Category Archives: Overdose deaths

In isolation, worries and stress are magnified During the Coronavirus Pandemic. COVID-19 could lead to an epidemic of clinical depression!

Jonathan Kanter wrote in the Conversation that Isolation, social distancing and extreme changes in daily life are hard now, but the United States also needs to be prepared for what may be an epidemic of clinical depression because of COVID-19.

We are clinical psychological scientists at the University of Washington’s Center for the Science of Social Connection. We study human relationships, how to improve them, and how to help people with clinical depression, emphasizing evidence-based approaches for those who lack resources.

We do not wish to be the bearers of bad news. But this crisis, and our response to it, will have psychological consequences. Individuals, families and communities need to do what they can to prepare for a depression epidemic. Policymakers need to consider – and fund – a large-scale response to this coming crisis.

A perfect storm of depression risks

Most of us know the emotional components of depression: sadness, irritability, emptiness and exhaustion. Given certain conditions, these universal experiences take over the body and transform it, sapping motivation and disrupting sleep, appetite and attention. Depression lays waste to our capacity to problem-solve, set and achieve goals and function effectively.

The general public understands depression as a brain disease. Our genes do influence how easily we may fall into clinical depression, but depression is also, for most of us, substantially influenced by environmental stress. The unique environmental stressors of the COVID-19 crisis suggest that an unusually large proportion of the population may develop depression. This pain is likely to be distributed inequitably.

Stress and loss

Exacerbating the widespread stress of this crisis, many of us are suffering significant personal losses and grief reactions, which are robust predictors of depression. The ongoing and unpredictable course of these stressors adds an additional layer of risk.

As this crisis unfolds, death tolls will rise. For some, especially those on the front lines, acute experiences of grief, trauma and exhaustion will compound the stress and place them at even greater risk.

Interpersonal isolation

Prolonged social isolation – our primary strategy to reduce the spread of the virus – adds another layer of risk. Our bodies are not designed to handle social deprivation for long. Past studies suggest that people forced to “shelter in place” will experience more depression. Those living alone and lacking social opportunities are at risk. Loneliness breeds depression.

Families, who must navigate unusual amounts of time together in confined spaces, may experience more conflict, also increasing risk. China experienced an increase in divorce following their COVID-19 quarantine. Divorce predicts depression, especially for women, largely due to increased economic hardship over time.

Financial difficulties

The biggest stressor for many is financial. Unemployment and economic losses will be severe. Research on past recessions suggests that rising unemployment and financial insecurity lead to increased rates of depression and suicide. debt and financial deprivation during recessions are at significant risk for depression due to increased stress and difficult life circumstances. Minority-owned businesses may be at particular risk for buckling under the strain.

Recovery will be harder

Home foreclosures during the 2008 recession produced a 62% increased risk of depression among those foreclosed.

The mental health burden of economic recession will be distributed inequitably. When the stock market crashed in 2008, the rich experienced large wealth losses but not increased rates of depression. In contrast, those who experience unemployment,

While the COVID-19 crisis increases risk for depression, depression will make recovery from the crisis harder across a spectrum of needs.

Given depression’s impact on motivation and problem-solving, when our economy recovers, those who are depressed will have a harder time engaging in new goal pursuits and finding work. When the period of mandated social isolation ends, those who are depressed will have a harder time re-engaging in meaningful social activity and exercise.

When the threat of coronavirus infection recedes, those who are depressed will face increased immunological dysfunction, making it more likely they will suffer other infections. Depression amplifies symptoms of chronic illness. The inequitable distribution of the burden of the crisis will exacerbate existing racial health disparities, including disparities in access to depression treatment.

What to do?

Self-help suggestions are readily available. A good list, more evidence-based than most, is here. It is our experience, however, that such self-help encouragements for depression are not enough, and at times even insulting, for those who are truly struggling.

We need higher-level shifts in policy and how we approach the problem. Economic relief measures from the federal government are crucial responses both to economic recession and psychological depression. We call for a public health campaign to increase awareness of depression and treatment options, and for improvements in mental health sick-leave policies and insurance reimbursement to minimize barriers to treatment access.

How we talk about depression must change. The distress we feel is a normal human response to a severe crisis. Acknowledging and accepting these feelings prevents distress from turning into disorder. Describing depression solely as a brain disease increases helplessness and substance use among those who are depressed and decreases help-seeking. Emphasizing the causal role of our environmental context, in contrast, matches how depressed individuals across different ethnicities view the causes of their suffering, decreases stigma and increases help-seeking.

Finally, we recommend specific treatment options be prioritized. As we have discussed elsewhere, easy-to-train, cross-culturally applicable and effective treatment options exist. We wish for an army of practitioners to be trained and embedded in community and treatment centers across the country, and this army should represent the great diversity of our country.

Some specific suggestions to help us all:

Protect Your Family’s Mental Health During the COVID-19 Pandemic. 

Begin the Day with Gratitude

Before your feet hit the floor in the morning, think of something that you’re grateful for. Making this a focus for yourself, and teaching your kids to do the same, can have a significant impact on your emotional health. The heaviness of our current situation can quickly weigh us down, and if we begin our day with doom and gloom, then we have set the negative feeling pendulum into full swing.

A study published in the journal Psychotherapy Research found that writing a gratitude letter can improve a person’s outlook and emotional well-being. It even seems to change brain activity in a positive way, based on MRI scans of study participants.

Get into a Routine and Make a Daily Schedule

Depression and anxiety can keep you from feeling in control of your life. One way to counteract that feeling is by making a regular schedule and sticking with it. When you organize and structure your life, you know what to expect. Make sure you have a family routine.

Remember, kids are used to routine and structure in schools. Many thrive on having consistency in their lives, which consequently helps them feel in control, something kids need now more than ever.

Not only will having a plan can help you stay centered, it will keep you focused on the tasks at hand. A study published in the Annual Review of Psychology on psychological habits showed people rely on their routines and habits when they are stressed. That helps them get through difficult times, suggesting that establishing healthy routines could help with physical, emotional and mental health during difficult times like these.

So, go ahead and make a schedule. The first item on the list should be to make your bed. According to a survey by OnePoll and Sleepopolis, which provides mattress reviews, people who make their beds regularly tend to report feeling happier and more productive. Plus, if making your bed is on your to-do list, you can accomplish your first goal of the day.

How to Cope with Coronavirus Anxiety. 

Get a Good Night’s Sleep

According to the National Sleep Foundation, adults need between seven and nine hours of sleep each night. And research shows the amount and quality of sleep we get has a significant impact on mental health. The amount of sleep kids need varies considerably by their age. That ranges from newborns snoozing away most of the day (14 to 17 hours recommended), to preschoolers splitting time awake and asleep (11 to 13 hours in la la land recommended), to teens who are advised to get eight to 10 hours of sleep daily, though they rarely do.

Researchers have discovered that those suffering from mental health conditions, such as anxiety and depression, are at an increased risk of insomnia. And not getting adequate rest can raise one’s risk for mental health problems.

So, during times of high stress, sleep is of utmost importance. In addition to following a routine, another way that you can ensure a healthy night’s rest for you and your kids is by making sure the whole family is active during the day.

Go Outside

Research from Sweden suggests that being outside is associated with a lower risk of developing psychiatric disorders. In a separate study published in the International Journal of Environmental Health Research, researchers showed that spending about 20 minutes in the park can improve your overall well-being.

Even if you can’t get to a park, just getting some fresh air – while keeping 6 feet from others outside your household – can do you a world of good.

Eat Healthy

During this stressful time, it’s important to watch what you eat. That’s because what you put into your body will affect how you think and feel. Research has long documented the positive impact nutrition has on mood and that eating well is associated with lower levels of anxiety and stress.

Research has demonstrated the benefits of eating unprocessed food and having a diet that’s high in vegetables, fruits, unprocessed grains, with fish and only modest amounts of lean meats and dairy. Studies suggest that those who eat this way have depression rates 25% to 35% lower than those who consume a traditional Western diet characterized by processed foods, lots of red meat and high intake of unhealthy fats and carbs. The saying “you are what you eat” applies as much to mental health as it does to your physical health.

In a time of uncertainty, you need to take care of your mental health. Sure, you may be more confined than you usually are, but you don’t have to let anxiety and depression consume you. Make your mental health a priority by following the measures outlined above.

Also, if you need professional help, please reach out, as there are trained professionals who would like to assist you. Don’t forget, with COVID-19, you are not alone in how you are feeling. More importantly, remember this, too, shall pass.

Depression costs the U.S. economy US$210 billion yearly. That is under normal conditions. An epidemic of depression requires a multi-faceted, multi-level response.

Are We Only Going to See More Substance Abuse and Bad Behavior Including Gambling?

I was amazed that when our Governor of the great state of Maryland shut done businesses yesterday that the liquor stores were exempt, but not my medical offices. I also noticed that the substance abuse/methadone clinic next store to my office was still open for business and as usual, very busy. I continued to wonder when my oldest daughter asked how the pandemic will affect individuals suffering from substance use problems, particularly now that many of these individuals are in forced isolation.

Yale University professor Adrian Bonenberger noted that the coronavirus quarantine means different things to different people: A necessary inconvenience. A fusion of work and home life. A leap into social media, or virtual meetings once held face-to-face. For some, it’s possible to see a silver lining: more time with one’s family, and a change to the regular routine. But for people who suffer from substance use disorder, gambling addiction, or problematic video gaming—otherwise known as internet gaming disorder—the quarantine is fraught with danger.

“People will likely be practicing social distancing per the government’s recommendation,” said Marc Potenza, Ph.D., MD, HS, professor of psychiatry, who directs Yale’s Center of Excellence in Gambling Research, the Women and Addictive Disorders Core at Women’s Health Research at Yale, and the Yale Research Program on Impulsivity. “Oftentimes stress is linked to addictive behaviors, and there can be little question that the social distancing around coronavirus or COVID-19 has been a stressful interruption of routine for many.”

For people in treatment for substance use disorder, COVID-19 could lead to the type of stress and isolation most likely to result in risky behavior.

“Everyone is trying to protect the vulnerable from COVID-19, and the only way to make that happen is social distancing,” said Ellen Edens, MD, MPH, associate professor of psychiatry. “But social distancing can also be especially harmful for people with mental conditions or substance use disorder.”

According to Edens, there is a related concern: those who depend on medications to treat a substance use disorder may fall through the cracks. Like those with an opioid use disorder who take methadone or buprenorphine, both of which block cravings, treat opioid withdrawal and prevent opioid overdose; or those with a prescription for disulfiram, a medication that causes people to become sick if they drink alcohol and is most effective when taken under direct observation. Disulfiram is unavailable nationwide, according to Edens, though the intensively monitored in-person treatment often required for best outcomes, particularly early in treatment, is also unlikely in the current context.

Edens also notes that the most vulnerable moment for someone with substance use disorder is at the beginning of treatment, when they are deliberately and intensely plugged into group therapies and peer support groups like those popularized by Alcoholics Anonymous or AA. “With social distancing, one of the key components of addiction treatment—the reforging of family, social, or professional connections that may have been severed, exemplified by ‘network therapy’ or a ‘community reinforcement approach’—is lost,” she said. “The psychiatric community is doing what it can to make up for the sudden disruption of tested and effective in-person programs with things like old fashioned telephone calls. But between the technology gap with older patients and specific challenges faced by patients for whom disconnection is essentially the greatest danger, it’s difficult. Many AA groups that have closed their doors to comply with the injunction against gatherings of numerous people, and while it’s certainly prudent, it also leaves many attendees adrift.”

Another possible fallout from COVID-19 stems from the shutdown of casinos across the United States, coupled with the postponement or cancellation of professional sporting events including the NBA, NHL, MLS, and MLB (suspended), the Masters (postponed), the Boston Marathon (postponed), and the NCAA men’s and women’s basketball tournaments (canceled). Although gambling and sports gambling have been online and lightly regulated for years, there has never been an absolute vacuum of physical gambling locations. It’s likely that in the absence of a physical space in which to gamble, and without many of the typical outlets for gambling in place, some people with gambling addition will make their way to the internet.

The rise of e-sports is one possible place where online gambling and problematic video gaming could converge. A growing field with audiences for a single event in the millions, and over $1 billion in revenue as of 2019, e-sports, in which people play video games online competitively, requires no crowds, and can be accessed by anyone with a smartphone or laptop.

“A quarantine, particularly at home, may lead to bingeing on video games, alcohol, or drugs given the significant change to routine life. It could also lead to a relapse for those who had been doing well previously. Second, those who may have been considering coming to treatment now may suddenly be hesitant given possible exposure to the virus in a hospital or treatment setting and have decided to delay getting help,” said Brian Fuehrlein, MD, Ph.D., FW ’13, associate professor of psychiatry and director, Psychiatric Emergency Room, VA Connecticut Health Care System. Fuehrlein was careful to echo his colleagues in underlining the necessity of home quarantine and the importance of following it, and was unequivocal about the dangers posed to vulnerable populations like those who will be significantly economically impacted by social distancing.

There has already been an observable change in normal behavior at the VA, according to Fuehrlein—and the opposite of what one might expect, which is more cases. Fewer patients have been coming in for any reason, which does not bode well for long-term mental wellness. “Currently, we are seeing an uptick in those who were considering treatment for substance use disorder but have now decided to stay home instead (and thus are likely continuing to drink or use). Our census in the psych ER has actually been running lower than average,” said Fuehrlein.

In the long run, this will almost certainly turn into a large problem, or even a secondary epidemic for people already suffering from the various diseases of addiction. “I think in the long run we will see a sharp increase in depression, anxiety, and addictions of all types as a direct consequence of the current pandemic,” said Fuehrlein. “This may be due to the death of a loved one, a financial crisis, the loss of a job or housing, or some related tragedy. At the moment those consequences have yet to play out.”

Potenza echoes Fuehrlein and Edens’ concerns for people suffering from substance use or gambling problems at home, away from the usual forms of treatment. He brought up another population that will be at risk—in addition to the tens of millions of American workers (over 18% of the work force, according to an article published March 17, 2020 in the Los Angeles Times), millions of school children who have been cut loose with weeks of unstructured time. Without supervision, these groups will be especially vulnerable to what the DSM-5 defines as internet gaming disorder, on top of the better-known associated substance use disorder.

Said Potenza, “Oftentimes, it appears that people who are experiencing negative mood states or life stressors may turn to gambling, gaming, or use various substances including alcohol and drugs. COVID-19 is almost certainly creating more stress, and while health professionals and the government are mobilizing to address the threats posed by the virus, some of the recommended actions like social distancing and staying at home seem likely to lead to more gambling, more gaming, and more substance use.”

Almost 20 million American adults suffered from substance use disorder in 2017, while nearly 10 million American adults struggled with a gambling problem as of 2016. Both groups, in which there is almost certainly some overlap, rely on a therapeutic model that relies on person-to-person meetings. Potenza, Edens, and Fuehrlein all agreed that patients suffering from mental illness and substance use disorder could receive effective treatment via phone or computer, and that technology was racing to keep up with the changing demands of quarantine and the patient population. Any mechanism by which a connection could be forged, according to them, was preferable to isolation during the search for an effective vaccine and perhaps a cure.

“Ultimately,” said Potenza, “we don’t know what will happen. And that’s a source of stress for most if not all of us.”

It’s stockpiling, but not as you know it. Why coronavirus is making people hoard illegal drugs

Ms. Emma Reynolds of London (CNN) wrote that it’s not just toilet roll that people are panic buying. Some illegal drug users are reportedly stockpiling their substance of choice as restrictions intended to stop the spread of coronavirus disrupt the international supply chain.

And the consequences could be devastating, with experts concerned that people will adopt riskier habits, substitute unfamiliar drugs or enter withdrawal, which can be dangerous if unmanaged. Since heavy users often have other health problems, this could mean increased strain on services that are already near breaking point.

UK drug policy and crime experts told CNN they were worried over a growing number of reports of shortages and escalating prices for drugs, as international borders close and supply lines are cut off.

“There are reports coming through of people stockpiling their favorite drug or their drug of choice, and of course, that just creates a shortage, which has inevitably led to price increases,” Ian Hamilton, senior lecturer in addiction and mental health at the University of York, told CNN. He said he expected to see heroin “disappearing very, very quickly” in the UK.

Steve Rolles, senior policy analyst at the Transform Drug Policy Foundation, told CNN there was “anecdotal evidence of price rises… and that doesn’t seem surprising.”

“It does seem likely that the supply of drugs that these people are using, in particular heroin, is going to be restricted … it’s going to be more challenging to move drugs around.

“As weeks stretch into months, I think we’re likely to see a drought, a heroin drought.”

Alex Stevens, criminal justice professor at the University of Kent, told CNN that in areas including Birmingham and Bristol, users of heroin and synthetic cannabinoids “are reporting that they’re getting less in a £10 ($12) bag than they would have done four or five weeks ago.”

But this is an industry that operates on supply and demand. The dark web and sites including Craigslist are still active, with many users buying drugs through the mail at a time when police are not focused on monitoring post, according to several experts. “If the heroin isn’t available, they will probably find another route, whether it’s alcohol or inhalants, or benzodiazepines or something else,” said Rolles.

Rolles has even heard reports of dealers dressing in nurse’s uniforms and supermarket uniforms to make deliveries unnoticed.

What happens during a drought?

When the UK last experienced a heroin drought in 2010-11, the drug’s purity at “local dealer level” fell to 18%, according to the National Crime Agency. Street prices reportedly increased, and there was a reduction in the number of deaths involving heroin and a simultaneous (but smaller) increase in deaths involving methadone.

That may sound positive, but the experts say the effects could be different this time. Users may move from less dangerous drug-taking methods to injecting. They may use lethal combinations of drugs. They may use too much of their stockpile. And they may be more likely to overdose alone because of social distancing.

Women are using code words at pharmacies to escape domestic violence during lockdown

One vital difference between 2010 and 2020 that is causing anxiety among the experts is the proliferation of fentanyl, a synthetic opioid that is up to 50 times stronger than heroin and can therefore be transported in much smaller quantities. The drug has not yet become widespread in countries including Britain, but is wreaking havoc in the United States.

Fentanyl is the drug most often involved in overdoses in the US, according to the National Center for Health Statistics. The rate of overdoses involving the opioid skyrocketed by about 113% each year from 2013 through 2016. If you’re used to heroin and you take fentanyl, “the risk of overdose is extreme,” said Hamilton.

The drug is often manufactured in China, but little is moving out of the original coronavirus epicenter. It is also manufactured in Mexico and possibly Eastern Europe.

With many drug users dealing with mental health issues such as depression and anxiety, coronavirus isolation presents an unprecedented challenge.

“People who have an active disorder, addiction disorder, they’re going to look for ways to get a drug,” Cynthia Moreno Tuohy, executive director at NAADAC in the US (National Association for Alcoholism and Drug Abuse Counselors), told CNN.

Asking for help

The suicide rate in the United States has seen sharp increases in recent years. Studies have shown that the risk of suicide declines sharply when people call the national suicide hotline: 1-800-273-TALK.

There is also a crisis text line. For crisis support in Spanish, call 1-888-628-9454.

The lines are staffed by a mix of paid professionals and unpaid volunteers trained in crisis and suicide intervention. The confidential environment, the 24-hour accessibility, a caller’s ability to hang up at any time and the person-centered care have helped its success, advocates say.

The International Association for Suicide Prevention and Befrienders Worldwide also provide contact information for crisis centers around the world.

Tuohy expects more “poly-use” of readily available marijuana and alcohol, which is already seeing increased consumption worldwide.

It takes longer to build up data on illegal drug consumption, but analysts are watching closely.

Federal confidentiality laws in the US have been relaxed to allow people to access counseling and peer support faster. NAADAC is offering telehealth training, and resources to help clients find services available in their state.

“Whenever there’s a natural disaster, we know that relapse goes up, because of anxiety, the fear of the unknown,” said Tuohy. “Now we have an ongoing, natural disaster, if you will.

“The longer a crisis goes on, the less hope that people see … it doesn’t feel like there’s going to be a light at the end of the tunnel.

“Long term, we’re likely to see suicide go up as a result of depression. So I know that the suicide centers are gearing up and the suicide hotlines already are taking calls.”

A vulnerable population

Any disruption to the illicit drug supply will have the biggest effect on the most vulnerable populations. Heavy drug users are more likely to live with multiple people, have respiratory or other health issues or be homeless — and are therefore more at risk of contracting Covid-19.

“They are in a double tier of vulnerability in that they’re more likely to get the virus and they’re more likely to be affected negatively by it,” said Rolles. “So there’s a big responsibility, I think, on society to look after and protect those populations.”

If that doesn’t happen, hospitals and treatment facilities will face a huge additional strain, he warns.

Governments are conscious of the risks. The UK government has asked local authorities to house all homeless people. Low risk and pregnant prisoners are being released across the world.

Facilities in the US, UK and Canada are allowing stable users to pick up supplies of addiction treatment medications like methadone and buprenorphine once a week or every two weeks instead of daily, but this also presents risks.

Mat Southwell, a drug user and global advocate from Bath in southwest England, told CNN he was delivering a methadone prescription to a woman who cannot pick it up for herself, is suicidal and self-harms. She had gone three days without it.

Coronavirus is revealing how badly the UK has failed its most vulnerable

Will Haydock, from Public Health Dorset also in southwest England, told CNN that UK clinics were seeing an increase in people accessing treatment. He said this was encouraging but warned that for providers already making “significant changes to service design” this was adding to pressure. “It’s going to be a real challenge to deal with that influx of people who want support,” he said.

“This is a particularly vulnerable group of people, and you’re looking at services that are already really stretched.

“If we’re not able to offer the kind of level of support that we would like to, we will see more people die earlier than they need to.”

A spokesperson for the UK’s Home Office told CNN it is “monitoring the impacts of coronavirus” and law enforcement are “continuing to prevent drug trafficking and are successfully disrupting the drugs supply within the UK.”

The world was already facing a drug crisis before the coronavirus pandemic. The US is in the throes of an opioid epidemic. An estimated 10.3 million Americans ages 12 and older misused opioids in 2018. In 2017, there were more than 70,200 overdose deaths in the US and 47,600 of those deaths involved opioids.

The UK has seen near-record levels of drug-related deaths for six years in a row, and Scotland’s death rate is the highest in the European Union.

“I’m very apprehensive about what’s happening right now and what’s going to happen over the next few weeks to this group of our society who are extremely vulnerable, who’ve been exposed to adverse experiences, neglect and abuse from childhood onwards, and now risk being put at the back of the queue for support when in fact, they should be in front of it,” said Stevens, from the University of Kent.

The coming weeks and months will be crucial in identifying the effects of coronavirus on illegal drug use, alcoholism, suicide, domestic abuse, anxiety, and depression — and what it means for all of us as well as how we need to compromise, care and treat each other.

Some Hospitals Sue Opioid Makers For Costs Of Treating Uninsured For Addiction. Who is Really Treating Our Patients and Words for CMS Administrator Seema Verma. Really??

Screen Shot 2019-10-26 at 11.44.45 PMI had a brother who basically tried to destroy our family with his drinking and his use of drugs. I remember having to home from college and medical school to rescue him many times after my parents were feed up with his abuses and problems with the police. Finally he and his girlfriend wrapped his car around a telephone phone resulting his death. So, I understand the opioid problem but have minimal empathy. We all make our own choices in life and need to stop blaming everyone else but those that use, steal, lie and continue to use opioids. Now, what are the real numbers?

Blake Farmer reported that while thousands of cities and counties have banded together to sue opioid makers and distributors in a federal court, another group of plaintiffs has started to sue on their own: hospitals.

Hundreds of hospitals have joined up in a handful of lawsuits in state courts, seeing the state-based suits as their best hope for winning meaningful settlement money.

“The expense of treating overdose and opioid-addicted patients has skyrocketed, straining the resources of hospitals throughout our state,” said Lee Bond, chief executive officer of Singing River Health System in Mississippi in a statement. His hospital is part of a lawsuit in Mississippi.

Hospitals may find there are downsides to getting involved in litigation, says Paul Keckley, an independent health analyst.

“The drug manufacturers are a soft target,” he says. But the invasive nature of litigation may generate “some unflattering attention” for hospitals, he adds. They’d likely have to turn over confidential details about how they set their prices, as well as their relationships with drug companies.

So despite representing the front lines of the opioid epidemic, most hospitals have been hesitant to pile on.

Just about every emergency room has handled opioid overdoses, which cost hospitals billions of dollars a year, since so many of the patients have no insurance. But that’s just the start. There are also uninsured patients, like Traci Grimes of Nashville, who end up spending weeks being treated for serious infections related to their IV drug use.

“As soon as I got to the hospital, I had to be put on an ice bath,” Grimes says of her bout with endocarditis over the summer, when bacteria found its way to her heart. “I thought I was going to die, literally. And they said I wasn’t very far away from death.”

Grimes is in recovery from her opioid addiction but still getting her energy back after spending a month being treated through a special intravenous line to her heart at Vanderbilt University Medical Center. Most patients could be sent home with a PICC line, but not someone with a history of illicit IV drug use who could misuse it to inject other substances. Vanderbilt and other academic medical centers have recognized this problem and established special clinics to manage these complex patients.

Grimes, 37, says she’s grateful for the care she received, which also included multiple procedures and treatment for pneumonia, hepatitis A and hepatitis C. But like most patients in her situation, she’s uninsured and strapped for cash.

“I can’t pay a thing. I don’t have a dime,” she says. “So they do absorb all that cost.”

Hospitals estimate treating complicated patients like Grimes costs an average of $107,000 per person, according to court documents. The total costs to U.S. hospitals in one year, 2012, exceeded $15 billion, according to a report cited in the suits. And most patients either couldn’t pay or were covered by government insurance programs.

The expense is a leading reason cited by the hospitals that’ve banded together in a handful of lawsuits in Tennessee, Texas, Arizona, Florida, Kentucky, Mississippi and West Virginia. These suits are all separate from the big consolidated federal case in Ohio that includes cities and counties around the country. But the most prominent hospitals in those states, like Vanderbilt, have opted not to join the litigation.

West Virginia University President Gordon Gee, who oversees the state’s largest hospital system, has been urging others to join the suits. He and former Ohio Governor John Kasich established an organization meant to highlight the harm done to hospitals by the opioid crisis.

“I think the more hospitals we have that want to be involved in this in some way, the better off we are,” he says. “You know, there’s always safety in mass.”

By “safety,” Gee acknowledges a central concern for hospitals weighing the risk versus reward of going to court. They may have the tables turned on them by the pharmaceutical companies, since until recently, patients in the hospital were often prescribed large quantities of opioids, contributing to the epidemic.

“I suspect there are some hospitals … who are afraid that if they get into it, those who on the defense side will point out, well, maybe hospitals were really the problem,” he says.

The lead defendant in the suits, Purdue Pharma, did not respond to requests for comment.

Gee says hospitals can claim they were victims of dubious opioid marketing.

Still many high-profile hospitals are sitting out the lawsuits, even though they’re typically the ones that treat the most complicated and expensive patients.

Paul Keckley says if hospitals join the litigation, they may be forced to cough up actual totals for their opioid-related financial damages. That could force hospitals to reveal how much more they charge for some services, compared to the actual costs of providing the care.

“Hospitals basically have charged based on their own calculations and the underlying cost of delivering that care has been virtually non-transparent,” Keckley says. “Then you open a whole new can of worms.”

Keckley says especially big academic medical centers have relationships with drugmakers that they may not want publicly highlighted.

Still, hospitals might benefit without having to put their names on lawsuits and exposing themselves to risk. In Oklahoma, the state won an early opioid lawsuit in August. The payout does not direct money to hospitals, per se. However, Patti Davis, president of the Oklahoma Hospital Association, says they’re happy to see some of the money was earmarked for treatment.

“When we see treatment, we get very excited because it’s our hospitals providing a lot of the treatment,” she says.

But nationally, hospitals can’t count on potential settlement money to trickle down to their bottom lines, says attorney Don Barrett. He’s a Mississippi litigator helping hospitals sue in state courts.

Two decades ago, when the target of litigation was Big Tobacco, Barrett was working for states. He says hospitals didn’t join in, to his surprise. And when the states won those suits and started getting paid damages, hospitals missed out. Only about a third of the money was even spent on health or tobacco control, according to one watchdog’s estimate.

“I guess they thought that the states were going to take care of them, that these local governments were going to take this money and give it to the hospitals where it would do some good,” he says. “Of course, they didn’t give them a damn penny.”

Some states did set up trust funds that might help patients in the hospital stop smoking. But many are using the money to fill potholes, pay teachers and otherwise close gaps in state budgets.

Though not detailed in the lawsuits, many of the participating hospitals are in varying levels of financial distress, and not always primarily because of the opioid epidemic. Facilities owned by Community Health Systems make up a large share of the hospitals suing in Alabama, Florida, Mississippi, Tennessee and Texas. The investor-owned hospital chain, based in Franklin, Tenn., has been struggling mostly because of an outsized debt load taken on during a rapid period of expansion.

A CHS spokesperson declined to comment, citing a policy not to talk about pending litigation.

But Barrett says he expects more hospitals to join the cause rather than relying on states to determine how settlement money is spent.

“We’re not going to allow that to happen this time,” he says. “We can’t afford to allow it to happen this time.”

The Real Cost Of The Opioid Epidemic: An Estimated $179 Billion In Just 1 Year

SelenaSimmons-Duffin reported that there’s a reckoning underway in the courts about the damage wrought by the opioid crisis and who should pay for it.

Thousands of cities and counties are suing drugmakers and distributors in federal court. One tentative dollar amount floated earlier this week to settle with four of the companies: $48 billion. It sounds like a lot of money, but it doesn’t come close to accounting for the full cost of the epidemic, according to recent estimates — let alone what it might cost to fix it.

Of course, there’s a profound human toll that dollars and cents can’t capture. Almost 400,000 people have died since 1999 from overdoses related to prescription or illicit opioids. Since 2016, the number of opioid deaths per year rivals or has exceeded the number from traffic accidents. These are lives thrown into chaos, families torn apart — you can’t put a dollar figure on those things.

But the economic impact is important to understand. The most recent estimate of those costs comes from the Society of Actuaries and actuarial consulting firm Milliman in a report published this month.

“We pride ourselves that this is objective, nonpartisan research,” says Dale Hall, managing director of research at the Society of Actuaries. He adds, “We’re not here to influence any court proceedings.” As actuaries, they calculate financial numbers associated with risks, for instance, for insurance companies.

So how much did the epidemic cost in just one year, 2018? The total number they came to was $179 billion. And those are costs borne by all of society — both by governments providing taxpayer-funded services (estimated to be about a third of the cost) and also individuals, families, employers, private insurers and more.

Screen Shot 2019-10-26 at 11.49.53 PMWhen you start to break that number apart, a picture emerges of how opioid addiction ripples out into communities and across generations.

Overdose deaths: $72.6 billion

It makes sense that the biggest contributor to the costs of the epidemic comes from overdose deaths, according to Stoddard Davenport of Milliman, one of the report’s authors.

“When you think about the course of a person’s life that struggles with opioid use disorder, early mortality is the most significant adverse event that can happen, and I think that bears out when you look at the economic impact,” he says.

Every day, 130 people die from opioid overdoses. Most of them are in the 25-55-age range, right in the middle of their prime working years, and lost earning potential accounts for most of those costs.

“The mortality costs have a small component of end of life health care, coroner expenses and things like that,” he says. “The grand majority of it, however, is composed of lost lifetime earnings.”

Preliminary data suggest overdose deaths dipped in 2018 for the first time in years, but many experts say it’s too early to say whether that marks a turnaround.

Hall points out that whether the annual death toll stays as high as 47,000 in coming years “will be certainly a driver of what these overall economic costs will be.”

Health care: $60.4 billion

The next biggest amount comes from health care costs. The researchers took several large databases of insurance claims that had been scrambled to hide the identity of the patients and flagged people who had been coded as having opioid use disorder. Then the researchers calculated their overall health care costs — not just directly related to their addiction, but any additional costs — and compared them to similar patients without addiction.

Screen Shot 2019-10-26 at 11.50.26 PMNearly one-third ($60.4 billion) of the estimated economic burden of the opioid

“Looking at the difference in costs gives us a sense for how much more complicated is their overall health care picture and what those additional expenses look like for two otherwise comparable people,” Davenport explains.

Opioid addiction is linked to other health problems. Patients might have chronic pain or mental illness that underlies their addiction; infectious diseases like HIV and hepatitis C can spread among injection drug users; and there can also be higher costs for other conditions like anemia, liver disease, and pulmonary heart disease, according to another Milliman analysis from earlier this year.

There are also health costs for people who live in the same household as someone with an opioid use disorder — their lives might be more complicated and their mental and physical health can suffer as a result.

Then there are the costs for infants born dependent on opioids — what’s called neonatal abstinence syndrome. “The epidemic effect is starting to create a second generation that extends down to children and unfortunately newborns as well,” Hall says. In 2018 those costs were $800 million, but they estimate this year they could be almost $1 billion.

There are still more costs the report could not capture, including elevated costs for patients whose opioid use disorder is undiagnosed and potential ongoing expenses for children born with neonatal abstinence syndrome as they grow up.

Lost productivity: $26.5 billion

When someone is addicted to opioids, they might not be able to apply for or hold down a job, or they might be incarcerated and unable to work. The researchers broke this section out into reduced labor force participation, absenteeism, incarceration, short and long term disability, and workers’ compensation.

“What we’re trying to capture is the amount of time that folks are spending not doing economically productive activities,” Davenport says. Other productivity costs — like “presenteeism,” when someone shows up at work but isn’t as productive as they otherwise would be — were not included here.

It’s also worth noting, many of these costs fall to private employers, for instance, and families who have a family member not bringing home income.

“It’s around 30% falling on the federal state and local governments,” he says. “The rest [falls to] the private sector and then of course to individuals.”

Criminal justice: $10.9 billion

Measuring this part of the costs of the epidemic is a different beast. The researchers captured costs related to police, court cases, correctional facilities and property lost to crime, Davenport explains. They drilled down into criminal justice expenses to see “what proportion of those total budgets involve substance use disorders, and then what proportion of that is represented by opioids.”

Having an opioid addiction dramatically increases the chance of being caught up in the criminal justice system. As NPR has reported, only 3% of the general population reported being recently arrested, on parole or on probation. For people with opioid use disorder, that jumped up to nearly 20%.

Child and family assistance and education: $9 billion

The team took a similar approach to calculate the costs for things like food assistance, child welfare, income, and housing assistance, and education. They took those total costs, figured out what portion was related to substance use, and what part of that was related to opioid use.

The epidemic has a profound impact on families and communities — parents with opioid use disorder have to navigate treatment and sometimes battle for custody of their kids; the state has to handle child welfare cases and find new homes for foster kids; and schools are providing counseling for kids with addicted parents.

Screen Shot 2019-10-26 at 11.50.53 PM“Typically an epidemic will start in one place but then it broadens out,” says Hall. “We’re starting to see a broadening out of the impact of the opioid epidemic into some second-generation effects.”

Hall adds there are also “the costs of educating people about the epidemic and ways to prevent future opioid use disorder.” Those costs — mostly from federal grants for elementary and secondary education programs — came out to $1.2 billion last year.

What’s missing: Turning the crisis around

These are some solid numbers that capture the current economic burden of the epidemic. Estimating what it’s going to cost to fix the crisis — to treat those who are addicted, to reduce overdose deaths, and more — is another story.

“The notion of abatement is that we want to deal with the problem that exists but also to begin to remedy it,” says Christopher Ruhm, professor of public policy and economics at the University of Virginia. He worked for several years on a 30-year abatement plan for Oklahoma as part of that state’s case against several drug companies.

For Oklahoma, Ruhm estimated treatment; prevention, education and surveillance for one year would cost $836 million. The judge in the case made his own calculations and ordered Johnson & Johnson to pay $572 million, though the amount has since been adjusted, and the case is currently being appealed.

If you scale Ruhm’s numbers up from that one state to the whole country, you get $69 billion to fund a year’s worth of abatement programs.

“I’m not saying that’s an appropriate calculation in the sense that things could be different in Oklahoma from other places,” Ruhm cautions. There are also costs that might come up on the federal level that wouldn’t be factored in for Oklahoma, such as research into effective addiction treatments.

Still, it gives you a rough idea, as society starts to take stock of what this epidemic is costing already, how much it will cost to try to fix it and who should ultimately pay.

Why Are Insurance Executives Treating Our Patients?

Kevin Campbell believes that peer-to-peer consults waste time and harm patients, I’m wondering where this opinion comes from, his medical degree?

Kevin Campbell reported that in two recent surveys, physicians said that pre-authorizations are burdensome to their practice and that they could lead to adverse patient outcomes. Kevin Campbell, MD, agrees that the insurance companies shouldn’t be part of patient practice, and says that the peer-to-peer review process is even worse.

The opinions expressed in this commentary are those of the author. The following transcript has been edited for clarity.

Insurance companies have been granted far too much control over patient care over the last several decades. Nowhere is it more apparent than when physicians are asked to obtain “pre-approval” for guideline-based, medically necessary procedures. According to one survey from the Medical Group Management Association, 83% of those surveyed said prior authorizations are “very” or “extremely” burdensome to their practice and their staff. Another survey conducted of physicians found that nearly one-third of doctors believe that spending time obtaining pre-authorizations actually led to adverse patient outcomes.

Ninety percent of those practice managers have indicated that the amount of pre-authorizations have significantly increased over the last year. To illustrate the sheer volume of this work, there were 182 million pre-authorization transactions conducted last year alone.

While Congress has given lip service to this issue by hosting a hearing with doctors in September, no real changes have occurred. In fact, the insurance companies have lobbied Congress that these pre-authorizations are needed to reduce costs and prevent unneeded treatments.

I find this practice offensive. Who are insurance executives to decide who needs or does not need a procedure? Who are they to determine the appropriateness of a procedure? Did they go to medical school? Have they ever looked a patient in the eyes and told them they cannot have a life-saving procedure done because it costs too much?

Worse than the pre-authorization is the peer-to-peer consultations. As an electrophysiologist, I spent nearly a decade training at Duke in order to become an expert in the implantation of pacemakers and ICDs and performing ablations. When I have a pre-auth denied, I have to get on the phone and argue my case for the procedure — which is based on ACC and HRS guidelines — to someone who has NEVER even seen a pacemaker, and almost always does not even understand how a pacemaker functions! Often these are retired pathologists, pediatricians, or other non-specialists that are making decisions about MY clinical judgment. In fact, an EP colleague of mine recently told me that he had to do a peer-to-peer consult to argue the appropriateness of an ICD implantation. When he began the consultation, the insurance company representative, who was supposedly an MD, said that he could not justify putting ACID into a patient. The trick here is that this guy did not even know that it was an AICD or a defibrillator and not ACID. This just illustrates the level of incompetence of the reviewing doctors that insurance companies hire to review the appropriateness of procedures.

We cannot stand for this any longer. Insurance companies are working around the clock to avoid paying for care. Our patients and our employers pay insurance companies for coverage. The physicians that care for patients every day — by and large — provide evidence-based care and do what is indicated for patients based on guidelines. It is insulting and frankly disgusting to have someone who has no knowledge of a particular specialty making a determination of care appropriateness on a patient that they have never evaluated and with no expert knowledge on the topic. Moreover, these reviewing MDs are actually compensated for NOT approving procedures.

Our patients are suffering. Our staff is becoming overworked in dealing with pre-authorizations. Our doctors are wasting valuable time on the phone arguing with ignorant MD reviewers employed and incentivized by insurance companies. Let’s take medicine back — contact your congressman or congresswoman today.

Verma to Democrats: Some insurance ‘better than no insurance at all’

Michael Brady noted that CMS Administrator Seema Verma on Wednesday defended the Trump administration’s actions on healthcare, telling the U.S. House of Representatives’ Energy and Commerce Committee that her agency is trying to provide greater access to care in the face of rising healthcare costs.

Verma touted the CMS’ efforts on a range of healthcare issues from health IT interoperability to opioid abuse throughout her testimony, but the committee’s Democratic members met her with fierce criticism. They said that under the Trump administration, the healthcare system is heading in the wrong direction and that the Affordable Care Act is succeeding “despite” the administration’s best efforts to undermine it.

The Democrats were especially concerned about the CMS’ expansion of short-term, limited-duration insurance, a recent drop in the number of people with insurance, waivers for Medicaid work requirements and the administration’s unwillingness to share information about what it’ll do if a court throws out the ACA.

The CMS loosened restrictions on short-term, limited-duration insurance last year to provide more affordable coverage options to consumers who don’t have employer-sponsored insurance but earn too much to receive subsidies for plans offered through ACA exchanges or qualify for federal programs like Medicaid. Unlike plans sold on the exchanges, they don’t have to meet the ACA’s mandates.

Critics, including the committee’s Democratic members, argue that these plans are affordable because they don’t cover as much as ACA-approved plans that have caps of cost-sharing and require payers to cover people with pre-existing conditions. Throughout the hearing, several committee members called them “junk” health plans. And the representatives repeatedly confronted Verma on the lack of ACA protections for consumers.

“What are people with these junk plans supposed to do when they need vital healthcare services that are not covered by these junk plans?” said Rep. Paul Tonko (D-N.Y.).

Verma responded that when the other plans available to people are unaffordable, the short-term plans are “better than no insurance at all.”

“If there were more affordable options available under Obamacare, people wouldn’t have to make compromises,” Verma said.

Several committee members also took aim at the Trump administration for a recent falloff in the number of people who have health insurance. Nearly 2 million more people lacked health insurance in 2018 compared with the year before, according to a report from the U.S. Census Bureau. The report showed that a dropoff in Medicaid coverage caused most of the decline.

“Under this administration, thousands of children and families have lost coverage of basic health services … the numbers just don’t lie,” said Rep. Diana DeGette (D-Colo.).

But the worries about Medicaid weren’t limited to Democrats; Republicans had concerns too.

“How do we ensure that the populations, some of the most vulnerable in our communities, are actually getting the care that we have promised to them?” said Rep. Cathy McMorris Rodgers (R-Wash.).

Committee Democrats also brought up the administration’s approval of Medicaid work requirement waivers, which seem increasingly likely to get struck down by the courts because of HHS’ failure to consider their effects on coverage. Low-income, working-age adults in Arkansas were less likely to have health insurance, work or participate in community engagement activities after the state’s work requirement went into effect, according to a recent study in the New England Journal of Medicine. That’s despite Arkansas’ unemployment rate declining over that period.

“Can you point me to one study that says a work requirement makes people healthier?” asked Rep. Joe Kennedy III (D-Mass.). “Healthier people might work, but working doesn’t necessarily make people healthier.”

Several members of the committee also wanted to know what the administration would do if the 5th U.S. Circuit Court of Appeals were to uphold a lower court ruling that would invalidate the ACA entirely. They were especially frustrated that HHS had “stonewalled” them on their requests for documents about the administration’s contingency plans, especially those related to likely coverage losses and protections for pre-existing conditions.

Committee members also wanted to know why the administration didn’t ask the courts to safeguard the parts of the law that the administration says it supports. They asked about protections for pre-existing conditions or allowing kids to stay on their parents’ health insurance until they are 26 years old.

“Did the administration file some kind of motion in the Texas case to say that the pre-existing conditions should be maintained?” DeGette asked.

“We will maintain what works and we will try to address the problems that we’re having with the ACA,” Verma replied.

She added that people with pre-existing conditions “don’t have the protections today” if they can’t afford the coverage.

“Where is the plan?” asked Rep. Jan Schakowsky (D-Ill.).

An analysis by the left-leaning Urban Institute estimates that roughly 20 million people will lose coverage if the courts toss out Obamacare altogether.

And hopefully, we will hear from Ms. Warren regarding how she proposes to pay for Medicare for All, her answer for the Democrats’ new health care system. I can’t wait to hear how all their plans are going to be paid for.

Happy Halloween to All you Goblins, Devils, Witches and Yes you Politicians that act like Goblins and Devils and Witches and Donkeys!