Yes, President Trump has declared opioid abuse a national emergency. But a hotel CEO is leading a much more targeted – and more promising – effort to address the country’s rampant addiction problem.
Gary Mendell, the chairman of HEI Hotels & Resorts who lost his son to drug addiction six years ago, has convinced four of the five major U.S. insurers – Aetna, UnitedHealth, Cigna and several of the Blue Cross plans – and a dozen smaller companies to sign onto eight principles of care for patients struggling with addiction.
The hope is that these insurers, which cover a total of nearly 250 million patients, will jumpstart a new era for addiction treatment in the United States by making it easier for patients to access key medications proven effective in helping ease off opioids. The aim is also to direct these patients to the best doctors who use treatments actually backed by science.
The problem right now isn’t so much a lack of treatment – there are more than14,500 drug-abuse treatment facilities in the United States. What’s severely crippling the system is a widespread lack of knowledge about how best to help someone struggling with addiction, according to Mendell. Unlike for other illnesses like cancer or heart disease, where there’s a well-known standard of care, far fewer standards exist for opioid addiction.
“What we all care about is that every American in this country who has a substance use disorder gets treatment based on evidence just like every other disease,” Mendell told me.
Patients too often don’t know where or how to seek help and providers don’t always know which treatments are most effective, Mendell says. Is behavioral therapy enough? Or is medication a better approach? What about a combination of the two?
“You can go to 10 different treatment programs and you will get 10 different approaches,” Mendell said. “No one has any idea who is doing what.”
The problem extends to insurers, which often don’t know which providers are delivering the best care for patients trying to overcome opioid addiction. Mendell said that’s why he’s starting with this corner of the health-care industry, since insurers are instrumental in the kind of treatments patients can access because of the contracts they set up with providers.
The task force Mendell assembled last spring, through his nonprofit group Shatterproof, also includes top names in policy and advocacy: Don Berwick, former director of the Centers for Medicare and Medicaid Services; Michael Botticelli, former director of the Office of National Drug Control Policy; and former ONDCP deputy director Tom McLellan, among others.
In crafting its eight recommendations – released earlier this month – the task force drew heavily from the November 2016 U.S. Surgeon General’s Report on Alcohol, Drugs and Health. Among the evidence-based recommendations are universal screening, coordinated physical and mental care and, perhaps most importantly, access to FDA-approved medications.
The next step is for insurers to start promoting these principles in specific ways and on a defined timeline, said Josh Rising, director of health-care programs at The Pew Charitable Trusts, which is hosting the task force meetings.
For example, he’d like to see insurers ease the prior authorization process patients must go through to obtain three medications -- methadone, buprenorphine and naltrexone -- shown to be effective in treating people with opioid addiction. Insurers can identify which health providers tend to prescribe these medications.
“Payers play a key role in driving treatments,” Rising said.
Mendell lost his son, Brian, in 2011 after seeking out a series of providers who presented conflicting approaches to the role of medication in treatment. Brian was showing marked improvement at a treatment program in Arizona, where he was finally prescribed suboxone along with also receiving counseling for anxiety. But when Brian transferred to an outpatient program in Los Angeles some months later, and pressured by his doctors to phase down his medications, things took a turn for the worse.
That resistance to using medication for substance abuse disorders is one of chief things that needs to change, Mendell stresses.
Clinical research indicates that patients given medication are more likely to recover than if they’re only treated with residential stays or a 12-step program. But because providers are still resistant to prescribing these medications, fewer than half of all people in the United States who could benefit from addiction medication are able to access it, according to research by Pew.
“This is done for all other diseases,” Mendell said. “It’s just not done for addiction.”
The eventual goal is for the recommendations to be adopted by nonprofit groups -- like the National Quality Forum and the National Association of Healthcare Quality -- that create widely accepted standards of care. And then for Medicare and Medicaid – the government’s two big health insurance programs – to come on board too. (Some state Medicaid programs, for example, don’t cover all three of those medications used in substance abuse treatment.)
But for now, the task force is focusing on the major insurance companies because they can sometimes adapt more quickly than public programs, which often take years to assume new approaches, Rising said.
“We identified private payers for this particular task force in part because there was a sense that they might be more nimble,” Rising said.
To Mendell, that’s the quickest and most likely way to start getting helpful treatment to the estimated 21 million Americans who abuse opioids. The problem is acute; fatalities have multiplied in recent years. The number of deaths involving opioid overdoses tripled between 1999 and 2015, according to CDC data.
“It’s a 9/11 every eight or nine days and no one is talking about it,” Mendell said.
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AHH: Medical professionals are starting to acknowledge a reality few people are aware of: People living with undetectable levels of HIV cannot transmit the virus. It's a historic moment, our colleague Lenny Bernstein reports, because the public recognition could destigmatize the 1.2 million Americans living with HIV, perhaps make people more comfortable with getting tested and provide comfort and relief for couples with one HIV positive partner.
Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, said at an international conference in July that people with undetectable viral loads in their blood cannot transmit the virus. And in September, the CDC released a letter stating that people who are taking daily medication “and maintain an undetectable viral load have effectively no risk of sexually transmitting the virus to an HIV-negative partner.” There are now more than 500 organizations in 67 countries that agree, Lenny notes.
What does it mean to have an undetectable viral load? It means that fewer than 200 copies of the virus is in a milliliter of blood, Lenny explains. People with HIV should maintain that level or lower for at least six months before they can be considered incapable of sexually transmitting the virus. Those who take daily medications can potentially bring viral loads to 50 or even 25 copies.
"Like many developments in the four-decade history of HIV, this one has been slow to gain acceptance among mainstream health-care providers," Lenny writes. "Many are not aware of it or must unlearn the habit of drilling safe-sex lessons into patients, as they have been doing almost since the AIDS epidemic began. HIV-positive people also must alter deeply ingrained beliefs that nothing good can come of revealing their status."
Progress begets further questions: Like what happens if someone forgets to take their daily medication or if someone fluctuates above or below the 200-copy threshold over time? There aren't yet evidence-based answers to these questions, experts say.
OOF: New research reveals the sugar industry concealed findings of studies it funded revealing that sugar was indeed harmful, and instead pointed a finger at the effects of fats. The industry never disclosed the findings of research it funded in the 1960's in the midst of debate on the effects of sugars and fats on cardiovascular health, our colleague Marwa Eltagouri reports.
Here’s what they found about the effects of sugar: Researchers from the University of California at San Francisco found that the Sugar Research Foundation funded research in 1968 looking at the relationship between sugar consumption and heart disease, and concluded rats a high-sugar diet exhibited increased levels of triglycerides, or fatty substances in the bloodstream, Marwa writes. Studies also found a connection between sugar consumption and enzymes linked to bladder cancer.
What happened to that research? Researchers behind the new report said it's likely the sugar industry stopped the study and never published the results. “This is continuing to build the case that the sugar industry has a long history of manipulating science,” Stanton Glantz, a professor of medicine at U.C.S.F. and author of the report told the New York Times.
In a statement last week, the Sugar Association chided the new UCSF report and dismissed it as “a collection of speculations and assumptions about events that happened nearly five decades ago.”
OUCH: It's been nearly two months since Congress missed its deadline to extend funding for the Children's Health Insurance Program for 9 million low-income kids. Officials in nearly a dozen states are preparing to notify families that CHIP is running out of money for the first time since its creation two decades ago, putting coverage for many at risk by the end of the year, our colleagues Colby Itkowitz and Sandhya Somashekhar write.
"Many states have enough money to keep their individual programs afloat for at least a few months, but five could run out in late December if lawmakers do not act," Colby and Sandhya write. "Others will start to exhaust resources the following month. "The looming crunch, which comes despite CHIP’s enduring popularity and bipartisan support on Capitol Hill, has dismayed children’s health advocates."
“We are very concerned, and the reason is that Congress hasn’t shown a strong ability to get stuff done,” said Bruce Lesley, president of Washington-based First Focus, a child and family advocacy organization. “And the administration is completely out, has not even uttered a syllable on the issue. How this gets resolved is really unclear, and states are beginning to hit deadlines.”
--The Trump administration has made some recent proposals to cut the costs of high drug prices, such as changing how Medicare reimburses hospitals for certain drugs and proposing an idea to pass drug rebates directly to seniors. But there's one thing the administration isn't doing: cracking down on the pharmaceutical companies themselves, The Post’s Carolyn Y. Johnson writes.
"President Trump swept into office threatening to bring the hammer down on high drug prices, accusing pharmaceutical companies of 'getting away with murder,'" Carolyn writes. His actions could "ultimately lower out-of-pocket drug prices for some. But there's one part of the health-care system so far being spared any real pain: the drug companies themselves."
“The most interesting thing about all this is it's all under the umbrella of drug pricing, but frankly ... it looks as if they're hitting everybody except the drug industry. Which is fairly amazing,” Ronny Gal, a senior research analyst at investment firm Sanford C. Bernstein told Carolyn.
So what exactly has the Trump administration done to make changes to drug costs? 1. Earlier this month, the Centers for Medicare and Medicaid Services finalized a rule that slashes the amount Medicare reimburses hospitals for drugs purchased through the 340B drug discount program. 2. CMS has requested feedback on a proposal to provide rebates negotiated between drug companies and health plans directly to seniors who are buying the prescriptions. Carolyn notes this would increase premiums but decrease the price that individuals pay when filling prescriptions.
"Both of the rules that we've seen take direct aim at what patients who are ill are actually paying, out-of-pocket, so it's a very good first step,” said Rena Conti, a health economist at the University of Chicago. “It doesn’t go back to lowering prices. But to the extent that we get intermediaries — which include physicians and hospitals, but also pharmacies and insurers — out of the business out of making money off the high price of drugs, the system will be hopefully be more efficient and more transparent."
And during the Thanksgiving holiday, Trump promised to have another go at repealing and replacing Obamacare after Congress finishes its work on a tax overhaul:
ObamaCare premiums are going up, up, up, just as I have been predicting for two years. ObamaCare is OWNED by the Democrats, and it is a disaster. But do not worry. Even though the Dems want to Obstruct, we will Repeal & Replace right after Tax Cuts!— Donald J. Trump (@realDonaldTrump) November 23, 2017
--A few more choice selections from The Post and around the Internet:
- The Children's National Health System and Food Allergy Research and Education host "An Evening of Food for Thought."
- The Senate Health, Education, Labor and Pensions Committee holds a hearing on the nomination of Alex Azar to serve as the Secretary of Health and Human Services on November 29.
Rep. John Conyers Jr. (D-Mich.) said he will step down as the top Democrat on the House Judiciary Committee amid an ethics probe of sexual misconduct claims:
Several lawmakers called for changes to the way Congress handles allegations of sexual misconduct after two prominent Democrats were accused of impropriety:
The top 4 moments from the Miss Universe pageant:
Watch Jay-Z stop a concert to tell a 9-year-old girl she can be president: