Archive for Opioid

STUDY: Opioid Epidemic May Have Cost U.S. Governments $37.8 Billion in Tax Revenue

STUDY: Opioid Epidemic May Have Cost U.S. Governments $37.8 Billion in Tax Revenue

UNIVERSITY PARK, Pa. — The opioid epidemic may have cost U.S. state and federal governments up to $37.8 billion in lost tax revenue due to opioid-related employment loss, according to Penn State researchers. Additionally, the researchers found that Pennsylvania was one of the states with the most lost revenue, with approximately $638.2 million lost to income and sales tax. The study looked at data between 2000 and 2016.

Joel Segel, assistant professor of Health Policy and Administration, said that the results — recently published in the journal Medical Care — could help governments that are hoping to make up for lost revenue.

“This is a cost that was maybe not thought about as explicitly before, and a cost that governments could potentially try to recoup,” Segel said. “Instead of focusing on the cost of treating people with opioid use disorder, you could think about it in terms of a potential benefit to getting people healthy, back on their feet, and back in the workforce.”

Previous research estimated that in 2016 there were nearly 2.1 million Americans with an opioid use disorder, and approximately 64,000 deaths were the result of an opioid overdose. According to the National Institute on Drug Abuse, there were 2,235 opioid-related overdose deaths­­­ in Pennsylvania alone.

Segel said that while previous studies have looked at the cost of the opioid epidemic in terms of substance abuse treatment and other medical costs, he and the other researchers were interested in exploring other costs that may not have been captured before.

“We wanted to take a systematic approach to how we could think about some of the tax revenue that is lost if someone is unable to work due to opioid use,” Segel said. “This could be an important consideration for either state or federal budgets.”

The researchers used data from the National Survey on Drug Use and Health, as well as information from a previous study that estimated declines in the labor force due to the opioid epidemic. They used the TAXSIM calculator from the National Bureau of Economic Research to estimate losses in tax revenue.

After analyzing the data, the researchers found that from 2000 to 2016, there was an estimated decline of 1.6 million participants in the labor force, with about 68,000 of those in Pennsylvania. There were about 180,000 overdose deaths, with approximately 6,100 occurring in Pennsylvania.

Additionally, the researchers estimated losses of $11.8 billion to state governments and $26 billion to the federal government in tax revenue due to reductions in the labor force. For state governments, this included lost sales tax and income tax revenue. Losses to the federal government were entirely due to lost income tax revenue.

Segel said the results help show the value of treating people with opioid use disorder and should be considered when treatment programs are being considered and evaluated.

“The state of Pennsylvania has been developing some innovative programs, and our results are something to consider as these programs are being considered for implementation,” Segel said. “Not only are treatment programs beneficial to the individual and to society, but if you’re thinking about the total cost of these treatment programs, future earnings from tax revenue could help offset a piece of that.”

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Penn State has made a multi-year investment in bringing together researchers from many fields to address the challenges of substance abuse in Pennsylvania and beyond.

Dennis P. Scanlon, distinguished professor of health policy and administration and director of the Center for Health Care Policy Research; Yunfeng Shi, assistant professor of health policy and administration; and John R. Moran, associate professor of health policy and administration, all with Penn State, also participated in this work.

This work was supported by the Commonwealth of Pennsylvania under the project “Estimation of Societal Costs to States Due to the Opioid Epidemic,” and part of larger work supported under a Strategic Planning Implementation award from the Penn State Office of the Provost, “Integrated Data Systems Solutions for Health Equity.”

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New Statistics Show Doctors Positively Impacting Opioid Epidemic

New Statistics Show Doctors Positively Impacting Opioid Epidemic

MONTGOMERY — Alabama’s physicians are having a positive impact on the opioid epidemic here at home while national statistics are showing for the first time, Americans’ odds of dying from an accidental opioid overdose are higher – 1 in 96 – than from a motor vehicle crash – 1 in 103.

Using data from the Center for Disease Control and Prevention comparing overdose deaths from 2017 to 2018, states and the District of Columbia are ranked by the largest positive change between the two years. The area with the largest decrease in opioid deaths ranked No. 1, while the state with the highest increase in opioid deaths ranked No. 50.

Alabama ranked 14 in the new CDC study with a decrease of 5.3 percent.

  • Predicted 12-month count, June 2017: 836
  • Predicted 12-month count, June 2018: 792

Because fatal drug overdoses are often underestimated, the CDC also factored for predicted cases. Metrics include percent completeness in overall death reporting, the percentage of deaths with the cause of death pending further investigation and the percentage of drug overdose deaths with specific or drug classes reported, according to the CDC.

National rankings of fatal opioid overdose rates in each state and the District of Columbia for 2017 are also based on data from the CDC’s National Center for Health Statistics. The data include deaths from both legally prescribed and illegally produced fentanyl.

The age-adjusted opioid overdose death rate for the U.S. was 14.9 per 100,000 individuals. In Alabama, the age-adjusted opioid overdose death rate was 9 per 100,000 individuals. Alabama ranked 36 out of 51 states, including the District of Columbia for 2017, the third lowest in the Southeast and far below the national average.

“This is extremely good news for Alabama and shows that the hard work of our physicians and the programs that the Medical Association and our leadership have instituted are truly making a difference in our state by saving lives,” said Association Executive Director Mark Jackson. “Until 2013 Alabama was one of the only states offering an opioid prescribing education course when the FDA developed the blueprint for Risk Evaluation and Mitigation Strategies for producers of controlled substances. As the need for that prescribing track has grown, we’ve made adjustments to ensure the prescribers attending it will receive the latest information available. Now, we’ve added an online, OnDemand track that makes it even easier for prescribers to get the latest education available. With any luck, Alabama’s death numbers due to prescription drugs will continue to drop. Our efforts are definitely paying off in a big, big way.”

Visit the OnDemand Education Center at www.alamedical.org/onlinecme.

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It’s Not Just About Opioids…

It’s Not Just About Opioids…

According to the National Institute on Drug Abuse, more than 30 percent of overdoses in the United States involving opioids also involve benzodiazepines, or “benzos.” Statistics from the Centers for Disease Control and Prevention show more than 115 Americans die each day from an opioid-related overdose.

However, between 1996 and 2013 the number of adults who filled a benzodiazepine prescription increased by 67 percent from 8.1 million to 13.5 million. In 2015, 23 percent of people who died of an opioid-related overdose also tested positive for benzodiazepines.

In a study published in the British Medical Journal in March 2017 of more than 300,000 continuously insured patients receiving opioid prescriptions between 2001 and 2013, the percentage of persons also prescribed benzodiazepines rose to 17 percent in 2013 from nine percent in 2001. The study showed those concurrently using both drugs are at higher risk of visiting the emergency department or being admitted to a hospital for a drug-related emergency.

In March 2016, the CDC issued new guidelines for the prescribing of opioids, which included a recommendation to avoid prescribing benzodiazepines concurrently with opioids when possible. In October 2016, the Food and Drug Administration issued a “black box” warning for prescription opioids and benzodiazepines highlighting the dangers of administering these medications together. (See https://www.advisory.com/daily-briefing/2016/09/01/black-box-opioid-benzodiazepines)

Let’s talk about benzos.

As with all medications, benzodiazepines have their usefulness. If prescribed and taken correctly, this class of medications can be extraordinarily helpful to patients. Benzodiazepines calm or sedate a person by raising the level of the inhibitory neurotransmitter GABA in the brain. Common benzodiazepines include alprazolam (Xanax), diazepam (Valium) and clonazepam (Klonopin).

Alprazolam is the most prescribed benzodiazepine in Alabama, according to the Alabama Board of Medical Examiners.

“Benzodiazepines are very effective medications for the treatment of acute anxiety just as opioids are very useful for the treatment of acute pain. But also like opioids, benzodiazepines will cause the development of physiologic tolerance if used regularly, and this often causes a loss of therapeutic effect if the dose is not continuously escalated. For this reason, they are not ideal medications as the primary treatment of chronic anxiety,” said Luke Engeriser, M.D., Assistant Professor of Psychiatry at USA Health College of Medicine and Deputy Chief Medical Officer, AltaPointe Health Systems in Mobile. “Benzodiazepines are most useful when prescribed for brief periods when someone is going through a major crisis or exacerbation of symptoms, for example after the loss of a loved one. Ideally, regular use of the medication would only be for one or two weeks. We
also sometimes will use a benzodiazepine for a time-limited period when we are initiating an antidepressant medication like an SSRI or SNRI for treatment of chronic anxiety. Although these antidepressant medications are very effective for anxiety, it sometimes takes a few weeks before the medication has a sufficient therapeutic effect.”

Other physicians, like David Herrick, M.D., of Montgomery, agree with Dr. Engeriser that as physicians prescribe benzodiazepines, extra care should be taken in monitoring the patient.

“All medications have their place, but it’s the way they are used or misused that’s creating a deadly problem. While using opioids and benzos together is not completely forbidden, it is something that has to be done very, very carefully. Most people don’t have to be on benzodiazepines all the time. If the patient has a real anxiety disorder, then that patient should be under the care of a psychiatrist,” Dr. Herrick said. “Benzos are intended to be used for the short term. I think the medical community should consider benzodiazepines just as risky as opioids and monitor and treat their patients who are using them just as carefully as their patients who are taking opioids…with the same amount of care and concern.”

Going back to school.

According to Dr. Merrill Norton, PharmD., ICCDP-D, Clinical Associate Professor at the University of Georgia College of Pharmacy, although benzodiazepines have been in use since the 1950s, education about their proper use and potential harm has not kept up with the times.

“The problem with opioids and benzodiazepines, even at prescribed levels, is understanding which opioid interacts with which benzo?” Dr. Norton explained. “This is where the physician has to be very astute. What needs to happen now is a consistent training mechanism for physicians who prescribe buprenorphine, methadone, or have patients on these medications. What the benzo is doing is helping modify the anxiety that is being triggered by the opioid withdrawal. That’s why they use it. And this is why the physician needs to be better trained not only in the prescribing of the opioid but also with benzos and how they react to one another.”

Dr. Norton suggested before prescribing a benzodiazepine, physicians should evaluate the patient for tendencies to misuse drugs and/or alcohol or if the patient has a history of misuse. Depending on the complexity of the patient’s care needs, consultation or referral to an addiction medicine physician may be necessary. Certain aberrant behaviors also may be a feature in some patients who are prescribed benzodiazepines and may include diversion of valid prescriptions, illicit sale or use in manners alternate to the prescribed dosage, route and frequency.

“Physicians need to know that benzodiazepines are useful short term but have extreme dangers to medication safety to patients who are placed on long-term regimes. Physicians also need to be aware of each benzodiazepine medication’s half-life, tolerance curves, basic pharmacodynamics and pharmacokinetic properties of each, and how to identify and manage benzodiazepine withdrawal when it occurs. Basically, physicians need to re-educate themselves on these medications. I’m finding that most physicians are already very cautious when it comes to prescribing benzodiazepines, but I don’t know how aware they are of the many types of drug interactions that can happen,” Dr. Norton said.

The Medical Association will again offer three live Prescribing and Pharmacology of Controlled Drugs courses in 2019. Drs. Engeriser, Herrick and Norton have all participated in these lectures in the past as guest faculty members and stress the importance of presenting evidence-based information and case studies to the attendees. The courses in 2019 will be March 2-3 in Auburn, Aug. 2-4 in Destin, and Nov. 23-24 in Birmingham. More information about specific topics and faculty will be available from the Association’s Education Department at a later date.

The Medical Association recently unveiled its new online OnDemand Education Center, which includes seven Alabama Opioid Prescribing courses that meet the Alabama Board of Medical Examiners’ requirements for holders of an ASCS and are free to members. One course specifically deals with benzodiazepines: Use and Misuse of Benzodiazepines.

What tools can physicians use to avoid potentially deadly medication interactions?

There are many tools physicians can use to help screen their patients for a history of alcohol and/or drug addiction before prescribing benzodiazepines. Physicians agree that adding a benzodiazepine into the mix of medications for a patient who has a history of addiction may only be adding fuel to the fire.

“Prescribing a benzodiazepine to a patient with a history of addiction to other substances increases the risk that a patient could develop an addiction to benzodiazepines or that the benzodiazepine could trigger a relapse on the drug of choice. When prescribing any controlled substance, we should also regularly check the PDMP,” explained Dr. Engeriser.

The Prescription Drug Monitoring Program was developed to promote the public health and welfare by detecting diversion, abuse and misuse of prescription medications classified as controlled substances under the Alabama Uniform Controlled Substances Act. Under the Code of Alabama, 1975, § 20-2-210, et seq., the Alabama Department of Public Health was authorized to establish, create and maintain a controlled substances prescription database program. This law requires anyone who dispenses Class II, III, IV, V controlled substances to report daily the dispensing of these drugs to the database. For more information about the Alabama PDMP, or to set up an account, log on here: http://alabamapublichealth.gov/pdmp/

Another helpful tool Dr. Norton suggested physicians can have at their fingertips to help spot bad drug interactions is the app, UpToDate. This app is one of the fastest apps physicians can use to double-check for drug interactions as they are writing prescriptions. It is, however, a subscription service, but the app comes with clinical decision support with evidence-based clinical information, including drug topics and recommendations. To learn more about UpToDate, services, subscription options, and how to download the app for your mobile device or EHR, log on here: https://www.uptodate.com/home/why-uptodate

Medical Association members can also subscribe to The Medical Letter on Drugs and Therapeutics at a reduced rate. The Medical Letter is a biweekly publication that provides evidence-based, peer-reviewed evaluations of new FDA-approved drugs with conclusions reached by a consensus of experts; new information on previously approved drugs including pivotal clinical trials, new indications, and safety warnings; consensus recommendations for
the preferred and alternative treatments for common disorders; and comparative reviews of drugs for a given indication with particular attention to clinical efficacy, adverse effects, drug interactions, and cost. A subscription includes online and print access, a mobile app, and CME opportunities. To learn more about The Medical Letter, log on here: https://bit.ly/2Jj2EwW

What’s next?

A new study by the University of Michigan and published in the Journal of General Internal Medicine maps out county-by-county the prescribing habits of benzodiazepines. The South ranks at the top of the spectrum.

The study is based on data about all prescriptions written in 2015 by primary care providers for patients in the Medicare Part D prescription drug program. The researchers combined that information with county-level health and socioeconomic data from the County Health Rankings project, a project of the Robert Wood Johnson Foundation and the University of Wisconsin.

In the single year studied, the 122,054 primary care providers included in the study prescribed 728 million days’ worth of benzodiazepines to their patients, at a cost of $200 million.

The states with the highest intensity of prescribing — which the researchers defined as prescription days of benzodiazepines relative to all prescribed medication days — were Alabama, Tennessee, West Virginia, Florida and Louisiana. States with the lowest intensity were Minnesota, Alaska, New
York, Hawaii and South Dakota. Across all types of providers, primary care and otherwise, benzodiazepines accounted for 2.3 percent of all medication days prescribed to Part D participants by those providers that year.

Physicians agree it’s time to take another look at these medications.

“Benzos have as many problems as opioids do — they are addictive, sedating and deadly if they are not prescribed and used properly.” Dr. Herrick said. “We as physicians need to be more aware of these dangers and treat benzos the way we treat opioids with a lot more respect than we are right now. If you write the prescription and sign your name to it, you had better understand what you’re writing before you hand it off to your patient because it could cost that patient his life. We have gotten a bit cavalier about how we prescribe benzos, and we need to take a look at how and why we prescribe them. This is a real issue, and we need to take it more seriously. It’s time we take a hard look at how these are prescribed and why.”

Dr. Engeriser, however, offered a word of caution. Where physicians who prescribe opioids may have instinctively wanted to stop prescribing them altogether as the national epidemic was on the rise that cannot be the case with benzodiazepines.

“As providers become more careful about prescribing practices, there will likely be an increase in the desire to stop using benzodiazepines for certain patients. Benzodiazepine withdrawal is similar to alcohol withdrawal and can lead to seizures, delirium tremens, and death. For that reason, it is critical that patients not have their benzodiazepines abruptly stopped. There are different strategies for the tapering of benzodiazepines. The important thing in the outpatient setting is to taper the benzodiazepine slowly enough that severe withdrawal symptoms do not emerge. This is often done more easily with a benzodiazepine with a longer half-life such as clonazepam than a shorter half-life like alprazolam. On an inpatient unit, benzodiazepine taper can be more rapid, using as needed benzodiazepines to treat emergent withdrawal, with dosing guided by a scale, such as the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar).” Dr. Engeriser said.

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Study: Is the Opioid Crisis Response Overlooking Women?

Study: Is the Opioid Crisis Response Overlooking Women?

CONNECTICUT Women’s Health Research at Yale is calling on a government committee to revise its report on a coordinated response to the opioid epidemic so that it reflects the unique needs of women.

In a commentary published in the peer-reviewed journal Biology of Sex Differences, WHRY Director Carolyn M. Mazure, Ph.D., and Jill Becker, Ph.D., chair of the Biopsychology Area of the University of Michigan Psychology Department, detailed the laboratory, clinical and epidemiological evidence showing the need for the report to endorse and encourage the research of sex and gender differences. They argued such data is necessary to generate gender-based interventions that more fully address the opioid epidemic.

“All data must be reported by sex and gender so that gender-specific treatment and prevention strategies derived from this research are provided to practitioners and the public,” the authors said. “We encourage biomedical researchers and clinical care providers, as well as the public, to insist that a successful response to the opioid crisis should highlight the importance of understanding sex and gender differences in the current opioid epidemic.”

Mazure and Becker noted that the draft report of the White House National Science and Technology Council’s Fast-Track Action Committee (FTAC) created to respond to the opioid crisis does include important concerns about maternal and neonatal exposure to opioids. But they said the draft, released in October, overlooks significant and growing data on sex and gender differences in opioid use disorder (OUD). For example, they wrote that women are more likely than men to be prescribed and use opioid analgesics, and females and males experience pain and the effects of opioids differently.

In addition, women more quickly develop addictions after first using addictive substances, and women are more likely than men to relapse after a quit attempt.

The authors also described how women with opioid addiction are more likely than men to have experienced early trauma and have been diagnosed with depression. And women with opioid addiction suffer greater functional impairment in their lives, impacting their ability to work, secure steady housing, and — because women are more often family caretakers — avoid negative effects on children.

“Our experimental models will not begin to yield the desired information until they employ appropriate models that include both females and males, and our clinical and epidemiological investigations will not uncover needed data until both women and men are studied,” the authors said. “A successful response to the opioid crisis will only be found when scientists, practitioners and the public incorporate the essential importance of understanding sex and gender differences into the solution for OUD.”

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MME Edit Coming in Early 2019

MME Edit Coming in Early 2019

The Alabama Medicaid Agency is working on implementing Morphine Milligram Equivalent (MME) edits in early 2019. Higher doses of opioids are associated with higher risk of overdose and death – even relatively low dosages (20-50 MME per day) may increase risk. Therefore, beginning in early 2019, Alabama Medicaid will limit the amount of cumulative MME’s allowed per day on opioid claims. The edit will begin at 250 cumulative MME per day and will gradually decrease over time. The final MME target will be 90 MME per day. Claims for opioids that exceed the maximum daily cumulative MME limit will be denied.

Claims prescribed by oncologists will bypass the edit. Long-term care, hospice patients, and children will also be excluded.

Overrides for quantities exceeding the MME limit may be submitted to Health Information Designs (HID). Information regarding override requirements and MME examples will be made available on the Alabama Medicaid Agency website closer to the implementation of the
new limitations. Additional information will be disseminated to all impacted providers through a provider ALERT closer to
implementation; please check the Alabama Medicaid Pharmacy webpage for additional information.

For more information: http://www.medicaid.alabama.gov/content/4.0_Programs/4.3_Pharmacy-DME.aspx

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BCBS Alabama to No Longer Cover OxyContin Beginning in 2019

BCBS Alabama to No Longer Cover OxyContin Beginning in 2019

BIRMINGHAM, AL – Effective Jan. 1, 2019, Blue Cross Blue Shield of Alabama will no longer cover OxyContin for members with the exception of Blue Advantage members. This is in response to concerns for members’ care and safety.

Since 2015, opioid prescriptions in the U.S. and in Alabama have declined. Over the last two years, opioid prescriptions for BCBS Alabama’s commercial members have decreased 18 percent. While progress is being made, this issue calls for continued action by all parties.

Beginning Jan. 1, 2019, the following changes to Blue Cross’ Opioid Management Strategy for commercial members will be implemented:

  • Roxybond, the new instant release oxycodone formulation that is considered “abuse deterrent” by the FDA, will be covered.
  • Lucemyra (lofexidine), the first non-opioid approved drug to treat the symptoms of opioid withdrawal, will be covered.
  • OxyContin, and its generic (oxycodone ER), will no longer be covered. Xtampza ER (oxycodone ER) will be available to all members at a non-preferred brand cost share.

Letters have been mailed to members receiving OxyContin or oxycodone ER notifying them of the change and recommending that they follow up with their doctor to discuss potential alternatives. Providers have also been notified with a list of covered alternatives.

Several alternatives will be covered at the lowest copay for members who need a long-acting opioid for around the clock pain management: Morphine ER, Tramadol ER, Fentanyl ER and Methadone will be covered.

Blue Cross always encourages its members to consult their doctors about any treatments or prescription drugs they may need, and the company relies on physicians’ expertise to know what is best for their patients. Blue Cross will continue to develop and adopt actionable policies and procedures that promote safe prescribing of opioid medication and appropriate access to treatment for opioid use disorder. In addition, we will continue to collaborate with Alabama physicians and pharmacists to help curb the growing epidemic of opioid misuse by offering support, resources, and educational tools to network providers. This, combined with our strategies to improve access to medications used to treat substance abuse and drug overdoses, demonstrate our commitment to the health of our membership.

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Overshadowed by Opioids, Meth is Back and Hospitalizations Surge

Overshadowed by Opioids, Meth is Back and Hospitalizations Surge

The number of people hospitalized because of amphetamine use is skyrocketing in the United States, but the resurgence of the drug largely has been overshadowed by the nation’s intense focus on opioids.

Amphetamine-related hospitalizations jumped by about 245 percent from 2008 to 2015, according to a recent study in the Journal of the American Medical Association. That dwarfs the rise in hospitalizations from other drugs, such as opioids, which were up by about 46 percent. The most significant increases were in Western states.

The surge in hospitalizations and deaths due to amphetamines “is just totally off the radar,” said Jane Maxwell, an addiction researcher. “Nobody is paying attention.”

Doctors see evidence of the drug’s comeback in emergency departments, where patients arrive agitated, paranoid and aggressive. Paramedics and police officers see it on the streets, where suspects’ heart rates are so high that they need to be taken to the hospital for medical clearance before being booked into jail. And medical examiners see it in the morgue, where in a few states, such as Texas and Colorado, overdoses from meth have surpassed those from the opioid heroin.

Amphetamines are stimulant drugs, which are both legally prescribed to treat attention deficit hyperactivity disorder and produced illegally into methamphetamine. Most of the hospitalizations in the study are believed to be due to methamphetamine use.

Commonly known as crystal meth, methamphetamine was popular in the 1990s before laws made it more difficult to access the pseudoephedrine, a common cold medicine, needed to produce it. In recent years, law enforcement officials said, there are fewer domestic meth labs and more meth is smuggled in from south of the border.

As opioids become harder to get, police said, more people have turned to meth, which is inexpensive and readily available.

Lupita Ruiz, 25, started using methamphetamine in her late teens but said she has been clean for about two years. When she was using, she said, her heart beat fast, she would stay up all night and she would forget to eat.

Ruiz, who lives in Spokane, Wash., said she was taken to the hospital twice after having mental breakdowns related to methamphetamine use, including a monthlong stay in the psychiatric ward in 2016. One time, Ruiz said, she yelled at and kicked police officers after they responded to a call to her apartment. Another time, she started walking on the freeway but doesn’t remember why.

“It just made me go crazy,” she said. “I was all messed up in my head.”

The federal government estimates that more than 10,000 people died of meth-related drug overdoses last year. Deaths from meth overdose generally result from multiple organ failure or heart attacks and strokes, caused by extraordinary pulse rates and skyrocketing blood pressure.

In California, the number of amphetamine-related overdose deaths rose by 127 percent from 456 in 2008 to 1,036 in 2013. At the same time, the number of opioid-related overdose deaths rose by 8.4 percent from 1,784 to 1,934, according to the most recent data from the state Department of Public Health.

“It taxes your first responders, your emergency rooms, your coroners,” said Robert Pennal, a retired supervisor with the California Department of Justice. “It’s an incredible burden on the health system.”

Costs also are rising. The JAMA study, based on hospital discharge data, found that the cost of amphetamine-related hospitalizations had jumped from $436 million in 2003 to nearly $2.2 billion by 2015. Medicaid was the primary payer.

“There is not a day that goes by that I don’t see someone acutely intoxicated on methamphetamine,” said Dr. Tarak Trivedi, an emergency room physician in Los Angeles and Santa Clara counties. “It’s a huge problem, and it is 100 percent spilling over into the emergency room.”

Trivedi said many psychiatric patients are also meth users. Some act so dangerously that they require sedation or restraints. He also sees people who have been using the drug for a long time and are dealing with the downstream consequences.

In the short term, the drug can cause a rapid heart rate and dangerously high blood pressure. In the long term, it can cause anxiety, dental problems and weight loss.

“You see people as young as their 30s with congestive heart failure as if they were in their 70s,” he said.

Jon Lopey, the sheriff-coroner of Siskiyou County in rural Northern California, said his officers frequently encounter meth users who are prone to violence and in the midst of what appear to be psychotic episodes. Many are emaciated and have missing teeth, dilated pupils and a tendency to pick at their skin because of a sensation of something beneath it.

“Meth is very, very destructive,” said Lopey, who also sits on the executive board of the California Peace Officers Association. “It is just so debilitating the way it ruins lives and health.”

Nationwide, amphetamine-related hospitalizations were primarily due to mental health or cardiovascular complications of the drug use, the JAMA study found. About half of the amphetamine hospitalizations also involved at least one other drug.

Because there has been so much attention on opioids, “we have not been properly keeping tabs on other substance use trends as robustly as we should,” said study author Dr. Tyler Winkelman, a physician at Hennepin Healthcare in Minneapolis.

Sometimes doctors have trouble distinguishing symptoms of methamphetamine intoxication and underlying mental health conditions, said Dr. Erik Anderson, an emergency room physician at Highland Hospital in Oakland, Calif. Patients also may be homeless and using other drugs alongside the methamphetamine.

Unlike opioid addiction, meth addiction cannot be treated with medication. Rather, people addicted to the drug rely on counseling through outpatient and residential treatment centers.

The opioid epidemic, which resulted in about 49,000 overdose deaths last year, recently prompted bipartisan federal legislation to improve access to recovery, expand coverage to treatment and combat drugs coming across the border.

There hasn’t been a similar recent legislative focus on methamphetamine or other drugs. And there simply aren’t enough resources devoted to amphetamine addiction to reduce the hospitalizations and deaths, said Maxwell, a researcher at the Addiction Research Institute at the University of Texas at Austin. The number of residential treatment facilities, for example, has continued to decline, she said.

“We have really undercut treatment for methamphetamine,” Maxwell said. “Meth has been completely overshadowed by opioids.”

Kaiser Health News coverage in California is supported in part by Blue Shield of California Foundation.

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Study: Risky Sedative Prescriptions for Older Adults Vary Widely

Study: Risky Sedative Prescriptions for Older Adults Vary Widely

Despite years of warnings that older adults shouldn’t take sedative drugs that put them at risk of injury and death, a new study reveals how many primary care doctors are still prescribing them, how often, and where the practice is most prevalent.

Mapped out county by county, the nationwide study shows wide variation in prescriptions of the drugs known as benzodiazepines. Some counties, especially in the Deep South and rural western states, had three times the level of sedative prescribing as those with the lowest levels.

The study, published in the Journal of General Internal Medicine, also highlights gaps at the provider level: Some primary care doctors prescribed sedatives at a rate more than six times that of their peers.

Researchers found that top prescribers of drugs such as Xanax, Ativan and Valium also tended to be high-intensity prescribers of opioid painkillers.

The counties with the most intense sedative prescribing tended to have lower incomes, less-educated populations, and higher suicide rates, the study finds. They also overlap with other maps showing high county-level opioid painkiller prescribing.

“Taken all together, our findings suggest that primary care providers may be prescribing benzodiazepines to medicate distress,” says Donovan Maust, M.D., M.Sc., a geriatric psychiatrist from the University of Michigan who led the study with a team from U-M and the University of Pennsylvania.

“And since these drugs increase major health risks, especially when taken with opioid painkillers, it’s quite possible that benzodiazepine prescribing may contribute to the shortened life expectancies that others have observed in residents of these areas.”

Where prescriptions are highest

The study is based on data about all prescriptions written in 2015 by primary care providers for patients in the Medicare Part D prescription drug program. The researchers combined that information with county-level health and socioeconomic data from the County Health Rankings project, a project of the Robert Wood Johnson Foundation and University of Wisconsin.

In the single year studied, the 122,054 primary care providers included in the study prescribed 728 million days’ worth of benzodiazepines to their patients, at a cost of $200 million.

The states with the highest intensity of prescribing — which the researchers defined as prescription days of benzodiazepines relative to all prescribed medication days — were Alabama, Tennessee, West Virginia, Florida and Louisiana.

States with the lowest intensity were Minnesota, Alaska, New York, Hawaii and South Dakota.

Across all types of providers, primary care and otherwise, benzodiazepines accounted for 2.3 percent of all medication days prescribed to Part D participants by those providers that year.

Primary care doctors accounted for 62 percent of all benzodiazepine prescriptions. This confirms other findings that led Maust and his colleagues to focus on primary care providers in the new study. Previous studies have shown such providers account for the majority of benzodiazepines prescribed to older adults, a population much less likely than younger adults to see a psychiatrist.

Higher sedative prescription intensity was also associated at the county level with more days of poor mental health, a higher proportion of disability-eligible Medicare beneficiaries, and a higher suicide rate.

More about sedative risks

Benzodiazepines have often been prescribed to ease anxiety or insomnia, though several studies by Maust and others have shown that patients receiving the drugs often don’t have a formal diagnosis of either condition.

But the drugs come with a price: clouded thinking ability, higher risk of auto accidents, falls and fractures, and a tendency to hook patients into long-term use despite their intended use as a short-term treatment.

Benzodiazepines as a class are the second-most common group of drugs associated with medication-related overdose deaths, right behind opioid painkillers.

Such risks have landed benzodiazepines on the American Geriatric Society’s list of prescription drugs that people over age 65 should avoid, although their short-term use in treating anxiety or insomnia that haven’t responded to other options is still considered acceptable.

More about the study

To be included in the county-level study, a given primary care provider had to prescribe a benzodiazepine at least 10 times in 2015. The individual physician-level study looked at 109,700 doctors after excluding the 10 percent of prescribers who saw the fewest Medicare beneficiaries.

The researchers divided individual prescribers into four groups according to the intensity level of their benzodiazepine prescribing.

The range was large. For the lowest group, about 0.6 percent of total prescriptions were for benzodiazepines, compared with 3.9 percent for the highest-intensity group. That’s a 6.5-fold difference in benzodiazepine prescribing.

Those in the highest-intensity group were also likely to be high-intensity prescribers for opioids and antibiotics, and also for other drugs that have been classed as high-risk for older adults.

“That the same providers appear to be high-intensity prescribers of both medications is potential cause for concern,” says Maust.

Female primary care providers were less likely to be high-intensity benzodiazepine prescribers. The more years a physician had been in practice, the higher their chance of being a high-intensity prescriber.

Physicians with higher percentages of patients who were white or who received Extra Help payments available to low-income, low-resource patients under Part D of Medicare were also more likely to be high-intensity sedative prescribers.

Researchers could not see data down to the patient-level in the available Medicare data, so they couldn’t look at what conditions patients were listed as having, other clinical findings, or the patients’ individual social and economic status.

In addition to Maust, the research team included senior author Steven Marcus, Ph.D. of the University of Pennsylvania, and U-M Department of Psychiatry faculty L. Allison Lin, M.D., M.Sc., and Fred Blow, Ph.D. Maust, Lin and Blow are all members of the U-M Institute for Healthcare Policy and Innovation.

Funding for the work came from National Institutes of Health (AG048321, DA045705), the American Federation for Aging Research, the John A. Hartford Foundation, and the Atlantic Philanthropies.

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POLL: Rural Americans “Profoundly Worried” about Opioid Crisis

POLL: Rural Americans “Profoundly Worried” about Opioid Crisis

BOSTON — According to a new NPR/Robert Wood Johnson Foundation/Harvard T.H. Chan School of Public Health poll, rural Americans cite drug/opioid abuse as the biggest problem facing their local community (25 percent), followed by economic concerns (21 percent).

The poll of 1,300 adults living in the rural United States found that a majority of rural Americans (57 percent) say opioid addiction is a serious problem in their community, and about half (49 percent) say they personally know someone who has struggled with opioid addiction. “What has been widely recognized is the serious economic problems facing rural communities today. What has not is that drug/opioid abuse in rural communities is now viewed with the same high level of concern as economic threats,” said Robert J. Blendon, co-director of the survey and the Richard L. Menschel Professor of Health Policy and Political Analysis at Harvard T.H. Chan School of Public Health.

On economic issues, rural Americans largely hold negative views of their local economy, but nearly one-third have seen economic progress in recent years. A majority of rural Americans (55 percent) rate their local economy as only fair or poor, while over the past five years, 31% say their local economy has gotten better, and 21 percent say it has gotten worse.

Rural Americans are divided over whether they expect the major problems facing their communities will be solved in the near future, and a majority believe outside help will be necessary to solve these problems. About half of rural Americans (51 percent) say they are confident that major problems facing their local community will be solved in the next five years, and 58 percent believe their community needs outside help to solve its major problems. Among those who say their community needs outside help, about six in ten rural Americans (61 percent) think the government will play the greatest role in solving major problems facing their local community.

In addition, many rural Americans are optimistic about the future. A majority of rural parents (55 percent) think their children will be better off financially than themselves when their children become their age. “There is no single vision of life in small-town America, just as there is no one-size-fits-all solution to improving health,” said Richard Besser, president and CEO of the Robert Wood Johnson Foundation. “But we see in this diversity a common thread — an understanding that health and wellbeing means many things: better access to health care, good job opportunities, and quality education for all.”

View the complete poll findings.

Key Findings

Many rural Americans are optimistic about future jobs

Many rural Americans are optimistic about future job opportunities, but they recognize new training and skills may be important for the future rural workforce. Looking ahead five years, 39 percent of rural Americans believe the number of good jobs in their local economy will increase, while 47% believe they will stay the same.

About one-third of rural Americans (34 percent) say it will be important for them to get training or develop new skills in order to keep their job or find a better job in their local community in the next five years, including 25 percent of all rural adults who say they will need computer and technical skills and 24% who say they will need a first or more advanced educational degree or certificate.

Education, job growth, and health care will improve rural economies

When it comes to improving their local economy, a majority of rural Americans think the following approaches would be very helpful: creating better long-term job opportunities (64 percent), improving the quality of local public schools (61 percent), improving access to health care (55 percent), and improving access to advanced job training or skills development (51 percent). (See table below.)

Rural Americans’ Views on Approaches to Improving the Local Rural Economy

 Q44. Recently, a number of leadership groups have recommended different approaches for improving the economy of communities like yours. For each of the following, please tell me how helpful you think this approach would be for improving the economy of your local community…[insert item]. Do you think this would be very helpful, somewhat helpful, not too helpful, or not at all helpful? 

Percent saying “very helpful”
1.     Creating better long-term job opportunities 64%
2.     Improving the quality of local public schools 61%
3.     Improving access to health care 55%
4.     Improving access to advanced job training or skills development 51%
5.     Improving local infrastructure like roads, bridges, and public buildings 48%
6.     Improving the use of advanced technology in local industry and farming 44%
7.     Improving access to small business loans and investments 44%
8.     Improving access to high-speed internet 43%

NPR/Robert Wood Johnson Foundation/Harvard T.H. Chan School of Public Health, Life in Rural America, 6/6/18 – 8/4/18. Q44. Questions asked among a half-sample of respondents: Half Sample A N=669, Half Sample B N=631 rural adults ages 18+.

There are sizable gaps between how minorities and non-minorities believe people are treated in rural communities

Despite low recognition of discrimination against minority groups in their local community by all rural Americans, rural adults belonging to several minority groups see much higher rates of discrimination against members of their group. For example, only 21 percent of all rural Americans say that generally speaking, they think Latinos are discriminated against in their local community, yet 44 percent of Latinos living in rural areas say they think Latinos are discriminated against in their local community. A majority of Latinos (56 percent) also say they think recent immigrants are discriminated against in their local community, compared to 29 percent of all rural Americans who share this view.

*Not enough cases for analysis. NPR/Robert Wood Johnson Foundation/Harvard T.H. Chan School of Public Health, Life in Rural America, 6/6/18 – 8/4/18. Q19. Total N=1,300 rural adults ages 18+.

Methodology

The poll in this study is part of an on-going series of surveys developed by researchers at the Harvard Opinion Research Program (HORP) at Harvard T.H. Chan School of Public Health in partnership with the Robert Wood Johnson Foundation and National Public Radio. The research team consists of the following members at each institution.

Harvard T.H. Chan School of Public Health:  Robert J. Blendon, Professor of Health Policy and Political Analysis and Executive Director of HORP; John M. Benson, Senior Research Scientist and Managing Director of HORP; Mary T. Gorski Findling, Research Associate; Logan S. Casey, Research Associate in Public Opinion; Justin M. Sayde, Administrative and Research Manager.

Robert Wood Johnson Foundation: Carolyn Miller, Senior Program Officer, Research and Evaluation; and Jordan Reese, Director of Media Relations.

NPR: Andrea Kissack, Senior Supervising Editor, Science Desk; Joe Neel, Deputy Senior Supervising Editor, Science Desk; Vickie Walton-James, Senior Supervising Editor, National Desk; Laura Smitherman, Deputy Senior Supervising Editor, National Desk; Luis Clemens, Supervising Editor, National Desk; Ken Barcus, Midwest Bureau Chief.

Interviews were conducted by SSRS of Glen Mills (PA) via telephone (including both landline and cell phone) using random-digit dialing, June 6 – August 4, 2018, among a nationally representative probability-based sample of 1,300 adults age 18 or older living in the rural United States. Interviews were conducted in English and Spanish. The margin of error for total respondents is ±3.6 percentage points at the 95% confidence level. The sample of Rural Americans is defined in this survey as adults living in areas that are not part of a Metropolitan Statistical Area (MSA). This is the definition used in the 2016 National Exit Poll.

Possible sources of non-sampling error include non-response bias, as well as question wording and ordering effects. Non-response in telephone surveys produces some known biases in survey-derived estimates because participation tends to vary for different subgroups of the population. To compensate for these known biases and for variations in probability of selection within and across households, sample data are weighted by cell phone/landline use and demographics (sex, age, education, and Census region) to reflect the true population. Other techniques, including random-digit dialing, replicate subsamples, and systematic respondent selection within households, are used to ensure that the sample is representative.

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New Interactive Map Shows How Alabama Measures Up in the National Opioid Crisis

New Interactive Map Shows How Alabama Measures Up in the National Opioid Crisis

WASHINGTON, Oct. 4, 2018 – A new interactive data tool launched by the United States Department of Agriculture and NORC at the University of Chicago shows for the first time an in-depth, county-by-county, look at the impact of the opioid epidemic across the entire country. The tool is intended to help leaders build grassroots strategies to better address the needs in their communities.

The opioid misuse Community Assessment Tool enables users to overlay substance misuse data against socioeconomic, census and other public information. This data will help leaders, researchers and policymakers assess what actions will be most effective in addressing the opioid crisis at the local level.

USDA’s launch of the Community Assessment Tool closely follows President Trump’s declaration of October as National Substance Abuse Prevention Month. Approximately 72,000 Americans died from drug overdoses in 2017; 49,000 of those deaths involved an opioid. Many of these deaths have been fueled by the misuse of prescription pain medications. The severity of the current opioid misuse crisis requires immediate action.

Rural Development partnered with the Walsh Center for Rural Health Analysis at NORC at the University of Chicago to create the Community Assessment Tool. NORC at the University of Chicago is a non-partisan research institution that delivers reliable data and rigorous analysis to guide critical programmatic, business and policy decisions. Today, government, corporate and nonprofit organizations around the world partner with NORC to transform increasingly complex information into useful knowledge. The Walsh Center focuses on a wide array of issues affecting rural providers and residents, including health care quality and public health systems.

In April 2017, President Trump established the Interagency Task Force on Agriculture and Rural Prosperity to identify legislative, regulatory and policy changes that could promote agriculture and prosperity in rural communities. In January 2018, Secretary Perdue presented the Task Force’s findings to President Trump. These findings included 31 recommendations to align the federal government with state, local and tribal governments to take advantage of opportunities that exist in rural America. Increasing investments in rural infrastructure is a key recommendation of the task force.

To view the report in its entirety, please view the Report to the President of the United States from the Task Force on Agriculture and Rural Prosperity (PDF, 5.4 MB). In addition, to view the categories of the recommendations, please view the Rural Prosperity infographic.

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