America Out Loud PULSE: Understanding and Fixing Opioid Addiction

From my America Out Loud Pulse podcast with  Dr. Molly Rutherford https://www.americaoutloud.com/understanding-and-fixing-the-opioid-addiction/

Opioid addiction and the increasing number of overdoses has finally caught the public’s attention. Some 107,000 people died of overdoses in 2021. About two-thirds of those deaths involved synthetic opioids like fentanyl that is 50-100 times more potent than morphine. According to the Drug Enforcement Administration (DEA), in 2021 fentanyl killed more Americans than guns and traffic crashes combined.

How did this happen? Management of non-cancer pain went through a slow evolution starting in 1980. Then we had “pain as the 5th vital sign”—adding to the standard heart rate, respiratory rate, temperature, and blood pressure. We were told the new breed of opioids were “safe and effective” (just like the Covid vaccines).

Then physicians gave all the pain meds the patient said they need based on some 1 to 10 smiley and frowny faces. Of course, we might have done a better job by just talking with the patient—seeing the patient as a whole. The patient may be someone who lost their job, whose dog just died, or who is miserable in their love life.

The next thing you know, patients got addicted and we were told to cut back on the pain meds. Some states even had specific laws capping the amount of pain meds a patient could legally obtain. Then patients got drugs on the street. The drugs were laced with the faster acting and more powerful fentanyl, a narcotic legitimately used as an anesthetic in hospital settings. Fentanyl was cheap (like other things from China) and flowed freely across the Mexican border. Then the patients (as well as other opioid users) started to die from overdoses. What comes next?

In this episode Dr. Molly Rutherford delves into the addiction problem and offers some positive solutions for patients

Hoaxes, Scams, and Your Medical Care

By Marilyn M. Singleton, MD, JD

Hoaxes and scams have been dominating the news lately. We have a marginally known actor faking a hate crime supposedly to raise his Hollywood profile. His attempt to claw his way to the middle could have resulted in race riots, injury, and death. His punishment? All charges dropped.

The scandal about Hollywood and other elites buying their children’s way into top-rated universities really hit home. I remember when I had tutored some recent Vietnamese immigrants for a debate contest to win a scholarship for college. I could only hope that their hard work was rewarded and not wiped away by special favors bestowed on the “haves.”

Now we continue to have a slew of healthcare hoaxes: corporate stakeholders, legislators, and government agencies promise everything and have no accountability for their failure to keep their promises.

Take the large health systems’ claim that hospital consolidation and buying up physician practices would benefit consumers with cheaper prices from coordinated services and other unspecified savings. A major study of California hospital mergers found just the opposite. The analysis showed that the price of an average hospital admission went up as much as 54 percent. When the large hospital systems bought doctors’ groups, the prices rose even more. There was as much as a 70 percent increase in prices of medical services in geographic areas with minimal competition. This finding seems obvious to any of us who has the choice of shopping at Walmart or Target or Costco.

Logic aside, some legislators believe that having the government take over medical care would solve our access and cost problems. Single payer means no competition whatsoever. The single payer plans (H.R. 1384 and S. 1804) that abolish private insurance leave patients with an empty choice. Patients can contract with a physician to pay cash for government medical services covered by the government. But if the physician contracts for such services he cannot be part of the government program for any patient for 2 years. Realistically, these single payer bills make it financially unfeasible for physicians to privately contract with patients. Thus, only well-heeled patients, along with independently wealthy doctors, can buy their way out of the system.

There are variations on the theme of government involvement that allow buy-ins to Medicare, Medicaid, or iterations of the Affordable Care Act marketplaces. All of these all have the same defect: expanding the government healthcare monopoly.

The opioid crisis is an example of the unintended consequences of intervention by oversight agencies not directly involved in patient care. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), now the Joint Commission, a nonprofit organization that accredits more than 20,000 healthcare organizations and programs in the U.S, is for all practical purposes a government surrogate. In 2001, JCAHO declared that pain was the “5th vital sign” that had to be addressed or face consequences. The Federation of American Medical Boards told physicians that “in the course of treatment,” large doses of opioids were just fine. Moreover, Medicare has a hospital payment formula that relies on patient satisfaction surveys. If the patients are satisfied, including being so zoned out on opiates that they can’t taste the bad food, the hospital is paid more. The hospital is penalized for a bad rating.

And now to deal with the opiate issue, the government has issued guidelines that have been found to be harmful to some patients. One-size-fits-all restrictions have caused physicians to fear being flagged as over-prescribers by the medical board. Consequently, some physicians are tapering patients off opioids more quickly than they would ideally like. And in the public eye patients have been transformed from objects of compassion to criminal drug addicts.

Individualized medical care must not be reserved for the chosen few. Patients need physicians who are empathetic, thorough, and not married to a medical cookbook written by disinterested third parties. Perhaps this is why Mick Jagger of the Rolling Stones chose to have his heart surgery in the U.S. and not with his British homeland’s National Health Service.

Central control is not a good idea. Period. Do not believe the hoax perpetrated by the ruling class who will never have to live by their own rules. It is highly unlikely that Venezuela’s President Maduro is starving along with his people.


BDr. Singleton is a board-certified anesthesiologist. She is President of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School.  Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law.  She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers. She lives in Oakland, Ca.

Legislative Update, June 13, 2018: Special Opiate Edition

In this special edition of Legislative Update, Marilyn Singleton, MD, JD breaks down the surge of opiate-related legislation under consideration on Capitol Hill.

In response to the opiate abuse epidemic, Congress has put forth almost 60 bills, many of which are receiving votes by the full House this week (the week of June 11th). In addition, the Senate Finance Committee, on June 12, “unanimously approved its big bill to address the opioid crisis,” reports Politico.

Here is a peek inside the provisions under consideration:

Privacy

H.R. 3331, a bill to amend title XI of the Social Security Act to promote testing of incentive payments for behavioral health providers for adoption and use of certified electronic health record technology. This bill amends title XI (General Provisions) of the Social Security Act to specify that the Center for Medicare and Medicaid Innovation may test models to provide incentive payments to behavioral health providers for: (1) adopting electronic health records technology, and (2) using that technology to improve the quality and coordination of care. Rep. Lynn Jenkins (R-KS); https://www.govtrack.us/congress/bills/115/hr3331/text.

While not specifically an opioid bill, urging mental health professionals to use EMR is one more assault on privacy.

H.R. 5009, Jessie’s Law, would require HHS with outside experts to develop best practices for displaying information about opioid use disorder in a patient’s medical record. HHS would be required to develop and disseminate written materials annually to health care providers about what disclosure could be made while still complying with federal laws governing health care privacy. Rep. Tim Wahlberg (R-WI); https://www.govtrack.us/congress/bills/115/hr5009/text.

H.R. 5795, the Overdose Prevention and Patient Safety Act, would amend the Public Health Service Act so that requirements pertaining to the confidentiality and disclosure of medical records relating to substance abuse disorders align with the provisions of HIPAA. The bill would require HHS to issue regulations prohibiting discrimination based on data disclosed from such medical records, to issue regulations requiring covered entities to provide written notice of privacy practices. Rep. Earl Blumenauer (D-CT); https://www.govtrack.us/congress/bills/115/hr5795/text.

Legislation Affecting Medicaid, CHIP

H.R. 3192, CHIP Mental Health Parity Act, would require all Children’s Health Insurance Program plans to cover mental health and substance abuse treatment. States would not be allowed to impose financial or utilization limits on mental health treatment that are lower than limits placed on physical health treatment. Rep. Joseph Kennedy III (D-MA); https://www.govtrack.us/congress/bills/115/hr3192/text.

H.R. 4005, Medicaid Reentry Act, would amend Title XIX (Medicaid) of the Social Security Act to allow Medicaid payment for medical services furnished to an incarcerated individual during the 30-day period preceding the individual’s release. Rep. Paul Tonko (D-NY); https://www.govtrack.us/congress/bills/115/hr4005/text.

H.R. 5477, the Rural Development of Opioid Capacity Services Act (DOCS Act), would require the Centers for Medicare & Medicaid Services (CMS) to to conduct a 5-year demonstration project to increase the number of providers participating in Medicaid to provide treatment for substance abuse disorders. The CMS must select 10 states for inclusion under the demonstration project, giving preference to states that have a prevalence of substance-use disorders (in particular, opioid-use disorders) comparable to or higher than the national average. Rep. Tom Halloran (D-AZ); https://www.govtrack.us/congress/bills/115/hr5477/text.

H.R. 5789, a bill to amend title XIX of the Social Security Act to provide for Medicaid coverage protections for pregnant and post-partum women while receiving inpatient treatment for a substance use disorder, would direct HHS to issue guidance to states on best practices under Medicaid and CHIP for treating infants with neonatal abstinence syndrome. The bill would also direct the Government Accountability Office to study Medicaid coverage for pregnant and postpartum women with substance abuse disorders. Rep. Bill Foster (D-IL); https://www.govtrack.us/congress/bills/115/hr5789/text.

H.R. 5797, the IMD Care Act, would expand Medicaid coverage for people with opioid use disorder who are in institutions for mental disease (IMDs) for up to 30 days per year. Under a current polity called IMD exclusion, the federal government generally does not make matching payments to state Medicaid programs for most services provided to IMDs to adults between the ages of 21 to 64. Rep. Mimi Walters (R-CA); https://www.govtrack.us/congress/bills/115/hr5797/text.

H.R. 5799, the Medicaid Drug Review, Utilization, Good Governance Improvement Act the (Medicaid DRUG Improvement Act), would require Medicaid programs to implement additional review of opioid prescriptions, monitor concurrent prescribing of opioids and certain other drugs, and monitor the use of antipsychotic drugs by children. Rep. Marsha Blackburn (R-TN); https://www.govtrack.us/congress/bills/115/hr5799/text.

H.R. 5800, the Medicaid Institutes for Mental Disease Are Decisive in Delivering Inpatient Treatment for Individuals but Opportunities for Needed Access are Limited without Information Needed about Facility Obligations Act (Medicaid IMD ADDITIONAL INFO Act), would direct the Medicaid and CHIP Payment and Access Commission to study institutions for mental diseases in a representative sample of states. Rep. Fred Upton (R-MI); https://www.govtrack.us/congress/bills/115/hr5800/text.

H.R. 5801, the Medicaid Providers Are Required To Note Experiences in Record Systems to Help In-Need Patients (PARTNERSHIP Act), would require providers who are permitted to prescribe controlled substances and who participate in Medicare to query prescription drug monitoring programs (PDMPs) before prescribing controlled substances to Medicaid patients. The bill would also require PDMPs to comply with certain data and system criteria, and PDMPs would receive additional federal funds to help cover administrative costs. Rep. Morgan Griffin (R-VA); https://www.govtrack.us/congress/bills/115/hr5801/text.

H.R. 5808, the Medicaid Pharmaceutical Home Act of 2018, would require Medicaid programs to operate pharmacy programs that would identify people at high risk of abusing controlled substances and require those patients to use a limited number of providers and pharmacies. Rep. Gus Bilirakis (R-FL); https://www.govtrack.us/congress/bills/115/hr5808/text.

H.R. 5810, the Medicaid Health Homes for Opioid-Use-Disorder Medicaid Enrollees Encouraged Act (the Medicaid Health HOME Act), would allow states to receive 6 months of enhanced federal Medicaid funding for programs that coordinate care for people with substance use disorders. The bill would require states to cover all FDA-approved drugs used in medication-assisted treatment for five years, but states could seek a waiver from the requirement. Currently a few states exclude methadone. Rep. Leonard Lance (R-NJ); https://www.govtrack.us/congress/bills/115/hr5810/text.

Legislation Affecting Medicare

H.R. 3331 amends title XI (General Provisions) of the Social Security Act to specify that the Center for Medicare and Medicaid Innovation may test models to provide incentive payments to behavioral health providers for: (1) adopting electronic health records technology, and (2) using that technology to improve the quality and coordination of care. Rep. Lynn Jenkins (R-KS); https://www.govtrack.us/congress/bills/115/hr3331.

H.R. 3528, the Every Prescription Conveyed Securely Act, would require prescriptions for controlled substances covered under Medicare Part D to be transmitted electronically starting January 1, 2021. Rep. Katherine Clark (D-MA); https://www.govtrack.us/congress/bills/115/hr3528/text.

H.R. 4284, the Indexing Narcotics, Fentanyl, and Opioids Act of 2017 (INFO Act), would require HHS to appoint a Federal Coordinator for the Department of Health and Human Services to coordinate programs within the Department of Health and Human Services that relate to opioid abuse reduction. Rep. Robert Latta (R-OH); https://www.govtrack.us/congress/bills/115/hr4284/text.

H.R. 4841, Standardizing Electronic Prior Authorization for Safe Prescribing Act of 2018, would require health care professionals to submit prior authorization requests electronically starting January 1, 2021, for drugs covered under Medicare Part D. Rep. David Schweikert (R-AZ); https://www.govtrack.us/congress/bills/115/hr4841/text.

H.R. 5582, the Abuse Deterrent Access Act of 2018, would require the Centers for Medicare & Medicaid Services to report to Congress on the adequacy of access to abuse-deterrent opioid formulations for individuals with chronic pain enrolled in a prescription drug plan under Medicare or Medicare Advantage (MA). The report must account for any barriers preventing enrollees from accessing such formulations under Medicare or MA. Rep. Buddy Carter (R-GA); https://www.govtrack.us/congress/bills/115/hr5582/text.

H.R. 5590, the Opioid Addiction Action Plan Act, would require the Centers for Medicare & Medicaid Services (CMS) to develop an action plan to provide recommendations on changes to the Medicare and Medicaid programs to enhance: (1) the treatment and prevention of opioid addiction, and (2) the coverage and reimbursement of medication-assisted treatment for opioid addiction. The CMS must convene a stakeholder meeting to solicit public comment on the action plan. Rep. Adam Kinzinger (R-IL); https://www.govtrack.us/congress/bills/115/hr5590/text.

H.R. 5603, Access to Telehealth Services for Opioid Use Disorders Act, would permit HHS to lift current geographic and other restrictions on coverage of telehealth services under Medicare for treatment of substance abuse disorders or co-occurring mental health disorders. HHS would be directed to encourage other payers to coordinate payments for opioid use disorder treatments and to evaluate the extent to which the demonstration project reduces hospitalizations, increases the use of medication-assisted treatments, and improves health outcomes. Rep. Doris Matsui (D-CA); https://www.govtrack.us/congress/bills/115/hr5603/text.

H.R. 5605, the Advancing High Quality Treatment for Opioid Use Disorders in Medicare Act, would require the Centers for Medicare & Medicaid Services (CMS) to carry out a demonstration program to: (1) increase access of opioid use disorder treatment services for Medicare beneficiaries, (2) improve physical and mental health outcomes for such beneficiaries, and (3) reduce Medicare expenditures. Opioid use disorder care teams of practitioners may apply for participation in the demonstration project. The CMS must establish a performance-based incentive payment for participating teams. The CMS must adopt or develop program quality standards and performance methods. Rep. Raul Ruiz (D-CA); https://www.govtrack.us/congress/bills/115/hr5605/text.

H.R. 5675. This bill would require Medicare prescription drug plan (PDP) sponsors, for plan years beginning on or after January 1, 2021, to establish drug management programs for at-risk beneficiaries. Current law authorizes, but does not require, PDP sponsors to establish such programs. Rep. Gus Bilirakis (R-FL); https://www.govtrack.us/congress/bills/115/hr5675/text.

H.R. 5684, Protecting Seniors From Opioid Abuse Act, would establish individuals who are identified as at-risk beneficiaries for prescription drug abuse as qualifying participants in medication therapy management programs under the Medicare prescription drug benefit. Rep. Mike Kelly (R-PA); https://www.govtrack.us/congress/bills/115/hr5684/text.

H.R. 5685, Medicare Opioid Safety Education Act of 2018, would require the Centers for Medicare & Medicaid Services to provide Medicare beneficiaries with educational resources regarding opioid use and pain management, as well as descriptions of covered alternative (non-opioid) pain-management treatments. Rep. John Faso (R-NY); https://www.govtrack.us/congress/bills/115/hr5685/text.

H.R. 5686, Medicare Clear Health Options in Care for Enrollees Act of 2018 or the Medicare CHOICE Act of 2018, would require Medicare and Medicare Advantage prescription drug plan (PDP) sponsors to annually disclose information to enrollees about: (1) the adverse effects of prolonged opioid use; and (2) the plan’s coverage of nonpharmacological therapies, devices, and non-opioid medications. PDP sponsors may limit disclosure to a subset of enrollees (such as those who were prescribed an opioid in the previous two-year period). Rep. Erik Paulsen (R-MN); https://www.govtrack.us/congress/bills/115/hr5686/text.

H.R. 5715, the Strengthening Partnerships to Prevent Opioid Abuse Act, would require the Centers for Medicare & Medicaid Services (CMS) to establish a secure online portal to allow: (1) data sharing among the CMS, Medicare prescription drug benefit plans, and Medicare Advantage (MA) plans; and (2) referrals by such plans of substantiated fraud, waste, or abuse in order to initiate or assist investigations by contracted entities under the Medicare Integrity Program. The CMS must disseminate and report certain collected information to such plans, including information regarding providers that were referred through the portal and trends in identifying suspicious activity. Additionally, for plan years beginning on or after January 1, 2021, MA organizations must submit information to the CMS regarding investigations or other actions taken by MA plans against providers that prescribe high volumes of opioids (as determined by the CMS). Rep. James Renacci (R-PH); https://www.govtrack.us/congress/bills/115/hr5715/text.

H.R. 5716, the Commit to Opioid Medical Prescriber Accountability and Safety for Seniors Act (the COMPASS Act) would require the Centers for Medicare & Medicaid Services (CMS) to identify outlier prescribers of opioids under the Medicare prescription drug benefit and Medicare Advantage prescription drug plans. Specifically, the CMS must: (1) establish an opioid-prescription threshold for determining whether a prescriber is an outlier compared to other prescribers, based on specialty and geographic area; (2) use National Provider Identifiers (unique provider identification numbers currently included on claims for covered drugs) to identify outlier prescribers; and (3) annually notify identified outlier prescribers of their status and provide them with resources on proper prescribing methods. The CMS may also identify and notify outlier prescribers based on co-prescriptions of covered drugs that have adverse effects when used in combination with opioids. Rep. Peter Roskam (R-IL); https://www.govtrack.us/congress/bills/115/hr5716/text.

H.R. 5796, Responsible Education Achieves Care and Healthy Outcomes for Users’ Treatment Act of 2018 (REACH OUT Act of 2018), would allow HHS to award grants to certain organizations that provide technical assistance and education to high-volume prescribers of opioids. The bill would appropriate $100 million for fiscal year 2019. Rep. Brian Fitzpatrick (R-PA); https://www.govtrack.us/congress/bills/115/hr5796/text.

H.R. 5798, the Opioid Screening and Chronic Pain Management Alternatives for Seniors Act, would add an assessment of current opioid prescriptions and screening for opioid use disorder to the Welcome to Medical Initial Preventive Physical Examination. Rep. Larry Bucshon, MD (R-IN); https://www.govtrack.us/congress/bills/115/hr5798/text.

H.R. 5804, Post-Surgical Injections as an Opioid Alternative Act, would freeze Medicare payment rate for certain analgesic injections provided in ambulatory surgical centers. Rep. John Shimkus (R-IL); https://www.govtrack.us/congress/bills/115/hr5804/text.

H.R. 5809, the Postoperative Opioid Prevention Act of 2018, would create an additional payment under Medicare for nonopioid analgesics. Under current law, certain new drugs and devices may receive an additional payment – separate from the bundled payment for a surgical procedure – in outpatient hospital departments and ambulatory surgical centers The bill would allow nonopioid analgesics to qualify for a five-year period of additional payments. Rep. Scott Peters (D-CA); https://www.govtrack.us/congress/bills/115/hr5809/text.

Legislation affecting the FDA

H.R. 5333, the Over-the-Counter Monograph Safety, Innovation, and Reform Act of 2018, would change the Food and Drug Administration’s (FDA) procedures for regulatory activities for over-the-counter medications. The bill would require the Government Accountability Office to study exclusive market protections for certain qualifying OTC drugs. Rep. Robert Latta (R-OH); https://www.govtrack.us/congress/bills/115/hr5333/text.

H.R. 5473, Better Pain Management Through Better Data Act of 2018, would require the FDA to conduct a public meeting and issue guidance to the industry addressing data collection and labeling for medical products that reduce pain while enabling the reduction, replacement, or avoidance of oral opioids. Barbara Comstock (R-VA); https://www.govtrack.us/congress/bills/115/hr5473/text.

H.R.5752, Stop Illicit Drug Importation Act of 2018, would amend the federal Food, Drug, and Cosmetic Act (FDCA) to strengthen FDA’s seizure powers and enhance its authority to detain, refuse, seize, or destroy illegal products offered for import. The legislation would subject more people to debarment under the FDCA and thus increase the potential for violations, and subsequently, the assessment of civil penalties. Rep. Marsha Blackburn (R-TN); https://www.govtrack.us/congress/bills/115/hr5752/text.

H.R. 5687, the Securing Opioids and Unused Narcotics with Deliberate Disposal and Packaging Act of 2018 (the SOUND Disposal and Packaging Act) would permit the FDA to require certain packaging and disposal technologies, controls, or measures to mitigate the risk of abuse and misuse of drugs. This bill would also require that the Government Accountability Office study the effectiveness and use of packaging technologies for controlled substances. H.R. 5687 would permit the Secretary of Health and Human Services to require drug developers and manufacturers to implement new packaging and disposal technology for certain drugs. Rep. Richard Hudson (R-NC); https://www.govtrack.us/congress/bills/115/hr5687/text.

H.R. 5806, the 21st Century Tools for Pain and Addiction Treatment Act, would require the HHS acting through the Commissioner of Food and Drugs, to hold at least one public meeting to address the challenges and barriers of developing non-addictive medical products intended to treat pain or addiction and to issue one or more final guidance documents, or update existing guidance documents, to help address challenges to developing non-addictive medical products to treat pain or addiction. Rep. Michael Burgess, MD (R-TX); https://www.govtrack.us/congress/bills/115/hr5806/text.

H.R. 5811, the Long-Term Opioid Efficacy Act of 2018, would allow the FDA to require that pharmaceutical manufacturers study certain drugs after they are approved to assess any potential reduction in those drugs’ effectiveness for the conditions of use prescribed, recommended, or suggested in labeling.

H.R. 5811 would expand an existing mandate that requires drug developers to conduct post-approval studies or clinical trials for certain drugs. Under current law, in certain instances, the FDA can require studies or clinical trials after a drug has been approved. H.R. 5811 would permit the FDA to use that authority if the reduction in a drug’s effectiveness meant that its benefits no longer outweighed its costs. Rep. Jerry McNerney (D-CA); https://www.govtrack.us/congress/bills/115/hr5811/text.

Miscellaneous

H.R. 449, Synthetic Drug Awareness Act of 2017, would require the Surgeon General to report to Congress on the public health effects of the increased use since January 2010 by individuals who are 12 to 18 years old of drugs developed and manufactured to avoid control under the Controlled Substances Act (e.g., synthetic marijuana, also known as “spice,” and synthetic amphetamines, also known as “bath salts”). Rep. Hakeem Jeffries (D-NY); https://www.govtrack.us/congress/bills/115/hr449/text.

H.R. 4275, Empowering Pharmacists in the Fight Against Opioid Abuse Act, would require the Drug Enforcement Administration (DEA) to develop and disseminate training programs and materials on: (1) the circumstances under which a pharmacist may refuse to fill a controlled substance prescription suspected to be fraudulent, forged, or indicative of abuse or diversion; and (2) federal requirements related to such refusal.

The DEA must seek input from relevant stakeholders. Rep. Mark DeSaulnier (D-CA); https://www.govtrack.us/congress/bills/115/hr4275/text.

H.R. 4684, Ensuring Access to Quality Sober Living Act of 2017, would require the Substance Abuse and Mental Health Services Administration to publish best practices for operating recovery housing, to distribute such publication to the states, and to provide technical assistance to states seeking to adopt such practices. “Recovery housing” means a shared living environment free from alcohol and illegal drug use and centered on peer support and connection to services to promote recovery from substance use disorders. Rep. Judy Chu (D-CA); https://www.govtrack.us/congress/bills/115/hr4684/text.

H.R. 5041, Safe Disposal of Unused Medication Act, would require hospice programs to have written policies and procedures for the disposal of controlled substances after a patient’s death. Rep. Tim Wahlberg (R-WI); https://www.govtrack.us/congress/bills/115/hr5041/text.

H.R. 5102, the Substance Use Disorder Workforce Loan Repayment Act of 2018, would amend the Public Health Service Act to create a loan repayment program for individuals who complete a period of service in a substance use disorder treatment job in a mental health professional shortage area or a county where the drug overdose death rate is higher than the national average.

The substance use disorder treatment job must be a full-time position where the primary intent and function is the direct care of patients with or in recovery from a substance use disorder.

Individuals must enter into an agreement of service of up to six years with the Health Resources and Services Administration. The repayment program would pay one-sixth of the principal and interest on any eligible loan for each year of service; the maximum total amount of repayment by the program is $250,000 per individual. Rep. Katherine Clark (D-MA); https://www.govtrack.us/congress/bills/115/hr5102/text.

H.R. 5176, the Preventing Overdoses While in Emergency Rooms Act of 2018, would authorize $50 million in 2019 and require HHS to develop protocols and grant a program for health care providers to address the needs of people who survive a drug overdose. Rep. David McKinley (R-WV); https://www.govtrack.us/congress/bills/115/hr5176/text.

H.R. 5197, Alternatives to Opioids (ALTO) in the Emergency Department Act, would direct HHS to carry out a demonstration program for hospitals and emergency departments to develop alternative protocols in pain management that limit the use of opioids. Rep. Bill Pascrell, Jr. (D-NJ); https://www.govtrack.us/congress/bills/115/hr5197/text.

HR 5202, Ensuring Patient Access to Substance Use Disorder Treatments Act of 2018, would clarify permission for pharmacists to deliver controlled substances to providers under certain circumstances, i.e., delivered to the location listed on the practitioner’s certificate of DEA registration, for substance abuse treatment, or for intrathecal injection, and not for general dispensing by the practitioner. Rep. Ryan Costello (R-PA); https://www.govtrack.us/congress/bills/115/hr5202/text.

H.R. 5228, the Stop Counterfeit Drugs by Regulating and Enhancing Enforcement Now Act (the SCREEN Act), would require drug distributors to cease distributing any drug that HHS determines might present an imminent or substantial hazard to public health. CBO cannot determine what drugs could be subject to such an order nor can it determine how private entities would respond. Consequently, CBO cannot determine whether the aggregate cost of the mandate would exceed the annual threshold for private-sector mandates. Rep. Frank Pallone, Jr. (D-NJ); https://www.govtrack.us/congress/bills/115/hr5228/text.

H.R. 5261, Treatment, Education, and Community Help to Combat Addiction Act of 2018 (the TEACH to Combat Addiction Act of 2018), would direct HHS to designate regional centers of excellence to improve the training of health professionals who treat substance abuse disorders. Rep. Bill Johnson (R-OH); https://www.govtrack.us/congress/bills/115/hr5261/text.

H.R. 5272, Reinforcing Evidence-Based Standards Under Law in Treating Substance Abuse Act of 2018 (the RESULTS Act of 2018), would require the National Mental Health and Substance Use Laboratory to issue guidance to applicants for SAMHSA grants that support evidence-based practices. Steve Stivers (R-OH); https://www.govtrack.us/congress/bills/115/hr5272/text.

H.R. 5327, Comprehensive Opioid Recovery Centers Act of 2018, would direct HHS to award grants to at least 10 providers that offer treatment for people with opioid use disorder, and would authorize $10 million a year from 2019 – 2023. Rep. Brett Guthrie (R-KY); https://www.govtrack.us/congress/bills/115/hr5327/text.

H.R. 5353, the Eliminating Opioid Related Infectious Diseases Act of 2018, would amend the Public Health Service Act by broadening the surveillance and education about Hepatitis C prevention and treatment of infections associated with injected drug use. Rep. Leonard Lance (R-NJ); https://www.govtrack.us/congress/bills/115/hr5353/text.

H.R. 5483, Special Registration for Telemedicine Clarification Act of 2018, would amend the Controlled Substances Act to establish a deadline for the Drug Enforcement Administration to promulgate regulations for the special registration of practitioners to practice to telemedicine. Rep. Buddy Carter (R-GA); https://www.govtrack.us/congress/bills/115/hr5483/text.

H.R. 5580, the Surveillance and Testing of Opioids to Prevent Fentanyl Deaths Act of 2018 (STOP Fentanyl Deaths Act of 2018), would establish a grant program for public health laboratories that conduct testing for fentanyl and other synthetic opioids. It would direct the CDC to expand its drug surveillance program with a focus on collecting data for fentanyl. Rep. Ann Huster (D-NH); https://www.govtrack.us/congress/bills/115/hr5580/text.

H.R. 5587, Peer Support Communities of Recovery Act, would direct HHS to award grants to nonprofit organizations that support community-based, peer-delivered support, including technical support for the establishment of recovery community organizations, independent, nonprofit groups led by people in recovery and their families. The bill would authorize $15 million per year for the 2019-2023 period. Based on historical spending patterns for similar activities, CBO estimates that implementing H.R. 5587 would cost $62 million over the 2019-2023 period; the remaining amounts would be spent in years after 2023.

Rep. Ben Lujan (D-NM); https://www.govtrack.us/congress/bills/115/hr5587/text.

H.R. 5788, the Securing the International Mail Against Opioids Act of 2018, would provide for the processing by U.S. Customs and Border Protection of certain international mail shipments and to require the provision of advance electronic information on international mail shipments of mail.

Rep. Mike Bishop (R-MI); https://www.govtrack.us/congress/bills/115/hr5788/text.

H.R. 5812, the Creating Opportunities that Necessitate New and Enhanced Connections That Improve Opioid Navigation Strategies Act of 2018 (the CONNECTIONS Act), gives the Director of the Centers for Disease Control and Prevention authorization to carry out any evidence-based prevention activity and provide training and technical assistance to States, localities, and Indian tribes. Rep. Morgan Griffith (R-VA); https://www.govtrack.us/congress/bills/115/hr5812/text.

Soporifics and Soullessness

By Marilyn M. Singleton, M.D., J.D.

Have we lost our collective minds? A mass shooting with no readily apparent motive is an extreme representation of our sense that our social fabric is unraveling. This is one of those things that people don’t believe can happen until it happens. And despite the unspeakable tragedy, it took less than an hour for politicians to criticize the President ghoulishly exhorting that we need more than prayers and consolation. Maybe we do, but at least give the circle of victims a chance to deal with their personal grief before spouting off. At least CBS had the decency to fire its soulless vice president and senior counsel Hayley Geftman-Gold after she posted “I’m actually not even sympathetic bc [sic] country music fans often are Republican gun toters [sic].”

We have become a culture where Tim Tebow is mocked for kneeling in prayer before a football game while others are praised for “taking a knee” during the National Anthem—which by the way is not praying. Taking a knee in American football is when the quarterback drops to one knee immediately after receiving the snap, thus automatically ending the play. Taking a knee is a boring but effective move by the winning team toward the end of the game, as it does not allow the opponent the opportunity to regain possession of the ball. In urban lingo it means to take a temporary break from an activity.

Clearly, “taking a knee” is not praising a Higher Power that many on this earth believe in. And standing for the Anthem does not make one a racist. Note to partisan “news” presenters: when you push a pendulum on one direction really hard, when released it swings the other way with equal or greater force.

Living in virtual reality is no longer beyond the fringe. Children are becoming obese because they are participating in sports through video games rather than actually tossing around a ball to one another.

What happened to talking to each other? You don’t need a psychology professor to tell you that smart phones increase loneliness. Just walk down the street and you’ll see far too many couples walking, each with their own cell phone, obviously not talking to each other. Texting a few abbreviated words has replaced real conversation and emotional connection.

And we wonder why opiate use has risen to epidemic levels. People have always had their troubles. And man’s desire to avoid suffering whether physical or emotional, whether through alcohol, opium, mushrooms, or coca leaves has been documented for at least 9,000 years. But now the public has been convinced they can’t just be “high on life” and learn to cope. Big Pharma’s direct-to-consumer television ads quietly list innumerable side effects while extolling the virtues of their wares and the consumer’s inability to live without them.

Nearly 70 percent of Americans take at least one prescription drug. The statistics from the Rochester Epidemiology Project in Olmsted County, Minnesota (which are comparable to those elsewhere in the United States) reveal that the top three medications consumed are antibiotics (17%), antidepressants (13%), and opioids (11%). Antidepressants and opioids were the most commonly prescribed among young and middle-aged adults.

As physicians we do not want to become numb to patients’ needs while being consumed by government dictates. Electronic medical records should not become the excuse for hiding behind a computer screen—particularly with members of the younger generation who came out of the womb with a cell phone strapped to their ear by the umbilical cord. We need to be free to spend precious time getting to know our patients. Medications have saved countless lives, but prescriptions cannot become the tool to move along the overbooked office schedule or a quick fix to placate the demanding patient.

Let’s take heart. When left to our own devices and stripped of artificial political labels, we humans rise. Just ask our first responders and medical personnel or the hurricane volunteers or the victims helping victims or the thousands of people donating blood or the over 30,000 donors to the Go Fund Me page for the Las Vegas victims.

United we stand.


Dr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).

Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.

While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.

Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.

Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

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