The National Attorneys General Training & Research Institute
Substance Abuse Newsletter September 2017
The following is a compendium of news reports over the past month that may be of interest to our AG offices who are dealing with substance abuse issues. Neither the National Association of Attorneys General nor the National Attorneys General Training & Research Institute expresses a view as to the accuracy of news accounts, nor as to the position expounded by the authors of the hyperlinked articles.
The National Association of Attorneys General (NAAG) has sent a letter to America’s Health Insurance Plans (AHIP), asking its insurance company members to review payment and coverage policies and revise them, as needed, to encourage healthcare providers to choose alternatives to prescribing prescription pain relievers known as opioids. Opioid overdoses kill 91 Americans every single day. More than half of those deaths involve prescription opioids. Codeine, hydrocodone (e.g. Vicodin), morphine and oxycodone (e.g. OxyContin, Percocet) fall into this medication class. “When patients seek treatment for any of the myriad conditions that cause chronic pain, doctors should be encouraged to explore and prescribe effective non-opioid alternatives, ranging from non-opioid medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) to physical therapy, acupuncture, massage, and chiropractic care,” reads the NAAG letter signed by 37 state and territorial attorneys general. The full content of letter may be accessed here.
The U.S. Drug Enforcement Administration is proposing a reduction for controlled substances that may be manufactured in the U.S. next year by 20 percent as compared to 2017, per the notice published in the Federal Register on August 7, 2017 and available for public inspection. The DEA has proposed to reduce more commonly prescribed schedule II opioid painkillers, including oxycodone, hydrocodone, oxymorphone, hydromorphone, morphine, codeine, meperidine and fentanyl. Demand for these opioid medicines has dropped, according to sales data obtained by DEA from IMS Health, a company that provides insurance companies with data on prescriptions written and prescription medications sold in America. The Proposed Aggregate Production Quotas (APQ) for Schedule I and II controlled substances that is being published in the Federal Register reflects the total amount of controlled substances needed to meet the country’s legitimate medical, scientific, research, industrial, and export needs for the year and for the maintenance of reserve stocks. The Federal Register notice is available here.
Attorney General Jeff Sessions announced the formation of the Opioid Fraud and Abuse Detection Unit, a new Department of Justice pilot program to utilize data to help combat the devastating opioid crisis that is ravaging families and communities across America. Attorney General Sessions said that the new Opioid Fraud and Abuse Detection Unit will focus specifically on opioid-related health care fraud using data to identify and prosecute individuals that are contributing to this prescription opioid epidemic. Additionally, as part of the program, the Department will fund twelve experienced Assistant United States Attorneys for a three year term to focus solely on investigating and prosecuting health care fraud related to prescription opioids, including pill mill schemes and pharmacies that unlawfully divert or dispense prescription opioids for illegitimate purposes. The following districts have been selected to participate in the program: Middle District of Florida, Eastern District of Michigan, Northern District of Alabama, Eastern District of Tennessee, District of Nevada, Eastern District of Kentucky, District of Maryland, Western District of Pennsylvania, Southern District of Ohio, Eastern District of California, Middle District of North Carolina, and the Southern District of West Virginia.
The U.S. Department of Health and Human Services Office on Women's Health (OWH) recently released the Final Report: Opioid Use, Misuse, and Overdose in Women. The report examines prevention, treatment, and recovery issues for women who misuse opioids, have opioid use disorders, and/or overdose on opioids. It also presents findings and takeaways from OWH's national and regional opioid meetings held in 2016.
The AMA Opioid Task Force this week released an updated naloxone guidance document for physicians and other health professionals to encourage them to co-prescribe naloxone when clinically appropriate. The updated resource recommends that physicians consider several key questions that the task force believes can be helpful when determining whether to co-prescribe naloxone to a patient, or to a family member or close friend of the patient: Is the patient receiving a high dose of opioids?; Does the patient also have a prescription for a benzodiazepine?; Does the patient have a history of substance use disorder?; Does the patient have an underlying mental health or other medical condition that makes him or her more susceptible to overdose? Would the patient be in a position to help another person at risk of overdose? The AMA document may be accessed here.
Kansas Attorney General and NAAG President Derrick Schmidt has written an article for The Hill titled: State Attorneys General: Local responses to a nationwide crisis. The article may be accessed here.
Drug companies and the federal government will partner to develop new pain medications that are less addictive than the drugs that fueled the nation’s opioid epidemic, Gov. Chris Christie said Monday. Christie, who chairs President Trump’s commission on combatting opioid addiction, announced a plan for a public-private partnership to fast track the creation of non-opioid drugs and alternative treatment options for those already addicted. He made the announcement after meeting with Trump counselor Kellyanne Conway and several leaders of the pharmaceutical industry, National Institute of Health and Federal Drug Administration.
Maryland’s Garrett College, Frostburg State University (FSU), and Allegany College of Maryland (ACM) and now require incoming full-time students to complete an education program in relation to heroin and opioids as part of a new Maryland law. The Start Talking Maryland Act of 2017 became law July 1. It requires schools to offer drug education that includes the dangers of heroin and other opioids starting as early as third grade. Each school approaches the way students are trained a little differently. Garrett College and Allegany College require the training through Blackboard, a tool that allows faculty to add resources for students to access online. Allegany will have a training program on Blackboard for incoming spring 2018 semester students. Currently, there isn’t state funding for the training programs, said Renee Conner, dean at ACM. FSU pays for the online educational platform for the program utilizing fines from students who violate the university’s judicial and substance abuse programs. The remainder of the cost is absorbed by FSU’s operating budget.
Alabama Attorney General Steve Marshall has been appointed by Governor Kay Ivey to co-chair the newly-created Alabama Opioid Overdose and Addiction Council. The Council, which was established by Executive Order on August 8, will examine the state’s opioid crisis and identify ways to reduce its harmful impact on Alabamians.
West Virginia Attorney General Patrick Morrisey announced his office will kick off its “Opioid Abuse Prevention Game of the Week” initiative for a second consecutive year. The effort won praise last year engaging with teams and communities at nearly 60 games across the Mountain State. The Attorney General’s Office staffs an information booth at select high school sporting events to distribute opioid abuse awareness materials. Field representatives also discuss the dangers of opioid use with the respective coaches and provide educational material for display and distribution in the schools to foster more discussion of the issue. The initiative is part of a broader partnership to tackle opioid use in high school athletics. It involves the Attorney General’s Office, West Virginia Secondary School Activities Commission and the West Virginia Board of Medicine.
Oklahoma Attorney General Mike Hunter has announced the names of the individuals who will serve on the Oklahoma Commission on Opioid Abuse. The nine-member commission, chaired by Attorney General Hunter, contains members from the medical community, law enforcement, private sector businesses and a member from the Oklahoma House, Senate and includes two members as advisers. Attorney General Hunter, Gov. Mary Fallin, House Speaker Charles McCall and Senate President Pro Tempore Mike Schulz selected the members of the commission after the passage of Senate Concurrent Resolution 12 in May. The full list of appointed members may be accessed here.
In conjunction with National Prescription Opioid and Heroin Epidemic Awareness Week, Arkansas Attorney General Leslie Rutledge today launched a first-in-the-nation education initiative called “Prescription for Life” at Fort Smith Southside High School. Prescription for Life features a digital platform to help high school students in the State understand the dangers of prescription drug misuse and how to prevent abuse. Southside High School is the first institution to use the program in the country after Rutledge announced the creation of the initiative in July, which comes at no cost to participating schools in Arkansas. “If Prescription for Life helps save just one life and creates a dialogue with high school students about opioid abuse, then the program is a success,” said Attorney General Rutledge. “Arkansas is the first in the nation to launch such an educational program, and it is my goal that it will become a model for other states to adopt. I know that Fort Smith Southside will not regret bringing this curriculum to their classrooms.”
States are enacting strict limits on the number of powerful prescription painkillers doctors can prescribe, a move that many believe will help fight the opioid crisis but has raised alarms among some physicians. At least 17 states have enacted rules to curb the number of painkillers doctors can prescribe. Some, including Arizona, Connecticut, Delaware, Massachusetts, New Jersey and Ohio, have passed laws limiting the duration of initial opioid prescriptions to five or seven days. Others are passing dosage limits. In Kentucky, a law went into effect last month capping opioid prescriptions for acute pain to three days. Kentucky, like most other states, has exemptions for cancer and hospice patients, major surgeries and patients dealing with severe or chronic pain. she said. Patrice Harris, chair of the American Medical Association board of trustees, said doctors recognize that it is important to cut back on the number of opioids that are prescribed. “I think there’s been a general agreement that we need to be more judicious in our prescribing,” she said.
Deaths associated with opioid overdoses in hospital intensive care units nearly doubled over a seven-year period from 2009 and 2015, and the costs of treating overdose victims in the ICU has skyrocketed, researchers report. The average cost of caring for an opioid overdose patient in the ICU increased by 58% from $58,500 to $92,400, according to a retrospective analysis of hospital billing records from 162 hospitals in 44 states. Admissions to ICUs linked to opioid overdoses increased by 34% at the hospitals from January of 2009 to September 2015, according to the analysis appearing online in Annals of the American Thoracic Society. Lead researcher Jennifer P. Stevens, MD, of Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, said the study is among the first to quantify the impact of the opioid epidemic on the nation's ICUs. She said the findings highlight a "new level of crisis" associated with overdoses of prescription and illicit opioids.
Hawaii has decided to turn its medical marijuana program into a <href="#103160021c63">cashless payment system in the hopes of avoiding the problems that other states and businesses have faced when dealing large sums of cash. The goal is that by October 1, all of Hawaii’s licensed dispensaries will no longer use cash, but instead ask their customers to pay with a debit payment app. Governor David Ige stated: “Cannabis is illegal at the federal level, still a schedule one controlled substance. Because of this, all financial institutions in Hawaii have decided against providing banking services to the dispensaries. This solution allows the dispensaries to be able to write checks, to do all of the normal financial transactions that most businesses would do.” Hawaii legalized medical marijuana in 2000, but only recently implemented its program. Banking has been tremendously difficult for cannabis companies. The major banks refuse to work with these businesses because marijuana is still federally illegal. The major credit card companies have also turned their backs on customers wanting to use their bank cards to engage in such transactions.
Surety Bond Authority, Inc., a surety bond company based in California, is now expanding its service reach by providing marijuana surety bonds in every state that require them as part of the licensing, adult use, and tax payments guarantee of marijuana establishments. The legalization of medical and recreational marijuana has seen significant changes in the marijuana industry. With various jurisdictions endeavoring to regulate the industry and setting what type of bond conditions should be implemented, laws are enacted that require marijuana establishments, such as cultivators, dispensaries, processors, and retailers, to post surety bonds as part of business licensure requirements. To ensure a healthy, legal economy, marijuana surety bonds guarantee payment of all sales and excise taxes due to the government and indemnifies a state or city against all claims arising from the issuance of a license or permit.
The National Highway Traffic safety Administration has released a Report to Congress on marijuana that discusses the current state of knowledge, the challenges of trying to develop a reliable test to determine impairment, and recommendations for the future. The report may be accessed here.
Attorney General Brad Schimel announced he will be appointing an assistant attorney general to assist local district attorneys and law enforcement in the prosecution of methamphetamine-related cases. In February 2017, Attorney General Schimel briefed the Wisconsin State Legislature on the growing threat of methamphetamine and included findings from a January 2017 joint Wisconsin Department of Justice and Federal Bureau of Investigation study. The report details methamphetamine use increased 250 to 300 percent from 2011 to 2015. Recently, the Wisconsin State Crime Laboratory Bureau (WSCLB) has experienced a 13.5% increase in methamphetamine submissions, from 1,012 in 2015 to 1,149 in 2016. There is also anecdotal evidence that some opiate addicts are switching from the use of prescription drugs and heroin, to methamphetamine. AG Schimel announced that the new assistant attorney general will be located in Eau Claire and work in the Division of Criminal Investigation (DCI)’s Eau Claire field office. Basing them out of this office will allow them to respond quickly and effectively to cases throughout the northwest part of the state involving methamphetamine trafficking and to work proactively with both DCI criminal agents and outside law enforcement agencies. The new methamphetamine assistant attorney general will represent the state in criminal cases; advise local prosecutors on matters relating to methamphetamine trafficking; and assist in the development of legislation concerning the growing threat that methamphetamine poses to local communities.
The stimulant methamphetamine is linked to a heightened risk of stroke among young people, reveals a review of the available evidence, published in the Journal of Neurology Neurosurgery & Psychiatry. A stroke caused by a bleed into the brain (haemorrhagic) rather than a clot (ischaemic) is the most common type associated with taking this drug, with men twice as likely to succumb as women, the findings show. Given the often disabling or fatal consequences of a stroke, and the increasing use of methamphetamine among young people, particularly in countries around the Pacific rim (North America, East and Southeast Asia, and Oceania), the findings are a cause for concern, warn the researchers. They base their findings on a comprehensive trawl of research looking at a potential link between methamphetamine use and associated stroke risk in young people (under the age of 45), and published up to February 2017. The report may be accessed here.
Local, state, and federal authorities worked together to bust a multi-million dollar methamphetamine operation in Dahlonega, GA, all starting with a traffic stop. Investigators said they first found 15 kilograms of the drug on Angel Luis Rivera-Santiago and Victor Rafael Aponte after the pair were pulled over. From there, FBI and Lumpkin County officials searched a second location, where cocaine and $166,000 were also found. The investigation then took officials to a third location, where they discovered a methamphetamine conversion lab. Once the street value of the drug was totaled, agents with the Georgia Bureau of Investigation said the 30 kilograms of crystal methamphetamine was valued at $3,234,000.
An Arizona drug company has agreed to pay Illinois $4.45 million to settle allegations that it deceptively marketed and sold a prescription opioid drug for uses not approved by the U.S. Food and Drug Administration. The settlement became official on August 18, 2017. Insys did not admit to any liability or wrongdoing as part of the settlement agreement. Illinois sued the company in August of 2016 in Cook County Circuit Court, alleging Insys deceptively marketed and sold Subsys, a form of the prescription opioid drug fentanyl that's sprayed under the tongue. The drug is intended to treat patients suffering from cancer pain. The company heavily marketed the drug to Illinois doctors with records of prescribing high volumes of opioids regardless of whether those doctors were prescribing opioids to treat cancer pain, the state alleged.
The coroner who released the controversial report saying kratom use led to the death of Tupper Lake, NY police Sgt. Matthew Dana has provided more information about the investigative process that led up to his ruling. The coroner’s report says Dana suffered a hemorrhagic pulmonary edema — blood in the lungs — as a result of an overdose of kratom. Franklin County Coroner Shawn Stuart said Dana was taking the Red Vein Maeng Da strain of kratom as a powder form, either putting it into capsules or just using a spoonful and a glass of water. Dana died Aug. 6 at the Tupper Lake home he shared with his girlfriend. Stuart worked alongside local medical examiner Dr. C. Francis Varga, and the Pennsylvania-based National Medical Services Labs performed the toxicology testing. The accredited, privately owned laboratories discovered no narcotics or opioids in Dana’s blood, Stuart said.
West Virginia Attorney General Patrick Morrisey, in cooperation with the state’s Department of Health and Human Resources (DHHR) and its Office of Health Facility Licensure and Certification (OHFLAC), won a court order enforcing a $380,500 penalty against an illegal pain clinic. The court order found that Dr. Yasar Aksoy, MD, engaged in severe violations of the state’s Chronic Pain Clinic Licensure Act. It further states he unlawfully operated his practice as a pain clinic without a license and ignored multiple orders to reverse course, all placing the public at risk.
Possession of small quantities of narcotics like heroin, cocaine and methamphetamine are no longer felonies in Oregon under a measure signed into law by Governor Kate Brown. The bill, passed by the state legislature in July and signed into law on August 15, reduces to a misdemeanor offense the possession of small quantities of drugs that an individual has for personal use. The intent of the Oregon law is to reduce jail populations and allow low-level offenders an opportunity to seek substance abuse treatment without a felony conviction on their record. Offenders could still face felony charges if someone is already a convicted felon, has been caught twice before with a “useable” amount of the drugs, or is believed to be selling the narcotics.
Joanne Thomka is the Editor of Substance Abuse News and may be reached at 202-326-6269. Substance Abuse News is a publication of the National Association of Attorneys General. Any use and/or copies of this newsletter in whole or part must include the customary bibliographic citation. NAAG retains copyright and all other intellectual property rights in the material presented in this publication. For content submissions or to contact the editor directly, please e-mail email@example.com.