Study Analyzes Pediatric Opioid Exposures

177Using data from the National Poison Data System, a new study published in the journal Pediatrics examined the more than 188,000 reported exposures to prescription opioids among children and adolescents younger than 20 years old between 2000 and 2015. The study found that healthcare facility (HCF) admission occurred in 8.7 percent and 21.5 percent of exposures among children aged 0-5 years and teenagers, respectively, while serious outcomes were more frequent among teenagers. Highlights from the report included:

  • The annual number and rate of exposures increased early in the study period but declined after 2009, except for buprenorphine exposures, which increased during the last three years of the study;
  • Hydrocodone accounted for the largest proportion of exposures (28.7 percent), and 47.1 percent of children exposed to buprenorphine were admitted to an HCF;
  • Children aged 0-5 years accounted for almost 90 percent of buprenorphine exposures;
  • The odds of being admitted to an HCF were higher for teenagers than for children aged 0-5 years; and
  • The rate of prescription opioid-related suspected suicides among teenagers increased by 52.7 percent during the study period.

The study concluded that greater efforts are needed to prevent opioid exposure to children of all ages, while particular attention should be paid to buprenorphine exposures among young children, which frequently result in HCF admission and are not declining in frequency.

Despite progress, Lake County’s fight against opioid epidemic sees early setbacks in 2017

il_lcnsIt was only three days into the New Year when Lake County sheriff’s deputies responded to a report of an unconscious man at a Deep Lake Road home outside Lake Villa. The 27-year-old’s heroin overdose was reversed by deputies using the opiate antidote Naloxone.

Since then, the saves have just kept on coming for the sheriff’s office.

On Jan. 8, deputies responded to a car accident in Ingleside, near Rollins and Wilson roads, and found the driver of one of the vehicles unconscious. Deputies determined the 31-year-old was overdosing on opioids, but the first dose of Naloxone had no effect. A second deputy arrived and two more doses were administered before the driver regained consciousness. Four days later, a 30-year-old Ingleside woman found by a family member could not be revived. The following day, deputies were successful in reviving a 30-year-old man from unincorporated Libertyville who needed two doses.

Last year, the sheriff’s office was responsible for saving 14 lives using Naloxone, and if the start of 2017 is any indication, the opioid epidemic might be increasing. In 2016, deputies saved two people in January and didn’t have another save until March.

“This is a major communitywide problem. Overdose from opioids has become far too common and exactly why treatment is a critical component,” said Undersheriff Ray Rose, who is part of the Lake County Opioid Initiative. “We as a community have to ensure those suffering from opioid addiction receive proper treatment to end this epidemic.

Mary Gardner of Waukegan, seen here in June 2016, is one of the former opioid addicts who received extended treatment through the Lake County Health Department’s Medication Assisted Treatment program. (By Frank Abderholden / Lake County News-Sun)

“We need to give people a second chance to get where they need to be,” he said. “But that alone is not the solution. One guy we saved — it was the fourth time we saved him. That’s why treatment is the next step. That’s how we will be able to solve the epidemic.”

Sheriff Mark Curran said deputies have saved more than 25 lives since the Naloxone program began just over two years ago.

“While I am grateful for the lives saved, we are currently in an opioid epidemic and are losing far too many lives to opioids,” Curran said.

According to the latest statistics from the Lake County coroner’s office, opioid or heroin-related deaths went up from 39 in 2014 to 42 in 2015.

Lake County Coroner Dr. Howard Cooper said that for the first three quarters of 2016, there were 31 opioid- or heroin-related deaths, which was down from the same period in 2015.

“It’s an epidemic, and not just in Lake County but the nation as a whole,” Cooper said. “The biggest problem is (heroin) is very inexpensive and very easily obtained. So it’s a huge problem.”

Contraband recently seized by the Lake County Sheriff’s Office includes heroin and prescription drugs. (Lake County Sheriff’s Office)

Debbie Guggenheim, director of the Jordan Michael Filler Foundation of Highland Park — which is named for a 23-year-old man who died of an overdose in January 2014 — said the epidemic is getting worse. She said police have made 130 saves since the program started three years ago

In October, the foundation donated almost 1,500 doses of Naloxone nasal spray to the Lake County Opioid Initiative to supply police officers with the antidote for 2017. The foundation has also pushed for legislation to loosen privacy laws when parents are trying to find out medical conditions of their 18-year-olds, who as adults are protected under the law from having doctors disclose any medical information about them.

“We are still fighting an uphill battle for sure,” she said of opioid addiction in general. “It’s a major, major problem.”

A specific problem Guggenheim sees is the rise of fentanyl overdoses, which are usually fatal because the synthetic opioid is so much more powerful than heroin.

“It’s now in pill form, and it’s frightening,” she said. “It’s lethal to the touch. If you have an open sore or get enough on your skin, it can kill. It’s terrifying, and it’s being cut with heroin more and more.”

Guggenheim added that fentanyl is so deadly it takes four to six doses of the antidote to revive victims, and most officers aren’t carrying four doses. She pointed out that the window in which a person overdosing needs the antidote is smaller with fentanyl than with heroin, where the antidote is needed within 3 to 4 minutes.

According to Cooper, there were eight fentanyl deaths in the county during the first three quarters of 2016. In 2015, there were three people with the drug in their system when they overdosed. He said fentanyl is about 100 times more powerful than morphine.

“The more publicity about (fentanyl), the better,” Guggenheim said. “Some parents have never heard of it.”

In Lake County, advocates, law enforcement, prosecutors and health services have teamed up under the umbrella of the Lake County Opioid Initiative to try and save lives and get people into treatment. They use a wide array of strategies.

At the organization’s website,, a map is featured of 31 places in the county where someone can take old prescription drugs or unused medication for disposal. All are police stations, except for Walgreens stores in Deerfield and Waukegan. Sometimes a young person’s first encounter with an opioid drug comes from the medicine cabinet at home or a friend’s house, according to the website.

Lake County State’s Attorney Michael Nerheim has also approached the problem in a number of ways, from drug court — where more than 30 people opted for treatment to avoid going to jail in 2016, a slightly higher number than in 2015 — to the newest program called “A Way Out.”

“It’s a pre-arrest strategy,” Nerheim said. Rather than getting arrested and then offered treatment, an addict in this program can go to one of seven police stations 24 hours a day, seven days a week, and tell authorities he or she is seeking treatment for their addiction. Drugs and paraphernalia can be turned over without charges.

“We’re trying to help people who have decided on their own to get treatment,” he said. “Anyone that struggles with an addiction knows sometimes there is a window of opportunity. A person wakes up at 2 a.m. and decides they are tired, they are done, they need help. Now they have somewhere to go.

“We’ve had over 60 people take advantage of it, and you don’t have to be a resident of that town,” Nerheim added. “We had one guy cross a couple of county lines from the south to go to Mundelein after hearing about it on the news. (It’s) about people ready to help themselves.”

Departments participating in A Way Out include Grayslake, Gurnee, Libertyville, Mundelein, Lake Forest, Round Lake Beach and Round Lake Park. Nerheim said other departments can refer people to those departments.

When people do end up in jail with an addiction, Rose said officials have a program for them. Since August, five people joined a program where they are given Vivatrol, which can cut opioid cravings for up to 28 days with a single injection. According to Rose, Lake County is only the second county in the state to administer the drug, whose cost has dropped from $1,100 per treatment to just $3.

“It’s the best option in terms of treatment,” Rose said. “It cuts the craving and the need for opioids, and it does a good job of doing it. This really seems to be a success. The problem is once they are out, they need to seek treatment on their own.”

Lake County Opioid Initiative co-founder Chelsea Laliberte — who lost her brother, Alex “Lali” Laliberte, in December 2008 to an overdose involving heroin and other drugs — said A Way Out will be expanded this year to a few more departments because a little more funding is available.

“That program has helped 65 people since June,” said Laliberte, whose family started Live4Lali, a foundation fighting to save lives through the antidote.

Live4Lali also has a clinic in Arlington Heights, open three days a week, where parents can get educational materials, free training and the antidote if they suspect their child may be experimenting with heroin or opioids. They have trained 600 parents, and Lali’s Law in Illinois now allows someone to ask for the antidote at a pharmacy.

“It’s always about ‘just in case,'” Laliberte said. “There is a stigma that families don’t want to talk about it because they are so ashamed.”

She added that the problem of opioid addiction knows no geographical boundaries, with the 130 saves happening in towns from Antioch to Zion, Waukegan to Fox Lake, and more high-income communities like Highland Park, Deerfield, Libertyville and Buffalo Grove.

“This is an issue that affects all walks of life,” Laliberte said. “This is not going away. People need to reach out and ask for help. There are so many resources out there.”

Cooper said his office is starting a pilot program this spring to address the issue with high school students.

“I believe to stop it, we need to get into the schools,” he said. “I want kids to know that the first time you try (opioids), you can be hooked. And it’s a very difficult habit to break.”

Next school year, Cooper said he intends to go to all the high schools in the county and then maybe middle schools.

This year, the Lake County Health Department’s Behavioral Health and Primary Care program will use a $325,000 grant from the U.S. Health Resources and Services Administration, an agency with the U.S. Department of Health and Human Services, to double the number of people in its Medication Assisted Treatment program for opioid addiction.

“We’ve added 65 patients as part of our program, and our goal is to get to 100 new clients,” said Loretta Dorn, director of clinical operations for the program. “That will bring the total to 200 overall. It shows you what kind of need there is.”

According to Dorn, it takes about a week from the first call to get into the program, which is offers outpatient treatment only.

“We found people can be successful in outpatient treatment,” she said. “But there are a lot of people who need more additional treatment.”

Dominic Caputa, the Health Department’s associate director of clinical operations, said the other aim of the program is get people additional services.

“They can get access to therapy, primary care and a dentist,” he said, adding that charges are based on a sliding scale of affordability.

Nerheim said some progress is being made, because Lake County is doing better at addressing opioid addiction than other areas of the country.

“Nationally, the rates are still climbing, but here in Lake County they are leveling off and declining,” he said, adding that some of the decline can be attributed to all the overdose saves that didn’t become a death statistic.

Between 2000 and 2015, the national rate of deaths from drug overdoses has increased 137 percent, including a 200 percent increase in the rate of overdose deaths involving opioids, which are classified as opioid pain relievers and heroin, according to the Centers for Disease Control and Prevention.

More persons died from drug overdoses in the United States in 2014 than during any previous year on record. From 2000 to 2014, nearly half a million people in the United States died from drug overdoses. In 2014, there were approximately 1.5 times more drug overdose deaths in the United States than deaths from motor vehicle crashes, according to the CDC.

Laliberte said Lake County is fortunate, because many other areas in Illinois and other states do not have the cooperation between the community, advocates, law enforcement and the health department.

“It’s working. It’s not perfect, but we’re certainly making a lot of progress,” she said. “It’s a very complex problem and requires us to try new strategies. Really it’s a community problem and it will take a community response.”

No Needle Needed: America’s Heroin Epidemic

areas-in-the-us-with-the-highest-heroin-abuse-1For years, drug addiction advocacy groups have warned there was a growing epidemic in the U.S. that would only get worse if lawmakers failed to pay attention. Specifically, the concern for many was that heroin was becoming more and more appealing to teenagers — many of whom were overdosing and dying.

Nationwide, heroin deaths increased 45 percent between 1999 and 2010.

In 2002, 166,000 Americans reported using the drug, but in 2012, 335,000 Americans said they had used heroin in the past year. But according to Michael’s House, a rehab facility for recovering heroin addicts, the average age of heroin users in the U.S. is currently 21 years old.

Heroin use has become so problematic in some states such as Vermont that the state’s Gov. Peter Shumlin devoted much of his State of the State address to discuss the use of the drug in the state.

Unlike the heroin of yesteryear, which required a needle, users nowadays can buy a powder-filled capsule that can be broken open and snorted — for just $10.

Part of the attraction to heroin for many teens is the price and ease of ingesting the drug.

Unlike the heroin of yesteryear, which required the use of a needle, users nowadays can buy a button — a powder-filled capsule that can be broken open and snorted — for just $10. And the drug is widely available.

And instead of buying from a dealer in an alley, teens can purchase buttons from people on varsity sports teams, Ivy League campuses and in suburban neighborhoods.

Addiction fueled by pain pills

What’s even more terrifying for some such as Dan Duncan, associate executive director at St. Louis’s National Council on Alcoholism and Drug Abuse, is that most heroin users’ addiction starts with the use of pain pills.

According to Dr. Nora Volkow, director of the National Institute on Drug Abuse, there were 210 million prescriptions for opiate medications written in 2011 alone in a country with 312 million people. But since the pills are so expensive on the black market, many turn to a cheaper alternative like heroin, which is a painkiller.

Andrew Jones’ family knows this to be true all too well. Jones was in his sophomore year of college when he had his first experience with an opiate. Though Jones was always someone who discouraged drug use, including marijuana, Jones became addicted to prescription painkillers after he had to take them for a virus that damaged his pancreas, broke his hand and had his wisdom teeth removed.

“He would steal them, he would buy them, he would find them wherever he could,” said Jones’ friend Katie Gerstenkorn. “He stole painkillers from me, actually.”

Although experts say it takes months or longer to become truly habituated to heroin, Jones’ friends and family say that after he was given a capsule of heroin at a party, he became hooked.

“He couldn’t get away from the drug,” said his mom, Pam. “It’s a hunger, it’s a thirst. You throw all your morals out the window.”

Jones eventually began stealing money from his roommates so he could buy more heroin. He went to rehab, was released –then overdosed, and then went back to rehab.

His family and friends said they thought he was going to overcome his addiction, but soon Jones overdosed and died at the age of 23.

Jones’ story is tragic, and drug addiction experts say that his is a typical story. Duncan said that in 2008 the NCADA saw a spike in the number of people calling the organization’s help line, and Duncan says most of those calls were specifically about helping teens.

“It became clear that this was a problem in some of the best high schools in the area,” he said. “Public, private, most of them,” .

St. Louis County Police Chief Tim Fitch added that what he found most startling about the surge in deaths from heroin overdoses was the average age of the users.

“Historically the age for most heroin deaths has been in the 40-to-45 range,” Fitch said. “But now the average age is between 18 and 25.”

And as “Emily” told TeenVogue, she started using heroin at the age of 14 after joining the varsity cheerleading squad at her school. By the age of 15, Emily says she was a regular user, but she was able to hide her addiction by getting good grades and staying out of trouble.

“It was like I was leading a double life,” she said. “I thought, maybe this is my little secret, and it’s not as bad as everyone says it is.”

Emily says at first she only used the drug during the weekend, which she got from a friend of a friend’s 30-year-old brother. She said he gave her the drug for free and then began to pressure her to have sex with him, which she eventually agreed to.

“I slept with him because I felt like he was giving something to me, so I had to give something to him,” she said.

Soon Emily was skipping school, decided to not try out for the cheerleading squad, and began to use heroin on a daily basis. Emily said it wasn’t until a friend of hers expressed an interest in trying the drug on her 16th birthday that she realized heroin was a drug many other teens were using as well.

During the next two years Emily went to rehab six times, overdosed twice, and attended 12-step meetings, but she continued to use the drug. But then she says something in her brain clicked.

“I was willing to go to any length to get high, and then it became clear that I needed to go to any length to get sober,” she said. “I had to change every single thing in my life, which was terrifying. But when the pain of staying the same was greater than the pain of change, that’s when I knew I really had to do something.”

“We can’t arrest our way out of this”

In an interview with the PBS NewsHour earlier this month, Shumlin said that since 2000, there has been a 770-percent increase in the number of people seeking treatment for opiate addictions.

“What started as an OxyContin and prescription drug addiction problem in this state has now grown into a full-blown heroin crisis,” he said. “Last year, we had nearly double the number of deaths in Vermont from heroin overdose as the previous year.”

While Shumlin says that the heroin epidemic is by no means more serious than the problem that is occurring in other states, he said the difference is that “I’m willing to confront it and, as governor, take it on head on. …

“We have lost the war on drugs,” he added. “The notion that we can arrest our way out of this problem is yesterday’s theory … As far as I’m concerned, this is one of the real battles that we’re facing that we have got to win. And we have got to do that by changing the discussion and changing the policy, so that we say that what heroin addicts and folks that are addicted to opiates are facing is a public health issue, not a crime issue. And we have got to be willing to fight it from that vantage point.”

Dr. Gabor Maté concurred. He told Vice that after helping many heroin addicts find sobriety, he agrees that our current prevention and recovery methods are failing, and says we need to reconsider what causes an addiction and change our approach in how we help addicts.

He said part of ending this epidemic is figuring out why kids are taking heroin, which he says is the strongest pain reliever known to medical professionals, and relieves physical and emotional pain. Maté says the real question is not why is there a heroin epidemic, but why is there so much pain among young people today?

Maté explained that some children are traumatized and abused during their childhood, which is why they turn to drugs like heroin. The other reason is that there are people who are not getting their emotional needs met and are indirectly abused.

“Their parents are too busy, too stressed, too distracted, too depressed, too overwhelmed themselves to give them what they need,” he said. “So children grow up with a sense of emotional lack and emptiness, fear, and distress. Heroin partially soothes that pain and that distress.”

Maté went on to explain that people are continuing to use drugs such as alcohol and heroin despite all of the warnings, and adds that part of the reason so many young people die is that rehab and addiction programs appear to be ineffective and unsuccessful for the most part.

He pointed to actor Cory Monteith as an example, and said the actor, who died of a heroin overdose last year, repeatedly went to rehab since the age of 19. He died when he was 31.

“Addiction is not the problem,” Maté said. “Addiction is the addict’s attempt to solve a problem.”

World Premier of the “A Way Out” introduction video!

Push to combat drug trade may mean starting with China, responsible for the majority of fentanyl

AP News– If President-elect Donald Trump wants to fulfill his campaign promise of stemming the flow of drugs coming across the United States’ border with Mexico, he may want to start by looking at China.

Manufacturers and organized crime groups in the world’s most populous country are responsible for the majority of fentanyl — the synthetic opioid that is 50 times more potent than heroin — that ends up in the U.S. and the majority of precursor chemicals used by Mexican drug cartels to make methamphetamine, according to numerous published U.S. government reports.

“The Mexican cartels are buying large quantities of fentanyl from China,” Barbara Carreno, a spokesperson with the U.S. Drug Enforcement Administration (DEA), told “It’s much easier to produce than waiting around to grow poppies for heroin and it’s incredibly profitable.

China is responsible for the majority of fentanyl — the synthetic opioid that is 50 times more potent than heroin.

The DEA estimates that a kilogram of fentanyl, which sells for between $2,500 and $5,000 in China, can be sold to wholesale drug dealers in the U.S. for as much as $1.5 million and that the demand for the drug due to the prescription opioid crisis in places like New England and the Midwest have kept the prices high.

What is fentanyl

  • Fentanyl is a synthetic opioid, 50 times more potent than heroin, that’s responsible for a recent surge in overdose deaths in some parts of the country. It also has legitimate medical uses.
  • Doctors prescribe fentanyl for cancer patients with tolerance to other narcotics, because of the risk of abuse, overdose and addiction, the Food and Drug Administration imposes tight restrictions on fentanyl; it is classified as a Schedule II controlled substance.
  • The DEA issued a nationwide alert about fentanyl overdose in March 2015. More than 700 fentanyl-related overdose deaths were reported to the DEA in late 2013 and 2014. Since many coroners and state crime labs don’t routinely test for fentanyl, the actual number of overdoses is probably much higher.

Trump, along with numerous other presidential hopefuls, promised while on the stump in states hard-hit by drug addiction to quickly tackle the widespread use of drugs like fentanyl and heroin. While heroin addiction has been a concern for decades, in recent years the number of users of heroin and fentanyl — and its more potent derivatives like carfentanil — has skyrocketed as the government clamps down on the abuse of prescription opioids like OxyContin and Percocet.

“We’re going to build that wall and we’re going to stop that heroin from pouring in and we’re going to stop the poison of the youth,” Trump said during a September campaign stop in New Hampshire.

The problem with cracking down on fentanyl and its derivatives is that while these substances may be banned in the U.S., they may not be illegal in their country of origin. China, for example, only last year added 116 synthetic drugs to its controlled substances list, but failed to include carfentanil – a drug that is 10,000 times more potent than morphine and has been researched as a chemical weapon by the U.S., U.K., Russia, Israel, China, the Czech Republic and India.

“It can kill you if just a few grains gets absorbed through the skin,” Carreno said.

While Mexican cartels obtain these substances in large quantities through the murky backwaters of the Chinese black market, anybody with a credit card and Internet access can call one of the numerous companies in China’s freewheeling pharmaceutical industry that manufactures fentanyl and its more potent cousins.

Earlier this year, The Associated Press found at least 12 Chinese businesses that said they would export carfentanil to the United States, Canada, the United Kingdom, France, Germany, Belgium and Australia for as little as $2,750 a kilogram.

Besides synthetic opioids, Chinese companies are also producing massive amounts of the precursor chemicals used to make methamphetamine.

As the methamphetamine industry evolved over the last decade or so from small, homegrown operations in the U.S. to the super-labs run by Mexican cartels, cooks and producers of the drug have begun to rely more and more on China for their ingredients. Mexico now supplies 90 percent of the methamphetamine found in the U.S., and 80 percent of precursor chemicals used in Mexican meth come from China, according to a study by the U.S.-China Economic and Security Review Commission.

“China is the major source for precursor chemicals going to Mexico,” David Shirk, a global fellow at the Washington, D.C.-based Woodrow Wilson International Center for Scholars, told “The problem is finding who the connection is between organized crime groups in China and organized crime groups in Mexico.”

Shirk added that law enforcement and drug war experts generally have a good picture of the major players in Mexican organized crime, but the Chinese underworld is less well mapped and it is more difficult to pin down the major players in the drug trade there.

Despite U.S. efforts to crackdown on both the fentanyl and methamphetamine trades, U.S. government officials acknowledge that much of the onus lies with the Chinese. Chinese state officials take allegations of drug-related corruption seriously, launching investigations when deemed appropriate, but a U.S. State Department report found that drug-related corruption among local and lower-level government officials continues to be a concern.

When he takes office in January, Trump has a few things working in his favor in respect to combatting the drug trade.

One is the continued fracturing of some of Mexico’s largest and most powerful drug cartels. The Sinaloa Cartel, for example, was seen for years as an impenetrable drug organization until cracks began to appear in its armor following the re-arrest earlier this year of its leader, Joaquín “El Chapo” Guzmán, and the power struggle that ensued.

“When the violence goes up, business always goes down,” Shirk said.

Another factor that will help Trump’s war on drugs is U.S. anti-drug officials claim that their work in collusion with their Chinese counterparts is already helping greatly. Six months after China added a slew of synthetic drugs to its controlled substances list, monthly seizures in the U.S. of acetylfentanyl — a weak variant of fentanyl — were down 60 percent, the DEA reported.

 “We’re continuing to work with the Chinese to see if they might control more of these substances,” Carreno said. “When they put controls on these substances it makes a huge difference.”

Pharma Execs Arrested in Shockingly Organized Scheme to Overprescribe Notorious Opioid

slate_facebook_iconOn Thursday, the Centers for Disease Control and Prevention released data showing that overdose deaths caused by synthetic opioids such as fentanyl—the drug that killed Prince—rose by nearly 75 percent in 2015. On the same day, federal prosecutors in Massachusetts announced the arrest of six former employees, including a former CEO and two former vice presidents, of the Phoenix-based and NASDAQ-traded fentanyl producer Insys Therapeutics. The individuals are charged with bribing doctors and otherwise conspiring to induce the over prescription of a fentanyl product called Subsys.

The indictment details a variety of brazenly dishonest methods by which doctors and insurance companies were allegedly convinced to issue and fund prescriptions of Subsys:

  • Insys paid doctors to give educational lectures about the use of Subsys. That’s ostensibly legal, except that prosecutors allege that the company paid said doctors in direct proportion to the frequency with which they wrote Subsys prescriptions, with one Insys employee allegedly texting another that the doctors hired to give lectures “do not need to be good speakers” so long as they were high-volume Susbys prescribers. These “lectures,” meanwhile were allegedly often nothing more than dinners at high-end restaurants attended only by the doctors getting paid, the Subsys employees paying them, and the doctor’s friends. One Florida doctor is alleged to have made $275,000 in speaking fee bribes in three years.

For the rest of the article go to Slate here:

Pills that kill: why are thousands dying from fentanyl abuse?

princeNatasha Butler had never heard of fentanyl until a doctor told her that a single pill had pushed her eldest son to the brink of death – and he wasn’t coming back. “The doctor said fentanyl is 100 times more potent than morphine and 50 times more potent than heroin. I know morphine is really, really powerful. I’m trying to understand. All that in one pill? How did Jerome get that pill?” she asked, her voice dropping to a whisper as the tears came. “Jerome was on a respirator and he was pretty much unresponsive. The doctor told me all his organs had shut down. His brain was swelling, putting pressure on to the spine. They said if he makes it he’ll be a vegetable.”

The last picture of Jerome shows him propped immobile in a hospital bed, eyes closed, sustained only by a clutch of tubes and wires. Natasha took the near impossible decision to let him die.

“I had to remove him from life support. That’s the hardest thing to ever do. I had him at 15 so we grew together. He was 28 when he died,” she said. “I had to let him die but after that I needed some answers. What is fentanyl and how did he get it?”

That was a question asked across Sacramento after Jerome and 52 other people in and around California’s capital overdosed on the extremely powerful synthetic opioid, usually only used by hospitals to treat patients in the later stages of cancer, over a few days in late March and early April 2016. Twelve died.

Less than a month later, this mysterious drug – largely unheard of by most Americans – killed the musician Prince and burst on to the national consciousness. Fentanyl, it turned out, was the latest and most disturbing twist in the epidemic of opioid addiction that has crept across the United States over the past two decades, claiming close to 200,000 lives. But Prince, like almost all fentanyl’s victims, probably never even knew he was taking the drug.

For the rest of the article from The Guardian US edition click here:

Over prescribed and Underfunded: Illinois Surge in Overdose Deaths


Heroin related death rates in Illinois

Chris Nielsen’s future looked bright. A senior in high school, he played catcher on his school’s baseball team in a Chicago suburb and was offered a full scholarship to play the sport at Michigan State University. But at age 17, after his first knee surgery, he was prescribed Percocet and Dulotin to help ease post-surgery pain.


Nielsen grew up around drugs. Both of his parents were addicted to heroin, and his father died from an overdose when Nielsen was just a few years old, he said. His uncles also used, and drugs and addicts became common fixtures in Nielsen’s childhood.

For the rest of the article from “Me
dill Reports Chicago” go here.

Best intentions gone awry: Origins of the opioid epidemic

Millions of Americans live with acute or chronic pain. Many of them rely on prescription drugs to improve their ability to function and maintain their quality of life. While all prescription drugs have some risk of misuse, some drugs, identified by the Drug Enforcement Administration (DEA) as controlled substances, are particularly dangerous. Specifically, prescription opioids have high abuse potential and can lead to life-threatening adverse events when taken in excess or in combination with other drugs.1

Opioids are a class of drugs that include the illegal drug heroin, as well as legal prescription pain relievers like oxycodone, hydrocodone, codeine, morphine, fentanyl and others.2

Drug overdose is the leading cause of accidental death in the U.S., with 47,055 lethal drug overdoses in 2014.2 Opioid misuse, abuse, addiction, and overdose accounts for over 60% of this epidemic, with four in five new heroin users starting out misusing prescription painkillers. In 2014 there were 18,893 overdose deaths related to prescription pain relievers, and 10,574 overdose deaths related to heroin.2

Here is a graphic depiction of the rising wave of opioid deaths. Notice in particular the sudden acceleration in recent heroin deaths:


This graph puts the death toll into perspective. After 20 years of heavy combat in South Vietnam, U.S. military casualties represented only one-third of the death toll from 10 years of opioid overdoses.


But simply focusing on the number of deaths – tragic as they are – actually obscures the true dimensions of the problem. According to the National Survey on Drug Use and Health (NSDUH), in 2012 an estimated 2.1 million Americans were addicted to opioid pain relievers and 467,000 were addicted to heroin. These estimates do not include an additional 2.5 million or more pain patients who may be suffering from an opioid use disorder because the NSDUH excludes individuals receiving valid opioid prescriptions.1

How did we get here?

Physicians trained in the 1960s and 1970s were taught to reserve opioids for the most severe forms of pain, such as cancer or end-of-life care. That approach continues to be appropriate.3 Then in the late 1990’s, opioid prescribing policies changed. Patient advocacy groups and pain specialists (with some not-so-subtle help from pharmaceutical companies) began to argue that doctors were undertreating common forms of pain that could benefit from opioids, such as backaches and joint pain.3

Around this time the American Pain Society introduced the “pain as the 5th vital sign” campaign, (adding pain to the four original vital signs representing essential body functions: heartbeat, breathing rate, temperature, and blood pressure). 4

This effort garnered impressive institutional support, including sponsorship by the Joint Commission on Accreditation of Healthcare Organizations, the National Pharmaceutical Council, and the U.S. Department of Veteran’s Affairs.5

According to the National Pharmaceutical Council, the “5th vital sign” message was built on a simple logic:

  • That pain is the most common reason individuals seek health care. Each year, an estimated 25 million Americans experience acute pain due to injuries or surgery and another 50 million suffer chronic pain.6
  • The adverse consequences of undertreated pain may cause serious medical complications, impair recovery from injury or procedures, and can progress to chronic pain. Undertreated chronic pain can impair an individual’s ability to carry out daily activities and diminish quality of life.6

Advocates for enhanced pain treatment successfully lobbied state medical boards and state legislatures to change statutes and regulations. One particular goal was to lift any prohibition of opioid use for non-cancer pain. In Washington State, for example, state law was modified to stipulate that “no disciplinary action will be taken against a practitioner based solely on the quantity or frequency of opioids prescribed.”1

In at least 20 states, these new guidelines, statutes, regulations and laws dramatically liberalized the long-term use of opioids for chronic non-cancer pain, reflecting the prevailing thought at the time that there is no clinically appropriate ceiling on maximum opioid dosing.1

Here is a view of the guide issued by the Department of Veteran’s Affairs that describes their approach to more aggressive pain management:

The “fifth vital sign” pain relief message was amplified by multimillion-dollar promotional campaigns aimed directly to prescribers.1 Newlong-acting drugs like OxyContin® were promoted as less addictive.4

The combination of a more aggressive approach to pain management and pharmaceutical company marketing efforts led to a dramatic increase in prescription opioid sales. Subsequent studies have shown a strong, linear relationship between opioid sales volume and the morbidity and mortality rates associated with these products.1

Looking back with the benefit of hindsight, it seems clear that the 5th vital sign initiative badly misfired. Whatever advantages gained in terms of alleviating pain were swamped by steeply increased opioid utilization and subsequent epidemic of addiction and overdose. These abuses led the U.S. Centers for Disease Control and Prevention (CDC) to see a need for new prescribing guidelines for narcotic painkillers.

New guidelines

In March of this year, the CDC published The Guideline for Prescribing Opioids for Chronic Pain aimed at improving patient care and safety and preventing opioid overdose.9

Out of the 12 recommendations that comprise the new guideline, three stand out as key:

  • First, non-opioid therapy is preferred for chronic pain. (Aside from active cancer, palliative, or end-of-life care.) When used, opioids should be added only when their expected benefits are likely to outweigh their substantial risks.10
  • Second, use the lowest possible effective dose to reduce the risks of opioid use disorder and overdose. The rule of thumb is “start low and go slow.”10
  • Third, doctors should monitor all opioid-using patients closely. This includes, for example, avoiding concurrent use of conflicting drugs, reviewing data from prescription-drug monitoring programs, and having a clear “off-ramp” plan to taper and discontinue therapy.10

Here is a sample online banner message aimed at changing doctor prescribing patterns for opioids:

In general, the new CDC guidelines try to shift the entire perspective on opioid use by stressing the importance of avoiding opioid prescriptions as the first-line of treatment for patients with chronic pain.3 Doctors are being asked to question whether they need to prescribe opioids as early in treatment as they have become accustomed. The guidelines also remind prescribers that the evidence in support of starting opioid treatment early and keeping people on them for prolonged periods is thin. It sets stricter limits on who should be eligible for treatment with chronic opioids, the maximum dose that should be used, and the kind of cautions they need to understand in order to avoid serious risk. The guidelines also establish new rules for monitoring patients who are taking opioids.9

What will doctors do?

While the new CDC prescribing guidelines are welcome, they are only a first step toward a solution. At this point, the tendency to aggressively treat pain using opioids is firmly entrenched in the medical community. For example, just this year the National Safety Council conducted a national survey of physicians who spend over 70% of their time seeing patients for pain. What they found was revealing:

  • 99% of doctors prescribe highly addictive opioids for longer than is recommended by the CDC (three days).11
  • 74% of doctors incorrectly believe morphine and oxycodone – both opioids – are the most effective way to treat pain.11
  • 99% of doctors have seen a pill-seeking patient or evidence of opioid abuse, but only 32% usually refer the patient to treatment.11
  • 67% of doctors are, in part, basing their prescribing decisions on patient expectations.11

Many question just how much, or how fast the average doctor will actually change his or her prescribing behavior. Recently, CDC Director Dr. Tom Frieden admitted as much when the new guidelines were released, saying that changing medical practice is not quick, or easy.3

One question that arises is whether there are external influences acting on doctors that make it harder for them to limit opioid use. Some cite the time constraints affecting physicians’ practice in this era of healthcare reform that emphasizes quality and value-based payment. This argument says that it’s much easier for a busy clinician to prescribe a 30-day supply of oxycodone or Percocet to treat a patient’s chronic pain than it is to convince him or her to do physical therapy.3

Do hospital rankings play a role?

Another potential external influence acting on opioid prescribing patterns concern the ways hospitals are ranked and reimbursed. As part of the 2010 the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) developed the value-based purchasing program to shift from pay for volume to pay for value.7

Hospitals are scored based on their performance on various measures, including outcomes of care, readmission rates, efficiency and the patient experience. Crucial for this discussion, the patient experience includes patient scoring of their satisfaction with their pain control.4

Hospital administrators were quick to develop initiatives to improve their scores and avoid penalties. For example, many hospitals have instituted readmission avoidance programs because these scores are closely monitored.7

Because CMS attached significant reimbursement penalties to patient satisfaction, some doctors believe that administrators began to hold physicians directly responsible for patient satisfaction, to the point of withholding pay or bonuses. As a result, some physicians felt pressured to prescribe opioids when patients demanded them.4

In a recent editorial in the Journal of the American Medical Association, CMS responded to suggestions that pain management questions should be taken out of the satisfaction survey in order to remove any potential for misaligned incentives to prescribe opioids.8 They began by insisting that effective pain control is a critical quality issue for inpatients, and that therefore they ought to measure that part of the patient experience. CMS went on to point out that nothing in the survey suggests that opioids are a preferred way to control pain. Finally, they observed that there is no empirical evidence showing that failing to prescribe opioids lowers a hospital’s patient satisfaction scores.8

Where do PBMs fit in?

There are at least two potential ways PBMs can participate in a solution to the opioid epidemic. The first is via their clinical management programs such as step therapy or prior authorization. These are simple measures that can directly influence both physician prescribing patterns and patient use.

There is undoubtedly going to be a major effort to re-orient physicians away from opioid prescribing over the coming years. The data in this chart, published in 2015, shows that, while some areas of specialization have dramatically cut opioid use, in others the trend is still high and rising.


The second way PBMs can help is through a more forensic approach designed to uncover instances of fraud or abusive prescribing patterns that contribute to excessive opioid use. Most PBMs already perform prescription claims reviews to uncover potentially fraudulent use of dangerous drugs.9 For example, OptumRx uses retrospective claims analysis to identify members who meet certain criteria, such as using multiple prescribers, multiple dispensing pharmacies, and multiple controlled substance claims over a set period. The next step is to proactively work to get this patient specific data into the hands of the prescribers, so each of them can have a complete picture of the patient’s behavior.

Going forward, these existing programs could be enhanced with new enabling legislation.1 For example, PBMs could vastly enhance their insight into individual behaviors if they had access to each patient’s complete controlled substance claims history, including cash claims, and access to state-run prescription-drug monitoring programs (PDMP). However, at the present time many state laws prohibit PBMs from accessing this data.1


The new prescribing guideline constitutes an important step toward a solution for the opioid crisis by presenting the best available evidence to provide options for patients and clinicians. But, it is just one step. Experts agree that, while guidelines are important, much more action will be required in order to translate guidelines into new patterns of behavior. These will necessarily include not just doctors, hospitals and PBMs, but also pharmaceutical manufacturers, educators, addiction treatment specialists and communities.1

A combined Optum response

At Optum, we recognize that controlling the opioid epidemic will require a comprehensive approach. Therefore, we are preparing to deploy the resources from across the entire United Health Group family of companies – not just OptumRx.

Optum companies help deliver better outcomes in three key ways: by connecting all parts of the health system to the right data for better outcomes; by advancing beyond traditional pharmacy cost management by engaging members in programs to improve their health; and by empowering consumers with self-managed well-being and care programs, to better manage their health and take control of their own wellness.

Please watch for much more about this major initiative in 2016.


  1. Johns Hopkins Bloomberg School of Public Health. The Prescription Opioid Epidemic: An Evidence-Based Approach. Nov. 2015. Accessed at: 05.02.2016.
  2. American Society of Addiction Medicine (ASAM). Opioid Addiction: 2016 Facts & Figures. [PDF].
  3. Modern Healthcare. CDC opioid prescribing guidelines unlikely to affect physicians’ practices. March 15, 2016. Accessed at: 05.02.2016.
  4. The opioid epidemic: It’s time to place blame where it belongs. April 6, 2016. Accessed at: 05.02.2016.
  5. Joint Commission on Accreditation of Healthcare Organizations; National Pharmaceutical Council. Pain: Current Understanding of Assessment, Management, and Treatments. Dec. 2001.
  6. National Pharmaceutical Council. Pain: Current Understanding of Assessment, Management, and Treatments. Accessed at: 05.04.2016.
  7. Health Affairs. Medicare Hospital Readmissions Reduction Program. Nov. 12, 2013. Accessed at: 03.28.2016.
  8. Measurement of the Patient Experience: Clarifying Facts, Myths, and Approaches. Published online March 10, 2016. doi:10.1001/jama.2016.1652. Accessed at: 05.02.2016.
  9. Drug Benefit News. Opioid Prescribing Guideline Strikes Needed Balance in Pain Care, Plans Say. April 8, 2016.
  10. New England Journal of Medicine. Reducing the Risks of Relief — The CDC Opioid-Prescribing Guideline. 2016; 374:1501-1504 April 21, 2016DOI: 10.1056/NEJMp1515917. Accessed at: 05.03.2016.
  11. National Safety Council. Prescriber attitudes and behavior related to prescription opioid pain medication. March 13, 2016. Accessed at: 05.16.2016.

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