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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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Healthcare News PBM Profits, Expensive Drug(s), Food Protein, and the Opioid Scam

Cigna gets major boost from Express Scripts in Q2,” Robert King, FierceHealthcare, August 1, 2019

And some claim PBMs do not matter in the cost of healthcare? Cigna healthcare insurance generated ~ $38 billion in revenue the second quarter 2019 and a major increase due mostly to a merger with pharmacy benefit manager (PBM) Express Scripts.

According to company financial results released Thursday, Cigna’s pharmacy services business generated $23.5 billion in revenue in the second quarter which represents a massive increase compared to the $1.1 billion generated in the second quarter of 2018. The company reported $1.41 billion in net income.

The major reason for the spike is the gain from the membership and resources achieved from the deal for Express Scripts. Cigna completed the $67 billion merger with the PBM giant late last year.

More Plant-Based Protein in Diet May Add Years,” Nicole Lou, MedPageToday, August 27, 2019

“Significant reductions were found (specifically) in mortalities related to cardiovascular disease. Norie Sawada, MD, PhD, of Japan’s National Cancer Center in Tokyo reported and colleagues reported a positive result in a prospective cohort study of plant protein being substituted for meat protein. It was reported in recent JAMA Internal Medicine study, “Association of Animal and Plant Protein Intake With All-Cause and Cause-Specific Mortality.”

The JAMA study (Association of Animal and Plant Protein Intake With All-Cause and Cause-Specific Mortality) suggests diets with higher plant-based protein intake may contribute to long-term health and longevity. In this cohort study; 70,696 Japanese adults were followed up on for a mean period of 18 years. The outcome associated a higher intake of plant protein resulted in lower total mortality. Moreover, the substitution of plant protein for animal protein, mainly for red or processed meat protein, was associated with lower risk of total, cancer-related, and cardiovascular disease–related mortality.

Furthermore, switching out 3% of daily calories from red meat to plant protein — approximately 260 g of a soy-based food for the average person eating 2,000 calories per day — was linked in statistical models (not through analysis of individuals who actually changed their diets) to reductions in mortality risk.

It is no secret retail drives the meat processing market where large manufacturers and meat packers are big enough to control the market and can drive the pricing down or up per each of cattle. Smaller cattle producers can be driven out of the market as they do not have the massive volume ability to lower their costs of production past a certain point. The criticisms of the plant based protein study I have read are similar to the criticism I have read limiting opioid prescriptions in which they advocate do not limit opioid at all. We could all do with less red meat in our diets which still remains a reality.

The $6 Million Drug Claim, Katie Thomas and Reed Abelson, NYT, August 25, 2019

The link should take you to a different site other than the NYT where you can read the article.

Alexion Pharmaceuticals manufactures Strensiq a drug used to treat a rare bone disease perinatal/infantile and juvenile – onset hypophosphatasia. Adult Dawn Patterson also suffers from the same disease, the excruciating pain from it, which leaves her struggling to work or care for her family. It is a rare disease found more often in children and even rarer in adults.

Dawns husband’s union covers the cost of the drug. The union is suffering sticker shock from the mounting bills for treatments of her and her two of her children who also have the disease. In 2018, the union faced a potential $6 million bill for the Patterson household with an estimated a lifetime cost of $60 million to treat the family over 10 years.

The cost of Strensig as well as other drugs is coming under increased scrutiny and debate over whether any drug should cost $millions of dollars after cost of R&D and start up are recovered. Americans are being priced out of lifesaving treatments as drug companies maximize their profits well beyond start up costs. It has been found, the investment of $1 invested in R&D has provided $14.50 in revenue for cancer drugs (World Health Organization).

As I reported in “Cigna gets major boost from Express Scripts in Q2” (above), Pharmacy Benefit Managers are taking a hefty cut in the process in representing insurance companies with manufacturers. In an earlier post “Can you Patent the Sun,” I had talked more on the topic of costs and company reasoning to set higher prices. Manufacturers are pricing new and older drugs higher and establishing a pseudo morality to maximize their profits.

The US is more vulnerable than is European countries only because Europe sets pricing rather than allow the market to do so.

Opioid Maker Turned Blind Eye to Diversion, Kristina Fiore, MedPage Today, August 28, 2019

In newly unsealed documents, Mallinckrodt employees were worried the existing programs to prevent opioid diversion were not working. One former employee testified about Mallinckrodt not having a computerized system from 2008 to 2009 for tracking unusual orders. Employees had to use their judgment to identify suspicious sales. U.S. Drug Enforcement Agents met with Mallinckrodt PLC and informed the company the agency viewed it “as the kingpin within the prescription drug cartel.”

Superior Court for the State of Alaska Third Judicial District in Anchorage, State of Alaska, Plaintiff vs. Mallinckrodt PLC, Mallinckrodt LLC, and SPECGX LLC.

“In reality, however Mallinckrodt shipped opioids into Alaska without an adequate system in place to prevent diversion of its opioids and to investigate, report, and refuse to fill orders that it knew or should have known were suspicious, breaching both its common law duties and its statutory duties under Alaska law. Despite its legal and ethical duty to report “suspicious orders” of its drugs, and, upon information and belief, ample red flags of potential diversion, Mallinckrodt has never once reported a single prescriber to state law enforcement or the Alaska State Medical Board. Instead, Mallinckrodt incentivized distributors to flood the State with opioids beyond even what the expanded market for chronic pain market could bear.”

Mallinckrodt Was Required to and Failed to Maintain Effective Controls Against Diversion and to Report Suspicious Prescribers. , Page 35, B

There are multiple state lawsuits being filed federal courts nationwide claiming pharmaceutical companies misled people as to the safety of opioid usage.

Opioid settlement would divide money based on local impact, Geoff Mulvihill and Andrew Welsh-Huggins, AP, August 30, 2019

Purdue the maker of OxyContin is negotiating a multi-billion-dollar settlement to resolve a crush of lawsuits over the nation’s opioid crisis. The settlement contains formulas for dividing up the money amongst state and local governments across the country.

The formulas would take into account several factors; opioid distribution in a given jurisdiction, the number of people who misuse opioids, and the number of overdose deaths.

Spelling out the way the settlement is to be split is meant to prevent squabbles over the money avoiding the mistakes experienced with the hundreds of billions of dollars received under the nationwide settlement with Big Tobacco during the 1990s.

September 8; States Attorneys and Purdue have reached an impasse and it is expected Purdue will now file for bankruptcy. It is not clear what the breakdown is over. One of the four states attorneys negotiating with Purdue, Pennsylvania’s Josh Shapiro said Saturday he intends to sue the Sackler family as other states have.

“I think they are a group of sanctimonious billionaires who lied and cheated so they could make a handsome profit. I truly believe that they have blood on their hands.”

Run75441 (Bill H)

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Purdue Offers Up $10 – 12 Billion to Settle All Lawsuits – MedPage Update

Just revealed:

The opioid/OxyContin maker Purdue and members of the billionaire Sackler family owning the company have offered to settle thousands of lawsuits against the company for $10 to $12 billion. according to people briefed on the offer. More than 2,000 states, cities, and counties across America are pursuing the OxyContin maker over the large bills for cleaning up the opioid crisis — and are deciding whether to accept the offer by Friday. The Financial Times is reporting on this offer from the Sacklers and Purdue.

On August 26, Purdue paid $270 million to Oklahoma and Teva Pharmaceuticals paid $75 million also to Oklahoma.

From the Financial Times: “Purdue said it believes a ‘constructive global resolution is the best way forward’ and is working with state attorneys-general and other plaintiffs to achieve it. While Purdue Pharma is prepared to defend itself vigorously in the opioid litigation, the company has made clear that it sees little good coming from years of wasteful litigation and appeals”.

For all the harm done to this nation due to purposeful deceit and lies on the use of opioids claiming it was not addictive, someone needs to go to prison from the Sackler family.

Purdue Exposed

Medpage Today, Kristina Fiore, August 28,2019

I suspect with the new information being available, Purdue finally threw in the towel and offered a settlement. I also suspect this will impact other companies decisions to appeal as J & J is doing.

STAT News Wins Legal Fight Over Purdue Documents

A trove of documents detailing Purdue Pharma’s role in the opioid epidemic will be made public, STAT News reported, as the Kentucky Supreme Court denied the company’s request to review lower courts’ decisions to release them.

STAT waged a 3.5-year legal battle to make those records public. While some remain under seal, the outlet posted a sought-after video deposition of Richard Sackler. It had obtained a transcript of that deposition in February, which gained further attention when comedian John Oliver hired famous actors including Bryan Cranston and Michael Keaton to re-enact it.

The documents promise new information on how Purdue promoted its oxycodone product OxyContin and what, exactly, its executives knew about its risk of addiction. Among those documents are depositions of other Purdue executives; physician testimony; emails and memos about marketing strategies; internal reports on clinical trials; and communications about earlier legal cases.

All of the documents were part of Kentucky’s lawsuit against Purdue over its alleged illegal marketing of OxyContin. That suit was settled in 2015, with Purdue shelling out $24 million.

Purdue may soon be paying a far higher bill, with media including NBC News reporting that the company has pitched a $10 to $12-billion settlement in the consolidated cases set to go to trial before a federal judge in Ohio in October.

This does not bode well for Purdue, its settlement, or threat of years of litigation. The smoking gun was always there and pieces of it can be found in previous posts of mine. Relating the US Senate Joint Committee numbers to when Oxycontin was introduced after 1995 and the incremental increase in deaths from opioids, the use of a part of the Porter and Jink letter to the NEJM which said opioids were not addictive “minus the part where it said when used in a hospital setting,” the abuse of the Porter and Jink letter in the number of citations, the millions spent in lobbying state legislatures to block new laws, etc.

John Oliver uses Keaton and Cranston to portray Richard Sackler in this 20 minute Clip. It is worth watching. “the launch (Oxycontin) would be followed by a blizzard of prescriptions that will bury the competition. The blizzard will be so deep, dense, and white,.”

Run75441 (Bill H)

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J & J and It’s Subsidiary Janssen’s Actions “Created a Public Nuisance”

“The court found that Johnson & Johnson’s actions had created a “public nuisance,” which Oklahoma law defines to mean an act (or failure to act) that ‘annoys, injures or endangers’ the health and safety of an ‘entire community.’

In a 42-page opinion, Oklahoma State Judge Thad Balkman details how Johnson & Johnson’s sales and marketing assured doctors the appearance of addiction in patients due to the use of J & J opioid products was actually evidence of ‘under-treated pain’ and required the prescribing of more opioids. Sales representatives used these aggressive marketing tactics to target prescription-happy doctors referred to as ‘Key Customers’ in internal correspondence.”

I can not help but feel there comes a time when one must look at the continuing misuse of opioids under a doctor’s care and wonder what the doctors were thinking.

Multiple times I have written on the deadliness of opioids. To market and promote the use of opioids, the pharmaceutical industry deliberately took one sentence of a letter written by Doctors Porter and Jink to the NEJM in 1980 and claimed the use of opioids as safe in all environments and not mentioning Porters and Jink’s study was done in a hospital setting.

Addition Rare in Patients Treated with Narcotics, NEJM 1980: “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.” Boston Collaborative Surveillance Drug Program, Boston University Medical Center, Waltham NA 02154

From 1980 till 2015 the letter was cited 491 of 608 times affirming the use of opioids does not cause addiction. There was a significant increase in citation after the introduction of OxyContin in 1995. The “median number” of citations of a NEJM letter was 11 times in total. The citation of one sentence in whole or partially was many times more.

In Prescription Painkiller Addiction: A Gateway to Heroin Addiction,” Recall Report documents the start of the explosion in opioid use tying it to the introduction of OxyContin by Purdue Pharma in 1995/96.

The United States Congress Joint Economic Committee provides two charts detailing 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 (rate) of population from Overdoses solely from opioids and Overdoses from all drugs during the time period of 1968 to 2015. There has been arguments made there is no discernable evidence showing the impact of prescription opioids on the numbers of deaths. These two charts certainly points in a direction of the impact of prescribed opioids on the death rate.

Up till seeing the Joint Committee data, I had not seen earlier data. In these charts can be seen the additional yearly data predating 1980 when the Jick and Porter letter had been written to the NEJM going back as 1968. This data is important to see the magnitude of the introduction of prescribed opioids such as Oxycontin and the influence of them and the pharmaceutical industry on the usage of opioids said to be a safe drug to use outside of supervision.

State Judge Thad Balkman’s verdict will be appealed in higher state courts. If upheld, it will go to the federal courts. J & J is not a company without financial resource and they will contest this verdict as far as they can take it. The importance of the verdict is in holding a company, a citizen amongst us as declared by SCOTUS responsible for the abuse of opioids as shown in the numbers presented in this post, in earlier posts, and in the related documentation presented in all of my posts on opioids.

Reference Data

What the Oklahoma Johnson & Johnson Verdict Means for the Future of Opioid Litigation, Jay Willis, Microsoft News, August 27, 2019

Opioid Use since 1968 and Why It’s Abuse Increased, run75441 (Bill H), April 7, 2019

The Rise in Opioid Overdose Deaths, US Senate Joint Economic Committee, August 01 2017

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

run75441 (Bill H)

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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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