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Opioid crisis 'officially' an emergency, Trump declares

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Photographs by AP/EVAN VUCCI

White House senior adviser Kellyanne Conway listens as Secretary of Health and Human Services Tom Price speaks with reporters about the opioid crisis, Tuesday, Aug. 8, 2017, in Bridgewater, N.J.

President Donald Trump on Thursday declared the country's opioid crisis a national emergency, saying the epidemic exceeded anything he had seen with other drugs in his lifetime.

The president's declaration came in response to a question as he spoke to reporters outside a national security briefing at his golf club in Bedminster, N.J., where he is on a working vacation.

"The opioid crisis is an emergency, and I'm saying officially right now it is an emergency. It's a national emergency. We're going to spend a lot of time, a lot of effort and a lot of money on the opioid crisis," he said.

"It is a serious problem, the likes of which we've never had. You know, when I was growing up, they had the LSD, and they had certain generations of drugs. There's never been anything like what's happened to this country over the last four or five years."

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He indicated that the White House was still working on the official paperwork.

"This is a worldwide problem, not just a United States problem. This is happening worldwide. But this is a national emergency, and we are drawing documents now to so attest," he said.

The scale of the crisis, which has been building for well over a decade, is such that a presidential declaration may not have much immediate impact, but it should allow the administration to remove some bureaucratic barriers and waive some federal rules governing how states and localities respond to the drug epidemic. One such rule restricts where Medicaid recipients can receive addiction treatment.

"It's symbolic, mostly, and it actually involves a lot of reporting and paperwork," Richard Frank, a professor of health economics at Harvard Medical School, told The Washington Post earlier this week when asked about the importance of a presidential declaration.

Governors in Arizona, Florida, Maryland and Virginia have already declared emergencies. And in recent months the Centers for Disease Control and Prevention, the Food and Drug Administration, Congress, physician groups and the insurance industry have all taken institutional steps to address the crisis. At the street level, police, firefighters and paramedics now routinely carry naloxone -- brand name Narcan -- the anti-overdose drug that can yank a patient from the brink of death.

The problem is that drug addiction is widespread, with an estimated 2.6 million opioid addicts in the U.S., a number that's growing.

In March, Trump established the President's Commission on Combating Drug Addiction and the Opioid Crisis, which is led by New Jersey Gov. Chris Christie. Last week, the commission issued a preliminary report that described the overdose death toll as "September 11th every three weeks" and urged the president to declare a national emergency.

"The opioid epidemic we are facing is unparalleled. The average American would likely be shocked to know that drug overdoses now kill more people than gun homicides and car crashes combined," the report states.

The report actually understated the lethality of the epidemic. The commission based its estimate of the number of fatal drug overdoses on 2015 statistics. But new federal data covering the first nine months of 2016 showed that the death toll jumped significantly since 2015.

Trump's declaration Thursday came days after he received an extended briefing on the subject in Bedminster. After that event, Health and Human Services Secretary Tom Price told reporters that declaring a national emergency is a step usually reserved for "a time-limited problem," such as the Zika outbreak or problems caused by Hurricane Sandy in 2012.

Price seemed to suggest at the time that the president was leaning against the recommendation, arguing that the administration could deploy the necessary resources and attention to deal with the crisis without declaring a national emergency. Still, Price stressed that "all things" were "on the table for the president."

Christie applauded Trump's decision in a statement, saying the president "deserves great credit."

Attorney General Jeff Sessions commended Trump for "taking this drastic and necessary measure to confront an opioid crisis that is devastating communities around the country and ripping families apart."

Opioids are a broad category of legal and illegal drugs, ranging from prescription painkillers to heroin. In the past couple of years, according to the Drug Enforcement Administration, much of the street-level heroin in the U.S. has been laced with illicit fentanyl, a powerful synthetic opioid that is much cheaper to produce than heroin.

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Addicts often say they want the most powerful drug they can find and seek batches of drugs that have been linked to rashes of overdoses.

Although heroin has been around for a long time, the current opioid crisis has its origin in the 1990s, when the pharmaceutical industry marketed new formulations of prescription opioids. They soon flooded the market, making America by far the world's leading consumer of these painkillers.

At the beginning of this decade, government officials shut down many "pill mills" in which doctors dispensed huge numbers of prescription opioids, and many addicts switched to street heroin.

Limiting painkillers

In the face of the crisis, states have enacted or are seeking to implement strict limits on the number of prescription painkillers doctors can prescribe, a move that many believe will help fight the crisis but has raised alarms among some physicians.

At least 17 states have enacted rules to curb the number of painkillers doctors can prescribe. Some, including Arizona, Connecticut, Delaware, Massachusetts, New Jersey and Ohio, have passed laws limiting the duration of initial opioid prescriptions to five or seven days. Others are passing dosage limits.

In Kentucky, a law went into effect last month capping opioid prescriptions for severe acute pain to three days.

"We know that most people who eventually become addicted to heroin have started with a prescription opiate," said Kentucky state Rep. Kimberly Moser, a Republican who sponsored the bill and is also a nurse.

Kentucky has exemptions for cancer and hospice patients, major surgeries, and patients dealing with severe or chronic pain.

"We felt it was important to just set that pause button and have prescribers just stop and think about the appropriateness of what they're prescribing. Is it medically necessary?" she said.

Last year, 1,404 people died of drug overdoses in Kentucky, according to the Kentucky Office of Drug Control Policy. About half of the deaths involved fentanyl, which is often used in hospitals but also has been manufactured illicitly overseas and has cut into the heroin supply.

In the spring, Arkansas mandated that physicians and other prescribers of powerful painkillers check the state's prescription drug monitoring database to determine whether a first-time patient has filled similar prescriptions before. Before the new law was signed by the governor, practitioners were only encouraged to consult the database, which was created in 2012.

The Centers for Disease Control and Prevention last year issued guidance for providers, recommending shorter durations for opioid prescriptions, stating that three days should be sufficient and a course of more than seven days "will rarely be needed."

According to a CDC study, patients who use such painkillers for longer periods of time are more likely to end up addicted to them.

Sens. John McCain, R-Ariz., and Kirsten Gillibrand, D-N.Y., introduced federal legislation in April to limit an initial opioid prescription to seven days. It would not apply to the treatment of chronic pain, cancer, hospice or palliative care.

More than 52,000 people died of drug overdoses in 2015, according to the CDC. Drug overdoses sharply increased during the first nine months of 2016, according to the National Centers for Health Statistics. They were driven by increases in opioid deaths, especially from heroin and fentanyl. But for many people, their first exposure to opioids is through prescription painkillers.

"Given that this current opioid epidemic is in very real part caused by the prescribers, we should be OK with some guidance," said R. Corey Waller, chairman of the legislative advocacy committee for the American Society of Addiction Medicine. "If we had been able to control this and follow the evidence, we wouldn't necessarily need these rules."

But Waller and other physicians also have concerns with the new state laws. In Connecticut, doctors worried that a law limiting initial opioid prescriptions to seven days would be overly prohibitive, said David Emmel, chairman of the Connecticut State Medical Society's legislative committee. But now that the regulations have been in place for about a year, doctors have adapted to the rules, which Emmel said are "not horrifically restrictive."

Patrick Padgett, executive vice president of the Kentucky Medical Association, said some doctors are glad that there is a limit on the number of days a painkiller can be prescribed, because it gives them a guideline they can show to patients who are seeking longer courses of the drug.

But Mishael Azam, chief operating officer of the Medical Society of New Jersey, said the state's five-day limit, which went into effect earlier this year, is still a "work in progress" for the state's physicians. Doctors, she said, are still being educated about the law and some are now leery of treating pain patients because of it.

"That's the general tone -- doctors are to blame," she said, and treating a patient individually is discouraged. "Medicine, in all other realms, we're supposed to be personalizing and individualizing. But when you do a hard mandate, it doesn't allow for any sort of personalization."

Information for this article was contributed by John Wagner, Lenny Bernstein, Joel Achenbach and Jenna Johnson of The Washington Post; by Jill Colvin and Jonathan Lemire of The Associated Press; and by staff members of the Arkansas Democrat-Gazette.

A Section on 08/11/2017

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