Tuesday, January 23, 2018

Tom Petty, the opioid epidemic and changing structural inequities in the US

In October 2017, the rock musician Tom Petty died at the age of 66. Given Mr. Petty’s history of heroin addiction back to at least the 1990s and the frequency with which overdoses seem to cause the death of celebrities, there was some early assumption that it may have caused his. This was confirmed by the coroner, (NY Times, January 19 2018); however, the cause was not heroin but rather prescription opioids (oxycodone plus 3 types of fentanyl), combined with two also-addictive anti-anxiety medicines known as benzodiazepines: “The coroner, Jonathan Lucas, said that Mr. Petty’s system showed traces of the drugs fentanyl, oxycodone, temazepam, alprazolam, citalopram, acetyl fentanyl and despropionyl fentanyl.” (The citalopram is an SSRI anti-depressant). According to a statement from his wife and daughter, he had many ailments including a fractured hip that caused him great pain.

Thus, Mr. Petty becomes another victim of the epidemic of prescription opioid-related deaths. His previous heroin addiction (chronic use of opiates or opioids leads to tolerance, requiring higher and higher doses for relief) and his stature as a rich and famous person (which seems to make it even easier to find doctors who will prescribe such drugs) may have increased his risk, but his death is one instance of a widespread American problem that has been the subject of academic articles, government reports, and opinion pieces from medical providers, patients, and the general range of pundits.

David Blumenthal and Shanoor Servai of the Commonwealth Foundation write in their report “To Combat the Opioid Epidemic, We Must Be Honest About All Its Causes” that “History offers only one other recent example of a large industrialized country where mortality rates rose over an extended period among working-age white adults: Russia in the decades before and after the Soviet Union’s collapse. The economic and social contexts have been eerily similar, and substance abuse has been a dominant factor in both countries: alcohol in Russia, opiates in the United States.” A major study by Princeton economists Anne Case and Angus Deaton in 2015, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century” (which I have previously cited, Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015) posits opioid-related deaths as a major cause of the surprising  increase in mortality rate among white Americans. Blumenthal and Servai note that “Based on weighted estimates, 92 million, or 37.8%, of American adults used prescription opioids the prior year (2014); 11.5 million, or 4.7%, misused them; and 1.9 million, or 0.8%, had a use disorder. The epidemic is spreading so rapidly that it’s likely the numbers are higher now.”

So it’s a very big problem, with many causes, and the solutions are not simple. Doctors play a big role, since they must prescribe the opioids (whether these are taken by the designated patient or illicitly redistributed). While well-known surgeon and author Atul Gawande, in an interview with Sarah Kliff on Vox.com, says “We started it”, I don’t think that is completely true. Certainly doctors have been vehicles for its perpetration but there are other forces at work. One is the movement that began in the 1990s to adequately address patients’ pain, which was seen as insufficient by many critics. In many institutions pain was labeled the “fifth vital sign”, and staff were instructed to ask about pain relief in every interaction. While this is important, especially for acute short-lived pain (such as post-operative or post-traumatic), the use of opiates for chronic pain skyrocketed. The obvious problem is, as cited above, the more you have taken them the more you need; tolerance to opiate and opioid effects often requires increasing doses. The “high” resulting from these drugs (whether intended or not) increases their potential for abuse.

Long-acting opiates and opioids (such as extended release morphine or oxycodone, methadone, and fentanyl patches) are preferred as they can control pain with less of a “high”, but they still lead to tolerance. While addiction is not an issue for people who are dying of their cancer, it is for people with chronic diseases such as sickle-cell and chronic pain syndromes, most commonly in the US back pain. Opiates and opioids have been shown to be poor choices for long-term treatment of chronic back pain, but taking them is often easier and cheaper for patients than complicated (and often expensive) modalities such as physical therapy, and it relieves the pain more quickly and completely until higher and higher doses are needed. So patients, as well as physicians, are part of the problem, and physicians are working to try to help people, while complicating the problem.

Real villains include those who have originated and perpetuated this crisis only to make money. This includes insurance companies, who often deny more expensive treatments such as extended physical therapy or drugs such as buprenorphine, essentially pushing doctors and patients into the use of opioids. They certainly include the pharmaceutical companies who have developed and heavily marketed these drugs, notably the Sackler family who owned Purdue and made and pushed Oxy-Contin®, as documented in the New Yorker article “The family that built an empire of pain” (October 30, 2017). In brief, they acquired the rights to long-acting morphine, but because this was losing its patent protection (and thus its profitability), they developed a long-acting form of oxycodone, which was patented and thus more profitable. Counting on the negative associations that the public and even physicians associated with morphine, they pushed Oxy-Contin, which was at least as addictive and dangerous, for an ever-expanding list of chronic conditions. Back pain, of course, was the target market, and it soon seemed as almost everyone had an indication for opioids. And we have since been paying the price with their deaths.

The flaws of capitalism that directly drove and continue to drive this epidemic through the pursuit of profit should be clear enough. The structural flaws that have and continue to ruin the lives of so many Americans (not to mention people in the rest of the world) may be less obvious but are no less real. The dramatic redistribution of wealth from the vast majority of us to the already-wealthiest, with the concomitant decrease in the quality of life for so many, proceeds apace. The 1%, maybe even the 5%, are doing great, although the biggest benefit (including from the new GOP tax “reform”) law goes to the 0.1% or less. The richest 1% now owns half the world’s wealth and the 8 richest men have as much as half the world’s population!  Worldwide, it is those in the poorest countries that suffer most. In the US, it remains minorities. While the shocker in the Case and Deaton study was the fact that white mortality is increasing, the fact remains that minorities, especially African-Americans, still have far higher mortality rates.

If we wish to decrease this excess mortality, it certainly will be important to address the opioid crisis, by physicians becoming more reticent to prescribe long-term opioids for chronic conditions, patients to accept alternative treatments, and insurers being willing to pay for those treatments. It will also be important to address other chronic addictions, like alcohol (Blumenthal and Seervai observe that while “11.5 million, or 4.7%, misused them [opioids and opiates]; and 1.9 million, or 0.8%, had a use disorder…By comparison, there are 17.1 million heavy alcohol users among adults over 18.” Legal does not mean safer, whether we are talking alcohol abuse or “legitimized” (by prescription) opioid abuse. It most often reflects the relative power of the industries that financially benefit.

The core problem is in the unfair, unjustifiable, and oppressive structural inequities in our society. These are so deeply seated that we often assume they are inevitable, and that there is no other way. There is. We may not be able to eliminate inequality, but if we are to seriously address the epidemic of unnecessary deaths, we need to do more than treat the symptoms; we must grapple head-on with and change our society’s structure. 

Tuesday, January 2, 2018

The Future of ACA and Health Care for Americans: We need Medicare for ALL!

It’s a new year. 2017 ended with the GOP passing a landmark tax bill that will provide huge long-term windfalls to corporations and the very, very rich, but little and time-limited benefit most folks. “Most”, in this case, being the vast majority. The “99%” probably underestimates it. Hey, how about I give you $10 once and you support my getting $1,000 a year in perpetuity? Well, why not? At least I get my $10. Except, whoops, you’ve raised prices on me by $20 a year.

The Republicans just missed out on their repeal of the Affordable Care Act in 2017, but there is a strong possibility they’ll try again in 2018. The decision will certainly be made on political grounds; maybe they’ll want to do it while they have a one-vote majority in the Senate if they think they might lose it. On the other hand, maybe doing it will increase the likelihood of them losing even more Senate seats. Tough one; you know the American people will stand for a lot of screwing-over, but it may be possible for you to push it too far.

In the meantime, however, the Trumpenik administration has slashed subsidies for people getting coverage on the federal exchanges. The President himself tweeted on December 26, 2017 that the “Tax Cut Bill…essentially Repeals (over time) ObamaCare”. It didn’t, but it did make it much more difficult for many Americans to obtain health insurance, and most of them are in states that voted for Trump and the GOP. As CBS reported on the same day, 80% of the 8.8 million newly covered are in these states. The four states with the highest enrollment, totaling 3.9 million, were Florida, Texas, North Carolina and Georgia. While these are states all went for Trump in 2016, all but Texas are in danger of going Democratic in the future. Florida has long been a swing state (remember the hanging chads of 2000!), NC is probably flippable in a presidential election (although, barring a court ruling overturning it, amazing gerrymandering will protect Republican House seats there), and Georgia is changing quickly. Of the 11 states with the biggest increases in enrollment, 8 voted Republican (Iowa, Kansas, Kentucky, Missouri, Nebraska, North Dakota, South Dakota and Wyoming). So cutting subsidies for buying insurance on the exchanges is a great way to punish your base.

There is even a school of thought that believes the cutbacks in funding for purchase of private insurance, along with the dramatic expansion of Medicaid (in the states that have done so), creates the opposite of GOP intentions, a more publicly-funded health insurance system. This topic is addressed in the NY Times article “Years of Attack Leave Obamacare a More Government-Focused Health Law” by Robert Pear, also on December 26. While only about 10 million have gotten coverage by private insurers through the exchanges, and this will drop as both the individual mandate and subsidies are eliminated, over 75 million people have benefited from Medicaid expansion. The “Medicare for All” movement advocated by Sen. Bernie Sanders is gaining increased momentum in many states (for example, Maine, where it may be pushed over the resistance of the Republican governor), as people increasingly realize that this is their only protection. Eliminating the mandate means healthy people will not buy insurance that they can no longer afford without subsidies, so that the cost of insurance for sick people will become truly unaffordable. If they do not qualify for Medicaid, they will be plumb out of luck, unless Medicare is expanded to cover everyone.

Some advocate for gradual expansion of Medicare, rather than going straight for Medicare for All, by extending it to those over 50 or 55 first. This is most often heard from “mainstream” (“centrist”) Democrats (the Republicans care about the health of the American people not at all), who have been most remarkable for their tentativeness and cautious incrementalism when in power, as opposed to the Republicans’ aggressiveness. And, while expanding Medicare to cover everyone is the simplest and most straightforward route to a single-payer insurance system, it must be an “improved and expanded” Medicare for all, as advocated and detailed by groups such as Physicians for a National Health Program (PNHP). Without this improvement people may legitimately fear an underfunded health system that requires major out-of-pocket expenses, that restricts access to certain procedures and specialties even when medically indicated, and that is more focused on cost-cutting than on health care.

Incremental efforts, such as gradually ratcheting down the age of Medicare eligibility, may seem to be tactically good ideas, but in fact they are silly and likely to cost more both in dollars and in worse health outcomes. Medicare, despite its limitations in funding, has made a phenomenal difference in the health of those eligible since its introduction in 1965. Those who receive Medicare now, the aged, blind and disabled, are the population with the greatest health care needs and costs. However, as physicians we regularly see those just under the age of 65 but with chronic illness suffering serious health outcomes and costs until they become eligible. While lowering the age to, say, 55 would enroll many of those with greatest need, there would always be people with need just below the age cutoff. More important, as the age of eligibility goes down, the marginal cost per covered life also goes down, because younger people are healthier. What makes sense is to simply wrap everyone together, getting both the benefit of an overall healthier younger population paying in and using little care and not excluding individuals of any age who (from chronic or acute illness or accident) do need care.

The day after all these appeared, December 27, a British physician named Rachel Clarke (@doctor_oxford), author of the current [British] Sunday Times bestseller “Your Life in My Hands”, posted a note on Twitter about her father dying of cancer after a long illness. “One major surgery,” she wrote, “countless chemotherapies, & a small army of community and palliative nurses so that he could be at home with us.”  She continued: “The bill? £zero. Grief, pain, emptiness – but not bankruptcy. Thank you, #NHS.”  How many of us could say the same in the US? Some, perhaps many, of us; those with money and good insurance, which is becoming increasingly rare. But MOST of us could not.

The lives of all of us, the health of all of us, and the commitment of society and government to the health of all of us, is what is at issue here. The Republican Party and its leader have demonstrated their clear and persistent opposition to it. And it is all of us, including their voters, who are suffering and will continue to suffer for it.

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