Call your Republican Representative or Senator and raise Holy Hell!

President Obama signed a bill aimed at addressing opioid addiction Friday, though he called out Republicans for the measure’s shortcomings.

Lawmakers in both parties reached a compromise over the bipartisan Comprehensive Addiction and Recovery Act, though Senate Democrats held out hope until the final hour that they could win more funding for treatment.
“This legislation includes some modest steps to address the opioid epidemic,” Obama said in a statement. “Given the scope of this crisis, some action is better than none. However, I am deeply disappointed that Republicans failed to provide any real resources for those seeking addiction treatment to get the care that they need.”

He also noted that GOP lawmakers had blocked an additional $920 million in funding for addiction treatment.

The bill passed the Senate 92-2 last week, with Sens. Ben Sasse (R-Neb.) and Mike Lee (R-Utah) the only dissenters.

Despite overwhelming support, many Democrats are calling for stronger measures to address the crisis.

“My administration has been doing everything we can to increase access to treatment, and I’m going to continue fighting to secure the funding families desperately need,” Obama said in his statement Friday. “In recent days, the law enforcement community, advocates, physicians, and elected officials from both sides of the aisle have also joined in this call.”

“Now, it’s up to Republicans to finish the job and provide adequate funding to deal with this public health crisis,” he added. “That’s what the American people deserve.”

The Current State of the Opioid Abuse Epidemic

Two Princeton economists startled Americans recently when they reported that between 1999 and 2013, white middle-aged men and women in the United States, especially those with a high school education, were dying at an increasing rate from prescription and illegal drug overdose, alcohol and liver-related disease, and suicide.[1] Such results are not news to those engaged in day-to-day patient care; to those patients who continue to endure debilitating pain and chronic disease; or to those who have buried a loved one from a drug or alcohol overdose. Fortunately, there is the impression that finally the government and media are paying attention to this national epidemic.[2]
Presidential candidates are sharing personal stories of pain and loss and thus diminishing the stigma associated with pain, depression, posttraumatic stress, and addiction. The President’s first mention of healthcare in his final State of the Union Address was about the crushing problem of drug abuse. In February 2016, Obama announced his plans to invest over $1.1 billion in the next 2 years to expand access to treatment for prescription drug abuse and heroin use, improve access to the overdose-reversal drug naloxone for first responders, and support targeted enforcement activities.[3]
The Princeton study also forces us to recognize that drug abuse is not a malady afflicting only poor, minority, inner-city communities but rather is an across-the-country phenomenon, affecting rural white adults in particular.[1] Of note, this mortality trend countering the declining death rates from other chronic diseases demonstrates that the undertreatment of pain among minorities has inadvertently “protected” them from overdose, thus reducing a decades-long death rate gap between white and nonwhite patients. These realizations are driving bipartisan support in Washington that is reflected in the Comprehensive Addiction and Recovery Act (CARA), intended to revise punitive drug policies, promote best medical practices, and strengthen data sharing among states’ prescription drug monitoring programs.[4]
But are these laudable and necessary efforts the right way to go? Will increased access to care for those already harmed by addiction, addressing the enduring shortfalls in prescriber education, and research into alternative abuse-deterrent medications actually reverse this deadly epidemic?
The short answer is maybe but probably not without more initiative. Why so?

A Social Problem, Not Just a Medical Issue
First, researchers are struggling to understand why white individuals, in particular, are doing so poorly with drug abuse. Although there are no definite answers, many speculate that this cohort of patients suffers, in addition to social and economic isolation, from acute job loss. It is known that poverty, stress, and lack of social support are independent risk factors for opioid abuse. Similarly, job loss per se has been found to increase the risk for cardiovascular disease (CVD) and death.[5] Of note, recession alone does not increase CVD mortality; however, when recession is associated with job loss, heart attacks, strokes, and deaths rise. This suggests that increases in stress, despair, and possibly time spent engaging in related unhealthy behaviors often seen with financial insecurity (eg, physical inactivity, smoking, drinking, and drug abuse) may be culprits.
Second, and even more surprising, is that although awareness of the harms of opioid abuse is rising, the overwhelming majority of patients who survived an overdose continue to be prescribed high-dose opioids, often by the same prescriber.[6] It is easy to attribute these results to poor care, bad decisions, or sloppy prescribing, but it might be possible that many of the prescribers simply do not know that their patients are overdosing. Given the fact that there are no widespread systems in place to notify prescribers when overdoses occur, it is highly unlikely that prescribers will suddenly increase the level of medical supervision and care for these patients.
Third, the notion that there is a small group of prolific prescribers who are driving the opioid overdose epidemic is not accurate. The bulk of prescriptions are written by general practitioners trying to help patients with a broad array of health conditions. In fact, the distribution patterns of prescribing opioids among Medicare and Medicaid patients are no different from other drugs given for chronic diseases, where 10% of all drug prescribers account for 60% of all drug prescriptions.[7] These statistics would suggest that focusing on law enforcement, albeit merited, does not warrant significant additional resources to address improper prescribing at large.
Fourth, and most disappointing, is that despite a plethora of local, regional, state, and federal efforts to curb the overdose epidemic, things are actually getting worse. More people died from prescription and illicit drug overdoses over the past year than during any previous year on record.[8] Clearly, there is a need to do a better job in prescribing and intervening before prescription drug misuse or other substance use progresses to addiction. But are these responses a big enough step in the right direction?

Underassessment: The Overlooked Problem
The 18th century French philosopher Voltaire had many amusing quotes about medicine, such as: “common sense is not so common” and “the Art of Medicine consists of amusing the patient, while nature cures the disease.” However, there is one quote in particular that is worth mentioning that might provide an overlooked solution for the overdose epidemic. Voltaire said (most probably after a dissatisfying encounter with his physician): “Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings [of whom] they know nothing.”[9]This statement is still relevant for current medical practice 250 years later, but is it still accurate?
Clearly the understanding of diseases and pharmacology have infinitely increased since Voltaire’s era, a time when the concepts of infections and antibiotics were unimaginable, let alone unknown. Obviously we know much more about how to prescribe medicines and how to cure diseases, but what about knowing our patients? How well do healthcare providers know their patients nowadays; and how does this intimate, context-sensitive, and unbiased knowledge contribute to the decision to prescribe (or not) drugs? When was the last time a healthcare professional used an online multidimensional, patient-reported outcome tool during a routine office visit incorporating data on sleep, movement, and diet based on a wearable FitBit-like device? When was the last time a prescriber was able to show a patient a longitudinal treatment outcome on a dashboard in real time to justify continuing or stopping treatment?
If your answer is never, you probably understand that the problem of medicine in general, and pain medicine in particular, is not the over- or underprescription of opioids, or over- or undertreatment of anything, but rather a fundamental underassessment of complex physical conditions and nuanced life narratives.
So yes, $1 billion funding of appropriate, cost-effective treatments can be expected to help with the current epidemic, but in order to reduce and not just halt rising death rates, prescribers really need to get to know their patients, like Voltaire said. Beyond human contact, professionals need to start quantifying human social traits (ie, phenotypes) at every clinical encounter in addition to their routine use of lab tests and imaging. Insurance companies need to pay for this, so that lack of time will not be an excuse for not measuring behavior, and patients need to have this actionable information (ie, health data) available. Not measuring pain interference, mood, diet, activity, exercise, and sleep limits the understanding of the effects of any therapy and makes prescribers incapable of guiding patients and their families to cope with, and remove, the obstacles that deny them the health and wellbeing they seek.

Proven Screening Tool for Alcohol Abuse Underutilized

WASHINGTON ― Despite the fact that a growing number of older Americans have problems involving the use of alcohol, physicians still do not routinely offer universal screening, brief intervention, and referral to treatment (SBIRT) for drinking, despite established efficacy, new research shows.

Data presented here at the American Association of Geriatric Psychiatry (AAGP) 2016 Annual Meeting revealed that by 2020, 4.4 million adults will need treatment for alcohol use disorder, a 60% increase from 2000.

Study investigator Rushiraj Laiwala, MD, said that in contrast to the past, when individuals tended to drink less as they got older, today the reverse is true.

The total percentage of those aged 65 years and older who drink and who engage in heavy and binge drinking is on the rise, said Dr Laiwala, a geriatric psychiatry fellow at the University of South Carolina School of Medicine, in Columbia.

Because of the growing population of older Americans, the number of heavy drinkers will increase from 1 million currently to 2 million by 2060. The number of binge drinkers will increase from 4 million to 9 million by 2060, said Dr Laiwala.

And yet, he said, “we know that older drinkers are less likely to be identified compared to their younger counterparts.”

Rebecca Payne, MD, assistant professor of psychiatry at the University of South Carolina School of Medicine, who presented an overview of SBIRT, said that alcohol use is frequently missed in patients of all ages.

“We do know that physicians in general are less likely to ask their older patients about drinking specifically compared to younger patients,” Dr Payne told Medscape Medical News.

“It’s been proven that we can cut down on hazardous drinking by physician’s advice, but we still aren’t doing it,” says Lawrence Schonfeld, MD, professor emeritus of mental health law and policy at the Louis de la Parte Florida Mental Health Institute, College of Behavioral and Community Sciences, University of South Florida.
Dr Schonfeld, who was not involved in the AAGP presentation, developed the Florida BRief Intervention and Treatment of Elders (BRITE) project. The study was funded initially by the state and then through a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA).

The study included SBIRT data on some 85,000 individuals aged 55 years or older at primary and geriatric practices, aging and mental health services centers, and urgent care clinics, among other sites. BRITE ran from 2006 to 2011.

Time is the major reason physicians are reluctant to screen or offer interventions, said Dr Payne. Clinicians may also feel that they have a knowledge or training deficit ― for example, they may feel unsure about sending patients for treatment. Personal and family history of alcohol use may also contribute to a hesitancy to screen.

Patients, on the other hand, seem to be willing to be screened, said Dr Payne. In a 2006 survey, 92% said they would give an honest answer if asked about their drinking, and 93% said they thought their physician should ask how much they drink, she said.

If physicians are not doing the most basic screening, “they’re not going to be asking critical questions, like, How much are you drinking?” said Dr Schonfeld. The BRITE project found that aging services sites did a better job than physicians at both screening patients and offering follow-up treatment and referrals (Am J Public Health. 2015;105: 205–211).

Both Dr Schonfeld and Dr Payne noted that physicians may also be reluctant to use SBIRT because they think they are not going to be paid for their time.

Medicare, private insurers, and some Medicaid programs pay for SBIRT, with pay differing by whether it is a 15-minute or 30-minute screening and intervention service. The primary codes for commercial insurance are 99408 and 99409, and Medicare has several G codes that apply, including 396, 397, 442, and 443.

New View of Drinking

The National Institute on Alcohol Abuse and Alcoholism recommends that people older than 65 years should have no more than seven drinks a week and no more than three drinks on any one day.

But the agency has also proposed a new way of looking at drinking, with new terms ― low-risk and at-risk or heavy drinking.

Dr Payne advocates universal screening for all patients and that it become incorporated into practice. First, patients should be asked a prescreening question, which could be, “Do you sometimes drink beer, wine, or other alcoholic beverages?” She encourages use of such language because some people may not consider beer or wine to be alcohol. A negative answer requires no further screening.

With a positive response, patients can be prodded to the next level, which may incorporate the Short Michigan Alcohol Screening Test–Geriatric Version, the Michigan Alcoholism Screening Test– Geriatric Version, the CAGE Questionnaire, or the Alcohol Use Disorders Identification Test.

Those “can be delivered by you or anyone in your office,” said Dr Payne. “Whatever makes the most sense to you and applies the best to your clinical practice, use it,” she said.

Physicians should review the patient’s responses with them. “It sends the message that you actually looked at it, and you can clarify any questions they might have about it.”

The brief intervention is a discussion focused on raising awareness of use; it motivates the individual toward change. It can consist of one to five sessions, she said.

Physicians can give the patient information on how their drinking compares with recommendations of the NIAAA and what impact alcohol might have on medications or sleep patterns, for instance. Dr Payne said she asks patients to come up with a change plan. The plan is discussed with the patient and is revisited within an agreed-upon period.

Only about 5% of patients need referral to treatment, said Dr Payne.

Sofia’s Story

My name is Sofia and I am a recovering addict and alcoholic.

I started using when I was 12 years old. What started out as drinking alcohol and smoking weed quickly escalated into regular use of narcotics, and by the age of 13 I was abusing cocaine and prescription pills on a regular basis.

Unfortunately, my drug use was not the only cause for concern. I was also struggling with a severe eating disorder, anorexia nervosa, along with a handful of other psychological disorders including depression, anxiety, and obsessive compulsive disorder. I had an extremely negative self-image and hated the person I was becoming.

My life was out of control, and my drug use was exasperated by my desire to feel as if I had a sense of power over myself and my surroundings. I used in order to stop feeling and thinking about all the negative things in my life, and this desire to forget only increased with the shame of my drug use and the mistakes I made while using.

Not surprisingly, my drug abuse involved a number of run-ins with the law. At the mere age of 15, I was arrested for underage drinking and resisting arrest. My BAC (blood alcohol content) was more than double that of what is considered normal for someone of legal drinking age. However, this incident did nothing to deter me from my drug use and other harmful behaviors I was engaging in.

Over these years, my drug use progressed into using anything and everything I could get my hands on. In particular, ecstasy and LSD became my drugs of choice due to their quality of making one feel artificially “happy”. However, I was not happy at all. Not only did I have a horrible relationship with myself, but I had destroyed my relationship with my family in the process. I hated my parents for trying to stop me from using drugs, but I hated myself most of all.

After an incident in which I threatened to commit suicide, I was forced into a long-term drug treatment program where I resided for nearly three months. This experience not only changed my life forever – it saved my life. Looking back, I am so incredibly grateful for everything that my family did for me both during my years of drug abuse and my time spent in treatment. Without their unyielding support, I would not be alive and well today.

With the support of my family, the tools I learned while in treatment, and my newfound desire to change, I was able to successfully complete treatment and begin my journey of recovery. Today, I have been clean and sober for nearly seven years.

Over the past seven years, I have accomplished more than I ever thought possible while I was using. I graduated from college with high honors, have begun working within the field of substance abuse treatment, and will soon be continuing my studies in graduate school where I will earn a degree in Addiction Studies. I now have a wonderful relationship with my family, and most of all, I have a healthy and loving relationship with myself.

I hope that my story will give hope to those out there that are struggling with addiction, whether you’re concerned about your own drug or alcohol addiction or that of a loved one. I am a testament to the fact that there is always hope, and recovery is possible for anyone. There is strength in surrender, and I am so proud of myself for all that I have overcome.

U.S. House Passes Two Bills to Help Fight Opioid Abuse

The U.S. House of Representatives has unanimously passed two bills aimed at fighting opioid abuse and its harmful effects. One bill would reauthorize federal funding to states for prescription drug monitoring programs, while the other would create uniform standards for diagnosing and treating newborns exposed to opioids.

The prescription drug monitoring bill, called the National All Schedules Prescription Electronic Reporting Reauthorization Act (NASPER), would provide state funding to establish, implement and improve prescription drug monitoring programs, the Boston Herald reports. The programs are designed to help screen and treat people who are addicted to prescription opioids or at risk of becoming addicted, the article notes.

NASPER originally became law in 2005. It is administered by the Substance Abuse and Mental Health Services Administration (SAMHSA). The reauthorization of NASPER would allow SAMHSA to provide grants to states for prescription drug monitoring programs, offering timely access to accurate prescription information.

The bill on diagnosing and treating newborns exposed to opioids, if passed by the Senate, would become the first federal measure to address the issue, according to the newspaper. The bill, called the Protecting Our Infants Act of 2015, is designed to reduce the problem of neonatal abstinence syndrome (NAS). Babies born with NAS undergo withdrawal from the addictive drugs their mothers took during pregnancy, such as oxycodone, morphine or hydrocodone. Symptoms can include seizures, fever, excessive crying, tremors, vomiting and diarrhea, she said. Withdrawal can take several weeks to a month.

“Right now there is no standard for treatment with NAS,” bill author Katherine Clark, U.S. Representative from Massachusetts, told the Herald. “This problem leads to long stays in the NICU and hundreds of millions in Medicaid dollars.”

In a news release, Clark noted, “Our nation‘s opioid crisis cuts across all boundaries, destroys lives, and has a devastating impact on hundreds of newborns every day.”

HHS Will Revise Regulations on Prescribing Buprenorphine for Opioid Addiction

The Department of Health and Human Services (HHS) will remove some obstacles that limit the ability of doctors to prescribe buprenorphine for patients who are addicted to heroin or prescription painkillers.

The Department of Health and Human Services (HHS) will remove some obstacles that limit the ability of doctors to prescribe buprenorphine for patients who are addicted to heroin or prescription painkillers, The Huffington Post reports.

Under current regulations, doctors who are certified to prescribe buprenorphine (sold as Suboxone) are allowed to write prescriptions for up to 30 patients initially. After one year, they can request authorization to prescribe up to a maximum of 100 patients. The HHS will develop revisions to the regulations “to provide a balance between expanding the supply of this important treatment, encouraging the use of evidence-based [medication-assisted treatment], and minimizing the risk of drug diversion,” the department said in a press release.

In areas hard hit by opioid addiction, doctors’ buprenorphine treatment slots can fill up quickly, the article notes. One recent study found buprenorphine treatment is unavailable in U.S. counties where more than 30 million people live.

Legislation proposed earlier this year by U.S. Senators Edward Markey of Massachusetts and Rand Paul of Kentucky would increase the first-year cap from 30 patients to 100, and would allow nurse practitioners and physician assistants to prescribe buprenorphine. After one year, physicians could seek to remove the cap entirely if they were certified as substance abuse treatment specialists, or if they went through an approved training.

Dr. Jeffrey Goldsmith, President of the American Society of Addiction Medicine, said in a statement that his organization “applauds the Administration for taking this step to expand access to evidence-based addiction treatment and close the gap between those who need treatment and those who receive it.”