Alcohol & Substance Abuse

Updated at 2:50 p.m. ET

President Donald Trump declared a public health emergency to deal with the opioid epidemic Thursday, freeing up some resources for treatment.

More than 140 Americans die every day from an opioid overdose, according to the Centers for Disease Control and Prevention.

“We are currently dealing with the worst drug crisis in American history,” Trump said, adding, “it’s just been so long in the making. Addressing it will require all of our effort.”

“We can be the generation that ends the opioid epidemic,” he said.

Trump also directed agency and department heads to use all appropriate emergency authorities to reduce the number of deaths caused by the opioid crisis.

Trump spoke personally about his brother Fred who struggled with alcoholism and died in his 40s. Because of him, Trump said, he had never tried alcohol or cigarettes. “He would tell me ‘don’t drink, don’t drink,’ ” Trump said. “He had a very, very, very tough life because of alcohol.”

The administration will also launch an ad campaign so that young people can see “the devastation and ruination [drugs cause] people and people’s lives.”

The move stops short of declaring the crisis a national emergency, which Trump first said in August that he would declare. He repeated that pledge this week. But the White House said it determined that declaring a public health emergency was more appropriate than a national emergency.

Dr. Andrew Kolodny, co-director of the Opioid Policy Research Collaboration at Brandeis University’s Heller School, calls the announcement “very disappointing.” Without funding for new addiction treatment, he says, declaring a public health emergency isn’t enough. “This is not a plan,” he says. “The administration still has no plan” for dealing with opioids, he says.

After taking office, Trump created a commission to study the opioid crisis, headed by New Jersey Gov. Chris Christie. In an interim report, the commission called on the president to declare a national emergency under either the Public Health Service Act or the Stafford Act. Doing so, the commission said, could free up funds for treatment, ensure wider access to the anti-overdose drug naloxone and improve monitoring of opioid prescriptions to prevent abuse.

Public health emergencies expire after 90 days, although the administration says they can easily be renewed. The designation gives the administration access to the Public Health Emergency Fund, but that fund is nearly empty.

In outlining its opioid plan, administration officials highlighted four areas. It allows expanded access to telemedicine services, giving doctors the ability to prescribe medications to treat addiction to those in remote locations. It speeds the hiring process for medical professionals working on opioids. And it allows funds in programs for dislocated workers and people with HIV/AIDS to be used to treat their addictions.

Dr. Keith Humphreys, a professor of psychiatry at Stanford University and a former adviser in the Obama administration, calls the Trump administration’s response “pathetic,” saying it mostly repurposes long-existing public health programs. Humphreys notes that aside from the emergency declaration, there is little that was recommended by the White House commission in the president’s plan.

The commission had also recommended rapidly increasing treatment capacity for recovering addicts by granting Medicaid waivers, mandating educational initiatives at medical and dental schools to tighten opioid prescribing, and funding a program to expand access to medications used to treat addictions.

In a briefing Thursday, the administration said some of these initiatives are underway. The Food and Drug Administration has already expanded education requirements around prescribing opioids, officials said. Just this week, the FDA director told a congressional committee that the agency will begin working to promote medication-assisted treatment — using methadone, buprenorphine or naltrexone to help addicts in recovery — although that initiative doesn’t carry any additional funding.

The final report of the White House’s commission on opioids is due next week. On Thursday, Christie praised the president for what he called “bold action.”

Christie said, “The President is showing an unprecedented commitment to fighting this epidemic and placing the weight of the Presidency behind saving lives across the country.”

The biggest question mark surrounding the president’s plan for addressing opioids involves money. Congress is currently spending $500 million a year on addiction treatment programs, but that money runs out next year. The administration says it will work with Congress in the budgeting process to find new money to fund addiction treatment programs. This week, a group of Democratic senators introduced a bill that would provide more than $45 billion for opioid abuse prevention, surveillance and treatment. Not coincidentally, that is the same amount of money Republican sponsors included for preventing opioid abuse in bills that would have repealed the Affordable Care Act.

Humphreys, a former official in the Office of National Drug Control Policy, says that if the president is serious about opioids, he should endorse that bill. Another option would be to restore a funding cut proposed for Substance Abuse and Mental Health Services Administration, the agency within the Department of Health and Human Services that oversees addiction treatment programs. In its 2018 budget, the Trump administration is proposing cutting the agency’s budget by nearly $400 million.

Copyright 2017 NPR. To see more, visit http://www.npr.org/.

Many Alaskans are calling for the repeal of last year’s criminal justice overhaul. Others want the law to be given more time.

The Legislature is trying to follow a middle path, which may leave many dissatisfied.

Alaskans disturbed about rising crime are focusing their anger on a law passed more than a year ago, Senate Bill 91. The law was the subject of intense testimony Tuesday night.

Sherry Miller from Eagle River said she’s concerned the law will repeatedly require her family to confront David Joseph Thomas, the man who killed her daughter, Linda Bower, three years ago.

“If he is denied parole, this murderer gets an automatic parole hearing every two years until granted,” Miller said. “This means that me and my family have to endure this monster – and horror of her murder – every two years until parole is granted.”

Most people who spoke during more than three hours Tuesday night expressed concern during public testimony about SB 91.

Anchorage resident Leonard Martens said his cousin Gregory Gill was killed in September by a man who had committed earlier offenses.

Martens said these offenses should have led to tougher penalties than the new law allows.

“I urge you to repeal SB 91 and take SB 54 off the table until we can put facilities in place to do the treatment and the rehabilitation,” Martens said. “You got the cart ahead of the horse on this, guys.”

But while lawmakers are looking to make changes to SB 91, they’re unlikely to support the repeal of the law.

Instead, the debate is focusing on Senate Bill 54, a measure that would make limited changes to the law.

It would increase the penalties for those who commit class C felonies and petty thefts, as well as those who violate the conditions of release.

Some members of the public are cautioning lawmakers against acting too quickly to reverse SB 91. They said the reductions in jail time under the law are providing savings that will fund treatment and other services for offenders. They said these services will reduce the number of repeat offenders.

Ketchikan resident Christine Furey said she has struggled with addiction, and that substance abuse led to the early deaths of her sister and her best friend.

She doesn’t want to see the law repealed.

“It’s like you guys are dangling a way out in front of our faces just to rip it away without giving us a chance, without giving the people who have supported these bills a chance,” she said.

And police chiefs who spoke during the hearing supported passing SB 54.

Soldotna Police Chief Peter Mlynarik said the Legislature should take several steps to support police. He said it should begin by passing SB54 and increasing funding for public safety. Then it should take more actions.

“Fulfill the promises of SB 91, so fund drug and alcohol rehabilitation programs,” he said. “Place statutory limitation on releasing repeat offenders on their own recognizance. Restore the bail schedule. And enable courts to sanction those who pays fines and restitution.”

The House Judiciary Committee debated amendments to Senate Bill 54 today.

Alaska Republican Sen. Lisa Murkowski sent a letter Thursday with her Democratic colleague Elizabeth Warren of Massachusetts to the president regarding the nation-wide opioid epidemic.

The four-page document frames the health crisis as a bipartisan issue, and lays blame for a lackluster policy response squarely in one place.

Murkowski and Warren are critical of President Donald Trump’s response to the opioid crisis, specifically what they believe is a lack of action from the administration after promising to tackle the issue.

The senators point to a statement the president made in August at his Bedminster, N.J., golf club.

“The opioid crisis is an emergency, and I’m saying officially right now it is an emergency, it’s a national emergency,” Trump said Aug. 10 in a response to a question from a reporter. “We’re going to spend a lot of time, a lot of effort and a lot of money on the opioid crisis.”

“But do you need emergency powers to address it?” the reporter followed up.

“We’re going to draw it up and we’re going to make it a national emergency,” Trump replied. “It is a serious problem, the likes of which we have never had.”

The designation of a “national emergency” is significant because it unlocks funding and can potentially waive federal rules that would make access to treatment more widely available.

Just two days earlier, on Aug 8, former Health and Human Services Secretary Tom Price stopped short of pushing for an official declaration, saying the federal government could bring the necessary resources to bear on the problem without the designation.

In their letter to Trump, Warren and Murkowski wrote, “We are extremely concerned that 63 days after your statement you have yet to take the necessary steps to declare a national emergency on opioids, nor have you made any proposals to significantly increase funding to combat the epidemic.”

Alaska and Massachusetts are two of the six states that have declared health emergencies related to opioids and heroin.

In the months since Alaska Gov. Bill Walker declared a public health emergency, first-responders, volunteers and law enforcement officials have been able to get thousands of doses of the overdose-reversing medication nalaxone.

The move also allowed state officials to pursue federal grants and new treatment programs aimed at curbing addiction, and it spurred the Legislature to pass bills that reduce access to prescription pain medications.

The senators point to guidance issued by the Trump administration’s Commission on Combating Drug Addiction and the Opioid Crisis, which recommended the federal government follow steps taken by states like Alaska and Massachusetts.

Both Warren and Murkowski sit on the Senate’s Health, Education, Labor, and Pensions committee. They’ve been signatories together on similar bipartisan efforts under the current administration, like a March letter to Attorney General Jeff Sessions asking for clarity on federal marijuana enforcement.

A spokesman for Sen. Dan Sullivan said he didn’t sign the letter because had not had time to thoroughly review it in advance.

This story was co-published with The New York Times.

At a time when the United States is in the grip of an opioid epidemic, many insurers are limiting access to pain medications that carry a lower risk of addiction or dependence, even as they provide comparatively easy access to generic opioid medications.

The reason, experts say: Opioid drugs are generally cheap while safer alternatives are often more expensive.

Drugmakers, pharmaceutical distributors, pharmacies and doctors have come under intense scrutiny in recent years, but the role that insurers — and the pharmacy benefit managers that run their drug plans — have played in the opioid crisis has received less attention. That may be changing, however. The New York State attorney general’s office sent letters last week to the three largest pharmacy benefit managers — CVS Caremark, Express Scripts and OptumRx — asking how they were addressing the crisis.

ProPublica and The New York Times analyzed Medicare prescription drug plans covering 35.7 million people in the second quarter of this year. Only one-third of the people covered, for example, had any access to Butrans, a painkilling skin patch that contains a less-risky opioid, buprenorphine. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval for them.

In contrast, almost every plan covered common opioids and very few required any prior approval.

The insurers have also erected more hurdles to approving addiction treatments than for the addictive substances themselves, the analysis found.

Alisa Erkes lives with stabbing pain in her abdomen that, for more than two years, was made tolerable by Butrans. But in January, her insurer, UnitedHealthcare, stopped covering the drug, which had cost the company $342 for a four-week supply. After unsuccessfully appealing the denial, Erkes and her doctor scrambled to find a replacement that would quiet her excruciating stomach pains. They eventually settled on long-acting morphine, a cheaper opioid that UnitedHealthcare covered with no questions asked. It costs her and her insurer a total of $29 for a month’s supply.

The Drug Enforcement Administration places morphine in a higher category than Butrans for risk of abuse and dependence. Addiction experts say that buprenorphine also carries a lower risk of overdose.

UnitedHealthcare, the nation’s largest health insurer, places morphine on its lowest-cost drug coverage tier with no prior permission required, while in many cases excluding Butrans. And it places Lyrica, a non-opioid, brand-name drug that treats nerve pain, on its most expensive tier, requiring patients to try other drugs first.

Erkes, who is 28 and lives in Smyrna, Georgia, is afraid of becoming addicted and has asked her husband to keep a close watch on her. “Because my Butrans was denied, I have had to jump into addictive drugs,” she said.

UnitedHealthcare said Erkes had not exhausted her appeals, including the right to ask a third party to review her case. It said in a statement, “We will work with her physician to find the best option for her current health status.”

Matthew N. Wiggin, a spokesman for UnitedHealthcare, said that the company was trying to reduce long-term use of opioids. “All opioids are addictive, which is why we work with care providers and members to promote non-opioid treatment options for people suffering from chronic pain,” he said.

Dr. Thomas R. Frieden, who led the Centers for Disease Control and Prevention under President Obama, said that insurance companies, with few exceptions, had “not done what they need to do to address” the opioid epidemic. Right now, he noted, it is easier for most patients to get opioids than treatment for addiction.

Leo Beletsky, an associate professor of law and health sciences at Northeastern University, went further, calling the insurance system “one of the major causes of the crisis” because doctors are given incentives to use less expensive treatments that provide fast relief.

The Department of Health and Human Services is studying whether insurance companies make opioids more accessible than other pain treatments. An early analysis suggests that they are placing fewer restrictions on opioids than on less addictive, non-opioid medications and non-drug treatments like physical therapy, said Christopher M. Jones, a senior policy official at the department.

Insurers say they have been addressing the issue on many fronts, including monitoring patients’ opioid prescriptions, as well as doctors’ prescribing patterns. “We have a very comprehensive approach toward identifying in advance who might be getting into trouble, and who may be on that trajectory toward becoming dependent on opioids,” said Dr. Mark Friedlander, the chief medical officer of Aetna Behavioral Health who participates on its opioid task force.

Aetna and other insurers say they have seen marked declines in monthly opioid prescriptions in the past year or so. At least two large pharmacy benefit managers announced this year that they would limit coverage of new prescriptions for pain pills to a seven- or 10-day supply. And bowing to public pressure — not to mention government investigations — several insurers have removed barriers that had made it difficult to get coverage for drugs that treat addiction, like Suboxone.

Experts in addiction note that the opioid epidemic has been changing and that the problem now appears to be rooted more in the illicit trade of heroin and fentanyl. But the potential for addiction to prescribed opioids is real: 20 percent of patients who receive an initial 10-day prescription for opioids will still be using the drugs after a year, according to a recent analysis by the CDC.

Several patients said in interviews that they were terrified of becoming dependent on opioid medications and were unwilling to take them, despite their pain.

In 2009, Amanda Jantzi weaned herself off opioids by switching to the more expensive Lyrica to treat the pain associated with interstitial cystitis, a chronic bladder condition.

But earlier this year, Jantzi, who is 33 and lives in Virginia, switched jobs and got a new insurer — Anthem — which said it would not cover Lyrica because there was not sufficient evidence to prove that it worked for interstitial cystitis. Jantzi’s appeal was denied. She cannot afford the roughly $520 monthly retail price of Lyrica, she said, so she takes generic gabapentin, a related, cheaper drug. She said it does not manage the pain as well as Lyrica, which she took for eight years. “It’s infuriating,” she said.

Jantzi said she wanted to avoid returning to opioids. However, “I could see other people, faced with a similar situation, saying, ‘I can’t live like this, I’m going to need to go back to painkillers,’ ” she said.

In a statement, Anthem said that its members have to meet certain requirements before it will pay for Lyrica. Members can apply for an exception, the insurer said. Jantzi said she did just that and was turned down.

With Butrans, the drug that Erkes was denied, several insurers either do not cover it, require a high out-of-pocket payment, or will pay for it only after a patient has tried other opioids and failed to get relief.

In one case, OptumRx, which is owned by UnitedHealth Group, suggested that a member taking Butrans consider switching to a “lower cost alternative,” such as OxyContin or extended-release morphine, according to a letter provided by the member.

Wiggin, the UnitedHealthcare spokesman, said the company’s rules and preferred drug list “are designed to ensure members have access to drugs they need for acute situations, such as post-surgical care or serious injury, or ongoing cancer treatment and end of life care,” as well as for long-term use after alternatives are tried.

Butrans is sold by Purdue Pharma, which has been accused of fueling the opioid epidemic through its aggressive marketing of OxyContin. Butrans is meant for patients for whom other medications, like immediate-release opioids or anti-inflammatory pain drugs, have failed to work, and some scientific analyses say there is not enough evidence to show it works better than other drugs for pain.

Dr. Andrew Kolodny is a critic of widespread opioid prescribing and a co-director of opioid policy research at the Heller School for Social Policy and Management at Brandeis University. Kolodny said he was no fan of Butrans because he did not believe it was effective for chronic pain, but he objected to insurers suggesting that patients instead take a “cheaper, more dangerous opioid.”

“That’s stupid,” he said.

and I am now forced to be on stronger pain meds after dealing with out of control pain for weeks. How is this ok?

— Alisa Erkes (@alisa2089) April 27, 2017

Erkes’s pain specialist, Dr. Jordan Tate, said her patient had been stable on the Butrans patch until January, when UnitedHealthcare stopped covering the product and denied Erkes’s appeal.

Without Butrans, Erkes, who once visited the doctor every two months, was now in Tate’s office much more frequently, and once went to the emergency room because she could not control her pain, thought to be related to an autoimmune disorder, Behcet’s disease.

Tate said she and Erkes reluctantly settled on extended-release morphine, a drug that UnitedHealthcare approved without any prior authorization, even though morphine is considered more addictive than the Butrans patch. She also takes hydrocodone when the pain spikes and Lyrica, which UnitedHealthcare approved after requiring a prior authorization.

Erkes acknowledged that she could have continued with further appeals, but said the process exhausted her and she eventually gave up.

While Tate said Erkes had not shown signs of abusing painkillers, her situation was far from ideal. “She’s in her 20s and she’s on extended-release morphine — it’s just not the pretty story that it was six months ago.”

Many experts who study opioid abuse say they also are concerned about insurers’ limits on addiction treatments. Some state Medicaid programs for the poor, which pay for a large share of addiction treatments, continue to require advance approval before Suboxone can be prescribed or they place time limits on its use, both of which interfere with treatment, said Lindsey Vuolo, associate director of health law and policy at the National Center on Addiction and Substance Abuse. Drugs like Suboxone, or its generic equivalent, are used to wean people off opioids but can also be misused.

The analysis by ProPublica and The Times found that restrictions remain prevalent in Medicare plans, as well. Drug plans covering 33.6 million people include Suboxone, but two-thirds require prior authorization. Even when such requirements do not exist, the out-of-pocket costs of the drugs are often unaffordable, a number of pharmacists and doctors said.

At Dr. Shawn Ryan’s addiction-treatment practice in Cincinnati, called BrightView, staff members often take patients to the pharmacy to fill their prescriptions for addiction medications and then watch them take their first dose. Research has shown that such oversight improves the odds of success. But when it takes hours to gain approval, some patients leave, said Ryan, who is also president of the Ohio Society of Addiction Medicine.

“The guy walks out, and you can’t blame him,” Ryan said. “He’s like, ‘Hey man, I’m here to get help. What’s the deal?’”

Craft distilleries in Alaska are reeling after a decision that could change the part of their businesses most accessible to the public: tasting rooms.

Distilleries have been operating tasting rooms since 2014 legislation allowing that practice.

But now, state officials say distilleries aren’t allowed to serve mixed drinks.

The tasting room at the Port Chilkoot Distillery in Haines opened almost three years ago, serving cocktails like ‘High Bush Cranberry Gimlets,’ ‘Spruced Up Gin,’ and ‘Moscow Moose.’

Craft distilling is a growing industry in Alaska, with nine currently in the state.

Port Chilkoot part-owner Heather Shade says the tasting room has been a crucial part of their growth.

“The tasting rooms allow a small business to start up, they allow us to succeed in a challenging economic environment in the state,” Shade said. “And it allows up to grow our staff, infrastructure and distribution by having cash flow into our businesses to do that.”

Shade is trying to figure out how this part of her business will be affected by a recent decision from the State’s Alcoholic Beverage Control Board.

A complaint against Juneau’s new distillery brought attention to a potential gray-area in Alaska statute.

The legislation that allows distilleries to open tasting rooms says they can sell their own product.

ABC Board Director Erika McConnell points out that doesn’t include the other beverages that distilleries use to make cocktails, like the vermouth in a martini.

In a memo to the board McConnell writes, “There is nothing in the statutory language itself to suggest that a bloody Mary, a martini, or a margarita qualifies as ‘the distillery’s product.’”

Shade said there’s a reason for not serving spirits straight up.

“The purpose of mixing our products with ingredients and ice and serving them in this way is that so people know how it’s going to taste in their cocktail,” Shade said. “They know how they might want to make it at home.”

But the board sided with McConnell and voted to uphold an advisory that prohibits the sale of mixed drinks made with outside products, starting immediately.

Port Chilkoot does make a lot of its own mixers on-site, including ginger beer, Shade said.

“We’re going to continue operating the way we’ve been,” she said. “We produce our ice on site. We produce our juices and syrups and almost everything.”

She said they will stop using alcoholic mixers produced off-site.

At the recently-opened Amalga Distillery in Juneau, Brandon Howard said the same – they’re not going to stop serving cocktails.

Amalga makes its own ginger beer and tonic water that it uses is most of its drinks, Howard said.

“Until we have clarity from the board and until we know that these regulations that they’re considering are completely legal, yes, we are going to continue doing what we’re doing,” Howard said.

Both Shade and Howard said not only would serving exclusively straight spirits take away from the experience of the drink, they don’t think it’s responsible.

“I think it’s irresponsible to serve an individual basically three ounce shots of gin and then just send them out,” Howard said. “The mixed drink part of our business is not an insignificant part, but the way in which it leads to bottle sales for us is massive.”

According to ABC Board’s McConnell, it is okay for the businesses to continue mixing drinks with products they make themselves.

Dale Fox is the president and CEO of Alaska CHARR – that’s Cabaret, Hotel, Restaurant and Retailers Association. Fox said  CHARR helped get the original legislation passed, and now they agree with the ABC Board’s decision to limit tasting rooms.

“It’s morphed into bringing in other spirits that are not the product of that distillery,” Fox said. “Mixing drinks, entertainment and a whole series of other things that were not allowed in that provision.”

Fox said if you want to mix drinks, get a bar license. That’s why he said even if state lawmakers clarify the rules and allow for the sale of cocktails at distilleries, CHARR probably won’t support it.

State Rep. Chris Tuck said new legislation is on the way.

“We will be introducing something to rectify the situation.”

Tuck was the primary sponsor on the tasting room legislation back in 2014. He and several other legislators wrote to the ABC Board to say they never meant to prohibit distilleries from serving mixed drinks.

“When we had our grand opening of the bill signing, even then at that ceremony we had mixed tastings for people to try,” Tuck said.

McConnell said the board will be looking closer at regulations around distilleries.

Shade and Howard are challenging the state’s interpretation. They say for now they will continue with business as usual. That includes cocktails.

Alaska State Troopers say a man arrested in Anchorage with heroin that was headed for Bethel. Troopers report that the man was attempting to smuggle the drugs by hiding them inside his body.

According to court documents, troopers approached William “Billy” Aloysius, 33, at the Ted Stevens Anchorage International Airport on August 31 as he was waiting for his flight home to Bethel.

Troopers already were investigating Aloysius after receiving tips that he could be distributing drugs.

Aloysius consented to a luggage search and troopers found a glass smoking pipe, often used to smoke methamphetamine, in his carry-on. Aloysius “admitted to consuming both methamphetamine and heroin.”

Troopers then obtained a second search warrant and transported Aloysius to the Alaska Native Medical Center for a CT scan.

The investigation revealed a foreign object identified as 19.8 grams of black tar heroin in Aloysius’ rectum. The drug’s street value in Bethel runs between $19,800 to $23,000 according to Troopers.

Aloysius is charged with a class B felony and is being held in the Anchorage Correctional Complex.