Tag Archives: l.a. times

The Next Opioid Epidemic: Fentanyl

Fentanyl has been in the news:

In 2014, it began being reported on the U.S. East Coast that heroin was being laced with fentanyl, creating a combination that is “untenably addictive.”

The Sacramento Bee reported in April that 51 overdoses, including 11 deaths, had been reported thus far in the Sacramento area in 2016; toxicologists tied eight of the deaths directly to fentanyl (watch the short video in the article that describes “death as collateral damage” to the drug dealers interested in market dominance).

Later in April, the L.A. Times reported the issue had migrated to the San Francisco area, where fentanyl pills made to look like Norco were a primary culprit.

The chief health officer in British Columbia proclaimed a Canadian public health emergency because of more than 200 overdose deaths during the first three months of 2016; a large portion of them involved “greenish pills purporting to be OxyContin 80 mg tablets.”

In June, it was confirmed that Prince died from an accidental overdose of fentanyl, unbelievable because he was an outspoken advocate of clean living (from having a “swear jar” to not consuming alcohol)

One of the common threads throughout these stories is China’s involvement. The Wall Street Journal published a front-page article on June 23 titled “China’s Role in U.S. Opioid Crisis.” The opening paragraph sets the stage:

Last spring, Chinese customs agents seized 70 kilograms of the narcotics fentanyl and acetyl fentanyl hidden in a cargo container for Mexico. The synthetic opium-like drugs were so potent that six of the agents became ill after handling them. One fell into a coma.

The article goes on to describe how fentanyl often is disguised as hydrocodone and Xanax on the black market — dangerous drugs by themselves but not nearly as potent or fatal as fentanyl. Because China does not regulate fentanyl or analogs used to create fentanyl, there is a significant financial incentive for the drug dealers — $810 of materials can create 25 grams of fentanyl and yield as much as $800,000 in pills sold on the black market.

See also: Opioids Are the Opiates of the Masses

According to the Canadian Globe’s expose on the issue (an excellent look at the black market), accessing fentanyl can be as easy as “Sign up for an account, choose a method of payment, and receive the package in three to four business days.” Reinforcing the financial model: “A kilogram ordered over the internet – an amount equal in weight to a medium-sized cantaloupe – sells on the street in Calgary for $20 million, making it a drug dealer’s dream.”

So, fentanyl is a problem. It’s 25 to 50 times more potent than morphine. It’s highly addictive. It’s available fairly easily on the black market. And it is prescribed by doctors. Way too often.

Approved by the FDA and on script pads supplied by the DEA, its federal legitimacy adds to the lack of stigma associated with use. Which is one reason why I think Prince could rationalize his use. A doctor likely prescribed it for his chronic pain — and other patients fall into that same trap (with fentanyl and other dangerous prescription drugs).

According to the FDA’s own warnings (as reported on drugs.com):

Because of the risks of addiction, abuse and misuse with opioids, even at recommended doses, and because of the greater risks of overdose and death with extended-release opioid formulations, reserve Fentanyl Transdermal system for use in patients for whom alternative treatment options (e.g., non-opioid analgesics or immediate-release opioids) are ineffective, not tolerated or would be otherwise inadequate to provide sufficient management of pain.

See also: How to Help Reverse the Opioid Epidemic  

In my opinion, fentanyl should be used to help people die with dignity during end-of-life care. Period. It’s that dangerous. And yet we see it being prescribed, used and paid for.

Month. After. Month.

If you are prescribing fentanyl: Why?

If you are being prescribed fentanyl: Why?

If you are paying for someone’s fentanyl: Why?

Too many people are overdosing and dying not to ask a simple question: Why?

Wellness Industry’s Terrible, Horrible, No-Good, Very Bad Week

Just as the Bear Stearns implosion presaged the 2008 financial crisis, the events of the last few days, building on earlier events, are presaging the collapse of the “pry, poke, prod and punish” wellness industry.

For those readers still living in Biosphere 2, here is a brief review of how we got here:

First was Honeywell’s self-immolation with the Equal Employment Opportunity Commission (EEOC). We’re not sure how Honeywell’s benefits consultants failed to advise that all the company needed to do was offer a simple wellness program alternative that didn’t require medical exams, and there would be no way Honeywell would get hit with an  EEOC lawsuit. But they didn’t.

Second, the Business Roundtable (BRT) decided to go to the mat with the president over this EEOC-wellness issue. It is possible that there is some conspiracy at work here, where large companies really want to retain the ability to shame and fine overweight employees into quitting (because you can’t fire people for being overweight). But we lean toward a less sensationalistic interpretation: that the BRT is simply getting lousy advice, likely from consultants whose business model depends on more companies doing wellness. Because the BRT’s member CEOs have actual day jobs, they can be excused for taking the BRT’s word for the benefits of wellness and not investigating this industry on their own; if they did, they would find that the wellness industry attracts more than its share of well-intentioned innumerates and outright scoundrels, perhaps because the industry lacks adult supervision.

Third was our popular Health Affairs posting, which spurred see-we-told-you-so pickups by the Incidental Economist and Los Angeles Times, the latter of which helpfully added the word “scam” to the discussion.

Thus, we bore witness to a perfect storm, the first-ever lay media feeding frenzy on wellness, from both the right-leaning Federalist and the, uh, non-right-leaning All Things Considered. Those would be the first times wellness in general (as opposed to specific programs like, for instance, the Truven/Highmark Penn State debacle or Nebraska’s falsified outcomes) has attracted the lay media. Additionally, the comments, even on the typically erudite All Things Considered, were merciless. Skeptics that we are, we still underestimated employee resentment of forced screenings and risk assessments.

The wellness true believers’ rebuttals were quite in character. As we say in Surviving Workplace Wellness, in this field you don’t have to challenge the data to invalidate it. You merely have to read the data. It will invalidate itself. Because most of the true believers’ “A Team” are ethically compromised, they had to go to their bench to find a rebutter. Against all those eviscerations in the major national media, they countered with: Siyan Baxter, a graduate student at the University of Tasmania, who claimed a positive return on investment (ROI) for wellness. She wrote in a journal that contains the words “health promotion” in its very title and has never once published a negative article about wellness savings. Publication bias, anyone? That isn’t even the punchline. The punchline is that, as our book predicted, Ms. Baxter self-invalidated. She says, right in the article: “Randomized controlled trials show negative ROIs.”

How did she still come up with a positive assessment of wellness? Because she “averaged” those ROIs with studies she herself describes as low quality, to get a positive ROI. (These 5- to 30-year-old studies were conducted in an era when, as the award-winning book The Big Fat Surprise observes, the American Heart Association bestowed a “heart-healthy” endorsement on every box of Kellogg’s Frosted Flakes.)

Her approach is, of course, is like averaging Ptolemy and Copernicus to conclude that the earth revolves halfway around the sun.

The other rebuttal was from Professor Katherine Baicker, who is considered a deity in this field because she basically launched it with a claim, published five years ago in Health Affairs, that wellness achieves a very precise 3.27-to-1 ROI. (As with Baxter, the wellness programs where Baicker found savings were conducted during the era when the AHA apparently conflated Tony the Tiger with Dean Ornish). Having recently stated she no longer had interest in wellness and having more recently blamed readers for relying on the headline “Workplace Wellness Can Generate Savings” and not reading the fine print, she nonetheless decided to defend her legacy.

Her defense on NPR is worth reviewing. Baicker said: “There are very few studies that have reliable data on the costs and benefits.” That, of course, is not the case – the wellness true believers’ own meta-analysis above shows that in well-designed assessments, the programs lose money. Baicker also said: “It could be that when the full set of evidence comes in, it will have huge returns on investment, and the billions we’re spending on it are warranted.”

This all sounds a little different from the three significant digits of: “Wellness achieves a 3.27-to-1 ROI.” And it is invalid because, as any epidemiologist knows – and as Dr. Gilbert Welch elegantly explained in Overdiagnosed — if an impact is truly meaningful, it would show up in a small or medium-sized sample. This means that, if indeed there were “billions” to be saved, we’d know it based on the hundreds of millions of employee-years that have been subjected to wellness in the last 10 years.

The “full set of evidence” is already in….and it’s game, set and match to the skeptics.