“The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped.” – Hubert Humphrey
passionate pachyderms
Pharmacist Steve steve@steveariens.com 502.938.2414
Two House members (Foster& Kelly) have added an amendment to HR 2470 #20 amendment – which would assign a “unique number” to every person getting chronic pain meds
Two Senate members ( Manchin & Braun) has a bill S. 2089: FDA Opioid Labeling Accuracy Act that would prohibit the FDA from labeling any opiate for long term pain use – with a few exceptions – until studies have been done to “prove” that they work for treating long term pain. I guess the couple of millenium that they have been used to treat pain in insufficient ?
They claim that global warning is caused by an excessive amount of CO2 and our increasing national debt is caused by the cost of supporting our Social Security, Medicare & Medicaid programs. A part of the solution to this problem can be brought by using the carbon footprint calculator which helps in calculating the consistency of damage to the environment over millions of years.
The proposed House bill – as I remember – has been tried before by a dictator of a country that in the late 1930’s – early 1940’s – assigned a “unique number” to a subset of the country’s population. In fact they wanted the unique number to be “permanent” so they tattooed them to the inside of their forearms… As I remember, that numbering system did not work out so well and a lot of people died
The Senate bill would deny most chronic pain pts long term pain management, and we all know that chronic pain pts that get denied adequate pain management… some end up committing suicide and others will end of dying of “natural causes” because under/untreated pain will cause their other co-morbidity issues to become life threatening. Maybe even a premature… see chart below
How would all of this help solve global warning and our national debt problem ? If these proposed bills make it to law and cause more chronic painers to commit suicide or die prematurely… there would be less CO2 being generated … since every time that one of us exhales.. we exhale CO2.
Most of the chronic painers consume a lot of healthcare dollars in treating their numerous medical issues and many are on Medicare disability or Medicaid or maybe both..
Many talk about a “covert genocide” and perhaps there is a “end game” to help address global warming and our growing national debt.
Congress doesn’t seem to be capable of directly dealing with these two issues… so … maybe there is a hidden agenda here… because if they tried to create a direct solution… probably HALF of the country would not be happy… and maybe many in Congress would not get re-elected ?
The Swiss people took drastic measures to reduce the number of people dying from opioid overdose. Their approach is effective – and unorthodox. The first in a series describing how Europeans have tackled their overdose issues.
By Taylor Knopf
ZURICH and GENEVA, Switzerland — Today, Platzspitz Park serves as a peaceful respite for those meandering along the Limmat River and past the Swiss National Museum. But it’s best known by the nickname “Needle Park.”
That’s because in the 1980s the park was hijacked by thousands of heroin users and dealers. The space, despite being in the heart of downtown Zurich, became one of the most famous examples of Switzerland’s “open drug” scenes.
Local police were tired of trying to control and disperse large groups of users, so Needle Park became one of the spots law enforcement left alone.
Rates of HIV infection soared from the sharing of needles. And the number of drug overdose deaths climbed.
People were injecting and dying outside one of the most beautiful hotels in Zurich. The same thing happened near political buildings in Bern, the nation’s capital, said Rita Annoni Manghi, director of the opioid substitution and heroin-assisted treatment programs at Hôpitaux Universitaires Genève.
Platzspitz Park, nicknamed “Needle Park,” sits next to a river by the National Swiss Museum in downtown Zurich. It’s a clean, peaceful space now, but in the 1980s was filled with heroin users and dealers. Photo credit: Taylor Knopf
It was the equivalent of people dying on the White House lawn, she said.
“So you are obliged to see the problem,” she said. “And Switzerland is not so modern, but it’s very pragmatic. And Swiss politics is very pragmatic.”
The rise in HIV infections, drug overdose deaths and the public nature of the drug problem led the Swiss to make major changes in how they approached illegal drugs and treated people who use drugs.
And in 1994, Switzerland went on to pass one of the most progressive and controversial drug policies in the world, which included the dispensing of heroin.
“Its famous tradition of protecting bank secrets, its having granted women the right to vote only in the 1970s, and its referendum-based rejections of minarets on mosques and decriminalization of cannabis illustrate its quirky conservatism,” Csete wrote.
But the Swiss are pragmatic. Instead of endlessly fighting drugs, they took a new approach and began supporting drug users through new treatment options.
The majority of Swiss citizens supported the measures, despite some pushback inside and outside the country.
The nation cut its drug overdose deaths significantly. HIV and Hepatitis C infection rates dropped. And crime rates also dropped.
The Four Pillars
To address the Swiss drug problem, elected officials, community members, law enforcement and medical experts all worked together to create the “four pillars” drug policy.
Those four pillars of the Swiss law are harm reduction, treatment, prevention and repression (or law enforcement).
“The goal was not to fight drugs anymore. It’s completely ridiculous to fight drugs,” said Jean-Félix Savary, secretary general of the Romand Group of Addiction Studies in Geneva. “We came to this conclusion and decided to change.”
Rita Annoni Manghi, medical director of the opioid substitution and heroin-assisted treatment programs at Hôpitaux Universitaires Genève (left) sits a heroin injection spot inside the facility with Christel Ding (right), a nurse who supervises the program. Photo credit: Taylor Knopf
“It was a big revolution. We don’t try to ask people not to take drugs, but take care of problems generated by the situations around people being addicted to drugs.”
The policies became as much about public order as public health, Savary said.
There was some resistance among some Swiss civil groups. Their push ultimately forced a national referendum in 1997 challenging the four pillars policy. But 70 percent of Swiss citizens voted in favor of the law. The four pillars have withstood other challenges as well, as the majority of Swiss voters continue to support it.
The multi-pronged approach included some controversial measures — such as legalized drug consumption rooms and heroin-assisted treatment facilities — but ultimately, the statistics show it has been successful.
Sponsored
Over the past two decades, the number of opioid-related deaths in Switzerland has decreased by 64 percent.
The number of new HIV infections also dropped significantly. In 1986, more than 3,000 people tested positive for HIV in Switzerland. In 2017, there were fewer than 500 new positive tests in a country of 8.4 million.
Switzerland began mandatory Hepatitis C reporting in 1988. The number of reported cases peaked between 1999 and 2002, declining since then.
Harm reduction
Harm reduction strategies aim to lessen the damage caused to a person by their use of drugs. Needles exchange programs fall under this category, as do legalized drug consumption rooms.
Offering drug users clean needles and other supplies reduces their use of dirty needles, therefore reducing the spread of HIV and Hepatitis C infections.Drug consumption rooms go one step further by providing users with a safe place to use under medical supervision, which reduces the chance of an overdose.
(What’s a drug consumption room like? More on that later in our series.)
Swiss drug experts said the public also benefits: passersby no longer see people injecting in the streets or come in contact with many used syringes.
Harm reduction staff workers make a point not to judge people who come through their doors. And many build relationships with frequent visitors. Resources are available to drug users at these facilities as well to connect them to anything they might need, from a place to sleep, eat, do laundry, or find addiction treatment.
The Swiss are also very deliberate when it comes to placing their drug consumption rooms.
For example, in Geneva, a lot of people gathered and injected near the main train station. So now, around the corner, a drug consumption room is housed in a modern green building that stands out among the backdrop of the traditional Swiss architecture.
Lowering barriers to treatment
“The goal in this field is to get as many users as possible into treatment,” said Thilo Beck, addiction psychiatrist and medical director of the heroin-assisted treatment program in Zurich.
The drug consumption room in Geneva is around the corner from the train station and was placed there because so many users gathered together and injected heroin. Now, they use inside with clean supplies and medical staff. Photo credit: Taylor Knopf
He said that 75 percent of active users in Switzerland are in treatment on a given day, and about 95 percent have been in treatment at some point.
This is medication-assisted treatment, using methadone or buprenorphine. It also includes slow-release morphine or heroin, which aren’t used to treat people with substance use disorder in the United States.
“Treatment is available and accessible,” Beck said. “I think that’s how it should be in every country.”
There are circumstances in Switzerland that make treatment so accessible. First, the country has universal health care, so everyone has health insurance.
The four pillars law also expanded opioid substitution therapy (or medication-assisted treatment) and lowered the threshold for entry. Someone can walk into a clinic for the first time and start treatment 20 minutes later, Beck said.
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Before the 1990s, this type of treatment was viewed as the first step toward abstinence. Beck said that people were supposed to stay on the treatment for six months to stabilize them, then taper off and stop.
“But this was not happening. Some people might do that, but the majority will not,” he said. “What we learned is you have to be pragmatic and take the problems as they are and think of the most feasible solution.
“It doesn’t help to think of goals that are not achievable.”
People in drug treatment programs no longer need to visit a treatment center every day to receive methadone, buprenorphine or morphine. Stable patients receive take-home doses. Physicians can also write prescriptions for these same treatments. And there’s no expectation of abstinence from street drugs and no mandatory drug-screening tests.
“By offering opioid substitution therapy almost unconditionally to virtually anyone willing to change their consumption from heroin to another product, the health care system became a viable competitor among those supplying people addicted to opioids in Switzerland,” wrote Christian Schneider, a drug analyst who works at the Swiss Federal Office of Police.
Switzerland’s low-threshold opioid substitution program allows stable patients to receive take-home doses of methadone, buprenorphine or morphine. Here, a worker at a substitution program in Geneva prepares a week of doses for a patient. Photo credit: Taylor Knopf
The treatments are safer than street drugs because the consumer knows exactly what’s in it. Switzerland doesn’t have the same fentanyl problem as the United States, but there are other unwanted substances in their street drugs. Drug check sites help with this problem. These are places a user can take their drug to be checked, and it’s given back to them with a list of what is inside it.
And because a person in treatment is spending less time and money finding and buying drugs, they can focus on other things in their life, such as housing, work or family.
“Prescribed in a way tailored to fit the needs of consumers, opioid substitution therapy not only offered a much safer and much cheaper substitute but also ensured availability and access to products in a way that street dealers could never match,” Schneider concluded.
Law enforcement
The role of law enforcement changed under the four pillars approach. As more and more users went into treatment, the demand for opioids on the black market fell, as did the purity of the products.
The purity of heroin taken by Swiss police over the last decade or so is poor, averaging between 15 and 20 percent purity. The purity and price were much higher before the four pillars law.
The police are focusing less on the users and more on big time dealers.
“You have to help the consumer and fight the criminal,” Manghi said. “And the consumer may deal a little, but they are not organized enough to do high-level crime.”
Savary, a Swiss drug and harm reduction expert, explained that getting law enforcement support was essential to gaining public support for the four pillars law. From what Savary has seen, one supportive police officer has more influence than 100 medical experts.
The Swiss are prosecuting fewer opioid-related crimes. In 1993, the country had about 20,000 cases a year. Today, the Swiss average about 5,000 opioid-related cases annually.
Prior to the four pillars law, house break-ins were common in Switzerland, Savary said. After the law was adopted, there was a huge drop in burglaries.
“We reduced theft by 98 percent. We never had a security figure like this,” he said, referring to crime statistics. “With health measures, you can have a very big security impact… You can do both. It’s cheap and effective. It sounds like a miracle, but you can do it.”
They’re essentially a “middle man” between drug makers, health care plans, and patients, negotiating the prices most of us pay for prescription drugs.
The flowchart below explains the way it works. It’s from The Commonwealth Fund, a private foundation that supports independent research on health care issues.
Independent Pharmacies Losing Business
In the last two years, health insurance companies, which set deductibles and co-pays, have bought up the three main PBMs: Express Scripts, CVS Caremark, and Optum RX.
A number of independent pharmacies have told Spectrum News they are now losing business and revenue because of PBMs, including Five Points Pharmacy in Cocoa, a pharmacy that has been welcoming customers since 1958.
Louella McCormick Edwards started coming to 5 Points Pharmacy with her mother. But now, Edwards says most of her family can no longer get their medication filled at 5 Points after their health plans dropped the pharmacy from their networks.
“We have nowhere to go and people are running around for days and days trying to find places to get medicine,” Edwards said.
5 Points Pharmacy owner Dr. James Wright says he wants customers to understand that insurance companies and PBMs are the entities responsible for removing 5 Points Pharmacy from their networks.
“I usually show people the notice or rejection notice when we try and run the claim that says ‘med not covered here’,” he said.
Express Scripts, CVS Caremark, and OptumRX are the three largest PBMS, controlling 75 percent of the market, according to Fortune Magazine.
All have their own pharmacies. And all are now owned by insurance companies.
Calls for Transparency at State, Federal Levels
Florida Rep. Anna Eskamani, D-Orlando, is now calling for more transparency about whether PBMs actually save consumers money.
“Everyone is impacted by the cost of drugs and medication,” said Eskamani. “Our seniors, especially here in Florida, are going to feel that pinch. Folks on a fixed income. I think there is something to be said about the monopoly control of PBMs and how that is the anti-thesis of the free market principal.”
It’s a concern also being voiced at the federal level. In April, the Senate Finance Committee questioned PBM CEOs about their negotiation process with drug manufacturers.
At the hearing, Sen. Ron Wyden, D-Oregon, described his concerns involving PBMs.
“The deals they strike with drug makers and insurers are a mystery, how much they’re pocketing out of the rebates they negotiate is a mystery…,” Wyden said.
Currently, PBMs are not required to disclose their financial negotiations.
Would it Help?
Spectrum News 13 Watchdog Reporter Stephanie Coueignoux flew to Washington D.C. to speak with JC Scott, president and CEO of the Pharmaceutical Care Management Association, which represents PBMs.
While Scott supports transparency, and believes PBMs are one of the most transparent aspects in the health care system, he believes making negotiations public would ultimately hurt instead of help consumers.
“If you think about playing a game of cards, it would be the PBMs showing their cards to the drug company across the table in a way that lets the drug company raise prices even higher,” Scott said.
Dr. Wright at 5 Points Pharmacy does not agree. He showed us paperwork his pharmacy received for one prescription — paperwork he says patients never see.
Wright explains:
The customer’s co-pay is $60.
$1.23 is how much the medication costs, which the pharmacy pays.
$58.70 is how much the insurance company and PBM take from the total transaction.
“It’s just a strange, strange situation,” Wright said. “[They’re] passing on the cost to [me] and the patient. And patients would not know about it. It’s like a tax that no one is aware of.”
We asked Scott for his response to pharmacies claiming PBMs are putting them out of business.
“There is always going to be a tension point between negotiators when you’re trying to drive costs down, and that’s some of what you’re seeing,” Scott said.
An infographic from PCMA showing what they would like to see in terms of transparency. (PCMA)
Eskamani argues that’s where the issue of transparency comes in, that PBMs are inflating prices for out-of-network pharmacies, instead of lowering costs for everyone.
Scott says that’s simply not the case.
“I think that’s a conversation to have with them, and perhaps we need to do a better job of educating them on all the ways PBMs are already transparent, and willingness to engage with them in that important dialogue,” Scott said.
Scott said PCMA understands there is an affordability problem, but says his industry is ready to find a solution.
For Edwards, as her family scrambles to find affordable medication, talk is cheap.
Visibly upset, Edwards told Spectrum News, “It’s like extortion to me, that’s what it is. You extorting us. That’s exactly what it is.”
Eskamani says she’s working on legislation for the upcoming session that would require PBMs in Florida to be more transparent when it comes to drug pricing and availability.
MINNEAPOLIS (WCCO) — Curbing Minnesota’s opioid crisis means owners of sick pets will make more trips to their pharmacies. The state’s new opioid law went into effect at the beginning of the month, and parts of it have forced veterinarians to clear up confusion.
For eight years, Boo Boo has been by Bobby Wilbur’s side. A degenerative disc disease often has the cocker spaniel out of commission.
“It gets to the point where he can’t go up steps,” Wilbur said.
A prescription for Tramadol helps with the pain, which Wilbur would fill a few times a year. During his last visit stop at the pharmacy, that changed.
Part of Minnesota’s new opioid law places a time limit on when prescriptions for people and pets can be filled.
“They wouldn’t refill my medication because it had been more than 30 days since his last refill,” Wilbur said. “This doesn’t make any sense to me it means I will have a larger quanity on hand than I normally would.”
Minnesota’s Board of Pharmacy has fielded questions in the last few weeks from doctors, veterinarians, patients and pet owners — all trying to better understand the new pain pill law and the long list of provisions that comes with it.
“An opioid prescription needs to be filled within 30 days of the time it’s issued for the first fill, and then if it can have refills it needs to be filled every 30 days after that,” Board of Pharmacy executive director Cody Wiberg said.
Wilerg explains the 30-day rule is meant to bring patients back in to be re-evaluated to see if an opioid is still necessary. Since, sadly some have accessed medicine for themselves through their vet office.
“There’s still way too many people dying from opioid abuse,” Wiberg said.
The board has questioned some of the language and plans to make changes next session, meaning, at least for now, Wilbur will be back at his pharmacy every month to make sure Boo Boo finds help when it is needed.
A prescription for Tramadol can be phoned into a pharmacy by a vet so it wouldn’t require another appointment. But some stronger drug classes will before a refill is granted.
Click here for answers of frequently asked questions of Minnesota’s new opioid law.
State is placing persons who are involuntarily committed to treatment – the section 35 process – in jail or prison even though no charges have been levied against them
Sheriff Nick Cocchi, left, on his way to visit men civilly committed for drug or alcohol abuse at the Hampden county jail in Ludlow, Massachusetts. Photograph: Josh Wood/The Guardian
The scene plays out every day in Massachusetts, thousands of times a year.
A loved one is addicted to opioids. Their life is spinning out of control as they use more and more. Their family panics. Rehab can be unaffordable – and it may require waiting for a spot. But they need to get their loved one somewhere they can’t use before it’s too late.
It’s about now that they might consider section 35, a process in Massachusetts by which persons abusing drugs or alcohol can be involuntarily committed to treatment for up to 90 days after a family member, guardian, law enforcement officer or doctor petitions a judge. Many states have similar laws in place and have turned to them in battling the opioid crisis gripping the nation.
But in Massachusetts, involuntarily committed men can end up in jail or prison even though no charges have been levied against them.
That’s how Jim, a 29-year-old student, arrived at the Hampden county jail in the western Massachusetts town of Ludlow in March after overdosing on opioids. Despite being forced into jail with no charges, he told the Guardian he was glad to be there.
“I’ve never been in trouble with the law, but it was absolutely necessary for a cop to come to the house, put me in handcuffs and take me here,” he said.
Eight days into his stay, he said jail was “the best thing that’s probably ever happened to me”.
As Massachusetts struggles against an opioid crisis that kills five times as many people than automobile accidents every year in the state, the placement of civilly committed men in correctional facilities has emerged as one of the most controversial tactics to confront addiction in the state – and one not seen anywhere else in the nation where a detox facility is the preferred method.
To proponents, the section 35 process is seen as lifesaving, putting people in a place where they absolutely cannot get drugs and where they cannot simply walk out. But its detractors say that forced rehabilitation does not work, that putting men in correctional facilities is unconstitutional and that putting patients in prison settings is detrimental to recovery and increases the risk of relapse once patients are released.
Women were once held in correctional facilities in Massachusetts for addiction, but after an ACLU lawsuit, the state ended the practice in 2016.
But the state has ramped up its incarceration of civilly committed men. According to Prisoners’ Legal Services, a not-for-profit that has been a key opponent of the practice, Massachusetts places more than 2,000 men involuntarily committed for substance abuse in correctional facilities per year.
The Hampden county jail wing looks like a jail, but the people here are patients, not inmates, and have been charged with no crime. Photograph: Josh Wood/The Guardian
In March, PLS filed a lawsuit against the department of correction and department of public health on behalf of 10 unnamed patients being held at the Massachusetts Alcohol and Substance Abuse Center (Masac), a facility operated by the DoC in the town of Plymouth.
The lawsuit charges that holding the men in correctional facilities is unconstitutional, constitutes unlawful discrimination on the basis of gender and disability and is overall detrimental to recovery. They also describe an abusive environment where patients are “routinely” humiliated by correctional officers (COs) and where patients lack access to opioid substitution medications such as Suboxone.
“These people are being shamed and stigmatised on the basis of a disease that’s acknowledged as a disability,” said Bonnie Tenneriello, PLS staff attorney.
One of the unnamed plaintiffs said officers called patients pussies, bitches, junkies and crackheads while telling him that his “mother is a whore”.
Another plaintiff described how during detox, his roommate urinated and defecated on himself, but that nobody cleaned it up.
Others described being too afraid to call their employers or loved ones as all phone calls coming from the facility inform the person being called that they are receiving a call from a correctional facility.
PLS says patients have been sent to solitary confinement for seemingly minor offences like smoking a cigarette, not answering questions or taking extra milk with their meals.
“All of that is counter-therapeutic, all of that is traumatising, all of that is telling people you are not a full citizen, you are not to be trusted, you are a bad person,” said Tenneriello of placing patients in correctional facilities.
A cell – or bedroom – in the wing for civilly committed men at the Hampden county jail. While the facility is locked, cells remain unlocked. Photograph: Josh Wood/The Guardian
‘It’s a jail mentality’
Joel Kergaravat, 36, was hooked on heroin and crystal meth when his mother petitioned him to be sectioned last summer. They both thought that sectioning him would mean rehab, but instead he was put in restraints and loaded into a hot van for a long drive to Masac.
His experience at Masac appeared to mirror allegations laid out in the lawsuit.
Once he got to Masac, he did not have access to detox medications. “It’s barbaric not to give people that medication, because you’re basically vomiting and shitting yourself for six days,” he said. “That’s what happens. It’s not pretty.”
Inside, he said guards were abusive. He felt the place was unsanitary and unclean and worried about getting sick. Patients would get into fistfights.
“It’s a jail mentality,” he said. “They have you in a prison setting so people act accordingly.”
When he got out, he was traumatized. He got back on drugs and at one point tried to kill himself by overdosing – a result, he says, of his experience at Masac.
“If you’re going to force people into treatment, that’s fine, put them into treatment,” he said. “You can’t just rename a prison or a section of a prison and call it treatment.”
A sheriff champions section 35
The Hampden county sheriff, Nick Cocchi, might be the biggest proponent of section 35 in the state.
Cocchi views his mission as a rehabilitative one. His COs don’t carry weapons of any kind and those on the section 35 wing don uniforms consisting of polo shirts – an attempt to look less guard-like. He keeps a folded, ageing piece of paper in his pocket that lists the names of those that have died at the jail in the 26 years he has been working there. When western Massachusetts residents call him and send him Facebook messages pleading for advice about loved ones who have been trapped by addiction, he invites them to his office, even if it is a weekend. Men who have previously been sectioned call him up when they are relapsing.
Cocchi says that when done right, forced rehab works.
His enthusiasm about section 35 was born out of a desire to provide treatment closer to home for residents of western Massachusetts.
“You serve no purpose taking somebody two and a half hours from home, detoxing them and then saying ‘here’s a bus ticket to get back to where you’re going.’ Where’s the support?” he said. “There’s no support. And when there’s no support, there’s relapse.”
Sheriff Nick Cocchi says that done right, forced rehab works. If Massachusetts stops allowing correctional facilities to hold men civilly committed for drug and alcohol abuse, he says it will ‘devastate’ the state. Photograph: Josh Wood/The Guardian
He said the kind of abusive treatment outlined against Masac in the lawsuit brought by PLS doesn’t happen at his jail. He said that there need to be reforms to the section 35 process, but that his facility is “second to none” in the state.
Recently the gregarious sheriff brought the Guardian into the section 35 wing, walking in with a five-month-old bull mastiff puppy named Brooklyn.
“What’s up guys?” he beamed at the patients – or “clients” as they are referred to in the jail administration’s parlance. “I don’t want anyone to panic – this is not a drug sniffing dog!”
The wing appeared clean and orderly. The patients wore a uniform of brown pants and yellow or blue T-shirts with inspiring mottos like “recovery works” and “one day at a time” on them. They appeared friendly with the sheriff and the COs, stopping them to share their thoughts and concerns about their time on the unit.
Several patients eagerly lined up to speak to the Guardian about their experience at the jail, all saying positive things. Many were optimistic that being closer to home, having counseling about their discharge plan and having access to advice after they were out would mean it would be easier to stay off drugs or alcohol once released.
Some had spent time at Masac in Plymouth and said their current surroundings were much better.
Jim, the 29-year-old student who was sectioned after an overdose, said: “The COs don’t treat you like inmates, they treat you like a patient essentially.”
The wing has only been receiving section 35 patients since May, but Cocchi says he is confident that statistics will eventually show that his program has a higher success rate than any other treatment facilities.
“There’s also a group out there that says forced treatment doesn’t work – when you force someone to go into treatment, it doesn’t work,” he said. “That is absolutely false.”
If people trying to put an end to correctional facilities holding civilly committed men are successful, Cocchi says “they will devastate the commonwealth of Massachusetts, specifically western Massachusetts right now … And I will not lay down on that.”
‘Setting them up to die’
But opponents of jailing section 35 patients say that even if the abuses laid out against Masac are not present at a correctional facility, keeping civilly committed men there is wrong and dangerous.
“No matter how well run any prison might be, we’re saying that it’s a disease,” said Tenneriello, the PLS attorney. “Putting people in prison because they have a disease is fundamentally wrong”
Leo Beletsky, an associate professor of law and health sciences at Boston’s Northeastern University is an expert on the opioid epidemic and sits on the state’s section 35 commission.
He points to studies, like one by the Massachusetts department of public health, that show that persons recently released from incarceration are 120 times more likely to die of an opioid overdose than members of the general public.
“By putting people in correctional settings, we’re essentially setting them up to die,” he said.
Physician Sarah Wakeman, an addiction medicine specialist and medical director of the Substance Use Disorders Initiative at Boston’s Massachusetts general hospital, said those leaving forced rehab are at particular risk for overdosing given they did not want to be there in the first place and have lowered their tolerance.
To Wakeman, more focus needs to be placed on making sure that voluntary treatment for substance abuse is more readily accessible.
“The reality is that tough love is not a useful intervention to help a person suffering from addiction,” she said.
Beletsky said the section 35 system remains popular as it is much easier to access than voluntary treatment programs.
“Section 35 in many ways is the path of least resistance for getting into treatment,” he said. “It’s immediate, it’s free, it requires no navigation.”
It “illustrates how broken our systems of care are,” he said. “In many ways it’s easier to put somebody away than have them access normal healthcare.”
Putting someone in jail and totally abstaining from their drug of choice.. when they are discharged, their opiate tolerance will be very near to what is normally considered a “opiate naive” person. When they go back to the environment from where they came and is influenced to go back using their drug of choice and if they try and use the same amount… they will most like OD because of little/no tolerance that they had when regularly using.
“abstinence rehab” has a 5% success rate because they were addicted in the first place. All likelihood, they had a legal prescription for a opiate for an acute pain episode and they abruptly stop the opiate because the prescriber gave them too many doses and when they stopped they had become “dependent” and start going into withdrawal… All they, their family and friends know is what the media reports every night that “those opiates” are HIGHLY ADDICTIVE.
So if the person took opiates and went into withdrawal when they stopped the opiates.. THEY MUST BE ADDICTED. So they go to rehab and after week or so… they have “dried out” have no desires to take opiates again, but they are now labeled as an “addict in recovery”. Which the person will never be able to eradicate from their medical records for the rest of their life.
The exact number of people living with SCD in the U.S. is unknown. Working with partners, the CDC supports projects to learn about the number of people living with SCD to better understand how the disease impacts their health.
It is estimated that:
SCD affects approximately 100,000 Americans.
SCD occurs among about 1 out of every 365 Black or African-American births.
SCD occurs among about 1 out of every 16,300 Hispanic-American births.
About 1 in 13 Black or African-American babies is born with sickle cell trait (SCT).
Since Sickle Cell disease is almost totally a health issues that affects people of color … could this particular physician being violating both the Civil Rights Act (1964) and the Americans with Disability Act (1990) ?
That’s the simple message greeting visitors to this picturesque town of about 200 people, delicately placed inside less than one square mile of southern Choctaw County and seemingly designed to make you feel as nostalgic as possible.
It’s that version of small-town America we all hope to find when we take a random right turn on the interstate. Gilbertown is like apple pie and white picket fences. The sort of place where you expect to see a lemonade stand in every neighborhood. It’s kids playing in streets against a backdrop of beautifully manicured lawns and American flags fluttering in the wind.
And of course, everyone’s doors are unlocked, so they say.
Gilbertown has, for now at least, retained a unique charm that cannot be said for so many similar sized towns across the country, apparent victims to the unique demands of 21st century life. When jobs leave, so do the people.
But this snippet of traditional southern life, nestled quietly on either side of state road 17 about eight miles from the Mississippi line, has managed to keep its mom-and-pop stores open against national trends. It still has a newspaper, if you can believe that. Hunting camps dominate the vast forests in the area, while a nearby paper mill provides jobs to a large number of locals.
Despite what it does have going for it, Gilbertown is unfortunately not immune to another increasingly familiar aspect of small-town American life: its recently reported relationship with opioids.
Over a seven-year span starting in 2006, a single pharmacy dispensed 1.3 million pain pills to patients, placing it retrospectively at the heart of the opioid crisis in Alabama, according to recently released federal data obtained by the Washington Post. The D&L pharmacy, which has been closed for about six years and is now an insurance business, later sold its dispensary business to the Hometown Pharmacy, located about 200 feet away.
While the overall figure of opioids dispensed does appear alarming, the current owner of the Hometown Pharmacy told AL.com that the initial calculations made, apportioning as many as 928 pills to each of the 200 residents over the seven years, is misleading.
“The simple issue is that the pharmacy wasn’t just used by people who live in this town,” said Cole Floyd. “During that time the pharmacy was the only one in southern Choctaw County. While it’s hard to make accurate calculations, each of the three pharmacies in the county probably had as many as 4,500 people using them.
“That drastically changes the number of people per person receiving pills,” he added.
Based on Floyd’s rough number, each person using the pharmacy received about 41 pills a year over seven years. He admitted that some of those people could have had issues, but insisted that the volumes dispensed were not unusually high.
But Floyd also said that had the number of opioids dispensed been over any legal limit, the Drug Enforcement Agency would have likely visited D&L. “At the end of each day, our computer uploads data regarding the number of controlled drugs bought and sold by us in any given day. That includes opioids and other controlled drugs. If that number is above [a certain] percent of all controlled drugs [dispensed], not just opioids, then we would expect a visit from DEA.”
Floyd also said that the wholesale drug companies also had to report sales to the DEA and that his store policy was to not dispense drugs for people who are from outside of Choctaw County. Along with a database for each patient, the strict dispensary controls help his team prevent addicts who are “doctor shopping,’ which is when people visit multiple doctors to maximize the amount drugs they can obtain.
The former owners of the D&L Pharmacy continue to operate drug stores in Birmingham, according to Floyd.
While Floyd had read The Washington Post story, not everyone in Gilbertown was aware of the town’s top rank in state. Indeed, Gilbertown was the only town in south Alabama to make the top 10 list for opioid pills per capita. Most of the heaviest pain pill use in state occurred in the hills of north Alabama, especially in Walker County and other neighboring counties northwest of Birmingham.
In Gilbertown on Monday, Summer Turner, who was working a shift at Magnolia Traditions clothing store, said she had never heard of people abusing any kind of drug in the town. “I’ve been here for 20 years and I don’t remember any trouble like that here,” she said, adding that she doesn’t often lock her door.
Fifty feet away at the Heavenly Creations book store, which also sold flowers, gifts, rental tuxedos, and doubled as a small church, Minister Shirley Pearson said she was also not aware. “I’ve never felt like this is a place where that happens or where people feel fear,” she said. “I suppose I am upset that outsiders are suggesting we have a problem here. We have a lot of spirituality and people sometimes pull over while on road trips to come pray. We turn no one away.”
A stone’s thrown from Pearson’s church is a monument to one of Gilbertown’s past glories and a reasons tourists still visit the town. It was the first place in Alabama to successfully drill for oil all the way back in Jan 1944 and the reason the state started its oil and gas board. At the base of a tall drilling rig monument, which no longer works and was moved about a mile from where the original drilling began, two fresh faced teens diligently worked at a snow cone hut.
“What’s an opioid?” said Hudson Abston,18, while standing next to his colleague and fellow Southern Choctaw High School graduate Emily Phillips, 17. “We don’t get a whole lot of trouble around here. There was a couple of robberies about two years ago,” he added excitedly.
At the rear of the snow cone hut, next to a restored caboose and memorial fountain, and not far from the spotless public bathroom, you’ll find the mayor and police chief’s office. The police chief has two officers working under him and a third part-time officer due to start Tuesday, said Mayor Billy C. May, currently in his first term as mayor after being elected three years ago.
“The new cop isn’t being hired because of the drugs,” joked Mayor May. “I know that this country has problems with these drugs, but that’s not an issue in this town.
“We are a rural town, but we serve as a hub and a destination for thousands of people who live in other rural areas here in Choctaw County. We have people coming from as far as Philadelphia [Mississippi] to use our two medical facilities.”
May said that the downtown medical facility, Franklin Primary Health Center, receives about 25 to 50 patients a day. “They are packed five days a week and sometimes open on Saturdays,” he said, suggesting that the perceived high level of opioid dispensed in the town was due to the large numbers of people coming from out-of-state and other areas of the county.
“People like this town and we’re doing well. We’re growing,” said Mayor May. “We have a county museum, the old oil well, and we have a picture of a dinosaur that was dug up here years ago. It’s in the Smithsonian now. It was a fish dinosaur I think, about 85 feet long.”
During the recent Interim Meeting of the American Medical Association, the organization’s president, Dr. Barbara McAneny, told the story of a patient of hers whose pharmacist refused to fill his prescription for an opioid medication. She had prescribed the medication to ease her patient’s severe pain from prostate cancer, which had spread to his bones. Feeling ashamed after the pharmacist called him a “drug seeker,” he went home, hoping to endure his pain. Three days later, he tried to kill himself. Fortunately, McAneny’s patient was discovered by family members and survived.
This story has become all too familiar to patients who legitimately use opioid medication for pain.
Since the Centers for Disease Control and Prevention published its guideline for prescribing opioids for chronic pain in March 2016, pain patients have experienced increasing difficulty getting needed opioid medication due to denials by pharmacists and insurance providers.
More troubling are recent press reports, blog posts, and journal articles that describe patients being refused necessary medication or those dismissed by their treating physicians, who practice in fear of regulatory reprisal. At the interim meeting, the AMA responded to these developments, passing several resolutions against the rash of laws and mandatory policies that limit or prevent patient access to opioid painkillers.
The CDC designed its guideline as non-mandatory guidance for primary care physicians. But legislators, pharmacy chains, insurers, and others have seized on certain parts of its dosage and supply recommendations and translated them into blanket limits in law and mandatory policy. Today, in more than half of U.S. states, patients in acute pain from surgery or an injury may not by law fill an opioid prescription for more than three to seven days, regardless of the severity of their surgery or injury.
Although many of these laws exempt patients with chronic or cancer pain, in practice they often affect those with long-term pain, like McAneny’s patient. Some insurance companies and major pharmacy chains, like Walmart, Express Scripts, and CVS, also have mandatory restrictions on the opioid prescriptions they will fill. In addition to imposing supply limits, insurers and pharmacies are increasingly using the CDC’s dosage guidance (the equivalent of 50 to 90 milligrams of morphine a day) as the basis for delaying or denying refills for long-term pain patients, even though the CDC guidance is intended to apply only to patients who have not taken opioids before.
The Drug Enforcement Administration and some state medical boards are also using this dosage guidance in ways that were never intended, such as a proxy or red flag to identify physician “over-prescribers” without considering the medical conditions or needs of these physicians’ patients. As a result, some physicians who specialize in pain management are leaving their practices, while others are tapering their patients off of opioids, solely out of fear of losing their licenses or criminal charges.
The laudable goal of these laws and policies is to stem the tide of unprecedented overdose deaths and addiction in the U.S. But here are three interesting facts: Opioid prescribing is currently at an 18-year low. The rate of prescribing opioids has dropped every year since 2011. Yet drug overdose deaths have skyrocketed since then.
Recent data from the CDC suggests that illegally manufactured fentanyl, its analogs, and heroin are responsible for well over half of all overdose deaths. Stimulants like cocaine and methamphetamines are responsible for another third. Deaths related to prescription opioids come next in line, although many of those who died were not the intended recipient of the prescribed medication. In addition, most deaths involve multiple substances that are used in combination, often including alcohol.
The vast majority of people who report misusing prescription opioids did not get them from a doctor under medical supervision, and as many as 70 percent reported prior use of substances like cocaine and methamphetamines.
Conflating the misuse of opioids with their legitimate medical use, and treating all opioids — illegal or prescription — alike is stigmatizing patients for whom opioid painkillers are necessary and medically appropriate.
There’s no question that taking opioid medications carries risks: The CDC places the risk of addiction with the long-term use of opioids at 0.07-6 percent. The risk of addiction justifies judicious prescribing, trying other forms of treatment before prescribing opioids, and carefully screening patients for a history of addiction and mental health issues when opioids are being considered.
But most patients who use opioid medication for pain do not become addicted, although they may develop physical dependence. Addiction is the compulsive use of a substance despite adverse consequences. Appropriate medical use is just the opposite, use on a set schedule as prescribed with benefits to health and function.
Nearly 18 million Americans currently take opioids long-term to manage pain; many of them have complex medical conditions. When appropriately prescribed opioids are denied, patients whose pain has been well-managed by them may experience medical decline, lose the ability to work and function, and resort to suicide. Denying opioids to patients who have relied on them — sometimes for years — may cause some to turn to street drugs, thereby increasing their risk of overdose.
Dr. Terri Lewis, a researcher and rehabilitation specialist, recently conducted a nationwide survey of 3,000 pain patients. More than half of those surveyed (56 percent) reported disruptions in care or outright abandonment by their physicians. Among those reporting disruption or abandonment, many experienced adverse health consequences (55 percent) as well as hopelessness or thinking about suicide (62 percent) as a result. In other surveys, physicians said that they were prescribing fewer opioids or ceasing treatment of pain patients altogether because of regulatory scrutiny, even in cases where they believed that doing so would harm their patients.
The CDC guideline and its progeny of laws and policies have created chaos and confusion in the medical community. Some physicians are telling their patients that changes in the law are the reason they are tapering them to a preset dosage of opioids or off of opioids altogether. Yet the specific dosage thresholds in the CDC guideline were never intended to apply to patients currently taking opioids. Indeed, nothing in the current legal or regulatory environment justifies forcibly tapering a patient off of opioids who is doing well, and there is no solid evidence to support such a practice.
Some physicians are also using the CDC’s dosage thresholds, or simply their patients’ use of opioids, as a reason for abandoning them. Abandoning pain patients out of fear of regulatory reprisal may violate a physician’s ethical duty to place a patient’s welfare above his or her own self-interest. If serious harm results from abandoning a patient’s care, it may also serve as a basis for discipline or malpractice claims. In addition, physicians and pharmacies have responsibilities under the Americans with Disabilities Act not to discriminate on the basis of a patient’s condition, including chronic pain, or a perceived condition, as when a person with pain is erroneously regarded as a person with opioid use disorder or addiction when there is no clinical basis for that perception.
Small-town America does have an opioid problem, but not in this Alabama town