GAO tells HHS it should set clear measures for expanding medication-assisted addiction treatment

The Government Accountability Office released a study today recommending that the Department of Health and Human Services, as it works to expand access to medication-assisted treatment for addiction, should develop clear measures to gauge its performance.

Senate Majority Leader Mitch McConnell (R-Ky.), who requested the study, said it "will help to ensure that dollars are spent wisely to fight the crisis of opioid abuse taking lives in communities across the country. The announcement of GAO’s conclusions will help us as we continue to build a comprehensive approach to combating heroin and prescription drug abuse."

Medication-assisted treatment (MAT) is a combination of behavioral therapy combined with medication such as methadone and buprenorphine to manage addiction. The report found that HHS has implemented five key steps in expanding access to MAT for opioid users since 2015, but many who need MAT still don't have access to it, especially in rural areas. In addition to recommending that HHS create and implement performance measurements, the report recommends that the agency should establish timeframes for when it will evaluate efforts to expand MAT.

UPDATE, 2:35 p.m.: "President Trump's commission on the opioid crisis . . . called for a large expansion of medication-assisted treatment, which many experts have called the most effective approach and which Food and Drug Administration commissioner Scott Gottlieb has endorsed,' The Washington Post reports.

Rural hospitals sue Blue Cross Blue Shield of Oklahoma over drastic reimbursement cuts

Haskell County Community Hospital
(Photo provided to The Oklahoman)

Four rural Oklahoma hospitals have sued Blue Cross Blue Shield of Oklahoma for breach of contract over crippling proposed provider reimbursement rate cuts, Dale Denwalt reports for The Oklahoman.

"BCBS does not favor supporting rural, critical-access hospitals," the lawsuit states. "BCBS, through its actions and behavior, is attempting to drive critical access hospitals out of business in favor of driving business to large metropolitan hospitals and related services."

BCBS has not confirmed the rate cuts it's asking for, but Don Buchanan, CEO of Haskell County Community Hospital in Stigler, said BCBS wants to cut reimbursement by 30 percent for all services except those in the emergency room.

"Unfortunately, it's not a rate that would allow us to continue to serve Blue Cross patients. It borders on being below the cost of actually providing that care," Randy Simmons, CEO of Prague Community Hospital, told Denwalt.

"In Prague, BCBS is the third-largest payer behind federal health care programs. Simmons said losing patients who use the insurer would be devastating for the hospital, and in turn would critically limit health care in the community," Denwalt reports. The other two hospitals named in the suit are Drumright Regional Hospital and Fairfax Community Hospital.

The hospitals' contracts with BCBS were set to expire Oct. 31, but a Tulsa judge issued a temporary restraining order. A hearing on the lawsuit is set for Nov. 3.

National Rural Health Day is Nov. 16

National Rural Health Day, Nov. 16 this year, was created by the National Organization of State Offices of Rural Health in 2010 to highlight efforts to improve health in rural communities while acknowledging the unique challenges in accessing health care services.

The Federal Office of Rural Health Policy will organize NRHD events, including a series of Twitter chats and webinars in the days leading up to Nov. 16. On National Rural Health Day, the office will provide a day-long webcast of a summit that includes speeches and panel discussions of current efforts to increase accessibility to health care in rural areas. Click here to see the full schedule and to find out more information about participating in the Twitter chats or registering for the webinars.

Rural areas face confusion as ACA enrollment opens

Open enrollment for health insurance under the Patient Protection and Affordable Care Act begins tomorrow, but many people, especially in rural areas, may face confusion about how to sign up. That could lead to fewer people being covered by health insurance. "Much of the cutbacks and confusion, health-care advocates said, follows President Trump's constant disparagement of the law.

Congress was not able to pass a repeal or replacement law, so the administration may be knocking the legs out from under the law in other ways. The Department of Health and Human Services slashed the ACA advertising budget by 90 percent, which means there are many fewer messages to tell people when open enrollment is, or whether they qualify. HHS also cut by 40 percent grants to pay navigators, which are regular citizens trained to help people sign up for ACA plans.

The Trump administration has also decreased overall access to the plans, trimming open enrollment from three months to six weeks. The enrollment website, www.Healthcare.gov, is also being taken offline for maintenance for 12 hours almost every Sunday during open enrollment, even though weekends are generally a convenient time for people to apply.

"Most recently, Mr. Trump announced plans to cut off subsidies that reimburse insurance companies for assistance they are required to provide to low-income customers who struggle with co-payments and deductibles. The cuts resulted in a crazy quilt of premiums for 2018 that differs radically from the pattern of the last four years, which will upend expectations of consumers in many states," Abby Goodnough and Robert Pear report for The New York Times.

Rural areas risk being undercounted in 2020 census

In an attempt to save money, the Census Bureau will try to get most people to fill out the 2020 census form online instead of using a paper questionnaire. When more people fill out the survey online, the bureau doesn't have to follow up with costly door-to-door visits. The problem with pushing online self-response is that many rural areas lack broadband or any internet service, and those people may be under-counted. If rural residents are under-counted, their jurisdictions may receive less government funding and redrawn political maps may not accurately reflect their presence.

The Center for Urban Research at the City University of New York analyzed 2010 census mail return rates and the share of households in each congressional district with inadequate internet service and created a map that shows the counties most likely to be under-counted in 2020. "If these districts already tend to have low self-response via mail, and households in these districts also tend to be less connected to the internet, then the preferred online option for self-response in 2020 may not help boost response as much as it would in other districts with better digital access," the report says.

The darker the area, the harder it is to count. Click on the map to enlarge it,
or click here for the interactive map with county-level data. (CUNY map)

New Mexico is the hardest state to count, the report says. "Obtaining an accurate head count gets a lot harder in communities that are difficult to navigate, such as New Mexico’s frontiers, and communities where people might move around regularly with no fixed address or simply will not open the door for a government worker," Andrew Oxford reports for The New Mexican.

The bureau meant to test the new system in rural West Virginia, but said it could not afford to because of the budget cuts. Census Bureau Director John H. Thompson resigned following the budget cuts, and a permanent replacement has not yet been appointed.

Study warns chemicals used in fracking could lead to neurological problems in nearby children

A newly released study found that multiple pollutants in the air and water near hydraulic-fracturing wells are linked to brain problems in children. More than 1,000 studies have looked at possible health hazards from fracking, but this is the first to focus on neurological health of children living near fracked wells. "Researchers focused on five types of pollution commonly found near the sites—heavy metals, particulate matter, polycyclic aromatic hydrocarbons, benzene, toluene, ethylbenzene, xylene and endocrine-disrupting compounds—and scrutinized existing health studies of the compounds' impacts to kids' brains," Brian Bienkowski reports for Environmental Health News.

Early exposure to those five types of pollutants is associated with a host of problems, from learning and developmental disorders to neurological birth defects. The study's lead author, Ellen Webb of the Center for Environmental Health, told Bienkowski that the research on children's health near oil and gas sites is "slowly emerging" but "It's only reasonable to conclude that young children with frequent exposure to these pollutants would be at high risk for neurological diseases." Webb recommends an increase in the required distance (at least a mile, she suggests) between fracking wells and places where children live or go frequently, such as schools, parks or hospitals. She also recommends "more research on low level, chronic exposure, mandatory testing of industrial chemicals used on site, and increased transparency of the chemicals used in drilling," Bienkowski reports.

Seth Whitehead, a spokesperson for the Independent Petroleum Association of America, counters that there is no hard evidence that pollutants associated with fracking do harm children. "This is not unlike saying bleach — which can be found in most folks' laundry rooms — can make you sick if you drink it and that more research is needed to understand the extent to which people get sick from drinking bleach from their laundry rooms," he said in an email to Bienkowski.

Any public-health issues caused by fracking are likely to disproportionately impact rural America, since most of the nation's fracking occurs in rural areas. Research has shown that fracking can contaminate drinking water up to one kilometer away from the well pad.

Small rural college requires patriotism/fitness class

Freshmen at the College of the Ozarks (Photo by Shann Swift)

College of the Ozarks, a private institution in rural Missouri, is making headlines by requiring all freshmen to take a new course called Patriotic Education and Fitness. "In requiring the new course, the college is signaling that patriotism is largely synonymous with the military, to judge from its materials. The required course debuted last year as a retooled version of previous courses in physical education and patriotism — this time, with a more-intentional emphasis on the military," Sam Hoisington reports for The Chronicle of Higher Education.

A press release says that students will "learn map reading, land navigation, rifle marksmanship, rope systems and knots, and rappelling" as well as "the formation of American government and politics, military customs, task organization and courtesies, and flag protocol and procedures," Hoisington reports.

President Jerry Davis says the college has attracted a lot of publicity because it's willing to stand up for what it believes. "Our college, given who we say we are, needs to make a strong statement about what we represent and what we’re a part of," he told Hoisington. The college was in the news last month after refusing to play sports against any team whose members kneel during the national anthem.

Puerto Rico deal with small-town electric contractor is canceled, and under investigation

After widespread controversy, Puerto Rico is canceling a $300 million contract with a small Montana company to repair some of the hurricane-devastated island's electrical grid, and The Wall Street Journal reports that the FBI is investigating the deal with the Puerto Rico Electric Power Authority.

Andrew Scurria writes that agents "are looking into circumstances surrounding the disaster-recovery deal the public-power monopoly known as Prepa signed with Whitefish Energy Holdings LLC," based in the northern Montana town of the same name.

Interior Secretary Ryan Zinke is from Whitefish, but insists he had nothing to do with the contract. "Only in elitist Washington, D.C., would being from a small town be considered a crime," he said in a statement on Oct. 27. News of the deal broke nationally on Oct. 24, but it was first reported Oct. 21 by The Flathead Beacon in nearby Kalispell.

Questions about the contract go beyond connections, The Washington Post reports. Whitefish was not required to provide proof that it would complete the work it promised, and the two-year-old company has only two employees. Whitefish CEO Andrew Techmanski said the company's structure allowed it to hire subcontractors quickly.

Most counties dependent on exports are small, so they could be hurt most by changes to NAFTA

Changes to the North American Free Trade Agreement could have an outsized impact on many places in rural America. "Although counties containing big cities such as Los Angeles, New York and Houston generate the highest dollar volumes of exports, the most export-dependent places tend to be relatively small, often rural or suburban counties whose economies are based on a single industry – or sometimes even a single company or plant," Drew DeSilver reports for the Pew Research Center. "In fact, of the 154 counties or county equivalents where exports accounted for more than a quarter of GDP last year, only 11 had populations above 100,000 and half had fewer than 25,000 residents, according to a Pew Research Center analysis of data compiled by the Brookings Institution for its 'Export Monitor 2017' report." Many of the high-export counties manufacture automobiles or auto parts.

Pew Research map; click on it to enlarge it.

Three U.S. counties rely on exports for more than 50 percent of the local gross domestic product. Leading the pack is Hancock County, Ky., a county of 8,810 residents which brings in 55.3 percent of its GDP from manufacturing aluminum and other nonferrous metal products.

In the counties with the greatest growth in exports, "booming U.S. oil and gas production and higher precious-metals prices have turbocharged export growth in many resource-rich counties. In 17 of the 30 counties with the highest annualized real export growth rates between 2003 and 2016, the economic sector that contributed the most to that growth was mining, oil and gas extraction," DeSilver reports.

Canada and Mexico are the two biggest destinations for U.S. exports, so a change in the U.S.'s trade relationships with those countries could hurt rural America. The NAFTA renegotiation talks are ongoing, but have been granted an extension after negotiators have had a hard time meeting stringent American demands.

How a small daily in Tenn. did its job when white nationalists and counter-protesters came to town

White nationalists at the rally. (T-G photo by William Mitchell)

When big news happens in small towns, national journalists often parachute in to cover it. But Terry Corrigan, editor of the Shelbyville Times-Gazette in Tennessee, says local papers can do a better job than the outsiders, Callum Borchers reports for The Washington Post.

Shelbyville, a town of about 21,000 south of Nashville, more famous as the site of the Tennessee Walking Horse Celebration, was the site of a white nationalist rally on Saturday, Oct. 28. Crowd counts are important in stories like this, and the Times-Gazette gave itself a wide berth: It reported that the rally crowd of 200 to 400 was outnumbered by 400 to 600 counter-protesters. The Tennessean of Nashville reported "about 160" and "more than 400," respectively.

The T-G prints six days a week, and Corrigan told Borchers its news staff consists of "four old white guys" with about 65 years of combined experience covering Shelbyville. And though it lacks the resources of national news media, the paper provided an impressive amount of in-depth coverage before, during and after the event, using angles and local sources that national reporters might never have thought of.

"I went down and ate breakfast at Barb’s diner [Thursday] morning at 5 a.m. to talk to the boys who are in there every morning,” Corrigan told Borchers. “That’s the kind of story we’ve been doing leading up to it, as much as we can.”

But Corrigan knew it was still important to defend his turf against national press. When he covered a wildfire for a small newspaper in Arizona in 2002, he remembered being frustrated that the police were "enamored" of big-name reporters and would take them to places where local media hadn't been allowed. So Corrigan talked to the Shelbyville police this week and asked them not to make the same mistake.

"I said: ‘Don’t do that to us. We are the ones you depend on week to week. If somebody’s done something bad, you want it in our paper, so maybe you can find ’em. Just remember we’re the ones that are here all the time.’ And they seemed okay. They understand," he told Borchers.

Monsanto attacks weed scientists who say new 'low volatility' dicamba is still too volatile, hurts crops

Bob Scott, University of Arkansas
(NPR photo by Dan Charles)

Monsanto Co. is fighting back against weed scientists who say its herbicide dicamba is hurting crops, Dan Charles reports for NPR. Monsanto, BASF and DuPont all sell herbicides containing dicamba, as well as seeds for corn and soybeans that are genetically engineered to withstand it. The companies came out with new "low-volatility" formulas in 2016, and have blamed reported crop damage since then on improper application of the weedkiller. But weed scientists say they weren't able to test the products before they hit the market.

"I wish we could have done more testing. We've been asking to do more testing for several years, but the product was not made available to us," University of Arkansas weed scientist Bob Scott told Charles. "These are proprietary products. Until they release those formulations for testing, we're not allowed to" test them.

When scientists were finally able to test the new low-volatility versions, they found that damage to nearby crops didn't come from physical drift--windblown droplets of dicamba--but from volatization, the chemical's propensity to turn into a powder and drift elsewhere.

"In Arkansas, where state regulators proposed a ban on dicamba during the growing season next year, Monsanto recently sued the regulators, arguing that the ban was based on 'unsubstantiated theories regarding product volatility that are contradicted by science,'" Charles reports. "The company called on regulators to disregard information from Jason Norsworthy, one of the University of Arkansas' weed researchers, because he had recommended that farmers use a non-dicamba alternative from a rival company. Monsanto also attacked the objectivity of Ford Baldwin, a former university weed scientist who now works as a consultant to farmers and herbicide companies."

Kevin Bradley, a professor of weed science at the University of Missouri, says Monsanto executives have repeatedly called his supervisors to express their displeasure with his research on dicamba. Scott says Monsanto's actions are an "attack on all of us, and anybody who dares to [gather] outside data."

Monsanto's Vice President of Global Strategy Scott Partridge told Charles, "We are not attacking Dr. Bradley. We respect him, his position, opinion, and his work. We respect him, and academics in general."

Two weeks ago the Environmental Protection Agency said dicamba use will still be allowed next year, though with additional restrictions. Some say that's not enough, because the restrictions address application, and not the fundamentally volatile nature of the herbicide. Arkansas may ban it at the state level, and will hold a public hearing for the proposal on Nov. 8.

Rural hospitals and universities forge partnerships

Medical Center Hospital in Odessa.
(Odessa American photo by Edyta Blasczyk)

Rural hospitals all over the country are struggling, but some have hit on a strategy in which hospitals and universities both benefit. For example, the Texas Tech University Health Science Center placed academic surgeons (i.e. surgeons who teach medical school classes and also do research) in five rural hospitals in western Texas. The university benefited because it relies on Graduate Medical Education funding to offset the cost of indigent care and education, Medical Xpress reports. Hospitals benefit because they often have difficulty recruiting surgeons in rural areas. Hospitals also enjoyed significant financial savings, in part because the need to transfer patients to another facility was drastically reduced, which brought participating hospitals an average increase of $4.7 million in net revenue.

One of the hospitals, Medical Center Hospital in Odessa, pulled the plug on the program in April 2016 because of a dispute among local and contract surgeons about the residency program, Jennifer Bruha reports for the Odessa American. "The move would have led to cost savings at Medical Center since Texas Tech does not get paid to take call because they are a teaching facility. The hospital would have also received money for allowing the residency program because the state pays Texas Tech and then the university reimburses Medical Center for the cost, Ector County Hospital District 5 candidate Julie Molland said in May."

Texas Tech presented findings from the program at the American College of Surgeons Clinical Congress this week. "Some of the results included a reduction in rural area surgical costs, improved quality of care and an increase in revenue for the academic surgical programs," Bruha reports.

Trump's opioid emergency declaration has no money, but could free up some and offer other aid

President Trump' declaration that the opioid epidemic is a national public-health emergency carries no extra money, but it "will help the government speed any available resources to communities, where the epidemic is playing out on the streets every day, and will eliminate some obstacles that stand in the way of providing assistance," Lenny Bernstein reports for The Washington Post.

One example: supplies of naloxone, branded as Narcan, which can stop an overdose in its tracks. "The emergency allows the federal government to speed more people and resources to the streets where naloxone is needed," Bernstein writes. "Acting Health and Human Services Secretary Eric Hargan could negotiate lower prices for government agencies. And he could put out model instructions for states and cities to issue 'standing orders' that make the antidote more readily available in pharmacies around the country."

The biggest need in rural areas is for treatment facilities, and greater access to them. "Barriers include a federal policy that prohibits Medicaid from paying inpatient facilities with more than 16 beds," Bernstein notes. "The emergency declaration would allow HHS to grant waivers to any state requesting one."

In an editorial, The Wall Street Journal says innovative approaches are needed: "Education for prescribers has improved in recent years but more is needed from within the profession. Beyond better prescribing, the problem gets complicated fast. FDA Commissioner Scott Gottlieb said in testimony at a House hearing this week that the agency is supporting the development of alternative painkillers with less addictive features. Another priority is expanding access to naloxone."

Congress should "consider the government’s role in allowing too-easy access to painkillers, particularly among society’s poor and vulnerable," the editorial says. "A 2016 Centers for Medicare and Medicaid Services bulletin noted that “'Medicaid beneficiaries are prescribed painkillers at twice the rate of non-Medicaid patients”' and are three to six times more at risk for overdose." In Medicare, "500,000 beneficiaries received more than 120 mg a day for at least three months—equivalent to 12 tablets a day of 10 mg Vicodin. That figure excludes patients with cancer or in hospice, who tend to need heavy pain meds. The only way to explain this cascade of pills is an epidemic of fraud."

Daily Yonder: Both parties to blame for failure to protect small meatpackers from corporate giants

"The U. S. Department of Agriculture announced last week that it was throwing out Obama administration rules that would have provided basic legal protections for poultry and livestock producers who are under contract with corporate meatpackers. The move illustrates the clear divisions within agricultural policy and shines a spotlight on the confusing and frustrating debate happening throughout farm country," Bryce Oates reports for The Daily Yonder. The Trump administration first delayed the implementation of the rules in March.

The Farmer Fair Practices rule would have updated how a USDA agency, the Grain Inspection and Packers Administration, handles anti-trust enforcement. That would have given small contract meatpacking outfits more power to compete with the huge agribusinesses that increasingly dominate the industry.

In what Oates calls the best analysis of the issue he's seen, The New Food Economy writes that the update to the GIPSA rules would have "made it a little easier for poultry and livestock farmers to sue processors or meatpackers over unfair treatment by updating language in the Packers and Stockyards Act of 1921 to clarify a stance USDA and GIPSA have long held: that farmers shouldn’t have to prove 'competitive injury' (that their buyers have done something to impact all farmers in their position, as a class) in order to pursue legal action." The rule change would have especially affected the chicken industry, where titans like Perdue and Tyson control most of the process.

Oates casts blame not only on the Trump administration, but on the Obama administration for delaying and watering down their proposals. "What is so galling is the lack of political representation on these issues by either party," he writes. "For Republicans of the current political moment, there’s an obvious hesitation to erect any rules and regulations whatsoever, even popular regulations that 'protect the little guy.' For Democrats, there is a lack of focus on actually fighting for and delivering on promises they make to family farmers."

This track record from both parties, he says, makes it easy for farmers to feel as though both parties have left them behind.

Wendell Berry says declining number of farmers limits grasp of economics, environmental policy

Wendell Berry (Photo by Guy Mendes)

In an interview with Time magazine's Sarah Begley, Kentucky writer-farmer Wendell Berry talks about why more people should live in rural areas and work the land through agriculture or animal husbandry. One big reason, he says, is that people who live in rural areas can better appreciate why we need to take care of our environment through policy -- an area in which activists have mostly failed.

"The more people who live in cities, the fewer there are who have knowledge of what I'm calling the economic landscapes. So that's the wrong way to get a lobby for better land care. There's nobody lobbying for the best use of farming and forest and mining landscape," Berry says. "For land use and land maintenance in those economic landscapes, we have done no good. We've not ever been able to put any meaningful restraints on the coal industry. They've done what they wanted to do. So-called farming has become increasingly dependent on toxic chemicals. There's still too much soil erosion."

Those who have never lived near a farm don't have that bone-deep knowledge of finite resources that comes from dealing with the vagaries of nature, Berry says: "This has been a dominant idea throughout our history: if you don't have it here, you can get it from somewhere else. If you use up this commodity here, you can't produce it here anymore, you've worn out the possibility here, get it from somewhere else. Or if you're short of labor or you're too good for certain kinds of labor, go to Africa and get some slaves. That recourse has haunted us, has plagued us to death." Read the whole interview here.

Illinois House rejects ban on 'bump stocks' in vote split along rural and urban lines, not party

In the wake of the deadly shooting in Las Vegas, politicians of both parties seemed interested in banning bump stocks, an accessory used by the shooter to make a semi-automatic weapon fire as rapidly as a fully automatic weapon. But the Illinois House rejected a ban on bump stocks Oct. 26, mainly due to votes from rural Democrats.

"State Rep. Martin Moylan's prohibition on 'trigger modifications' got only 48 of the 71 votes it would have needed to pass. Fifty-four members of the Democratic-controlled House voted against it," John O'Connor reports for The Associated Press. "Moylan's bill defined trigger modification as any after-market alteration 'intended to accelerate the rate of fire of a firearm,' which critics complained is virtually universal" and would hurt sports shooting, O'Connor reports.

O'Connor's story supports the theory that America's growing political divide is not just Democrats vs. Republicans, but also urban vs. rural.

Trump picks Ky. engineer to run strip-mine agency

J. Steven Gardner

President Trump has nominated a Kentucky mining engineer, J. Steven Gardner, to head the Office of Surface Mining Reclamation and Enforcement in the Interior Department. OSM, as it is generally called, oversees state regulation of strip mining and the surface effects of underground mining. In a few states, it directly enforces the 1977 federal strip-mine law.

Gardner "was a frequent critic of environmental rules during the Obama administration, including those from the OSM," Devin Henry reports for The Hill. "In a February op-ed in the Lexington Herald-Leader, Gardner celebrated the repeal of an OSM rule protecting streams from coal mining waste. . . . When Gardner's name was floated for the position in August, the Sierra Club called him a 'horrible choice'." In Kentucky public-policy circles, he is known as an effective advocate who is willing to consider the other side's arguments.

Kentucky Resources Council Executive Director Tom FitzGerald, the state's leading environmental lawyer-lobbyist, told the Herald-Leader, “I think his great challenge will be stepping out of a role as a very visible pro-coal partisan, into the job heading an agency that was charged with protecting the public and the environment from the adverse effects of surface coal mining. I wish him every success in making that transition.”

Read more here: http://www.kentucky.com/news/state/article181114706.html#storylink=cpy

Mining interests and Republican political leaders saluted the pick. Senate Majority Leader Mitch McConnell of Kentucky said, “Steve will be a strong leader and I look forward to the U.S. Senate considering his nomination.” The White House notice of Gardner's appointment said he was president of the Society for Mining, Metallurgy and Exploration. in 2015, was a member of the Kentucky Board of Licensure for Professional Engineers and Surveyors, and has served on the Kentucky Geological Survey advisory board.

In a statement issued by the Interior Department, Gardner said, "My whole life, I have been involved with mining on multiple levels, and I understand the importance of these issues to the communities we serve. I pledge to work every day on behalf of the men and women across this country who look to the OSM office as a partner in bettering life for all people on mining lands."

Family that brought us OxyContin, and arguably the opioid epidemic, is profiled in 2 magazines

Arthur Sackler (Wikipedia photo)

As President Trump prepared to declare a limited public-health emergency in response to the deadly opioid epidemic, Esquire magazine and The New Yorker published fascinating articles on the secretive family that made a fortune selling OxyContin and arguably spurred the epidemic: the Sacklers of New York.

If you've heard of the Sacklers, it's not likely in connection with drugs. The name is attached to art museums and university institutions all over the world. But the family has stayed mostly silent on the genesis of their multi-billion-dollar fortune. "The family’s leaders have pulled off three of the great marketing triumphs of the modern era: The first is selling OxyContin; the second is promoting the Sackler name; and the third is ensuring that, as far as the public is aware, the first and the second have nothing to do with one another," Christopher Glazek writes for Esquire.

Physician and pharmaceutical promoter Arthur Sackler bought Purdue Pharma in 1952 at the age of 39; his two brothers Mortimer and Raymond, also doctors, ran the business and bought out Arthur's share after he died in 1987. By that time, Purdue was in the process of developing OxyContin.

Purdue's aggressive advertising had helped Valium become America's most-prescribed medication in the 1960s. In the 1990s OxyContin succeeded partly for the same reason. OxyContin was popular for chronic pain sufferers because it didn't have the stigma of morphine. And though it was 50 percent stronger than morphine, many doctors incorrectly believed it was much less powerful -- a misconception Purdue actively encouraged. Doctors thought that addicts would stay away from a time-released narcotic, but it was the opposite: OxyContin had a breakthtaking amount of oxycodone in one pill, and addicts soon discovered they could access it all at once by crushing the pill and snorting it.

"The vehicle of that fortune was OxyContin, but its engine, the driving power that made them so many billions, was not so much the drug itself as it was Arthur’s original marketing insight, rehabbed for the era of chronic-pain management," Glazek writes. "That simple but profitable idea was to take a substance with addictive properties—in Arthur’s case, a benzo; in Raymond and Mortimer’s case, an opioid—and market it as a salve for a vast range of indications."

Patrick Radden Keefe writes for The New Yorker, "Sales representatives marketed OxyContin as a product 'to start with and to stay with.' Millions of patients found the drug to be a vital salve for excruciating pain. But many others grew so hooked on it that, between doses, they experienced debilitating withdrawal. Since 1999, two hundred thousand Americans have died from overdoses related to OxyContin and other prescription opioids. Many addicts, finding prescription painkillers too expensive or too difficult to obtain, have turned to heroin. According to the American Society of Addiction Medicine, four out of five people who try heroin today started with prescription painkillers."

In 2007, Purdue Pharma agreed to pay a civil penalty of $600 million for misleading doctors, patients and regulators about the addictive nature of OxyContin. That avoided a trial and testimony, but Richard Sackler had to give a deposition in a suit filed by the state of Kentucky, similarly charging the company with deceptive marketing that had created the epidemic, costing the state dearly. The suit was filed in Pike County, at the eastern end of the state; in a bid to get the case moved, Purdue Pharma did a survey that “was revealing in ways that Purdue may not have intended: according to the filing, twenty-nine per cent of the county’s residents said that they or their family members knew someone who had died from using OxyContin,” Keefe reports. “Seven out of ten respondents described OxyContin’s effect on their community as “'devastating.'”

The case was settled for $24 million, but not before Richard Sackler had to give a deposition, Keefe reports: “Tyler Thompson, the lead attorney, told me that Sackler’s demeanor during the session reminded him of Jeremy Irons’s portrayal of Claus von Bülow, the aristocrat accused of murdering his wife, in the 1990 bio-pic 'Reversal of Fortune.'  "A smirk and a so-what attitude—an absolute lack of remorse,' Thompson said. 'It reminded me of these mining companies that come in here and do mountaintop removal, and leave a mess and just move on."” The deposition remains sealed; Purdue Pharma is appealing the judge's ruling, in a suit by the medical-and-science news site Stat, that it should be public.

There's much more in the two long articles, but here's a passage from Esquire with ironic resonance. In a memoir, Arthur's second wife Marietta Lutze said he became obsessed with collecting art: 

"Boxes of artifacts of tremendous value piled up in numerous storage locations," she wrote. "There was too much to open, too much to appreciate; some objects known only by a packing list." Under an avalanche of "ritual bronzes and weapons, mirrors and ceramics, inscribed bones and archaic jades," their lives were "often in chaos. . . . Addiction is a curse, be it drugs, women, or collecting."

Rural infant mortality rose 5% in 2014-15

New statistics from the federal Centers for Disease Control and Prevention show that infant mortality rose 5 percent in rural areas from 2014 to 2015, and the rural infant-mortality rate was 25 percent higher than it was in large urban areas. Infant mortality has long been higher in rural areas, especially for black infants, but these new figures show an across the board increase in mortality for all rural infants.

Overall infant mortality decreased from 2007 to 2015, but rural areas are still worse off
than other areas. (CDC chart; click on it to enlarge)

The figures are alarming, but must be considered in context. Infant mortality as a whole dropped in all areas from 2007 to 2015 and is low overall. So that means any increase in infant mortality can move the statistical needle a lot. In raw numbers, rural areas went from 6.55 deaths per 1,000 births in 2014 to 6.8 deaths per 1,000 births in 2015. In urban areas the rate stayed about the same at 5.4 deaths per 1,000 births in both years. Comparatively, the death rates from 2007 were 7.5 deaths per thousand in rural areas and 7.1 per thousand in urban areas.

CDC chart; click on it to enlarge.

Lack of access to adequate health care is the most likely reason for the discrepancy between urban and rural infant mortality; the fact that more and more rural hospitals are closing their doors, and over half of all rural hospitals lack obstetric units could be reasons for increased rural infant mortality from 2014 to 2015. Women who have difficult deliveries can't get to a well-equipped hospital in time to help save the baby, and women who have a hard time accessing general health care may not receive adequate prenatal care.

Trump OKs drone experimentation plan; could make use and deliveries easier in rural areas

An Amazon.com delivery drone. (Amazon photo)

"President Donald Trump launched a program on Wednesday to expand testing of drones to include flights over people, nighttime operations and flights out of sight of the operator," David Shepardson reports for Reuters.

"The pilot program aims to speed up the integration of unmanned aerial vehicles into the national airspace system and test drone detection and tracking while waiving some limits on their use." That could benefit rural areas, and make use of them in agriculture more practical. Drones also could be used to deliver life-saving medications to remote areas, and retail giants like Amazon could deliver packages for less. UPS and FedEx charge extra fees to deliver packages to some rural areas.

Trump's Oct. 25 memo means "states and local governments would be able to seek Federal Aviation Administration approval for testing and expanded use," Shepardson reports. "The White House stopped short of proposing new regulations that would allow broader nationwide use of drones or any timetable for new authority. The memo said the Transportation Department could allow drone flights at up to 400 feet with the goal of approving at least five pilot projects. The program would expire in three years."

The Transportation Department website said that the cost of the program will be revealed soon.