Demon Copperhead author Barbara Kingsolver talks about the opioid epidemic and Appalachia's difficulty with it

Barbara Kingsolver

Barbara Kingsolver says she intended her Pulitzer Prize-winning novel Demon Copperhead to be her "great Appalachian novel" that told the story of how the opioid epidemic has ravaged the region, and its impact on children.

Ezra Klein of The New York Times interviewed Kingsolver, who grew up in Nicholas County, for his podcast, "The Ezra Klein Show." The Times transcribed the interview. It is wide-ranging, but a big chunk has her telling Klein how the opioid epidemic has impacted a whole generation of children who have become orphans and are being raised by grandparents and the foster system — and getting the bulk of their social services at school.

 

"We have a generation of orphans coming up through our schools," Kingsolver said, adding later, "There’s so many more kids in need than there are social networks to catch them — but the caseworkers are so overloaded and so pathetically underpaid. . . . This is something that I think the world needs to know about, this country — voters — need to know about. We need to know how this epidemic has left a generation of innocents that nobody’s taking decent care of. . . . These kids have been left behind. Our burdened public school systems are being asked to raise these kids." 

Klein and Kingsolver also talked about how Central Appalachia was targeted by Purdue Pharma with a drug that was so addictive and with doctors who were told otherwise. "This was done to them," Kingsolver said of her neighbors in southwest Virginia and southeastern Kentucky. "Nobody wants to be addicted."

 

Kingsolver also talked about the stigma associated with addiction and how people have been brainwashed to think it is a moral failing, instead of the brain disease that it is. 

"We have been trained, culturally trained, to think of addiction in this way, as a personal failing that needs to be punished. Incarceration does not cure addiction any more than it cures cancer. Addiction is a disease," she said. "It’s impossible to describe how terrible this disease is, not just the dope sickness of it but the fact that your entire life has to become just a really difficult, hard work in process of, every morning, getting your means, getting your fix, getting through another day. And nobody wants to live like that." 

Kingsolver told Klein that she hopes her novel will help people have more compassion and think of people with addiction as having a disease and to get rid of the idea that you don't treat a person with addiction until they "hit bottom." 

"That’s how we treat the disease of addiction. And it’s incredibly inhumane. And effective treatment will only happen after we switch over from putting this in the hands of the police and the prisons to medical workers who can meet addicted people where they live and offer them the first steps of clean needles and fentanyl test strips so that they won’t die in the weeks that it will take for them logistically, physically, emotionally, to get to the beginnings of treatment," she said. 

And to those who maintain a moral objection to such "harm reduction" programs, she said, "It’s as if people feel that addicted people deserve to die. Imagine if we looked at any other disease that way."

Supreme Court freezes Purdue Pharma's bankruptcy plan

The U.S. Supreme Court has frozen a bankruptcy reorganization plan for OxyContin manufacturer Purdue Pharma that would shield members of the Sackler family, who own the firm, "from civil claims in exchange for paying up to $6 billion to address the U.S. opioid crisis," Axios reports. "Justices will review the agreement and hear arguments in the case in December."

Adrriel Bettelheim writs that the ruling "marks a win for the Biden administration after the Justice Department argued the bankruptcy court couldn't grant the family members legal immunity from claims by opioid victims." The company said it was optimistic that the high court would find ten plan to be legal, NBC News reports.

"The 2nd U.S. Circuit Court of Appeals ruled in May that the bankruptcy plan could proceed, reversing a lower court ruling against immunity since the Sackler family members weren't declaring bankruptcy themselves," Bettelheim notes. "The deal furthered a settlement that would send billions of dollars to states, local governments and Indigenous tribes affected by the opioid epidemic. But experts questioned whether it would lead to copycat cases, in which corporations tried to limit liability through bankruptcy courts. Purdue filed for bankruptcy in 2019 after facing thousands of lawsuits over its marketing" of OxyContin, a painkiller widely blamed for starting the opioid epidemic.

Documents show how top opioid maker Mallinckrodt drove the epidemic by getting doctors to prescribe more pills

Average number of pain pills distributed per person, per year, by county, 2006-2014
(May by The Washington Post; click the image to enlarge it or click here for the interactive version.)

Even as the opioid epidemic raged across the U.S. in 2013, the nation's top opioid manufacturer, Mallinckrodt Pharmaceuticals, continued to aggressively court and lavishly reward doctors who prescribed more pain pills, even after sales reps cautioned the company that some doctors were running illegal pill mills, according to a treasure trove of newly released documents mined by Maryl Kornfield, Scott Higham and Steven Rich for The Washington Post.

The company also "played a key role in an industry-wide effort to convince the health-care industry that addiction was rare among opioid users and marketed its drugs to specific segments of society" such as seniors, the Post reports. "The Mallinckrodt documents are part of a cache of 1.4 million records, emails, audio recordings, videotaped depositions and other materials the company turned over as part of its $1.7 billion bankruptcy settlement in 2020. Several state officials with claims against the company, led by Massachusetts Attorney General Maura Healey (D), urged that the documents be made public."

The Post was granted exclusive access to the files, which are part of the Opioid Industry Documents Archive, a digital vault of records created or obtained by state and federal opioid lawsuits and managed by Johns Hopkins University and the University of California at San Francisco; it's the largest repository of such evidence from an opioid company to date.

"For the first time in a long time, industry secrets are going to be turned over to the public and millions of documents will live online in an archive forever,” Healey told the Post. "Making this evidence available to the public will hopefully pave the way for important reforms that will stop dangerous conduct and save lives."

Though OxyContin maker Purdue Pharma has been the prime bogeyman of the opioid epidemic, Mallinckrodt produced more narcotics because its pills were often more potent. "Between 2006 and 2014, Mallinckrodt accounted for 27 percent of the opioid market compared with 18% for Purdue Pharma, measured by the potency of the pills they produced," the Post reports.

Mallinckrodt's 30-milligram Exalgo pill quickly became the opioid of choice on the street, and in Massachusetts supplied to more than half of the people who died from opioid overdoses in the past 12 years—far more than Purdue and its affiliate Rhodes Pharmaceuticals supplied, the Post reports.

Retired Drug Enforcement Administration supervisor Jim Geldhof, who investigated Mallinckrodt before his 2016 retirement and now consults with cities in opioid lawsuits, told the Post: "Everybody thinks of Purdue when they think about the opioid epidemic, but Mallinckrodt was far worse."

In videotaped depositions from 2018 to 2020, top Mallinckrodt executives "took little or no responsibility for the opioid epidemic. Several skirted questions about whether an opioid epidemic even existed," the Post reports. "For years, drug companies have argued they were simply filling orders written by medical professionals for legitimate patients. But the Mallinckrodt files show that the company had detailed knowledge of the prescribing patterns of doctors and bemoaned their loss when they fell into trouble with regulators." Sales representatives whose clients prescribed more Exalgo were showered with perks like free trips to Hawaii and Europe.

In six months in 2013, company sales representatives contacted the top 239 Exalgo prescribers more than 7,000 times. "More than a quarter of those prescribers — 65 — were later convicted of crimes related to their medical practices, had their medical licenses suspended or revoked, or paid state or federal fines after being accused of wrongdoing," The Post reports.

One of those top prescribers was Cincinnati orthopedic surgeon George Griffin, whom the company knew was in legal trouble for overprescribing pain pills. "For one patient, he prescribed 640 mg a day of OxyContin — despite warnings from a pharmacist that the patient was a drug dealer with a history of drug-related felonies, according to the board," the Post reports. In 2019 Griffin was convicted of unlawful distribution of controlled substances and sentenced to 40 months in prison.

A former Massachusetts doctor, Fathalla Mashali, who was convicted of health-care fraud and more, complained that the companies have not faced the same consequences as the doctors they influenced. "We got prosecuted criminally and we lost all our money, lost everything," Mashali said. "The Sacklers get to keep their money, Mallinckrodt to keep their money. All the companies get to keep their money."

As part of its 2020 bankruptcy settlement, Mallinckrodt turned over $1.725 billion to a trust serving communities affected by the opioid epidemic, the Post notes.

DEA issues public warning about deadly black-market pain medications laced with fentanyl and methamphetamine

"The Drug Enforcement Administration issued a public warning Monday that a growing number of pain medications bought on the black market are laced with the synthetic opioid fentanyl or the stimulant methamphetamine, driving overdose deaths to record levels," Devlin Barrett reports for The Washington Post. "Officials said the DEA hasn’t issued such a public safety alert since 2015, when the agency warned that agents were seeing an alarming amount of heroin laced with fentanyl. Fentanyl, even in much smaller amounts, is deadlier than street heroin."

Drug overdose deaths in 2020 surpassed a record 93,000, up nearly 30 percent from 2019. "In recent years, the death toll has risen sharply, fueled in large part by fentanyl, a synthetic opioid that is relatively cheap to manufacture and distribute," Barrett reports. "Last year, drug overdoses killed more than twice as many Americans as car crashes."

Illegal drug trafficking is increasingly shifting from plant-based drugs such as cocaine and heroin to chemical-based drugs such as meth and fentanyl. "The DEA has seized 9.6 million counterfeit pills already this budget year, which is more than it seized in the previous two years combined, officials said. The number of seized counterfeit pills found to contain fentanyl has jumped 430 percent since 2019," Barrett reports.

The drug epidemic, mostly fueled by opioids, has been getting worse since 1999. "At first, that drug abuse centered around prescription pain pills, such as Oxycodone, Vicodin or Percocet," Barrett reports. "In recent years, the death toll has risen sharply, fueled in large part by fentanyl, a synthetic opioid that is relatively cheap to manufacture and distribute. Last year, drug overdoses killed more than twice as many Americans as car crashes."

Researchers conclude that pain from working in coal mines, not layoffs (as some think), leads to opioid addiction

Common wisdom holds that opioid abuse has skyrocketed in Appalachian coal-mining areas because of despair from layoffs. "But that may not be the case at all. There is evidence that it was the presence of coal mining jobs that helped create the opioid epidemic, not their absence," Bill Bishop reports for The Daily Yonder.

A newly published study notes that coal mining is physically taxing and dangerous work, and that many coal miners who abuse opioids began using the drug after it was prescribed to them for workplace injuries, Bishop reports.

"The two economists found that as active coal mining jobs decreased in counties, the overdose death rate also declined. The national shift away from coal to natural gas hasn’t set off a drug epidemic in coal counties because of economic despair, the two academics write," Bishop reports. To the contrary, they argue that the shift from coal to natural gas has helped mitigate the opioid epidemic.

Much as in Appalachia, opioids flooded Utah coal country

Wikipedia base map, adapted

Utah's coal country stands out in the federal database showing where opioid pills were distributed from 2006 through 2012, reports Yue Stella Yu of The Salt Lake Tribune.

Carbon County got enough pills for each resident to receive 105 per year, "the highest per capita rate among all Utah counties, and rivals rates in some Virginia counties in the Appalachian mining region," according to an analysis by The Washignton Post, which fought to get access to the Drug Enforcement Administration data. Adjoining Emery County’s ranked second in the state, at 64.9 pills per resident per year.

Also, "Carbon County had the highest opioid prescription rate in Utah every year between 2006 and 2017, hitting its peak in 2008 at 194.2 prescriptions for every 100 people, according to data from the Centers for Disease Control and Prevention," Yu notes.

"Behind those high rates are families in Utah’s mining heartland who saw their loved ones and friends become dependent on the pills, addicted residents who searched for hard-to-find treatment, strapped parents who sometimes drained retirement funds to pay for it, and those who have grieved losses," Yu writes. "The death rate for Carbon County’s 20,000 residents, calculated from 2011 to 2016, rose to more than three times the state average, according to data compiled for the Utah Legislature last year."

The county "once prospered from its rich coal and oil reserves, but the heavy labor required by the industries takes a physical toll on many workers," Yu notes, citing Debbie Marvidikis, health promotion director of the Southeast Utah Health Department. "The acute need for pain treatments and a lack of access to alternative therapies contributed to the county’s opioid use, she said." Marvidikis said users “were trying to take care of their health needs. What they didn’t know was how addictive opioids are, and how dependent you can become on them in just a matter of a few weeks.”

In text, pictures, audio and video, Post looks at 4 localities among many suing drug makers over opioids: 'We was addicted to their pills, but they was addicted to the money'

L-R: Lee, Wise and Russell counties; City
of Norton is within Wise (Wikipedia map)

"Towns and cities across America are fighting back against the drug industry, seeking billions of dollars in damages to treat addiction and rebuild their communities," through a lawsuit in federal court in Cleveland, Joel Achenbach of The Washington Post reports, in a deep, multimedia story from Southwest Virginia -- where Lee, Wise and Russell counties and the City of Norton are plaintiffs in the suit.

In photographs, audio, video and text, the story is told by a Post team and people who are in recovery, including some who relapse; a police officer who saw the epidemic coming but was largely ignored; pharmacists who refused to fill dodgy prescriptions; and the district director of the state health department. "People here are familiar with pain," Achenbach writes. "Coal miners tell stories of explosions they survived. Disability rates are high. This was a place where the purveyors of pain pills found a ready market."

Jason Boyd and daughter (Washington Post photo by Melina Mara)

The most compelling account comes from Jason Boyd, a recovering and relapsing father of four who makes a case that sounds like a good opening or closing argument in a trial: “We was addicted to their pills, but they was addicted to the money, because that’s what it is about. The definition of murder is when you sit and you plan about how killing somebody. Well that’s pretty much the definition of what they done. They sit back and say, ‘All right, this is addictive,’ but it’s same thing as just sitting there saying, ‘Well, we will murder a whole bunch people and make millions of dollars off of it.’ ”

Achenbach notes, "The drug companies issued broad defenses of their actions during the opioid epidemic. They have said previously that they were trying to sell legal painkillers to legitimate pain patients who had prescriptions. They have blamed the epidemic on over-prescribing by physicians and also on corrupt doctors and pharmacists who worked in 'pill mills' that handed out drugs with few questions asked. The companies also said they should not be held responsible for the actions of people who abused the drugs."

Those statements were made to The Post last month in response to its release of a Drug Enforcement Administration database that is central to the lawsuit, Achenbach writes. It "became public through legal action by The Washington Post and HD Media, owner of the Charleston Gazette-Mail in West Virginia. Over seven years, the database shows, drug companies shipped a combined 74 million opioid pills to the city of Norton and the three surrounding counties — enough for 106 pills per resident every year." The city and Lee and Dickenson counties are also among the plaintiffs in a similar lawsuit in Virginia, The Coalfield Progress reports.

The Post reported that the database showed Norton, a town of 4,000, received more pain pills per person, 306, than any other place in America in 2006-12. That is misleading, City Manager Fred Ramey told the Progress, “since all demand is not local” and Norton “is a regional commercial hub and home to two hospitals, a VA clinic, and regional cancer facility along with a number of doctors that serve the medical needs of a multi-county area that includes a portion of Eastern Kentucky.”

Study: Rural dentists show awareness of opioid epidemic in their prescribing, and are in good positions to fight it

While rural and non-rural dentists prescribe about the same number of pain pills, rural dentists do so more often in combination with ibuprofen or acetaminophen and at lower dosage rates. So says a new study, which also found that rural dentists are more likely to have suspected their patients of drug abuse -- and not prescribed opioids to them as a result of that suspicion.

AARP photo illustration

The study, published in The Journal of Rural Health, pointed out that rural dentists are in a great position to help combat the opioid crisis, largely because rural communities have been hit so hard by the opioid epidemic and because dentists prescribe about 12 percent of annual opioid prescriptions.

"Recognizing and engaging rural dentists as leaders in addressing opioid misuse will be an important step toward reducing the fatal impacts of this epidemic among rural communities," the researchers write. "Rural dentists encountering this epidemic can implement screening for opioid misuse and abuse, as well as provide a referral for treatment."

The researchers delivered an online survey to dentists in the National Dental Practice-Based Research Network to measure both rural and non-rural dentists' pain management practices, their perceptions of the scope of the problem and the perceived adequacy of their training around preventing the misuse and abuse of opioids.

The survey excluded those who did not provide an email address, and those who practiced exclusively in orthodontics, oral pathology or pediatric dentistry, because those types of practices rarely prescribe opioids. Of the 822 dentists who completed the survey, 91 were in a rural practice and 731 were not; 11.1% of them were in an area that is short of health professionals. Rural practice was defined as those with a ZIP code with more than 50% of its population living in a non-metropolitan county or in a rural census tract. (Many metro counties have rural census tracts.)

"Rural dentists were significantly more likely to prescribe opioids in combination with a recommendation to use ibuprofen or acetaminophen for pain management, and were significantly less likely to prescribe six to seven days' supply of opioids," the researchers report. They also found that only one-third of the dentists said their training to prevent misuse or abuse of opioids was "sufficient and up to date." Rural dentists appeared slightly less likely to say that. The rest said their training was either sufficient, but out of date; insufficient; or that they had received no such training.

The researchers said the American Dental Association's new policy was a great support for dentists because it sets limitations for opioid dosage and duration for acute pain, elevates the significance of mandatory continuing education for prescribing opioids and other controlled substances, and provides a recommendation for dentists to use state prescription-drug monitoring programs.

The journal article concludes, "Dentists should employ recommended risk-mitigation strategies broadly, as a substantial segment of dental patients report at least some non-medical use of their pain medications, and recent substance abuse—including problematic alcohol use or illicit drug use—has been reported by approximately one in five dental patients."

The article acknowledged several limitations to the study: Self-reported data is retrospective in nature, making it subject to potential bias; no objective prescribing data was collected; a patients may live in a different ZIP code (perhaps an urban one) than the dentist; and the study did not differentiate between the complexity of procedures as potential reasons for the dentists' prescribing practices.

The corresponding author of the study report is Dr. Jenna McCauley of the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina.

Opioid distribution database shows rural counties inundated with pain pills in 2006-12; see data by county and drugstore

UPDATE: Paintsville (Ky.) Herald Editor Aaron Nelson took a look at the data and found that "Two pharmacies in Paintsville ranked number one and number four across the entire state of Kentucky for opioid shipments between 2006 and 2012." And he named the pharmacies in his story.

Washington Post map; click on the image to enlarge it or click here to view the interactive version.

Between 2006 and 2012, pharmaceutical companies distributed 76 billion doses of prescription pain medicine, "enough pills to supply every adult and child in the country with 36 each year," Scott Higham, Sari Horwitz and Steven Rich report for The Washington Post. But rural counties, especially in Appalachia, received some of the highest shares of pain pills per person.

Washington Post map; click on image to enlarge it.

UPDATE, July 18: The Post has updated the story to include a link to the raw data, a portal to search for data by county, a map showing opioid deaths from 2006-2012, and more.

That's according to a Drug Enforcement Administration database, made public for the first time, that tracks the path of every DEA-regulated pain medication in the U.S. County-level data shows the places that received the most pills, fueling the prescription opioid epidemic that resulted in nearly 100,000 deaths in that time period, the Post reports.

"The states that received the highest concentrations of pills per person per year were: West Virginia with 66.5, Kentucky with 63.3, South Carolina with 58, Tennessee with 57.7 and Nevada with 54.7. West Virginia also had the highest opioid death rate during this period," Higham, Horwitz and Rich report. "Rural areas were hit particularly hard: Norton, Virginia, with 306 pills per person; Martinsville, Va., with 242; Mingo County, West Virginia, with 203; and Perry County, Kentucky, with 175." The Post's Joel Achenbach has a close-up look at Norton.

Nearly half of the pills were distributed by three companies: McKesson, Walgreens and Cardinal Health. The top manufacturer was Mallinckrodt's SpecGx, with nearly 38 percent of the market.

Because the database is partly comprised of data that drug makers gave the DEA, it shows what they knew about the number of pills they were shipping at the epidemic's peak, the Post points out. Drug manufacturers, distributors and pharmacies must log and report each narcotic transaction, and are supposed to report suspiciously large or frequent orders to the DEA and withhold such shipments.

Nevertheless, nearly 2,000 communities, counties and Indian tribes have alleged in federal lawsuits that the drug companies filled suspicious orders and did not report them in order to maximize profits. The lawsuits were consolidated into one case, which is now larger in scope than the lawsuit against cigarette manufacturers in the 1980s, the Post reports.

The database was released Monday after the Post and HD Media, which publishes the Charleston Gazette-Mail, won a years-long legal battle to access documents and data from the ongoing litigation. The West Virginia newspaper won a Pulitzer Prize in 2018 for reporting on drug distribution, using other data.) The Post reports that the DEA, the Justice Department, and drug companies all fought hard against release of the data. The companies said the database would reveal information that could give competitors an unfair advantage, and the Justice Department said the data could compromise ongoing DEA investigations.

Post Executive Editor Marty Baron said, “The Post has invested tremendous legal and journalistic resources in obtaining, analyzing and presenting this database. But there is more work to be done — by us, by other journalists and by individuals seeking to learn what has transpired in their own communities. With this database on our site, many others can now contribute to a full understanding of the causes and impact of a devastating opioid epidemic.” Kristen Hare of The Poynter Institute opined, "This is a remarkable display of public service reporting performed by The Post. The information, available to every journalist in every corner of the country, can be used to impact, literally, every person in America."

VA doctors prescribe far more opioids to rural veterans, perhaps due to lack of long-term treatment alternatives

Rural veterans got almost a third more opioids than urban veterans from doctors in the Department for Veterans Affairs, according to a study of outpatient prescription practices in 2016.

Opioid prescribing in the Veterans Health Administration among rural veterans declined from 2012 to 2016, but rural "rates remain 32 percent higher than urban counterparts," said the study, published in the most recent issue of the journal Military Medicine.

One reason: More rural vets use opioids long-term; rates of short-term use among rural and urban vets were similar, according to the study. A 2017 study also found that rural vets were far more likely to use opioids long-term. "The findings suggest that rural veterans with chronic pain use opioids for long periods because alternative treatments are available primarily in urban areas," Wyatt Olson reports for Stars and Stripes. "The hypothesis is supported by the study’s finding that VA facilities serving rural areas with more dense populations of veterans had smaller rural-urban differences in dispensed opioid volume — as compared to facilities treating the sparsest rural populations of veterans."

Ky. appeals court OKs release of records showing how Purdue Pharma promoted OxyContin, opioid epidemic

The Court of Appeals of Kentucky on Friday upheld an Appalachian judge’s ruling to release secret records about the marketing of OxyContin, the branded form of oxycodone that "has been blamed for helping to seed today’s opioid-addiction epidemic," reports Stat, the medicine-and-science publication of The Boston Globe, which fought to get the records.

Purdue Pharma is privately held. (AP photo by Douglas Healey)

In the court file is a deposition of Richard Sackler, a former president of Purdue Pharma, the family-controlled company that makes OxyContin and pleaded guilty in federal court to fraudulently marketing of as less addictive than other painkillers.

The deposition "is believed to be the only time a member of the Sackler family has been questioned under oath about the marketing of OxyContin and the addictive properties," Stat's David Armstrong and Andrew Joseph report. "Other records include marketing strategies and internal emails about them; documents concerning internal analyses of clinical trials; settlement communications from an earlier criminal case regarding the marketing of OxyContin; and information regarding how sales representatives marketed the drug."

The case was a lawsuit filed in 2007 by then-state Attorney General Greg Stumbo, alleging similar fraud and increased costs to the state for drug treatment and health care. It was transferred to federal court, where it lingered for several years under then-AG Jack Conway, who got it transferred back to Pike Circuit Judge Steven Combs. Depositions were taken, and in December 2015, as one of his last official acts, Conway settled the case and agreed to destroy 17 million pages of documents he had obtained through discovery.

However, some copies of the documents remained on file in Pike County, and Stat asked for them. in May 2016, Combs ordered them released, but stayed the order pending Purdue's appeal. He wrote, “The court sees no higher value than the public (via the media) having access to these discovery materials so that the public can see the facts for themselves.”

Jack Conway

Almost a year and a half after oral arguments in the case, the three-judge appeals panel unanimously agreed, saying it was the only way to hold Conway accountable. Without naming Conway, Judge Glenn Acree wrote, “Some agent of the government compromised the claim against Purdue; i.e., some agent sold the people’s property. . . . Without access to court records, how can the public assess whether a government employee’s decision to compromise a valuable claim of the people adequately protected their interest or maximized the claim’s value?”

Conway told the Louisville Courier Journal Friday, “Kentucky got many times over what any state has gotten from Purdue Pharma. After eight and a half years, I thought it was best to get what we could. I hope it all comes out, (that) all of the documents eventually get released, and sooner rather than later.”

Purdue has 30 days to appeal, and indicated that it would, either to the state Supreme Court or through a rehearing by the appeals court. Either could refuse further action.

“It's taken a long time, but we're now very optimistic that these records will see the light of day very soon,” Stat Managing Editor Gideon Gil, a former health reporter and regional editor for the Courier Journal, told Kentucky Health News.

Louisville lawyer Jon Fleischaker, who represented Stat, told the publication, “Really what the court is saying is these are public records. The public has an interest in them, and the public has a right to them.”

Stat Editor Rick Berke said, “More than two years after we filed this suit, the scourge of opioid addiction has grown worse, and the questions have grown about Purdue’s practices in marketing OxyContin. It is vital that that we all learn as much as possible about the culpability of Purdue, and the consequences of the company’s decisions on the health of Americans.”

Powerful — and controversial — opioid nears FDA approval

Dr. Raeford Brown

A powerful — and controversial — new opioid may soon be approved by the U.S. Food and Drug Administration.

"The drug, Dsuvia, consists of a single-dose tablet of sufentanil, a synthetic opioid that is many times more potent than fentanyl and 500 times stronger than morphine," Emma Court reports for Marketwatch. "The tablet comes in a preloaded plastic applicator that is used to deposit the medication under a patient’s tongue."

The FDA's Anesthetic and Analgesic Drug Products Advisory Committee recently recommended the drug for U.S. approval with a 10-3 vote; the FDA is expected to make a final decision by Nov. 3, and though it usually follows such committee recommendations, it doesn't have to, Court reports.

Dsuvia comes in a single-dose package.
(Photo by AcelRx)

Dr. Raeford Brown, the committee's longtime chair and a professor of anesthesiology and pediatrics at the University of Kentucky, wrote an open letter to the FDA protesting Dsuvia, questioning the wisdom of adding another strong opioid to the market as the nation struggles with an opioid addiction epidemic. Brown noted that the drug's design makes it easier for someone who doesn't have a prescription to get ahold of it. The letter was on the letterhead of consumer advocacy group Public Citizen.

"This drug offers no advance, in my mind, over previously available opioid formulations, but provides great risk of harm to patients and the general public health," Brown told Court.

Dsuvia's manufacturer, AcelRx Pharmaceuticals Inc., says the concerns are unfounded. Dr. Pamela Palmer, co-founder and chief medical officer of AcelRx, said the design makes it easier for battlefield medics to use and that the dosage is too small for many drug addicts to get "excited about." The drug can also help elderly or obese patients, she said, since intravenous opioids can be difficult to administer for such patients and oral opioids take more time to begin working, Court reports. Palmer also said that the drug would only be distributed at hospitals and other medically supervised settings, and that it wouldn't be available at pharmacies.

Opioid crackdown means some can't get needed meds

Because of crackdowns on opioid prescriptions to combat the opioid epidemic, some patients who say they legitimately need those prescriptions say they're unable to get them. "Some said they coped by using medical marijuana or CBD oil, an extract from marijuana or hemp plants; others turned to illicit street drugs despite the fear of buying fentanyl-laced heroin linked to soaring overdose-death numbers," Brianna Ehley reports for Politico.

Jon Fowlkes, a former law enforcement officer who took OxyContin to help with excruciating back pain from a motorcycle crash, said his doctor abruptly refused to renew his prescription. He told Ehley he contemplated suicide because he couldn't live with the pain, but was able to find a doctor willing to prescribe the drug blamed for starting the epidemic of addiction and overdoses. He worries what will happen if that doctor also stops -- not an idle fear, Ehly reports, since President Trump has set a goal of cutting prescriptions by a third over the next three years and has stepped up prosecution of doctors who inappropriately prescribe narcotics, including opioids (synthetic opiates).

Stories like Fowlkes' "illustrate the unintended consequences of efforts to suddenly reverse years of loose prescribing practices that fueled an addiction crisis — and why so many of the estimated 25 million Americans suffering from chronic pain feel angry and forsaken," Ehly reports. "While studies suggest that other therapies are safer and more effective for many chronic conditions, large numbers of these patients are now hooked on the narcotics and on the relief they say they get from constant, grinding pain."

Doctors and pharmacists acknowledged those fears, but told Ehly they're under great pressure to limit such prescriptions and fear losing their licenses or going to prison. Some said they chose to no longer treat patients with chronic pain because of those risks.

"Jianguo Cheng, president of the board for the American Academy of Pain Medicine, said that besides being scared, many doctors are also fed up with time-consuming requirements, including pill counting, where a patient brings her prescribed medication to the clinic so the doctor can make sure they aren’t being misused. Doctors also have to order regular urine tests to detect abuse," Ehly reports. "And few are trained how to safely wean someone off opioids. Some patients told him their doctors failed to treat their withdrawal symptoms, and they were sick for weeks after being tapered off their painkillers."

Blue Cross and Blue Shield advises acetaminophen or ibuprofen for primary pain treatment instead of opioids

The Blue Cross and Blue Shield Association now recommends using acetaminophen or ibuprofen instead of opioids as the first or second choice for managing pain. Opioids may be best for things like cancer treatment or palliative care, but "in most cases, ibuprofen and acetaminophen can treat pain more effectively than opioids, said Dr. Trent Haywood, chief medical officer for Blue Cross, which has about 106 million members," Alex Kacik reports for Modern Healthcare. "It's important that physicians understand that alternatives like medication-assisted treatment exist, which pairs medication with behavioral counseling, he said."

According to its internal analysis, 21 percent of the Blues' commercially insured members filled at least one opioid prescription in 2015, and the number of Blue members with an opioid-use disorder diagnoses increased 493 percent from 2010 to 2016.

Haywood says opioids are half as effective as over-the-counter pain medications, but two to four times more harmful. Doctors may not be aware of that, partly because of misleading marketing campaigns by pharmaceutical companies. In 2007 Oxycontin maker Purdue Pharma reached a $635 million settlement with the federal government over claims that Purdue downplayed the addictive nature of the drug. Several states and tribes have filed similar claims against several drug firms.

Another possible reason doctors prescribe opioids so much is that they, and hospitals, used to get performance incentives based on how much pain their patients reported. And there may be a more sinister reason: An analysis by CNN and Harvard University found that doctors who prescribe more opioids get speaking or consulting fees from drug manufacturers.

Insurers, pharmacies, distributors and providers have restricted the number and size of opioid prescriptions they give out, "but physicians worry that reducing the supply could cut off access to patients who need the potent drugs," Kacik reports. "Also, insurers have been slow to cover alternatives to opioids. Prior authorization for medication-assisted treatment is another big roadblock."

After decades of addiction and legal action, OxyContin's maker says sales staff won't visit doctors' offices to sell it

Photo by The Associated Press

Purdue Pharma, the manufacturer of OxyContin, says it will no longer market its opioid drugs with visits to doctors' offices and it's halving its sales force. The move comes "after years of criticism and mounting lawsuits . . . claiming its sales practices are partly responsible for the opioid epidemic," reports Ben Poston of the Los Angeles Times.

"It's pretty late in the game to have a major impact," Brandeis University researcher Dr. Andrew Kolodny, a longtime critic of the pharmaceutical industry's role in the opioid epidemic, told Poston. "The genie is already out of the bottle. Millions of Americans are now opioid-addicted because the campaign that Purdue and other opioid manufacturers used to increase prescribing worked well. And as the prescribing went up, it led to a severe epidemic of opioid addiction." The drug went on sale in 1996; in 2007, in federal court in southwest Virginia, Purdue paid $635 million in fines to end an investigation by the U.S. Department of Justice.

Poston writes, "One remaining question is whether other opioid makers will follow suit and cease marketing the drugs to doctors, said Kolodny, executive director and co-founder of Physicians for Responsible Opioid Prescribing."

"In an attempt to stem the abuse of OxyContin, Purdue spent a decade and several hundred million dollars developing a version of the painkiller that was more difficult to snort, smoke or inject," Poston notes. "Since those 'abuse-deterrent'  pills debuted seven years ago, misuse of OxyContin has fallen and the company has touted them as proof of its efforts to end the opioid epidemic. But a study released in January 2017 found that rather than curtail deaths, the change in OxyContin contributed heavily to a surge in heroin overdoses across the country and that, as a result, there was 'no net reduction in overall overdose deaths'." States with the most OxyContin abuse rates had the largest increases in heroin deaths.

Substance abuse about as common in rural areas as urban, but rural users are less likely to get treatment, studies find

In some ways, substance abuse is worse in urban areas, but rural drug users are less likely to get treatment, according to two studies by the Rural and Underserved Health Research Center at the University of Kentucky and reported by Melissa Patrick of Kentucky Health News.

One study found that the percentage of adults with substance-use disorders was about the same in rural areas as in metropolitan areas. However, researchers Tyrone Borders and Hefei Wen note that there are "statistically significant" differences that indicate more serious problems in urban areas. For example, the share of urban adults with an illicit drug-use disorder in the previous year, 3.33 percent, was significantly higher than the rural rate of 2.86 percent. Also, the share of urban adults with any type of drug-use disorder in 2014-15 was significantly higher than in 2011-13, when it was 3.07 percent.

The number of adults with heroin-use disorders in the past year was "significantly higher" in metropolitan areas, 0.31 percent than rural areas, 0.20 percent. Disorders involving prescription painkillers were more common in rural areas, involving 1 percent of the rural population and 0.87 percent of the urban. Overall opioid-use disorders were virtually the same in urban and rural areas, 1.07 percent and 1.09 percent respectively, and those rates have been stable over time.

Rates in 2014-15 of perceived need for treatment, and use of treatment,
among rural Americans with drug use disorders in the previous year.

The other study, by the same authors, looked at the perceived need for treatment of substance-use disorders, compared to the actual use of treatment. They found that overall, the rates of perceived need for treatment and actual use of treatment were low among rural residents with drug-use disorders, and have changed little since 2008, despite the implementation of policies to increase access to treatment.

They found that the rates of perceived need for treatment for use of illicit drugs and opioid-use disorders were about the same in urban and rural areas, but the perceived need for treatment in rural areas more than doubled between 2008-10 and 2011-13, from 7.8 percent to 18.5 percent. The rate declined to 13.4 percent in 2014-15.

The study found that 26.7 percent of urban adults with an opioid-use disorder got treatment during the study period, significantly higher than the 17.9 percent among rural adults. The gap almost disappeared in 2014-15, when the urban and rural rates were 24.3 and 24.1 percent, respectively. The difference was even greater in treatment for heroin use, 48.6 percent for urban adults and 25.7 percent for rural ones.

There was little difference in treatment rates for abuse of prescription painkillers: 19.5 percent for urban adults and 20.6 percent for rural. However, the perceived need for treatment of disorders related to prescription painkillers was significantly higher in rural areas, 13.2 percent, than the urban rate of 8.1 percent.

The researchers suggest "a need for improved insurance reimbursements for screening and treatment in rural primary care; a need to address the limited access to behavioral-health and substance-abuse treatment in rural areas; the need for targeted substance-abuse treatment, needle exchanges, and safe-sex education programs in areas with rising heroin use; and issues around the limits on the number of patients that can receive medication assisted treatment for opioid use," Patrick reports. "They also say that stimulating positive perceptions about treatment among illicit drug users and their families and friends could  encourage them to get treatment."

State-mandated drug-monitoring databases appear to have boosted use of heroin, W.Va. study shows

The opioid epidemic was partly caused by prescription-drug abuse, so almost all states have instituted prescription-monitoring databases so doctors can judge whether a patient is pain-pill shopping. But those efforts to lower addiction appear to have created a perverse incentive for addicts to choose a more easily accessible high: heroin. Researchers from West Virginia University found that "after West Virginia required doctors to use its database, overdoses from heroin among 18- to 34-year-olds actually went up, more than doubling in just three years," Francie Diep reports for Pacific Standard.

The data came from an analysis of WVU-affiliated hospitals and outpatient centers; lead researcher Sara Warfield and her colleagues looked for how often the facilities admitted adults for prescription-painkiller and heroin overdoses between 2008 and 2015. The prescription-monitoring database was mandated in 2012, and that year heroin overdoses among young adults began spiking "significantly." Kentucky has experienced a similar pattern.

The study isn’t deep enough to prove cause and effect, but it jibes with other research suggesting that increasing prescription monitoring without taking steps to help people overcome addiction triggers an increase in illicit opioid use. "Another way to think about this idea is that to solve a drug problem, you can't only dry up the drug supply," Diep reports. "You also have to reduce drug demand." The researchers recommend more needle exchange programs, naloxone availability, and drug treatment programs, and note that West Virginia has done all three in recent years.

Disability benefits are nearly twice as common in rural areas, and they can deepen a cultural divide

From 1996 to 2015, "the number of working-age adults receiving federal disability payments increased significantly across the country — but nowhere more so than in rural America," The Washington Post reports in the latest piece of a series on "how disability is shaping the culture, economy and politics" of 102 rural counties "where, at minimum, about one in six working-age residents receive either Supplemental Security Income, a program for the disabled poor, or Social Security Disability Insurance for disabled workers. These are places — primarily white, rural and working-class — where once-dominant industries have collapsed or modernized and the number of people who are jobless or receiving public-assistance benefits has soared."

Tyler McGlothlin and his mother, Sheila
(Washington Post photo by Linda Davidson)

One of those places is Grundy, Va., near where the Old Dominion meets Kentucky and West Virginia, and one of those families is the McGlothlins: a father who became disabled in the coal mines, became addicted to painkillers and is now in jail for selling them; a mother whose disability check isn't enough for her household, which includes her son's fiance; and the son, who got fired from McDonald's for "missing a shift during a snowstorm," then totaled his car and had to drop out of community college, and now begs for money -- following in the footsteps of his father, who was confronted personally and on social media by a neighbor who was offended when the disabled miner wouldn't accept a job offer, Terrence McCoy reports.

McCoy gets into the head of Sheila McGlothlin: "She had wanted something more for him, something other than what she felt most days: shame. She knew how she must look, in her pajamas and mismatched socks, to people who work. She knew what they must say about her disability: It’s only anxiety, only depression. Why couldn’t she work? Why did she buy soda and cigarettes when they needed food? How could she afford the Internet and cable TV bills on a $500 monthly disability check? She would sometimes consider how she would answer. She would say that cigarettes and soda make hard days a little easier. That television is just about her only connection to a world that hasn’t seemed to want her anymore. But it’s simpler to say nothing at all, so she rarely leaves the house now."

Disability has become so prevalent that the federal government will spend more on it this year than food stamps, welfare, housing subsidies and unemployment, combined, and the programs are running out of money, the Post reports. In rural counties, 9.1 percent of working-age people are on disability — nearly twice the urban rate and 40 percent higher than the national average. In Buchanan County, where Grundy is the seat, one in four adults are on SSI or disability, but that doesn't mean it's a broadly popular pursuit. “There is a critical divide in the minds of low-income whites, between people who work, even if they struggle, and what has historically been called ‘white trash’,” University of California, Davis professor Lisa Pruitt, who researches rural poverty and grew up in Newton County, Arkansas, which has one of the nation’s highest disability rates, told McCoy. “The worst thing you can do in rural America among low-income whites is not work.” The a mentality, she told him, is that “only lazy white trash” accept “handouts.” A poll by the Post and the Kaiser Family Foundation confirmed that such feelings are more common in rural areas: