One of the most unsung acts of the Trump Administration could also be one of its most substantive in combatting the opioid epidemic. It’s a novel legal argument advanced in a letter from the U.S. Attorney for Massachusetts to state health and public safety officials, which we’ll get to in a moment.
In other key developments in the past few days, the Centers for Medicare and Medicaid Services modified a controversial draft Medicare rule that was frightening chronic pain patients; the National Safety Council has issued a report card on states’ response to the crisis (thirteen are “improving,” 29 are “lagging,” and eight are “failing.”); there were new developments in the litigation (which, by my count, now includes more than 500 lawsuits against opioid manufacturers and/or distributors); journals carry new articles on Hepatitis C, medical cannabis as an opioid substitute, how to treat gastrointestinal pain without opioids, and the growing use of prescription opioids in conjunction with something called “EDM.” Finally, a European Union publication tells a troubling story about “codeine abuse” in Europe.
In a letter to Massachusetts health and public safety officials, U.S. Attorney Andrew Lelling, argues that detainees and prisoners who had been, prior to incarceration, receiving medication-assisted treatment (MAT) for opioid use may have a federal statutory right to continue their therapy while in custody under the Americans with Disabilities Act of 1990. (I first learned of this letter from this WBUR report, later also reported by Stateline, the Pew Charitable Trusts’ initiative.)
Why is that so important? Many addicts end up in custody, and most US jails and prisons currently offer either no or very limited MAT programs. It’s long been recognized—as we noted here and Vox recently wrote about here—that when such prisoners leave the institution, they’ve lost their tolerance and are at great risk for relapse and fatal overdose. And this was so even before the arrival of extremely powerful, illicit fentanyl on the streets.
A February letter in JAMA-Psychiatry, however, reported on an extremely effective MAT program institute at the Rhode Island Department of Corrections, which reduced overdose deaths among recently released prisoners by 60%. The dramatic success of that program, according to Stateline, is creating momentum for other states to institute similar programs. That’s so notwithstanding traditional bias against opioid-substitution therapies in correctional settings. (A Barnstable County sheriff tells Stateline, for instance, that buprenorphine is “contraband.”) Clearly, US Attorney Lelling is giving that healthy momentum toward making MAT available behind bars a powerful push.
While we’re on this subject, ProPublica has a relevant story on Vivitrol, the injectable form of naltrexone to which the Trump Administration has given special preference as the form of MAT it would like federal prisons to offer. Naltrexone is not itself an opioid—a marketing advantage—but its effectiveness is also not as empirically well established as buprenorphine or methadone. And when given a choice between buprenorphine (a sublingual film), methadone (a drink), or Vivitrol (a shot in the buttocks), only four of 303 inmates involved in the Rhode Island study chose Vivitrol.) ProPublica reports on a paper in Drug Safety suggesting, in ProPublica’s words, “a heightened chance of overdose among those who stop taking [Vivitrol] too early.” Vivitrol’s manufacturer, Alkermes, tells ProPublica that the study’s methodology was so faulty as to amount to “misrepresentation of data.”
CMS softened a proposed new Medicare rule that had frightened pain patients and prompted a front-page article in the New York Times and a letter in opposition signed by 220 professors of medicine, addiction, and pain management. As characterized by the Times, the draft rule would have cut off reimbursement for long-term, high-dose prescriptions, leaving some chronic pain patients in dire circumstances. According to The Hill, the new draft will require pharmacists to double-check such scripts with the prescribing physician. Once confirmed, however, the prescriptions can now be filled and reimbursed.
After hints last month that the U.S. Department of Justice might file its own suit against opioid manufacturers and distributors, the department modified course this week. Instead, as reported by Reuters, it merely asked for permission to participate, as a “friend of the court,” in settlement negotiations. The filing suggested that the government can best combat the epidemic by focusing on other enforcement efforts, and a large DEA crackdown the same day, reported by the Washington Post, seemed timed to reinforce the point. (Twenty-eight prescribers or pharmacists were arrested, while 147 entities that handle controlled substances had their licenses revoked.)
By my tally, more than 500 suits have now been filed against opioid manufacturers and/or distributors by cities, counties, states, Indian tribes, hospitals, and unions (as third-party payors of medical care). At least 487 are now consolidated in federal court in Cleveland.
Also, we have an article this week observing that about 80 of those suits name three of the most eminent pain doctors of the previous two or three decades as co-defendants: Lynn Webster, Perry Fine, and Scott Fishman. Another giant in the field, Russell Portenoy, is named as a defendant in at least 18 suits in federal court. (An attorney for the first three declined comment, as did Portenoy.)