Kentucky doctors and hospitals are changing the culture of opioid prescribing, acknowledging their role in spurring the epidemic

Dr. Philip Overall in the emergency room at St. Claire Hospital in Morehead, which has cut the unit's opioid-prescription rates by half. (Photo by John Flavell for the Lexington Herald-Leader)

Acknowledging their role in causing the opioid epidemic, some Kentucky doctors have mounted an effort with hospitals to reduce prescriptions of painkillers.

The effort began at St. Claire Hospital in Morehead, which has stopped using opioids as its first response to pain. It has been adopted by the University of Kentucky and endorsed by the state health cabinet and the Kentucky Hospital Association.

This is "the first coordinated push . . . to stifle traditional opioid prescribing practices" in Kentucky, reports Alex Acquisto of the Lexington Herald-Leader. "Progress has mostly been a result of independent gumption on the part of providers," like Dr. Philip Overall, emergency-room director at St. Claire, and Dr. Phillip Chang, chief medical officer for UK HealthCare.

Dr. Phillip Chang (H-L
photo by Alex Slitz)

Chang came up with the Kentucky Statewide Opioid Stewardship program, or Kentucky SOS. He and other doctors, mostly from Central Kentucky, have formalized its philosophy "into an actionable plan for others," which has been accepted by "all but nine of the state’s 125 hospitals," including all acute-care and critical-access hospitals, Acquisto reports. "For its statewide scale and applicability across hospital departments, KY SOS is the first of its kind in the country, Chang said."

The hospitals are collecting prescription data for Chang and his team, who will use it to develop appropriate reduction benchmarks hospitals should aim for, Acquisto reports.

The doctors' idea came from experiences with patients.

Dr. Jacob Perry, a St. Claire surgeon, "performed an emergency laparoscopic surgery to remove a patient’s gallbladder — an invasive procedure that pretty much guaranteed an opioid prescription to deal with post-operation pain," Acquisto writes. "Instead of taking the painkillers his patient had been given, she managed her pain with Advil, and two days later, she returned to work. Perry recalled being flummoxed, and then determined: If all she needed was an over-the-counter pain pill, could others manage their pain the same way?"

Perry started asking patients to whom he had prescribed opioid how many pills they had taken, and “The vast majority were like, 1, 2, 3, maybe four,” he said. SO, "He began lowering some of his prescription doses, from 30 to 20," Acquisto reports.

Perry was mentored by Chang when he was at UK. Chang’s inspiration came in 2013, when he was UK's chief of trauma and critical care, Acquisto writes: "A male patient in his 20s kept visiting Chang’s clinic for a few weeks after being treated for a trauma injury. Each time he visited he complained of pain, and each time Chang refilled his opioid prescription."

“I had this epiphany: We’re prescribing too much,” Chang told a group of health-care providers at the Hazard hospital last month. “We’re creating addicts. Seventy-five percent of addiction stemmed from health care. We are responsible.”

When the patient came back for a third refill, Chang looked up his prescription history and found that "In just four weeks, he and a few other area doctors had prescribed this patient more than 1,000 pills," Acquisto reports.

“People ask why we’re not after meth or cocaine,” Chang said. “Because three out of four heroin users started with prescription opioids, meaning something we wrote. This is the only addiction crisis that started with hospitals and physicians. This is the only thing we caused. This we’re responsible for.”

The Morehead hospital urges its staff are urged to maximize alternatives to opioids, "like ice, heat, and over-the-counter painkillers such as acetaminophen," Acquisto reports. "Ibuprofen, muscle relaxers, and other non-steroidal anti-inflammatory drugs (NSAIDs). If opioids are necessary, “prescribe the lowest effective dose and quantity,” or a dose that lasts no longer than three days, the hospital says.

First Ky. Senior Hunger Summit brings awareness to issue, seeks solutions; nearly 3,000 Ky. seniors on waiting list for home meals

By Melissa Patrick
Kentucky Health News

One in six Kentuckians older than 60 have faced the threat of hunger in the past year, prompting state officials to hold the first-ever Kentucky Senior Hunger Summit Oct. 30 in Frankfort to raise awareness of the issue and to help connect people in communities to find solutions.

Shannon Gadd, commissioner of the Department for Aging and Independent Living, told Kentucky Health News that while the government can't fully fund or supply all of the resources needed to help all of these hungry seniors, it can act as a connector and catalyst to raise awareness of the issue and to marshal resources.

"To tackle food insecurity, it will require a grassroots, community-led effort. I believe that many resources already exist and there is much great work happening," Gadd said in an e-mail. "The first step to addressing the issue is bringing everyone to the table to discover that good work and how we can work together to tackle the problem. The summit was a kickoff and there will be more to come."

In Kentucky, 16.6 percent of those 60 and older suffer from food insecurity, a 10% increase over the last four years. Kentucky ranks 39th for food insecurity and 46th for home-delivered meals, according to the United Health Foundation's annual America's Health Rankings.

Gadd said there were 2,917 Kentucky seniors on a waiting list for home-delivered meals on June 30, the end of the 2018-19 fiscal year.

She said the need for such services is great in Kentucky because "we have a very high number of adults ages 60 and older with independent-living difficulty, which translates to a higher need for home-delivered meals and other supportive services."

Kentucky seniors rank 49th in physical inactivity and 45th in the percentage of seniors who are "able-bodied," according to the rankings.

Gadd said other factors to consider "include supporting an increasing 60-plus population while sustaining a decrease in funds, a previous practice of funding only hot meals rather than frozen or shelf-stable meals, and the use of multiple food providers across the state, rather than a single state contract."

Who's at risk and health consequences

James Ziliak, founding director of the Center for Poverty Research at the University of Kentucky, pointed out that because most seniors live on a fixed income, any increase in their out-of-pocket spending puts them at risk of becoming food-insecure.

James Ziliak

Ziliak, who has done research on food insecurity for more than a decade, noted that poverty is a substantial factor in whether a senior is food-insecure. For example, he said seniors with incomes under the federal poverty line ($12,490 for an individual and $16,910 for a couple) are 30% more likely to have food insecurity.

The risk of food insecurity is at least twice as high for minorities, Ziliak said. After controlling for age, income and race, the risk also increases for those with less education, those who have a disability, those who are divorced or separated, those who have a grandchild living in the home. In addition, he said that seniors who self-report as socially isolated have a 50% greater risk of food insecurity.

Ziliak also presented his and Craig Gunderson's research on the health consequences of senior hunger. Gunderson is from the University of Illinois at Urbana-Champaign.

They found that food-insecure seniors, compared to those who were food-secure, had a 60% higher risk for depression; 40% higher risk for congestive heart failure; 22% greater risk for coronary heart disease; 53% greater risk for a heart attack, and 37% greater risk for chest pain. They were also 52% more likely to report they had asthma, and 20% more likely to report fair or poor health.

"The health consequences are real," Ziliak said. "Feeding people feeds their soul, it feeds their mental health, it feeds their physical health. We need to make sure we are doing our job."

Feeding people can also help them live longer. A study co-authored by Ziliak and published in Health Affairs found that people in the Supplemental Nuitrition Assistance Program (SNAP, formerly known as food stamps) have 1 to 2 percentage points less risk of mortality.

Ziliak noted that Kentucky leads the nation for the number of people between the ages of 50 and 59 who are food insecure, and said this is something that Kentucky should be paying attention to.

"It's a tidal wave coming, people," he said. "One in five of Kentuckians between the ages of 50 and 59 are food insecure. That's astounding. We lead the nation."

A recent report by the Kentucky Center for Economic Policy, "SNAP is Good for Kentuckians' Health," cited research showing that food-insecure seniors had roughly the same quality of life as someone 14 years older -- and that SNAP participation leads to a 30% reduction in the likelihood that seniors will cut back on needed medications. It also cited a 2018 study of older adults, which concluded that getting SNAP benefits was associated with a 14% reduction in hospitalization and a 10% reduction in emergency-room use.

"SNAP is a really important tool, not only in our anti-poverty, anti-hunger toolbox, but also in our public health toolbox. And I think we would do well to start thinking of that more as a public health program," Dustin Pugel, author of the report, told Kentucky Health News.

A 2018 federal report shows food-insecure households spend about 45% more ($6,100) on medical care in a year than people in food-secure households ($4,200). And currently, the health-care costs for food insecurity in Kentucky are more than $854 million.

What can be done?

Ziliak suggested several solutions, including making sure that the 65% of seniors who are eligible for SNAP but don't use it get signed up; making it easier for them to sign up for the program and stay on it; changing federal regulations to give seniors more SNAP benefits; and changing the rules so mobility-challenged seniors can use SNAP to buy prepared food, not just in grocery stores.

In Kentucky, SNAP recipients over 65 must re-certify every two years, but those under 65 must do so annually. In 2017, 63,000 Kentuckians over 60 years old participated in SNAP, according to KCEP.

Pugel noted that the U.S. Department of Agriculture wants to restrict people with modest savings from getting SNAP, which would result in fewer seniors qualifying for the program. "If what we're trying to do is reduce food insecurity and improve health, especially among seniors, then that is a harmful policy; that is counterproductive to those goals," he said.

Roger McCann, executive director at Community Action Kentucky, said he hopes society is moving to a time when people recognize that food insecurity and other social determinants, like transportation and housing, play a significant role in a person's health and that addressing those determinants should be part of a person's medical care. He said this holistic approach would result in better health outcomes for everyone.

For example, he said, just like a person gets a prescription for a test or a drug, patients should also get prescriptions to have healthy meals delivered to them as they recover from a procedure if they live alone. "If you don't eat, your're not healthy," he said. "It is as simple as that."

Others spoke at the conference about innovative ways to address seniors' food insecurity, including a university program in Ohio that has a congregate meal program on its campus, and a hospital in Owensboro that donates its extra food to create frozen home-delivery meals. Gadd spoke about the need to work across state agencies to find solutions and the need to consolidate resources and to create a centralized database to help people.

State Agriculture Commissioner Ryan Quarles told the crowd that he has been working on this issue for several years through his Kentucky Hunger Initiative, a first-of-its-kind program that involves farmers, charitable organizations, faith groups, community leaders and government entities. "It affects every county, every city and every community in Kentucky," he said.

The Aging and Disability Resource Center provides information and resources about aging and disability issues.

The home-delivered meal program was titled C2 by the Older Americans Act. This table shows the breakdown of federal and state funds for each area development district for fiscal 2019-20. The numbers do not reflect state administrative costs. The program is overseen by the state Department for Aging and Independent Living, which provided the table. (Click on it for a larger version.)

Kentucky schools can tap federal money to provide more school-based health services for students enrolled in Medicaid

Kentucky school districts can now use federal Medicaid funding to expand school-based health services, the state announced Friday.

“The Medicaid state plan amendment will allow school districts to use federal funding to expand access to qualifying physical- and mental-health services for students enrolled in Medicaid,” Kristi Putnam, deputy secretary of the Kentucky Cabinet for Health and Family Services, said in the news release.

Examples of services that could now be covered include physical and behavioral health screenings, immunizations, dental care, speech therapy supports, and mental health counseling, says the release.

Historically, schools could only bill Medicaid for students who were disabled or met other limited criteria. The Centers for Medicare and Medicaid Services changed that in December 2014 to let states provide school-based health services to any student enrolled in Medicaid, and get federal reimbursement for it.

More than two in five Kentucky children are covered by Medicaid, but the state just recently decided to seek the money, a decision that seems largely driven by an increase in behavioral-health issues in schools.

“Approval of this amendment is a game-changer,” Health Secretary Adam Meier said in the release. “This will provide additional resources to support increased access to mental health services for students using money already being spend by school districts."

Putnam pointed out that the additional funding will help support the School Safety and Resiliency Act, or Senate Bill 1, that calls for one trained school resource officer in every school and one guidance counselor for every 250 students by July 1, 2021, or as funds and qualified personnel become available. School-based mental-health providers fall under a subsection of the guidance-counselor requirements and are listed as optional. The bill has no funding attached to it.

It's important to note that Medicaid will only pay for licensed mental-health providers, not guidance counselors, unless they have a special certification, which most of them don't, Eva Stone, district health coordinator for the Jefferson County Public Schools, told Kentucky Health News in April.

Terry Brooks, executive director of Kentucky Youth Advocates, applauded the decision to take advantage of this previously untapped funding, especially for the purposes of funding SB 1.

"The importance of preventive health and behavioral health services is undeniable as is the insight to provide them in schools to maximize students access," Brooks said in a prepared statement. "Ensuring children have these services not only positively impacts health, it is a catalyst to better academic achievement and even better school environment."

Being able to treat children in schools will also reduce many of  the barriers parents have to get their children health care, such as lack of transportation, non-flexible work schedules, or finding a provider who accepts Medicaid, the state news release says.

The release says the change to Medicaid will be phased in, and approval for reimbursements to school districts is retroactive to August 1, 2019.

WVLK Radio will focus on the opioid epidemic from 9 a.m. to 6 p.m. Wednesday, Nov. 13, with 'Enough: Opioid Awareness Day'

WVLK Radio in Lexington will host a day-long program to talk about the opioid epidemic on Nov. 13 titled, "Enough: Opioid Awareness Day."

"We just thought it was a singular issue where it was right to spend an entire day to try to find solutions and to discuss the intent of the problem," said Dave Krusenklaus, WVLK's program director.

Kruser, as he is called on the air, said the programming was inspired by state Senate President Robert Stivers of Manchester, who has said the opioid epidemic is not a problem in Kentucky, but is the problem in Kentucky, one that has touched everybody.

On Nov. 13, the station will offer a diverse day of programming about opioids from 9 a.m. to 6 p.m.

Guests will talk about the many aspects of the disease, and will include health-care providers and representatives of programs that treat opioid addiction, public-health officials, people who are recovering from opioid addiction, family members of those who have lost loved ones to addiction, lawmakers (including U.S. Reps. Hal Rogers and Andy Barr of the 5th and 6th Districts), law-enforcement officials, government and city officials working on this issue, and more.

"This is not a problem that you could necessarily legislate away," Krusenklaus said. "This is a human condition problem that we've got to solve ourselves. . . . This is an issue that you have to keep out in front of people."

State ends advisory against recreational use of Ohio River, maintains advisory for Briggs Lake Near Russellville

The state has ended the recreational public-health advisory it issued Sept. 26 due to harmful algal blooms in the Ohio River. "Results from recent water samples collected throughout the advisory area from the McAlpine Dam near Louisville to the Greenup Dam near Greenup are below the recreational advisory threshold for microcystin toxins," the Division of Water and the Department for Public Health said in a news release.

The advisory was issued when water samples indicated the presence of toxin-producing algal blooms. "Although the advisory is being removed, the DOW and DPH advise there are always risks associated with recreating in natural waters, especially with the incidental ingestion of water, and recommend avoiding contact with waters that have visible algal blooms," the release said.

An advisory remains in effect for Briggs Lake, off Duncan Chapel Road northeast of Russellville. The Division of Water has a webpage about harmful algal blooms in Kentucky. All current HAB advisories in Kentucky are at http://watermaps.ky.gov/HABs.

Medicaid program that pays employer-sponsored insurance premiums for employees has a new application process

By Melissa Patrick
Kentucky Health News

A program that will pay the premiums of working Medicaid members who have access to insurance through their employers has a "new and improved" application process, the state says.

The voluntary program, called the Kentucky Integrated Health Insurance Premium Payment program or KI-HIPP, allows Medicaid members to sign up for their employer-sponsored health insurance plan and have Medicaid pay their part of the premium.

Starting Nov. 4, KI-HIPP allows primary policyholders who are not on Medicaid to apply for the program if they have at least one Medicaid-eligible person on their policy. In addition, it allows families with anyone enrolled in a 1915(c) Medicaid Home and Community Based Services waiver.

“KI-HIPP is an excellent example of a government partnership that works with the employer-sponsored insurance market to expand insurance coverage options, particularly for families,” Medicaid Commissioner Carol Steckel said in a news release. “It allows Medicaid beneficiaries to choose a plan that meets their needs and empowers them to take control of their health. The added benefit is that this partnership saves the Medicaid program money.”

As of Oct. 30, the program had 220 members enrolled which would translate to a projected annual savings of nearly $800,000 for the Medicaid program, says the release.

Jason Dunn, a policy analyst for Kentucky Voices for Health, told Kentucky Health News that while KI-HIPP could be a great plan for some people and their families, he cautioned that it is important for consumers to carefully examine what he called the "risk" before making a switch, especially those with very low incomes.

For example, he pointed out that those who choose KI-HIPP will have more paperwork to manage, since participants are required to submit a copy of their paystub each pay period as proof of premium payment. It also requires the participant to submit annual re-certifications for both plans.

Dunn also noted that there is a risk that KI-HIPP participants could end up paying more out-of-pocket costs for their health care if they don't see providers who accept both the employer-sponsored insurance and fee-for-service Medicaid. If the provider only takes the employer's insurance, the KI-HIPP participant must pay all out-of-pocket costs, including co-pays, deductibles and co-insurance. "And that can be pretty pretty expensive," he said. "All that can be thousands of dollars a year."

Dunn added that individuals also need to explore what would happen if they were part of the KI-HIPP program, but then became no longer eligible for Medicaid, or were no longer able to meet the KI-HIPP requirements. In either case, the premium would no longer be reimbursed by Medicaid, and the employer could have to pick up the cost until the next open enrollment if they were not permitted to dis-enroll from the employer's plan.

Tens of thousands of Kentuckians go on and off Medicaid each month, for various reasons. As an example of that, the health cabinet confirmed that as of Nov. 4, 25 people had left the KI-HIPP program because their incomes rose above the Medicaid eligibility limit; by Nov. 6, the number of KI-HIPP participants had risen from 195 to 199.

To improve the application process, the system now includes a stand-alone application which is designed to make it easier for newly eligible Kentuckians to apply for KI-HIPP or to add it to an existing Medicaid case. "It's great to make it easier to apply, but we just want to make sure people know what they're applying for and what the risks are," Dunn said.

The release notes that Kentuckians enrolled in the existing Health Insurance Premium Payment (HIPP) program will move to KI-HIPP in December, and HIPP program members will get a letter in the mail with guidance on how to make this transition.

Sign up for KI-HIPP at benefind.ky.gov or call 855-459-6328. For more information see https://chfs.ky.gov/agencies/dms/member/pages/kihipp.aspx. Click here for a link to a Kentucky Voices for Health explainer about the program.

Is Bevin 'trying to rip health care away from our families'? Is it true Beshear 'sold out Kentucky' in an opioid lawsuit? Here are facts.

Northern Kentucky debate (Photo by Albert Cesare, Cincinnati Enquirer)

By Al Cross
Kentucky Health News

Health-related issues figure prominently in some of the final messages that the candidates for governor are delivering to voters as Tuesday's election approaches.

Democratic Attorney General Andy Beshear says of Republican Gov. Matt Bevin, "He has tried to rip health care away from our families."

A Republican TV commercial says Beshear is "so liberal, he wants to give taxpayer-funded health care to people who can work and choose not to."

And a Bevin TV ad says, "Beshear did profit from opioids" and "sold out Kentucky."

The three commercials have varying degrees of truth, and as usual for political ads, fall far short of telling the whole story. They obscure a fundamental difference between the candidates on an issue that affects hundreds of thousands of Kentuckians.

That is the expansion of the federal-state Medicaid program by Beshear's father, then-Gov. Steve Beshear. At last count, the expansion covered more than 450,000 people, paying their bills when they get health care.

Bevin's proposal

Bevin wants to require as many as half of those people (estimates vary) to work, volunteer, attend school or take job training at least 80 hours a month, and make monthly reports, in order to keep their benefits. Those who are medically frail or must care for children would not be included.

Studies indicate that most Kentuckians who would be affected by the "community engagement" rules are already meeting them. One study based on polling found that 97 percent already meet the requirements; another, based on claims data, showed that 64% are.

A federal judge in Washington, D.C., has blocked Bevin's plan, known as a waiver, and judges who heard an appeal last month sounded skeptical of it. Bevin has issued an order that would abolish the expansion six months after a final court decision against his plan. He has said the Supreme Court will decide the issue; the high court does not have to consider appeals.

The first version of Bevin's plan estimated that after five years, the state's Medicaid program would have 95,000 fewer people than it would without it—largely because of noncompliance, including lack of reporting. "This is paperwork and it is intended to tear health care away from people," Beshear said in a debate, pledging to do away with the plan "in my first week of office."

Bevin "has justified the idea both in terms of cost—because the state pays about 10% of the costs of the expansion—and values," Idrees Kahloon of The Economist magazine writes in a "Democracy in America" column about the governor's race after interviewing Bevin.

"When your correspondent asked him whether the point of the waiver was to save the state money, he flatly answered, 'No,' and then held up both his index fingers, one of which was more curved than the other, the result of having had to set it himself when he was young."

“I have scars on my body that we couldn’t afford to get stitched up so they’re as thick as a finger instead of thin as a string,” Bevin told Kahloon. “Every dollar we give to an able-bodied, working-age person with no disabilities and no dependents is a dollar we’re not able to provide … for those truly in need in our state.” Bevin often says he has empathy for the uninsured because he didn't have health insurance until he joined the Army.

Kahloon, a native of Morehead, notes, "Many of the counties in Kentucky most reliant on Medicaid—both for health coverage and to keep rural hospitals financially solvent—are also steadfastly Republican strongholds. To make inroads with them, Mr. Beshear must instill fear about the prospect of policy change. Whether he has done so is unclear."

State House Minority Leader Rocky Adkins, who ran second in the May primary, talked about Medicaid as he campaigned last week with Beshear in Democratic counties in Eastern Kentucky. In that region, he said, “The only growth we’ve seen here has been in the health-care industry.” Bevin has discounted estimates of the Medicaid expansion's creation of jobs.

Opioid epidemic

There has been less debate about the Medicaid expansion than about Beshear's record on the opioid epidemic. The Bevin ad's contention that Beshear "did profit from opioids" and "sold out Kentucky" are based on Beshear's partnership in the law firm of Stites & Harbison. It represented Purdue Pharma in the lawsuit filed against the maker of Oxycontin by then-Attorney General Greg Stumbo in the mid-2000s.

Stumbo's successor, Jack Conway, settled the case for a $24 million payment by Purdue Pharma shortly before Beshear became attorney general. Beshear has said he took no part in the matter, but has refused to say whether he shared as a partner in the fees the law firm earned from Purdue. After Beshear took office, he approved a retroactive $4 million contract for work on the case by a Louisville firm that later made Conway a partner.

Beshear said in 2017 that he did not "recall doing any work" on the case at Stites & Harbison. "I was there a long time," he said. "I don't want to suggest that no one asked me a question about what General Conway was like or not like, but I was not an active participant in that case."

This year Beshear wrote a memo that "says he stepped away from anything related to the state's litigation against Purdue when he took office," Phillip Bailey reports for the Louisville Courier Journal. "Why write that memo three years later? Beshear made multiple attempts to stiff-arm that question and others when I asked about the memo last week . . . Beshear said it was more appropriate to go through a campaign spokesman to schedule an interview, but he eventually relented."

Beshear told Bailey, "We had a policy from the beginning that I was not involved in any Purdue matter other than making a recommendation about where the settlement funds went," but wanted to document it because Purdue Pharma was rumored to be headed for bankruptcy.

Bevin's chief of staff, Blake Brickman, told Bailey, "The memo only raises further questions. Any competent and ethical attorney knows that recusal letters are put in the record immediately, not over three years after the alleged recusal occurred."

In 2017, Purdue Pharma got Pike Circuit Judge Steven Combs to seal the case file, including the only deposition from a member of the Sackler family that owns the company. Stat, the health-and-science publication of The Boston Globe, asked Combs to unseal the file, and Beshear's office took no position on the issue (after denying an open-records request for the deposition, citing Combs' order). Combs granted Stat's motion, but Purdue has appealed.

As attorney general, Beshear has sued nine opioid manufacturers and distributors, alleging that they caused or worsened the opioid epidemic, which has left thousands of Kentuckians dead from overdoses. He says no other attorney general in the nation has filed as many suits against opioid makers and distributors. Bevin has noted that none of the suits have resulted in settlements.

Register by Friday, Nov. 8, for Covering Substance Abuse and Recovery: A Workshop for Journalists, in Ashland Nov. 15

Friday, Nov. 8 is the deadline to register for Covering Substance Abuse and Recovery: A Workshop for Journalists, to be held in Ashland, Ky., on Nov. 15. Space is limited; details and registration are here.

The workshop has been designed with rural journalists in mind, because research at Oak Ridge Associated Universities has found that the stigma still attached to drug abuse keeps people from seeking help. “The increasing news media reports of opioid-related overdoses and crimes has led many to overlook the fact that prevention programs are working and that many people are entering treatment and living in active recovery,” ORAU said in a report on its study.

It also said local news media could help by reporting more success stories from people in recovery. "We think stigma also discourages some news outlets from reporting on substance abuse and recovery, and that’s why we’re holding this workshop," said Al Cross, director of the Institute for Rural Journalism and Community Issues, which publishes Kentucky Health News.

"We have a national-quality lineup of reporters who have won Pulitzer Prizes for their coverage, a weekly newspaper editor-publisher who has tackled the subject head-on, a recovering addict who writes a newspaper column about his experiences, and several experts on the subject," Cross told editors in an email this week. "We don’t know of another such workshop having been held anywhere, and we want you to be part of it."

The workshop will be held at the Marriott Delta Downtown, 1441 Winchester Ave., from 8:30 a.m. to 5 p.m. Nov. 15. Early arrivals will have an informal gathering at the hotel the night before.

Cross wrote, "As we planned this workshop, I thought of one of the best-known lines from the play Death of a Salesman: 'He's not the finest character that ever lived. But he's a human being, and a terrible thing is happening to him. So attention must be paid. He's not to be allowed to fall into his grave like an old dog. Attention, attention must finally be paid to such a person.' Let's pay attention to these people and their problem, and help solve it."

E-cigarette users need to watch for symptoms of lung injury and should seek help immediately if detected, health officials warn

Centers for Disease Control and Prevention illustration

By Melissa Patrick
Kentucky Health News

If you use electronic cigarettes, contrary to current warnings, it's important to watch for symptoms of lung injury, and to immediately seek medical care if you have any of them: cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, fatigue, fever or abdominal pain.

That was one of the main messages on a Nov. 1 "Lung Injury with Vaping" webinar, hosted by Elizabeth Anderson Hoagland, youth tobacco-prevention coordinator with the state's Tobacco Prevention and Cessation Program.

Also, Hoagland said, it's important for patients who have been hospitalized because of a vaping-related lung injury to make sure they follow up with their health-care provider one to two weeks after discharge and again in three to four months.

"I cannot emphasize this enough," Hoagland said. "The doctors I've been working with have all been really horrified at how sick these people get and how quickly they get sick. So really, that follow-up with a health-care provider is essential."

The federal Centers for Disease Control and Prevention says that because the cause or causes of these lung injuries is unknown, no one should use any e-cigarette or related products -- especially youth, pregnant women, and adults who do not currently use tobacco products.

As of Oct. 29, 1,888 cases of vaping-related lung injury had been reported to the CDC, and 37 deaths have been confirmed in 24 states. The CDC said more deaths are under investigation.

The CDC reports that 14 percent of the cases were in patients under 18 years old, 40% were in those 18 and 24; 25% were among those 25 to 34, and 21% of the patients were 35 and older.

In Kentucky, 31 cases are under investigation, with three of them confirmed and 11 considered probable results of electronic-cigarette use. Seven reported cases have been ruled out.

It is still not clear what is causing the lung injuries, "and the only commonality among all cases is that patients report the use of e-cigarettes, or vaping, products," says the CDC.

Hoagland noted that there are at least 450 e-cigarette devices on the market, along with thousands of e-cig liquids in stores, online and on the black market; and e-cig users often mix their own e-liquids.

"So if you are wondering about the scope of this investigation, we are talking about thousands of unique products to investigate to try and find the commonalities between them to determine what is causing the problem," she said. "So if you are wondering why this is taking so long, that is why."

Many cases have involved black-market products with tetrahydrocannabinol (THC), the psychoactive ingredient in marijuana, but Hoagland stressed that there are other causes.

"Here in Kentucky we have at least one case where someone using a tank-modified product, with nicotine only, became sick," she said. "A lot of the products that have caused illness have been associated with illegal THC products, but it's not only illegal THC products and I think it's very important to have that caveat." She added later, "I can say with confidence that we have people who are getting sick who are not testing positive for THC, which is why we say that no single product or substance has been linked to all cases."

The CDC reports that among 867 patients who reported e-cigarette use in the previous 30 days, 86% reported using products with THC; 34% reported exclusive use of THC-containing products; 64% reported using products with nicotine; and 11% said they used only nicotine-containing products.

Hoagland said it's important to not buy products off the street, especially THC products, and to not modify or add any substances to e-cigarette, or other products not intended by the manufacturer.

In addition, she noted that some long-term e-cigarette users have gotten sick after trying a new product and said, "This is not the time to experiment with new products."

An open letter about "vaping" from state Commissioner of Education Wayne D. Lewis Jr. and Health Commissioner Angela T. Dearinger links to a long list of resources on e-cigarettes, including options for youth cessation, youth-prevention programs for educators, sources for parents, resources for students and young adults, and general research and information.

Two Kentuckians, one 13, among plaintiffs in 26-state lawsuit alleging Juul deceived children into using electronic cigarettes

Two Kentuckians are suing Juul Labs, the manufacturer of the most popular electronic cigarette, claiming that the company used deceptive marketing practices to attract children. They are part of a consolidated federal case in Northern California with plaintiffs from 26 states. There may be more plaintiffs and more lawsuits.

One of the Kentuckians is a 13-year-old girl from Carrollton who "tried her first e-cigarette in sixth grade and was hooked by the next academic year," reports Bailey Loosemore of the Louisville Courier Journal. "She swears she didn't know the pods contained strong amounts of nicotine, a chemical that can change the course of growing brains. And though she says she no longer vapes, her parents aren't sure she'll ever be able to fully quit."

The other Kentucky plaintiff is John McFaull, 25, of Lexington. His attorneys include Barbara Bonar of Covington, who told the Courier Journal that she and other attorneys are "working with up to 100 more potential clients who could file their own suits or join others who have already been filed," Loosemore writes.

"We want to put these companies out of business," Ronald Johnson, a Fort Wright attorney who represents the 13-year-old, told Loosemore. "After going two decades where fewer and fewer kids smoked to a point where it was almost gone, now we have a new generation addicted to nicotine. … It was marketed as a safe alternative, but really it was a way to get a whole new market for cigarettes. It was so devious."

Juul issued a statement: "This case is without merit and we will defend our mission. Juul Labs is committed to eliminating combustible cigarettes, the number one cause of preventable death in the world. We have never marketed to youth and do not want any non-nicotine users to try our products."

Loosemore reports, "Bonar and Johnson said most of their clients are teenagers or college students who started vaping in high school. But it's not uncommon now for kids to pick up the devices even younger. A 2018 survey by the Kentucky Substance Abuse Prevention Program found that 4.2 percent of sixth graders had tried e-cigarettes, while 14.2% of eighth graders had experimented with the devices."

Kentucky and Ohio researchers get $5.7 million grant to improve Appalachian colorectal cancer screening and follow-up care rates

Researchers in Kentucky and Ohio have received a $5.7 million grant from the National Cancer Institute to increase colororectal cancer screenings and follow-up care among under-served people in Appalachia.

The research will be led by the cancer centers at the University of Kentucky and The Ohio State University. "We are excited to have the opportunity to take on the challenge of promoting colorectal cancer screening and follow-up in rural communities that have an elevated burden of this disease," said Mark Dignan, co-leader of the Cancer Prevention and Control Research Program at UK'.

The five-year study is designed to help community health centers and communities implement multi-level evidence-based strategies to increase their rates of colorectal cancer screenings, as well as follow-up and referral-to-care for patients between the ages of 50 and 74.

Kentucky has doubled its colorectal screening rates in the past 20 years, "but more work is needed to increase access to screening and follow-up care in the Appalachian region," says the news release.

"Rates of colorectal cancer incidence and related mortality in Appalachia are among the highest in the United States, and far too many people in this region do not receive potentially life-saving colorectal cancer screening," said Electra Paskett, co-leader of the cancer research program at OSU.

In Appalachian Kentucky, for every 100,000 people, 50.6 colon and rectum cancer cases were reported in 2012-16; the non-Appalachian counties everaged 57.9 cases per 100,000, according to the Kentucky Cancer Registry.

In that same period, 4,275 Kentuckians died from colon and rectal cancer, according to the Centers for Disease Control and Prevention. For every 100,000 people in Kentucky who died from these cancers, 19.8 of them lived in Appalachian counties and 15.4 of them lived outside the region.

The study was piloted in Lewis County, Kentucky and Guernsey County, Ohio, with activities rolling out to 10 other counties over the next three years, including Breathitt, Carter, Lawrence, Morgan and Powell counties in Kentucky and Adams, Belmont, Hocking, Lawrence and Morgan counties in Ohio.

Citing 'pending legal challenge,' Indiana suspends its Medicaid work requirements; lawsuit is fourth one to challenge them

Indiana’s Medicaid program has temporarily suspended its work and community-engagement requirements "due to a pending legal challenge," according to an Indiana state news release.

Kaiser Family Foundation graphic

The lawsuit against Indiana is the fourth federal challenge to a state's attempts to add work and community-engagement requirements to the Medicaid program, James Romoser reports for Inside Health Policy. The other three have been in Arkansas, Kentucky and New Hampshire. All four states are led by Republicans.

Kentucky, led by Gov. Matt Bevin, was the first state to be approved, but a federal judge in Washington, D.C. blocked its plan twice, and stopped a similar plan that had already taken effect in Arkansas. A three-judge appellate panel appeared skeptical of both plans in a hearing Oct. 11. The panel is expected to rule within a few months.

The same federal district judge who ruled on the Kentucky and Arkansas cases, and blocked the New Hampshire waiver in July, is the judge for the Indiana lawsuit, Romoser reports. Since, the Centers for Medicare and Medicaid Services and New Hampshire have appealed the ruling, which places it in the same appeals court that is considering the legality of the Arkansas and Kentucky cases, Romoser reports in a separate article.

Judge James Boasberg of Washington, D.C., has said the waivers are invalid because CMS failed to explain how work requirements would promote Medicaid's goal of providing health coverage.

Indiana health officials said they remain committed to the state's "Gateway to Work" program and are delaying work reporting requirements to allow time for the state's lawsuit to be resolved and give time for similar legal challenges to work their way through the appeals process.

That said, the work requirements would not have applied to all of the Indiana Medicaid enrollees, Lisa Gillespie reports for Louisville' WFPL. "Out of about 400,000 enrollees, 80,000 would have had to track their hours and risk losing coverage if they didn’t." she writes. Before the Arkansas program was shut down, 18,000 people lost their Medicaid coverage because of non-compliance.

Dustin Pugel, a policy analyst with the Kentucky Center for Economic Policy, told Gillespie that Indiana may have suspended its program because it would be an "administrative nightmare" to do so because of a court ruling.

“They voluntarily suspended, I assume, thinking about what will be coming similarly for them that came to New Hampshire, Arkansas and Kentucky,” Pugel said. “I imagine they were doing it this way so that they could smooth out any administrative bumps that could come up from having to pull the plug quickly in response to a judge’s order.”

Arizona has also suspended its plan to add work requirements to its Medicaid program due to all of the legal uncertainty.

Medicaid work and community engagement requirements have been a key difference between Kentucky's gubernatorial candidates as they fast approach election day on Nov. 5.

At an Oct. 15 debate, Attorney General Andy Beshear pledged to drop the plan if elected because "This is paperwork and it is intended to tear health care away from people."

Bevin replied, "This isn't about people being, having anything ripped away from them. What I propose is that people work and or volunteer and or go to school or be in training or take care of someone in exchange" for their benefits.

Bevin's original proposal estimated that in five years, Kentucky's Medicaid rolls would have 95,000 fewer people than without the plan, largely because of noncompliance. Academic health experts said in a friend-of-the-court brief that a more likely range was 175,000 to 297,500. Medicaid covers 1.4 million Kentuckians, around 450,000 of them under the expansion of the program to the working poor under the Patient Protection and Affordable Care Act.

Studies have indicated that most people in Kentucky who would be affected by the work rules are already meeting them. One study based on polling estimated that 97% were already meeting the requirements; another, based on claims data, indicated that 64% were.

So far, 18 states have asked for a waiver of the traditional Medicaid rules to allow such requirements, with six of the waivers approved, nine of them pending and three of them set aside by the court, including those in Kentucky, Arkansas and New Hampshire, according to the Kaiser Family Foundation.