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Monday, September 25, 2017

Reprinted with permission from AlterNet.

 

Even as pundits and political observers, including former intelligence director James Clapper and some House Democrats, are increasingly questioning President Trump’s mental stability, they’re not paying nearly as much attention to the threat he poses to people already proven to be grappling with mental illness, addiction and chronic pain. In early August, our mercurial president declared that the opioid crisis that plays the dominant role in roughly 60,000 overdose deaths a year is a “national emergency,” yet no meaningful response has yet been set in motion.

He seemed to be following the initial recommendations of his ex-crony Gov. Chris Christie’s opioid panel that called for everything from more inpatient treatment for addicts to better training of physicians. But that commission was  justly derided as “farcical” by critics because it ignored all the different ways that the Trump administration is scheming to undermine both Obamacare and Medicaid treatment programs for mentally ill people and substance abusers, at least half of whom are hobbled by mental illness.

Amid all this new attention to the opioid emergency, there’s a growing awareness that there’s not enough real-time access to the sparsenumber of drug treatment clinicians and to the effective medications for opioid addiction 90 percent of providers don’t offer. But there is far less notice being given to the generally poor quality of care given to substance abusers who manage to find addiction treatment.

“The opioid crisis is an emergency, and I’m saying officially right now it is an emergency. It’s a national emergency. We’re going to spend a lot of time, a lot of effort and a lot of money on the opioid crisis,” Trump said while on a “working vacation” at his New Jersey golf club.

In theory, that could free up more money for treatment and give states greater flexibility in using Medicaid funds to help addicts. But that seems unlikely, especially with millions of people with addiction and mental illness conditions enrolled in the 32 states and the District of Columbia that expanded state Medicaid programs under the Obamacare program. That is the same program still under attack by Trump and his HHS secretary Tom Price, even after repeal failed in Congress.

In an administration that wasn’t so dysfunctional, Trump’s declaration of added emergency funding and expanded powersshouldbe expected to promote the expanded use of “medication-assisted” treatment. This includes take-home Suboxone, with the primary ingredient buprenorphine, that now faces rigid prescription limits on doctors who must jump through regulatory hoops to prescribe it to more than 30 patients. Equally valuable, but potentially riskier if misused, is the more widely prescribed but stigmatized methadone, which can’t be provided outside of specialized clinics. All told, such medications can cut fatal overdose rates by up to 75 percent, but federal and state governments are still slow-walking making them easily available for all who need them. In the meantime, over 140 people a day die from opioid overdoses.

As science writer Maia Szalavitz, the author of The Unbroken Brain, has pointed out, “If the Trump administration wants to dramatically cut the death rate from opioid overdose, it should use its emergency powers to strip away the bureaucracy associated with obtaining methadone or buprenorphine.”

Yet such minimally necessary reforms are unlikely to be implemented by HHS or pushed through Congress by a crippled administration in political free-fall, and one that’s all too eager to pander to Trump’s right-wing base.

The administration’s hard-line views have already been made clear. HHS Secretary Tom Price has derided proven medication-assisted approaches as “substituting one opioid for another,” although his PR staff sought to clean up his comments by claiming they didn’t really reflect his or HHS’s policy views. And regardless of how many vague platitudes Trump might declaim about the opioid crisis, his real attitudes were best reflected when he, Price and other officials pandered to his base in a briefing by emphasizing tougher law enforcement and stronger security on the Mexican border to stop illegal drugs.

At his August briefing, Trump essentially ignored the role of expanding treatment options. Instead, he echoed the earlier law-and-order demands by Attorney General Jeff Sessions to drastically increase sentencing for drug offenders, even though 75 percent of them return to prison within five years after being released, largely because they can’t access effective drug treatment in or out of prison.  Trump is eager to ramp up these failed policies: “Strong law enforcement is absolutely vital to having a drug-free society,” he declared.

The administration has a wide array of other enforcement and regulatory schemes — joined with insurance subsidy cut-offs — that it’s advancing which could devastate the lives of emotionally disturbed people, substance abusers and chronic pain patients who have been using opioids in legitimate ways, but are now facing heedless cutbacks. Many people in all three groups are either being set adrift or could soon  find themselves without minimally acceptable care, leading to an increase in suicides, overdoses, emergency room visits and life-threatening incarceration. As a Huffington Post investigation found in 2016, the year after the suicide by hanging of Sandra Bland in July 2015, over 800 inmates died in local jails—roughly a third due to suicides in the first three days of incarceration.

First, Do Harm: The Federal Government’s Approach to Opioids, Addiction and Chronic Pain

The risk of suicide is already mounting steadily for all those chronic pain patients recently cut off from opioids in a drastic  way that focuses narrowly on arbitrary opioid dosage limits rather than on patient well-being, according to a recent open letter of concern penned by 80 academic experts. For instance, a few months after the CDC in 2016 rolled out influential new guidelines that spurred a crackdown on opioid prescribing for chronic pain patients, 47-year-old Donald Alan Beyer of Bovill, Idaho, a disabled logger with a degenerative disc disease who had injured himself on the job, walked out the back door of his home and shot himself in the head.

His son Garrett told the local paper, “He was in so much pain he could barely get out of bed to go to the bathroom. I guess he felt suicide was his only chance for relief.”

Beyer was left stranded when his doctor retired the previous year, and other doctors, apparently frightened of potential prosecution by the DEA or regulatory sanctions, declined to take on a new patient with chronic pain. (These strict responses to federal advisories began in the Obama administration, but they’ve been accelerated by the hard-liners now in charge of Trump’s federal health agencies.)

A 2016 article on Beyer’s suicide, and the far-reaching prescribing cutbacks published by the Pain News Network continues to draw comments from readers that amount to suicide notes in advance. A patient with a severe chronic cranial nerve pain condition, Renee Urbanek, wrote just two weeks ago, “My pain clinic just told me I will be weaned off all opioids. I will also have to end my life when that happens. I only had one yr to go to c my only daughter married. I’ll never hold a grandchild.”  Three months ago, “Craig” wrote, “We’re not going to get no help…By Sunday evening @6p.m. central I will be a statistic.”

Lauri Nickel of Phoenix, Arizona, 60, might have ended up as one of those statistics, after her degenerative disc disease she had managed with non-opioid medications, steroid injections and six spinal and neck surgeries since the 1990s was then drastically worsened by a badly administered steroid epidural over a decade ago. That botched procedure, in turn, eventually triggered the development of arachnoiditis, a severe inflammation in the membranes surrounding the nerves of the spinal cord that was misdiagnosed for years, leading to unbearable, burning pain. She managed to find some relief for about two years after she got an implanted spinal cord stimulator — and was also allowed to take high dosages of opioids, including a timed-release fentanyl patch that’s quite different from the counterfeit pills laced with fentanyl that are killing thousands each year. She even felt well enough to take part in the Susan B. Komen annual charity 5k walks.  But the stimulator stopped working, her pain increased and she needed additional surgeries, but she is now still too wracked with pain to do much of anything, stuck at home aided by modest doses of oxycodone that risks being removed at any point under the new crackdown. She also turned outside the traditional medical system for unproven, costly ketamine infusion treatment, and medical marijuana permitted in Arizona to help deal with her pain.

She’s not sure what her future holds, as she remains largely confined to bed in agony and uses Facebook to champion the cause of chronic pain patients. “We are shamed in pharmacies and treated like drug-seekers in the ER,” she says. “We are collateral damage.”

“If tapering is forced on people, significant harm is observed,” says Stefan Kertesz, a family practitioner and addiction researcher at the University of Alabama in Birmingham. “Some patients become emotionally volatile or they experience a disruption in their health care. They’re at higher risk of suicides and illicit outcomes,” which can mean using counterfeit street drugs laced with fentanyl or heroin.

Kertesz has emerged as a vocal critic of the current harsh restrictions, observing, “Every week my inbox tells me about another suicide of someone forced off opioids against their will or I hear about overdoses.” On his Facebook page, he reposted a disturbing video from August 4, 2017 featuring a Montana physician, Mark Ibsen, with his distraught patient, as the physician declared, “This patient is suicidal due to sudden severe cuts in her medications.”

Yet few government officials are doing anything about it, not even bothering to measure the real-world impact of the new guidelines or even study the actual benefits and harm of using opioids for chronic pain patients over the long term.

Surprisingly, Kertesz’s in-depth research on Alabama county death reports, and new CDC findings indicate that prescription drugs now account for only about 15 percent of opioid overdose deaths, whether or not the victims obtained them legally. Even CDC officials admit that prescription drugs aren’t the main culprits now in opiate deaths  As Debra Houry, the director of the agency’s injury prevention and control center, told a House committee in March, “More recently, the large increase in overdose deaths has been due mainly to increases in heroin and synthetic opioid (other than methadone) overdose deaths, not prescription opioids.

The available data indicate these increases are largely due to illicitly manufactured fentanyl. So it’s even more striking that while there has been nearly a 20 percent downturn in legal opioid prescribing since 2010, overdose deaths, mostly due to street opioids, are now increasing at the rate of 19 percent a year. And contrary to another common myth, 75 percent of new heroin users started on illegally obtained prescription pills while young, not from drugs prescribed them as older chronic pain patients.

So while it is obvious that the nation has been swamped by massive opioid overprescribing since the late 1990s until recently, our largely inept efforts to help addicts, chronicled in Anne Fletcher’s book Inside Rehab (supplemented by new findings in my own Mental Health, Inc.) has created a perfect storm of relapses, deaths and common treatment failures. Now a Category 5 hurricane unleashing even greater tragedy is headed our way under the Trump administration.

The administration and Republican leaders have a vested interest in the failure of government health programs: they have done whatever they could to hasten Obamacare’s demise and limit the scope of Medicaid, threatening coverage for at least four million people with mental and substance abuse disorders who were previously uninsured. Tom Price has already signaled through rule-making and a letter to the nation’s governors a willingness to grant state officials a relatively free hand to eviscerate government and private-sector health insurance programs. Administrators of both the state Obamacare exchanges and Medicaid programs have been offered far greater flexibility to limit required health benefits and eligibility for those programs.

The federal waivers Price wants to deploy are like catnip to budget-conscious officials eager to drastically cut spending. States such as Arizona, Indiana, Kentucky and Wisconsin, among others, are seeking or have already won permission to lock out Medicaid recipients if they don’t pay premiums; require so-called “able-bodied” recipients to work to be eligible for benefits; limit Medicaid eligibility to five years; and test them for illegal drugs without acknowledging the deterrent effect on addicts needing treatment. As a result, new risks face all of the 14 million recipients already added through the Medicaid expansion and millions more who could be denied coverage.

The dystopian future awaiting the most seriously mentally ill people and addicts needing treatment under a Trump administration can, perhaps, be glimpsed by looking at what happened when Tennessee, facing a fiscal crisis, used HHS waivers to cut over 350,000 people from the Medicaid rolls starting in 2005 and drastically curtailed benefits for others. These included limiting virtually all recipients to a total of five medications. With 35,000 of the most seriously and chronically mentally ill recipients losing all coverage, homelessness, emergency room visits and jailings rose sharply in Tennessee.

The Trump administration not only can learn from the past but is looking for ways to use waivers to undermine the “essential health benefits” required by the Affordable Care Act and the basic health care services that Medicaid is supposed to offer. Price and his new director of the Centers for Medicare and Medicaid Services (CMS), Seema Verma, have the authority to grant draconian administrators broad freedom to clamp down on the program through “Section 115” waivers.

Verma, an Indiana health care consultant who is a protégé of Vice President Mike Pence, has already had plenty of practice in Indiana adapting the waiver’s authority to boot people off the Medicaid rolls and limit their benefits under the guise of promoting “personal responsibility” —by requiring sliding-scale monthly premiums. In practice, as WFYI public radio reported, the state and private insurers too often made repeated bureaucratic mistakes that left even steadfast payers without coverage.

The far skimpier coverage that could be potentially offered nationally is a likely deathblow especially for the most troubled mentally ill people and addicts who turn to Medicaid for help. It’s disturbing that despite  at least 60,000 overdose deaths annually nearly three million—often mentally ill— substance abusers, including 2220,000 with opioid disorders, who got coverage for the first time under Obamacare and Medicaid could face new barriers to care; others will be frightened away from enrolling in Medicaid by those states that adopt drug-testing requirements applicants fear could lead to their arrest.

If these addicted individuals on a pathway to death or jail manage to retain their coverage under Trump and somehow get treatment, they are unlikely to get even minimally competent care. With about half of all addicts having mental illness and half of all those with serious, disabling mental illnesses suffering from substance abuse, effective dual-diagnosis programs that treat both illnesses together can reduce mental health symptoms and substance abuse disorders by up to 70 percent.

Unfortunately, the federal Substance Abuse and Mental Health Services Administration and state programs have abandoned useful, evidence-based assessment tools to measure whether clinics actually deliver effective dual-diagnosis treatment. As many as 90 percent of drug and mental health clinicsnow fail to do so, but SAMHSA pulled the plug on the evaluation program in 2012 just when opiate use started rising dramatically.

Stanford University Medical School professor Mark McGovern’s assessment tools have been essential in evaluating quality. Going by the names Dual Diagnosis Capability in Addiction Treatment (DDCAT) and Dual Diagnosis Capability in Mental Health Treatment (DD-CMHT), they’re used, respectively, for drug treatment and mental health centers. They measure everything from leadership to evidence-based treatments, and then are used to spur improvements. Except for a relative handful of states, such as Washington, spending their own funds on it, McGovern’s smart method to promote quality dual-diagnosis care isn’t widely used anymore.

“We had an opportunity to offer good care and save lives,” he says. “The human toll is immeasurable.”

All told, Trump’s pending attacks on people with mental illness, chronic pain and addictions are likely to kill far more people than the over 7,000 drug offendersgunned down by the death squads deployed by the Philippine strongman he admires. Indeed, Trump praised Rodrigo Duterte for doing an “unbelievable job on the drug problem,” according to a leaked transcript.

Art Levine is the author of the new book, Mental Health, Inc: How Corruption, Lax Oversight and Failed Reforms Endanger Our Most Vulnerable Citizens from Overlook Press, from which this article was adapted and updated.