Opioid epidemic - Political Support and Corruption

By pjain      Published June 10, 2020, 6:30 p.m. in blog Health   

Lessons and Timeline of Opioid epidemic in the United States and the World

What is the Problem?

MANY Different Drugs - illegal, prescribed, synthetic/chemical

Opioids are a diverse class of moderately strong, addictive, and inexpensive drugs.

  • Illegal Drug Trade - addict then dependency
  • heroin

  • Prescribed Pain-killers

  • morphine
  • oxycodone (OxyContin, Percocet)
  • hydrocodone (Vicodin, Norco).

  • Ultra-potent synthetic/chemical

  • fentanyl

Growth Industry : Prescriptions per 100 ZOOMed in "Red States" and Rural "Markets" the most

Overdoses, fueled by opioids, are the leading cause of death for Americans under 50 years old — killing roughly 64,000 people last year, more than guns or car accidents, and doing so at a pace faster than the H.I.V. epidemic did at its peak.

State|Deaths| Scripts USA | 14.6| ------|------|---------- WVa|52 | Delaware| 44 Maryland|37 PA | 36 Ohio| 36 NH | 36 Kentucky|31 Connecticut|31 RI| 30 Tennessee|28 Missouri|28 NM|27 VT|27 IN|26 LA|26 AZ|24 FL|23 SC|23 NC|22 ------|------|---------- NJ | 33 MA | 33 Maine|28 WA|15 CA | 13 | OR | 12 MI | 27

  • Data for 2018, Deaths/100k, Scripts per 100 people

Rural towns target markets

Lesson: Only prescribe for Acute NOT Chronic Pain - Long Term Use is highly Addictive

Traditionally, opioids have been prescribed for pain management, as they are effective for treating acute pain but are less effective for treating chronic pain.

Clinical guidelines advise that opioids should only be used for chronic pain if safer alternatives are not feasible, as their risks often outweigh their benefits.

Republicans delayed/blocked marijuana legalization while allowing pharmas to oversell Opioid prescriptions

Deaths from Prescribed and Synthetic opioids far exceed drug war

Lifespan impact

Pharmas Made money from pushing Opioids now Profiting from Antidotes

Politics and Lobbying

Clintons lost Health Care Babu plan

In 1993, the Clintons launched their plan to nationalize the health care system. They treated major medical providers, and especially drugmakers, as enemies. Unsurprisingly, those attacked fought back, working closely with the GOP. On substance, the bureaucratic nightmare of a plan deserved to fail. More practically, by creating powerful enemies, the Clinton administration helped ensure its program’s failure.

George W Bush policies let it happen

George W. Bush and the Republican Congress approved the budget‐​busting Medicare drug benefit—while making no effort to pay for it — they prohibited the Department of Health and Human Services from using its leverage to force down pharmaceutical prices.

Ostensibly this was backing a "market system" where drug research depends on private profits, price controls inevitably cut investment in new medicines.

The reality is US prices average 2-3x what Canada and Europe pays for same drugs. Why is US bearing the brunt of the "R&D".

2006 Feds opioid warning was nipped in the bud possibly by Bush's Leavitt and Alex Azar (now Trump's HHS)

A respected scientist Nora Volkow Director of NIDA National Institute on Drug Abuse and Elias Zerhouni director of the National Institutes of Health flagged “disturbing” data showing a dramatic uptick in opioid addiction and requested urgent action. Volkow’s memo to Carmona, however, included a number of statistics pulled from federal data showing signs of the emerging crisis, specifically noting an uptick in abuses of OxyContin, Vicodin and other prescription drugs among high schoolers with 1 out of 10 high school students will have abused Vicodin before graduating.

The U.S. Surgeon General Richard Carmona took initiative meeting former Health Secretary Mike Leavitt’s office, where President Donald Trump’s current Health and Human Services Secretary Alex Azar served as deputy at the time, as well as George W. Bush’s White House Domestic Policy Council. Both Leavitt and Azar had no comment on what happened.

However NOTHING happened, and Carmona term was ended and a new acting surgeon general took over who took no action.

The effort didn’t lead to any real action, and the toll of death and addiction climbed. This missed opportunity has lead to more than 133,000 people have died from prescription opioids since then — and hundreds of thousands more from street drugs including heroin and illicit fentanyl.

Revolving Doors Alex Azar a Pharma Lobbyist/Lawyer runs HHS, Bungled Covid-19 response

Significantly Alex Azar is a former pharmaceutical industry lobbyist and executive. Azar served as General Counsel of the United States Department of Health and Human Services (HHS) from 2001 to 2005. On July 22, 2005, he was confirmed as the Deputy Secretary of Health and Human Services; he served in that capacity until his January 2007 resignation.

  • From 2012 to 2017, Azar was President of the U.S. division of Eli Lilly and Company, a major drug company,
  • While he was at Eli Lilly, the company more than tripled the price of its Humalog best-selling insulin in US even as it was off-patent, but global prices remained low. These “Big 3” insulin makers control over 90 percent of the global market and maintain their lock on it in many ways. One is “pay-for-delay schemes,” like when Sanofi paid Eli Lilly to delay the launch of an insulin similar to its Lantus brand. Another is to sue potential competitors for intellectual property infringement, such as when Merck attempted to enter the insulin market in 2016.
  • Under Azar, Lilly spent millions lobbying Congress, the Department of Health and Human Services, spending $5.7 million in 2016 alone. The company has deep ties to the Trump administration. Vice President Mike Pence also knows Azar well from his time as governor of Indiana, where Eli Lilly is headquartered.

  • Azar was a member of the board of directors of the Biotechnology Innovation Organization, a large pharmaceutical trade association which has kept drug prices and opposed following means to reduce costs (and pharma profits)

  • Opposed allow Medicare to negotiate drug prices.
  • Oppose letting private citizens buy their drugs abroad.
  • Opposed transparency on the dealings between drug companies, pharmacies, PBMs, as the State of Nevada did this year with SB539, a bill with bipartisan support.

Now since 2017 is on the current Trump cabinet as the United States Secretary of Health and Human Services. Also seen as mismanaging the White House Coronavirus Task Force from January 2020 to February 2020, when he was replaced by Vice President Mike Pence.

Obama allied with Pharma to back Obamacare - did little to fight Opioid Crisis

President Obama learned from the Clintons’ failure. His administration made a deal with all of the major industry players. The American Medical Association, American Hospital Association, and American Insurance Association all backed the Obama proposal. The reason was simple: by forcing Americans (while providing taxpayer subsidies) to purchase more policies, Uncle Sam would in turn hike demand for physician and hospital services. Increased regulation would be costly, but still would yield increased profits.

PhRMA and the administration made a complex deal, which included industry contributions, estimated at $80 billion (mostly narrow Medicaid and Medicare discounts). But overall the pharmaceutical industry did well.

Obama vastly expanded the market and promised no Medicare negotiation (“noninterference”), no reimportation of lower‐​priced drugs from other nations, no Medicare Part D rebates, and no change in Medicare Part B.

Nothing in the deal that was a structural reform of the industry. They were first in line; they were on the winning side; they got a good deal that they could live with and they stuck to it.”

Obama slept while Opioids available on Black market

Drug firms heavily donated to house reps like Mr. Tom Marino of Pennsylvania who pushed the 2016 "Ensuring Patient Access and Effective Drug Enforcement Act." The Washington Post and “60 Minutes” revealed how the drug industry had worked behind the scenes with Mr. Marino on the law, helping to draft its language, hiring former D.E.A. lawyers as consultants and showering $1.5 million in donations to Congress. A former top D.E.A. enforcement official, Joseph T. Rannazzisi, said, “I just don’t understand why Congress would pass a bill that strips us of our authority in the height of an opioid epidemic in places like Congressman Marino’s district.” This law has been criticized for easing black market access even as other laws restricted and capped doctors ability to prescribe opioids liberally.

The law weakened the D.E.A.’s power to stop prescription opioids from being shipped to rogue doctors and pharmacies suspected of corruptly distributing them.

Due to crisis awareness, many people who became addicted to prescription pills have turned to other illegal drugs like heroin (or fentalyl laced versions) since the authorities began tightening access to legal opioids.

Trump - became too big to ignore, Focus on Fentanyl from China

Trump is no fan of the pill pushers, who, he complained, were “getting away with murder.” He campaigned against drug producers and criticized high drug prices. And has promised to bring them down.

However no real legislation or reforms materialized in 3+ years. Maybe it was scare tactics to boost election payouts from Pharmas who are largest political donors above all other industries.

--- TOC Fentanyl Trade - China's Curse on the World

Wuhan epicenter of Chinese Fentanyl Export Industry

Wuhan is a sprawling industrial city built along the Yangtze River in east-central China is known for its production of chemicals and vendors there ship huge quantities around the world.

Now Wuhan is the epicenter for the ingredients needed to cook fentanyl and other powerful synthetic opioids. Their biggest customers are now the Mexican drug cartels, which have embraced fentanyl in recent years because it is cheaper and easier to produce than heroin.

Mexican production of fentanyl and methamphetamine are made with precursor chemicals that are typically sent on planes or cargo ships from China, where despite U.S. pressure to ban them, they continue to be sold legally.

  • Covid-19 has disrupted the fentanyl supply chain, cut profits of Mexican traffickers and driven up street drug prices across the United States. The narcotics trade, which relies on the constant movement of goods and people, has been stymied by lockdowns, travel bans and other efforts to contain the virus, according to government officials, academic researchers and drug traffickers. The state program seeks to broaden access to MAT by launching or enhancing treatment programs at ERs, hospitals, primary care clinics, residential treatment programs, county mental health centers, jails and drug courts. Training more doctors to provide MAT is also a pillar of the campaign. In February, 2020 after a major manufacturer of the chemicals closed, vendors began posting apologies on the online sites where chemicals are typically sold, said Louise Shelley, a professor at George Mason University who tracks global fentanyl production.

Colombia cartels cutting cocaine/heroin with super-addictive Fentanyl

Addicts Dash for Trash

From a dealer’s perspective, fentanyl is easier to get and more profitable to sell.

Perversely, some law enforcement officials argue that drug users will seek out batches of drugs that contain fentanyl or that are known to have killed people, as that demonstrates the drugs’ potency.

More realistically, the "quality of the high" (rather deeper agony of withdrawal) is probably far more, so they go back to dealers that spike drugs with it.

Casual drug users are far higher risk of fentanyl poisoning, particularly with increased reports of fentanyl-adulterated cocaine.

TOC Policies to Target Opioid Crisis

Stop overprescribing

Opioids are too easy to prescribe, many states still don't have ways to prevent multiple prescriptions per patients, prescriptions easy to fill, and most people find their health insurance readily covers the costs. Nearly 250m prescriptions for opioids were written in the US in 2015 - far more, per capita, than in other countries. As a result, it is estimated that opioids have become a $10bn industry in the US. However the secondary addiction and overdose industry is far larger - ironically it creates a huge business for corporate hospitals.

Regulators and insurers can take a lead, "an ankle sprain or dental procedure does not call for a prescription of 30 or 60 powerful pain pills".

Stop unnecessary deaths by Naloxone and reducing prices

Overdoses don't have to be fatal. A drug called Naloxone blocks the effects of opioids on the brain and - when administered promptly, by injection or nasal spray - can save lives. It is also available as an auto-injector - an easy to use device a like an EpiPen - which allows people without medical training to inject people who have overdosed.

While Naloxone remains a prescription drug throughout the US, the Food and Drug Administration is exploring ways to make it more readily available eg an over-the-counter version, which could be bought without a prescription.

In 42 states, nurses and bystanders found with illegal drugs now have immunity from prosecution if they call for help, or administer Naloxone to someone who has overdosed. Forty states now allow pharmacists to prescribe Naloxone, or a doctor to issue standing orders rather than individual prescriptions, so that it is easier to obtain. A growing number of first responders, including police and fire departments, now stock Naloxone routinely.

Recent price increases make it more challenging, as the price of the auto-injector formulation jumped from $690 in 2014 to $4,500 in 2016.

Decriminalizing Opioid Addictions - treat as health issue, allow public housing

Addiction is a chronic medical condition, but it is often viewed as a moral failing and crime - a factor which can limit access to treatment.

State and federal prisons hold almost 300,000 people convicted for violating drug laws, with some states far more likely to imprison drug offenders than others.

However, nearly all housing authorities "institute more stringent bans than required by federal law", a study by the US Department of Housing and Urban Development found. So, drug users are usually not allowed to live in already hard-to-get-into public housing which, in turn, makes their lives less stable and access to support like social services less likely.

A more productive approach would be for the justice system to push for a commitment to undergo treatment can be enforced at the time of sentencing and access to such support made available in all prisons.

Openness and Data Driven - who is prescribing, Supplying, Using Opioids

Better use of data could help tackle inappropriate prescribing and the diversion of legal opioids into the black market.

Weak monitoring has enabled doctors and patients to flood the market with prescription opioids.

Employers, insurers, and pharmacies all have data that could help build a picture of who is prescribing and using the drugs.

However, that information is all too often held in silos and legal barriers often prevent sharing of data.

TOC Treating Opioid Addictions

Medication-assisted treatment MAT is effective but only 5-10% get it!

There is strong evidence that medication combined with therapy can reduce opioid addiction. Drugs such as methadone, buprenorphine, and naltrexone can all be used to treat people addicted to opioids.

But only one in four people with an opioid problem is actually treated for it, according to the National Survey on Drug Use and Health.

  • For example, ER doctors put patients on buprenorphine, one of three drugs approved by the Food and Drug Administration for medication-assisted treatment (MAT) of people with opioid dependency. It often gives immediate benefits to patients on MAT. These are limited to a few but growing number of health care institutions across California that offer medication-assisted treatment with funding and support from the state’s MAT Expansion Project, which started in 2018 and is financed by $265 million in federal grants. Even in Feb 2020 at the height of Covid-19, California’s Department of Health Care Services, which administers the project, touted its success, reporting that it has provided care for 22,000 previously untreated Californians with opioid addictions and created 650 new locations where patients can receive MAT.

    My withdrawals are gone .. I can live my life again

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

But the number of new people brought into treatment is only a small fraction of those who need it - perhaps reaching only 5% at best. In 2019, more than half a million Californians with an opioid use disorder lacked access to treatment.

  1. Obstacles to MAT is the stigma of addiction,
  2. Federal regulations depress the number of MAT providers,
  3. Hostility in some corners of the treatment community to the very notion of using drugs to combat drug addiction. Possibly there is an economic basis in loss of health care dollars due to extreme effectiveness of MAT vs ER-treatment of overdose which can net tens of thousands of profit. Perhaps some doctors also have guilt at earlier prescribing drugs liberally.
  4. Abusive "rehab" industry that has become a magnet in recent years for unscrupulous operators who aggressively recruit clients, eyes fixed on the dollar signs rather than on evidence-based treatments such as MAT.
  5. Traditional 12-step programs of sobriety that require participants to be free of drugs — including MAT drugs. MAT and patients can have difficulty finding housing and recovery therapy, which are integral to their treatment. This is a dilemma - get effective therapy or be shunned and even homeless.
  6. Since average doctors don't prescribe MAT, if you were looking for somebody to dispense buprenorphine and you called people on that list, you would have come up with one doctor who ran a cash-only, no-insurance practice, and he was very expensive.

Whole person therapy

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


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