THE PROGNOSIS

A new government survey shows opioid abuse is declining by double digits — welcome data to public health advocates and policymakers who are wrestling with an epidemic that has crippled communities across the nation.

And the improvements come as more people gain access to addiction-fighting medication, despite the Trump administration’s attempts to discourage Medicaid expansion and pull back on the Affordable Care Act.

Eleven percent fewer Americans reported pain reliever misuse in 2018 compared with the year prior, according to an annual survey released yesterday by the Substance Abuse and Mental Health Services Administration. Heroin use is declining among adults under age 26 and holding steady among those older. The survey also showed declines in the use of other drugs including cocaine, methamphetamine and hallucinogens.

Generally speaking, drug abuse has been on the decline since peaking around 2015 and 2016 (with the exception of marijuana). A few of the survey highlights:

  • 9.9 million Americans misused pain relievers in 2018, down from 12.5 million in 2015.
  • 808,000 Americans used heroin in 2018, down from 948,000 in 2016.
  • Opioid misuse especially declined among young adults ages 18 to 25. Three million abused opioids in 2015, compared with 1.9 million last year.

The data adds to a mounting pile of evidence that efforts to combat and draw attention to the drug abuse crisis are starting to work, although public health advocates say there’s still a long way to go. President Trump says he has made opioid abuse a top priority, and local and state governments are currently embroiled in hundreds of lawsuits demanding financial restitution from the top opioid makers and distributors.

The pharmaceutical company Allergan agreed yesterday to pay $5 million to two Ohio counties to settle claims related to its branded opioids, becoming the second drugmaker to settle over the issue. Endo Pharmaceuticals also announced a $10 million settlement with Cuyahoga and Summit counties, where the cities of Cleveland and Akron are located.

Health and Human Services Secretary Alex Azar called the survey “very encouraging news,” with some caveats.

“Many challenges remain, with millions of Americans not receiving treatment they need for substance abuse and mental illness,” Azar said in a statement. “Connecting Americans to evidence-based treatment, grounded in the best science we have, is and will remain a priority for President Donald Trump, for HHS.”

For those versed in opioid addiction, “evidence-based treatment” includes giving patients access to medications such as buprenorphine, methadone and naltrexone. Widely viewed as instrumental in helping patients get off and stay off prescription drugs and heroin, these medications are a huge piece of the puzzle in combating addiction.

The good news is that more people are getting medication-assisted treatment (popularly called MAT). The bad news is that improvements vary widely by state and have a lot to do with whether states have expanded their Medicaid programs under the ACA.

Let’s discuss the good part first.

The SAMSHA survey shows a particularly significant increase in access to buprenorphine, a drug increasingly preferred for treating addiction because of its wide availability and ability to be used immediately by those with addiction without first abstaining from drugs for a week or more. Nearly 649,000 patients received the medication last year, up from 520,000 two years earlier.

The Urban Institute released similar findings this morning. Its researchers looked specifically at medications dispensed via Medicaid, the low-income health insurance program that covers 4 in 10 people with opioid addiction. It found prescriptions for buprenorphine per 1,000 enrollees increased from 36 in 2011 to 124 in 2018.

But there’s a wide variation in the prescribing rates between the states — largely because of the political gap between blue states that embraced Medicaid expansion and some red states that spurned it. In these states, which are largely in the South, access is out of reach for many more low-income people.

In Medicaid-expanding states, buprenorphine prescriptions increased from 40 to 138 per 1,000 enrollees, Urban researchers found. In non-Medicaid-expanding states, they increased from 16 to 41.

“The differences across states are really astonishing,” said lead researcher Lisa Clemans-Cope.

Medicaid’s centrality in the fight against opioid abuse has put the Trump administration in an awkward position, as we’ve written before in The Health 202.

The Justice Department has taken a firm legal stance against the ACA, a law that has increased access to medication-assisted treatment by requiring insurers to cover it and expanding the Medicaid program. Yet Azar has consistently lauded medications such as buprenorphine as key to helping people overcome addiction.

To readers: The Health 202 is operating on a limited schedule for the month of August. The newsletter will publish on Tuesday, Wednesday and Thursday this week and will not publish next week. We'll be back in your inbox full time after Labor Day. 

AHH, OOF and OUCH

AHH: Facebook is making a small adjustment to its policy on “sensational” advertising that will make it easier for antiabortion ads focused on the survival of infants to be considered acceptable, my Washington Post colleague Marie C. Baca reports. It's the only change the company is making as a result of a year-long audit conducted by former senator Jon Kyl (R-Ariz.), which found little evidence of anti-conservative bias although it did conclude that Facebook's policies have the potential to restrict free speech.

Ads may now display medical tubes connected to the human body, although ads showing someone in visible pain or distress or where blood and bruising is visible can still be prohibited. The policy could benefit both antiabortion groups and other groups focused on cancer research, humanitarian relief or elder care that wish to display medical tubes in ads.

“Conservatives long have claimed that major social media sites exhibit political bias, pointing to Silicon Valley’s liberal leanings and companies’ regular political campaign contributions to Democrats,” Marie writes. “Tech executives have frequently pledged to treat all political content equally. ... But those promises have failed to sway the country’s most prominent Republicans, including President Trump, who repeatedly has claimed that Facebook, Google and Twitter are biased against the party.”

Facebook Vice President Nick Clegg said the company is committed to providing a forum for all users, regardless of their political views. “We take accusations of political bias made against us extremely seriously,” Clegg wrote in a blog post. “Our policies, and how we apply them, can have a huge impact, so we have a responsibility to apply them evenly, without favoring one side or another and without devaluing the principle of free expression.”

OOF: HHS warned communication staffers not to post anything on social media related to mental health, violence and mass shootings without prior approval, after Trump targeted mental illness as the cause of the mass shootings in El Paso and Dayton, my colleagues Yasmeen Abutaleb and William Wan report. (Here's a recent Health 202 looking at the president's claims.) An HHS employee said that after receiving the Aug. 5 directive, he had “no doubt this was meant to prevent anybody from making any statements that might contradict the president.

“We understand we’re not supposed to contradict the president, but it’s not typical” for the administration to require all social media posts be cleared by senior officials, he said.

—The morning Trump was scheduled to speak after the weekend shootings, some HHS employees, including those at the National Institutes of Health, received an email asking those who contribute to official social media accounts to hold off on posts until “we get the green light from HHS," according to a copy of the email obtained by my colleagues.

Later that afternoon, some employees received another email from Renate Myles, an NIH spokeswoman. Social media posts could resume, the note said, but employees were asked to “please send any posts related to mental health, violence or other topics associated with mass shootings for review before posting.” The instruction was lifted by the week's end.

HHS spokeswoman Caitlin Oakley said “It’s the department’s long-standing practice to not get ahead of the president’s remarks." “This allows the president to share his message first with the nation," she said. "Any suggestions that this was a formal policy put in place related to social media, or meant to stymie work on this issue, are factually inaccurate. These were staff-level discussions seeking to be sensitive and respectful to the victims and their families affected by tragedies of that weekend.”

OUCH: Yesterday, federal prosecutors charged a former Veterans Affairs pathologist with the deaths of three veterans after covering up his own drug and alcohol abuse on the job. Prosecutors say that during 12 years as chief pathologist in Fayetteville, Ark., Robert Levy misread thousands of fluid and tissue samples of ill patients, leading to multiple deaths and life-threatening trauma, The Post's Lisa Rein reports.

“Robert Morris Levy was indicted on three counts of involuntary manslaughter and 28 counts of mail fraud, wire fraud and false statements to law enforcement officials,” Lisa writes. “The Department of Veterans Affairs has told members of Congress and investigators that Levy was responsible for at least 15 deaths and the inappropriate treatment of many other patients.

“The charges unsealed Tuesday mark a rare criminal case against a physician, in or out of government, in a profession where mistakes or incidents of negligence are most often addressed in civil court through malpractice claims,” she continues. “The case already is prompting a reckoning and questions of oversight for the country’s largest medical system — a sprawling, decentralized network of 1,200 hospitals and smaller clinics that serve 9 million veterans a year.”

TRUMP TEMPERATURE

— Trump assured National Rifle Association chief executive Wayne LaPierre that universal background checks were off the table, my colleagues Tom Hamburger and Josh Dawsey report.

"Trump told LaPierre that the White House remained interested in proposals that would address weapons getting into the hands of the mentally ill, including the possibility of backing so-called 'red flag' laws that would allow the police to temporarily confiscate guns from people who have been shown to be a danger to themselves or others," they write. "Nonetheless, the president’s conversation with LaPierre...further reduced hopes that major new gun-safety measures will be enacted after the latest round of mass shootings."

"Federal legislation mandating background checks has been opposed by the NRA in the past," they continue. "After the latest shootings, officials across the country called for expanding background checks to cover all gun buyers, including those making purchases at gun shows. With the NRA in some disarray following complaints of mismanagement, there was some hope among gun-control advocates that Trump might defy the politically powerful organization."

— A few more good reads from The Post and beyond:

Facebook forbids the private sale of firearms on its Marketplace platform. But sellers are getting around that with a simple ruse: They list gun cases or boxes at inflated prices.
Wall Street Journal
MEDICAL MISSIVES
More women may benefit from gene testing for hereditary breast or ovarian cancer, especially if they've already survived cancer once, an influential health group recommended Tuesday.
Associated Press
STATE SCAN
D.C. Politics
The 200-bed facility in Takoma cannot be licensed under emergency rules.
Fenit Nirappil
OPIOID OPTICS
The Surgeon General was on the verge of alerting the public about opioids 13 years ago. The effort quickly evaporated and there’s no real answer to why.
SUGAR RUSH

The Daily Show with Trevor Noah: