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Two articles to think about, one on opioids, the other billing for hospital care

Via Naked Capitalism:

Place based economic conditions and the geography of the opioid overdose crisis

By Shannon Monnat, Associate Professor, Syracuse University. Originally published at the Institute for New Economic Thinking website

Over 400,000 people in the U.S. have died from opioid overdoses since 2000. However, there is widespread geographic variation in fatal opioid overdose rates, and the contributions of prescription opioids, heroin, and synthetic opioids (e.g., fentanyl) to the crisis vary substantially across different parts of the U.S. In a studypublished today in the American Journal of Public Health, we classified U.S. counties into six different opioid classes, based on their overall rates and rates of growth in fatal overdoses from specific types of opioids between 2002-04 and 2014-16 (see Figure 1). We then examined how various economic, labor market, and demographic characteristics vary across these different opioid classes. We show that various economic factors, including concentrations of specific occupations and industries, are important to explaining the geography of the U.S. opioid overdose crisis.

 

1 in 6 hospital patients get a surprise bill for out of network care

By Rachel Bluth, Kaiser Health News reporter. Originally published at Kaiser Health News.

About 1 in 6 Americans were surprised by a medical bill after treatment in a hospital in 2017 despite having insurance, according to a study published Thursday.

On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge. Most of those came from doctors offering treatment at the hospital, even when the patients chose an in-network hospital, according to researchers from the Kaiser Family Foundation. Its study was based on large employer insurance claims. (Kaiser Health News is an editorially independent program of the foundation.)

The research also found that when a patient is admitted to the hospital from the emergency room, there’s a higher likelihood of an out-of-network charge. As many as 26% of admissions from the emergency room resulted in a surprise medical bill.

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Doctor, Who Was Paid by Purdue to Push Opioids, Will Testify Against Drugmaker

Just this morning I read this article by The Guardian; opioids-to-testify-against-drugmaker/ar-BBVN3yk?li=BBnb7Kz&ocid=spartandhp" >

Doctor Who Was Paid by Purdue to Push Opioids to Testify Against Drugmaker

“In a newly released statement to an Ohio court hearing a combined lawsuit of more than 1,600 cases, Doctor Portenoy accuses drugmakers of underplaying the dangers of opioids and of pushing them on patients who did not need them. The doctor said the industry overstated the benefits of narcotics painkillers and ‘understated the risks of opioids, particularly the risk of abuse, addiction and overdose’”.

Apparently Doctor Portenoy was the hired gun for Purdue Pharma and others to promote the use of Opioids. Dr. Portenoy “did a study of only 38 patients and the results were mixed with more than one-third failing to benefit from the drugs. It also lacked the standard scientific rigor of control groups.

But the paper had a significant impact and tapped into a frustration among a group of younger pain doctors at their inability to offer anything more than superficial relief to patients whose lives were dominated by debilitating pain.”

Even though Portenoy’s study lacked the numbers that the Jick and Porter study had in their study, I am sure it had a tremendous impact on subsequent sales. It was a more recent study than the 1980 letter detailing the impact of Opioids in a hospital setting.

In the text of my post on April 7th;

The cause of the Opioid epidemic up till recently can be partially blamed on the misuse of a 1980 Jick and Porter letter to the NEJM. The letter cited the risk of addiction from the “use of Opioids in a hospital setting is rare.” Except when cited by people using this letter 608 times, 80.8% (491) of the citations to promote Opioids failed to mention the use of Opioids was in a hospital setting. Purdue Pharma, other companies, and doctors used this letter to promote the use of Opioids.

In 1996 with the introduction of OxyContin by Purdue Pharma, the use and abuse of the letter almost tripled. If we go back to the charts again, we can see that upon introduction of OxyContin in 1996 a year or so later the death rate per 100,000 doubles and continues to increase yearly. “The aggressive sales pitch led to a spike in prescriptions for OxyContin of which many were for things not requiring a strong painkiller. In 1998, an OxyContin marketing video called ‘opioids-pain/20180314/opioids-pain" >I got My life Back,’ targeted doctors. In the promotional, a doctor explains opioid painkillers such as OxyContin as being the best pain medicine available, have few if any side effects, and less than 1% of people using them become addicted.” Increases in drug poisoning deaths involving prescription Opioids increases with 37% of all drug-poisoning deaths in 2013 being attributed to Opioids a 4-fold increase from 1999.

In the 2017 letter to the NEJM, The Jick and Porter Letter is cited in the Supplemental Appendix. The bibliometric analysis of the increased numbers of citations of this letter aligns with the introduction of OxyContin in 1995/96.

“the authors of 439 (72.2%) cited it as evidence that addiction was rare in patients treated with opioids. Of the 608 articles, the authors of 491 articles (80.8%) did not note that the patients who were described in the letter were hospitalized at the time they received the prescription”

The increased numbers of deaths due to Opioid use, as shown in the Joint Commission charts, occurred shortly after the introduction of Oxycontin.

The Guardian article affirms what many of us have been thinking over the last couple of years.

There a pretty detailed discussion of the impact of pharmaceutical companies on the use of Opioids at Naked Capitalism as written by Yves Smith; New York Sues Big Pharma for Opioid Crisis Bill Black, Marc Steiner, Letita James, discuss the study and how Purdue and other Pharma companies influenced the market.

By run75441 (Bill H)

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Opioids, the Quiet Killer

(Dan here…re posted from March 7, Angry Bear)

by run 75441

There are no loud guns shots in the middle of the night. No screams for help or sounds of cars speeding away. No police sirens or flashing lights. It is pretty quiet when someone ODs on Opioids unless someone finds them before it is too late.

As I wrote earlier; “From 2006 to 2015, pharmaceutical companies spent opioids-policies">$880 million in lobbyingstate and federal legislatures and contributing to campaigns to prevent laws restricting Opioid prescriptions. Opioid manufacturer lobbying expenditures has outstripped those such as STOPPNow advocating for greater controls on Opioids and prescriptions by 200 times at the state level.”

In comparison, only the NRA and its gun lobbying efforts in legislatures displays a similar capability to oppose and defeat any and all laws for bullet-spewing-weapons laws the same as the Opioid industry efforts to block legislation. Legislators pay attention when either industry or lobby calls on them.

Any particular article advocating greater regulation of Opioids or reporting of Opioid dangers on medical blogs such as Medscape, centers such as opioids-policies">Public Integrity, news agencies such as Associated Press are met with a resistance (if they still have a comments section) the same as what is found on sites when they advocate for greater “gun control.” The evidence is overwhelming that there is an opioid epidemic in the nation resulting from usage and is similar to the epidemic of injury and deaths resulting from guns. Quietly, the industry and their lobbyists work the legislatures to stymie any effort to control opioids.

Latest Findings by the CDC

Today, opioids/71580?xid=nl_mpt_DHE_2018-03-07&eun=g1190552d0r&pos=0&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%202018-03-07&utm_term=Daily%20Headlines%20-%20Active%20User%20-%20180%20days">Medscape reported:

Emergency department (ED) visits for suspected opioid overdoses rose by 30% throughout the U.S. in a year, according to the CDC.

“All five regions of the U.S. saw significant increases during this time period,” said Anne Schuchat, MD, acting CDC director, in a CDC tele-briefing Tuesday.

If you come back later to Medscape article, you will see the comments section flooded with what appears to be an organized opposition to what supported facts MedScape presents and consequently any and all suggested Opioid control. Many of the posters appear to be the same ones time and time again. It is pretty apparent the pharma industry is attuned to any medical backed article going up advocating for Opioid control.

The analysis backing the increase in Opioid ER visits can be found in a new CDC Vital Signs report. The basis of its findings are from ~91 million ED visits in 52 jurisdictions in 45 states from July 2016 to September 2017. The data is reported in the CDC’s National Syndromic Surveillance Program (NSSP) Biosense Platform. The 142,557 visits to the ER reported as suspected opioid overdose cases equate to a 29.7% increase from the previous 1-year period.

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Opioids, the Quiet Killer

There are no loud guns shots in the middle of the night. No screams for help or sounds of cars speeding away. No police sirens or flashing lights. It is pretty quiet when someone ODs on Opioids unless someone finds them before it is too late.

As I wrote earlier; “From 2006 to 2015, pharmaceutical companies spent opioids-policies">$880 million in lobbying state and federal legislatures and contributing to campaigns to prevent laws restricting Opioid prescriptions. Opioid manufacturer lobbying expenditures has outstripped those such as STOPPNow advocating for greater controls on Opioids and prescriptions by 200 times at the state level.”

In comparison, only the NRA and its gun lobbying efforts in legislatures displays a similar capability to oppose and defeat any and all laws for bullet-spewing-weapons laws the same as the Opioid industry efforts to block legislation. Legislators pay attention when either industry or lobby calls on them.

Any particular article advocating greater regulation of Opioids or reporting of Opioid dangers on medical blogs such as Medscape, centers such as opioids-policies" >Public Integrity, news agencies such as Associated Press are met with a resistance (if they still have a comments section) the same as what is found on sites when they advocate for greater “gun control.” The evidence is overwhelming that there is an opioid epidemic in the nation resulting from usage and is similar to the epidemic of injury and deaths resulting from guns. Quietly, the industry and their lobbyists work the legislatures to stymie any effort to control opioids.

Latest Findings by the CDC

Today, opioids/71580?xid=nl_mpt_DHE_2018-03-07&eun=g1190552d0r&pos=0&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%202018-03-07&utm_term=Daily%20Headlines%20-%20Active%20User%20-%20180%20days" >Medscape reported:

Emergency department (ED) visits for suspected opioid overdoses rose by 30% throughout the U.S. in a year, according to the CDC.

“All five regions of the U.S. saw significant increases during this time period,” said Anne Schuchat, MD, acting CDC director, in a CDC tele-briefing Tuesday.

If you come back later to Medscape article, you will see the comments section flooded with what appears to be an organized opposition to what supported facts MedScape presents and consequently any and all suggested Opioid control. Many of the posters appear to be the same ones time and time again. It is pretty apparent the pharma industry is attuned to any medical backed article going up advocating for Opioid control.

The analysis backing the increase in Opioid ER visits can be found in a new CDC Vital Signs report. The basis of its findings are from ~91 million ED visits in 52 jurisdictions in 45 states from July 2016 to September 2017. The data is reported in the CDC’s National Syndromic Surveillance Program (NSSP) Biosense Platform. The 142,557 visits to the ER reported as suspected opioid overdose cases equate to a 29.7% increase from the previous 1-year period.

run75441 (Bill H)

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Crack v. Opioids and Violence v. Racism

Here’s is a PBS commentary by law professor Ekow Yankah:

That Kroger, the Midwestern grocery chain, has decided to make the heroin overdose drug naloxone available without a prescription is a sign of how ominous the current epidemic has grown.
Faced with a rising wave of addiction, misery, crime and death, our nation has linked arms to save souls. Senators and CEOs, Midwestern pharmacies and even tough-on-crime Republican presidential candidates now speak with moving compassion about the real people crippled by addiction.

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Opioid Use since 1968 and Why It’s Abuse Increased

In writing about the increase in Opioid abuse since 1980 and looking around for additional information for Robert Waldmann, I ran across this information as developed by the US Senate Joint Economic Committee. The committee is majority led by Republicans with Democrats being a part. The committee had added additional yearly data pre-1980, when the Jick and Porter letter had been written to the NEJM on the rarity of addiction from the use of Opioids, to 1968.


The bar chart on the left represents the total number of deaths per year from Overdoses solely from Opioids and Overdoses from all drugs during the time period of 1968 to 2015. The bar chart on the right represents the numbers of deaths per 100,000 of population from Overdoses solely from Opioids and Overdoses from all drugs during the time period of 1968 to 2015. To be redundant, from both of those charts you can see the increase in the total numbers of deaths by the numbers per 100,000 and the increasing number of deaths per year from 1968 to 2015. During this time period, there were several coincidental things going on which helped to increase the increased deaths. To point out the obvious, drug overdoses really did not start to increase until about 1997.

The Supporting Facts Leading to the Cause

1) This particular bar chart details the citation of a letter sent to the NEJM in 1980 by Doctors Jane Porter and Herschel Jick about a Boston Collaborative Drug Surveillance Program at Boston University Medical Center, Waltham, MA. The verbiage of this letter can be found in the Supplemental Appendix (scroll down). The published letter detail:

“Recently, we examined our current files to determine the incidence of narcotic addiction in 39,946 hospitalized medical patients who were monitored consecutively. Although there were 11,882 patients who received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients who had no history of addiction. The addiction was considered major in only one instance. The drugs implicated were meperidine in two patients, Percodan in one, and hydromorphone in one. We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.”

The letter says, we used Opioids in a “hospital” setting and there was no evidence of addition by patients except for one. From 1980 onward till 2015 the letter was cited 5 to 28 (1996) times per year affirming Opioids do not cause addition. The median number of citations of a letter in the NEJM is 11 times in total. There is nothing to indicate this letter had an impact until about 1997 when the numbers and rates of death due to Opioids doubled (see charts).

The bibliometric analysis of the citations and subsequent chart of the findings related to the Jick and Porter letter can be found in a subsequent 2017 letter to the NEJM entitled “A 1980 Letter on the Risk of Opioid Addiction,” dated June 1, 2017 authored by Doctors Leung, Macdonald, Dhalla, and Juurlink. The appearing and disappearing Supplemental Appendix which has the Jick and Porter Letter (cited) is a part of this article.

2) “In Prescription Painkiller Addiction: A Gateway to Heroin Addiction,” Recall Report organization documents the start of the explosion in opioid use tying it to the introduction of OxyContin by Purdue Pharma in 1995/96. Initially introduced here: Fighting Opioid and Painkiller Addiction Angry Bear September 2018. The increase in the citations of the Jick and Porter letter increases about the same time.

“An early manifestation of the opioid abuse, addiction, and overdose problem occurred largely in rural regions of Kentucky and other parts of Appalachia. OxyContin, a brand name for oxycodone, was introduced by manufacturer Purdue Pharma in 1996 and pushed hard to sell it to doctors. The company sold it as a less-addictive alternative to other painkillers because it was made in a time-release form, meaning users would get a slow onset of the drug, not a hit all at once which is more likely to lead to abuse.”

If a person wanted to abuse OxyContin, they would just grind it up and get the hit all at once.

3) In 2015, the US National Library of Medicine / American Health and Drug Benefits published the “New Perspectives in the Treatment of Opioid-Induced Respiratory Depression.”

“Overall, 44 individuals in the United States die from a prescription opioid overdose daily. In 2013 alone, an alarming 16,235 deaths were attributed to an opioid overdose, accounting for 37% of all drug-poisoning deaths in 2013 and a 4-fold increase from 1999. In addition, nearly 60% of all drug-poisoning deaths in 2013 involved prescription opioids and/or heroin. Furthermore, among individuals aged 25 to 64 years, deaths from a drug overdose—the majority of which were opioid-related—exceeded motor vehicle collisions as the leading cause of accidental death in 2013.”

4) Purdue Pharma pleads guilty in a DOJ lawsuit. In 2007 Purdue Pharma pled guilty in a lawsuit brought against the company by the Department of Justice. The charge was misleading doctors and consumers about how addictive OxyContin was. Purdue ended up paying over $600 million and three executives pled guilty to criminal charges.

5) People switched to Heroin to replace opioids as prescriptions for Opioids are reduced. The deaths from Heroin surpass the deaths by gun homicides. “OxyContin and other prescription opioids caused huge amounts of abuse, addiction, and overdoses. When doctors pulled back on prescriptions, a new epidemic began to arise. In 2015 heroin overdose deaths in the U.S. surpassed the number of deaths by gun homicide for the first time ever. In addiction treatment facilities around the country, heroin addiction is becoming the most common reason to enter treatment, surpassing even alcohol addiction.”

Summation

Robert brings forth a flawed argument made by Tom Nichols or Radio Free Tom; “‘A decaying country mired in poverty and addiction’. I am sorry you seem to have us confused with 1980, but with a positive message like this, you are a shoo-in Mike.” Robert argues back, “But Nichols really demonstrates his contempt for data and expertise by asserting that ‘poverty’ and ‘1980’ go together.” Of course Robert is correct in his facts. There is also no legitimate correlation between Opioids and poverty either. There is a lot of data to support Robert’s contention. The deaths from Opioids were less than one per 100,000 from 1968 until 1997 and from all drugs up till 1987. This can be seen in the charts at the top of the page.

The cause of the Opioid epidemic up till recently can be partially blamed on the misuse of a 1980 Jick and Porter letter to the NEJM. The letter cited the risk of addiction from the “use of Opioids in a hospital setting is rare.” Except when cited by people using this letter 608 times, 80.8% (491) of the citations to promote Opioids failed to mention the use of Opioids was in a hospital setting. Purdue Pharma, other companies, and doctors used this letter to promote the use of Opioids.

In 1996 with the introduction of OxyContin by Purdue Pharma, the use and abuse of the letter almost tripled. If we go back to the charts again, we can see that upon introduction of OxyContin in 1996 a year or so later the death rate per 100,000 doubles and continues to increase yearly. “The aggressive sales pitch led to a spike in prescriptions for OxyContin of which many were for things not requiring a strong painkiller. In 1998, an OxyContin marketing video called ‘opioids-pain/20180314/opioids-pain" >I got My life Back,’targeted doctors. In the promotional, a doctor explains opioid painkillers such as OxyContin as being the best pain medicine available, have few if any side effects, and less than 1% of people using them become addicted.” Increases in drug poisoning deaths involving prescription Opioids increases with 37% of all drug-poisoning deaths in 2013 being attributed to Opioids a 4-fold increase from 1999.

The party began to end after Purdue Executives plead guilty in 2007 and Purdue Pharma paid an $800 million penalty. People began to switch to Heroin as the supply of Opioids diminished and prescriptions were for 7 days or less.

In 1980, the country barely knew what Opioids were and the death rate from Opioids was less than 1 per 100,000. Poverty was low then also. The Opioid and Heroin crisis can be traced back to the healthcare industry; its misinformation, lies, and misuse of drugs; and its abuse of people’s trust.

by run75441 (Bill H)

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The Price of Naltrexone

In The New York Times Abby Goodnough wrote
” she got a Vivitrol (naltrexone) shot but it was so expensive — her co-payment was $600 — that she never got another” !!!

This is insane. Naltrexone is an opioid antagonist. It prevents opioids from causing a high (and relieving pain and suppressing coughing and breathing). In no way is it conceivably a drug of abuse. But opioid addicts who wish to cut off all effects of opioids have to pay for their Naltrexone.

Also (as explained in the excellent article) some of the same people who oppose the use of methadone and buprenorphine oppose naltrexone too. I have never understood their logic. I am sure it is based on a moralistic belief that there are no simple easy solutions. It isn’t even “no pain no gain” as cold turkey withdrawal while using naltexone is just as horrible as any other cold turkey withdrawal. Pointless speculation after the jummp.

But for now two practical proposals. Everyone who wants naltrexone for any reason should be given naltrexone (given no co-pay). I think this is obvious. Now somehow a drug which has been around practically forever is expensive, but the cost of paying off the pharmaceutical company whatever they demand for such a program (which will be great for them) is trivial compared to the costs of the opioid epidemic.

I should have provided a link to the Wiki on Naltrexone. Note the cost (retail) of oral Naltrexone is $0.74 a day — providing one a day to every addict and anyone who wanted to pretend to be an addict would cost hundreds of millions a year. This is a completely insignificant sum for the US government, so it should be done immediately. Delayed release Naltrexone is expensive (prescribing it with a $600 copay is bad practice of medicine). Here a technological improvement has made it possible for doctors to give the patients a better, but expensive option, which they don’t take.

I also have an impractical proposal that Naltrexone should be available over the counter — it can’t be abused and the reported side effects are the reported symptoms of being a person. However, I know this proposal is impractical.

My second practical proposal is phased drug assisted therapy. I think it should be
1) whatever you want for a week provided you don’t want a lethal dose (you want heroin — here’s your heorin)
2) second week whatever you want provided you take your methadone under our supervision. All the heroin you want will be none (it doesn’t do anything for someone full of methadone).
3) third week, 50% methadone 50% buprenorphine.
4) fourth week buprenorhine
5) fifth week 50% buprenorphine 50% naltrexone
6) 6th week through death do us part naltrexone.

Why not ?

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The AMA is Calling for a Relaxing of CMC Opioid Prescription Restrictions

A little history:

In 1980, the Porter and Jick letter to the editor of the New England Journal of Medicine by the Boston Collaborative Drug Surveillance Program stated:

“the risk of addiction was low when opioids such as oxycodone were prescribed for chronic pain.”

It was a brief statement by the doctors conducting the study, taken out of context, and cited many times afterwards as justification for the use of oxycodone.

In a June 1, 2017 letter to the NEJM editor, the authors reported on the broad and undocumented assumptions made as a result of the 1980 Letter on the Risk of Opioid Addiction.. Using bibliometric analysis of the impact of this letter to the editor, the citations of the 1980 letter were reviewed to determine the citation’s portrayal of the letter’s conclusions.

Identified in the bar chart are the number (608) of citations of the 1980 letter over a period of time from 1981 to 2017.

“72.2% (439) of the citations, quoted the letter or used it as evidence addiction was rare in patients when treated with opioids such as oxycodone. 80.8% or 491 of the citations failed to note the patients described in the letter were hospitalized at the time they received the prescription.”

There was a sizable increase of citations after the introduction of OxyContin (extended release oxycodone) in 1995. As the analysis noted “affirmational citations of the letter have become less common in recent years in contrast to the 439 (72.2%) positive and supporting citations of the 1980 correspondence in earlier years. The frequency of citation of this 1980 letter stands out as being unusual when compared to other published and cited letters. Eleven other published, stand-alone, and more recent letters on different topics published by the NEJM were cited at a median statistic of 11 times each.

Citations of the 1980 standalone letter on “addiction being rare” from the use of opioids such as oxycodone failed to mention, the patients administered to were in a hospital setting as noted in the Porter and Jick letter. Overlooked, a mistake, intentional misquote by the people citing this letter?

In 2007 in the pharmaceutical industry, “the manufacturer of OxyContin and three senior executives of Purdue Pharma plead guilty to federal criminal charges that they misled regulators, doctors, and patients about the risk of addiction associated with OxyContin.”

This year, law makers questioned Miami-Luken and H.D. Smith wanting to know why millions of hydrocodone and oxycodone pills were sent (2006 to 2016) to five pharmacies in four tiny West Virginia towns having a total population of about 22,000. Ten million pills were shipped to two small pharmacies in Williamson, West Virginia. The number of deaths increased along with the company and wholesaler profits.

60% of all drug-poisoning deaths in 2013 involved prescription opioids and/or heroin. Among individuals aged 25 to 64 years, deaths from a drug overdose—the majority of which were opioid-related—exceeded motor vehicle collisions as the leading cause of accidental death in 2013. Four in five new heroin users started out misusing prescription painkillers.

The information is out there as to why the abuse of opioids and related drugs is increasing. It is being ignored or argued against as limiting a patients rights to have unhindered access to opioids by doctors and patients alike. Sound familiar, similar to the gun lobby?

Today

AMA Delegates Back Physician Freedom in Opioid Prescribing At best, 20% of all doctors are members and the percentage has been declining. From the meeting; “The CDC’s guidelines on the use of opioids for pain management are well-intentioned, but some insurers and pharmacists have used them to restrict providing and need to be discouraged from doing so, members of the American Medical Association (AMA) House of Delegates said Tuesday.”

And the CDC response as told by one doctor. “a member of a pain management task force being convened by the Department of Health and Human Services. “Draft comments will be coming out in a couple of weeks and will very specifically address the misinterpretation of the CDC guidelines,” he noted. “This is really timely because the comments from the AMA will be extremely important in weighing in [on the issue].”

Doctors do no want interference with decision- making when it comes to patients. At the same time, little has been done to rein in addiction due to prescription opioids which lead to other addictions because prescriptions are expensive or are limited in access. Here is Janet from stopnow blog and who writes about addicted babies due to mothers taking opioids:

More overdose deaths last year than the entire Viet Nam War. The FDA approves sufentanyl 10 times stronger than fentanyl. Yesterday the AMA President was quoted using the same verbiage as Big PhRMA- undertreatment of pain. And now a campaign to undo the CDC guidelines which until they were released doctor education was coming from the drug companies. We need full disclosure – is this funded by Big PhRMA.

Here is a counter argument from a pharmacist where he misapplies the stats to suit his argument:

“it depends what numbers of overdose deaths you are referring to because it is certainly not more deaths due to opioid pain medications. There were 72,000 overdose deaths which includes ALL overdoses from ALL classes of medications. Overdoses from opioids were 49,000 and within that group only 19,354 were from opioid pain relievers. Deaths from fentanyl (illicit) totaled over 29,000, heroin almost 16,000, and cocaine 14,500. (One death could be counted in more than one category, numbers from NIH.) Vietnam war deaths totaled 58,220 versus 19,354 deaths from opioid pain medications. By the way, there were 10,684 deaths due to benzodiazepines, should the CDC mandate doses and days of therapy for those also?

I have no connections with or any payments/gifts from any drug manufacturer. My only concern is that in the national noise of the ‘opioid epidemic’ the focus is on those who abuse opioids and I want to make sure that we still hear the cry of the patient who needs pain relief and who does NOT abuse the medications.”

Yes the pharmacist is correct when he says of the 72,000 deaths only 19,354 can be attributed to opioid pain relievers in 2018. Janet cited the 20 years of Vietnam deaths. The pharmacist conveniently sidesteps the time periods involved here. In three years and if the numbers stay the same (they have been increasing YOY), the numbers of opioid deaths will be slightly less than 20 years of Vietnam if it were to remain at 19,000/year. Four in five new heroin users started out misusing prescription painkillers. Of recently cited 150,000 accidental deaths, opioids">72,000 (a record high) can be attributed to drug overdose deaths, a record high.

And this is ok?

60% of opioid deaths occur in those who were given a prescription by a physician. The other 40% of deaths are caused by people who obtained opioids by “doctor shopping,” and receive multiple scripts at once. The perceived safety and easy accessibility of these drugs have presented the highest risk for most users, even if they eventually seek out illicit opioids or “street drugs.” In 2014, only 22.1% of non-medical users obtained opioids through a doctor, meaning that the diversion rate of these drugs is very concerning. Many people are getting these medications illegally or without doctor supervision.”

by run75441 (Bill H)

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Fighting Opioid and Painkiller Addiction

Some History

In 1980, a letter to the editor of the New England Journal of Medicine by the Boston Collaborative Drug Surveillance Program stated “the risk of addiction was low when opioids such as oxycodone were prescribed for chronic pain.” It was a brief statement by the doctors conducting the study which was cited many times afterwards as justification for the use of oxycodone.

In a June 1, 2017 letter to the NEJM editor, the authors reported on the broad and undocumented assumptions made as a result of the 1980 Letter on the Risk of Opioid Addiction. Using bibliometric analysis of the impact of this letter to the editor, the citations of the 1980 letter were reviewed to determine the citation’s portrayal of the letter’s conclusions.

Identified in the bar chart are the number (608) of citations of the 1980 letter over a period of time from 1981 to 2017.

72.2% (439) of the citations, quoted the letter or used it as evidence addiction was rare in patients when treated with opioids such as oxycodone. 80.8% or 491 of the citations failed to note the patients described in the letter were hospitalized at the time they received the prescription.”

There was a sizable increase of citations after the introduction of OxyContin (extended release oxycodone) in 1995. As the analysis noted “affirmational citations of the letter have become less common in recent years in contrast to the 439 (72.2%) positive and supporting citations of the 1980 correspondence in earlier years. The frequency of citation of this 1980 letter stands out as being unusual when compared to other published and cited letters. Eleven other published, stand-alone, and more recent letters on different topics published by the NEJM were cited at a median statistic of 11 times each.

Citations of the 1980 stand alone letter on “addiction being rare” from the use of opioids such as oxycodone failed to mention, the patients administered to were in a hospital setting as noted in the letter by Porter and Jick. Overlooked, a mistake by the people citing this letter? “In 2007, the manufacturer of OxyContin and three senior executives of Purdue Pharma plead guilty to federal criminal charges that they misled regulators, doctors, and patients about the risk of addiction associated with OxyContin.”

Organization: “An early manifestation of the opioid abuse, addiction, and overdose problem occurred largely in the rural regions of Kentucky and other parts of Appalachia after the introduction of Oxycontin. A brand name for oxycodone, OxyContin was introduced in 1996 by Purdue Pharma and aggressively sold to doctors. Sold as a less-addictive alternative to other painkillers as it was made in a time-release formulation, allowing for a slow onset of the drug, and not a hit all at once which is more likely to lead to abuse. When used as prescribed, Oxycontin was safe. When ground up, it’s slow release characteristics were marginalized.

The aggressive sales pitch led to a spike in prescriptions for OxyContin of which many were for things not requiring a strong painkiller. In 1998, an OxyContin marketing video called “opioids-pain/20180314/opioids-pain">I Got My Life Back,” targeted doctors. In the promotional, a doctor explains opioid painkillers such as OxyContin as being the best pain medicine available, have few if any side effects, and less than 1% of people using them become addicted.

Shortly after 1996, Porter and Jick’s letter citations doubled and continued to be cited in a positive fashion with few negative citations and a failure to mention the hospital setting where the drugs were administered.

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By 2015 over a six-year period, more than 183,000 deaths from prescription opioids were reported in the United States. Today, millions of Americans are now addicted to opioids.” In part much of this was the result of doctors being told there was a low risk to opioid addiction.

Figure 2 shows each year being progressively worse and reaching a record high of 71,568 deaths (2017) in the US due to all drug overdoses as reported by the Centers for Disease Control (CDC) in their “Provisional* estimates on U.S. drug overdose. According to the CDC this is a record and represents a 6.6% national increase in overdose deaths over 2016.

At the end of the 12-month period of January 2018, the reported deaths was 69,703. The final and predicted number of deaths is expected to be as high as 71,568. 0.18 of 1% of the reports are pending the completion of investigation (numeric within chart). *Underreported due to incomplete data.

*Provisional counts of all drug overdose deaths are underestimated relative to final counts. The degree of underestimation is determined primarily by the percentage of records with the manner of death reported as “pending investigation” and tends to vary by reporting jurisdiction, year, and month of death. Specifically, the number of drug overdose deaths will be underestimated to a larger extent in jurisdictions with higher percentages of records reported as “pending investigation,” and this percentage tends to be higher in more recent months”.

In 2018 law makers questioned Miami-Luken and H.D. Smith wanting to know why millions of hydrocodone and oxycodone pills were sent (2006 to 2016) to five pharmacies in four tiny West Virginia towns having a total population of about 22,000. Ten million pills were shipped to two small pharmacies in Williamson, West Virginia. The number of deaths increased along with the company and wholesaler profits.

For context, the nearly 72,000 drug overdose deaths (spurred by the ongoing opioid painkiller addiction epidemic, including the increased use of more potent synthetic opioids [fentanyl]) outpaced fatalities from suicide, or from influenza and pneumonia, which claimed about 44,000 and 57,000 lives in 2016. It nearly rivaled the approximately 79,500 people who die from diabetes-related complications each year in the U.S. (the 7th leading cause of death).

Nearly 150,000 Americans die each year from accidents such as car crashes, injuries, or accidental overdoses. If the CDC’s latest figures are accurate, drug overdoses could account for nearly half of accidental deaths.

As tends to happen with public health epidemics, overdoses have an outsize effect in certain regions. For instance, the biggest spike in fatalities by percentage occurred in Nebraska, North Carolina, New Jersey, Indiana, and West Virginia (33.3%, 22.5%, 21.1%, 15.1%, and 11.2% rises, respectively). But areas like Wyoming, Utah, and Oklahoma experienced declines of 9.2% to 33%.

With the clamp down on opioid prescriptions by doctors due to the abuse, addiction, and overdoses, those addicted to opioids turned elsewhere. Again Recall Report;

“In 2015 heroin overdose deaths in the U.S. surpassed the number of deaths by gun homicide for the first time ever. In addiction treatment facilities around the country, heroin addiction is becoming the most common reason to enter treatment, surpassing even alcohol addiction.

In combatting the prescription painkiller addiction epidemic, public officials may have unwittingly contributed to the heroin epidemic. As prescription opioids became more difficult to obtain and more expensive, addicts turned to a cheaper similar high: “heroin.” Mexican drug cartels were more than willing to supply the demand and much of the cheap heroin in use in the country now comes through Mexico.”

The ease of accidentally overdosing can be a tragic consequence resulting from the abuse of opioids and heroin. Both drugs act upon areas of the brain controlling breathing and depress it. Too much opioid drug can cause a person to stop breathing and their subsequent death. Add alcohol or a sedative and the risk increases. To combat the impact of overdosing on opioids or heroin, Narcon in an injection or a nasal spray format acts as an antagonist reversing the effects of opioids and the overdose.

Stopping the abuse of opioids is an important measure in gaining control of the growing number of people becoming addicted to opioids and dying from its abuse. Once addicted, treatment is essential with detox and withdrawal the first painful step back to a normal life. Without supervised treatment and/or residing in a residential treatment center, the return to opioid usage and addiction is easy as the cravings for using it again are powerful. As a resident in a treatment center, therapy, support, and medical treatment with drugs is possible.

The abuse of opioids and subsequent addiction will remain a problem for years to come until the supply of it is brought under control.

Prescription Painkiller Addiction: A Gateway to Heroin Addiction, Recall Report Organization

A 1980 Letter on the Risk of Opioid Addiction, NEJM, June 1, 2017

Supplementary Appendix NEJM, June 1, 2017; Copy of Porter and Jick’s letter to NEJM in 1980.

Provisional Drug Overdose Death Counts CDC, National Center for Health Statistics, August 5, 2018

by run75441 (Bill H)

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News on Purdue Pharma…

(Dan here…From Esquire comes this note from the Boston Globe):

We begin with good news up here in the Commonwealth (God save it!), where Attorney General Maura Healey, who does not punch down, has opened hostilities against the pharmaceutical companies that have raked in the profits from the opioid crisis. From The Boston Globe:

She asserts that the privately held company and 16 of its key directors and executives actively obfuscated the truth about opioid use, downplaying the perils of addiction and overdoses with the aim of getting more people to take them at higher doses for longer periods of time in order to boost the business’s bottom line. “Purdue Pharma created the epidemic and profited from it through a web of illegal deceit,” the lawsuit alleges. While several other state attorneys general have taken similar legal action against Purdue, Healey’s action Tuesday opens a new front in the battle against the scourge of overdoses in Massachusetts. And the suit, filed in Suffolk Superior Court, hints the state could be seeking damages to the tune of billions of dollars.

“We found that Purdue misled doctors, patients, and the public about the real risks of their dangerous opioids, including OxyContin,” Healey said at a news conference, standing next to officials including Governor Charlie Baker as well as families who have lost loved ones to overdoses. “Their strategy was simple: The more drugs they sold, the more money they made — and the more people died,” Healey said. An investigation by Healey’s office found that since 2009, 671 people who filled prescriptions for Purdue opioids in Massachusetts subsequently died of an opioid-related overdose, the legal complaint says.

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