Lawmakers Pummel Biden’s Drug Policy Czar at House Hearing

— GOP and Democratic members raise issues with border control, medication-assisted treatment

https://www.medpagetoday.com/psychiatry/opioids/99473

WASHINGTON — Rahul Gupta, MD, MPH, director of the White House Office of National Drug Control Policy, got hit from all sides Monday at a House Committee on Oversight and Reform hearing on the federal response to the overdose crisis.

As often happens during a congressional discussion of substance use disorders, committee Republicans focused on the issue of border control. “One [outstanding question] is how President Biden’s border crisis and this administration’s open border policies have aided and abetted trafficking of illicit drugs, such as fentanyl, in our country,” said Rep. James Comer (R-Ky.), the committee’s ranking member. “Fentanyl is being smuggled across the southwest border at unprecedented rates … We must act now to secure our southern border to stem the flow of illicit fentanyl.”

Rep. Pat Fallon (R-Texas) also pressed the issue. When Gupta, in response to a question, said that the southern border of the U.S. was secure but the administration is continuing to work with Mexico on the drug issue, Fallon called that response “shockingly inadequate” adding “it shows just gross negligence … the Mexican drug cartels are controlling the southern border, not the federal government. It’s a gross dereliction of duty that’s putting Americans at risk.”

Medication-Assisted Treatment Questioned

But Republicans weren’t the only ones showing their displeasure. Rep. Stephen Lynch (D-Mass.) decried the use of medication-assisted treatment as a strategy for helping those with substance use disorder. “We allow doctors to have hundreds of patients and just give them Suboxone [buprenorphine/naloxone] and not really deliver any behavioral health services that would get at the underlying addictive activity,” he said. “We’ve got a couple of clinics that hand out Suboxone — the patients go out the door and then they either trade that or they buy fentanyl or methamphetamines, which is even a worse problem. They can’t get high with the Suboxone, so they’re going to harder drugs,” which leads to more stabbings and other violence.

“We’re actually seeing much more violent activity because an individual on methamphetamines might be up for days, and we’re seeing a lot of stabbings,” he said. Gupta noted that “people have different ways of getting at the treatment … Some may do OK cold turkey, while others may need medication for varying amounts of time … We’ve got to help people when they need it and where they need it.”

Lynch seemed unimpressed with that answer. “It’s not working where I am,” he said. “I’ve got tent cities, hundreds and hundreds and hundreds of people all together, right next to a methadone clinic, that are shooting up … I think we’re pushing more of this stuff out, and it’s not helping. So I think we’ve got to reassess.”

Should Cannabis Be Reclassified?

Rep. Ro Khanna (D-Calif.) wanted to know why cannabis — which he said could sometimes be a useful alternative to opioids for pain management — was classified by the Drug Enforcement Administration (DEA) as a Schedule I drug — a class with the most restrictions — while opioids were classified as Schedule II. Classifying cannabis as Schedule I also means that researchers are barred from conducting rigorous, large-scale studies on it, he added. “Do you see this as a contradiction that needs to be resolved?” Khanna asked.

Gupta agreed that “it’s important for us to continue to look at this from a research perspective, from a medical use perspective. Clearly, the policies that we’ve had in this country with regard to marijuana have not worked, and the president has said so.” Khanna reminded Gupta that “the president has the executive authority to direct DEA, HHS, and FDA to consider administratively rescheduling marijuana, which would facilitate research, which would facilitate patient access … At least make sure it’s rescheduled so it’s not more restricted than opioids themselves.”

Congresswoman Eleanor Holmes Norton (D-D.C.) said that she was “extremely disappointed that the Biden administration’s two budgets have proposed maintaining the rider that prohibits the District of Columbia from spending its local funds on commercializing recreational marijuana.” Gupta responded that “in the matter of the D.C. rider, I understand it’s with Congress, and I’ll leave it at that. And having said that, the president has been very clear that he supports decisions regarding legalization of marijuana to be left up to individual states, but at the federal level, he has supported decriminalization of marijuana use and automatic expungement of records.”

An Equity Lens

Norton wasn’t entirely negative about the administration’s response to the issue so far, however. “Since assuming office, the Biden administration has shown a robust commitment to advancing equity and centering recovery over punishment in federal response to the overdose crisis,” she noted, and gave Gupta a chance to further explain the administration’s policy in this area.

Gupta said that with his office’s recently released drug control strategy, “one of the things we are doing is looking at all of the metrics that are available to us … We were able to put forward a state model for nonviolent crimes; if someone has a mental health disorder, or addiction, let’s get the person help; let’s get them treatment; let’s get them housing — instead of incarcerating them. It’s not only a good thing to do and prevents recidivism, but it’s also cost-effective for the communities. It is these types of things that the strategy looks at, figuring out how to solve problems at a community level and making sure that we’re doing that with the lens of equity.”

Rep. Debbie Wasserman Schultz (D-Fla.) was also supportive of Gupta, praising his understanding of the issue. She saved her wrath for Florida Governor Ron DeSantis (R) and other Republican governors who are opposed to expanding Medicaid in their states. “Research shows that overdose rates are lower in states that expanded Medicaid coverage under the Affordable Care Act,” she said. “In fact, states that expanded Medicaid coverage experienced at least 10% fewer overdoses involving synthetic opioids like fentanyl, and 11% fewer overdoses involving heroin, when compared against states that haven’t expanded Medicaid.”

“Sadly, because Governor DeSantis is immune to facts, science, and even the shame that families must endure because of his callous inaction, he is not likely to be moved to act,” Wasserman Schultz concluded. “But that doesn’t mean we stop calling out his and other Republican governors’ cruel indifference and how it compounds this crisis and adds to the pain that millions of American families will suffer.”

This is a image I first posted in 2014, probably data from 2013 or 2012… so while the deaths from the two drugs, Alcohol & Nicotine use/abuse has not changed much in the intervening 8 to 10 yrs, but drug/opiate overdoses are up around SEVEN TIMES. From a White House administration perspective, the problem has been BIPARTISAN perspective over the up to last decade of time.  There is enough blame to go all around for both political parties.

Could it be time for the chronic pain community to align with those protesting “my body, my choice”, “healthcare is a RIGHT”, “I don’t what some politician/bureaucrat to decide what I do with my body”..  SCOTUS unanimously decided last week that the DOJ/DEA were applying undefined standard of care and best practices – objective standards – to determine if prescribers were not meeting those objective standards when treating pts dealing with subjective diseases Supreme Court Rules for Doctors on ‘Pill Mill’ Prosecution Proof: 9 to 0 in favor of practitioners

The pro-abortion groups seems to have a fairly large number of supporters and a LOT OF ENTHUSIASM.. and the chronic pain community represents a MASSIVE NUMBER OF VOTES.  After all 435 members of the House and 33-34 Senators will up for election/re-election in Nov 2022.  Could a coalition of those two very large groups – AND VOTERS – could that cause politicians to listen to their constituents. ?

 

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The illegal Fentanyl from China is killing more American EACH YEAR… than all the soldier killed in ALL THE YEARS of the Vietnam war, everyone killed at the attack on Pearl Harbor and all the people killed at 911  TOGETHER…

Now that the SCOTUS has declared that DOJ/DEA is incorrectly/illegally charging many prescribers of prescribing control meds without meeting a UNDEFINED standard of care and best practices Supreme Court Rules for Doctors on ‘Pill Mill’ Prosecution Proof: 9 to 0 in favor of practitioners

Who believes that the DEA will start to focus on their original charge back in 1973 to deal with illegal controlled substances being sold – mostly on our streets.

Here is graphic I have from 2014 – EIGHT YEARS AGO…  16K OD’s per year. the number of deaths from use/abuse of alcohol & tobacco hasn’t changed much BUT, the number of OD drug deaths is up ALMOST SEVEN TIMES.

There is substantial evidence that most/all of this illegal Fentanyl analog is made in China and shipped to Mexico, who turns the raw illegal Fentanyl powder and using their tablet presses, produces  millions and millions of fake tablets that looks like legal prescription tablets/doses.  Recently the DEA or CDC stated that 60% of the illegal Fentanyl tablets contain a LETHAL AMOUNT OF THE ILLEGAL FENTANYL.

That is like playing Russian Roulette with a 5 shot gun with only 2 chambers EMPTY.

If another nation or two is contributing to the deaths of > 100,000 of our citizens EVERY YEAR … are we at WAR ?   All it took to declare war against Japan when they attacked Pearl Harbor and killed about 3000 … All it took was the 911 attack on the twin towers in NY and killed about 3000 to declare war on the Bin Laden and his followers.   Of course, those deaths all happened in a SINGLE DAY… and since the OD deaths from illegal Fentanyl is abt 300/day… a number not significant enough for us to act ?  We don’t have to attack another country… we could start by CLOSING OUR SOUTHERN BORDER and initiate other efforts to stop the tsunami of illegal drugs coming into our country. There is – on average 7700 people that die in our country VERY DAY… maybe 4% are being killed by illegal drug coming into our country is not significant enough to worry about ?

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I love math issues… let’s look at this example .. Medicare pays for how many doses of 20 mg or 40 mg ?

I checked on www.goodrx.com in my zip code lowest available price # 30 doses 20mg $0.25 each $ 7.42 & 40 mg $0.13 each $3.89

Cost Plus Drug Co. #30 @ $.019 =5.70  + 1.01 (15% profit) + $3 dispensing fee + $5.00 delivery fee  = $14.71

I checked our Humana Part D and #30 esomeprazole 20mg $16.50 ($.55 each) – no coverage for 40 mg

since no strength or quantity was provided in the article, both strengths seem to be less expensive using www.goodrx.com It would appear that pharmacy dispensing fee, 15% profit margin & $5 shipping fee .. turns their price stated as in PENNIES ..turns into DOLLARS TOTAL COST.  There are other cash discount cards like single care and others.

Cuban’s estimated Medicare cost – unless that is the cost that the PBM charges Medicare after paying the pharmacy and adding all their administration fees, could be true, but could possible point out how crooked the PBM industry is and why they are paying multiple million files for over charging various entities – mostly Medicare & Medicaid.

The truth is, when Congress passed the Medicare Part D & Medicare Advantage med bill, they turned this medication program for Medicare folks to FOR PROFIT INSURANCE COMPANIES  and/or PBM companies, which are licensed insurance companies.  Congress agreed that they would not allow Medicare to negotiate prices.  The PBM industry for the last 50+ yrs have been extremely opaque on how their financial charges are determined.  The Insurance/PBM industry has one of the largest pots of money to lobby Congress and this might explain why Congress handed the medication for Medicare folks to this FOR PROFIT INDUSTRY and Medicare agreed not to try to negotiate a discount/lower price on covered medications…. that was back in 2003 +/- Part D program became active Jan 1, 2006.

 

‘Let’s get this done,’ Mark Cuban tells Biden on Medicare savings study

https://www.beckershospitalreview.com/pharmacy/mark-cuban-s-generic-drug-prices-would-save-medicare-billions-of-dollars-harvard-study.html

Medicare recipients could have saved up to $3.6 billion on generic drug costs in 2020 if Medicare paid the same prices as investor Mark Cuban’s pharmacy, according to a study published June 20 in Annals of Internal Medicine. Mr. Cuban tweeted the results, urging President Joe Biden and other elected officials to “have your people call my people and let’s get this done.”

The pharmacy, Mark Cuban Cost Plus Drug Co., has quickly gained speed from about 100 generic drugs at its launch in January to more than 700 generic drugs six months later. 

The researchers from the Program on Regulation, Therapeutics and Law at Boston-based Harvard Medical School and Brigham and Women’s Hospital identified 89 generic drugs for which they could compare prices between Mark Cuban Cost Plus Drug Co. and Medicare Part D plans.

If Medicare Part D plans matched Mr. Cuban’s prices for 77 of the 89 generic drugs, 37 percent of Medicare’s $9.6 billion 2020 drug costs could have been slashed, the study found. Twelve drugs did not cost less. 

The researchers found the best results with esomeprazole, a drug that treats acid reflux heartburn, which could have saved CMS up to $293 million if Medicare paid the same amount as Cost Plus Drug Co. Medicare paid $1.77 per pill. Cost Plus Drug Co. gets it for $0.19. 

Cost Plus Drug Co. sells its products with a $3 pharmacy dispensing fee, $5 shipping fee and a 15 percent profit margin. 

“Our sole mission is to be the low-cost drug provider for as many drugs as we can possibly offer,” Mr. Cuban told Becker’s. “That is counter to most business interests, particularly over a long period of time.”

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Will CVS Health Be a Positive Disruptor to Primary Care?

— Complex incentives pose reasons to approach this new model with caution

https://www.medpagetoday.com/opinion/second-opinions/99374

While working at one of the nation’s largest safety-net hospitals, I experienced first-hand how difficult it can be for people to access medical care. For many providers, the story of the patient with diabetes or a suspicious lump who couldn’t get an appointment in time or wasn’t able to take time off work will resonate all too well. Many hospitals have adopted initiatives to improve access, but innovation has been slow, confined to individual institutions, and hampered by regulation.

In the absence of a productive government, some believe it necessary to turn to industry. One industrial giant touting itself as the newest solution to healthcare is CVS Health. Its power unknown to many, CVS Health is a nation-wide conglomerate composed of 9,900 retail stores, which serves over 1 million customers a year through its senior pharmacy, runs 1,100 MinuteClinics, has 105 million plan members through its pharmacy benefit manager (PBM) Caremark, and manages health insurance for over 34 million people through traditional, voluntary, and consumer-directed health insurance products and related services, including Aetna. And now, CVS Health has unveiled its newest venture: primary care.

CVS Health wants to expand by transforming MinuteClinics into HealthHUB clinics, a one-stop-shop for primary care needs. Customers will be able to schedule primary care visits, browse CVS’s 6,000 branded medical products, and receive education on chronic disease management. On November 5, 2021, CEO Karen Lynch announced CVS Health would be hiring primary care physicians for their new HealthHUBs, a move which will make CVS Health the first company to offer physician patient care coupled with a pharmacy, covered through its own insurance plan, and managed by its own PBM.

Can such a vertically integrated, for-profit company deliver on its promise to increase access to high-quality care while lowering healthcare costs? With the majority (71%) of Americans living within a 5-mile radius of a CVS, the company is poised to deliver local, convenient primary care. However, the complexity of incentives in the integrated CVS Health model pose reasons to approach this new model with caution.

First, the relationship between a healthcare provider integrated with an insurance company has implications for how high-quality care can be incentivized. While providing high-quality care that keeps patients out of the hospital will lower costs on the insurance provider, incentives could also be skewed to keep patients from accessing costly services. Current insurance companies do this with utilization controls, such as gatekeeping, prior authorization requirements, and step therapy. In theory, stricter utilization controls at CVS Health could result in telehealth first and in-person visits restricted to HealthHUBs, leaving Aetna members with little choice in primary care services, and reliance on an unknown quality of new HealthHUB practitioners. Additionally, having providers employed by both an insurer and PBM could incentivize reduced referrals out-of-network, preventing patients from getting the care they need. Meanwhile, the company’s profits would likely offset any losses incurred from worsened patient health.

Second, complexities arise from the potential for induced demand. A provider service owned by a pharmacy could theoretically incentivize physicians to increase prescriptions, particularly those covered under the formulary negotiated by the PBM Caremark. While some may think physicians would not engage in such actions, multiple studies have shown that physicians, like all human beings, can be influenced by financial incentives.

Lastly, with an insurer providing care to its own patient population, it will be important to watch for any potential cream-skimming in which less healthy persons are de-incentivized to join the CVS Health plan. Cream-skimming has been widely reported in Medicare Advantage (MA) plans, and with a large portion of CVS’s 2020 revenue stemming from MA benefits, it will be important to keep an eye out for any additional cream-skimming tactics.

Some may argue that such profit tactics are worth tolerating if they reduce U.S. healthcare costs. One argument is that, with its 105-million-member strong network, the Caremark PBM could negotiate with manufacturers and providers to drive down drug and hospital prices. However, research has not shown that for-profit vertical integration will pass on cost savings to patients. Rather, the current PBM structure incentivizes formulary coverage of whichever drugs the PBM can negotiate the highest percent rebate on, with rebates passed off to the insurer or PBM rather than patients. In fact, a lawsuit is alleging that CVS Health denied consumers low-cost generic medications, choosing only to cover higher-priced brand-name drugs, which increased profits for their pharmacy and PBM, and cost patients higher co-pays. Therefore, it is very possible that patients will not see savings through increased vertical integration, and that the promises of integration-driven efficiency may just be another example of for-profit “health-washing.”

Is for-profit vertical integration the innovation the U.S. needs to increase access to quality care, deliver improved health outcomes, and lower overall healthcare costs? Despite incentives that could theoretically skew the company towards strict utilization controls, induced pharmaceutical demand, or cream-skimming, CVS Health has the potential to deliver on their promises by enacting tight internal controls.

The question then becomes: how will CVS Health be held accountable? Without transparency into CVS Health payment structures, quality measures, and health outcomes, the public will be left to question whether this new disruption will truly bring about the changes in primary care we have all been waiting for.

While the road ahead remains uncertain, one thing is clear: CVS Health is forcing traditional healthcare to adapt. One promising avenue may be state-wide global payment models, such as Accountable Care Organizations, that reimburse on value rather than volume. If the monopolization of privatized healthcare forces hospitals to accelerate their switch to such global payment models, then perhaps the public will glean benefits from the for-profit sector after all.

Lucia Ryll is a fourth-year medical student at Boston University School of Medicine, and a 2023 Boston University Questrom School of Business MBA Candidate.

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this is some items included in a Narxcare report… IF you notice Narxcare – someone – has CREATED a LME (Lorazepam ) Lorazepam Milligram Equivalents – just the TIP OF THE ICEBERG in this reporting system – there is a WHOLE LIBRARY of 3 color informational handouts the practitioner can print out. Also notice that any – per CDC – that anyone taking more than 50 MME opiates should be prescribed NARCAN.  there is all sorts of graphs included to give the practitioner viewing this report as much as a YEAR’S data on a pt… so that the practitioner can get a quick good/bad idea of the pt’s controlled substance use. Of course a LARGE BLIP in the middle of a graph covering the entire year may cause the practitioner to come to the wrong decision about the pt.

This appear to be a newer format and OVERDOSE RISK SCORE – the old format only had THREE SECTIONS – LOW-MED-HIGH over dose risk. Which was probably more useful and maybe more accurate than over the NINE DIFFERENT SCORES now used.

If you click on the images they will enlarge and be easier to read. 

Also notice that any one taking 50 MME’s has – according to Narxcare a 25-85 higher potential ratio to OVERDOSE and anyone taking >90 MME’s has a automatically score of having a higher potential for OVERDOSING.

In Indiana – don’t know about other states – the Narxcare report is AUTOMATICALLY INCLUDED when a practitioner pulls up a PDMP (INSPECT) report.

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We have been always been the UNITED STATES OF AMERICA… Our Constitution plainly states what is to be managed by the Federal gov and what is the responsibility of the states. We are not the 50 regional members of the North America Federalization Government.

This has been a interesting month for the bureaucrats in Washington DC..  SCOTUS decided that states could not prohibit USA citizen to own and bear arms, because it is guaranteed right by the 2nd Amendment of our Constitution.  SCOTUS also declared that RED FLAG laws regarding confiscating a person’s gun(s) was unconstitutional.

Congress turned around and passed a new “gun law” making  RED FLAG LAWS legal… I would presume that this law is going to handed to ATF… a “sister agency ” to the DEA… Both under the same Presidential Cabinet Seat of DOJ.  Most of us are well aware of all the RED FLAGS that the DEA has created surrounding prescribing/filling controlled meds… and RED FLAGS are not mentioned nor defined in the controlled substance act, but that has not stopped the DEA from turning their opinions into RED FLAGS and then apply those RED FLAGS as to who has violated the CSA.

SCOTUS following their other opinion(s) of what is stated/defined in our Constitution, they declared that the 50 y/o SCOTUS decision that the right to a abortion is guaranteed by the federal government is not supported by our constitution and  is neither guaranteed nor prohibited in our Constitution and sends the issue BACK TO THE STATES to dictate what is allowed/prohibited, in regards to abortion in individual state.  NO SCOTUS did not make abortion ILLEGAL

My first thoughts, with up to a dozen types of birth control/contraception. Including Plan B/morning after (72 hrs) pill for those who have been raped or there is incest.  I am sort of confused about the “my body, my choice”…  what about personal responsibility ? I have seen stats of one million + abortions performed every year.  Does that suggest one million + BAD DECISIONS “in the moment” ?

Personally, I am somewhere between agnostic and indifferent on the issue of abortion. The first question – after personal responsibility – One Million + abortions has got to involve some major $$$ of medical costs.  Not to mention some of these females may end up with  the need for some Psychological help when they later regret their decision.

I viewed a video from a female, probably in mid-late 30’s. Stating that she had a child when she was young and kept the baby and admitted that she was not a real good Mother to that kid… Then stated that “totally unexpected”, got pregnant again and had her first abortion in 2009.  Here is 2022 and she stated that she was in her last year in her PharmD degree and she found herself pregnant again and the “sperm donator ” did not want to be a FATHER and she did not want to give birth during her graduation and it would ruin her career.  Maybe, her first born was grown and left home and didn’t want to be a single Mother in her late 30’s and starting her career.

Obviously, she did not figure out how a pregnancy happened since apparently several years later was “totally unexpected” pregnant. I would hope by her 5th-6th yr of pharmacy school, she would have fair handle on how pregnancy happens and what contraceptives are available and how they work.

Maybe, as a country we should put vending machine .. right next the the ones that provide free Narcan, clean needles, etc, etc.. with free Birth Control pills, condoms , Plan B. Maybe be able to help prevent pregnancy rather than terminating pregnancies.

 

 

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This past week, we had a LESS THAN FOUR YEARS OLD Whirlpool washer FAIL ON US..  We had purchased it from a local owned appliance store we have been patronizing for some 3+ decades. We used a repairman that they recommended – didn’t know at the time that this guy had worked for a local Whirlpool service center until it was closed and he went into business for himself.  He told us that it was one of two boards – there was no error codes that would display and each board was $300-$400 each..  I contacted Whirlpool company customer service… they kept me on hold so long that I was able to search expected life span of such equipment – under HEAVY USE – EIGHT YEARS  — under light use – 10-12 yrs…  take a guess – TWO SENIOR CITIZENS is the only ones using this machine since it was purchased new and the anticipate life expectancy we should expect.

I was hoping that Whirlpool would provide the bad control boards and I would pay the labor… NOPE… I was told that I had to have THEIR APPROVED REPAIR SERVICE TO ASSESS THE MACHINE…  I had already paid $75 for an evaluation from a person who use to work for Whirlpool – and working on appliances for FORTY YEARS – and I was going to pay for another service run with NOT EVEN A PROMISE/HOPE that they may provide some compensation on this machine or credit on getting a new Whirlpool washer…

The CS person seemed to be totally unconcerned… and my closing statement to him was that our new washer would not be a Whirlpool…  I don’t know if he was chuckling under his breath, because after I went on line and found out all the different washing machine labels… they make…  Maybe he sensed that I would not be “smart enough” to find out that information..

We contacted our locally owned appliance store that we have been using for 3+ decades and our NEW LG WASHER WILL BE DELIVERED TOMORROW !

NO MORE WHIRLPOOL APPLIANCES FOR US !!!

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To protect people with addiction from discrimination, the Justice Dept. turns to a long-overlooked tool: the ADA

https://www.statnews.com/2022/06/22/to-protect-people-with-addiction-from-discrimination-the-justice-dept-turns-to-a-long-overlooked-tool-the-ada/

It was at Massachusetts General Hospital that Bryan found the care he needed for his opioid use disorder. He had previously tried, without success, to just quit. But when the hospital’s renowned addiction medicine team prescribed him Suboxone, a medication that can tame cravings, it worked.

Bryan also had cystic fibrosis, which by 2017 had progressed to the point he needed a lung transplant. It made sense that he would get that done at MGH too.

The transplant team, citing the Suboxone Bryan took, rejected him.

The denial confounded Bryan and his family. Bryan was doing what he was supposed to be doing, taking an effective medication that other doctors at that very institution had put him on. It helped him live free of misused painkillers and heroin. But the denial was also an emergency. Bryan kept getting sicker.

“At that point, you realize you’re 27 and dying,” Bryan said, recalling how he thought he would miss out on the future life he had envisioned for himself. “You’re not going to give someone a chance because of the past they had when they were younger?”

An unexpected ally agreed with Bryan.

In a 2020 settlement, the U.S. Justice Department found that MGH discriminated against Bryan under the Americans with Disabilities Act, the landmark 1990 civil rights law meant to ensure that people with disabilities have the same opportunities as everyone else. It’s not a well-known element, but the law classifies substance use disorder as a disability, meaning disfavoring someone for being in recovery or based on their past drug use is illegal. (The law does not extend its full protections to people still using drugs.)

Increasingly, Justice Department attorneys are leveraging the law to try to overcome some of the rampant discrimination that people with substance use disorders face. The cases typically center on people who are penalized because they take medication for opioid addiction — treatments that are considered the gold-standard — and on people who are denied those medications, particularly in the criminal justice system. The underlying argument rests on the idea that imposing barriers on treatment for a disability is tantamount to doing so on the basis of the disability itself.

The pace of the cases is picking up, with the government reaching agreements with or filing suit against institutions in Pennsylvania, Rhode Island, and Colorado in recent months. And in April, the Justice Department’s Civil Rights Division released guidance outlining how the ADA applies to substance use disorders, aiming to explain to people with addiction histories that they have rights they might not be aware of.

“We have so stigmatized drug use that it doesn’t even seem to register that what they’re saying is not OK,” Kelly Dineen, the director of the health law program at Creighton University, said about institutions that discriminate. The department’s actions, Dineen said, convey that “not only is it unethical, it’s unlawful.”

If anything, advocates say it’s an overdue enforcement of a law that’s been on the books for three decades, a policy that Justice Department lawyers have acknowledged they’ve only started wielding in recent years. But the hope is that what may seem like whack-a-mole investigations — a nursing facility that won’t take patients on Suboxone here, a detention center that won’t provide addiction medications there — will spark enough attention to motivate whole fields to change their policies, lest they want to duel with the Justice Department.

“The country’s top law enforcement agency has now stated plainly that denying health care and other vital services to people with opioid use disorder violates federal law,” said Sally Friedman, senior vice president of legal advocacy at the Legal Action Center. “So facilities like jails and skilled nursing facilities that routinely discriminate against people with opioid use disorder should see the writing on the wall, and that if they continue to discriminate, they shouldn’t be surprised when the Department of Justice comes knocking on their door or they get served with a lawsuit.”

Bryan, who asked to be identified by his first name only, ultimately got his transplant in November 2017 — at the University of Pennsylvania. As part of the settlement, on top of training transplant staff on the disabilities act, MGH had to pay $170,000 to Bryan and $80,000 to his mother, who stayed with him in Pennsylvania for six months as he recuperated.

In a statement, MGH said it “is committed to ensuring all its services, including organ transplantation, are available to all patients including those with disabilities. The MGH Transplant Center has ensured that all staff understand responsibilities under ADA.”

Listen to lawyers involved in these cases, and you’ll learn they’re not hard to find.

“This kind of discrimination is overt,” Gregory Dorchak, an assistant U.S. attorney in Massachusetts who has led many of these investigations, said on a recent webinar.

In 2018, the Justice Department first advocated for the legal theory that “discrimination on the basis of treatment is discrimination on the basis of disability,” Dorchak said. It came in an investigation of Charlwell House, a skilled nursing facility in Massachusetts that refused a patient who took Suboxone. Change the prescription, the nursing facility told the patient, and we’ll reconsider.

“Right there, you have, in that short message, essentially the smoking gun of the policy,” Dorchak said. “They articulate that, but for the medication being used, we would admit this person.”

The department reached a settlement with Charlwell House, under which the facility had to adopt a non-discrimination policy and provide ADA training. It has since reached agreements with about eight other skilled nursing facility organizations.

Such cases expose how many institutions — including health care facilities — don’t realize that withholding services from someone based on their addiction history or ongoing treatment amounts to illegal discrimination. It’s a result of both a lack of knowledge about ADA protections generally, and the specific stigma that people who’ve used drugs encounter, experts say.

“There is resistance to seeing those as medical conditions or disabilities,” Elizabeth Pendo, a professor of law at St. Louis University, said about substance use disorders. Instead, some people view them mainly as the ongoing consequences of bad decisions or lack of willpower. “Those misperceptions, those biases, those assumptions, they linger, and they’re harming people,” Pendo said.

The ADA considers as a disability any physical or mental impairment that substantially limits major life activities, or a history of such an impairment. Congress signaled that the definition should be interpreted broadly and the protections extended widely, legal scholars say. Under that framework, people in recovery from opioid and other substance use disorders have disabilities and can’t be discriminated against.

(There is an exception to the ADA’s protections: they do not extend to people who are currently using illegal drugs, meaning someone could lose out on a job, for example, for failing a drug test. However, there is an exception to that exception. Even people who are using drugs can’t be legally denied medical care — such as treatment for complications of injection-related infections — despite the fact that that happens frequently, experts say.)

These cases also highlight the discrepancy that exists between what’s considered standard-of-care treatment for opioid addiction and the perceptions of those therapies.

Two of the three approved treatments — buprenorphine (which Suboxone is a form of) and methadone — are opioids themselves. The medications are taken as controlled doses to overcome the misuse of other opioids and, in these patients, do not provide a high. Decades of research show they help control cravings, stave off withdrawal, enable people to live productive lives, and save lives. Some people take the medications for years, with experts likening it to using insulin to manage diabetes.

Still, some people maintain biases against the medications, thinking that taking them is not compatible with being in recovery — a perspective that the Justice Department now stresses can be discriminatory.

“The chief barriers to expanding MOUD access … are often based on misguided stereotypes and stigmas about the treatment and diversion concerns,” Dorchak and David Howard Sinkman, an assistant U.S. attorney in Louisiana, wrote in a recent paper, referring to medications for opioid use disorder. “Rooting out such unfounded fears is at the heart of the ADA.”

In other words, people are discriminated against for using medications that doctors have prescribed to help them stop using drugs in the first place. Forcing people off the medications can sometimes lead to people returning to illicit drug use.

While the U.S. attorney’s office in Massachusetts led many of the first ADA addiction cases, others are stepping up the pace. And in the past few months, the department has found that the Indiana state nursing board violated the ADA by effectively keeping a nurse who was on buprenorphine from getting her license; filed a lawsuit against Pennsylvania’s court system for allegedly denying people from participating in supervision programs if they were on certain medications; and won the right for people at a Rhode Island detention facility who were being treated for opioid addiction before entering the facility to stay on their medications.

As the Rhode Island and Pennsylvania cases show, the Justice Department is trying to use the ADA to expand access to medications in the criminal justice system, where only select facilities have embraced methadone and buprenorphine. As Sinkman and Dorchak wrote, “the vast majority of the nation’s jails and prisons ban the provision of lifesaving, FDA-approved, and doctor-prescribed drug treatment,” even as — as one 2007 study found — the risk of overdose death is 129 times higher for people in the first two weeks after being released from prison than that of other people.

In some cases, correctional facilities have argued they are compliant with the ADA because they offer inmates the third opioid addiction medication, naltrexone (also known as Vivitrol), which is not an opioid. But the Justice Department has asserted that institutions have the obligation to provide all three treatments, and that the decision of which treatment to use should be up to patients and their doctors, not jails or judges.

“These medications are not interchangeable,” Sinkman and Dorchak wrote. “One version of MOUD might work well for one patient but not another. This is why the ADA requires ensuring access to all three forms of MOUD in the criminal justice system.”

The Justice Department is not the only agency responsible for enforcing the ADA. In 2018, for example, Volvo had to pay $70,000 to resolve a suit brought by the Equal Employment Opportunity Commission after it allegedly refused to hire someone for being on Suboxone. In May 2020, the federal health department reached an agreement with a West Virginia agency, after a couple was allegedly denied permission to adopt their niece and nephew because the uncle was on Suboxone.

The question remains whether these individual deals are having a broader impact — whether they’re influencing other institutions to change their policies before they feel the heat of a federal investigation.

It’s still early to gauge the ripple effects. In one study, researchers at Boston Medical Center found that the rate of discriminatory rejections by Massachusetts nursing facilities was the same after the first settlement in 2018 as it was before. But since then, as the government has continued to pursue such cases, “the settlements have led to growing recognition that this is something that can’t just be ignored,” said Simeon Kimmel, an addiction medicine and infectious diseases physician at BMC.

It’s not that there’s been a shift across the entire industry, Kimmel said. But some skilled nursing facilities have developed relationships with addiction treatment programs and now accept people on these medications, even if others still reject those patients when referred.

By establishing precedents, the initial cases can also open the door for future legal action, whether by the government or by advocates. Indeed, Justice Department attorneys have cited cases not brought by the government as guiding their work in this area.

In one, a federal court in 2018 found that a Massachusetts jail’s refusal to allow a potential inmate to stay on methadone violated the ADA. (The judge also raised constitutional concerns.) And in 2019, a different federal court ruled similarly in a case involving a Maine jail’s ban on buprenorphine.

“The ADA has always applied to jails and prisons, but that legal precedent is something people can point to and build on to say, judges are now saying this explicit denial is illegal,” said Rebekah Joab, a senior staff attorney at the Legal Action Center. “It’s really hard to assert these rights as an individual, but having those decisions on the books allows individuals to say to a jail or prison, look, a judge has said this is illegal, and also you don’t want to be sued.”

Rachael Rollins, who was sworn in as the U.S. attorney in Massachusetts in January, told STAT that she intended to promote widely the work that the office has been doing in this area. Attorneys have done presentations for a trade group representing nursing facilities about ADA protections, and Rollins said she hopes to do trainings with medical schools and associations.

“We can ring the alarm to say to people, don’t make us come and have to find you,” Rollins said.

With his new lungs, Bryan is now living the life he feared he wouldn’t see. For most of his life, he was hospitalized twice a year as a result of his cystic fibrosis. He hasn’t been hospitalized in four years.

He’s still on buprenorphine, though now in the form of a long-acting injectable. He views his drug use as something in his past, and doesn’t think or talk about it much. He’s also experienced the stigma that comes with others viewing him as a drug user. All of that is why he asked to be identified by his first name only.

Bryan works as an engineer, and in the past year, has bought a house and gotten engaged.

“I couldn’t ask for a better life,” he said.

This story is part of a series on addiction in 2022, supported by a grant from the National Institute of Health Care Management.

 

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