Public health and politics

 Most people would agree that West Virginia is pretty close to being Ground Zero for the opioid crisis after being virtually cluster bombed for years by pharmaceutical companies dumping highly addictive drugs around the state. 

As the supply of pills declined, more people switched to injecting opioids, which of necessity involves needles...and which has become a political hot button issue in places like Charleston, WV. In 2018, the city shut down the needle exchange program operated by the Kanawha Charleston Health Department.

Of course, people with substance use disorder don't stop using when the supply of clean needles goes away, which can lead to all kinds of horror stories, including an underground market in used needles. It's a classic example of what economists call inelastic demand. 

What could possibly go wrong with that scenario? 

A grassroots group called Solutions Oriented Addiction Response (SOAR) took up the slack, which until recently offered sterile syringes, Naloxone, condoms, snacks, HIV testing, conversation and such until they came under fire from city officials. They're still around, although they've stopped syringe distribution.

This excellent report by WV Public Broadcasting shows what can happen when public health is politicized. And you may learn more about reusing needles than you ever expected to.

Rat cage or rat park?

Like many people in West Virginia today, I’ve been thinking, listening, talking and reading a lot about issues of addiction and recovery.

Along the way, I’ve been struck by some interesting research that suggests there’s a lot more to it than the effect of certain chemical molecules on the brain. There’s a social dimension that could well be decisive in overcoming this crisis.

An amazing example of how social conditions affect addiction was found in the Vietnam War era. As the war continued, drug use — particularly heroin — became something of an epidemic among soldiers serving there.

That wasn’t surprising, considering the realities they faced.

According to some research, as many as 35 percent of soldiers had tried heroin at least once, and 20 percent were fully addicted.

At the time, Connecticut Sen. Robert Steel said after visiting the war zone, “The soldier going to South Vietnam today runs a far greater risk of becoming a heroin addict than a combat casualty.”

Obviously, many people were concerned about what would happen when these veterans returned to their communities. But something surprising happened when they got home. Fully 95 percent of veterans with addictions stopped using and never relapsed.

How could this be? Author Dan Baum summed it up pretty well: “Take a man out of a pestilential jungle where people he can’t see are trying to kill him for reasons he doesn’t understand, and — surprise! — his need to shoot smack goes away.”

To state the obvious, the situations in which people live have a lot to do with their life choices, including those related to addiction and recovery.

I think we could learn a lot from a fascinating experiment conduced by researcher Bruce Alexander with rats under laboratory conditions.

It was long known that, if you put a rat in a cage and gave it unlimited access to addictive drugs, it would hit the drugs pretty hard, often to the point of death.

Alexander decided to try something a little different. As Johann Hari explains in his book “Chasing the Scream”:

“With a few of his colleagues, he built two sets of homes for laboratory rats. In the first home, they lived as they had in the original experiments, in solitary confinement, isolated except for their fix. But then he built a second home: a paradise for rats. Within its plywood walls, it contained everything a rat could want—there were wheels and colored balls and the best food, and other rats to hang out with and have sex with.”

He called the second place Rat Park.

The rats in the isolated cage used up to 25 milligrams of morphine a day. The rats in Rat Park used less than 5 milligrams, despite having a 24-hour supply of the drug.

In a variation on the experiment, he took addicted rats who had been in isolation and placed them in Rat Park. In a short time, they stopped using morphine.

It’s probably not just a rat thing.

According to Alexander, “When I talk to addicted people, whether they are addicted to alcohol, drugs, gambling, internet use, sex, or anything else, I encounter human beings who really do not have a viable social or cultural life. They use their addictions as a way of coping with their dislocation: as an escape, a pain killer, or a kind of substitute for a full life. Maybe our fragmented, mobile, ever-changing modern society has produced social and cultural isolation in very large numbers of people, even though their cages are invisible.”

He argues that “today’s flood of addiction is occurring because our hyperindividualistic, hypercompetitive, frantic, crisis-ridden society makes most people feel socially and culturally isolated. Chronic isolation causes people to look for relief. They find temporary relief in addiction to drugs or any of a thousand other habits and pursuits because addiction allows them to escape from their feelings, to deaden their senses and to experience an addictive lifestyle as a substitute for a full life.”

It’s probably no accident that waves of addiction seem to hit populations going through extreme stress, hard economic times and declining community and social capital.

While there is an urgent need for other forms of prevention, intervention and treatment, it’s pretty clear that we could take a lesson from our friends the rats, re-weave our broken connections and re-dedicate ourselves to constructing a society worthy of human beings.

Less cage. More park.

(This appeared as an op-ed in the Charleston Gazette-Mail.)

Fat city?

I love the city of Huntington. I'm no doubt biased. It's my county seat and it was always the city we could go to when we need a break from our small town. It's home of Marshall, my alma mater twice over.

It's been hit by tidal wave after tidal wave. Major deindustrialization, bad health, ground zero for opioid overdoses. But it keeps fighting back.

Usually any national attention it gets has to do with the opioid epidemic. This would be a case in point. Things are still bad there, but the fact that the city has made major progress in reducing overdoses doesn't always get the same level of attention.

I was pleasantly surprised to see this Washington Post story about how Huntington turned the corner from being America's most obese city. According to the CDC, the rate dropped by 13 percentage points over the last decade.

Some may remember when Jamie Oliver did a Food Revolution TV series about Huntington, with plenty of made up drama, but the heroes and heroines of this story are local.

And the city keeps plugging away.

What's at stake for WV in the health care fight

If you want to know what's at stake for West Virginians in the fight to preserve the Affordable Care Act (ACA), which is once again under attack by Prince Joffrey President Trump, consider this info by Gazette-Mail reporter Lori Kersey:

Low-income West Virginians received $90 million worth of mental health and substance abuse treatment last year, and nearly $300 million over the last four years, under a law the Trump administration is trying to repeal, according to West Virginia health officials.

Under the Affordable Care Act, commonly known as Obamacare, West Virginia expanded its Medicaid program to those who make up to 138 percent of the federal poverty line.

According to the West Virginia Department of Health and Human Resources, the state’s expanded Medicaid program spent about $58 million on mental health and substance abuse in fiscal year 2015, $61 million in 2016, $79 million in 2017 and $90 million in 2018.

Then there's this: according to the WV Department of Health and Human Resources, as of April 1, 160,356 West Virginians were covered by Medicaid expansion, a state option under the ACA. Another 22,600 state residents got coverage under the ACA exchange. Then there are around 12,000 young people who are able to stay on their parent's insurance until age 26, another ACA provision.

Then there's the fact that the ACA brings hundreds of millions of dollars to our economy, creating thousands of jobs and helping to keep rural hospitals and health care providers going.

Those are just numbers, but behind each number is a story. Here's a link to some collected from people who gained coverage thanks to Medicaid expansion.

This is our concern, Dude.

Harm reduction done right

In case you missed it, there was an interesting NY Times article about how Dayton Ohio and its county of Montgomery dramatically reduced opioid overdose deaths from last year to this.

Lots of things seemed to come together to make this possible. The most obvious of these was Gov. Kasich's decision to expand Medicaid under the Affordable Care Act. Dayton mayor Nan Whaley claimed it was the basis for everything they've been able to accomplish, saying

“If you’re a state that does not have Medicaid expansion, you can’t build a system for addressing this disease.”

That's sad but really true. Some of the states that need it most haven't done it year, although that number is fortunately diminishing.

Other factors were harm reduction programs, support groups, a strong program to distribute Naloxone to reverse the effects of overdoses, and, importantly, the growing cooperation between Dayton police and public health workers.

Unfortunately, Charleston WV has been going in the opposite direction, as this WV Public Broadcasting story relates. 

The Times article quotes Sam Quinones, author of “Dreamland: The True Tale of America’s Opiate Epidemic,”who told a congressional hearing that "the more cops and public health nurses go out for a beer, bridge that cultural chasm between them," the better the US will be able to deal with the problem.

"Everyone would know we were crazy"

"Imagine if the government chased sick people with diabetes, put a tax on insulin and drove it into the black market, told doctors they couldn't treat them then sent them to jail. If we did that, everyone would know we were crazy. Yet we do practically the same thing every day in the week to sick people hooked on drugs. The jails are full and the problem is getting worse every day"--Billie Holiday 1915-1959.

Resilience and tragedy

Ravenswood WV was once a booming factory town. It was the home of a major Kaiser Aluminum plant, with employment in the thousands.

It wouldn't be accurate, however, to say it was a company town. Or only that. It was also a union town and a stronghold of the United Steelworkers of America.

If you're at all aware of economic trends in American since 1980, you can probably guess the trajectory of the story. The plant faced massive layoffs early in the decade and was sold in the late 1980s, morphing into the Ravenswood Aluminum Corporation (RAC).

In 1990, the company ordered union members, who were working despite the expiration of their old contract, out of the factory, which had taken on the appearance of a factory, and declared them to be permanently replaced.

Thus began "the battle of Fort RAC," which lasted from the fall of 1990 to the summer of 1992. It wasn't a strike; it was a lockout.

I must admit to having fond memories of that struggle, as I've written elsewhere. Despite all odds, the members of USWA Local 5668 won their jobs back.

In 1995, the factory became Century Aluminum, which eventually closed in the Great Recession, laying off 651 workers. Century union retirees had to fight long and hard to secure promised benefits, but eventually succeeded in 2017.

Today, aluminum is still produced there by Constellium, which employs around 1,100 people, most of whom are union members.It's the largest employer in Jackson County.

It's been a tough ride, and there have been plenty of casualties, but union workers have fought hard, won some victories and showed remarkable resilience.

Today another kind of struggle is going on there, as it is all over West Virginia and much of the country. That would be the struggle of responding to the pharmaceutical crime of the opioid epidemic.

This article from The Nation tells some of that story. The title--"These kids are watching their parents die"--is stark, but it's a quote from a local nurse practitioner. It makes the good point that public school teachers are in the front lines of this fight, just as they were in the wave of teachers' strikes that have challenged failed austerity policies in several states.

 Their situation is pretty grim, but, like the Steelworkers before them, sometimes they win.

Miracles happen: good news from the opioid front

I'm proud of the latest episode of the Front Porch program/podcast from WV Public Broadcasting, which is about success stories in fighting the opioid crisis.  Sometimes the problem seems so overwhelming that nothing can be done. In reality, some things are working and some people are making it work.

This podcast focuses on the work of Lois Vance, care coordinator at Cabin Creek Health Systems, who works daily with people recovering from addiction with medically assisted treatment and plenty of group work and hand holding. Vance tells inspiring stories of people once at risk of overdose now working, taking care of their children, and leading fulfilling lives. I know it's true because I've met some of them.

Alas, there are threats to this successful program from congress, the Trump administration, and state government in West Virginia, all of which have threatened to attack the Medicaid expansion provisions of the Affordable Care Act that have been a lifeline to many of these people. In this case, it literally is a matter of life and death.

A close one

According to The Hill, WV Congresswoman Shelley Moore Capito, who has previously supported retaining Medicaid expansion, is now open to phasing it out. This would be a disaster to the Mountain State, where 175,000 people have gained coverage. According to WV DHHR Secretary Bill Crouch, that includes 50,000 people getting treatment for opioid addiction in a state that leads the nation in overdose deaths.

The House plan, according to the CBO, would over time cut Medicaid coverage for 14 million people. Even a kinder, gentler, slower Senate phaseout could end coverage for millions.

Just another reason why it's important for West Virginians to contact Senator Capito's office and urge her to preserve this lifeline for so many West Virginians. To find out how to do that, click here.

Dead or in jail

I spent a good chunk of Monday talking with women who were recovering from opioid addiction. This was part of an ongoing effort to interview people whose lives were touched by the Affordable Care Act (ACA).

Two of those women were particularly memorable. Both were parents who regained control of their lives thanks to medically assisted treatment they were able to access due to the the decision by then WV Governor Earl Ray Tomblin to expand Medicaid under the ACA.

One spoke of loved ones lost to overdoses, including a fiance who was like a father to her son. Another told of her experience with jail and probation. Thanks to treatment, both had been clean for several months, were holding down a job, paying taxes, maintaining a home, and caring for their children. Both were proud of being made assistant managers at their jobs.

Both said that "nobody wakes up one morning and decides to become an addict." Both were glad to finally be drug free and in control, for the first time in their adult lives.

When I asked how their lives would be different without the treatment the ACA supports, the answers were pretty stark: "Dead or in jail."

Treatment for addiction at risk

This op-ed of mine on WV's opioid crisis and how killing the ACA would make it worse ran in today's Gazette-Mail.

There’s hardly a community in West Virginia that hasn’t been impacted by our opioid/addiction/overdose crisis. For that matter, there probably aren’t even that many families that haven’t felt the effects of it directly or indirectly.

I knew it was bad, but I had no idea of the sheer magnitude of addictive pills dropped like little bombs into the state by drug companies and wholesalers until I read Eric Eyre’s series on the issue in the Gazette-Mail. While this has damaged the lives of many individuals, it goes way beyond the level of a purely personal problem.

It reminds me of a basic insight by sociologist C. Wright Mills. In his classic “The Sociological Imagination,” he talked about the distinction and overlap between personal troubles and social issues.

Personal troubles “occur within the character of the individual and within the range of his immediate relations with others.” Potentially, these troubles can be understood and resolved at the individual level.

Social issues, on the other hand, “have to do with matters that transcend these local environments of the individual and the range of his inner life.” These include many institutions, organizations, and social forces that operate and interact in a given social and historical situation.

It’s a question of level of magnitude. Social issues can cause huge suffering to any number of individuals, but they involve larger forces and institutions at work that help cause the damage.

Mills uses unemployment as an example:

“When, in a city of 100,000, only one man is unemployed, that is his personal trouble, and for its relief we properly look to the character of the man, his skills, and his immediate opportunities. But when in a nation of 50 million employees, 15 million men are unemployed, that is an issue, and we may not hope to find its solution within the range of opportunities open to any one individual.”

In the same way, if a few individuals in a rural state fall victim to opioid addiction, this could be regarded as a personal trouble for those involved. But when, as Eyre has reported, a handful of drug wholesalers pumped 780 million hydrocodone and oxycodone pills into the state over six years — or 433 pills for every man, woman and child in the state — while more than 1,700 West Virginians died of drug overdoses, we’re talking about a huge social issue.

I’ve had a hard time getting a handle on what 780 million pills would even look like. For starters, I took a (pretty uninteresting) pill out of my medicine cabinet and measured it. It came out to 2.5 pills per inch. Then I reached for a calculator ...

You may want to double check this, but here’s what I came up with if you placed them end to end: at 2.5 pills per inch and 63,360 inches per mile, that comes to 4,924.24 miles of pills. That’s about the distance in air miles from New York City to Honolulu (4,909).

Which is to say, a lot.

Eyre’s research found that many of these were prescribed in economically depressed coalfield counties, which had high levels of fatal overdoses. Kermit, in Mingo County, for example, with a population of 392 received nearly 9 million hydrocodone pills at a single pharmacy in a two-year period.

There’s plenty of blame to go around on this, from aggressive marketing by drug manufacturers and wholesalers to doctors who ran “pill mills” to unscrupulous pharmacies cashing in on misery to lax oversight by public agencies.

There has been one bright spot in all this in some states, including West Virginia. Medicaid expansion under the Affordable Care Act has made treatment for addiction accessible to many people for the first time.

The Pew Charitable Trusts reported in 2015 that at least 2.5 million adults out of the estimated 18 million potentially eligible for expanded Medicaid coverage had substance abuse issues. Around 2.8 million people with slightly higher incomes would be eligible for subsidized substance abuse treatment through state health exchanges.

According to Pew, “In addition to increasing the number of people with health insurance, the ACA for the first time made coverage of addiction services and other behavioral health disorders mandatory for all insurers, including Medicaid.”

It’s hard to get a handle on exactly how many people are getting addiction treatment for the first time through the ACA. According to Kaiser Health News in December 2016, in Rhode Island, more than 3,600 people were treated for addiction. Between January 2015 and March 2016, more than 63,000 people in Massachusetts got help. Around 10,000 people in New Hampshire were able to get treatment in 2015.

Closer to home, The Columbus Dispatch reported in July: “Nearly 500,000 low-income Ohio adults, most of them uninsured, received mental health and addiction services under the state’s hard-fought Medicaid expansion.”

According to WFPL public radio, in Kentucky, a new report “shows a 740 percent increase in substance abuse services for Medicaid expansion beneficiaries. The number of Kentuckians with traditional Medicaid who received treatment for substance was four times higher between 2014 and 2016, according to the report.”

I haven’t been able to find exact figures for how many West Virginians have received or are now receiving treatment for addiction under Medicaid expansion, but if we extrapolate Pew’s estimate that around 14 percent of the Medicaid expansion population nationwide has addiction issues, that would amount to around 24,500 people here who would be eligible for it, not counting those who gained coverage through the exchange.

That’s enough to take a big bite out of the problem. And we know this is something people want and need.

That’s the good news. Unfortunately, the new president and the Republican majority in the U.S. House and Senate plan to repeal the Affordable Care Act. Unless it is replaced by something comparable, this would pull the rug out from under many individuals, families and communities now on the road to recovery.

It remains to be seen if West Virginia’s delegation will let that happen.

To treat or to trash

So it's no secret that opioid addiction is destroying many lives and families in West Virginia and many other parts of the country. It's a sad fact that repeal of the Affordable Care Act, which seems to be on the agenda, will yank the rug out from under many who need treatment for mental health and addiction issues. According to a recent Harvard study, ACA repeal would threaten a 45 percent of funds available in WV for medically assisted treatment for those battling with addiction.

The game of chicken continues, but the casualties will be real.

780 million opioids?

A bit of a downer before the holidays: the latest Front Porch features Gazette-Mail reporter Eric Eyre on his series about WV's opioid epidemic. It's hard to get my head around this but over a few year's time, 780 MILLION opioids were dumped into WV, mostly to depressed areas in the southern coalfields.

I actually did the math, based on measuring one of my own (not very interesting) medicines: at 2.5 pills per inch w 63,360 inches per mile, 158,400 pills per mile divided into 780M=4,924.24 miles of pills. It's about the distance in air miles from New York City to Honolulu.

Damn.

An act of war

In case you missed it, please take a look at this great reporting from Gazette-Mail journalist Eric Eyre about WV's opioid epidemic. It's really hard to get your head around. Or my head, anyway.

Teaser: a handful of drug companies poured 780 MILLION pain pills into WV over a few years, even while our overdose rate increased. They specifically targeted a handful of rural communities in the coalfields.

It reminds me of Great Britain's shameful behavior towards China (or is that Jina?) during the opium wars, when that empire forced addictive drugs on the Chinese people.

If another country did this to us, we'd go to war. Unless it was Russia, which apparently gets a pass from the president elect.

Sad story. Will it get sadder?

You may have already heard a lot about WV's opioid overdose issue. The short answer to the question "How bad is it?" is "Pretty damn."

Yesterday's Washington Post talks about:

a national crisis that has been worst of all in rural West Virginia, where health officials estimate that overdose rates are now eight to 10 times higher than the national average. Middle-aged white men in this part of the country have lost a full year of life expectancy during the past two decades. Middle-aged white women have lost more than two years. The opiate epidemic has essentially wiped out an entire generation of health advances, and now West Virginia has begun to focus more of its resources on prevention and preservation among the next generation entering into the void.

The crisis has even led to the creation of a new term for children who lost parents due to overdoses: opiate orphans.

Sadly, the president elect and the Republican congress want to wipe out one ray of hope for dealing with this epidemic: Medicaid expansion under the Affordable Care Act.

Tomorrow, health care advocates are planning to rally around the country urging that the helpful provisions of the ACA not be repealed until they are replaced. An action is also planned for Charleston, which will occur near Senator Capito's office. More on that here.

From the horse's mouth

The city of Huntington is ground zero in WV's opioid crisis. When 26 people there overdosed in a few hours, the story made headlines nationwide. It was nice to see this editorial in that city's Herald-Dispatch about how to respond. Here's bit:

If locking up users and dealers were the "silver bullet," we would have won the war on drugs years ago. Largely because of tougher penalties for drugs, the American prison population rose from 400,000 in the 1970s to record levels of 2.3 million in recent years....

Local, state and federal government has spent billions fighting drugs for the past 50 years. A reasonable investment in prevention, treatment and recovery is long overdue.

The rest is here.

This is a much more productive approach than more mandatory minimums as proposed by Republican candidate for governor Bill Cole.

Houston, we've got a problem

It's no secret that West Virginia, and my own county of Cabell, is ground zero for the opioid plague. As of 2015, Huntington had the highest drug overdose rate in the nation, with West Virginia "leading" the pack among states.

To get a sense of just how bad things are, consider this: yesterday between 3:30 and 9:00 pm fully 26 overdoses were reported in Huntington. It's almost miraculous, but so far nobody has died. While there's no such thing as a good batch of heroin, this one was particularly powerful. Some patients required more than one dose of naloxone to come out of it.

This year's overdose rate for the city is about the same as last year, but there is a bit of good news: the rate of overdose deaths is down by about 25 percent, from 35 last year to 26 this year.

The epidemic has got to be exhausting to the emergency medical service workers. According to this MetroNews report, some individual first responders helped save as many as eight overdose patience in one day.

This clearly shows the need for more investment in drug abuse prevention, treatment and recovery. And don't count on "the market" to provide it.

Urgent owlet update...and other stuff

Photo credit: Sister in law Unit.

A while back I posted a picture of a baby great horned owl that was born on our hill. I'm pleased to say that he survived and has now taken to venturing forth. This isn't quite the same as fledging, according to the Spousal Unit. Apparently that is like moving out. Instead, the little critter is branching, which entails a return to the nest. You can see both in the picture above, with the nest in the upper left and the owlet in the lower right.

YOU REALLY CAN'T. I've often mentioned here my campaign to update state motto of West Virginia from "Mountaineers Are Always Free" to "You Can't Make This **** Up." This column by statehouse reporter Phil Kabler has a priceless example in it.

COAL-LAPSE. There's been a lot of coverage about the decline of coal. This AP article suggests it's happening faster than anticipated. Note that the article attributes most of this to market conditions rather than a certain Muslim socialist of questionable American birth.

SPEAKING OF SUBSTANCE ABUSE. I knew things were bad, but I didn't know things had gone this far.

Prison nation

On the latest Front Porch program/podcast, we spoke with my friend Pastor Matthew Watts of Grace Bible Church and Hope Community Development on Charleston WV's west side. This is a heavily edited version of a long conversation we had about prisons, race, mass incarceration, social changes and more.

WISDOM BOOKS. Regular readers of this blog know I'm a sucker for ancient Greek and Roman classics. Right now, I've made a decent start at rereading three classics that I plan on going through again and again: Plutarch's Lives, Herodotus' Histories and Thucydides' Peloponnesian War. (I'm about 320 pages through the first and just finished the life of Timoleon, the Corinthian leader who liberated Sicily from the rule of tyrants.) So it's no wonder that this Gazette-Mail op-ed on Thucydides caught my eye.

SAD SIGN OF THE TIMES. It's no secret that WV has a drug overdose problem and that my county of Cabell is ground zero. It was really sad for me to read that school nurses in that county are preparing to administer naxolone for opioid overdoses.

Addiction, politics, biscuits

Here's the latest Front Porch, which among other things talks about President Obama's recent visit to WV to discuss the addiction problem. It includes a few shameless appeals to get a local biscuit chain to underwrite the program.