THE PROGNOSIS

There was lots of back slapping and handshaking at the White House yesterday as President Trump signed Congress’s bipartisan bill targeting the country’s opioid crisis.

Yet the problem of addiction and overdose is still raging across the United States. There are hints the epidemic could be starting to recede, but it’s far from certain that we’ve turned a corner on a public-health scourge that causes around 70,000 deaths each year.

That’s not to say Congress and the administration aren’t at least trying to make a dent in a big problem. Democrats and Republicans alike cheered the opioids measure they passed this month, which contains a smorgasbord of provisions supporting treatment programs, stemming the influx of fentanyl into the country and trying to reduce opioid overprescribing, while stopping short of supplying a long-term funding stream to tackle the issue.

Trump — noting that it has been a full year since he first declared opioid abuse a public-health emergency — spoke yesterday in uncharacteristically measured terms about the opioids legislation. He promised it would deliver big changes but acknowledged the problem won't disappear overnight.

“You won’t see the results immediately. But you’ll see the results in the future and very quick future,” the president told a gathered audience.

Trump’s top health official, Health and Human Services Secretary Alex Azar, was also optimistic — but cautiously so — in a speech he gave Tuesday at the Milken Institute Future of Health Summit.

“We are so far from the end of the epidemic, but we are perhaps at the end of the beginning,” Azar said. He also tweeted about it:

How will we know when the opioid crisis has reached the end of its beginning? The most obvious way is examine deaths from overdose. And there’s some good news there. Provisional data from the Centers for Disease Control and Prevention indicates overdose deaths from all kinds of opioids might be dipping slightly, after massively spiking through 2016 and 2017. They’re down nearly 3 percent after reaching a high last November.

But the numbers are still grim: An estimated 69,000 people in the United States still die of opioid overdoses every year — considerably more than the approximately 40,000 annual deaths caused by motor vehicle accidents.

“Plateauing at such a high level is hardly an opportunity to declare victory,” Azar acknowledged. “But the concerted efforts of communities across America are beginning to turn the tide.”

There are several other indicators experts use to measure the extent of opioid abuse in the United States. The goal, Brandeis University psychiatrist Andrew Kolodny told me, is to get a good sense of how many people are newly struggling with opioid addiction and how many opioid users are getting treatment.

“It’s too soon to tell, and even if we are turning a corner there’s nothing to celebrate here because we still have an extraordinarily high overdose death rate,” Kolodny said.

Here are a few key indicators to watch in gauging the state of the crisis:

1. How often doctors are prescribing opioids.

There’s some dispute over this. The CDC says the prescription rate fell last year to its lowest level in a decade, at 58.7 opioid prescriptions per every 100 people (the agency says the rate peaked at 81.3 prescriptions per every 100 people in 2012). Similarly, an April report by the firm IQVIA found a 22 percent decrease in opioid prescriptions nationally between 2013 and 2017.

But the Mayo Clinic released a study in August suggesting that little has changed in the past five years on prescription opioid use. Researchers found that while prescriptions seemed to be leveling off, they weren’t decreasing among most groups of patients.

2. How often doctors are prescribing overdose reversal medications.

More prescriptions for naloxone — an overdose reversal drug — and medications used in treating patients with opioid addiction are other important indicators of where we are on the problem.

Azar said naloxone prescriptions are up 350 percent — a figure cited earlier this month by Surgeon General Jerome Adams, who also said retail dispensing of the drug was up 70 percent. Researchers have found that naloxone prescriptions paid for by Medicaid increased 1,109 percent between 2011 and 2016.

The secretary also said prescriptions for buprenorphine and naltrexone — two medications to treat opioid abuse — are being prescribed 21 percent and 47 percent more frequently, respectively. Those figures seem to be supported by research.

3. How many babies are born addicted to opioids.

Neonatal abstinence syndrome (NAS) is what some babies experience after being born to mothers addicted to opioids. It’s a heartbreaking problem, and one the administration is vowing to tackle. On Tuesday, HHS rolled out a pilot program to help mothers with opioid addiction and their children, implemented through Medicare’s innovation center.

And there’s no good news yet on this front. Using its most recent statistics available, the CDC says the incidence of NAS increased about 400 percent nationally from 2000 to 2012. And it’s reasonable to believe the problem has only gotten worse, as opioid abuse rates have only increased in the past six years.

4. How many people are dying from fentanyl and heroin.

Here, too, is some bad news. Fentanyl, a synthetic opioid that is many times stronger than heroin, has exploded onto the scene and causes an increasing share of overdose deaths. The CDC estimated there were nearly 29,000 synthetic opioid overdose deaths in September 2017 and more than 30,000 such deaths in March of this year. Heroin use is slightly up as well.

AHH, OOF and OUCH

AHH: In his first address at HHS, Trump is today at 2 p.m. expected to unveil a major proposal to change how Medicare pays for certain drugs, Politico’s Sarah Karlin-Smith and Dan Diamond report. The president is expected to point to his campaign vow to lower drug prices, less than two weeks before a critical midterm election.

“The proposal, which was sent to the White House earlier this month, would use Medicare’s innovation center to test three ways to lower the costs of drugs — including negotiating for some drugs that are directly administered by doctors, in hopes of keeping them in line with the lower rices paid in many other countries,” Sarah and Dan write. “The proposal applies only to drugs administered in doctors’ offices and outpatient hospital departments — medicines like cancer treatments and injectable treatments for rheumatoid arthritis or eye conditions. It won’t affect most prescriptions purchased by patients at local pharmacies.”

“The Trump administration will say that Medicare could save more than $17 billion over five years, with the cost of some drugs dropping by as much as 30 percent,” they add.

As Stat’s Nicholas Florko notes, a speech to address drug costs follows two recent wins for the administration on this issue, including a proposal from HHS to require drug companies to reveal prices in television ads (though there are some problems with that, as we noted) and the president’s signing of a bill to ban so-called “gag clauses,” which pharmacists say prevent them from telling customers when there is a cheaper way to pay for their medication.

OOF: Trump once again claimed that Republicans are trying to protect patients with preexisting conditions, tweeting yesterday that it’s Democrats who will not. It's a false claim that came less than two weeks before the midterms, our Post colleagues Felicia Sonmez and John Wagner report.

As we’ve written in The Health 202, health experts have noted that the president’s claim, and claims from Republicans who say they want to guarantee such protections, are misleading given the administration’s own efforts to dismantle the provisions in the Affordable Care Act.

“The misleading statement about the 2010 health care law, which passed with only Democratic votes, reflects a strategy that Republicans are hoping will pay off Nov. 6,” Felicia and John write. “Repeatedly tell voters that the GOP supports one of the ACA’s most popular provisions and hope they ignore or forget eight years of votes, rhetoric, legal efforts and bureaucratic moves to gut the law."

OUCH: A federal advisory panel is urging routine vaccination for homeless people, calling for them to receive regular hepatitis A shots to prevent outbreaks of a contagious liver disease.

Cases of the contagious disease, spread through contaminated food and dirty needles, have spiked since 2016, in part because of the surge in drug use and homelessness, our Post colleague Lena H. Sun reports.

“The recommendation would make it easier for shelters, emergency rooms and clinics that serve the homeless to offer hepatitis A shots along with other services,” Lena writes. “The vaccinations are already recommended as part of universal childhood vaccinations since 2006 and for other at-risk groups, including some international travelers, drug users and men who have sex with men.”

The expert panel voted unanimously to add homeless people to that list of at-risk groups, Lena reports.  And she adds the CDC is expected to adopt the recommendation and advise health-care providers accordingly.

TRUMP TEMPERATURE

— A new report from the Government Accountability Office reveals officials from HHS and the Homeland Security departments learned of the administration’s “zero tolerance” immigration policy only when it was announced by Attorney General Jeff Sessions. They had no warning of the impending policy, Politico’s Ted Hesson and Lorraine Woellert report.

“The GAO report echoes the findings of a similar investigation by the Homeland Security inspector general’s office,” Ted and Lorraine write. “In a September report, the DHS watchdog found the department wasn’t fully prepared to implement the zero-tolerance policy, or to handle the subsequent family separations.”

The GAO report “also found that neither DHS nor HHS initially had computer functionality that allowed staff to indicate whether a child had been separated from a parent,” they write. “Border Patrol updated its database to add a checkbox on April 19, about two weeks after Sessions’ memo, and the HHS refugee office similarly updated its database on July 6 — 10 days after a court ordered that families be promptly reunified.”

— Meanwhile, in a dispatch from McAllen, Tex., the Texas Tribune’s Teo Armus writes of Central American families who are heading to the United States in droves now that the family-separation policy is not in place.

He writes of a father who traveled with his 10-year-old son from Honduras to Louisiana, “first by car, then on foot, then on a raft across the Rio Grande, before they surrendered to Border Patrol agents.”

“If they had arrived a few months earlier, they likely would have been split up, the boy sent to a shelter or foster care and his father kept in detention — the result of a ‘zero tolerance’ policy meant to deter immigrants from crossing the border illegally,” Teo writes. “But after public outcry led President Donald Trump to end that policy in June, parents with children have been crossing the border in record numbers. In September, Border Patrol agents arrested 16,658 family members along the U.S.-Mexico border, up 80 percent from July and more than any other month on record, according to data released Tuesday."

Trump told reporters earlier this month that if migrants “feel there will be separation, they don’t come.” Teo writes that very day, 300 people were crammed in a respite center in McAllen, with a line of people outside. “Some said they had never heard of Donald Trump, much less anything about zero tolerance,” Teo added. “Others said they decided to make the journey now because they knew they would make it out of detention easily with children in tow.”

HEALTH ON THE HILL

— Rep. Pete Sessions (R-Tex.), in a tight race in Texas’s 32nd district, has been pointing to the resolution he introduced last month as proof of his support for protections for people with preexisting conditions.

But he’s being hammered by his Democratic opponent, former NFL player Colin Allred, who has pointed to Sessions’s record of repeatedly voting to repeal the ACA and called the measure a “political stunt,” The Hill’s Lisa Hagen reports.

“I think it’s the worst kind of Washington politics. I think people are so sick of that kind of cynical, political stunt,” Allred told Lisa. “When you get in a close election a month out, you propose a nonbinding resolution saying you support pre-existing conditions, I think people see through that and they resent it.”

Sessions criticized the “shameless” Democrats who have attacked his health-care record. “And he also sought to blunt those attacks by seizing on some Democrats’ push for ‘Medicare for all,’ which would institute a single-payer health-care system,” Lisa reports.  

— Here’s another example of how the preexisting conditions issue is dominating the midterm campaign. Arizona Republican Senate nominee Rep. Martha McSally  is locked in a competitive race to maintain a Republican Senate seat held by the late Sen. John McCain (R), who helped defeat the effort to repeal and replace the ACA. McSally released a new ad in which she claims she’s “leading the fight to… force insurance companies to cover preexisting conditions.”

Here’s the thing: McSally voted for a bill that would have weakened those protections.

McSally, who is running against Democrat Kyrsten Sinema was “peppered with questions from reporters in Arizona after a campaign event Wednesday afternoon,” our colleagues Felicia and John report.

“It’s not true. It’s not true. Stop parroting Democrat talking points,” McSally told a reporter who questioned her about her previous votes on health care, according to a video from Roll Call. “Health care is a complex issue.”

— A large majority of young Americans would support a universal health-care program, according to a new survey from Associated Press-NORC Center for Public Affairs Research and MTV.

It found 69 percent of Americans ages 15-34 support a single-payer health-care program. Broken down by party, it found 88 percent of young Democrats and 40 percent of young Republicans support such a program, and about two-thirds of young independents support it, the Associated Press’s Juana Summers reports.

AGENCY ALERT

— The Food and Drug Administration approved the first new flu drug in two decades.

Xofluza is a single-dose pill that can reduce how severe a flu is and the duration of symptoms, the Associated Press’s Linda A. Johnson reports, adding it was developed by Roche Group and Shionogi & Co. Roche is also behind older flu treatment Tamiflu. The new drug was approved for people 12 and older.

“Health officials have said an estimated 80,000 Americans died of flu and its complications last winter, the disease’s highest death toll in at least four decades,” per the AP. "The severe flu season increased demand for Tamiflu and led to spot shortages.”

Unlike Tamiflu, which is taken twice daily for five days, Xofluza only requires one dose. “Further testing is planned to determine whether Xofluza is better than Tamiflu for preventing spread of the flu to others and for treating patients at high risk for hospitalization and pneumonia, such as people with diabetes or lung disease, pregnant women, young children and the elderly,” Linda writes.

INDUSTRY RX

— Pharmacy benefit manager Express Scripts said it plans to expand its networks to include mail-order pharmacies. The company said the move was to accommodate the many pharmacies, including retail ones, that say they do more than half of their business through the mail, Axios’s Bob Herman reports.

“Express Scripts, which negotiates drug prices for 80 million Americans, may be opening the door for any mail-order pharmacy — including Amazon's newly acquired PillPack — to get full access to its large network, as long as the pharmacy agrees to Express Scripts' contract terms,” Bob writes.

“Express Scripts, a dominant pharmacy benefit manager that is getting gobbled up by Cigna, owns a massive mail-order drug business that represents almost half of its revenue,” he adds. “The company has been criticized (and sued) for steering patients toward itself, by excluding other pharmacies that deliver drugs to people's homes."

— Here’s something new to think about next time you see a digital ad for disinfecting wipes: During this flu season, Clorox paid to license information from Kinsa, a tech start-up that sells smart thermometers. The Internet-connected thermometers work with smartphone applications to track fevers and symptoms, the New York Times’s Sapna Maheshwari reports.

And here’s how Clorox used that information: The data showed the company what areas in the country had fever spikes, and Clorox in turn directed more ads to those areas, thinking that people in those households may need some of their disinfecting products.

“It is unique, Kinsa says, because it comes straight from someone’s household in real time,” Sapna reports. “People don’t have to visit a doctor, search their symptoms on Google or post to Facebook about their fever for the company to know where a spike might be occurring.”

— And here are a few more good reads: 

Republican incumbents are getting pummeled after voting to scrap protections for pre-existing conditions.
Politico
Controversy over the senator's ancestry has dogged her since she ran for the seat in 2012.
Politico
STATE SCAN
Fact Checker
Rep. Dave Brat (R-Va.) looks directly at the camera and tells a whopper about his rival, Abigail Spanberger (D), and her plans for health care.
Glenn Kessler
OPIOID OPTICS
The Trump administration is working to roll back health insurance coverage that public health experts say is critical to millions of Americans suffering from addiction to opioids.
Los Angeles Times
Within days of an OD from opioids or other drugs, users in Huntington, W.Va., are visited by a quick-response team at home, the hospital or in jail. Reversing an OD is just recovery's first step.
NPR
MEDICAL MISSIVES
Ten minutes of mild exercise can immediately alter how certain parts of the brain communicate and coordinate with one another and improve memory function.
The New York Times
DAYBOOK

Today

  • The Kaiser Family Foundation hosts an event on “Findings from Annual 50-State Medicaid Budget Survey” with the National Association of Medicaid Directors.
  • The Medicaid and CHIP Payment and Access Commission holds a public meeting.

Coming Up

  • The American Enterprise Institute holds an event on postelection analysis for 2018 and beyond on Nov. 8.
SUGAR RUSH

Melania Trump condemns attempted attacks on political figures

Late-night hosts react to bomb threats targeting Democrats, CNN