THE PROGNOSIS

If the opioid epidemic was simply a problem of supply – people being able to access drugs too easily – than a targeted new effort in Appalachia announced by Attorney General Jeff Sessions yesterday would be a huge stride toward combating the crisis.

The problem with this approach, however, is that experts agree the opioid epidemic is all about demand. Far too many Americans rely on opioid painkillers, creating a huge customer base for illicitly gained prescription drugs and more serious street drugs, such as heroin and fentanyl.

Sessions's new plan involves sending more Drug Enforcement Agency agents to the areas where opioid abuse is most rampant. But those fighting the epidemic on the ground say the law enforcement strategy must be coupled with medical help for those suffering from addiction, or the Trump administration won’t get very far in its efforts.

“This is a demand-driven problem and we are trying to apply supply-restricting solutions,” Michael Brumage, executive director of the Kanawha-Charleston Health Department in Charleston, W.Va., told me (West Virginia is the state hit hardest by the crisis). “That’s what we tried on the war on drugs, and that failed.”

Sessions is creating an entirely new DEA division overseeing the Appalachian region to help local law enforcement combat drug abuse, especially of prescription opioids, The Washington Post’s Sari Horwitz and Matt Zapotosky report. He also announced $12 million in new grants and the designation of an opioid coordinator to work with prosecutors to better manage prosecutions.

“Today, we are facing the deadliest drug crisis in American history,” Sessions said at a news conference yesterday. “Based on preliminary data, at least 64,000 Americans lost their lives to drug overdoses last year. That would be the highest drug overdose death toll and the fastest increase in that death toll in American history.”

The new Louisville Field Division will unify drug trafficking investigations in Kentucky, Tennessee and West Virginia, with a focus on the Appalachian Mountains, officials said. It will include about 90 special agents and 130 task force officers.

Washington Examiner's Kelly Cohen:

At least in terms of geography, Sessions is spot on. A few weeks ago, I wrote about the prevalence of opioid abuse in the Appalachian region – and how it gets worse and worse the closer in you get to West Virginia (which is basically the epicenter of the crisis).

If you look at what researchers call “diseases of despair” (drug and alcohol overdose, suicide and alcoholic liver disease), they have a stronger foothold in the center of Appalachia than on the fringes. In central Appalachia, those maladies led to 94.4 deaths per 100,000 people, but the rate is 52.3 deaths per 100,000 in southern Appalachia.

But law enforcement officers will tell you that keeping an area free of drug dealers for any length of time is a steep task. Brumage called the new DEA forces a “step in the right direction,” but his enthusiasm is tempered.

“Once you bust everybody in a particular area, you have a temporary lull but it lasts only a few days,” Brumage said. “There are always people and supply willing to fill the void.”

Activists who watched the uphill and international “war on drugs” of the past several decades also fear the Trump administration will halt its efforts with beefing up law enforcement, instead of also pouring more resources into helping Americans break free of their drug addictions.

“The emphasis continues to be punishment, so I think it’s very concerning,” said Gabrielle de la Gueronniere, director of policy for the Legal Action Center, a nonprofit organization that fights discrimination against people with a history of addiction. “We’re not really treating this as an illness. There’s a huge treatment gap.”

Sessions also announced that White House counselor Kellyanne Conway will continue to help lead the opioid effort:

Several reporters clarified that the Trump administration isn't creating a new "drug czar," as some reports suggested. Politico's Brianna Ehley:

Politico's Sarah Karlin-Smith:

On a related topic, Sessions said he's "dubious" of a law restricting DEA's enforcement powers, which The Post detailed in a recent investigation. Per The Post's Sari Horwitz:

AHH, OOF and OUCH

AHH: The effects of repealing the Affordable Care Act's individual mandate to buy health coverage -- namely, fewer insured Americans and somewhat higher marketplace premiums -- wouldn't change much even if Congress were to also pass a bipartisan measure stabilizing the marketplaces. That's per a letter from the Congressional Budget Office to Sen. Patty Murray (D-Wash.) -- who is deeply dismayed Republicans are seeking to repeal the mandate as part of their tax overhaul even as she and Sen. Lamar Alexander (R-Tenn.) push to pay insurers for subsidies to help low-income Americans afford health care.

"The interactions among the provisions would be small; the effects on premiums and the number of people with health insurance coverage would be similar to those referenced above," the CBO wrote, in a letter released yesterday by Murray's office.

In other words, giving marketplace insurers the $7 billion in subsidies would help them lower premiums, but it wouldn't be enough to really offset premium hikes should healthy people drop their coverage in the absence of a requirement to buy coverage. Murray has been heavily protesting the inclusion of mandate repeal in the Senate tax bill that is expected to get a vote this week. But she's stopped short of saying that passing it would cause her to back away from her marketplace stabilization deal with Alexander.

OOF: Many pain clinics are deriving huge profits from urine testing prompted by the country's opioid crisis, Kaiser Health News reports. "Spending on urine screens and related genetic tests quadrupled from 2011 to 2014 to an estimated $8.5 billion a year — more than the entire budget of the Environmental Protection Agency, according to a KHN analysis of billing data from Medicare and private insurance billing from the Mayo Clinic," reporter Fred Schulte writes.

But sometimes, doctors aren't paying attention when the tests yield abnormal results. "Medicare and other insurers pay for urine tests with the expectation that clinics will use the results to detect and curb dangerous abuse," Fred writes. "But some doctors have taken no action when patients are caught misusing pharmaceuticals, or taking street drugs such as cocaine or heroin...In nearly a dozen recent criminal cases, prosecutors have cited evidence that doctors supplied opiates to patients with repeated abnormal urine test results."

OUCH: An 84-year-old physician from New Hampshire said she was forced to surrender her medical license in part because of her unwillingness to use a computer or any new technology. Our colleague Marwa Eltagouri describes the office of Anna Konopka, who hand wrote her notes meticulously, kept patient records in file cabinets, and saw about 25 patients a week who are able to pay $50 in cash.

The New Hampshire Board of Medicine challenged Konopka's record-keeping, prescribing practices and medical decision-making, Marwa writes. But Konopka said she has wondered whether her license was seized partly because of her unwillingness to use technology to diagnose patients or log patients' prescriptions in the state’s mandatory electronic drug monitoring program, which has become critical in an effort to reduce opioid abuse.

Konopka insisted she only prescribed a “small amount” of painkillers to patients.

“Bureaucrats who don't know medicine — they are getting this kind of idea that they can handle this type of pain without narcotics,” she said. “I prescribe a small amount of OxyContin and they are doing beautifully. . . . They can work, and many of them could not work for many years. They are partially employed or fully employed and have a normal daily life.”

But Marwa also reports there were complaints about Konopka's prescribing practices that began in 2014. She is accused of leaving the dosage levels of a medication up to a young patient's parent. Konopa says the girl's mother ignored instructions.

“I'm not sending my patients to this doctor and this doctor. I treat everything. have enough experience and can treat any disease," Konopka said. She feels that electronic records get in the way of caring for patients. 

“Even if I knew how to use [the electronic system] I would be unwilling,” she said. “I cannot compromise the patient's health or life for a system. I refuse to."

HEALTH ON THE HILL

--Alex Azar, President Trump's pick for HHS secretary, has survived his first Senate confirmation hearing. For about three hours yesterday, senators on the Health, Education, Labor and Pensions Committee drilled the former Eli Lilly executive on a range of topics, but the most-asked question (particularly from the Democrats) was how he'd approach the issue of high drug prices. My colleagues Juliet Eilperin and Amy Goldstein have some key takeaways:

1. Azar acknowledged drug prices are too high and said he thinks the federal government has a role in trying to make medicine more affordable for patients. “I think there are constructive things we can do” to bring down the price of medicines, he said, adding that he favors fostering competition between brand-name drugs and generic equivalents. “We have to fight gaming in the system by patents and exclusivity agreements.”

The Post's Carolyn Johnson:

Politico's Sarah Karlin-Smith:

From a Washington University in St. Louis law professor:

From National Nurses United:

2. Azar named an additional three priorities he said would guide him if confirmed. They include making health care more affordable and available, shifting Medicare further in the direction of creating incentives for good outcomes rather than the volume of care, and fighting the opioid epidemic. 

3. Azar was pragmatic when asked to weigh in on how the Trump administration has seemed to undercut enrollment in the ACA marketplaces. “My understanding was that the choices made were about what’s working and what’s not working,” he said. He gave a variant of that answer to questions about funding cuts for the navigator groups aimed at enrolling patients, as well as on Trump’s decision to end cost-sharing subsidies to insurance companies/

"The three-hour hearing was the first of two that senators will conduct on Azar’s nomination," Juliet and Amy report. "Wednesday’s session was a courtesy hearing because the HELP Committee does not vote on the confirmation. That power rests with the Senate Finance Committee, which has not yet scheduled its hearing."

4. Asked about turning Medicaid into a block grant program, as several of the GOP health-care bills would have done, Azar indicated that he's in favor of the idea. “I support it as a concept to look at,” he said, adding that it “can be an effective approach.”

5. When probed on how he views requiring employers to pay for free contraceptives — an ideological flash point — Azar largely sidestepped, saying the administration has struck a balance between making affordable contraceptives available and respecting “the conscience objections” of others.

Azar noted only a small fraction of companies have taken advantage of the exemption. Asked about his own views on contraception, he said that “it seems to make some sense” that birth control would reduce unintended pregnancies and abortions.

Sen. Patty Murray (D-Wash):

National Women's Law Center:

--You might think Sen. Al Franken (D-Minn.) would stay away from the topic of women altogether, as he's under fire for sexual misconduct allegations. But, no. Franken echoed Murray's questions about whether Azar agrees with the Trump administration’s decision allowing employers to opt out of the federal requirement to cover birth control.

“I will follow the law there,” Azar replied. “But I also will, as the president has done, try to balance the conscience objections of businesses and individuals.”

--Senate Majority Leader Mitch McConnell (R-Ky.) has promised to include the Alexander-Murray bipartisan deal to fund extra Obamacare subsidies in a year-end, must-pass spending bill, at least according to Sen. Susan Collins (R-Maine).

Collins said "I do" have a commitment "from the majority leader, and so we're working out the details of that," the Maine Republican told reporters yesterday, per The Hill. "The government funding bill] is certainly a possible vehicle but obviously there needs to be some discussions with the House."

TRUMP TEMPERATURE

We're two-thirds of the way through the 2018 Healthcare.gov enrollment period. The initially rapid pace of signups on the federal health insurance website has slowed, with 37 percent fewer people enrolling during week four than in the previous week, according to the weekly snapshot provided yesterday by the Health and Human Services Department Just over half a million people selected plans during the past week, compared to just under 800,000 people the week before.

A few numbers to keep in mind over the final two weeks of open enrollment:

--So far, 2.78 million people have selected plans in the 39 states that use Healthcare.gov, more than in the first four weeks of enrollment last year.

--But because the sign-up period has been halved, signups would need to spike dramatically in the next two weeks for them to be anywhere near the final totals for 2017. At the end of the last sign-up season, 9.2 million people had selected plans on Healthcare.gov. The year before that, the total was 9.6 million.

A few more good reads from The Post and elsewhere:

MEDICAL MISSIVES
To Your Health
Innovative smoking-cessation products are the key to reducing deaths and disease caused by conventional cigarettes, they say.
Laurie McGinley
Speaking of Science
"We are learning how to engineer living systems,” said biochemist Andrew Ellington. “This is the edge of science."
Sarah Kaplan
SECOND OPINION
Opinions
Trump’s nominee for HHS secretary goes through the revolving door once again.
Dana Milbank
INDUSTRY RX
Morning Mix
Over the course of more than two years, Brooklyn Hospital Center billed 85 patients for their rape kits, according to an investigation by the New York Attorney General's office.
Samantha Schmidt
STATE SCAN
A San Diego campaign aims to attract patients from around the world. But experts say it'll take more than online ads to build a medical tourism hub.
Stat News
A medical charity that received hundreds of millions of dollars from pharmaceutical companies lost a crucial stamp of approval from the U.S. government, after allowing its donors improper influence over how the nonprofit was run.
Bloomberg
DAYBOOK

Today

  • CMS Administrator Seema Verma talks health care with Forbes editor Avik Roy at the Forbes Healthcare Summit.
SUGAR RUSH

Watch Trump’s full speech on taxes in St. Charles, Mo.:

Fact Check: Would the GOP tax plan cost Trump money?:

Late-night comedians weighed in on the latest allegations against NBC's Matt Lauer: 

In the wake of his firing from NBC, people are remembering cringe-worthy Matt Lauer moments from the "Today" show and beyond: