Wednesday, July 17, 2019

Opioid distribution database shows Ky. was 2nd for most legal pain pills per person between 2006-12; county-level data available

Washington Post map; click here to view the interactive version. 
Between 2006 and 2012, drug companies distributed 76 billion doses of prescription pain medicine, "enough pills to supply every adult and child in the country with 36 each year," Scott Higham, Sari Horwitz and Steven Rich report for The Washington Post. And rural counties, especially in Appalachia, received some of the highest shares of pain pills per person.

That's according to a Drug Enforcement Administration database, made public for the first time by the Post and the daily newspapers in Charleston and Huntington, W.Va. The database tracks the path of every DEA-regulated pain medication in the U.S. It includes local data that shows the counties that received the most pills, fueling the prescription-opioid epidemic, resulting in nearly 100,000 deaths in that time period.

The Post reports that "rural areas were hit particularly hard." The data showed Kentucky ranked second in pills per person per year, at 63.3, topped only by West Virginia at 66.5, which had the highest opioid death rate during the period. South Carolina, mainly due to high rates along its Atlantic coast, was third at 58; Tennessee was fourth at 57.7, and Nevada was fifth at 54.7.

A 2016 report from the Kentucky Injury Prevention and Research Center found that prescription opioids contributed to the overdose deaths of 2,481 Kentuckians between 2006 and 2012.

Section of map shows counties in and near Kentucky.
The Post's interactive map shows that several counties in Eastern Kentucky had the highest distribution rates in the state: Whitley at 187, Perry at 175, Floyd at 168, Bell at 156, Johnson at 152, Pike at 146, Clay at 134 and Lee at 133.

Clinton County, at 147, stands out in the south-central part of the state, as do McCracken, at 107, and Crittenden, at 119, both in Western Kentucky.

Nearly half of the pills were distributed by three companies: McKesson, Walgreens and Cardinal Health. The top manufacturer was Mallinckrodt's SpecGx, with nearly 38 percent of the market.

Because the database is partly comprised of data that drug makers gave the DEA, it shows what they knew about the number of pills they were shipping at the epidemic's peak, the Post points out.

Drug manufacturers, distributors and pharmacies must log and report each narcotic transaction, and are supposed to report suspiciously large or frequent orders to the DEA and withhold such shipments.

Meanwhile, nearly 2,000 communities, counties and Indian tribes have alleged in federal lawsuits that the drug companies filled suspicious orders and did not report them in order to maximize profits.

 The lawsuits were consolidated into one case, which is now larger in scope than the lawsuit against cigarette manufacturers in the 1980s, the Post reports.

Attorney General Andy Beshear, the Democratic nominee for governor, has filed nine lawsuits against opioid manufacturers and distributors, including ones against the top three distributors and top manufacturer. He says that is more than any other attorney general

Beshear is the Democratic nominee for governor. In a debate Wednesday, Republican Gov. Matt Bevin asked him, "How much money have we gotten" from the suits. "We will," Beshear replied. "You blow a lot of smoke," Beshear retorted.

The database was released Monday after the Post and HD Media, which publishes the Charleston Gazette-Mail, won a years-long legal battle to access documents and data from the ongoing litigation.

The West Virginia newspaper won a Pulitzer Prize in 2018 for reporting on drug distribution, using other data. The Post reports that the DEA, the Justice Department and drug companies all fought hard against release of the data. The companies said it would reveal information that could give competitors an unfair advantage, and Justice said the data could compromise DEA investigations.

State health department warns about danger of getting rabies, especially from bats; advises to never touch a bat

By Melissa Patrick
Kentucky Health News

Public health officials are reminding Kentuckians about the dangers of rabies exposure from bats and other wildlife.

Photo from Kentucky Department of Fish & Wildlife
“We want to highlight the importance of rabies prevention and control efforts in our communities, while also reminding Kentuckians of the existing dangers of coming into contact with rabid bats and other wildlife," Kelly Giesbrecht, veterinarian with the state Department of Public Health, said in a news release. "To avoid possible rabies exposure, wildlife should not be fed, handled or treated as pets.”

Rabies is a viral disease that affects the nervous system. It is transmitted from animals to humans by the saliva of a rabid animal, usually from a bite or scratch. The virus cannot infiltrate intact skin.

Because bats are so small, it is sometimes difficult to know if you have been bitten or scratched by one, so the health department warns that any suspected exposure should not be taken lightly. "If untreated, rabies is fatal," says the release.

Rule number one when it comes to protecting yourself from rabies is to never handle a bat.

If you find one in your home, call the local animal control office to remove it and then call a healthcare provider or local health department to determine if preventive treatment is required.

Only a small percentage of bats have rabies, but health officials warn that you can't tell if they have the disease just by looking at them -- though they advise extra precautions around bats that are flying during the day, are in locations where they are normally not found, like your home, or are unable to fly at all.

University of Kentucky Cooperative Extension graphic
It's also important to protect your home by sealing all of the holes that are larger than a quarter-inch. The health department says the best time to do this is in the fall or winter so that any bats that might already be inside are not unintentionally trapped.

The University of Kentucky Cooperative Extension Service offers further tips on how to protect your home from bats, noting that it's important to take the time to to seal all points of entry because bats return each year to their "nursery colony."

The most common ways for bats to enter homes are through chimneys, vents and openings behind shutters or under doors, siding, eaves and shingles.

The release also points out that it is illegal to remove bats from an area between May and August because that is when they raise their young. Instead, health officials say to consult with the Kentucky Department of Fish and Wildlife if you have a bat problem in your home during these months.

In the U.S., rabies is most commonly spread by bats, raccoons, skunks, coyotes and foxes. Once clinical symptoms are present, there is no known medical cure for rabies.

Symptoms of rabies can initially mimic the flu, including general weakness, fever and headache. A person can also have a strange sensations at the site of the bite from a rabid animal. These symptoms can progress within days to symptoms of anxiety, confusion and agitation. Further progression of the disease includes symptoms of hallucinations, insomnia and fear of water, all of which are quickly followed by death, according to the federal Centers for Disease Control and Prevention.

There are usually only one or two human cases of rabies in the U.S. each year, and the most common source is from bats. The health department reports that the last case of human rabies in Kentucky from a bat was in 1996.

"Among the 19 naturally acquired cases of rabies in humans in the U.S. from 1997 to 2006, 17 were associated with bats. Among these, 14 patients had known encounters with bats. In these cases, the bat was inside the home," says the CDC.

Tips to protect yourself from rabies:
  • Do not touch a bat, and teach children to not touch them.
  • Keep your pets vaccinated; it's not only good practice, it's the law in Kentucky.
  • Do not interact with wildlife, or intentionally feed wildlife.
  • If you've been bitten or scratched, wash the wound immediately with soap and water for at least 10 minutes and call your health-care provider.
  • Remember, bats have very small teeth which may leave marks that disappear quickly. If you are unsure, seek medical advice.
  • If a bat is found in a room with an unattended child or near a mentally impaired or intoxicated person, seek medical advice.
  • Report all animal bites to your local health department
  • If possible, confine the animal so it can be quarantined or tested.

Tuesday, July 16, 2019

After receiving 600 public comments, health cabinet removes proposal to ban tattoos on scarred skin in updated regulation

By Melissa Patrick
Kentucky Health News

The state Cabinet for Health and Family Services has updated its requirements for tattoo studios in Kentucky, and they no longer prohibit tattoos on scarred skin, as first proposed.

WFPL photo
The cabinet said in a news release it had received more than 600 public comments on this proposal. In addition, WHAS-TV reported that almost 100 people from all over the state attended a public hearing about the issue May 28 in Frankfort.

"Based on comments received, we elected to remove the language relating to scar tissue," Dr. Jeff Howard, commissioner of the state health department, said in the release.

Opponents of the proposal have said there is no medical reason to ban such tattoos. Others have said such a ban is a violation of their civil rights, and there are already industry rules around this issue. Still others pointed out the many reasons people want to cover their scars, including cancer survivors who want to cover their mastectomy scars.

The state announced the original amendment to the regulation in April, which simply said "tattooing over scarred skin is prohibited." The proposal did not give any reason for adding this language; when asked about it, a cabinet spokesman said only that the proposal was made in an effort to update a regulation that hadn't been updated in 15 years.

In May, the health commissioner issued another release, saying the proposal to ban tattooing on scarred skin in the regulation "had some unintended consequences" and that the language regarding this issue would be addressed once the public comment period ended on May 31.

On Tuesday, July 16, the cabinet announced that the ban had been removed, citing a "a lack of available evidence to support this prohibition." It said the intent of the first revision was to prohibit the tattooing of freshly scarred skin, but "freshly" was left out.

Under the new rule, which next goes before the Administrative Regulation Review subcommittee, a person registering as a tattoo artist will have to complete training about blood-borne pathogens. The rules also outline a registration process for tattoo studios and increased fees to offset inspection cost.

The regulation also updates requirements for disinfecting and sterilizing equipment and adds a new rule to require a notarized statement of parental consent for a minor who is seeking a tattoo without a parent or legal guardian present.

Monday, July 15, 2019

In e-cigarette documentary, on CNBC tonight, CEO of Juul Labs apologizes to parents of teens who are addicted to his devices

Juul Labs CEO Kevin Burns, left, and NBC reporter Carl
Quintanilla tour a Wisconsin Juul facility. (CNBC photo)
A new CNBC documentary exploring the increasing popularity of electronic cigarettes, especially among teens, features a surprising message from one industry CEO: an apology.

Kevin Burns is CEO of Juul Labs, which has about 40 percent of the e-cigarette market. It sells liquid nicotine pods in sweet flavors that are a prime driver in getting teenagers to try vaping. Reporter Carl Quintanilla asked Burns what he would say to a parent whose child was addicted to Juul.

Burns, who joined Juul in late 2017, replied: "First of all, I’d tell them that I’m sorry that their child’s using the product . . . It’s not intended for them. I hope there was nothing that we did that made it appealing to them. As a parent of a 16-year-old, I’m sorry for them, and I have empathy for them, in terms of what the challenges they’re going through."

Angelica LaVito reports for CNBC, "The Food and Drug Administration has declared teen vaping an 'epidemic,' citing federal survey data that showed nearly 21 percent of high school students vaped last year. Former FDA Commissioner Scott Gottlieb and health care advocates blame the surge in teen vaping on Juul."

"Vaporized: America's E-cigarette Addiction" will first air tonight at 10 p.m. ET.

Sunday, July 14, 2019

Bevin touts Medicaid proposal, claims 'hundreds of thousands' in Kentucky 'should be going to work and choose not to go to work'

By Al Cross
Kentucky Health News

Gov. Matt Bevin gave a vigorous defense of his plan to require work or other activities by "able-bodied" adults without dependents who are on Medicaid, in an interview at the Kentucky Chamber of Commerce's Business Summit and Annual Meeting in Louisville on Friday, July 12.

"Is there anyone in this room that thinks it is a good idea for able-bodied, working-age men and women between the ages of 19 and 64 who have no dependents – and they’re able-bodied, they’re healthy – and they choose not to work?" Bevin asked. "How many of you think it’s a good idea for you to subsidize them and allow them not to work? Anybody? That’s what Andy Beshear believes. I don’t. That’s what his father believed. I don’t. We’re not helping people by that."

Attorney General Andy Beshear, the Democratic nominee challenging the Republican incumbent, is the son of Steve Beshear, who as governor in 2014 used the Patient Protection and Affordable Care Act to expand Medicaid to people with household incomes up to 138 percent of the federal poverty level: $16,753 for individuals, $22,715 for a couple and $34,638 for a family of four.

Bevin spoke to reporters after his Chamber interview.
(Photo by Jack Brammer, Lexington Herald-Leader)
As a candidate in 2015, Bevin initially said he would abolish the expansion, then said he would request a waiver of federal Medicaid rules so the program's beneficiaries would have "skin in the game" through premiums, co-payments, deductibles or health savings accounts. After he was elected, he added "community engagement" requirements including work, but those have been blocked in federal court.

"They should do one of five things I have proposed for 20 hours a week, four hours a day, five days a week," Bevin said. "Work, go to school, volunteer, be in training for a specific job, take care of somebody that the state would otherwise be paying for to be taken care of." The fifth option, which Bevin didn't mention, would be enrollment in treatment for substance-use disorder.

"One or more of those things is possible in every community in Kentucky," he said. "And it is, I think, morally irresponsible if we don’t expect people to do what other people are paying to give them something that they themselves may or may not even have." Earlier, he said, "Many of your companies don’t even offer the same benefits Medicaid does."

Bevin said the lack of community-engagement rules "sets a bad precedent. It creates a sense of entitlement and expectation, and it sets a bad example for next generations of children who see their parents not going to work, and working the system. There are hundreds of thousands of people in this state that could be going to work, should be going to work, and choose not to go to work. That is their prerogative; they can choose that, but you should not be expected to subsidize that choice if they could choose otherwise."

Afterward, Bevin refused three times to give a source for his "hundreds of thousands" figure, but later in the day his office cited the Census Bureau's 2017 American Community Survey, a poll that estimated 443,723 Kentuckians "do not have a disability and are not in the labor force."

Those numbers apparently include people who retired before 65, attend college, or work at taking care of others without pay. Mike Randle, publisher of Southern Business & Development Magazine, told the Chamber members the day before Bevin spoke that of the 95 million Americans "outside the workforce," 44 million are retirees, 20.5 million are college students, 13 million are caretakers and “unknown millions” are mentally ill and/or addicted to drugs.

In May, the last month for which figures are available, more than 1.35 million Kentuckians were on Medicaid, including 446,639 covered by the expansion. Estimates vary, but somewhere around half of the expansion members appear likely to be covered by the community-engagement requirements. Nationally, most Medicaid beneficiaries work; no other state has work requirements, though several are trying to implement them.

Bevin said he grew up in poverty, without health care, and his body still shows it. "I’m empathetic to that world, not sympathetic. But I know for a fact that if you give people something when they don’t need it, in the case of these able-bodied people, you don’t have it to provide to the people who do need it." (For a transcript of his remarks, go here.)

The state has estimated that if the waiver is allowed, in five years Kentucky Medicaid would have 95,000 more members than without the waiver, in large measure because they would fail to comply with work or reporting requirements. Bevin repeated his vow that if the U.S. Supreme Court ultimately blocks the waiver and he is still governor, he will abolish the Medicaid expansion.

The chamber's Jacqueline Pitts also asked Bevin about the economic impact of the expansion, more than 90 percent of which is paid for by the federal government, but that question was tacked on to a broader question on the topic and he did not answer it.

Beshear called earlier in the week for "a legitimate, non-political study" of the impact of the expansion on the state's economy and tax revenues.

Beshear declined to appear at the Chamber meeting, saying the group supports Bevin and his agenda. The Chamber said it has a history of working with officials of both parties.

Medicaid boss says state won't tolerate abuse of independent drug stores by pharmacy middlemen she calls 'predators'

By Melissa Patrick
Kentucky Health News

Kentucky legislators were assured at a July 8 meeting that the state is committed to resolving the payment issues that the states' independent pharmacies have with pharmacy benefit managers in Medicaid, issues that the pharmacies have said are so bad they threaten their survival.

Medicaid Commissioner Carol Steckel
“We are not going to tolerate it, and we will do whatever we have to do to ensure that the taxpayers of the commonwealth and the beneficiaries of the Medicaid program are treated the way they should be treated,” Medicaid Commissioner Carol Steckel told the Medicaid Oversight and Advisory Committee.

Pharmacy benefit managers, or PBMs, are the middlemen between insurance companies and drug companies. They determine what drugs are offered, how much someone pays for the drug and the payments to pharmacists.

Steckel said her agency had a “new-found spine” when it comes to how much control it has over PBMs, and will build on that “power and control” in the updated contracts it is negotiating with managed-care organizations, which will take effect in July 2020. The MCOs subcontract with PBMs.

Steckel, who has worked with Medicaid for 30 years, later referred to the PBMs as “predators” and said, “It makes me angry to have this kind of player in the Medicaid program.”

A few days later, Attorney General Andy Beshear announced his office would be submitting a request for more legal help to further its investigation of PBMs' pricing practices.

Beshear, the Democratic nominee for governor, launched an investigation in March to find out whether PBMs have overcharged the state and discriminated against independent pharmacies. “We all want to know if the actions of these companies have resulted in all of us paying too much for prescription drugs – and we’re going to find out," Beshear said in a news release.

Lawmakers have been working on this issue for years. Sen. Ralph Alvarado, a Winchester physician who is Gov. Matt Bevin's running mate for lieutenant governor, reminded the group that it once again felt like “Groundhog Day” -- which Senate Democratic Leader Morgan McGarvey has said before.

Senate Bill 5 of the 2018 legislative session put the Department of Medicaid Services, rather than the managed-care companies, in charge of setting pharmacists' reimbursement rates. It allows the department to regulate contracts between the companies, PBMs and pharmacists; requires more transparency in how PBMs spend the $1.7 billion a year they get for processing prescriptions; and gives the state authority to penalize the companies and PBMs for noncompliance.

In a report earlier this year, "Medicaid Pharmacy Pricing: Opening the Black Box," the state said two PBMs kept $123.5 million last year from the Medicaid program by paying pharmacies a lower rate to fill prescriptions, while charging the state more for the same drug. Much of the discussion at the July 8 meeting was around SB 5 and the MCO contracts now being negotiated.

Trevor Ray, an independent pharmacist and co-owner of Midway Pharmacy, which has four locations in Grayson County, praised the efforts behind SB 5, but said many issues still need to be addressed to ensure “fair, transparent and adequate reimbursement” for community pharmacies.

Ray said low dispensing fees are still an issue, even though the Medicaid department increased this fee to $2 per prescription after SB 5 became law. The Centers for Medicare and Medicaid Services says this amount should be around $10,64, plus the cost of the drug being dispensed.

Mark Glasper, executive director and CEO of the Kentucky Pharmacists Association, told Kentucky Health News in an e-mail that while the new fee helps, the amount barely scratches the surface of what is needed. "Independents are scratching to stay in business," he said. "The $2 dispensing fee afforded by SB 5 is merely a Band-Aid."

Ray questioned “backdoor fees” and "spread pricing,” in which a PBM keeps the difference between what it bills Medicaid for medications and what it pays the pharmacy to dispense the drugs. The Medicaid department said the 2019 spread pricing in Kentucky through May was 12.92 percent. This number doesn't include data from WellCare because it does not use this model.

Ray also explained a process in which pharmacies are paid one price for a drug, only to have a chunk of it taken back several months later, which he said is a problem with both spread pricing and “pass-through pricing,” which is what WellCare does. In pass-through pricing, an MCO is paid the actual discounted pharmacy price that the PBM negotiated with the retail pharmacy network.

The Medicaid department went over the changes proposed in the MCO contracts, including new language from SB 5; requirements that all PBMs use a “pass-through model;” language banning “take-back” fees; and language to remove any barriers to claims data. The new contracts will take effect July 1, 2020.

Steckel also told the lawmakers that DMS was using Kentucky data to replicate a West Virginia study showing the impact of removing pharmacy services from MCOs, which is what the pharmacists' lobby and many legislators would like to see happen.  The West Virginia study found that the state saved $54 million by removing prescription drugs from Medicaid managed care.

Ray concluded, “We're not asking for more money just to get paid more, we just want to be paid fairly.”

In 2016, Kentucky passed a law that allows the state Department of Insurance to regulate PBMs much like insurance companies are regulated, and to provide an appeal mechanism to resolve pricing disputes between pharmacies and PBMs.

The law has resulted in CVS Caremark, a PBM for all but one of the Medicaid management companies in Kentucky, being issued a $1.5 million fine in July 2018 for hundreds of reimbursement violations involving individual pharmacies, and for giving the department 'inaccurate or inconsistent" information. It also resulted in Caremark PCS Health being put on probation for one year. 

Saturday, July 13, 2019

900 participants in study aimed at eliminating hepatitis C in Perry County will get their meds through a device that tracks adherence

Participants in a University of Kentucky study aimed at eliminating the liver disease hepatitis C in one county will get their medicine in a device that tracks how closely they follow their prescriptions.

The Kentucky Viral Hepatitis Treatment Study is examining the concept of "treatment as prevention" by treating everyone in Perry County who is chronically infected with hepatitis C, which is common among those who inject drugs. The participants were identified through previous work in the county dealing with drug addiction.

Perry County (Wikipedia map)
Hepatitis C is a caused by a virus that is primarily spread by injection-drug users when they share needles or other equipment. Left untreated, it can lead to cirrhosis or liver cancer. 

Intent Solutions, an Atlanta-based company that provides technology to improve prescription-drug safety and adherence to prescriptions, has committed to dispensing the hepatitis C medication to the 900 participants in the study using an automated dispensing device called "Tad,"  short for “take as directed,” that also tracks how closely people take their prescribed medicine.

"By taking the medication as prescribed, the likelihood of being cured is exceedingly high," Jennifer Havens, principal investigator on the study, said in the news release. "Tad provides us with clear visibility into whether individuals are taking their medication properly. If they are not, we can intervene quickly to prevent waste and misuse, and to ensure the study aims are being met."

The study is funded by $15 million from the National Cancer Institute and the National Institute on Drug AbuseGilead Sciences has donated the medicine, valued at about $20 million, the release says.

The Tad system was originally developed to reduce the misuse, abuse and diversion of opioids, but the CEO of the company, Sam Zamarripa, said they have since found it is also well-suited to population health intervention programs, like this one.

"Prescription adherence is important in any treatment program, but especially so in the 12-week regimen required to rid the body of hepatitis C virus," Zamarripa said in the release. "Tad will increase the likelihood that these individuals will live.”

The Tad device is an automated dispenser the size of a smartphone that contains up to 30 days' worth of pills; it requires only the touch of a finger on its biometric keypad to dispense the correct daily or periodic dosage.

Perry County was chosen for the study because it has seen such a spike in hepatitis C, largely as a result of the opioid crisis. Havens estimated that at least half of the people in Perry County with the disease are struggling with, or have struggled with, opioids.

The program also includes support for the county's syringe exchange, access to medication-assisted therapy for opioid-use disorder, and help with housing and employment.

Since a drug is now available that cures those infected with hepatitis C, the World Health Organization has set a goal for elimination of the virus as a public-health threat by the year 2030.

The U.S. Department of Health and Human Services reports that more than 3 million Americans have hepatitis C, and most don't know they have it. For many, infection can lead to cirrhosis, liver cancer or death.

More than 12,000 people die every year in the U.S. from illnesses related to hepatitis C, which kills more Americans than any other infectious disease. While a cure now exists for hep-C infection, there is no vaccine to prevent it, as there is for hepatitis A and B.

As Jewish Hospital struggles, so does its organ-transplant program, with bad implications for U of L and regional health care

"Jewish Hospital’s pioneering transplant program is in trouble, and its demise could produce far-reaching repercussions" on the greater Louisville area, reports Boris Ladwig of Insider Louisville.

"Surgical teams have performed only one heart transplant in the first six months of the year, according to the most recently available data, running afoul of federal minimum requirements," Ladwig reports. The program is also under threat that the hospital, which has been unable to find a buyer, might close altogether.

The transplant program is linked to the University of Louisville's hospital and its medical school. U of L told Ladwig that it would keep supporting the program, “either at Jewish or in another location.” That would require new certification from the federal Centers for Medicare & Medicaid Services, "which would take more than a year and cost the university millions of dollars," Ladwig reports.

"Even more worrisome, the national consultant told Insider that an interruption of the transplant program could prompt an exodus of transplant surgeons, which could lead to departures of medical staff in transplant-related subspecialties," Ladwig adds. "Those developments could jeopardize UofL Hospital’s status as a Level 1 trauma center [one of only two in the state], and cause it to lose medical residency spots."

That helps explain "the increasing desperation with which university officials in the last few months have tried, so far in vain, to save the struggling Jewish Hospital, which, together with related facilities, has been losing more than $1 million per week."

KentuckyOne Health, has been trying to sell Jewish and seven other facilities in Louisville, and Jewish Hospital Shelbyville, for more than two years. The university in December "tried to find a partner to acquire the properties, primarily to save Jewish Hospital," but that failed, Ladwig notes.

U of L declined to comment on why the number of heart transplants has declined, but KentuckyOne blamed a national change in how hearts are allocated. The United Network for Organ Sharing told Insider that it changed the allocation policy in October, partly "to better identify the most medically urgent transplant candidates," Ladwig reports.
Insider Louisville chart
That does not seem to have had as much impact on other transplant centers in the region. "The University of Kentucky Medical Center is on pace to perform 24 heart transplants this year, which would be a drop of 17 percent," Ladwig reports. "Nationally, transplants are on pace to be down 12.6%."

Other types of transplants "have seen a precipitous decline at Jewish Hospital," Ladwig writes. "Kidney transplants are down 56%, liver transplants are down 29%. Both have fallen just 11% nationally. Only lung transplants at Jewish are in line with national declines.

Under the bylaws of the Organ Procurement and Transplantation Network, "heart-transplant programs that fail to perform at least one transplant every three months are deemed to be functionally inactive," Ladwig notes. "OPTN and UNOS manage the U.S. organ transplant network by contract with the federal government. The agency’s website lists no action against Jewish Hospital. UofL said it has not been notified by anyone to say the program is inactive or out of compliance."

Dr. Peter Hasselbacher, an emeritus professor of medicine at U of L, "who has written extensively about the transplant program at Jewish," told Ladwig that any heart-transplant program that does fewer than five a year “shouldn’t be doing any,” due to lack of practice.

"CMS guidelines call for transplant programs to perform 10 heart transplants over any 12-month period to retain certification," Ladwig reports. "The agency could not be reached to explain what happens to programs that fail to meet that threshold."

Friday, July 12, 2019

Ky. has 59 operating syringe exchanges and six in the wait; state drug-policy director credits public-health advocates for increase

By Melissa Patrick
Kentucky Health News

Kentucky is lauded nationwide for its embrace of syringe exchanges to thwart the spread of HIV and hepatitis C among intravenous drug users, but getting them approved locally continues to be a challenge and generally only happens after months, or even years, of educating the public.

Van Ingram, executive director of the Kentucky Office of Drug Control Policy, attributed the success of Kentucky's syringe exchanges to the ongoing efforts of the state's public health workers, who promote the exchanges as "harm reduction programs."

"It's just great public health advocacy at the local level, who just wouldn't give up," Ingram said July 11 at a health-related forum in Covington.

He was speaking broadly about the state's many efforts to battle the opioid epidemic, including a 2015 law that allows syringe exchanges with approval of the county health board and fiscal court and the legislative body of the city where the exchange is to be located.

Kentucky has 59 operating syringe exchange locations in 52 of its 120 counties, with six more approved but not operational. Since mid-February, when Kentucky Health News did its last syringe exchange roundup, 11 additional counties have been marked on the state health cabinet's map of exchanges.

Since February, Henderson, Hopkins, Taylor and Owen counties have been added to the map and are identified as operational locations. Magoffin County was also recently added, even though it opened last June, Hazard's WYMT-TV reports.

Among the 54 Kentucky counties the federal Centers for Disease Control and Prevention has identified as being the most vulnerable to outbreaks of HIV and hepatitis C among IV drug users, 33 have approved an exchange, with 29 of them operational.

The vulnerable counties that have not approved an exchange are Allen, Bell, Breckinridge, Carroll, Casey, Clinton, Cumberland, Edmonson, Gallatin, Grayson, Green, Harlan, Hickman, Johnson, Lawrence, Lewis, Martin, Menifee, Monroe, Rockcastle and Wayne.

Bath, Estill, Knott, and Leslie counties, which are included on the list of 54, were recently added to the exchange map, as have Todd County in Western Kentucky and Scott County in the Bluegrass region. These exchanges are marked as not yet operational.

State Sen. Whitney Westerfield of Hopkinsville "still thinks some of his colleagues are uneasy" about syringe exchanges, Max Blau reports for Stateline. "But he’s still hopeful that the results will mirror that of the CDC’s research, which shows that injection drug users who have access to syringe exchanges are five times more likely to get treatment than those who don’t.

“There’s not universal support, but we’ve moved in that direction,” Westerfield said. “I don’t see the people who hated [syringe exchanges] filing bills to reverse it. With harm reduction, there’s more general acceptance of it.”

Western Kentucky

Western Kentucky has been slow to adopt such programs, but that could be changing; three of the eight syringe exchanges west of Louisville are among the newest.

Henderson County's exchange offers an example of the importance of persistent public health advocacy and education when it comes to getting these exchanges approved.

Douglas White details in his article for The Gleaner the many evidence-based arguments that Green River Health District Health Department officials presented at a January meeting of the Henderson City Commission meeting in support of a syringe exchange. He noted that the issue had been discussed on and off for several years and the exchange had been approved by the Fiscal Court, but needed the approval of the city, which finally happened in February.

Clayton Horton, the health department's director, told Charles Taylor of the National Association of Counties about the importance of getting buy-in from the community.

“That required us to do a lot of education and do some advocacy with local governmental bodies,” he said. “We weren’t asking for resources; we’re weren’t asking them to pay for it. But we were asking them to consent and agree and to trust us and to trust the evidence-based practice to set these up and run them.”

Todd County's exchange was approved June 14, Adam May reports for WHOP in Hopkinsville, and his story also spoke to the importance of public health' leaders' role in educating the community.

Magistrate Brent Spurlin said "he was initially skeptical and heard from people who believe the needle exchange is only a way to enable addicts, but he changed his opinion as he learned more," May reports.

When Graves County opened its exchange in April, Mayfield Police Chief Nathan Kent told Chris Yu and Randall Barnes of Paducah's WPSD-TV that he applauded the health department for opening the program, and that he believed it would not enable drug users -- which is a common misperception.

“From our perspective, if folks come in here and take advantage of this opportunity, and they get the resources that convince them to make a change in their life, and they are able to overcome their addiction, then that’s just one more productive citizen,” Kent said.

Lauren Carr, the Graves County Health Department's harm-reduction coordinator, told WPSD that the first person who came to the exchange for clean needles told her, "No one has treated me like a person before."

“The whole goal of this program is to meet individuals where they’re at, but you can’t leave them there," she said. "You have to give them the resources, the education, and the things that they need to make better choices for themselves."

Hopkins County approved its exchange in April, Doreen Dennis reports for Surf KY News.

Cave City in Barren County was considering an exchange, but the city council voted unanimously against it, Gina Kinslow reported for the Glasgow Daily Times on Feb. 11. Barren County already has an exchange, in the county seat of Glasgow.

The middle of the state

The first sentence in Steve McClain's Georgetown News-Graphic article about Scott County finally passing its syringe exchange sums up the challenges involved in getting many of these programs passed: "After months and months of tense debate and votes, Scott County’s syringe exchange program launches Monday, July 1, from noon to 4:30 p.m."

And while there's not much posted online about Owen County's newly approved exchange, a December 2016 article in the Owenton News-Herald indicated that the Three Rivers District Health Department has been working on getting one there for years.

In another example of public-health persistence, the Anderson County Health Department proposed a syringe exchange three years ago and couldn't gain the support from either the city or county -- but in June of this year, the health board approved one, which now allows it to go before the city council and fiscal court, Ben Carlson reports for The Anderson News.

Taylor County approved its exchange in April. The Lake Cumberland District Health Department offers two educational videos about syringe exchanges to educate its community, one that addresses how syringe exchanges help with the cost of Hepatitis C and the other titled, "Why in the World Would You Give a Needle to a Drug Addict?", shown below.

Exchange models vary

Ingram told the forum attendees, "When you've seen one syringe exchange program in Kentucky, you've seen one syringe exchange program in Kentucky." While they all work toward what is commonly called "harm reduction," they vary in their hours, locations and services offered.

One of the more unique set-ups is the use of mobile exchanges, which Laurel, Knox, Clay and Jackson counties will share. Whitley County, which has a stationary exchange, was supposed to join the program, but has decided to not participate, according the county health department.

WKYT-TV reported in April that Lexington's program was expanding to two days a week, and since September 2015 has served more than 2,700 people, with an average of 175 coming in every Friday.

"The thing we are most proud of is 128 people have entered rehab through this service," health department spokesman Kevin Hall told WKYT. "We have on-site counselors available to offer referrals into programs and so that is 128 people who get a second chance."

Another evolution of these programs is that many of them now regularly distribute naloxone, a drug that can reverse an opioid overdose.

Terry DiMio reports for the Cincinnati Enquirer that at least 92 lives have been saved with naloxone that was handed out at two Northern Kentucky syringe exchanges. Since opening the two exchanges have handed out 1,358 naloxone kits, she reports.

Click here to get a list of all the exchanges and their hours of operation, as well as a list of facts about syringe exchange programs.

State health department is sending nurses to jails, treatment centers, homeless shelters, other sites to give hepatitis A shots

Nurses administered vaccinations at the Fayette County
Detention Center. (Cabinet for Health and Family Services photo)
The state Department for Public Health has sent a team of nurses to give hepatitis A vaccinations at county jails, state probation-and-parole offices, homeless shelters, treatment centers and drug stores, the Cabinet for Health and Family Services announced in a press release.

"Since April, the team has provided more than 2,100 vaccines at 40 different sites," the release says. "The state is collaborating with local partners on harm-reduction programs, aimed at reaching those who are most at risk. At least 18 additional vaccination events are scheduled through August."

“We have found it particularly challenging to reach the at-risk population in rural Kentucky,” said Dr. Jeffrey Howard, commissioner of the department. “One reason is the stigma associated with substance-use disorder. In some of our rural communities, more than 80 percent of hepatitis A cases have occurred in those with SUD. Due to the stigma surrounding SUD, the at-risk population is often hesitant to seek preventative care.”

The department identified the outbreak in November 2017, and has been criticized for not reacting more robustly to it. It has identified 4,700 cases, almost half of them requiring hospitalization, and 58 deaths have been linked to the outbreak.

"Kentucky was the first state to experience a large, rural spread of the disease," the press release says. "Similar to outbreaks in other states, the primary risk factors have been illicit drug use and homelessness. A contaminated food source has not been identified, and transmission of the virus is believed to have occurred through person-to-person contact. Hepatitis A is a highly contagious liver infection."

Thursday, July 11, 2019

Perry County becomes the 35th Kentucky community with a comprehensive anti-smoking ordinance; Hazard keeps partial ban

The Perry County Fiscal Court unanimously passed a comprehensive smoke-free ordinance on June 18, becoming the 35th community in Kentucky to do so.

The law, which took effect immediately, bans smoking, including the use of electronic cigarettes, in all places of employment and public buildings. It also prohibits smoking within 15 feet of any public door, window or ventilation system, as well as any public outdoor seating and recreational areas.

Perry County (Wikipedia map)
The county seat of Hazard will continue to operate its own smoke-free ordinance, which was implemented in 2016. The county ordinance "does not affect property within the City of Hazard," Katie Kelley of the Hazard Herald reports. The city's ban is considered only partial because it doesn't include all workplaces, says the Kentucky Center for Smoke-Free Policy.

The county ordinance will be enforced by the county Code Enforcement Board, with a possible fine  for violators of up to $50. Fines have also been set for business owners and employers who fail to comply with the ordinance. Business owners and employers are required to post "no smoking" signs.

At 28 percent, smokers are more prevalent in Perry County than the rest of the state, where that rate is 25%, but Emily Bennett with Hazard's WYMT-TV reports that most there are pleased with the ban.

Local diners at Frances' Diner, a restaurant that used to allow smoking, told Bennett that they are now able to eat without worrying about their health.

Matthew Combs, who works in Hazard, told her that he suffered from allergies and asthma and that being able to eat in a smoke-free environment is "wonderful."

One local health official pointed out the dangers of secondhand smoke, especially for employers who are exposed to it all day.

 "If it's a smoking venue, it is the equivalent to them having a pack a day habit themselves for a non-smoker having to work in a smoking environment where that is allowed," Scott Lockard, the public health director for the Kentucky River Regional Health Department, told Bennett.

Another told Bennett that such policies eventually create a "new norm."

Sherrie Stidham, a health educator, told Bennett, "We're wanting to set a new norm. We don't want children to get used to seeing everybody in these places and smoking and think it's an okay thing to do."

Wednesday, July 10, 2019

Kentucky opens first sober-living unit in a medium-security prison anywhere, with plans to open others across the state

By Melissa Patrick
Kentucky Health News

BURGIN, Ky. – Kentucky again leads in ways to deal with drug abuse, this time with a pilot program that provides aftercare for prisoners who have gone through drug treatment but are still serving time.

SOAR's logo was designed and painted by one of the program
participants. (Photo by Melissa Patrick, Kentucky Health News)
Supporting Others in Active Recovery (SOAR) allows inmates who have completed an addiction treatment program – and meet some other requirements – to live in a dorm that is committed to sober living while they complete their sentences.

"This is the best program I've been in," said Gevoyl Beauchamp, an inmate who has been in the program since it opened in April.

The six-month program at Northpoint Training Center, a medium-security prison near Burgin, has room for 88 participants. Inmates who have completed the program can request to stay in it.

"The important part of this is keeping them in that therapeutic community instead of being released back into the general [prison] population where there is less of a mindset for recovery," Northpoint Warden Brad Adams told Kentucky Health News.

Michael Reynolds, one of the participants, said being part of SOAR has allowed him to participate in programs that will help him live a sober life after he is released, such as those that teach life skills or employment "soft skills" and ones that focus on parenting or anger management.

"I'm looking for a change in my life," he said.

State Justice and Public Safety Secretary John Tilley told nearly 50 people at a July 9 news conference to announce the program that the plan is to "work the kinks out of it and take it to scale."

"It doesn't look at treatment as some 28-day program or some six-month program, or even a year-long program," Tilley said. "It looks at it like a life-long commitment to clean and sober living."

The pilot is funded in part by a $300,000 grant from the Kentucky Office of Drug Control Policy. Tilley said funding for the expansion of the program has not yet been secured.

"For every dollar we spend, the state recovers roughly three to four dollars," Tilley said. "So I'm going to continue to ask the legislature for more money. I'm going to continue to chase every federal grant dollar that we can chase, because this is a good use of taxpayer dollars. This is what will help us dig out of this."

Secretary John Tilley talks to inmates at Northpoint Training
Center at the announcement. (Photo by Melissa Patrick)
The need for such programs in Kentucky is great, Tilley said, because Kentucky ranks in the top 10 states for per-capita incarceration, with 24,000 people in the system, and 48,000 on supervision.

Tilley added that prosecutors tell him that 95 percent of their cases are related to addiction. Further, he said that by some measures it is estimated that between 60 and 70 percent of people in the corrections system need substance-abuse treatment.

In 2017, 1,565 people died in Kentucky from a drug overdose. Tilley, saying he was speaking "cautiously," said he sees a light at the end of the tunnel because this number is coming down.

"The good news is that Kentucky is leading the way in drug policy," Tilley said. "We've had to be the leader. We've had to put political differences aside to innovate because the problem is so acute here."

Tilley noted that Kentucky was the first state to limit prescription opioids to three days for acute pain, and the first to mandate monitoring of prescriptions. It leads the nation in its number of syringe exchange programs, with 58 sites operating in 51 counties as of June 5.

The justice secretary has long called for a public-health approach, not a criminal-justice approach, when it comes to addiction, which has been proven to be a chronic brain disorder.

"But until policymakers build an infrastructure that allows us to do that in this country, in this state, we'll continue to have to give it our best effort in corrections – and this represents our best effort," he said. He added later, "This is a public-health epidemic; it is not a corrections epidemic. Its impact is in the criminal-justice system."

Tilley, a Democrat, was appointed justice secretary in December 2015 by Republican Gov. Matt Bevin. He had been a state representative from Hopkinsville and was instrumental in passing Kentucky's 2015 anti-heroin bill. Among other things, the bill created a system in which local officials could allow syringe exchanges; increased penalties for high-volume traffickers; allocated money for drug treatment; and let the Department of Corrections medicate inmates for opioid-use disorders.