Thursday, 26 April 2018

The Opioid Epidemic: What's the Solution?

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From the print edition of The New American

Foreign enemies are smuggling deadly poison across the border, killing record numbers of civilians. Instead of confronting the invaders, government and media demonize the nation’s physicians, blaming them for the catastrophic rise in death rate, while gagging a lone medical doctor who devised a brilliant yet inexpensive antidote to the poison. Sounds like the premise of a Hollywood suspense-drama, doesn’t it? Unfortunately, it is a factual summary of the current opioid epidemic crushing our country in its death grip.

Deaths from opioids have more than quadrupled in less than two decades. The Centers for Disease Control and Prevention (CDC) reports that nationwide, more than 42,000 of nearly 64,000 drug-overdose deaths in 2016 involved opioids. Late last year President Donald Trump declared it a public health emergency, and drug overdoses have become the leading cause of death for Americans under age 50.

How did this catastrophe happen? “It began in the late 1990s, when doctors and health care providers started facing pressure to treat chronic pain more aggressively,” declared The Hill in March. The Hill also blamed pharmaceutical companies for “marketing these drugs to medical providers as not addictive or harmful.”

Major media dutifully tout this popular party line, trumpeted by the President’s Commission on Combating Drug Addiction and the Opioid Crisis (CCDAOC). Chaired by former New Jersey Governor Chris Christie, CCDAOC published its findings last November, maintaining that the situation “originated within the healthcare system” and blaming doctors for a “growing compulsion to detect and treat pain,” as if they have collectively contracted some strange new behavioral disorder. According to the commission, deceptive marketing by drug companies and the plaintive cries of pain-racked patients made doctors throw caution (and their professional licenses, years of medical training, and Hippocratic oaths) to the wind and prescribe dangerous opioids helter skelter.

Doctors and drug companies make easy scapegoats. Never mind that the U.S. Food and Drug Administration requires all manufacturers to include a black box warning — the strongest measure short of banning a drug — about substantial life-threatening risks of overdose and substance abuse on opioid packaging. And let’s ignore the fact that addiction epidemics have been around since the U.S. Civil War, when the Union Army “issued nearly 10 million opium pills to its soldiers, plus 2.8 million ounces of opium powders and tinctures,” sending an estimated 400,000 addicts home after the war, as recounted in January’s Smithsonian Magazine. There is cruel irony in the fact that in 1924 the federal government outlawed heroin, marketed for medical use by Bayer since the 1890s, thereby encouraging pharmaceutical companies to develop exponentially more potent — yet legal — alternatives.

CCDAOC also overlooks the blatantly destructive role Medicaid and Obama­Care are playing. Medicaid patients pay pennies on the dollar — sometimes nothing at all — for opioids that cost hundreds for patients with private insurance or thousands on the black market. “Studies show that Medicaid patients misuse opiates at a significantly higher level than those with private insurance, and are at a much higher risk of dying” — predictable results quoted by The New American contributor Michael Tennant from a January report issued by the U.S. Senate Homeland Security and Governmental Affairs Committee. “Medicaid recipients are 10 times more likely to suffer from addiction and substance abuse than the general population.” The committee also found that ObamaCare’s expansion of Medicaid to cover more than one-fifth of all Americans has only exacerbated the problem. Drug overdose deaths, opioid-related hospital stays, and taxpayer-funded treatment for opioid abuse have skyrocketed in states with Medicaid expansion as compared to their non-expansion neighbors.

Perhaps it is easier for CCDAOC to stereotype doctors as drug dealers in white coats running pill mills. The data certainly sound damning. CDC declares that “40% of all opioid overdose deaths involve a prescription opioid.” Note that more people die using illegal drugs. Moreover, CDC does not know how many of its incriminating “40 percent” also include illicit substances or misuse of prescription meds. A National Center for Health Statistics Data Brief in December explains that drug overdoses are tough to categorize because death reports make no distinction between pharmaceutical and illegal forms. “In many deaths, multiple drugs are present, and it is difficult to identify which drug or drugs caused the death.”

CDC admits that the problem is driven by illicit drug use. On its Opioid Data Analysis web page, the agency concludes, “It is presumed that a large portion of the increase in deaths is due to illegally-made fentanyl [a powerful synthetic narcotic] and not prescription opioids.” Researchers with the CDC’s Division of Unintentional Injury Prevention wrote an American Journal of Public Health editorial in March, stating that since their agency includes all synthetic opioid deaths in estimates of prescription-related mortality, its data are likely significantly inflated.

But everyone knows that prescription meds are “gateway drugs” — right? Don’t most heroin users say that’s what started them on the road to addiction? Not so, according to the federal government’s annual National Survey on Drug Use and Health, which consistently reports that three out of four cases of opioid misuse start with a person taking drugs they bought illegally or medication that was actually prescribed for a friend or family member. Scientific American reported last May that 90 percent of all addictions begin in teen and young adult years — not a demographic indicative of patients being treated for severe or chronic pain. It quoted a University of Michigan study that found that recreational drug use, “not medical treatment with opioids, is by far the greatest risk factor for opioid addiction,” and a Journal of the American Medical Association analysis that found that 87 percent of nearly 136,000 emergency-room patients treated for opioid overdose in 2010 had no chronic pain condition. Furthermore, a 2010 Cochran study reported that less than one percent of patients taking prescribed opioids for chronic pain actually developed addiction during treatment.

Reason magazine listed similar research results in February. Only one person died from opioid-related overdose in a 2015 study that followed 550 pain patients treated with narcotics for up to 13 years. Among 2.2 million North Carolina residents who took prescription opioids in 2010, 478 narcotic-related fatalities occurred, amounting to a rate of 0.022 percent. And only eight percent of opioid-related fatalities in Massachusetts involved a prescription drug, according to a 2016 study.

On the flip side, multi-drug users with histories of substance abuse run a much higher risk. In a 2012 study in Utah, 61 percent of narcotic-overdose deaths involved illegal drugs, while 80 percent involved substance abuse — including alcohol and illegal as well as prescription opioids.

Regardless, doctors increasingly face criminal and civil charges for patient overdose. “The number of doctors penalized by the US Drug Enforcement Administration has grown more than fivefold in recent years,” reported CNN. The agency took action against 479 doctors in 2016, up from 88 in 2011. Do the numbers make sense? In a nation of more than 740,000 physicians and surgeons, could 0.06 percent of them — or even double or triple that number — cause the opioid crisis we are witnessing?

War on Doctors

“Throughout the United States, physicians are being threatened, impoverished, delicensed, and imprisoned for prescribing in good faith with the intention of relieving pain,” said Jane Orient, M.D., executive director of the Association of American Physicians and Surgeons (AAPS), calling the targeting of doctors a “national disgrace.” Dr. Orient made these comments in 2004 while defending an Arizona physician indicted on charges related to legal prescription of pain meds. Now, more than a decade later, the witch hunt continues. Despite increasingly strict regulations and legal prosecutions, doctors are still falling victim to the failed War on Drugs, and “patients who urgently need pain relief are being left in agony,” Orient wrote last October in an editorial for The New American.

Take the case of Dr. James Graves, sentenced in 2002 at age 55 to 63 years in prison — effectively a life sentence — for manslaughter in the cases of four patients who died from OxyContin overdose. In the Winter 2017 AAPS Journal of American Physicians and Surgeons, Dr. Lawrence Huntoon quoted Dr. Graves’ son appealing to the Florida Office of Executive Clemency for commutation of his father’s sentence. He explained that when Graves realized several of his patients were actually drug addicts faking symptoms to obtain prescriptions, he discharged them and appealed to the state attorney general to investigate other suspicious cases. The deaths were caused by patients using their prescribed medicines against Graves’ explicit instructions, combining them with alcohol or other drugs, or crushing and injecting them intravenously. Yet Graves has been denied the possibility of a new trial and is still incarcerated.

Huntoon brings up a disturbing point that courts are kinder to terrorists. He cites the “Lackawanna Six” from Buffalo, New York, imprisoned in 2003 for providing material support to al-Qaeda. All six were freed after serving 10 years or fewer. “How does this compare with the situation of physicians sentenced to life in prison for wrongful behavior of their patients?” Huntoon asks.

“Physicians have been tried and given longer prison sentences than convicted murderers; many have lost their practices, their licenses to practice medicine, their homes, their savings and everything they own.” So says Ronald Libby in his book The Criminalization of Medicine: America’s War on Doctors. “Some have even committed suicide rather than face the public humiliation of being treated as criminals.”

Libby details cases of secret FBI wiretapping, commando-style armed invasion of doctors’ homes and offices at odd hours, and agents posing as patients with made-up complaints, fake IDs, and phony insurance cards. Often on the advice of their attorneys, doctors plea-bargain a single felony to avoid the humiliation and staggering legal costs of a trial, “which they would probably lose” anyway.

Dr. Punyamurtula Kishore lost more than that, even though he practiced non-narcotic addiction treatment, and no one died. He had to surrender his medical license and U.S. passport, serve jail time, waive all rights to appeal, and pay $9.3 million in restitution. Orient summed up his “alleged crime: ordering too many urine tests.” This Indian-born doctor with a master’s degree from the Harvard School of Public Health, who has served on the faculty of Harvard and the University of Massachusetts, founded a practice in that state that quickly grew to 52 offices. He pioneered a successful sobriety-centric, non-narcotic approach to addiction treatment that combines inexpensive home detoxification and treatment custom-tailored to patients’ specific needs, with a focus on maintaining dignity and learning long-term coping skills to remain sober. More than 250,000 patients benefited from Kishore’s practice, which at its height employed 29 doctors and 370 staff members. Most importantly, his success rates exponentially outstripped standard medication-assisted treatment models. “After a year of the conventional treatments, only 1% to 5% of patients have not relapsed, while 37% to 50% of Dr. Kishore’s patients have not relapsed after the same period of time,” wrote Martin Selbrede, vice-president of the Chalcedon Foundation, a non-profit Christian think tank. Among other notable achievements, Kishore received the Boston Celtics’ “Hero Among Us” award in 2004 for his work in addiction treatment, and in 2010 the American Society of Addiction Medicine elected him a fellow. A short time later, he was jailed.

In a media-pandering nighttime armed invasion of Kishore’s home, the Massachusetts attorney general had him arrested in 2011 on 16 felony charges of fraudulent Medicaid claims and kickbacks for urine drug screening. The agency leveled an additional 22 charges in 2013. A news release from the attorney general’s office accused him of “blatant theft of state funds,” and the state Board of Registration in Medicine claimed him to be “an immediate and serious threat to public health, safety and welfare,” though all the charges were financial in nature and there were no deaths, overdoses, or patient injuries involved. By 2015, his finances drained, his practice destroyed, and his morale exhausted in endless legal battles, he agreed to plead guilty to one felony: larceny over $250. He told The New American, “When I accepted the plea bargain, they immediately released me from prison,” though he had only served eight months of his 11-month sentence.

Photo: Newscom

This article appears in the May 7, 2018, issue of The New American. To download the issue and continue reading this story, or to subscribe, click here.

Believing himself targeted for the success of his non-conventional model of treatment, Kishore points out that his former practice was following federal safe harbor regulations and had consistently received favorable reviews from regulatory agency audits. Regarding his non-conventional method of urine drug screening, Kishore explains that his testing was custom-tailored. A highly supervised patient residing in an addiction treatment center might only require once-a-week screening, whereas an emancipated minor undergoing therapy in his home environment where he is more likely to relapse may need a test every day or two.

Kishore’s complete story will be told in an upcoming documentary called Hero in America. Funded by the Chalcedon Foundation, it tells “the nightmarish account of how the State of Massachusetts — in league with Big Pharma — systematically, and unjustly, persecuted a Christian physician whose pioneering work in addiction recovery was achieving record results.”

What’s Your Poison?

Before investigating the true source of this deadly opioid epidemic, let’s understand the drugs involved. The term “opioid” can refer to various substances under three classifications: natural, semi-synthetic, and synthetic. Natural opioids include morphine, codeine, and heroin, all derived from poppy seeds. Semi-synthetics include oxycodone and hydrocodone. Tramadol and fentanyl are examples of fully synthetic opioids.

Here’s how they work: Our brains contain areas called “receptors” that react to various chemicals, controlling everything from how we think and feel to how we breathe. Opioid receptors are “found in areas of the brain that control pain and emotions,” explains the National Institute on Drug Abuse (NIDA). “When opioid drugs bind to these receptors, they can drive up dopamine levels in the brain’s reward areas, producing a state of euphoria and relaxation.” They are, therefore, effective pain killers, but users can become addicted. Additionally, the brain’s respiratory center contains opioid receptors; high opioid doses can slow breathing or stop it altogether.

Many opioids are available by prescription. Many more claim huge demand in the black market. Fentanyl, the drug that killed pop star Prince, is up to 100 times more potent than morphine and as much as 50 times more potent than heroin. In prescription form, it is often the only medication that relieves advanced cancer pain or chronic back pain for patients who are more concerned with crippling agony than potential addiction risk.

However, fentanyl is a popular product of clandestine laboratories. Being fully synthetic, it is easier and cheaper to produce than heroin, which depends on seasonal crops. Moreover, its exponential potency intensifies the high of other drugs, so dealers up their profits by “cutting” fentanyl into heroin, cocaine, and other substances. Mixed in a basement warehouse and sold on the street, these “recreational” combinations leave hapless users playing a deadly game of Russian roulette.

Not that all addicts are unaware; many shop for it. “If there’s a dope out there that’s killing people, everybody wants it.... That’s the killer dope. That’s the strongest out there.” Those are the words of an unidentified patient at the New Orleans Odyssey House Detox Center to NPR reporter Eve Troeh in 2016, the year opioid deaths topped the murder rate in that city.

On the street, fentanyl or fentanyl-laced drugs sport names such as Jackpot, Murder 8, China Girl, and China White, the last two names providing a clue to the source. Based on U.S. Drug Enforcement Administration (DEA) and United Nations narcotics monitors, President Trump accuses China of being the main source, explaining that fentanyl is either shipped here directly or to Mexico and then smuggled across the border. He emphasized the urgency of the situation to China’s President Xi Jinping during his visit to Shanghai late last year.

Nation Under Siege

“I would say 99% of what we are seeing on the street, bought and sold, is product from China, India, Mexico, or from second or third-hand distributors. It is not pharmaceutical grade, FDA approved fentanyl,” said Lisa McElhaney, president of the National Association of Drug Diversion Investigators, quoted by the Pain News Network. Addressing a recent seminar of pain-management providers, McElhaney explained that the U.S. opioid black market is dominated by imported fentanyl, often designed as counterfeit pills made to look like oxycodone or the anti-anxiety drug Xanax. She emphasized how easy it is to make, “but it has such a heavy potency and purity level that it is fatal,” while “the profit margin is phenomenal.”

“Phenomenal” is an understatement. Last August, Mexican authorities seized more than 140 pounds of powdered fentanyl and nearly 30,000 fake tablets at a highway checkpoint near Yuma, Arizona, on the U.S. border. The drugs were hidden inside a tractor-trailer rig and had an estimated street value of $1.2 billion. Put in perspective, “the Defense Department said that in the previous 4½ years, its total seizures of fentanyl had amounted to 106 pounds and about 36,000 fentanyl pills,” reported CBS News.

In October the Justice Department (DOJ) indicted two Chinese nationals acting as traffickers to individuals in the United States. Deputy Attorney General Rod Rosenstein said that one of the defendants had operated chemical plants in China “capable of producing quantities of fentanyl and fentanyl analogues tons at a time.” Rosenstein expressed hope that the Chinese government would cooperate with DOJ. But in December, Yu Haibin, leader of the China National Narcotics Control Commission, denied fault, blaming the United States. He accused doctors of over-prescribing pain killers and impugned state governments for legalizing marijuana, claiming there is little proof that China is the source of epidemic-inducing fentanyl.

However, Senators Rob Portman (R-Ohio) and Tom Carper (D-Del.) released a Senate committee report in January revealing that hundreds of millions of dollars’ worth of fentanyl is pouring into this county through international mail; the U.S. Postal Service is powerless to stop most of it. The study profiled six online vendors — five based in China, one in an unknown location — who sent packages to U.S. buyers primarily through USPS. The profits are staggering. These customers paid a total of $230,000 in 500 financial transactions; the street value would be $766 million. But the costs are catastrophic. Seven people died of synthetic opioid overdose after receiving their purchases, and 18 have been arrested for drug-related offenses. Investigators believe another individual was acting as a local distributor for one Chinese manufacturer.

Why is USPS so vulnerable? Portman blames sheer volume and antiquated security measures. Though the Postal Service set up an advanced electronic data pilot program at JFK Airport in 2015 to help U.S. Customs better identify illegal cargo, Portman says it has been “rife with problems, lack of coordination ... and other setbacks that have left the agency wholly unprepared.” Customs officials at JFK Airport, where one million pieces of international mail arrive daily, told USA Today that they are able to intercept only 40 percent of illegal packages.

Kathleen McLaughlin of STAT News learned how easy it is to buy from China. She located 40 companies through simple Internet searches. “Drug dealers operate out in the open online in China, offering fentanyl and other synthetic substances for sale in unrestricted quantities,” she explained. The industry is “under pressure but not illegal in China.” McLaughlin negotiated via online chat with one Chinese marketer who offered to send a free sample and even gave pointers on entering the business.

The “pressure” McLaughlin mentioned references more than 100 fentanyl variants that China has listed as controlled substances, though fentanyl remains unregulated. While China dwarfs other countries in opioid trade, India competes because it imposes fewer regulations. “India has not placed fentanyl, or most other opioids, on its controlled substances list, easing production and export,” reported The Diplomat in January, naming that country as the leading supplier of fentanyl’s synthetic cousin, tramadol, to international markets.

Adding to the chaos of unregulated narcotics is an even deadlier relative in the opioid family tree: carfentanil. Developed in the 1970s as an elephant tranquilizer, it is 100 times stronger that fentanyl, causing governments to ban it under the Chemical Weapons Convention. It is the most potent commercial opioid in the world, says the DEA. Yet carfentanil is not a controlled substance in China and is gaining popularity in the U.S. black market. Pennsylvania has witnessed a recent upsurge in carfentanil-related overdoses, where two traffickers had been ordering it directly to their apartment from China for months before their arrest in March. Westmoreland County Coroner Ken Bacha reported 30 of his 194 overdose deaths last year were linked to carfentanil. The drug is also connected to deaths in Ohio, Minnesota, and Illinois. Florida officials recently reported 50 carfentanil-related deaths in a six-month period.

Moreover, in its 2017 National Drug Threat Assessment, DEA says Mexico and Colombia “dominate the US heroin market,” owing to their proximity and well-established drug-trade infrastructure. Half of the agency’s field divisions rated heroin as the top drug threat in 2016. Driven by major drug cartels such as Sinaloa and Jalisco New Generation, the heroin industry is responding to skyrocketing demand in the U.S. market. “The cartels are very attuned to shifts in drug abuse in the United States,” Mike Vigil, former DEA chief of international operations, told Business Insider. The Mexican newspaper Rio Doce quoted one heroin producer in northern Sinaloa state: “Before I cooked some 40 kilos a year,” he said. “But now I’m cooking like some 30 kilos a month.”

Prescription for Healing?

Despite overwhelming proof of illegal narcotics flooding in from foreign countries, despite blatant evidence that the U.S. opioid epidemic is driven by unlawful drug use, and despite the fact that the crisis is exploding in the midst of ever-tightening restrictions on lawful prescriptions, CCDAOC blindly insists that doctors are causing the problem. Its recommendations center on proven-ineffective, costly, and unconstitutional solutions within the healthcare system: education campaigns, prescription monitoring programs, overdose rescue and treatment services, and research for pain management alternatives — all funded by taxpayers, of course. The commission’s final report does mention illicit fentanyl imports, recommending funding to continue the failed “War on Drugs,” but it entirely ignores Mexican heroin and transnational drug cartels. One wonders if CCDAOC chair Christie doesn’t have a personal ax to grind, with his emotional telling of a former schoolfellow whose death involved prescribed oxycodone — an addict who washed down his Percocet with vodka.

Meanwhile, doctors fear prescribing legal medications, meaning legitimate pain patients are denied effective treatment and are more likely to turn to the black market for dangerous alternatives. The government pours billions into addiction treatment models with staggering failure rates while offering free or low-cost opioid access to Medicaid recipients-turned-addicts or dealers. “Where are the drug-sniffing dogs in schools where children are known to be getting addicted?” Orient asks. “Is there any way that such massive international trafficking could thrive without some level of political protection? And is the government attempt to remedy the problem making it worse?”

Perhaps the answer to the opioid epidemic lies in getting the federal government out of its unconstitutional involvement in healthcare. Instead of swallowing the government’s line to blame doctors, taxpayers should blame the federal government for creating and exacerbating the opioid epidemic, and for failing in its constitutional duty to protect our borders from opioid invasion. And they should demand the unshackling of physicians such as Kishore who offer real solutions with proven results.

How Does Addiction Happen?

by Rebecca Terrell

Addiction amounts to more than abuse. When a drug acts on the central nervous system (CNS), it creates a chemical imbalance. Our bodies naturally try to restore equilibrium. But if we become accustomed to the presence of this foreign substance, a new normal develops. The person becomes tolerant (i.e., it takes more of the drug to achieve the desired effect) and then physically dependent (i.e., CNS changes become semi-permanent or permanent). Once the body operates normally only in the presence of the addictive substance, sudden drug reduction or withdrawal can cause severe illness or even death.

Risk of addiction depends on a variety of factors: type of drug and the length of time used, dosage amount, route of administration, underlying medical conditions, family history, and other biological and environmental factors. Addiction varies from person to person.

Depending on the severity of addiction, opioid withdrawal symptoms can occur within a few hours after the most recent dose and may last weeks. They include insomnia, sweats, racing heart, high blood pressure, fever, painful muscle cramps, nausea and vomiting, anxiety, depression, agitation, and cravings. Withdrawal can be so traumatic that victims attempt suicide. Since opioids affect respiration, heart rate, blood pressure, and body temperature, withdrawal can be life-threatening — especially if medically unassisted. Therefore, while a craving for opioids’ euphoric effects may contribute to developing addiction, the desire to avoid withdrawal can become an even larger motivation to continue drug abuse and a devastating obstacle to recovery.

Photo: Newscom

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