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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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The New MADD Movement: Parents Rise Up Against Drug Deaths

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Work as Treatment

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

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

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

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

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

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

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

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

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

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

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

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

Diverging Work Experiences

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

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

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

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

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

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

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

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

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

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

That’s when Osborne said he decided to leave.

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

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

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

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

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

Medication Hesitancy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

USE OUR CONTENT

This story can be republished for free (details).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

USE OUR CONTENT

This story can be republished for free (details).

Calls to Overhaul Methadone Distribution Intensify, but Clinics Resist

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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This story can be republished for free (details).

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

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

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

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

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

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

Among the takeaways from this week’s episode:

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

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

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

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

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

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

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

To hear all our podcasts, click here.

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

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

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

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

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

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

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

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

Among the takeaways from this week’s episode:

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

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

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

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

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

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

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

To hear all our podcasts, click here.

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

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

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

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

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

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

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

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

Among the takeaways from this week’s episode:

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

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

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

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

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

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

To hear all our podcasts, click here.

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

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

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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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Other opioids are just not available.

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

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

“It’s a marathon from hell,” he said.

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

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

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

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

He’s still living on the streets.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Police resumed arrests at the beginning of May.

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

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

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

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

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

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

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

They Fell In Love Helping Drug Users. But Fear Kept Him From Helping Himself.

Sarah and Andy fell in love while working to keep drug users from overdosing. But when his own addiction reemerged, Andy’s fear of returning to prison kept him from the best treatment.

She was in medical school. He was just out of prison.

Sarah Ziegenhorn and Andy Beeler’s romance grew out of a shared passion to do more about the country’s drug overdose crisis.

Ziegenhorn moved back to her home state of Iowa when she was 26. She had been working in Washington, D.C., where she also volunteered at a needle exchange — where drug users can get clean needles. She was ambitious and driven to help those in her community who were overdosing and dying, including people she had grown up with.

“Many people were just missing because they were dead,” said Ziegenhorn, now 31. “I couldn’t believe more wasn’t being done.”

She started doing addiction advocacy in Iowa City while in medical school — lobbying local officials and others to support drug users with social services.

Beeler had the same conviction, born from his personal experience.

“He had been a drug user for about half of his life — primarily a longtime opiate user,” Ziegenhorn said.

Beeler spent years in and out of the criminal justice system for a variety of drug-related crimes, such as burglary and possession. In early 2018, he was released from prison. He was on parole and looking for ways to help drug users in his hometown.

He found his way to advocacy work and, through that work, found Ziegenhorn. Soon they were dating.

“He was just this really sweet, no-nonsense person who was committed to justice and equity,” she said. “Even though he was suffering in many ways, he had a very calming presence.”

People close to Beeler describe him as a “blue-collar guy” who liked motorcycles and home carpentry, someone who was gentle and endlessly curious. Those qualities could sometimes hide his struggle with anxiety and depression. Over the next year, Beeler’s other struggle, with opioid addiction, would flicker around the edges of their life together.

Eventually, it killed him.

People on parole and under supervision of the corrections system can face barriers to receiving appropriate treatment for opioid addiction. Ziegenhorn said she believes Beeler’s death is linked to the many obstacles to medical care he experienced while on parole.

About 4.5 million people are on parole or probation in the U.S., and research shows that those under community supervision are much more likely to have a history of substance use disorder than the general population. Yet rules and practices guiding these agencies can preclude parolees and people on probation from getting evidence-based treatment for their addiction.

A Shared Passion For Reducing Harm

From their first meeting, Ziegenhorn said, she and Beeler were in sync, partners and passionate about their work in harm reduction — public health strategies designed to reduce risky behaviors that can hurt health.

After she moved to Iowa, Ziegenhorn founded a small nonprofit called the Iowa Harm Reduction Coalition. The group distributes the opioid-overdose reversal drug naloxone and other free supplies to drug users, with the goal of keeping them safe from illness and overdose. The group also works to reduce the stigma that can dehumanize and isolate drug users. Beeler served as the group’s coordinator of harm reduction services.

“In Iowa, there was a feeling that this kind of work was really radical,” Ziegenhorn said. “Andy was just so excited to find out someone was doing it.”

Meanwhile, Ziegenhorn was busy with medical school. Beeler helped her study. She recalled how they used to take her practice tests together.

“Andy had a really sophisticated knowledge of science and medicine,” she said. “Most of the time he’d been in prison and jails, he’d spent his time reading and learning.”

Beeler was trying to stay away from opioids, but Ziegenhorn said he still used heroin sometimes. Twice she was there to save his life when he overdosed. During one episode, a bystander called the police, which led to his parole officer finding out.

“That was really a period of a lot of terror for him,” Ziegenhorn said.

Beeler was constantly afraid the next slip — another overdose or a failed drug test — would send him back to prison.

An Injury, A Search For Relief

A year into their relationship, a series of events suddenly brought Beeler’s history of opioid use into painful focus.

It began with a fall on the winter ice. Beeler dislocated his shoulder — the same one he’d had surgery on as a teenager.

“At the emergency room, they put his shoulder back into place for him,” Ziegenhorn said. “The next day it came out again.”

She said doctors wouldn’t prescribe him prescription opioids for the pain because Beeler had a history of illegal drug use. His shoulder would dislocate often, sometimes more than once a day.

“He was living with this daily, really severe constant pain — he started using heroin very regularly,” Ziegenhorn said.

Beeler knew what precautions to take when using opioids: Keep naloxone on hand, test the drugs first and never use alone. Still, his use was escalating quickly.

A Painful Dilemma 

The couple discussed the future and their hope of having a baby together, and eventually Ziegenhorn and Beeler agreed: He had to stop using heroin.

They thought his best chance was to start on a Food and Drug Administration-approved medication for opioid addiction, such as methadone or buprenorphine. Methadone is an opioid, and buprenorphine engages many of the same opioid receptors in the brain; both drugs can curb opioid cravings and stabilize patients. Studies show daily maintenance therapy with such treatment reduces the risks of overdose and improves health outcomes.

But Beeler was on parole, and his parole officer drug-tested him for opioids and buprenorphine specifically. Beeler worried that if a test came back positive, the officer might see that as a signal that Beeler had been using drugs illegally.

Ziegenhorn said Beeler felt trapped: “He could go back to prison or continue trying to obtain opioids off the street and slowly detox himself.”

He worried that a failed drug test — even if it was for a medication to treat his addiction — would land him in prison. Beeler decided against the medication.

A few days later, Ziegenhorn woke up early for school. Beeler had worked late and fallen asleep in the living room. Ziegenhorn gave him a kiss and headed out the door. Later that day, she texted him. No reply.

She started to worry and asked a friend to check on him. Not long afterward, Beeler was found dead, slumped in his chair at his desk. He’d overdosed.

“He was my partner in thought, and in life and in love,” Ziegenhorn said.

It’s hard for her not to rewind what happened that day and wonder how it could have been different. But mostly she’s angry that he didn’t have better choices.

“Andy died because he was too afraid to get treatment,” she said.

Beeler was services coordinator for the Iowa Harm Reduction Coalition, a group that works to help keep drug users safe. A tribute in Iowa City after his death began, “He died of an overdose, but he’ll be remembered for helping others avoid a similar fate.”(Courtesy of Sarah Ziegenhorn)

How Does Parole Handle Relapse? It Depends

It’s not clear that Beeler would have gone back to prison for admitting he’d relapsed and was taking treatment. His parole officer did not agree to an interview.

But Ken Kolthoff, who oversees the parole program that supervised Beeler in Iowa’s First Judicial District Department of Correctional Services, said generally he and his colleagues would not punish someone who sought out treatment because of a relapse.

“We would see that that would be an example of somebody actually taking an active role in their treatment and getting the help they needed,” said Kolthoff.

The department doesn’t have rules prohibiting any form of medication for opioid addiction, he said, as long as it’s prescribed by a doctor.

“We have people relapse every single day under our supervision. And are they being sent to prison? No. Are they being sent to jail? No,” Kolthoff said.

But Dr. Andrea Weber, an addiction psychiatrist with the University of Iowa, said Beeler’s reluctance to start treatment is not unusual.

“I think a majority of my patients would tell me they wouldn’t necessarily trust going to their [parole officer],” said Weber, assistant director of addiction medicine at the University of Iowa’s Carver College of Medicine. “The punishment is so high. The consequences can be so great.”

Weber finds probation and parole officers have “inconsistent” attitudes toward her patients who are on medication-assisted treatment.

“Treatment providers, especially in our area, are still very much ingrained in an abstinence-only, 12-step mentality, which traditionally has meant no medications,” Weber said. “That perception then invades the entire system.”

Attitudes And Policies Vary Widely

Experts say it’s difficult to draw any comprehensive picture about the availability of medication for opioid addiction in the parole and probation system. The limited amount of research suggests that medication-assisted treatment is significantly underused.

“It’s hard to quantify because there are such a large number of individuals under community supervision in different jurisdictions,” said Michael Gordon, a senior research scientist at the Friends Research Institute, based in Baltimore.

A national survey published in 2013 found that about half of drug courts did not allow methadone or other evidence-based medications used to treat opioid use disorder.

A more recent study of probation and parole agencies in Illinois reported that about a third had regulations preventing the use of medications for opioid use disorder. Researchers found the most common barrier for those on probation or parole “was lack of experience by medical personnel.”

Faye Taxman, a criminology professor at George Mason University, said decisions about how to handle a client’s treatment often boil down to the individual officer’s judgment.

“We have a long way to go,” she said. “Given that these agencies don’t typically have access to medical care for clients, they are often fumbling in terms of trying to think of the best policies and practices.”

Increasingly, there is a push to make opioid addiction treatment available within prisons and jails. In 2016, the Rhode Island Department of Corrections started allowing all three FDA-approved medications for opioid addiction. That led to a dramatic decrease in fatal opioid overdoses among those who had been recently incarcerated.

Massachusetts has taken similar steps. Such efforts have only indirectly affected parole and probation.

“When you are incarcerated in prison or jail, the institution has a constitutional responsibility to provide medical services,” Taxman said. “In community corrections, that same standard does not exist.”

Taxman said agencies may be reluctant to offer these medications because it’s one more thing to monitor. Those under supervision are often left to figure out on their own what’s allowed.

“They don’t want to raise too many issues because their freedom and liberties are attached to the response,” she said.

Richard Hahn, a researcher at New York University’s Marron Institute of Urban Management who consults on crime and drug policy, said some agencies are shifting their approach.

“There is a lot of pressure on probation and parole agencies not to violate people just on a dirty urine or for an overdose” said Hahn, who is executive director of the institute’s Crime & Justice Program.

The federal government’s Substance Abuse and Mental Health Services Administration calls medication-assisted treatment the “gold standard” for treating opioid addiction when used alongside “other psychosocial support.”

Addiction is considered a disability under the Americans with Disabilities Act, said Sally Friedman, vice president of legal advocacy for the Legal Action Center, a nonprofit law firm based in New York City.

She said disability protections extend to the millions of people on parole or probation. But people under community supervision, Friedman said, often don’t have an attorney who can use this legal argument to advocate for them when they need treatment.

“Prohibiting people with that disability from taking medication that can keep them alive and well violates the ADA,” she said.

This story is part of a partnership between NPR and Kaiser Health News.

Listen: Missouri Efforts Show How Hard It Is To Treat Pain Without Opioids

KHN Midwest correspondent Lauren Weber was interviewed by KBIA’s Sebastián Martínez Valdivia to discuss the challenges Missouri faces in managing patients’ pain amid the opioid epidemic.

KHN Midwest correspondent Lauren Weber speaks with KBIA’s Sebastián Martínez Valdivia about the challenges Missouri faces in trying to treat chronic pain without opioids. Weber had reported that only about 500 of Missouri’s roughly 330,000 adult Medicaid beneficiaries used a new, alternative pain management plan to stem opioid overprescribing in the program’s first nine months. Meanwhile, 109,610 Missouri Medicaid patients received opioid prescriptions last year.

You can listen to the conversation on the KBIA website.

No Quick Fix: Missouri Finds Managing Pain Without Opioids Isn’t Fast Or Easy

In the first nine months of an alternative pain management program in Missouri, only a small fraction of the state’s Medicaid recipients have accessed the chiropractic care, acupuncture, physical therapy and cognitive-behavioral therapy meant to combat the overprescription of opioids.

ST. LOUIS — Missouri began offering chiropractic care, acupuncture, physical therapy and cognitive-behavioral therapy for Medicaid patients in April, the latest state to try an alternative to opioids for those battling chronic pain.

Yet only about 500 of the state’s roughly 330,000 adult Medicaid users accessed the program through December, at a cost of $190,000, according to Josh Moore, the Missouri Medicaid pharmacy director. While the numbers may reflect an undercount because of lags in submitting claims, the jointly funded federal-state program known in the state as MO HealthNet is hitting just a fraction of possible patients so far.

Meanwhile, according to the state, opioids were still being doled out: 109,610 Missouri Medicaid patients of all age groups received opioid prescriptions last year.

The going has been slow, health experts said, because of a slew of barriers. Such treatments are more time-consuming and involved than simply getting a prescription. A limited number of providers offer alternative treatment options, especially to Medicaid patients. And perhaps the biggest problem? These therapies don’t seem to work for everyone.

The slow rollout highlights the overall challenges in implementing programs aimed at righting the ship on opioid abuse in Missouri — and nationwide. To be sure, from 2012 to 2019, the number of Missouri Medicaid patients prescribed opioid drugs fell by more than a third — and the quantity of opioids dispensed by Medicaid dropped by more than half.

Still, opioid overdoses killed an estimated 1,132 Missourians in 2018 and 46,802 Americans nationally, according to the latest data available. Progress to change that can be frustratingly slow.

“The opioids crisis we got into wasn’t born in a year,” Moore said. “To expect we’d get perfect results after a year would be incredibly optimistic.”

Despite limited data on the efficacy of alternative pain management plans, such efforts have become more accepted, especially following a summer report of pain management best practices from the U.S. Department of Health and Human Services. States such as Ohio and Oregon see them as one part of a menu of options aimed at curbing the opioid crisis.

St. Louis chiropractor Ross Mattox, an assistant professor at chiropractic school Logan University, sees both uninsured patients and those on Medicaid at the CareSTL clinic. He cheered Missouri’s decision to expand access, despite how long it took to get here.

“One of the most common things I heard from providers,” he said, “is ‘I want to send my patient to a chiropractor, but they don’t have the insurance. I don’t want to prescribe an opioid — I’d rather go a more conservative route — but that’s the only option I have.’”

And that can lead to the same tragic story: Someone gets addicted to opioids, runs out of a prescription and turns to the street before becoming another sad statistic.

“It all starts quite simply with back pain,” Mattox said.

Practical Barriers

While Missouri health care providers now have another tool besides prescribing opioids to patients with Medicaid, the multistep approaches required by alternative treatments create many more hoops than a pharmacy visit.

The physicians who recommend such treatments must support the option, and patients must agree. Then the patient must be able to find a provider who accepts Medicaid, get to the provider’s office even if far away and then undergo multiple, time-consuming therapies.

“After you see the chiropractor’s for one visit, it’s not like you’re cured from using opioids forever — it would take months and months and months,” Moore said.

The effort and cost that go into coordinating a care plan with multiple alternative pain therapies is another barrier.

“Covering a course of cheap opioid pills is different than trying to create a multidisciplinary individualized plan that may or may not work,” said Leo Beletsky, a professor of law and health sciences at Northeastern University in Boston, noting that the scientific evidence of the efficacy of such treatments is mixed.

And then there’s the reimbursement issue for the providers. Corry Meyers, an acupuncturist in suburban St. Louis, does not accept insurance in his practice. But he said other acupuncturists in Missouri debate whether to take advantage of the new Medicaid program, concerned the payment rates to providers will be too low to be worthwhile.

“It runs the gamut, as everyone agrees that these patients need it,” Meyers stressed. But he said many acupuncturists wonder: “Am I going to be able to stay open if I take Medicaid?”

Structural Issues 

While helpful, plans like Missouri’s don’t address the structural problems at the root of the opioid crisis, Beletsky said.

“Opioid overutilization or overprescribing is not just a crisis in and of itself; it’s a symptom of broader structural problems in the U.S. health care system,” he said. “Prescribers reached for opioids in larger and larger numbers not just because they were being fooled into doing so by these pharmaceutical companies, but because they work really well for a broad variety of ailments for which we’re not doing enough in terms of prevention and treatment.”

Fixing some of the core problems leading to opioid dependence — rural health care “deserts” and the impact of manual labor and obesity on chronic pain — requires much more than a treatment alternative, Beletsky said.

And no matter how many alternatives are offered, he said, opioids will remain a crucial medicine for some patients.

Furthermore, while alternative pain management therapies may lessen opioid prescriptions, they do not address exploding methamphetamine addiction or other addiction crises leading to overdoses nationwide — even as a flood of funds pours in from the national and state level to fight these crises.

The Show-Me State’s refusal to expand Medicaid coverage to more people under the Affordable Care Act also hampers overall progress, said Dr. Fred Rottnek, a family and addiction doctor who sits on the St. Louis Regional Health Commission as chair of the Provider Services Advisory Board.

“The problem is we relatively cover so few people in Missouri with Medicaid,” he said. “The denominator is so small that it doesn’t affect the numbers a whole lot.”

But providers like Mattox are happy that such alternative treatments are now an option, even if they’re available only for a limited audience.

He just wishes it had been done sooner.

“A lot of it has to do with politics and the slow gears of government,” he said. “Unfortunately, it’s taken people dying — it’s taken enough of a crisis for people to open their eyes and say, ‘Maybe there’s a better way to do this.’”