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The opioid crisis reached emblematic apogees this week. First, the New York Times devoted its lead Sunday editorial to the topic—a 1650-word magnum opus that chased other urgent issues off the page. Then, on Wednesday, Google trumped even that gesture, dedicating the space just below its search box—the most valuable hortatory real estate mankind has ever known—to urging readers to “help curb opioid abuse.” (As an aside, the week ended with a Cabinet nomination collapsing when it was alleged that, among other things, the nominee, a chief White House doctor nicknamed “the Candyman,” had handed out prescription drugs with abandon, including, on at least one occasion, an alarmingly large supply of Percocet.)
We’ll discuss the Times and Google stories in a moment, but the week also featured fascinating new research on attempts to repurpose obesity drugs to fight opioid craving; a discussion of lethal fraud in the for-profit drug treatment industry; an apparent breakthrough in FDA recognition of the safety and effectiveness of the cannabidiol (CBD), a compound found in marijuana, for treating certain epilepsies; and more wrenching, anecdotal reminders of the unimaginably grim human toll the epidemic is exacting.
The Times and Google
While the Times editorial provided a familiar overview of the origins of the epidemic, including the role of opioid overprescribing in the late 1990s and 2000s, it placed these recent events in the historic context of the nation’s two earlier opioid epidemics, dating back to the nineteenth century. (It appeared to rely largely on David Courtwright’s book, Dark Paradise: A History of Opiate Addiction in America.) It concluded that Congress and the Administration were not doing enough, and endorsed the view of Andrew Kolodny, who co-heads the Opioid Policy Research Collaborative at Brandeis’s Heller School, that we need a commitment of at least $6 billion a year for 10 years to combat the crisis. (In an interview with Opioid Watch published earlier this month, Kolodny gave both his view on the origins of epidemic—an indictment that amounts to a precis of the litigation now proceeding against the manufacturers in more than 600 lawsuits throughout the nation—and, in part 2, his view of why he regards opioids as “lousy” pain drugs and his controversial position that chronic pain patients on very high doses must be tapered down, even against their will.)
The Google public service announcement was related to the DEA’s National Prescription Drug Take Back Day, and it mainly directed readers to an online locator system it created to help people find nearby facilities where they can dispose of leftover opioid medications. (The company also said it was giving $750,000 to the Parent Helpline of The Partnership for Drug-Free Kids to get families of addicts the support they need.) The National Safety Council is also addressing the safe disposal issue, offering free, DEA-approved Stericycle Seal&Send envelopes for those purposes. Meanwhile, at least two frequent defendants in the opioids litigation, drug distributor AmerisourceBergen and retailer Wal-Mart, are making free DisposeRx pouches available, yet another way of safely disposing of unused opioid pills. Finally, there is apparently yet another way of getting rid of opioids that requires neither a GPS device or a pouch. The FDA says it’s safe to just flush them down your toilet.
Google did something else significant last week relating to opioids, though it made no show of it. It began taking applications once again for the purchase of AdWords relating to the addiction treatment market, but this time under the close supervision of an outside group called LegitScript, which will try to ensure that the ads are not deceptive. Google halted AdWords auctions for detox industry participants after a Verge story last September exposed the way bad actors were using those ads to lure recovery patients to unsavory detox treatment centers.
One of the nation’s authorities on this kind of fraud is Dave Aronberg, the State Attorney for Palm Beach County—one of the nation’s premier destinations for those seeking drug treatment. We have an interview with Aronberg this week in which he explains the dense thicket of often lethal frauds in that industry, now known collectively as the Florida Shuffle. Using illegal gifts and kickbacks, dirty operators engage in “patient brokering,” milking patients of their insurance benefits and then, Aronberg says, actually encouraging relapse, so patients’ benefits can be milked again. “When people get caught up in the Florida shuffle,” he says, “the only way they leave is in an ambulance or a body bag.”
Regulation and Legislation
An FDA panel voted unanimously to approve pharmaceutical-grade cannabidiol, or CBD, for treatment of two rare forms of epilepsy. STAT has that story. CBD is a non-psychotropic compound found in marijuana, which has long been believed, anecdotally, to possess positive medical benefits. The drug, Epidiolex, is made by GW Pharmaceuticals, a UK company. While the DEA will likely maintain marijuana’s Schedule I status—unprescribable because the DEA deems it to have no legitimate medical purpose—cannabidiol will have to be rescheduled, according to STAT. The FDA has previously approved synthetic THC (Marinol), the main active ingredient in marijuana, and Cesamet, another synthetic cannabinoid. Another GW Pharma drug, Sativex—a synthetic combination of THC and cannabidiol—has been approved in the UK.
In related news, on May 5, San Diego State University will hold a public forum on marijuana as an alternative to opioids, with CBD being one of the topics. Meanwhile, CNN’s Sanjay Gupta, who will air a special report on Sunday, April 29, called Weed 4: Pot vs. Pills,” published an open letter to AG Jeff Sessions on Tuesday. In it he asks for “safe and regulated medical marijuana” to be made available nationwide. He argues that marijuana can treat pain (in lieu of opioids), ease opioid withdrawal symptoms, and hope “heal the diseased addict’s brain, helping them break the cycle of addiction.” (This week, Pennsylvania became the second state to approve the use of medical marijuana to treat opioid withdrawal.) Finally, here at Opioid Watch we have discussed some of the literature on medical marijuana versus opioids in writing about a recent Columbia study showing that marijuana can boost the painkilling power of very low-dose oxycodone.)
In other key regulatory and legislative developments:
- The FDA is attempting to streamline approvals of new drugs that can be used for medication-assisted treatment (MAT) of opioid addiction, according to Modern Healthcare. Specifically, it’s urging fewer clinical trials for what’s known as “depot buprenorphine.” These are long-lasting delivery systems for buprenorphine, administered by implantation or injection. Braeburn’s Probuphine, an implant that lasts six months, and Indivior’s Sublocade, an injection that lasts a month, are existing, FDA-approved examples of the genre. The FDA wants more of these products, the magazine explains, because too many participants receiving daily doses of buprenorphine (like Suboxone or Subutex) for MAT drop out. (Fewer than 50 percent adhered to the regimen according to a 2016 study in the American Journal on Addictions, e.g.) The hope is that people taking these longer lasting treatments will pursue their MAT programs longer.
- Incredibly, methadone treatment for addiction is currently not covered by Medicare, according to the AP. Fortunately, chances are good that Congress will plug this unconscionable loophole in upcoming opioid-related legislation.
- Researchers are looking to see if several commercially unsuccessful obesity drugs, including Qsymia, Belviq, and Contrave, could be repurposed to fight addiction cravings, according to STAT, whose reporting is prompted by an article in Neuropsychopharmacology. The magazine interviews Nora Volkow, director of NIDA, who is enthusiastic about the prospects. “I published a paper many years ago on the similarities in the changes of brain pathways of people who were addicted, and those who were obese,” she tells STAT. She thinks the drugs that quell food craving might not only help with opioids, but with cocaine, marijuana, meth and inhalants. Conversely, she says, anti-addiction drugs might help people with obesity.
- A new article in the New England Journal of Medicine reviews lessons Canada could teach us about combating the opioid overdose deaths, including the medically-supervised use of pharmaceutical-grade heroin as a “treatment for severe, treatment-refractory opioid use disorder.”
- Seniors who use prescription opioids may be more likely to have serious falls, ABC News reports, citing a study in the Canadian Medical Association Journal.
- Use of high-dose opioids during surgery increases risk of readmissions, according to Clinical Pain Advisor, reporting on a study in the British Journal of Anaesthesiology.
- People with autism spectrum disorders (ASD) are twice as likely to develop substance abuse disorders, reports Slate, citing a Swedish study.
- A Mayo Clinic study finds that nearly two-thirds of opioids prescribed after surgery go unused, according to UPI, with one in three patients not taking a single pill.
Also of Note
- Anesthesiologist and pain specialist Tracy Jackson, at Vanderbilt, takes 12 chronic pain patients on a rustic retreat for innovative physical therapy, with reportedly encouraging results, per the Tennessean.
- Six of Prince’s heirs have sued Walgreen’s and a local hospital for allegedly failing to take adequate interventions after learning of an overdose Prince suffered six days before his fatal one, according to the Star Tribune. The case doesn’t sound like a slam dunk, though. The fatal dose was from a counterfeit Vicodin pill, containing a lethal dose of fentanyl, and no one knows how he got ahold of that.
- Seattle has allowed the creation of a “tiny house village” for homeless people where drug use is tolerated, the Seattle Times reports. Neighbors are not pleased with the experiment. It seems that they don’t like having their children watch people shoot up on their front lawns or having packages stolen from their doorsteps. Emergency 911 calls have jumped 62 percent at the camp, and 30 percent in the immediate vicinity.
- An Iowa woman who lost two sons in one night, to hydrocodone and alcohol overdoses after high-school graduation parties, has devoted her life to spreading opioid awareness.
- A former police chief in Walhalla, SC, was arrested and charged with illegally obtaining prescription opioids from his officers and at least one civilian.
- STAT has another conflict-of-interest story, based on a blog entry by The Hastings Center. Complex situation but, basically, Insys gave money to the patient advocacy group US Pain Foundation. The money was earmarked for use by another nonprofit, which then foreseeably used it to pay patient co-pays so that the patients could afford to buy Insys fentanyl products, which insurers would prefer they not buy, because they’re far more expensive than products the insurers claim are just as good.
- McKesson Corp.’s board has cleared itself of wrongdoing in connection with the events that led it to pay a $150 million fine to settle a DEA probe in January 2017, Bloomberg reports. The probe was for allegedly having failed to adequately monitor and report suspicious orders of opioids, after having entered into a consent decree in 2008 for allegedly having failed to do the very same thing. A committee of the company’s independent directors also found no need for CEO John Hammergren to forfeit any of the $20 million in compensation he received in the same fiscal year that the settlement was paid.