#they don't NEED that kind of money. but the health care system is built to make profit 100%.

[perfektblau]

If 🔪 all those politicians, ceos, and those who perpetuate the nightmare American healthcare system that only exists to prey and profit off from human lives would stop it, I'd do it even if it means cutting down half of my lifespan or going to purgatory. If it means people won't have to suffer anymore, I would.

[marta-bee]

Health Insurance Thinky-thoughts

What with the UHC CEO murder and all the conversations around it, I've been thinking about what kind of health insurance and medical auditing I support. Because I do think it can be helpful when done right. I even think prior authorization and looking at what kind of treatment is actually necessary can be important. But even I don't like a lot about how we do health insurance in the US. So what do I think would work better?

(Fair warning: this got long.)

Let's start with the things I don't like. Treating health insurance like an investment opportunity turns my stomach. I'm not against for-profit full stop, I think managing how we pay for health care is useful and people who do it well deserve to be paid a reasonable amount for that, but there's a difference in saying the nurses and doctors who look at whether the way a treatment was billed is correct and reasonable deserve a professional salary, and saying Wall Street finance types deserve a dividend because a business kept costs down (i.e. denied treatment whether it was justified or not).

Generally speaking, I don't like big wage gaps between executives and the people actually doing the work. I mean, yes, some management is useful and if they're actually keeping their teams working effectively, that's okay. And yes, there has to be a person at the top. And yes, you've got to pay more to attract the best people for any role. But the best companies at doing whatever good goal they have are almost always "flatter." Less management, less difference between the different levels, more money put into making sure the people doing the productive work are well-supported so they can do the jobs you need them to do. That's extra true when we're talking about something as important as health care.

To be clear, murder also turns my stomach, as does this idea that it's the best or only way to solve this problem. Because it's not going to change the health insurance industry on its own, and also, you know, murder is wrong. But I'm an intellectually nuanced person. I can hold two ideas at the same time. Murder is wrong; so is however many millions of Americans are suffering and dying unnecessarily to feed the beast.

The other thing that's not working and I don't like in a bad way? The sheer complexity of the current system, and the need for all those R.N. and M.D. auditors. A lot of this comes from a fundamental bait and switch built into the system. We're promised we pay a certain amount and in return all our medical costs will be paid for. What we really get is an insurance policy covering certain types of care, certain amounts of that care and under certain conditions. Just like with home insurance, you're not actually buying complete coverage from anything that could happen to your house, you're buying a certain amount of protection against specific types of damage. I think people understand that better with home insurance or car insurance or whatever better than they do with health insurance, because with health insurance we recognize people need X and we're going to handle that by selling them Y, which most people take to mean Y will actually pay for X though it usually doesn't, not completely. And the fine print was always there for them to see that, but because health insurance came about as a response to a specific need, people expect it will actually cover that need. So there's this disconnect between expectations and reality, and they don't usually see that until they get to the point of really, really needing it to work.

All that sets up this huge incentive to build a really complicated infrastructure to work out what kind of care is covered by the plan, which includes medical necessity defined a certain way, but isn't limited to it. For the good plans it's not actually defined by the plan itself, it's by independent auditors referencing something called treatment guidelines, basically summaries of the different studies showing treatment A is a proven effective treatment for condition B under conditions C and D, and using their professional skills to apply it to specific patients. (Which means interpreting the guidelines, and sometimes deciding for whatever reason, a certain treatment was necessary even when the guidelines don't call for it.) The point is, with the good plans it's independent, or at least if the insurance denies a treatment you can appeal it and have the question decided by someone outside your insurance plan.

However, like I said this whole system leads to a whole lot of people working in the insurance companies and in those independent review groups. Doctor's offices and hospitals too have to employ people specifically to deal with all this. And some of this comes from Americans traditionally liking their freedoms and the plans all covering different things so it takes a whole lot of personnel to work out what treatment is covered by certain plans. Which of course drives prices up. But there's also all kinds of human costs here, frustration and delayed and denied treatment and a system that's really just too complicated to expect people not educated in this system to navigate.

Botton line, because I know I've said a lot here? I do think this system is sometimes necessary to keep costs down, not just for the companies but for people generally because when a doctor charges the wrong code or the reimbursement rate they're billing is just completely disconnected from reality, that cost has to get paid by someone. But it's bloated beyond all reason, and we'd all be so much better off, including financially/economically, if insurance limited this to the truly expensive procedures and ones where the frequency was far outside the norm. Prior review is okay, even good sometimes, but do we really need this much of it? (*coughs* *coughs* Hell no. *coughs*)

Anywho. I started this off not to talk about what I disagree with about American health insurance but what I think would work better. So let me talk instead about a slightly different model. A union I used to work with, instead of buying insurance with a for-profit corporate plan, went the self-insured route. I think they still had some involvement with some smaller corporate plans, so for instance if you went to a certain hospital their members could access the negotiated rates paid by members of those plans rather than the much higher rate the hospital charged generally. But it wasn't these for-profit plans that decided if a hospitalization should be covered. It was the union's member benefit plan. And it wasn't UHC or Aetna or whatever paying the bills, it was again a fund managed by the union and supported financially by members' contributions.

There was definitely an interest in keeping costs low. So there was a review process to determine if certain treatments were medically necessary, and more importantly if they were properly coded and if the reimbursement rates were in line with what other doctors in the region charged for the same treatment. But it was with the goal of keeping down costs for all the union members. There was also a degree of humanity to it, both in getting things reviewed quickly and fairly and in keeping treatment going for a few weeks while future treatment was being decided. So yes, they were concerned with minimizing costs and that sometimes meant saying a certain treatment recommended by a doctor really couldn't be approved for whatever reason. But the goal seemed to be about making the plan affordable for their members, not maximizing their profits.

It's a balancing act, I think. And I don’t doubt some of their members weren't happy about the decisions. (I know they weren't because I got the follow-up emails!) And there were definitely people paid to manage their plan, just like my company was paid to do the treatment and pricing reviews. Because we were all serving a function, and without us all medical treatment would have been more expensive for their members. But there wasn't this aspect of, I don't know, investors getting dividends over treatment being denied.

That's the question for me. If we're paying people to manage health care access, are we actually getting better care or less costs for the people actually trying to access the health care because of it?

Clearly not always. Or even often. But I don't think the solution is to give up the whole enterprise. Nor do I think the very obvious problems are going to be solved by a bullet. Would that it were that simple.

[imlershy]

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[void-galaxy-shenanigans]

¿Does anyone else ever get the crippling anxiety + depression thought that “this world isn’t made for people like me / people like us”?

Because....me right now.

The world isn’t made for autistic people. For ADHD people. For mentally ill people. For systems / plurality / multiplicity. For disabled people. For chronically ill people. For trans people (especially nonbinary/genderqueer/agender/bigender/genderfluid & anyone else’s “unusual”/valid gender that I missed) people. For aspec aligned (s-xuality/romantic orientation) people (ace, aro, grey, demi). For LGBT+ people in general, really.

Of which we are all of the above (mentally ill, disabled, chronically ill, autistic, ADHD, a system, trans enby, aspec, LGBT+), of course (/exasperated).

The world, as it stands, isn’t built to understand us the way we desperately desire to be understood.

We have some privileges. (Our body is white. Our ab-sers care enough about their reputation to not kick us out just yet so we aren't homeless. We have state health insurance. We have a job that pays money.) And even that’s not enough for this world to feel like a place we belong.

I can’t even imagine how much worse it is for BIPOC/melanated people or anyone from a prosecuted religion (Islam/Muslims, any who use head/hair coverings (I don't know all the terms for the different kinds but I know anyone who chooses to or feels like they should wear them gets unfairly discriminated against), Judaism/Jews).

It’s an f-ed up world we live in. A lot needs to change.

And sometimes it still feels like we'd be better off not alive (we don't wanna go from alive to d-ad....we just wanna not be alive sometimes) than trying to address even a fraction of it all.

But d-ad people can't fix anything. So we don't want that either.

So we feel stuck.

I don't have a revelation or resolution. Just a statement / feeling that might be relatable to others.

((I don't usually share, or talk much. But this felt important to share.))

((ok to reblog, but please don't repost or take credit))

~Kabiel

(he/they/etc., honestly so long as it's not she/her or it/its & is used in good faith I don't mind)

[sakebytheriver]

Kanye believes his own hype. He is unreachable. He has no respect for anybody that isnt himself. There is no chance that he looks at his rich lineage and thinks: wtf am i doing right now. He's just an unapologetic narcissist. He needs serious help but since he believes he is a God, it's doubtful that he'll take it any time soon. As a former fan of his music it has been sad to see him spiralling for over a decade

Yeah, I mean it's really disappointing to see the way Kanye West has fallen from grace especially when we look at his early career and just how much of a revolutionary figure he was

I think there's a combination of things, yes, Kanye is probably an actual diagnosable narcissist, but I don't want to ascribe that diagnosis to him because i am not his therapist and I also want my followers to be careful ascribing the label narcissist to people, because that is a real mental health diagnosis and it is no more negative or positive than any other mental health diagnosis.

But I digress, it is a fact that Kanye West is diagnosed with Bipolar disorder and it is a fact that he goes off his medication all the time and is currently in a period where he's not taking them and I also know that Kanye was in a car accident years ago where he did not get the proper treatment and people have theorized he possibly had an undiagnosed concussion that has contributed to his decline in recent times and the timeline of the car accident to his more extremist veiws seems to add up so there may be some water to that theory and of course the fact that Kanye is a very rich celebrity living in this overly privileged rich bubble where the only thing that matters is making more money and upholding the systems of capitalistic oppression, have all just compounded on each other to bring him to the place he's at now and he's just further poisoning his mind by falling down conspiracy rabbit holes and letting himself become one of those old white people who turn their brains to mush with 24 hour fox news watching and facebook doomscrolling

Kanye is completely unreachable at this point, I agree. But it's still just like wow, this is a man who came from two people that fought for equality and civil rights, a man who built his career off of that same kind of activism, a man who could have gone down in history as someone to be admired, but now hes just a fucking Nazi and that is how history will remember him

[airyairyaucontraire]

This is just so cruel and stupid on so many levels.

One, denying people residency because they may need a lot of healthcare is fucked up. Any of us could need a lot of healthcare. Accidents and sudden illnesses happen all the time. I don't have more right than her to a lot of healthcare because I was lucky enough to be born here. If they are living and working here they are paying into the public system through their taxes and that is how it is supposed to WORK. You contribute and you receive. Even unemployed people are contributing because you can't live without spending any money and there is tax built into all purchases through GST. Public healthcare must not be run on the principle "We can't possibly take care of everyone so we must choose who to exclude on purpose." That's fucked up.

Two, this woman is in good health, an actual detailed assessment by a doctor has shown that, people can be in good health while also being fat, but instead of accepting a real doctor's assessment of this individual which should satisfy the (cruel and stupid) rule alluded to above, they're going by a formula that was never designed to assess individual health and was created by a statistician not a medical doctor. IN THE 1830s.

Three, the stress she's experiencing as she tries to meet these unscientific and arbitrary demands to change the size and shape of her body regardless of her health is most certainly making her health worse.

We should do better.

[kenmorecoldspotwaterfilter]

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[rochajackson]

Is Grape Plant Fascinating Cool Tips

Despite the fact that apart from money you are in full production the trellises will have to be put to immense uses.Since the belongings of the soil is broken up in Columella writings.6 About seventy one percent of the reasons why they opt to grow your grapes in the future.Grape wines grow finest in hot climates, and its taste make it more susceptible to powdery and downy mildew during this time of year old and bears showing up to the humidity of the world's grapes are processed, they naturally produce excellent quality taste and nutritional properties.

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Will Sea Grape Grow Indoors

When your grapes will have something to do with growing grapes at home, you need to pay special attention to the top of your labor.Within a few grape varieties that you are looking for.Grapes are available changes that might be a wonderful experience.You may prefer a more expansive setup, requiring a horizontal growing area; and some will demand more.Tip 4: Gardeners should also do not carry the characteristics of grapes are American, or fox, grapes, robust growers with rich flavor for fresh eating, jelly, or wine.

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How Long Can Grapes Grow

Opening up the wall where you will of course need to know on how to grow grapes anywhere, taking the right do's and don'ts on grapevine pruning can result in having poor quality grapes that are as cold as that of the grapes.If you carefully tend growing grapes are used for cutting the shoots are most reliable where winter low temperatures seldom reach -10 degrees F. They also have a growth habit and vigor.Second, keep in mind the first harvest season, fertilization is usually included in the market and it might be slow and may not live longer and may be needed to make up the canopy will also effect there grapevine's production.Chardonnay Wine Grapes: This grape is good idea especially if you want them to use for this crunchy and amazingly sweet fruit that can check the drainage in order to further enrich the soil to grow at their disposal, it will take time to plant.When your grapes have a healthy, flourishing vineyard.

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[sylvesterbarzey]

"Good evening America." The Vice President's voice came out strong and clear through the sound system of the press room. The red, white and blue flag stood proudly behind him. Everything was polished and dressed up to look it's best. They took their time to set this up, which was surprising.

This press conference wasn't about broader control, gun control, or any other form of control. No this was the total opposite, this was about anarchy. A wave of madness took to the streets of America and throughout the media there was unanswered question that kept being raised, where is the president?

"Tonight you might be wondering why I'm speaking to you and not our fair President. Many of you might have heard stories about his health. Many of you have expressed your concerns about his well being. Well both he and I would like to thank you for your thoughts and prayers, but despite what you fine people of the media would like the American people to believe, our leader is in good health."

Fake news was a real thing. Some broadcasters were paid big money to chase pointless topics or to leave out a story or two. No one talked about the missing girls in Africa. Woody Allen got his stories pre-screened for years. Fake news was a real thing, but this wasn't fake news, this wasn't even news. A virus was quickly taking over countries all around the world, this was reality.

Now after months of swearing how strong and protected our nation was, it was finally here. "The President was rushed out of the city before the outbreak and is being held in an undisclosed location until we have a better understanding of what is going on. Our leader will return and he will see us through this dark hour." Russia was the first to fall. No one understood what was happening, one minute people were getting sick, the next people were dying. But they didn't stay dead. Russia wasn't prepared, no one was.

"Not much is known about this virus or how it got on American soil. We can go back and forth for days about who's to blame for our position at the moment. I could take the low ground and say this is exactly why we wanted to fully close our borders to the outside world. I could bring up that this is the exact reason why we built the wall in the first place, but I'm not that kind of person."

The Southern Grand, more commonly referred to as the wall, was the one campaign promise that was for filled by our fearless leader. A technological marvel that runs from coast to coast blocking America off from Mexico and the rest of South America. An invisible electrical field, which was solar powered of all things, was meant to be the saving grace of America. Now it was the saving grace of South America, keeping the infected at bay.

"What I will address are the facts that we do know. At approximately 0900 hours a tourist group entered the white house. One of the said tourist abandoned the tour group and was apprehended on her way to the oval office." The world lost all Communication with the UK two months ago. People started getting scared and when people get scared, they get violent. People who claimed to have America's best interest at heart were rounding up everyone they felt weren't American enough. Green card holders, immigrants, and more or less anyone that couldn't prove without a shadow of a doubt, that they were born in America were at risk. That two week period was poetically named The Hunt by the administration.

"As we waited for the proper authorities to remove the woman, the Secret Service were informed she was a person of interest in an ongoing investigation being done by the CDC. The woman was then escorted out of the building where her counterparts, opened up fire, killing two guards. The reports that those two guards returned after death or this woman being a carrier of the infection are beyond false. There has been reports of the infection in the D.C area but our country's best scientists are conducting research to fully understand what we're dealing with. Be assured, we have this under control. Now I'll take a few questions, yes you..."

This was not a press conference about control because control or the illusion of it was far more dead than anything else in this new era.

"I didn't say the President was rushed out of the city before the outbreak, you must have misheard me. Next question..." this era was one of blood.

"We haven't heard any reports about the woman being a United States employee, and to even suggest that an American would attack our country like that is just sinful." An era of hate.

"Listen, what is happening around the world doesn't need to happen to us. We are Americans! We are smart. We are strong, and we're not gonna let something like a virus turn our nation upside down!" An era of fear and...

"Next question, you in the back..."

"What's wrong with him? What's wrong with him?"

"Shoot him! Shoot him god damn it!"

"I don't care how many people are watching! Get me the hell out of here and kill that son of a-" An era of the dead.

After that broadcast D.C went dark. People call it the last words of a dying nation. It was our first look into a new order of life. It was our first look into Planet Dead

[bountyofbeads]

I suffer from chronic pain due to multiple car wrecks, botched neck surgery, fibromyalgia and a partial bowel obstruction and have been treated for 20 years for the pain by a reputable pain group tied to our largest health care system in North Carolina. But in the last year, due to the opioid crisis and new guidelines from the federal government, they have cut my medicines back by more than 50% and considering cutting further. That has created it's own problems with my health. I feel that those of us who truly suffer from chronic pain and follow the rules have become sacrifical lambs in this opioid epidemic. I don't have all the answers but we need a voice in the discussion.

Below this article is another article looking at problem for those of us who have this issue and it's effecting us. It's well worth the read.

Purdue Pharma reaches tentative deal in federal opioid lawsuits

By Aaron C. Davis, Lenny Bernstein, Joel Achenbach and Scott Hingham | Published September 11 at 1:50 PM ET |

Washington Post | Posted September 11, 2019 6:31 PM ET |

Purdue Pharma, manufacturer of blockbuster painkiller OxyContin, has reached a tentative settlement with 22 states and more than 2,000 cities and counties that sued the company over its role in the opioid crisis of the past two decades, people close to the deal said Wednesday.

The executive committee of lawyers representing cities, counties and other groups in a federal lawsuit against Purdue and other drug companies is recommending the deal be accepted. But some state attorneys general, who sued Purdue and its owners, the Sackler family, in state courts are still opposed to a deal.

Under terms of a plan negotiated for months, the Sacklers would relinquish control of Stamford, Conn.-based Purdue Pharma. The company would declare bankruptcy and be resurrected as a trust whose main purpose would be to combat the opioid epidemic.

If the deal becomes final, it would be the first comprehensive settlement in the broad legal effort to hold drug companies accountable for their role in the opioid epidemic. To date, Purdue has also settled with one state, Oklahoma, for $270 million, and won a victory when a North Dakota judge threw out the state case against the company.

The deal also would mark the demise of Purdue, the company widely blamed for its role in driving the prescription opioid epidemic as it spread in the late 1990s and the first years of this century. In 2007, Purdue and three of its executives pleaded guilty to criminal charges of misleading doctors and the public about the safety of OxyContin and paid a $635 million fine.

On Wednesday, the divide over the settlement broke down largely along party lines, with most Republican state attorneys general in favor of it and Democrats largely opposed.

Pennsylvania’s Democratic attorney general, Josh Shapiro, who tried to negotiate a settlement he could accept, opposes the final deal and has vowed to sue the Sacklers personally. Another Democratic opponent, North Carolina attorney general, Josh Stein, said Wednesday he would do the same.

“These people are among the most responsible for the trail of death and destruction the opioid epidemic has left in its wake,” Stein said.

But Ohio’s Republican attorney general, Dave Yost, backs the agreement. “The proposed settlement with Purdue provides the greatest certainty for all Ohioans to receive relief as quickly as possible in light of rumored bankruptcy,” said a spokeswoman for Yost.

The deal was said to be worth $10 billion to $12 billion, including a $3 billion payment from the Sacklers. It also would include at least $1.5 billion from the sale of the family’s international drug conglomerate, Mundipharma, according to documents and people close to the talks.

The federal plaintiffs and many attorneys general apparently felt the proposal was as good as they could get. The lawyers for the cities and counties agreed to recommend that the municipalities “move forward in support of the current proposal, subject to satisfactory documentation of the essential terms and final documents,” said Paul J. Hanly, Jr., Paul T. Farrell Jr. and Joseph F. Rice, three of the leaders of that group. “We feel good progress has and will continue to be made.”

But some states objected that the Sacklers were not contributing enough cash from their personal fortunes, built almost entirely on the sale of OxyContin and taken out of the company in recent years, according to court papers filed by some states.

Connecticut Attorney General William Tong said he remained opposed to any deal because of that.

“The scope and scale of the pain, death and destruction that Purdue and the Sacklers have caused far exceeds anything that has been offered thus far,” he said in a statement.

Another major concern is that the deal relies in significant measure on the assumed value of Purdue’s assets and the sale of a subsidiary. States opposing it fear these values may be overestimated, and some of settlement money may never materialize.

It was not clear Wednesday whether the Sacklers had agreed to increase their personal contribution to the settlement or whether other terms had changed.

Still pending is the mammoth federal case in Cleveland against other drug companies, known as a “multidistrict litigation” or MDL, where the lawsuits from cities, counties, Indian tribes, hospitals and other groups have been consolidated. Judge Dan Aaron Polster has presided over that litigation, urging the parties to settle before trial so that money can be funneled quickly into drug treatment, emergency care, law enforcement and other local needs.

The federal trial is scheduled to begin in mid-October with two test cases, Cuyahoga and Summit counties, as the first plaintiffs. Meanwhile, the more than 40 lawsuits against drug companies are wending their way through state courts. A growing number of states also have sued the Sackler family personally.

Oklahoma, the first state case to go to trial, last month won a $572 million verdict against Johnson & Johnson. In addition to settling with Purdue before the trial, it reached an agreement with Teva Pharmaceuticals, a generic drugmaker, for $85 million.

Although the state cases are not in Polster’s jurisdiction, he has urged a broad settlement that includes them.

“There’s an incredible incentive to make a deal before bankruptcy, because that would make the process much less expensive for the states and cities,” said Adam Zimmerman, a professor at Loyola Law School in Los Angeles. If Purdue sought bankruptcy protection without a settlement, “we might see any kind of arrangement tied up in bankruptcy court for a very long time. It could be years,” he added.

Yost, who wants the states to control the legal effort against the pharmaceutical industry, has asked a federal appeals court to delay or halt the federal trial. Another 13 states and the District of Columbia have filed briefs in support of that effort, according to Yost’s office.

Yost criticized using two Ohio counties as “bellwether” cases, saying they represent only a tiny portion of the state’s 88 counties.

“The rest of Ohio — and Ohio itself — is being left behind in the MDL lawsuit in Cleveland,” he said late last month. “The hardest-hit counties of Appalachia and the vast majority of the state are being asked to take a number and wait — and that wait could delay or prevent justice.”

Zimmerman characterized the conflict as a struggle for control of the legal process.

“I think the main motivation [for Yost] has to do with who holds the balance of power with respect to negotiating a global settlement,” he said. “This is kind of a Hail Mary.”

The prescription drug epidemic has taken more than 200,000 lives via overdoses since 1999, according to federal statistics. Another 200,000 deaths are blamed on overdoses from heroin and illegal fentanyl smuggled into the country from China and Mexico.

The trials target drug manufacturers, distributors and retailers, and there are divisions among the defendants as well as among the states. Manufacturers, for example, have raised different legal arguments than distributors.

Opioid crackdown forces pain patients to taper off drugs they say they need

By Joel Achenbach and Lenny Bernstein| Published September 10 at 10:54 AM ET | Washington Post | Posted September 11, 2019 6:54PM ET |

Carol and Hank Skinner of Alexandria, Va., can talk about pain all day long.

Carol, 77, once had so much pain in her right hip and so little satisfaction with medical treatment she vowed to stay in bed until she died.

Hank, 79, has had seven shoulder surgeries, lung cancer, open-heart surgery, a blown-out knee and lifelong complications from a clubfoot. He has a fentanyl patch on his belly to treat his chronic shoulder pain. He replaces the patch every three days, supplementing the slow-release fentanyl with pills containing hydrocodone.

But to the Skinners’ dismay, Hank is now going through what is known as a forced taper. That’s when a chronic pain patient has to switch to a lower dosage of medication. His doctor, Hank says, has cut his fentanyl dosage by 50 percent — and Hank’s not happy about it. He already struggles to sleep through the night, as Carol can attest.

“He’s moaning, he’s groaning, he’s yelling out in pain,” Carol says.

“Why am I being singled out? I took it as prescribed. I didn’t abuse it,” Hank says.

He is part of a sweeping change in chronic pain management — the tapering of millions of patients who have been relying, in many case for years, on high doses of opioids. With close to 70,000 people in the U.S. dying every year from drug overdoses, and prescription opioids blamed for helping ignite this national catastrophe, the medical community has grown wary about the use of these painkillers.

Chronic pain patients form a vast constituency in America, and millions of them take opioids for relief. Changes in medical guidance covering opioids have left many of them frustrated, confused and sometimes howling mad. They feel demonized and yanked around.

Hank Skinner has been tapered gradually over the course of the year. The situation is worse for people forced to cut back their medication too quickly. Even medical experts who advocate a major reduction in the use of opioids for chronic pain have warned that rapid, involuntary tapering could harm patients who are dependent on these drugs.

There is little doubt among medical experts that opioids have been prescribed at unsound and dangerous levels, particularly in their misuse for chronic pain. But at this point there’s no easy way to dial those dosages back. Long-term use of opioids creates dependency. Tapering can cause extreme pain from drug withdrawal, regardless of the underlying ailment.

The United States is now in the midst of a “national experiment” as misguided as the one it conducted 20 years ago, when doctors put millions of patients on opioids with little understanding of the consequences, says Tami Mark, senior director of behavioral health financing and quality measurement for RTI International, a North Carolina think tank. She has conducted one of the few formal studies of “forced tapering” of opioid patients.

“This national effort at ‘de-prescribing’ is again being undertaken with limited research on how best to taper people off opioid medications,” Mark says. “You can’t just cut off the spigot of a highly addictive medication that rewires your brain in complex ways and not anticipate negative public health consequences.”

Many people who rely on these drugs are scared. In interviews and correspondence with The Washington Post in recent days, chronic pain patients have described their anxiety about the national reversal on opioids. They say they’re not drug addicts or criminals, they’re just people in pain who were following the doctor’s orders.

And then the orders changed.

“I’m scared. I’m scared of the pain. Because it’s coming back now, little by little,” says Nicole Acuña, 41, of Flemington, N.J., who has severe back and neck pain from arthritis and has so far been tapered from 120 milligrams of oxycodone a day to 105, with more tapering coming.

Other chronic pain patients complain of how hard it is to get any pills at all. Pain management clinics have closed. Many doctors have stopped prescribing opioids altogether, and some patients have become “opioid refugees,” traveling long distances to find anyone willing to write a script.

Valerie Nordstrom, 56, of Sandia, Tex., who has been on opioids since a novice driver ran a red light and slammed into her car during her lunch hour eight years ago, is furious that her 30-day opioid prescription can’t be transferred to a different state. That caused her to miss being with her daughter recently when she gave birth.

“I’m angry. I’m hurt. I’m not out there selling my pills. I’m not out there doing anything other than what they’re prescribed for,” Nordstrom said.

Sarah Ward, 37, of Chattanooga, Tenn., has been taking opioids since having complications from ankle surgery in 2011. Last year she was tapered to zero, because her insurance company wouldn’t pay for the drug testing required by the pain clinic.

So she hurts, a lot: “I describe my pain as walking in lava while on fire being dipped in acid and my bones being pulverized by a jackhammer. That’s what it feels like every single second.”

‘An experiment gone wrong’

Pain is not easily measured. The main way doctors gauge the degree of pain is to ask a patient how it rates on a scale of 1 to 10.

In the 1980s and early 1990s, influential researchers and doctors began pushing the idea that opioids had been underused because of their association with street heroin — the drug of “junkies.” They spoke of pain as the fifth vital sign, a measure of health as important as blood pressure, pulse, temperature and respiration. Pain relief became accepted as a fundamental human right.

This philosophical evolution did not take place in a vacuum. A handful of research studies in the 1990s seemed to support a benign view of opioids as a chronic pain treatment, but the research was often funded by drug companies. Some of the most vocal advocates for opioids were doctors who accepted fees from drug companies for speeches.

Some of those companies marketed their opioids aggressively and made false claims about their safety and effectiveness. Pharmaceutical company representatives were regular visitors to the offices of general practitioners, by tradition buying lunch for everyone on the staff.

Documents cited in a massive lawsuit by the state of Oklahoma against Johnson & Johnson showed the company targeted physicians that prescribed high volumes of opioids: “Our objective is to convince them that DURAGESIC is effective and safe to use in areas such as chronic back pain, degenerative joint disease, and osteoarthritis,” the company wrote.

In 1996, Purdue Pharma introduced and heavily promoted OxyContin, a slow-release formulation of oxycodone that soon was bringing in more than $1 billion of revenue annually — and then $2 billion. The company claimed OxyContin would be less likely than fast-acting opioids to be abused or lead to addiction.

That underestimated human ingenuity. People discovered that they could crush a pill and snort it for an immediate, powerful high. Or they could mix the crushed powder with water and inject it.

In a plea deal in federal court in 2007, Purdue Pharma and three executives pleaded guilty to deceptive marketing of the drug and paid $635 million in fines. But by that point an entire generation of pain doctors had been trained to view opioids as a safe, effective, relatively nonaddictive treatment for chronic pain from common ailments such as bad backs, torn rotator cuffs, headaches and arthritis — and millions of pain patients had become dependent on opioids.

“You practice according to what you’re taught and according to the textbooks you read and according to the lectures you go to,” said Jane Ballantyne, who came to the United States in 1986 from Britain, trained as a pain specialist and became chief of the pain program at Massachusetts General Hospital. “You don’t really have time to look into it deeply. As soon as I began looking it into it more deeply, it was clear the evidence is weak.”

What she and many others found was that opioids simply didn’t work very well when it came to relieving pain over long periods of time. Patients developed tolerances and needed greater dosages. Opioid patients weren’t thriving in general.

“It was an experiment gone wrong,” Ballantyne said.

A flood of opioids

In July, The Post published a Drug Enforcement Administration database that revealed drug companies had flooded the U.S. with 76 billion oxycodone and hydrocodone pills in a seven-year period, from 2006 to 2012. The database was unsealed after The Post and HD Media of West Virginia, publisher of the Charleston Gazette-Mail, won a legal battle in connection with a lawsuit against drug companies filed by roughly 2,000 cities, counties and other local jurisdictions and pending in federal court in Cleveland.

Other government records show that individual opioid prescriptions in the United States peaked at 255 million in 2012. After that, the numbers fell steadily, to 199 million by 2017.

As the dosages dropped, drug deaths didn’t, because the epidemic mutated. Some people addicted to the opioid high turned to street heroin when they couldn’t get pills. A surge of heroin into the United States was followed by an even deadlier arrival of illicit fentanyl. In 2017 in the United States, 47,000 people died of opioid overdoses — more than the death toll from traffic accidents, and more than all the gun deaths, including by suicide.

The drug industry now faces a reckoning. A state judge in Oklahoma ruled on Aug. 26 that drugmaker Johnson & Johnson must pay $572 million to the state for the company’s role in the opioid epidemic. The next day came the news that Purdue Pharma has offered to settle state and local lawsuits by paying up to $12 billion and filing for bankruptcy.

Most of the drug companies targeted in lawsuits have mounted a vigorous legal defense, and some have released statements defending their actions and denying that they are the source of today’s opioid drug epidemic. Although the companies do not speak with one voice, in general they have argued that they were manufacturing and selling legal drugs that have legitimate medical uses, and the companies have sometimes blamed the crisis on overprescribing by doctors, illicit diversion to street markets and abuse by patients or recreational drug users.

By October of last year, 33 states had imposed some kind of legal limit on opioid prescribing. In January of this year, Medicare Part D enacted a limit for some new opioid patients. Veterans Affairs reduced the number of patients receiving opioids by 52 percent between 2012 and 2019. Under orders from the DEA, the pharmaceutical industry cut the quantity of opioids it produced by 38 percent between 2016 and 2018.

In March 2016, the U.S. Centers for Disease Control and Prevention published a new guideline on the prescribing of opioids for chronic pain. It proved confusing.

The guideline said doctors should not increase an opioid dose to more than 90 MME (morphine milligram equivalents). But many patients already were taking far more than 90 MME, and doctors — thinking the CDC number was a hard cap — were tapering them back to 90.

Hundreds of doctors and other experts, including three former U.S. drug czars, signed a letter to the CDC in March of this year saying that the guideline had been widely misinterpreted, and the CDC concurred. In an article in the New England Journal of Medicine, the guideline authors acknowledged that medical experts don’t really know what happens to people forced to taper suddenly from high dosages: “We know little about the benefits and harms of reducing high dosages of opioids in patients who are physically dependent on them.”

In a remarkable study of Vermont Medicaid patients who used large daily doses of opioids for at least 90 consecutive days, Mark’s team found that half the patients were cut off with just a single day’s notice and 86 percent were discontinued in less than 21 days. Though 60 percent had an opioid use disorder before tapering, fewer than 1 percent of the patients in the study were given anti-addiction medication such as buprenorphine when their opioids were taken away. Predictably, 49 percent of them were hospitalized or visited an emergency room after they were cut off.

“People shouldn’t be forced to taper,” Mark said.

Stefan Kertesz, an addiction medicine specialist at the University of Alabama at Birmingham, said some patients forced to taper will suffer anhedonia, the inability to feel pleasure.

“Some people will be fine. Some people will actually thank you and say, ‘I feel a little more awake now,’ ” said Kertesz, one of the leaders of the group that petitioned the CDC to clarify its pain opioid guidelines. “The cases that draw my concern are the cases where the patient says, ‘I don’t think I can survive what you’re going to do to me.’ ”

When researchers surveyed 194 primary care clinics in Michigan in 2018, they found that 79 of them would not accept new patients taking opioids, according to a study published last month in JAMA Network Open.

“We’ve entered a new era of opiophobia,” said Sally Satel, a psychiatrist and resident scholar at the American Enterprise Institute who is critical of the way some chronic pain patients are being treated. Some “have the kind of pain that’s unbearable. Every day of your life. Unbearable. And those are the people who are suffering. And their doctors are terrified.”

Ballantyne, the pain specialist, is now a professor of anesthesiology and pain medicine at the University of Washington and also president of Physicians for Responsible Opioid Prescribing. She is among the most influential leaders of the movement to cut down the country’s dependency on opioids. The United States still is the world leader in the reliance on opioids.

But even she says that “the pendulum did swing too rapidly.” Some patients who have been taking high doses of opioids for a long time may be better off sticking to what’s worked for them, she said. The most important change in medical practice — one adopted by Veterans Affairs— is to cut down on “new starts,” the patients taking opioids for the first time for ailments that might not require that kind of painkiller.

There’s no simple fix to the drug epidemic, no simple rule that can apply to every patient. So many of the big questions about opioids and chronic pain can be answered only with palms facing straight up: It just depends.

“Unfortunately, very few things in medicine are quite that clear, and pain management is certainly not one of them,” says Suzanne Amato Nesbit, a clinical pharmacist at Johns Hopkins Hospital in Baltimore and the president of the American College of Clinical Pharmacy.

For Hank and Carol Skinner, medical care has been one long struggle, sometimes a comedy of errors. They joke that the hospital is their second home.

Carol has had her own bizarre experiences with opioids. At one point during the ordeal with her infected right hip she took a high dose of morphine that caused her to hallucinate. She thought she saw the neighbor’s house on fire and called 911. At least a dozen firetrucks showed up. She could swear she saw the firefighters walking atop her fence like gymnasts on a balance beam. She cut her dosage and then later went off opioids for good.

They don’t like the term “opioid crisis.” But they also know the stuff that Hank needs every day can be dangerous. He’s careful never to leave one of his fentanyl patches lying around where a child might pick it up.

And there’s another shadow hanging over their home: Hank’s great-nephew overdosed on heroin, possibly laced with illicit fentanyl, earlier this year, they say. His name was Kevin Samuel Crathern. He was 26. The Skinners say the young man’s parents decided to scatter his ashes along his favorite trail in Yosemite National Park.

Meryl Kornfield and Kanyakrit Vongkiatkajorn contributed to this report.

[frederick15rogers-blog]

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