DEA: Fentanyl 'Primary Driver' of Overdose Crisis

By Pat Anson, PNN Editor

The U.S. Drug Enforcement Administration has released the 2019 National Drug Threat Assessment, a comprehensive report that outlines the threats posed to the nation by drug traffickers and the abuse of illicit drugs.

Not surprisingly, the annual report found that illicit fentanyl is the “primary driver” behind the overdose crisis, with fentanyl and its analogs involved in more overdose deaths than any other illicit drug. Fentanyl is a synthethic opioid 50 to 100 times more potent than morphine. The drug is prescribed legally to treat severe pain, but illicit versions of fentanyl have flooded the black market.

Of growing concern to the DEA is the appearance of illegal pill press operations in the U.S. that are manufacturing millions of counterfeit painkillers and other medications, using fentanyl powder smuggled in from China and Mexico.

“Fentanyl will remain a serious threat to the United States as record numbers of individuals suffer fatal overdoses from illicit fentanyl sourced to foreign clandestine production,” the report warns.

“Clandestine fentanyl pill pressing operations will likely increase as DTOs (drug trafficking organizations) seek to appeal to the large pill abuser population in the United States, with counterfeit fentanyl-containing pills continuing to be associated with clusters of overdoses and deaths due to inconsistent mixing and often unexpectedly high potency.”

With China cracking down on illicit fentanyl laboratories, the DEA expects the primary source of fentanyl production to shift to Mexico and India.  

Fewest Prescription Opioids Since 2006

One bright spot in the DEA report is the continuing decline in overdoses involving prescription opioids. As PNN reported, overdose deaths involving natural and semisynthetic opioids, which include painkillers such as oxycodone and hydrocodone, were 3.8% lower in 2018 than in 2017.   

The DEA said the supply of prescription opioids is now at its lowest level since 2006. DEA production quotas for hydrocodone and oxycodone have been cut nearly in half since 2016, with further cuts proposed for 2020.

But while the retail supply of opioid medication has fallen dramatically, the diversion of opioids and other controlled drugs by medical professionals and wholesale distributors – so-called “lost in transit” diversion – has soared. There were 18,604 lost in transit reports filed in 2018, nearly six times the number reported in 2010.

“It is unclear if these dosage units are being diverted, destroyed, or truly lost. Although representative of only a small number of DEA registrants, diversion by physicians, nurses, and other medical professionals and their staff remains a threat to communities across the United States,” the report warns.

The DEA predicts “a steady decrease” in the supply of opioids over the next several years and that prescription drug abusers “may shift to abusing heroin, illicitly produced synthetic opioids, and methamphetamine to obtain similar effects, which may further increase overdose deaths through at least 2020.”

The DEA said the threat posed by psychostimulants such as methamphetamine and cocaine is “worsening and becoming more widespread.” While most cocaine users prefer to snort or inject the drugs, law enforcement agencies are starting to find cocaine in tablet or pill form.

“Whether these instances are harbingers of a new trend, an experiment, or simply the result of accidental contamination within poly-drug operations remains to be seen. Tableting and capsulizing cocaine may allow traffickers to capitalize on the considerably larger CPD user market with a different version of cocaine, further maximizing profits,” the DEA said.

Finally, while the DEA officially considers the herbal supplement kratom a “drug of concern” and once tried to ban it, there is once again no mention of kratom in its annual drug threat assessment.

Drug Overdose Deaths Fell 4% in 2018

By Pat Anson, PNN Editor

Drug overdose deaths in the United States dropped in 2018 for the first time in nearly three decades, according to a new CDC report that highlights the rapidly changing nature of the overdose crisis. While deaths linked to many prescription opioids declined, overdoses involving illicit fentanyl, cocaine and psychostimulants rose.

There were 67,367 drug overdose deaths in the U.S. in 2018, a 4.1% decline from 2017 when there were 70,237 fatal overdoses.

The rate of overdose deaths involving natural and semisynthetic opioids, which includes painkillers such as oxycodone and hydrocodone, was 3.8% lower. There were nearly 2,000 fewer deaths linked to painkillers in 2018 than there was the year before.

However, the decline in deaths involving opioid medication was more than offset by a continuing spike in overdoses linked to synthetic opioids other than methadone, which primarily involves illicit fentanyl and fentanyl analogs. The death rate in that category rose 9% from 2017 to 2018.

SOURCE: CDC

While the overall trend is encouraging, a top CDC official was cautious about preliminary data for drug deaths in 2019.

“One thing that we’re seeing is that the decline doesn’t appear to be continuing in 2019. It appears rather flat, maybe actually increasing a little bit,” said Robert Anderson, PhD, Chief of the Mortality Statistics Branch, National Center for Health Statistics.

“We do know that deaths due to synthetic opioids like fentanyl are continuing to increase into 2019 and we’re seeing increases similarly with cocaine and psychostimulants with abuse potential, the methamphetamine deaths."

Overdose deaths often involve multiple drugs, so a single death might be included in more than one category and be counted multiple times. A death that involved both fentanyl and cocaine, for example, would be classified by CDC researchers as an overdose involving both synthetic opioids and cocaine.

“There’s a lot of overlap between these categories and so a death may be actually counted in multiple categories, in two or more in many instances, making it difficult to partition the decline,” said Anderson. “We really don’t have a good handle on how best to do that.”  

Opioid Prescriptions Decline Significantly

A second CDC study on opioid prescribing shows that prescriptions have declined significantly in 11 states with prescription drug monitoring programs (PDMPs) that participate in the Prescription Behavior Surveillance System (PBSS). The 11 states include California, Ohio, Texas and Florida, and represent over a third of the U.S. population.

The decline in opioid prescriptions in the states ranged from 14.9% to 33% from 2010 to 2016, indicating that prescriptions were falling long before the CDC released its controversial opioid guideline in March, 2016. Significant declines were also noted in high dose opioid prescriptions, the average daily dose and in prescriptions obtained from multiple providers.

Despite the nearly decade-long decline in prescriptions, CDC researchers continue to blame opioid medication for the ongoing overdose crisis, offering little evidence to support that view.

“PDMP data collected by PBSS indicate that steady progress is being made in reducing the use and possible misuse of prescription-controlled substances in the United States. However, some persons who were misusing prescription opioids might have transitioned to heroin or illicitly manufactured fentanyl, a change that has made the drug overdose epidemic and associated overdose rates more complex,” researchers said.

“Because the opioid overdose epidemic began with increased deaths and treatment admissions related to opioid analgesics in the late 1990s, initiatives to address overprescribing might eventually result in fewer persons misusing either prescription or illicit drugs. Reduction in overprescribing opioids might lead ultimately to a decrease in overall overdose deaths.”

PDMP data for the CDC study came from the PBSS monitoring program at Brandeis University, where Dr. Andrew Kolodny is Co-Director of the Opioid Policy Research Collaborative. Kolodny is the founder and Executive Director of Physicians for Responsible Opioid Prescribing (PROP), an activist group that has long been critical of opioid prescribing.

Do You Have ANT’s? How Awareness Helps Avoid Negative Thoughts

By Dr. David Hanscom, PNN Columnist  

This is the third in a series of columns on awareness -- a meditative tool that can be used to calm the nervous system to reduce pain and anxiety.  In my previous columns, I looked at environmental awareness (how mindfulness lowers stress hormones) and emotional awareness (how moods affect how we feel physically). 

The third level of awareness I’d like to introduce you to revolves around judgment and storytelling. On this level, you create a “story” or a judgment about yourself, another person or a situation. These judgments tend to be criticisms that are rough and inflexible. The brain has a bad habit of focusing on negative judgments that ramp up our emotions. 

We can categorize these negative thoughts into ten “errors of thinking” outlined by Dr. David Burns in his book “Feeling Good.” Burns calls these thoughts “ANTS,” which stands for automatic negative thoughts.

For example, imagine someone at work walked by you and didn’t acknowledge you. You might think they’re upset with you about a situation that occurred the day before. The error in thinking in this case would be “mind reading.” You can’t read other people’s minds. 

It’s possible that the other person had just received some bad news and wasn’t engaging with anyone. But you don’t really know. If you make assumptions, you’re wasting a lot of emotional energy.

Labeling 

Then there is the error of labeling. For example, a frequently late spouse becomes “inconsiderate.” A forgetful teenager becomes “irresponsible.” In the act of labeling, especially negative labeling, you’re overlooking circumstances and someone’s good qualities, limiting your capacity to enjoy being with them. 

Then there are the labels we have for ourselves: you knock something over and call yourself “clumsy.” If a lover breaks up with you, then you’re “unlovable.”  

Rehashing these critical judgments in our minds turns them into deeply embedded stories. Such stories are much harder to move on from than single judgments. Once a judgment sets into a story, you tend to lose all perspective. Over time, faulty thinking can become your version of reality. 

In my own experience, whenever I have an “ANT,” I become either angry or anxious (or both). I am also sometimes more reactive or impulsive. These emotions fuel negative thought and it becomes repetitive. As the thought keeps whirling around, it becomes stronger, along with my emotions. They quickly destroy my day and negatively affect my relationships. 

I’ve heard this thought pattern described as a vicious cycle or whirlpool. These kinds of thoughts, or stories, can become recurrent and might last for years. They take on a life of their own even though they are often fairly outrageous.  

Regardless of what sets these patterns of thinking off, they are a universal part of the human experience. This is true whether chronic pain is involved or not. With chronic pain you have the added frustration of the physical stimulus to keep these circuits really spinning.  

Self-Perceived Flaws 

To better understand the story concept, consider common situations where the brain focuses on a self-perceived flaw that is not physically painful. It might be your height, weight, the shape of your body, or even an individual body part. Or it might be some particular quality, such as a lack of intelligence, athletic skill, musical talent, etc.  

Thinking about these flaws over and over snares you in a destructive cycle of spinning neural circuits. For example, many years ago I had a patient with neck pain who was absolutely convinced that he was “stupid.” His self-labeling wasn’t rational, as he was clearly a bright guy. I don’t know if his view of himself somehow triggered it, but he eventually developed a significant chronic burning sensation around his mouth. 

Something similar often happens in the entertainment industry, where performers commonly focus only on their negative reviews. My wife, who is a tap dancer, has seen this in her profession for years. She pointed out to me that a performer might have 99 positive reviews but will fixate on the one that’s negative. It’s a common saying among entertainers that, “You’re only as good as your worst critic.” 

ANT’s and Relationships 

Another common phenomenon is focusing on a spouse or partner’s negative traits. The other person usually has innumerable positive qualities that are forgotten in the face of their “flaw.” Over time the “story” we tell ourselves can become so strong it can break apart an otherwise great relationship. 

One particular event from my own life comes to mind. It shows how creating stories has the power to disrupt your peace of mind and detract from your enjoyment of life. 

One day my wife and I were taking my father for a ride up to beautiful Point Reyes, located on the coast north of San Francisco. About 20 minutes into our trip I noticed that the car’s low-tire-pressure light had come on. It was a brand new car with only a thousand miles on it, so I thought it was probably just a malfunctioning light.  

I wasn’t convinced that we’d made the correct decision to buy this car in the first place -- it was more expensive than I was comfortable with -- so I was more than a little frustrated that the warning light had a glitch. 

I stopped to put a little air in the tire, just in case, and then kept driving for another 45 minutes. As we approached Point Reyes in the early afternoon, we realized that the tire was really low, so I pulled over to change it. But when I opened the trunk, there was no spare.  

The story in my head was starting to ramp up as I wondered in frustration why a new car wouldn’t have a spare. I called the car company’s roadside assist line and they told me these new cars had “run-flat” tires that should be good for 150 miles at a maximum speed of 50 miles per hour.  

I felt a little insecure about that concept. We were a long way from the last large town we’d passed and I thought that we should turn back. My wife thought that since my father rarely made it to California from the East, we should go out to dinner. So, we headed toward a restaurant. About three miles down the road the tire exploded. 

It was now about four o’clock in the afternoon and we were miles and miles from anywhere. Our only option was to get towed courtesy of AAA. It was hard for me to accept the fact that I had to get my new car towed for a flat tire.  

The tow truck driver showed up to take us to the service station and let the three of us ride in the cab, with my wife sitting on my lap. She started to complain about the bumpiness of the ride, which I found a little annoying. “I’m the one on the bottom, why are you complaining?” I thought.  

She wanted to have dinner in San Rafael and take a taxi home. I started to grind my teeth to keep my mouth shut. 

Magnifying the Problem

This is how the afternoon unfolded for me. Starting with the low tire, I’d made a decision to enjoy my time with my family in spite of the problem. I took note of my frustrations and concentrated on listening to the conversation and staying involved in the day. I was successful for a while -- until the tire blew up.  

Then my anger began to bubble. I became aware that in spite of everything I’d learned about dealing with stress, I was greatly magnifying the problem with the ANT thoughts in my head. I was thinking things like, “I can’t believe I got talked into buying this car” and “My wife made me buy it.” 

Although there might’ve been some truth in the things I was telling myself, I recognized that it wasn’t helping us get through the situation. Nonetheless, I wasn’t able to minimize my suffering through the stress relief techniques that had helped in the past, which was frustrating. I tried to talk myself out of it, but it didn’t work. 

Then I began to go really dark with thoughts like, “How can I be married to this woman?” I began to notice how irrational and big these thoughts had become. It felt like a bomb had exploded. I was miserable way out of proportion to the situation. 

I was guilty of multiple errors in thinking. They came in the form of labeling – “My wife is irresponsible”— and catastrophizing -- “Why did we get married?”  

Through it all, I negated her many positive qualities. To cite one, she’s great at keeping things light, no matter what the problem. And unlike me, she was able to keep her cool throughout the day. 

In the past, I would’ve remained in this agitated state of mind for days, with some carryover lasting for weeks. I wouldn’t have been able to separate my wife’s actions from my thoughts and realize that the problem wasn’t her, it was my reaction to the situation.  

It was a major step for me to become aware of how out of proportion the stories in my head had become. This degree of awareness changed the game for me. 

Eventually, we did get towed home. We went out to dinner. I still love my wife. And I learned yet another lesson in humility.

Dr. David Hanscom is a retired spinal surgeon. In his latest book -- “Do You Really Need Spine Surgery?” – Hanscom explains why most spine operations are unnecessary and usually the result of age-related conditions that can be addressed through physical therapy and other non-surgical methods.

Healthcare Technology Vendor Took Kickbacks to Promote Rx Opioids

By Pat Anson, PNN Editor

A decade ago, electronic health records (EHRs) were touted as a major innovation that would allow doctors to maintain a digital record of their patients’ medical history, diagnoses, prescriptions and insurance claims. A 2009 federal law encouraged doctors and hospitals to adopt EHRs with over $19 billion in funding to upgrade their information technology.

It didn’t take long for someone to game the system and use EHRs to commit fraud on a massive scale.

Practice Fusion, a San Francisco health information technology developer, agreed this week to pay $145 million to resolve criminal and civil allegations that it took kickbacks from drug companies to promote their products to physicians using its EHR software.

Federal prosecutors didn’t release the names of the drug companies, but according to Reuters, Practice Fusion solicited and received $1 million in kickbacks from OxyContin maker Purdue Pharma.

In return, Practice Fusion created an EHR alert advising physicians to switch new pain patients from immediate-released opioids to extended release opioids like OxyContin. From 2016 to 2019, the alert was triggered 230 million times, according to prosecutors.

“Practice Fusion’s conduct is abhorrent.  During the height of the opioid crisis, the company took a million-dollar kickback to allow an opioid company to inject itself in the sacred doctor-patient relationship so that it could peddle even more of its highly addictive and dangerous opioids,” Christina Nolan, U.S. Attorney for the District of Vermont, said in a statement. 

“The companies illegally conspired to allow the drug company to have its thumb on the scale at precisely the moment a doctor was making incredibly intimate, personal, and important decisions about a patient’s medical care, including the need for pain medication and prescription amounts.”

Prosecutors say Practice Fusion took kickbacks from more than a dozen pharmaceutical companies, allowing them to design the phony alerts and determine when a healthcare provider received them. “Numerous prescriptions” were written as a result. The federal case is the first criminal action against a vendor of electronic health records.

“Across the country, physicians rely on electronic health records software to provide vital patient data and unbiased medical information during critical encounters with patients,” said Ethan Davis, Principal Deputy Assistant Attorney General.

“Kickbacks from drug companies to software vendors that are designed to improperly influence the physician-patient relationship are unacceptable.  When a software vendor claims to be providing unbiased medical information – especially information relating to the prescription of opioids – we expect honesty and candor to the physicians making treatment decisions based on that information.”

Practice Fusion offers free EHR software to smaller, independent physician practices. The software is used by 112,000 health care providers who see 5 million patient visits each month. Practice Fusion was purchased in 2018 by Chicago-based Allscripts for $100 million in cash.

“Since learning of this matter we have further strengthened Practice Fusion’s compliance program. Allscripts recognizes the devastating impact that opioids have had on communities nationwide, and we are using our technology to fight this epidemic,” an Allscripts spokesman said.

Study Finds Opioids and Imaging Tests Given Too Often for Low Back Pain

By Pat Anson, PNN Editor

Many Medicare patients with low back pain receive care that is contrary to clinical guidelines – including opioid medication and advanced imaging tests, according to a large new study.

Researchers looked at Medicare claims for over 162,000 older adults with new low back pain (LBP) from 2011 to 2014. Over half (54%) made only one healthcare visit for LBP, which is consistent with evidence that many new cases of LBP "improve over time regardless of treatment."

It's what happened to the other patients that researchers found concerning.

Opioids were prescribed to about one-fourth of patients overall, and to about a third of those who made two or more visits to have their low back pain treated. Most clinical guidelines for LBP recommend that physical therapy and non-opioid pain relievers such as nonsteroidal anti-inflammatory drugs (NSAIDs) be tried before opioids.

Advanced imaging tests such as cat scans and magnetic resonance imaging (MRI) were ordered for about 15 percent of patients, which is contrary to advice from the American Academy of Family Physicians that most patients don't need advanced imaging for initial evaluation of low back pain.

Physical therapy (PT) was prescribed to only 11 percent of the Medicare patients. Most who were treated with opioids did not receive a prescription NSAID or physical therapy. Chronic opioid use developed in about one percent of patients overall, and nearly two percent of those with two or more visits.

"This study raises concerns about excessive use of low-value and potentially harmful treatments for the common problem of LBP in older adults," said Dan Pham, MD, of Harvard University, who published his findings in the journal Medical Care.

“Although prior research has suggested that PT may forestall the use of opioids in LBP, it is surprising that a high percentage of patients do not receive PT at all and many patients who eventually receive opioids did not first try PT. Similarly, it is surprising that when guidelines suggest that opioids should be a last resort for LBP, many patients on opioids have not yet tried prescription NSAIDs.”

It’s worth noting that Pham’s study only analyzed Medicare data compiled before the release of the 2016 CDC opioid guideline, which led to a widespread campaign to reduce opioid prescribing. Many physicians now refuse to prescribe opioids or only do it at low doses.  

Lower back pain is the world’s leading cause of disability. Over 80 percent of us suffer acute low back pain at least once in our lives.  

A guideline released by the American College of Physicians in 2017 strongly recommend that physicians treat acute low back pain with exercise and other non-pharmacological therapies. If medication is used, the guideline recommends NSAIDs or muscle relaxers. Opioids are only recommended for patients with chronic back pain who have failed at other treatments.

Some treatment guidelines also take a dim view of imaging for people with acute back pain. Early imaging for lower back pain is not recommended by the Choosing Wisely campaign, an initiative of the ABIM Foundation.

“Most people with lower-back pain feel better in about a month whether they get an imaging test or not. In fact, those tests can lead to additional procedures that complicate recovery,” Choosing Wisely states on its website.

The University of Michigan Center for Value-Based Insurance Design estimates there were 1.6 million unnecessary images for low-back pain in 2014, resulting $500 million in wasted spending. The Center recommends that imaging not be done in the first 6 weeks of low back pain.

A 2015 study found that physical therapy for low back pain significantly lowers healthcare costs by reducing the use of expensive treatments such as spinal surgery, injections and imaging.

New Migraine Prevention Drugs Making Inroads

By Pat Anson, PNN Editor

Over half the patients taking a new class of medication designed to prevent migraines say the benefits of treatment outweigh the drugs’ side effects, according to a new survey.

The drugs prevent migraines by blocking a protein — calcitonin gene-related peptides (CGRP) -- from binding to nerve receptors in the brain. Since 2018, the FDA has approved three injectable CGRP inhibitors for migraine prevention and recently approved the first oral tablet for migraine treatment.

Although the drugs are still relatively new, a recent survey of over 4,700 migraine patients by Health Union found that about a third (29%) are currently using a CGRP medication, while 12% had used one in the past.

Most said the drugs were effective at migraine prevention and worth the side effects, which include constipation, fatigue and weight gain. Only 9 percent said the drugs were not worth the side effects.

“CGRPs are in many ways a treatment revolution,” says Brian Green, vice-president of community development for Health Union. “There has not been a new class of medication specifically designed for treatment of migraine for decades. So this really is groundbreaking.” 

Green said patients with chronic severe migraine are more likely to be early adopters of CGRP therapy, as opposed to people who have episodic migraines and fewer attacks.   

Patients on CGRP therapy were more likely to say their migraine attacks increased over time and that they experience a wide array of symptoms, including head pain, brain fog, difficulty concentrating, fatigue, loss of words, memory loss and sensitivity to touch. 

“Their symptoms are so severe they want the first available new treatment,” Green told PNN. 

But the early adopters were also more impatient. Health Union’s survey found that patients who were not satisfied with a CGRP inhibitor wasted little time switching to a new brand. About 40% waited less than a month and 43% waited up to 3 months. Most of those who switched said the drugs did not work or stopped working after an initial period of efficacy. 

The three CGRP inhibitors currently on the market are Aimovig, Ajovy, and Emgality, which are taken by injection about once a month. The first oral CGRP for migraine treatment, Ubrelvy, was approved by the FDA last month and is expected to be available in the next few weeks.  

Most patients surveyed by Health Union said they would prefer taking a daily CGRP pill as opposed to a monthly injection.  

Constipation was the leading side effect reported by patients getting CGRP injections. Nearly a third said the drugs made them constipated, while others complained of reaction at the injection site (16%), fatigue (15%), weight gain (12%) and dry mouth (11%). 

About half the patients surveyed said they were still using a triptan or over-the-counter pain medication for migraine relief. Antidepressants and Topamax were the most commonly used medications for migraine prevention. 

Regardless of the drugs used, only 12% of patients said their migraines were well controlled under their current treatment plan.  

Arizona Drug Bust Shows Fentanyl Crisis Growing

By Pat Anson, PNN Editor

In one of the largest fentanyl busts in state history, nearly 170,000 counterfeit pills made with illicit fentanyl have been seized in Phoenix, Arizona. A DEA task force and Phoenix police seized the pills during a traffic stop on January 22, arresting two suspects who were under surveillance.

The blue pills were stamped with an “M” and a “30” – distinctive markings for 30mg fake oxycodone tablets known on the street as “Mexican Oxy” or “M30.” The total street value of the drugs was estimated at $3 million.

"These 169,000 pills, it can have a varying amount of fentanyl. They have no quality control, and what makes them that much more deadly is they look like legitimate oxycodone pills. They don't contain an active ingredient. It is just fentanyl with other ingredients," said DEA Spokesperson Erica Curry. 

"We are talking about a very deadly substance in such small quantities it can be lethal to anyone who doesn't have an opioid tolerance built up."

DEA PHOTO

Fentanyl is a synthetic opioid 50 to 100 times more potent than morphine. Counterfeit pills laced with illicit fentanyl have been appearing around the country and are linked to thousands of overdose deaths. In 2019, law enforcement agencies seized over 1.4 million fentanyl pills in Arizona alone.

According to a recent DEA analysis, about one in every four counterfeit pills have a potentially lethal dose of fentanyl.

Street Drug Users Aware of Fentanyl

Who would be foolish or desperate enough to take a street drug that might kill them? Do overdose victims even know the fake pills they’re buying contain fentanyl?

The answer in many cases is yes, according to a new study of street drug users in Vancouver, British Columbia – the first major North American city to see an influx of illicit fentanyl.  

The study drew on data collected from over 300 people recruited at drug treatment sites in 2018. The participants completed a brief survey on their drug use and provided a urine sample that researchers tested for fentanyl and other substances.

About 60 percent of those tested had fentanyl detected in their urine. Of those, nearly two-thirds (64%) knew they had taken fentanyl.

"This research shows the majority of people who use fentanyl know they're doing so," says Dr. Jane Buxton, an epidemiologist and professor at the University of British Columbia, who is corresponding author of the study published in the International Journal of Drug Policy.

"Making people who use drugs aware of the presence of fentanyl in the drug supply isn't enough; we need harm reduction services, substance use treatment, overdose prevention resources, and pharmaceutical alternatives to the toxic drug supply to reduce the devastating impact of fentanyl and its analogues on our communities."

The fentanyl crisis in British Columbia is growing worse by the year.  A similar study in 2015 found only 29% of participants tested positive for fentanyl, with only 27% aware that they'd used it.

When fentanyl first appeared in the illicit drug supply, many users took fentanyl unknowingly because dealers secretly added it to heroin, counterfeit pills and other street drugs. It’s no secret today. According to preliminary data from the BC Coroner, fentanyl or its analogues were found in 85 percent of fatal overdoses in 2019.

Researchers do not fully understand the reasons people knowingly take fentanyl. Some users are aware it is present in the illicit supply of opioids and have no other choice, while others may prefer the experience of taking fentanyl.

"This research lays groundwork that will help us learn more about why fentanyl use is increasing," said lead author Mohammad Karamouzian, a PhD student at UBC's School of Population and Public Health. "These findings will also contribute to more effective messaging campaigns and harm reduction strategies to help reduce preventable deaths and support the health of people who use substances, their families, and their communities."

Another key finding of the study was that people who used fentanyl were more likely to have also recently used heroin or crystal meth.  Those who used cannabis were less likely to use fentanyl.

A Cautionary Tale About Living Wills

By Dr. Lynn Webster, PNN Columnist

If you become sick and incapacitated, who will decide what type of medical treatment you receive?

Many people don’t want to leave it to chance. They document their end-of-life preferences in an advance healthcare directive – also known as a living will -- believing that will ensure that their wishes are followed.

However, too often that doesn't happen. As The New York Times reported, the language in advance healthcare directives is often unclear, so doctors and family members may not know what their legal obligations are under specific circumstances. Having an advance healthcare directive may also provide a person a false sense of comfort -- if nobody knows it exists.

One woman’s story is an example of how end-of-life wishes can be ignored. “Frances” was estranged from her family, so she asked her longtime business associate, Eleanor, to be her health care proxy.  If there ever came a time when Frances couldn't make her own decisions, Eleanor would do so as proxy. They signed the paperwork, but then Eleanor lost track of Frances.  

After an incapacitating stroke, Frances was placed in an assisted living facility. She suffered from aphasia and, perhaps, dementia. She no longer had a voice in where she was, what happened to her home or what medication she was given. All control of her life had been ceded to an unknown and potentially self-serving guardian.

States can legally give strangers control over a debilitated person's money, home and medical care. Court-appointed guardians are professionals who handle the affairs of the elderly or infirm when there are no family members to take on that responsibility and no paperwork leading to anyone else who is willing to do so.

Guardians may be honest and very much interested in the best for the incapacitated person, but this is not guaranteed. The guardian may have minimal accountability, and the person placed under guardianship can be at the mercy of this individual. Loss and abuse may follow.

A HuffPost article likened this situation to a “con game” that has led to “a silent epidemic of elder abuse.”

According to AARP, court-ordered guardianship "often leads to isolation and exploitation of older Americans." Approximately 1.3 million adults, most of them older than 65, are currently under guardianship in the United States. Frances is one of them. Her story strikes a chord with me, because people of a certain age or those with a disability, can so easily find themselves in that position.  

The Missing Health Care Proxy Document 

A neighbor remembered Frances had once appointed someone named Eleanor (whose last name was unusual enough and whose profile was high enough that she could be found online) as her proxy. The neighbor tracked Eleanor down, hoping she would be able to legally advocate for Frances.  

Eleanor was unable to find her copy of the healthcare proxy document. However, she drove eight hours to the assisted living facility where Frances had been placed and was able to ascertain that Frances was relatively comfortable and safe.  

Eleanor was still worried that the court-appointed guardian had questionable motives for getting involved in the case and was brokenhearted to know that the advance healthcare directives Frances had put in place had not been honored. No one besides Eleanor knew what they were and she was not allowed to participate in the decision-making process.  

"Frances had a will, a trust, a health care power of attorney, and other documents executed. She chose me as her health care proxy because I have extensive experience in finance administration. We'd worked in the same industry for decades and had a mutually trusting relationship. But we both failed to do what we needed to do to be sure Frances's preferences were honored,” Frances explained. 

Difficult Conversations Can Make All the Difference 

At some point in our lives, many of us may find ourselves in a position where we can't communicate our preferences. It can be helpful to think through the type of medical care you will and will not want to receive in various situations, and commit your wishes in writing by filling out your state's advance directive form.  

Unfortunately, if the probate court (or whatever it is in your area) chooses, the judge can set these arrangements aside and institute whatever she or he deems necessary, which usually includes appointing a professional guardian. This is most likely to happen when trustees or guardians cannot be located, so do your best to cover your bases in advance.  

It is important to have conversations with your closest family members, friends and healthcare providers about the medical care you would prefer in the most difficult situations. Give them copies of the paperwork.  

Avoid creating a vacuum that a professional guardian may be ordered to fill by firming up your own support network now—while you still have time.

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book, “The Painful Truth,” and co-producer of the documentary, “It Hurts Until You Die.” You can find Lynn on Twitter: @LynnRWebsterMD.

Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences.

Surgery Patients Given Tylenol for Post-Operative Pain

By Pat Anson, PNN Editor

Another hospital is touting the benefits of not giving opioid analgesics to patients after minimally invasive surgeries.

Surgeons at Houston Methodist Hospital say they were able to significantly reduce opioid prescriptions given to patients recovering from hernia repair, reflux surgery and other minimally invasive GI-related procedures by treating them with acetaminophen (Tylenol) for post-operative pain.

In a study involving over 400 surgery patients reported in the Journal of Thoracic and Cardiovascular Surgery, Houston Methodist surgeons compared patients treated with acetaminophen to a control group of patients given opioids.

Patients who were treated with acetaminophen had fewer post-operative complications (3%) than those given hydrocodone or tramadol (15%).  They were also significantly less likely to be discharged from the hospital with an opioid prescription than patients in the control group (10% vs. 87%).  

"Just a decade ago we routinely prescribed narcotics to treat pain at home after surgery," said lead author Min Kim, MD, head of the division of thoracic surgery at Houston Methodist Hospital. "We wanted to determine if we could manage pain at home after surgery with over-the-counter pain medication. We developed and implemented the pre-emptive pain control program, which led to excellent pain control at home without requiring prescription narcotics."

Patients in the pre-emptive pain management group received long-acting local anesthetics at each incision. They were also given scheduled doses of acetaminophen or naproxen in the hospital and at home.

"This study provides us with a strategy to successfully manage pain after surgery using over-the-counter pain medication. This led to fewer narcotic prescriptions which proactively decreases the chance of patients becoming addicted to narcotics," Kim said.

Opioid Addiction Rare After Surgery

Few patients actually become addicted after surgery. A 2016 Canadian study, for example, found that long term opioid use after surgery is rare, with less than one percent of older adults still taking opioids a year after major elective surgery.

Another large study in the British Medical Journal found only 0.2% of patients who were prescribed opioids for post-surgical pain were later diagnosed with opioid dependence, abuse or experienced a non-fatal overdose.

Nevertheless, many hospitals have reduced their use of opioids or stopped giving them to patients altogether.

A statewide effort in Michigan reduced the number of opioid pills given to patients after common operations from an average of 26 pills per patient to 18. The surgeries included minor hernia repair, appendix and gallbladder removal, and hysterectomies. Most were minimally invasive laparoscopic surgeries.

In Ohio, patients at Akron General Hospital are getting acetaminophen, gabapentin and non-steroidal anti-inflammatory drugs (NSAIDs) to manage their pain after elective colorectal operations. Surgeons say over 75 percent of them are sent home without an opioid prescription.

And in Vermont, a 2017 state law requires doctors to use non-opioid pain relievers as first-line treatments for post-operative plan. If they are prescribed opioids, patients are initially limited to no more than 10 pills.

Houston Methodist Hospital is expanding its pre-emptive pain management program to include patients recovering from pulmonary surgery.

3 Tips for Living With Chronic Pain

By Barby Ingle, PNN Columnist

A bunch of people on social media have been asking what my best tips are for the pain community.

With my health being so poor, as I am going through Valley Fever on top of all the chronic illnesses I live with, my thoughts immediately turned to health.  So many friends have helped me over the past few months with prayers and positive thoughts, or sending food or someone to help clean the house. It is all so appreciated and has shown me that people really care how others in the community are doing.

Here are three tips I’ve learned:

1. Share your pain story

2. Control your outlook, stress and pain levels as best you can

3. Keep a journal

We all have something that we are dealing with on a daily basis and sharing our stories provides hope to others by letting them know they are not alone. It doesn’t matter if you are sick or healthy, rich or poor, we all have challenges to face in life.

I share my experiences to let others know there are other options and reasons for hope. There is always something else to try. I may not always have immediate access to it, but I can work on a plan to create access.

Learning and practicing self-care is also key. It could be remembering to take deep breaths or meditate to help lower cortisol and other stress hormones. This helps me with relaxing, sleeping and stress reduction. This past year was very stressful for me, so I was taking daily walks to reduce stress and increase endorphins, which help lower pain.

I don’t drink alcohol or smoke, but drank two sodas a day for most of my life. I am currently abstaining from soda -- partially because of my last hospital visit and partially because I have no other vice in my life and wanted to see how long I can go without soda.

My husband has to have his coffee every day or he is cranky — and I was wondering if cutting out soda would do something positive for me. Sadly, it has not. But when I have encountered two stressful situations recently, I wanted that soda. My mind knew that it would soothe me, like a beer would for someone else. Soda is something that would help me feel better, but now I know I can live without it.  Just knowing that is a mental comfort.

Find your comforts, and if they are not already healthy ones, consider changing them to see if you can be soothed by something else that will be better for you in the long run. 

My final tip for patients is to track your pain level, medications, intake and activities every day in a journal for at least 120 days. This helps you and your providers see patterns, and you can adjust your treatment plans and goals more appropriately. Keeping a journal not only helps me see patterns, but it helps me communicate more effectively with my providers about my needs.

No matter where you are in your health journey, remember that you deserve access to proper and timely pain care and that you can find a way to get the care you need. It will take time and effort, but it is also possible.

Barby Ingle lives with reflex sympathetic dystrophy (RSD), migralepsy and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the International Pain Foundation. She is also a motivational speaker and best-selling author on pain topics. More information about Barby can be found at her website. 

Production of Two Excedrin Brands Halted

By Pat Anson, PNN Editor

Spot shortages of Excedrin are being reported after a pharmaceutical company halted production of two leading brands of the pain reliever due to “inconsistencies” in their ingredients.

GlaxoSmithKline (GSK) says consumers are not at risk, but as a precaution it has indefinitely suspended all production and distribution of Excedrin Extra Strength and Excedrin Migraine.

“Through routine quality control and assurance measures, we discovered inconsistencies in how we transfer and weigh ingredients for Excedrin Extra Strength Caplets and Geltabs and Excedrin Migraine Caplets and Geltabs,” GlaxoSmithKline said in a statement.

“Based on the available data, GSK believes that the product does not pose a safety risk to consumers. However, as a precautionary measure, GSK Consumer Healthcare has voluntarily implemented a discontinuation of production and distribution.”

Some drug stores in upstate New York have already run out of Excedrin Extra Strength and Excedrin Migraine. GSK said other Excedrin products are still available and urged consumers to ask their pharmacist for advice on alternative pain relievers.

“We are working hard to resolve the issue as quickly as possible, but at this point in time cannot confirm a definite date as to when supply will resume,” the company said.

In 2012, an Excedrin manufacturing plant in Lincoln, Nebraska was shut down for several months after Excedrin bottles were found to contain broken tablets and stray tablets for other medications. That led to a recall and shortages of Excedrin products around the world.

At the time, the Excedrin brand was owned by Novartis. An FDA investigation found that Novartis failed to adequately investigate hundreds of consumer complaints of foreign products found in over-the-counter drugs produced at the Nebraska plant. Novartis spent millions of dollars re-tooling the plant and shifted some production to third-party manufacturers.

GSK now holds majority ownership of Excedrin through a joint venture with Novartis. GSK did not say where the new production problems originated.

Medicare to Cover Acupuncture for Back Pain

By Pat Anson, PNN Editor

The Centers for Medicare & Medicaid Services (CMS) has finalized a decision to cover acupuncture for Medicare patients with chronic low back pain. Up to 12 visits in 90 days to an acupuncture therapist will be paid by Medicare, but no more than 20 treatments annually.

Acupuncture is an ancient Chinese treatment in which practitioners stimulate specific points on the body by inserting thin needles through the skin. About 3 million Americans receive acupuncture treatments, mostly for chronic pain. Some private insurers already cover acupuncture, but there is little consensus in the medical community about its value.

Lower back pain is the world’s leading cause of disability. CMS researchers reviewed clinical studies and found evidence that older adults with chronic back pain showed small improvements in pain and function after acupuncture treatments, although the exact mechanism of action was “unclear” and there was “inconclusive evidence” about the most effective acupuncture technique.

“Expanding options for pain treatment is a key piece of the Trump Administrations’ strategy for defeating our country’s opioid crisis,” Health and Human Services Secretary Alex Azar said in a statement. “Medicare beneficiaries will now have a new option at their disposal to help them deal with chronic low back pain, which is a common and sometimes debilitating condition.”  

The decision to cover acupuncture overturns decades of previous rulings that took a dim view of the procedure. In 1980, CMS said the use of acupuncture as an anesthetic was “not considered reasonable and necessary.”

In 2004, the agency rejected acupuncture as a treatment for fibromyalgia and osteoarthrosis because there was “no convincing evidence for the use of acupuncture for pain relief.”

CMS said it was “keenly focused” on finding alternatives to opioid painkillers.

“We are dedicated to increasing access to alternatives to prescription opioids and believe that covering acupuncture for chronic low back pain is in the best interest of Medicare patients,” said CMS Principal Deputy Administrator of Operations and Policy Kimberly Brandt.

“We are building on important lessons learned from the private sector in this critical aspect of patient care. Over-reliance on opioids for people with chronic pain is one of the factors that led to the crisis, so it is vital that we offer a range of treatment options for our beneficiaries.”

A recent study of over 140,000 Army veterans with chronic pain found that non-drug therapies such as acupuncture significantly reduce the risk of suicide, as well as alcohol and drug abuse.  

FDA Approves Cocaine Nasal Spray

By Pat Anson, PNN Editor

FDA advisory committees have taken a dim view of opioid medications recently, soundly rejecting new drug applications for the “opioid of the future” oxycodegol and a new extended-release version of oxycodone.

There was also a split 13-13 vote on a relatively mild opioid painkiller – a combination of tramadol and the anti-inflammatory drug Celebrex..

Advisory committee recommendations are not binding on the FDA, but the votes reflect a growing reluctance to approve any new medication that may worsen the so-called opioid epidemic.

"We can't approve a drug in the midst of a public health crisis," said advisory committee member Steve Meisel, PharmD, who voted no on oxycodegol.

FDA advisors may be rejecting opioids out of hand, but cocaine is a different story. The agency this month quietly approved a nasal solution containing cocaine hydrochloride (HCI) for use as a local anesthetic. The nasal spray, made by the Lannet Company, is intended to relieve pain in mucous membranes during surgeries and procedures in the nasal cavities of adults.

"The FDA's approval of our Cocaine HCl product, the first NDA approval to include full clinical trials in the company's history, marks a major milestone in Lannett's 70+ years of operations," said Tim Crew, chief executive officer of Lannett in a news release.

"We believe the product has the potential to be an excellent option for the labeled indication. We expect to launch the product shortly, under the brand name Numbrino."

Numb-rino. Get it?

While cocaine is well-known as a drug of abuse, it is classified by the DEA as a Schedule II controlled substance, alongside hydrocodone and oxycodone. Cocaine’s use in medicine is not unheard of. It was commonly used as an alternative to morphine in the last half of the 19th Century until it fell out favor because of high rates of addiction.

Numbrino is not the first nasal spray containing cocaine to be approved by the FDA. In 2017, the agency approved the nasal solution Goprelto, which is also intended for use during surgeries and procedures in nasal cavities. 

Nevertheless, the FDA’s approval of a drug containing cocaine was so unusual that Snopes conducted a fact check to see if it was true. An FDA spokesperson confirmed to Snopes that Numbrino was approved, along with warning labels and other safeguards to discourage its abuse.

“Cocaine hydrochloride nasal solution contains cocaine, a Schedule II substance with a high potential for abuse. However, when used according to the directions provided in the labeling, physical dependence and withdrawal symptoms are unlikely to develop because this drug is for single use during diagnostic procedures and surgeries,” the FDA said.

“To minimize these risks, the labeling suggests that health care facilities using the drug implement effective accounting procedures, in addition to routine procedures for handling controlled substances. Notably, this will be used as an anesthetic by trained health care professionals during diagnostic procedures and surgeries, not by patients directly. It is not available by prescription.”

Numbrino was approved without any of the controversy that surrounds opioid painkillers. In 2018, the FDA’s approval of Dsuvia — a single use opioid intended for severely wounded soldiers and trauma patients — was panned by critics, who called the drug a “dangerously unnecessary opioid medication." Like Numbrino, Dsuvia is not available by prescription and can only be administered by a healthcare professional.

Tolerance Reduces Sleep Benefits of Medical Cannabis

By Pat Anson, PNN Editor

Getting a good night’s sleep can be a godsend to someone suffering from chronic pain. That’s why many pain patients are experimenting with medical cannabis to help manage their sleep problems.

But a small new study found that while cannabis initially helps with sleep, regular use leads to drug tolerance that causes even more sleep problems. A second study raises doubts about the use of cannabinoids in treating cancer pain.

Researchers at the Rambam Institute for Pain Medicine in Israel enrolled 129 volunteers over age 50 with chronic neuropathic pain. About half used medical cannabis for at least a year, either by smoking (69%), oil extracts (21%) or vaporizers (20%). The other half did not use cannabis.

Sleep problems were common among both groups of patients, with about 3 out 4 having trouble falling asleep or staying asleep.

Researchers found that cannabis users were less likely to wake up during the night, compared to those who did not use the drug. But over time the benefits of cannabis were reversed, and frequent users found it harder to fall asleep and woke up more often during the night.

The findings are published in the British Medical Journal's Supportive and Palliative Care journal.

“This study is among the first to test the link between whole plant MC (medical cannabis) use and sleep quality. In our sample of older (50+ years) chronic pain patients we found that MC may be related to fewer awakenings at night. Yet patients may also develop tolerance to the sleep-aid characteristics of MC,” researchers wrote.

“These findings may have large public health impacts considering the ageing of the population, the relatively high prevalence of sleep problems in this population along with increasing use of MC.”

The study was observational and did not establish a direct causal link between cannabis and sleep.  Another weakness is that the specific timing of cannabis use by participants was unknown. Taking cannabis before bedtime may have a stronger association with sleep. The researchers said their findings were preliminary and more larger studies were needed.

Cannabinoids Not Recommended for Cancer Pain

Another study published in the same medical journal found that cannabinoids do not reduce pain in patients with advanced cancer.

Researchers at the University of Hull in the UK reviewed data from five high-quality clinical studies involving 1,442 cancer patients and found that pain intensity was no different between those taking cannabinoids and those given a placebo.

Patients using cannabinoids also had nearly twice the risk of short-term side effects such as dizziness, drowsiness, nausea and fatigue. They were also more likely to drop out of studies.  

“For a medication to be useful, there needs to be a net overall benefit, with the positive effects (analgesia) outweighing adverse effects. None of the included phase III studies show benefit of cannabinoids,” researchers concluded.

“When statistically pooled, there was no decrease in pain score from cannabinoids. There are, however, significant adverse effects and dropouts reported from cannabinoids. Based on evidence with a low risk of bias, cannabinoids cannot be recommended for the treatment of cancer-related pain.”

The American Cancer Society takes a different view, pointing out that studies have found marijuana smoking can be helpful in treating nausea from cancer chemotherapy.  Other studies have also suggested that THC, CBD and other cannabinoids slow the growth of cancer cells in a laboratory setting.

Medical marijuana is legal in 33 In U.S. states and cancer is recognized as a qualifying condition in many of them.

Public Officials Ignorant About Overdose Crisis

By Christopher Piemonte, Guest Columnist

A recent Washington Post article highlights an ongoing debate between the Drug Enforcement Administration and some public officials, who are demanding that DEA further reduce the supply of opioid medication. DEA has responded that, without more precise data, such a reduction would be ineffective and dangerous for Americans that need opioids.

At the center of the debate is the Aggregate Production Quota (APQ) for Schedule I and II opioids and other controlled substances. Every year, the DEA sets the maximum amount for each substance that can be produced. DEA began cutting the opioid supply in 2017 and has proposed further cuts in 2020.  

Congressional lawmakers and state attorneys general argue that the APQ for opioid medication is still too high, and the excess supply leads to overdose deaths. In a recent letter to the Acting Administrator of DEA, six attorneys general claim that the APQ does not account for opioids diverted to the black market, which “factor in a substantial percentage of opioid deaths.”

Citing data from the CDC, they assert that in 2016 “opioids obtained through a prescription were a factor in over 66% of all drug overdose deaths.”

There’s a problem with these claims: They’re wrong.

When asked about the accuracy of the letter, a spokesperson for CDC said prescription opioids were a factor in “approximately 27% of all drug overdose deaths,” a figure nearly 40% lower than that presented in the letter.

It would be one thing if this error were simply a typo or miscalculation. But these state officials, as well as many lawmakers, are insisting on a specific policy response without having made the effort to dig into the data and understand the nature of the problem itself. Specifically, they cite inaccurate data to support the incorrect notion that “prescription opioids have been a dominant driver in the growing crisis.” What’s worse, that false notion is the basis for their intransigent insistence on a blanket reduction in the supply of all prescription opioids.

Experts in law enforcement, medicine and policy agree that the attorneys general made an erroneous factual conclusion, and that an arbitrary opioid quota reduction would be both ill-informed and dangerous.

“There is no question that the DEA, or any agency, attempting to come up with valid quotas for controlled substances will find it difficult if not impossible. One of the problems with interpreting overdose death information is that illicit fentanyl and heroin deaths are frequently lumped together with oxycodone- and hydrocodone-related deaths,” said John Burke, President of the International Health Facility Diversion Association and a former drug investigator for the Cincinnati Police Department.

“The vast majority of people prescribed controlled substances take them as directed. Proposed cuts in quotas will negatively impact Americans who have a legitimate medical need for opioids, causing them even more discomfort and distress. These patients are routinely overlooked when considering the prescribing and dispensing of controlled substances, and it is a tragedy.”

Increased Demand for Street Drugs

Other experts warn that further reducing the supply of opioid medication will lead to drug shortages and increase demand for illicit drugs.   

“On the surface, it appears that limiting the quotas…could, in fact, provide a means to address the overdose crisis,” said Marsha Stanton, a pain management nurse, clinical educator and patient advocate. “That, however, will do nothing more than to minimize or eliminate access to those medications for individuals with legitimate prescriptions. We have already seen the effects of back-ordered medications, which create significant barriers to appropriate patient care.”

“Patients who lose access to prescriptions for opioids, have, in some cases, turned to street drugs as an alternative. This has led to increased morbidity and mortality since street drugs have uncertain content and are often used in a comparatively uncontrolled manner,” said Stuart Gitlow, MD, an addiction psychiatrist and past president of the American Society of Addiction Medicine.

“We, therefore, cannot afford to use a crude blunt instrument such as a quota change to address the drug abuse problem. Rather, we must focus on each patient individually and, through education of clinical professionals, ensure that each patient receives medically reasonable treatment.”

By continually insisting on cuts in opioid production, public officials demonstrate a lack of understanding of America’s overdose crisis. Put simply, they’ve failed to do their homework.

“For more than a decade, experts have urged government officials to focus on much more than reducing the opioid-medication supply. Yet, they remain fixated in intellectual laziness,” said Michael Barnes, Chairman of the Center for U.S. Policy and a former presidential appointee in the Office of National Drug Control Policy.

“Policy makers must reduce demand by prioritizing drug abuse prevention, interventions, and treatment. Prevention is the biggest challenge because it will require public officials to realize and respond to the socioeconomic underpinnings of drug abuse. The time is long overdue for politicians to get serious and do the work necessary to save lives and solve this crisis.”   

The disturbing reality is this: Despite rising death tolls and the shortcomings of recent responses, many officials involved in overdose-response policy misunderstand the complexity of America’s overdose crisis.

Until those individuals are educated about the nuances of the issue, they will continue to demand policy that does not adequately address the problem, and the crisis will carry on. Continued ignorance on the part of government officials would truly be, as Mr. Burke put it, a national tragedy.

Christopher Piemonte is a policy manager for the Center for U.S. Policy (CUSP), a non-profit dedicated to enhancing the health, safety and economic opportunity of all Americans. CUSP is currently focused on identifying and advancing solutions to the nation’s substance abuse, mental health and incarceration crises.