Sunday, July 9, 2017

What Can America Do About the Opioid Crisis?

The number of deaths due to the opioid crisis in America are rising faster than ever.
Drug overdose deaths in 2016 most likely exceeded 59,000, the largest annual jump ever recorded in the United States, according to preliminary data compiled by The New York Times. 
The death count is the latest consequence of an escalating public health crisis: opioid addiction, now made more deadly by an influx of illicitly manufactured fentanyl and similar drugs. Drug overdoses are now the leading cause of death among Americans under 50.
Ohio, which many believe to be the epicenter of the crisis has a number of true horror stories like this.
In 2016, Summit County had 312 drug deaths, according to Gary Guenther, the county medical examiner’s chief investigator — a 46 percent increase from 2015 and more than triple the 99 cases that went through the medical examiner’s office just two years before.  
There were so many last year, Mr. Guenther said, that on three separate occasions the county had to request refrigerated trailers to store the bodies because they’d run out of space in the morgue.It’s not unique to Akron. Coroners’ offices throughout the state are being overwhelmed.
These estimated deaths for 2016 alone exceed the total number of American deaths from the entire Vietnam and Iraq Wars.
And unlike previous drug epidemics that affected poor residents of big cities, the carnage has spread to both suburban and rural America, affecting both the rich and poor.
It is fair to say that the magnitude of this crisis has been underreported in favor of other stories like those about the daily exploits of the Tweeter-in-Chief. That’s shameful.
For us to try to come up with solutions to this crisis, we need to have an understanding of how we arrived at this desperate time in our history.
I believe the definitive book on this subject is Dreamland: The True Tale of America's Opiate Epidemic which I highly recommend to the reader who wants to learn more about this issue. Most interesting is the story the author conveys about a cottage industry based in Xalisco, Mexico which grew to serve many small to mid-sized American cities by selling heroin employing a business model similar to pizza delivery!
But in the meantime, here is an abridged history of how​ this all came about:
A number of years ago back in the 90s, strong opioids were seldom prescribed – even for those with acute pain due to the fear of addiction.
Then the pendulum swung violently the other way when Purdue Pharma started an advertising campaign to convince doctors that their new product, OxyContin was suitable to prescribe for any general pain complaints a patient might have. And best of all, they said the worries about addiction were greatly exaggerated. If you’re going to tell a lie, tell the big lie! Purdue knew these pills were addictive but lied about it. In May 2007 the company pleaded guilty to misleading the public about OxyContin’s risk of addiction and agreed to pay $600 million in fines.  Its president, top lawyer and former chief medical officer also pleaded guilty as individuals.
Doctors with a newfound religion to dutifully treat pain prescribed 'Oxys' to just about anybody who complained about pain. Many became hooked. Others took advantage of the plentiful pills stored in medicine cabinets everywhere to get high. Some doctors started what were known as ‘pill mills’ which served wholesale numbers of patients complaining of pain in order to get a prescription. The opioid epidemic was on!
Then the Law of Unintended Consequences took over. With all of these people addicted to prescription painkillers, the powers that be tried to solve this problem in the only way they knew how – make it much harder and more expensive to get these pills. But just making something illegal doesn’t make the problem go away. Instead, these addicts discovered that a closely related drug, heroin was freely available and relatively cheap. So instead of being hooked on prescription drugs whose content was strictly regulated, users were turning to street heroin with questionable strength and ingredients.
One of those ingredients that crept into the heroin supply was fentanyl, a synthetic opioid that is many times more powerful than heroin. This has led to a huge spike in overdose deaths in the last year or two.
Now more desperate, public officials are pledging more money to fight this crisis. But just throwing money at the problem doesn’t solve anything. And the so-called War on Drugs which relies on law enforcement as the solution has done little more than give America the highest incarceration rate in the world.
Based on recent experiences to fight all of this addiction or at least mitigate the harm, it appears that there is good news and bad news. The good news is that while there is no panacea, there are some promising solutions to at least make some headway to help dig us out of the hole we are in. The bad news is that these solutions are being held back due to ingrained attitudes and prejudices along with (surprise) a lack of money to pay for it all.
Of immediate help is a drug called naloxone, aka Narcan that a policeman, firefighter, or paramedic can use to save the life of someone who has overdosed on heroin. Unfortunately, if the overdose is due to the much more powerful fentanyl, the lifesaving drug may be overmatched. And as an example of the above mentioned ingrained attitudes is an Ohio sheriff who incredibly, refuses to have his deputies carry Narcan.
Most promising is what is known as Medication Assisted Treatment (MAT). In conjunction with therapy, a substitute opioid is administered that relieves the withdrawal symptoms but without the addict getting high. This allows the addict to function normally and perhaps even work until someday, hopefully kicking the addiction.
The most well known drug is methadone which has been around since the 1940s. Although it is effective, it must be administered daily at a certified distribution center which often, nobody wants near where they live.
A better alternative is Suboxone (buprenorphine and naloxone) which has a great advantage in being able to be prescribed and then picked up at the pharmacy. However, Suboxone can be difficult to obtain because it can only be had from a limited number of federally certified doctors who in turn are limited by law to how many patients each can treat. It is ironic that while the addiction treatment is so controlled, OxyContin, the source of much of the addiction has no such controls.
Unfortunately, there is still stubborn cultural resistance to MAT because some still erroneously see it as nothing more than substituting one addictive opioid for another.
To ultimately make headway against the opioid crisis we have to reduce the demand that is driving everything.
To help prevent more accidental addiction as a result of legitimate pain treatment, comprehensive plans for treating the pain need to be used instead of just bringing out the prescription pad to prescribe an opioid. In addition, there is ample anecdotal evidence that medical marijuana may be able to more safely take the place of prescription opioids in many instances.
More importantly, we need to find out why so many Americans feel a need to get high. Many blue collar workers devastated by the loss of jobs and whole industries have suffered "deaths of despair." But why are so many more affluent Americans also falling into the trap of addiction? Is something missing in their lives too? Maybe we need to acknowledge that this opioid crisis in America may not be the disease but is in fact a symptom of underlying social and economic problems that make America not such a happy place to live in for all too many. How else do we explain why America leads the world in drug overdose deaths - by a lot.
There is this observation on Page 330 of Dreamland that all too many Americans may well be suffering due to increasing isolation from one other.
The most selfish drug fed on atomized communities. Isolation was now as endemic to wealthy suburbs as to the Rust Belt, and had been building for years. It was true about much of a country where the streets were barren on summer evenings and kids no longer played Kick the Can as parents watched from porches. That dreamland had been lost and replaced, all too often, finally, by empty streets of bigger, nicer houses hiding addiction that each family kept secret. 
…the antidote to heroin wasn’t so much naloxone; it was community. 
Nobody can do it on their own. But no drug dealer, nor drug cartel, can stand against families, schools, churches, and communities united together.

Saturday, May 13, 2017

The Party of Cruel

In our previous episode, Those Republican Sociopaths, Speaker Ryan had a terrible dilemma to deal with if he was going to pass his beloved Repeal and Replace Obamacare Bill. On one flank were moderate Republicans (apparently, they do still exist!) who were feeling guilty that the bill might be too cruel with the possibility of 24 million Americans losing health insurance in the next decade. On the other flank were the hard-right Freedom Caucus members who in their hate of all things government, in effect complained that the bill wasn’t cruel enough! Not seeing a way to satisfy both the moderates and Freedom Caucus members at the same time, Ryan pulled the bill rather than lose a floor vote.
Afterwards, Ryan himself conceded that Obamacare would be the law of the land for the foreseeable future. And President Trump said he wanted to move on to putting together a budget.
But that didn’t last for long. Trump, approaching his 100th day in office was desperate for something in the ‘Win’ column. In addition, the large tax cut that was part of this repeal bill would serve as a stepping stone to further tax cuts in an upcoming budget bill. Although Trump was not likely familiar with all of the bill’s details, needing a win, he pressured Ryan to renegotiate a new bill that would satisfy enough House Republicans to pass it.
The hard-right didn’t want the guarantee of insurance for those with pre-existing conditions from Obamacare to remain. But the moderates would never agree to this. So the compromise was to leave the pre-existing conditions requirement in – but in a concession to the hard-right, the bill would give individual states the ability to opt out if they choose – just like many of the Republican led states opted out of the Medicaid expansion for Obamacare.
The bill passed in the House by the narrowest of margins. The large tax cut that would be given to the wealthy who helped to finance Obamacare was preserved. The money to pay for this tax cut came in the form of a massive cut to Medicaid, a program that benefits the poor, disabled, and elderly to try and keep the bill revenue neutral. The onerous details of this bill are too numerous to mention. The interested reader can check out this link, The Trumpcare Disaster.
So what does a Republican who passes a cruel bill like this which may cause as many as 24 million people to lose their health insurance do? Celebrate, of course!  
As a practical matter, this bill has almost no chance to become a law in its present form. With many of the parts of the House bill being so toxic, the Senate will likely start from scratch to put together a bill of their own – while trying to satisfy their own hard-right members, namely Ted Cruz, Rand Paul, and Mike Lee. And if the Senate somehow passes a bill, the Senate and House would then have to agree on a common bill that removes their differences before it can go to the president to sign. Good luck with that!!
Even if this Repeal and Replace bill never becomes a law, there will be some serious repercussions to the American political landscape.
Many Republican House members who were brave enough to hold town hall meetings back home have encountered bitter dissent from attendees who were scared to death of losing their health insurance. When the Democrats passed Obamacare, that dissent resulted in a 2010 wave election victory by the Republicans. The Democrats believe they can return the favor in the 2018 mid-term elections.
But even if Obamacare doesn’t get repealed, the chaos caused by all of the repeal activity has caused a great deal of uncertainty in the healthcare insurance marketplace which may cause more insurers to bail out of Obamacare, perhaps making the Republican predictions of its doom into a self-fulfilling prophecy.
But let’s try to end this all on a hopeful note. If Obamacare is flawed and the Republicans have no viable option to replace it, we must be reminded how President Trump famously complemented Australia as having "better health care than we do." Of course, the delicious irony (apparently lost on Trump) is that Australia like most of the rest of the industrialized world has universal government-funded health insurance, also known as single-payer insurance which by the way, includes Medicare here in America.
So although Trump is apparently a closet single-payer health insurance supporter, most Republicans are strongly against it on ideological grounds. For them, given a choice between the cruel bill passed by the House and universal coverage for all Americans, cruel apparently wins. But with the passage of this House bill, even if it never becomes a law, many Americans who voted for Trump based on his promise to repeal and replace Obamacare have gotten a strong jolt of reality.
I will conclude with this quote from Democratic Senator Joe Manchin of West Virginia where President Trump won in a landslide:
“I said, ‘Mr. President, 172,000 West Virginians got insurance for the first time,’” Manchin said. "They’ve got something they never had before. They don’t know how they got it, they don’t know who gave it to them, they don’t know the Democrats, nothing about, ‘It’s Obamacare.’ They don’t know any of that. All they know is they’ve got it.” 
“And you know what? They voted for you, Mr. President,” he said. “They’re going to know who took it away from them.”

Saturday, March 25, 2017

Those Republican Sociopaths

If I were given the exercise of trying to describe the Republican Party in only one sentence, this would be it:
The raison d’ĂȘtre of the Republican Party is to look out for the interests of big business and big money.
This is what I wrote in a previous post.
There, I said it! Yes, there are all those social issues like guns and gays and abortions. But, frankly I believe these mostly act as cover for the true agenda of the party which is to transfer as much wealth as possible to the rich from everybody else.
Admittedly, these are very partisan sentiments that many would take as hyperbole. But with the recent failed Republican proposed replacement of Obamacare along with their​ latest proposed budget, those sentiments appear to be completely justified.
From the time Obamacare became law with no help from the Republicans, it has been an obsession to ‘repeal and replace' it to where it became a mantra that was constantly repeatedly by their loyal partisans. At last count the US House of Representatives has passed a bill to repeal Obamacare at least 60 times. Of course, there was no need to say what they wanted as a replacement since with Obama as president, this was little more than throwing red meat to their base voters.
Obamacare has been called almost every derisive word imaginable. But the champion in this category will forever be Dr. Ben Carson who called Obamacare "the worst thing that has happened in this nation since slavery." At the end of the video was a dire warning about how what he calls socialized medicine will lead to a socialist state. These were the same tired old words uttered by Ronald Reagan warning us about the horrible dangers if Medicare were to become law back in the 60s. The last time I checked, the nation survived this horrible danger.
So it’s fair to say that the Republicans really, really, really hate Obamacare. And while even its strongest supporters acknowledge its many flaws, is their hate justified towards a program that allowed 20 million more Americans to have health insurance, along with benefits nobody wants to give up like no preexisting conditions to buy insurance along with parents being able to keep​ children on their health insurance up to age 26 if needed?
These features are so popular that they were originally part of the proposed replacement offered by the Republicans. But non-partisan overseers like the Congressional Budget Office (CBO) have warned that if this plan were to be implemented, as many as 24 million mostly poorer Americans would lose their health insurance over the next decade. Does anybody care about these people? But there is potential good news for the wealthy who had to help pay for Obamacare. They get what amounts to a healthy tax cut with its repeal. So to review, poor people get screwed out of insurance and the rich get a transfer of wealth coming their way.
But wait, things got worse as the bill went from just being partisan to downright sociopathic. Some of the more moderate (not sociopathic) Republicans backed away from the bill over concerns about some of their constituents losing coverage. This was undoubtedly fueled by the massive, nationwide protest. (Of special note starting at the 7:00 mark of the video are Town Hall participants begging their rep not to take away their Obamacare to save their own lives or the life of a loved one.) But the super hard line conservative Freedom Caucus (aka Tea Partiers) had their own agenda – nothing less than Obamacare’s complete repeal. The leftover benefits like no preexisting conditions were unacceptable to them. Essentially, they wanted to return to the way things were before Obamacare with no replacement, not caring about who would lose insurance or possibly die in the process. If that isn’t sociopathic, I don’t know what is!
But then out of desperation to pass the bill, President Trump and Speaker Ryan sold out by offering the Freedom Caucus a bill that stripped out essential health benefits that are the cornerstone of Obamacare – giving in to their cruel demands. But even a hollowed out shell of Obamacare was more than they would agree to. This was the fatal blow for the bill to repeal and replace. Trump and Ryan folded by cancelling the floor vote to avoid further embarrassment.
Much of candidate Trump’s appeal to his supporters was the “terrific” replacement for Obamacare he said he had. But after taking office, it became obvious he had no plan, instead delegating it to Ryan to work out the details. This along with Trump’s promise to insure everybody were exposed as just additional lies.
Perhaps the biggest Republican sociopath of all is Ayn Rand disciple, Speaker Paul Ryan. Yes, like his fellow Republicans, he is in favor of tax cuts to favor big business and big money. But every one of these handouts to the rich is paid for by extracting a corresponding pound of flesh from the poor – a Reverse Robin Hood if you will.
His most insidious proposed schemes were vouchers for Medicare and proposed block grants for Medicaid. To simplify things, this meant hard caps on federal money for these programs. When the cost of these programs exceeds the hard caps, they become more underfunded each year. This would mean Medicare recipients having to make up the shortfall out of pocket. And for Medicaid recipients, this means some of them losing their insurance as the CBO projected for the recently failed repeal and replace bill. In addition, it needs to be pointed out that Medicaid is not only a lifeline to insurance to the poor, but also is their ultimate safety net to nursing home care if needed.
President Trump with the defeat of the repeal and replace bill has announced his intentions to move on to the next part of his agenda which is tax and budget reform. One can only hope that this mean and vindictive man will not sabotage Obamacare in the meantime to try and get even. For his recently proposed budget, it’s just as bad. Many of the safety net programs that benefit the poor would be slashed or eliminated in favor of increased military and Homeland Security spending. What was left out of this preliminary budget are the tax cuts that candidate Trump promised which would mostly benefit the wealthy and large corporations.
But that is a fight for another day. In the meantime, the Trump administration has a more immediate worry with the announcement of FBI and Congressional investigations into their possible collusion with the Russians in tampering​ with the recent presidential election. Seemingly each day, another tidbit of information is being uncovered. The world will be watching!

Sunday, February 5, 2017

Trump the Narcissist

America has been taken on a wild ride from the time presidential candidate Donald Trump first descended that escalator to the first couple weeks of his improbable presidency.
America has never seen a major party candidate and now a president behave so erratically (since perhaps Richard Nixon in his final days in office). Admittedly, his supporters are still doing the happy dance for a president they feel is telling it like it is. But the rest of us see a man with an incredibly inflated opinion of himself who at the same time is often mean-spirited towards others he sees as inferior to him. It is any wonder that many have asked whether there is something wrong with Trump from a mental health standpoint?
By far, the most applied label to Trump by both laypeople and increasingly mental health professionals is that he is a narcissist.
The Wikipedia article on Narcissism lists the following traits power-hungry narcissists typically display:
An obvious self-focus in interpersonal exchanges
Problems in sustaining satisfying relationships
A lack of psychological awareness
Difficulty with empathy
Problems distinguishing the self from others
Hypersensitivity to any insults or imagined insults
Vulnerability to shame rather than guilt
Haughty body language
Flattery towards people who admire and affirm them (narcissistic supply)
Detesting those who do not admire them (narcissistic abuse)
Using other people without considering the cost of doing so
Pretending to be more important than they actually are
Bragging (subtly but persistently) and exaggerating their achievements
Claiming to be an "expert" at many things
Inability to view the world from the perspective of other people
Denial of remorse and gratitude
I will leave it to the reader to decide how many of the above traits apply to our new president. But in the category of Flattery, the mutual admiration between Trump and Vladimir Putin is more than ample evidence.
In fairness, mental health professionals have traditionally cautioned against diagnosing a subject from afar without having performed an examination with the patient's permission. But the ramifications of someone with possible mental health issues as the leader of the free world (who also has access to the nuclear codes) is scary enough for more and more mental health professionals to go public with their concerns.
One article published by Vanity Fair shortly after the election, Is Donald Trump Actually a Narcissist? Therapists Weigh In! has the following interesting observations:
“He’s so classic that I’m archiving video clips of him to use in workshops because there’s no better example of his characteristics,” said clinical psychologist George Simon, who conducts lectures and seminars on manipulative behavior. “Otherwise, I would have had to hire actors and write vignettes. He’s like a dream come true.”
“He’s applying for the greatest job in the land, the greatest task of which is to serve, but there’s nothing about the man that is service-oriented. He’s only serving himself.” 
Since Trump’s inauguration and his erratic behavior in the weeks since, more and more mental health specialists have been speaking out as outlined in this article alleging his ‘malignant narcissism’.
Just after the election, a group called Citizen Therapists Against Trumpism was created, which was joined by thousands of psychologists. They published a manifesto warning of Trump’s psychosis, citing the following as the signs to fear:
“Scapegoating and banishing groups of people who are seen as threats, including immigrants and religious minorities; degrading, ridiculing, and demeaning rivals and critics; fostering a cult of the Strong Man who appeals to fear and anger; promises to solve our problems if we just trust in him; reinvents history and has little concern for truth (and) sees no need for rational persuasion.”
Whether it is phone conversations with world leaders or just speeches in front of various groups, Trump seems to have an obsessive habit of boasting about himself. Perhaps the most egregious example was his speech in front of the hallowed memorial wall at the CIA. Very strange if not outright narcissistic!
In the months during the election campaign, it was apparent to most that along with Trump’s inexperience in government, he was poorly versed on the issues he would have to handle as president. But his standard reply to those with reservations over this is that he would hire some “terrific advisers”. But how has that turned out?
All presidents, no matter how knowledgeable they may be need advisers. Nobody can be a specialist in everything. But in the case of Trump who feels he is always the smartest man in the room wherever he goes, how does he decide who is most worthy to provide him with advice?
If someone is a narcissist, the ready answer is to pick someone who is an ideological soulmate and fawning admirer - like Steve Bannon who ran Trump’s campaign and has now become his top White House strategist. The additional danger with Trump’s inexperience is that he may well unwittingly allow somebody like Bannon to take the reins of office and run with them. The New York Times takes this sobering look at the man they call President Bannon?.
Plenty of presidents have had prominent political advisers, and some of those advisers have been suspected of quietly setting policy behind the scenes (recall Karl Rove or, if your memory stretches back far enough, Dick Morris). But we’ve never witnessed a political aide move as brazenly to consolidate power as Stephen Bannon — nor have we seen one do quite so much damage so quickly to his putative boss’s popular standing or pretenses of competence.
But a new executive order, politicizing the process for national security decisions, suggests Mr. Bannon is positioning himself not merely as a Svengali but as the de facto president.
So is there a point in calling out what may be some mental health issues with the president? I say the answer is an emphatic yes! While liberal partisans such as myself may indeed criticize Trump on ideological grounds, these pale in importance to the possible dangers to our democracy posed by a mentally unhinged leader.
For example, there is Trump’s bitter hostility towards the media. He has verbally abused them and done his best to delegitimize them labeling any news accounts unfavorable to him as “fake news”. His endless use of Twitter allows him to try and control the narrative when addressing his followers without the media to provide needed context and/or fact checking of what are sometimes his use of  "alternative facts".
Now more than ever, we need a vigilant media to hold President Trump’s feet to the fire. But instead, we have Bannon who has told the media to "keep its mouth shut". We as citizens cannot tolerate this kind of attitude that can only be described as totalitarian if not again, narcissistic.
Most sobering of all is that we have a president who cannot tolerate even the smallest criticism or affront without waging a prolonged and sometimes vicious counterattack. Will this man plunge us into a war if he is provoked or insulted? Did I remember to mention that he now has access to the nuclear codes?
Unless we can be assured that Donald Trump is mentally sound, I say we have to be afraid. Very afraid!