Tagged opioids

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! Did you guys get as big a kick out of the #healthpolicyvalentines hashtag as I did? (I feel I’m talking to the right crowd here.) They’re quite delightful, including this timely one from KHN’s own Rachel Bluth: “Not even a PBM could get in the middle of our love.”

On to the news from the week.

Thursday was a somber day for many as the country marked the anniversary of the Parkland, Fla., mass shooting at Marjory Stoneman Douglas High School that left 17 dead.

On the eve of the anniversary, the House Judiciary Committee approved two bills that would expand federal background checks for gun purchases. Although the legislation faces certain demise in the Senate, it is the first congressional action in favor of tightening gun laws in years. In the votes you see echoes of a recent trend: Lawmakers are no longer treating gun control as “the third rail in politics.” The difference is stark if you look at just over 10 years ago when then-candidate Barack Obama was sending out mailers assuring voters he supported the Second Amendment.

Politico: House Democrats Make First Major Move to Tighten Gun Laws

The Associated Press: Parkland Anniversary Highlights Democratic Shift on Guns

There were too many heartbreaking anniversary stories to highlight just one, but a project worth checking out is one from The Trace, a nonprofit news organization that reports on gun violence. In the year since Parkland, nearly 1,200 more children have lost their lives to guns. The Trace brought together more than 200 teen reporters from across the country to remember those killed not as statistics, but as human beings with rich histories.

14 Children Died in The Parkland Shooting. Nearly 1,200 Have Died From Guns Since.

A handy reference: The good people at The Tampa Bay Times and the AP put together a useful list of all the gun laws that have been enacted in the country since the shooting.

Tampa Bay Times and Associated Press: Here Is Every New Gun Law in the U.S. Since the Parkland Shooting


There are some lawmakers on the Hill who are almost giddy to hold hearings on “Medicare-for-all” — and they’re not Democrats. Republicans have been struggling to find a winning stance on health care, ever since Dems’ midterm victories, which were attributed in part to their stance on the issue.

For the previously floundering GOP lawmakers, MFA is practically a gift-wrapped present that fell right into their laps. They’re confident they can frame the idea as reckless, radical and expensive, and pick off moderate voters who want to keep their insurance the way it is. Democratic leadership blasted the GOP’s calls for hearings as “disingenuous,” but MFA supporters were raring to duke it out — verbally, of course. “They think it’s going to be a ‘gotcha’ moment,” said Rep. Pramila Jayapal (D-Wash.) in Politico’s coverage. “But they have been wrong on this and continue to be wrong on it.”

Politico: Republicans Can’t Wait to Debate ‘Medicare For All’

Meanwhile, Democrats introduced legislation this week that would allow people over 50 to buy in to Medicare. The measure is much more politically palatable than MFA, and its sponsors are selling it is a realistic and incremental step in the direction toward universal coverage.

Politico: Push for Medicare Buy-In Picks Up With ’50 and Over’ Bill


Here’s something you don’t hear every day: Republicans and Democrats maybe (just maybe!) have found some common ground on the health law. As part of a package of bills to shore up the Affordable Care Act, Democrats are proposing slapping some consumer warnings on short-term plans. The hint of bipartisanship in the air, though, was limited to the advisories — Republicans were not fans of the rest of the changes proposed.

Modern Healthcare: Short-Term Health Insurance Plans May Get Consumer Warnings


Advocates deem Utah’s move to limit voter-approved Medicaid expansion as a “dark day for Democracy.” The governor and lawmakers who rushed through the restrictions to the expansion, however, say the work requirements and caps are necessary to make it sustainable for the state.

The Associated Press: Utah Reduces Voter-Backed Medicaid Expansion in Rare Move


As 2020 comes into focus, the abortion debate is definitely on the front burner for President Donald Trump, who has seized on recent controversies over so-called late-term abortions. This week, Trump and White House officials met with advocates, including Susan B. Anthony List President Marjorie Dannenfelser. While the discussions weren’t open to journalists, Dannenfelser confirmed that Trump was keenly interested in the issue. “The national conversation about late-term abortion … has the power to start to peel away Democrats, especially in battle grounds,” Dannenfelser said in The Hill’s coverage.

The Hill: Trump Offers Preview of Abortion Message Ahead of 2020


There was some movement in the agencies this week that should be on your radar:

— The Food and Drug Administration has announced it’s cracking down on the $40 billion supplement industry, especially targeting diseases that really should require medical care. Right now, that landscape is pretty much the Wild Wild West, where anything goes. And consumers don’t realize that.

The New York Times: F.D.A. Warns Supplement Makers to Stop Touting Cures for Diseases Like Alzheimer’s

— The Environmental Protection Agency has released its plan to address long-lasting toxins in drinking water. Activists were not impressed, saying the “action plan” was quite short on action.

Reuters: U.S. Unveils Plan to Control Some Toxins in Drinking Water, Sets No Limits

— The Centers for Medicare & Medicaid Services released two major proposed regulations that are meant to help ease patients’ access to their health care records. Right now, many health care providers and hospitals offer patient portals, but they often lack material such as doctor notes, imaging scans and genetic-testing data. Sometimes they’ll even charge for the data. The rules would address restrictions such as those.

The Wall Street Journal: New Rules Could Ease Patients’ Access to Their Own Health Records


In a sign of the growing awareness about the United States’ maternal mortality problem, the task force that sets the standards insurers are required to follow is expanding its guidance when it comes to depression during and after pregnancy. The U.S. Preventive Services Task Force already recommends that doctors screen pregnant women and new mothers, but the old guidelines focused on patients who were experiencing symptoms. The new advice is more proactive about addressing women who may be at risk.

The Wall Street Journal: New Mothers at Risk of Depression to Get Counseling Services, Covered By Insurance, Under New Guidelines


It’s a well-established fact that doctors have an unconscious bias when it comes to race and pain — one that leaves many minority patients undertreated and undermedicated. What’s interesting is to see how that disparity has shaped the opioid epidemic in the country — the ones that wreaked havoc on white communities.

Los Angeles Times: Why Opioids Hit White Areas Harder: Doctors There Prescribe More Readily, Study Finds

While all eyes are on the massive consolidated opioid lawsuit in Ohio that’s being compared to the Big Tobacco reckoning of the ’90s, this little case in Oklahoma might steal its thunder.

Stateline: Pay Attention to This Little-Noticed Opioid Lawsuit in Oklahoma


In the miscellaneous file for the week:

• A powerful investigation from The Wall Street Journal and Frontline uncovers the history behind an Indian Health Service doctor who was accused of molesting Native Americans yet allowed to continue practicing for decades. Where did it go wrong?

The Wall Street Journal: HHS to Review Indian Health Service After Revelations on Pedophile Doctor

• Rural hospitals are collapsing everywhere, leaving vulnerable residents stranded in health deserts. It can be devastating for towns to watch their hospitals die. Ducktown, Tenn., offers a snapshot of what’s playing out in states all across the country.

Nashville Tennessean: Tennessee Rural Hospitals Are Dying. Welcome to Life in Ducktown

• Employer-sponsored health care is often held up as the gold standard. But is it really that great?

CNN: Employer Health Plans Cover Less Than You Think, Study Finds

• I vividly remember the global fear surrounding the bird flu back in the aughts. People were panicking and countries were stockpiling medical supplies, as everyone braced for an epidemic reminiscent of the catastrophic 1918 Spanish flu. But then nothing happened. So … where’d it go?

Stat: What Happened to Bird Flu? How a Threat to Human Health Faded From View


Early numbers show that the flu vaccine is doing a pretty good job this year, so remember it’s not too late to get your shot! And have a great weekend!

Discharged, Dismissed: ERs Often Miss Chance To Set Overdose Survivors On ‘Better Path’

The last time heroin landed Marissa Angerer in a Midland, Texas, emergency room — naked and unconscious — was May 2016. But that wasn’t her first drug-related interaction with the health system. Doctors had treated her a number of times before, either for alcohol poisoning or for ailments related to heavy drug use. Though her immediate, acute health issues were addressed in each episode, doctors and nurses never dealt with her underlying illness: addiction.

Angerer, now 36 and in recovery, had been battling substance use disorder since she started drinking alcohol at age 16. She moved onto prescription pain medication after she broke her ankle and then eventually to street opiates like heroin and fentanyl.

Just two months before that 2016 overdose, doctors replaced an infected heart valve, a byproduct of her drug use. She was discharged from the hospital and began using again the next day, leading to a reinfection that ultimately cost her all 10 toes and eight fingers.

“[The hospital] didn’t have any programs or anything to go to,” Angerer said. “It’s nobody’s fault but my own, but it definitely would have been helpful if I didn’t get brushed off.”

This scenario plays out in emergency departments across the country, where the next step — a means to divert addicted patients into treatment — remains elusive, creating a missed opportunity in the health system.

A recent study of Medicaid claims in West Virginia, which has an opioid overdose rate more than three times the national average and the highest death rate from drug overdoses in the country, documented this disconnect.

Researchers analyzed claims for 301 people who had nonfatal overdoses in 2014 and 2015. By examining hospital codes for opioid poisoning, researchers followed the patients’ treatment, seeing if they were billed in the following months for mental health visits, opioid counseling visits or prescriptions for psychiatric and substance abuse medications.

They found that fewer than 10 percent of people in the study received, per month, medications like naltrexone or buprenorphine to treat their substance use disorder. (Methadone is another option to treat substance use, but it isn’t covered by West Virginia Medicaid and wasn’t included in the study.) In the month of the overdose, about 15 percent received mental health counseling. However, on average, in the year after the overdose, that number fell to fewer than 10 percent per month.

“We expected more … especially given the national news about opioid abuse,” said Neel Koyawala, a second-year medical student at Johns Hopkins School of Medicine in Baltimore, and the lead author on the study, which was published last month in the Journal of General Internal Medicine.

It’s an opportunity that’s being missed in emergency rooms everywhere, said Andrew Kolodny, the co-director of Opioid Policy Research at the Heller School for Social Policy and Management at Brandeis University outside Boston.

“There’s a lot of evidence that we’re failing to take advantage of this low-hanging fruit with individuals who have experienced a nonfatal overdose,” Kolodny said. “We should be focusing resources on that population. We should be doing everything we can to get them plugged into treatment.”

He compared it to someone who came into the emergency room with a heart attack. It’s taken for granted that the patient would leave with heart medication and a referral to a cardiac specialist. Similarly, he wants patients who come in with an overdose to start buprenorphine in the hospital and leave with a referral to other forms of treatment.

Kolodny and Koyawala both noted that a lack of training and understanding among health professionals continues to undermine what happens after the overdose patient is stabilized.

“Our colleagues in emergency rooms are not particularly well trained to be able to help people in a situation like this,” said Dr. Margaret Jarvis, the medical director of a residential addiction treatment center in Pennsylvania.

It was clear, Angerer said, that her doctors were not equipped to deal with her addiction. They didn’t know, for instance, what she was talking about when she said she was “dope sick,” feeling ill while she was going through withdrawal.

“They were completely unaware of so much, and it completely blew my mind,” she said.

When she left the hospital after her toe and finger amputations, Angerer recalls her next stop seemed to be a tent city somewhere in Midland, where she feared she would end up dead. Instead, she persuaded her mother to drive her about 300 miles to a treatment facility in Dallas. She had found it on her own.

“There were a lot of times I could have gone down a better path, and I fell through the cracks,” Angerer said.

The bottom line, Jarvis said, is that when a patient comes into the emergency room with an overdose, they’re feeling sick, uncomfortable and “miserable.” But surviving that episode, she emphasized, doesn’t necessarily change their perilous condition.

“Risk for overdose is just as high the day after as the day before an overdose,” said Dr. Matt Christiansen, an assistant professor in the Department of Family & Community Health at the Marshall University Joan C. Edwards School of Medicine in West Virginia.

What ‘Dope Sick’ Really Feels Like

Detoxing off heroin or opioids without medication is sheer hell. I should know.

For many users, full-blown withdrawal is often foreshadowed by a yawn, or perhaps a runny nose, a sore back, sensitive skin or a restless leg. For me, the telltale sign that the heroin was wearing off was a slight tingling sensation when I urinated.

These telltale signals — minor annoyances in and of themselves — set off a desperate panic: I’d better get heroin or some sort of opioid into my body as soon as possible, or else I would experience a sickness so terrible I would do almost anything to prevent it: cold sweats, nausea, diarrhea and body aches, all mixed with depression and anxiety that make it impossible to do anything except dwell on how sick you are.

You crave opioids, not because you necessarily want the high, but because they’d bring instant relief.

Quitting heroin was my plan every night when I went to sleep. But when morning came, I’d rarely last an hour, let alone the day, before finding a way to get heroin. My first time in a detox facility, I made it an hour, if that. As I walked out, a staff member said something to the effect of “I didn’t think you’d last long.”

After my parents moved out of town, in part to get away from me, I would show up at their new home five hours away with big hopes of kicking the habit and starting a new life. But after a night of no sleep, rolling on the floor convulsing while vomiting into a steel mixing bowl, I’d beg them for gas money to drive the 300 miles back to where I lived and a little extra cash for heroin. I did this so often my mother once told me in frustration, “You show up, throw up and then leave.”

Going through “cold turkey” withdrawal is, not surprisingly, impossible for many. That’s why the medical community has largely embraced the use of methadone and buprenorphine — known medically as medication-assisted treatment, or MAT — combined with counseling, as the “gold standard” for treating opioid addiction. As opioids themselves, these drugs reduce craving and stop withdrawals without producing a significant high, and are dispensed in a controlled way.

“Detox alone often doesn’t work for someone with an opioid use disorder,” said Marlies Perez, chief of substance use disorder compliance at the California Department of Health Care Services, who estimated that it might be a realistic option for only 15 out of 100 people.

Studies have also shown that MAT reduces the risk of overdose death by 50 percent and increases a person’s time in treatment.

Yet even with strong evidence for MAT, there is debate over whether to offer MAT for people struggling with opioids. Some states, like California, have vastly expanded programs: The Department of Health Care Services has 50 MAT expansion programs, including in emergency rooms, hospitals, primary care settings, jails, courts, tribal lands and veterans’ services; the state has received $230 million in grants from the federal government to help with these efforts. But many states and communities hew to an abstinence or faith-based approach, refusing to offer MAT as an option. In 2017, only about 25 percent of treatment centers offered it.

Just as each person’s journey into addiction is unique, different approaches work for people trying to find their way out. Public health experts believe they should all be on the table.

Diane Woodruff, a writer from Arizona who became addicted to opioid medication prescribed for a bad back, described withdrawal like this: “If you’ve ever had the flu it’s like that but times 100.” Woodruff went through the sickness every month for five days until she could refill her prescription of OxyContin.

Other people described the sickness as if ants were crawling under their skin or acid was being injected into their bones. Woodruff was able to quit for good after she went cold turkey, sort of. She used kratom and marijuana to help with the detox.

Noah, a 30-year-old from San Francisco who asked that his last name not be used, said that MAT was a “miracle,” therapy adding, “It saved my life.” Noah spent five years on Suboxone, a brand-name formula of buprenorphine and naloxone, right around the time fentanyl began taking lives with impunity. Suboxone took away his craving for heroin, but he kept drinking alcohol and injecting cocaine and using other drugs for a while until joining a sobriety community. He finally weaned off MAT half a year ago.

“There’s no debate that MAT works — the evidence is clear,” said Dr. Kelly Clark, president of the American Society of Addiction Medicine. Opioid use changes the chemistry of the brain, sometimes permanently. Buprenorphine and methadone stop the withdrawals, diminish cravings and, when taken as prescribed, block the high from other opioids. These medications “tone down and reset the brain,” helping to “normalize” the individual, Clark added.

Within the nine years of my heroin use, I tried to get sober many times: detox, residential rehab, and with morphine and methadone under the guidance of a health care professional. For me, Suboxone didn’t prove the answer, although (to be fair) I never took it as prescribed under the supervision of a doctor. I was ambivalent and incapable of following directions, let alone a treatment plan. I didn’t want to be shackled to another opioid or have to check in with a health care professional every week or month or have to go to counseling — even if all that could have helped me to function better. (A common critique of methadone or buprenorphine is that it is just replacing one drug for another.)

But Suboxone ultimately kick-started me into sobriety. One day in December 2008, I tried one more time to detox successfully off heroin at my parents’ house. To make it easier, I had a couple of pills of Suboxone, illegally obtained. So, after the body aches and that weird feeling when I peed, the buzzing ball of anxiety began to grow in the pit of my stomach and, just when life began to seem unbearable, I crushed one of the Suboxone tablets up and snorted it off my dresser. Unbeknownst to me at the time, when Suboxone is crushed, it releases an anti-tampering chemical that sends the user into full-on withdrawal.

I spent the next three days shut up in a room as my body and mind began to unravel. I barely slept and there was plenty of diarrhea and vomiting. After the worst of it was over, I apathetically roamed my parents’ house, not sleeping for two weeks. Then, I joined a sobriety community and haven’t touched an opioid in 10 years.

MAT was not the escape route from addiction for me, personally, and I have mixed feelings about these medications. But with tens of thousands of opiate overdose deaths each year, it makes sense that people struggling with addiction and facing the terrifying specter of withdrawal have every option available.


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