw the line. 'Almost Like Malpractice': To Shed Bias, Doctors Get Schooled to Look Beyond Obesity https://t.co/ap127widIs via @khnews

— Stewart Lonky, MD (@LonkyMD) May 24, 2022

— Dr. Stewart Lonky, Los Angeles

Innocent Until Proven Otherwise

I wanted to raise a concern about the story “‘Desperate Situation’: States Are Housing High-Needs Foster Kids in Offices and Hotels” (June 1) — and it’s certainly not unique to your story. It says:

“These children already face tremendous challenges, having been given up by their parents voluntarily or removed from their homes due to abuse, neglect, or abandonment.”

Sometimes, of course, that’s true. But no reporter would write that every person in jail is a criminal. Many are awaiting trial and can’t make bail. Similarly, children can be in foster care for weeks, even months before any court ever determines if they have been “abused” or “neglected.” Until then, they are in foster care because their parents have been *accused* of abuse or neglect.

(Also, by the way, neglect laws are so broad and vague that often what the parent really is guilty of is poverty — but that’s another issue.)

— Richard Wexler, executive director of the National Coalition for Child Protection Reform, Alexandria, Virginia

[Editor’s note: Thanks so much for your insight. The article has been updated to reflect that the parents are absent “due to accusations of abuse, neglect, or abandonment.”]

.@sclaudwhithead looks at "hoteling," Georgia's practice that makes high-need foster kids sometimes sleep in hotels or offices. The pandemic made the problem worse, but state lawmakers spent more to try to pay extra for foster parents to take kids. #gapol https://t.co/xRXbKCSVEM

— Jeff Amy (@jeffamy) June 1, 2022

— Jeff Amy, Atlanta

Key to Harm Reduction: Buy-In From People With Addiction

With overdose deaths skyrocketing to never-before-seen levels, the United States needs harm reduction strategies to protect the health and wellness of Americans. In 2020, 41 million Americans needed substance use treatment within the previous year; however, of those who needed such treatment but did not receive it at a specialty facility, a staggering 97.5% did not feel they needed it. Although America has a troubling treatment gap exacerbated by systemic legal and regulatory barriers to evidence-based addiction care, most people who need substance use treatment don’t want this treatment as it is currently being offered.

To support our friends and family members living with addiction, our system must also embrace harm reduction approaches that engage people who use drugs (PWUD) before they are ready for abstinence-based treatment (“As Biden Fights Overdoses, Harm Reduction Groups Face Local Opposition,” June 14).

Harm reduction saves lives. Drug checking services and naloxone distribution prevent overdose deaths, while syringe and related service programs help stop the spread of infectious diseases such as HIV/AIDS and hepatitis. These are all worthy ends in themselves, but harm reduction has the further benefit of building a meaningful alliance between health care professionals and PWUD. With this therapeutic relationship, PWUD have facilitated access to high-quality, evidence-based treatment and services when they become ready for this help. It’s an obvious point, but too many people overlook the fact that a person can’t receive treatment or enter recovery if they’re dead.

As a physician, I swore an oath to do no harm — not to do nothing. Failing to embrace and expand harm reduction efforts, by definition, leaves too many of our friends, family members, and loved ones at an unacceptable risk of dying. The dichotomy between offering more addiction treatment and providing PWUD with the tools they need to live healthier lives is a false choice. The United States must simultaneously invest in treatment expansion and increase the availability of low-threshold harm reduction services; otherwise, I fear the country’s addiction and drug overdose crisis will continue to get worse.

— Dr. Brian Hurley, president-elect of the American Society of Addiction Medicine’s Board of Directors, Los Angeles

. @POTUS wants to expand #harmreduction programs as part of strategy to reduce #drug #overdose deaths, but idea faces complicated reality on the ground as programs operate on fringes of legality, w/ scant budgets, & fierce opposition. @renurayasam @khnews https://t.co/qbSBtMkn38 pic.twitter.com/pYV8mB1nEc

— Deni Carise (@DeniCarise) June 21, 2022

— Deni Carise, Philadelphia

How to Beat the Opioid Epidemic

Do you want to control the scourge of fentanyl in America (“The Blackfeet Nation’s Plight Underscores the Fentanyl Crisis on Reservations,” May 25)? There are two options:

1. Distribute the drug solely by the government, ensuring its purity, proper dosage, and safe setting for the user, providing real-time overdose care and optional consulting for anyone who wants to quit, all for free.

2. Make some nonaddictive antidepressants (generally SSRIs, or selective serotonin reuptake inhibitors) less restrictive. You know, how health care in your country is expensive, visiting a psychiatrist or psychologist, refilling, blah-blah. I know, the nation who can’t agree on banning AR-15s from being sold to 18-year-olds won’t agree on this.

What if you let people have some SSRIs over the counter? These are not recreational, are generally safe (way safer than opioids), and do help with anxiety. Hey, what drives people to opioids? Aren’t anxiety levels at their highest all across the globe?

Also, the drugmaker mafia will support it.

Just as we have embraced over-the-counter drugs for widespread diseases like colds, we might adopt the same concept in mental health care as well. Anxiety is becoming more widespread compared with colds (my gut says).

— Alireza Mohamadi, Tehran, Iran

Fentanyl spreads west, including to the Blackfeet Nation.https://t.co/ZrykuZQ06c

— Keith Humphreys (@KeithNHumphreys) May 25, 2022

— Keith Humphreys, Stanford, California

Dust-Up Over Pollution Coverage

This article appears written from a lopsided viewpoint (“Some People in This Montana Mining Town Worry About the Dust Next Door,” June 8).

Very few cities pass the World Health Organization’s unrealistic threshold of 5 micrograms per cubic meter, and why would you get a mechanical engineer to provide input on environmental issues? Why, because the real environmental specialist said this was not an issue? As for dust on a picnic table, that is a horrible example. We get dust on our picnic table anytime the wind blows, and we don’t live by a mine. Maybe WHO should recommend that the wind stop blowing because it causes dust.

From the WHO’s website: “In 2019, 99% of the world population was living in places where the WHO air quality guidelines levels were not met.” This is not a reasonable standard and was selected by bureaucrats that are out of touch with life and the real world. All of the real information and statistics say there is not a problem, but your article makes a problem where one does not exist and people who are not willing to fact-check you will think there is a problem. All these people with health issues are unfortunate and that’s very sad, but people everywhere have sad health issues. Stick to the scientific facts and real monitoring numbers, and don’t drag “The Sky Is Falling” people into news articles. Facts matter!

— John Utaz, Salt Lake City

Cultivating an interest in ‘dusts’ at the moment and this article includes extractive industries/ mining. https://t.co/JsXCA7rxkD

— Cat Rushmore (@CatRushmore) June 9, 2022

— Cat Rushmore, Glasgow, Scotland

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

‘An American Tragedy’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Monkey and the Monkey Bucks

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Among the takeaways from this week’s episode:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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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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

To hear all our podcasts, click here.

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

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

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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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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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