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Trump Administration’s Addiction Crisis ‘Listening Tour’ Gets An Earful

Trump administration officials have been visiting parts of the country affected by the opioid addiction crisis, including the Ohio Valley region. The administration called it a “listening tour,” and they got an earful in events marked by protests and controversies.

Some people working to combat the epidemic in the region say they’re concerned about the potential effects of the administration’s approach, including proposed health care changes and a possible return to harsher criminal prosecutions for drug charges.

The Trump Approach

Last October then-candidate Donald Trump laid out his plan to tackle the opioid epidemic. In a campaign event he focused on stopping the flow of drugs, issuing harsher trafficking penalties, and supporting addiction treatment.

“We’ll make sure they have the top treatment and get better,” Trump told the crowd in New Hampshire.

This month, President Trump sent his top health and law enforcement officials — Attorney General Jeff Sessions and Health and Human Services Secretary Tom Price — to hear from people most affected by the crisis.

Matt Boggs is executive director of Recovery Point West Virginia, which operates long-term recovery centers around the state. He was among those invited to talk with Secretary Price during his visit to the state capital, Charleston.

Matt Boggs takes an abstinence-based approach to treatment at Huntington’s Recovery Point.

“There was about 20 or so folks in the meeting. I was definitely honored to be a part of that,” Boggs said. “I was the only person in long-term recovery in the room. So that meant a lot.”

He said he appreciates that the administration is paying attention to the issue. But he has some concerns about certain aspects of their approach.

Medicaid’s Role

Boggs is worried about the effects of the administration’s approach to health care coverage under Medicaid.

He hopes the administration learned how important the Medicaid expansion from the Affordable Care Act was to those with substance use disorders in West Virginia.

“It provides these folks essential health services so that they can treat the underlying issues they have, other chronic illnesses, things like that,” Boggs said. “Without the Medicaid expansion, it would really hurt our efforts.”

Some projections estimate coverage for substance use disorders would be at risk under the House-passed version of the ACA replacement.

Price disagreed with the premise that individuals will lose health care and said the administration’s focus is on improvement.

“The goal is to make sure that the health care is the kind of care that individuals across this land need.”

Without analysis from the Congressional Budget Office it is unclear what effect the proposed bill will have on coverage for addiction treatment. That analysis is expected as early as next week.

Medical Treatment

Medicaid expansion has also helped those with substance use disorders get medication assisted treatment.

Secretary Price made a comment about such treatments involving methadone and buprenorphine during his stop in Charleston that gave some medical professionals concern.

“If we’re just substituting one opioid for another, we’re not moving the dial much,” Price said during his visit, according to the Charleston Gazette-Mail. “Folks need to be cured so they can be productive members of society and realize their dreams.”

Price then touted faith-based programs and naltrexone — a non-opioid medication.

The comment received responses from treatment specialists around the country who criticized it as going against evidence-based research on keeping every treatment option open.

“Decades of research have shown that the benefits of medication assisted treatment greatly outweigh the risks associated with diversion,” former Surgeon General Vivek Murthy wrote in a Tweet responding to Price’s comment. “It’s critical we get treatment right-millions of lives are on the line. Science, not opinion, should guide our recommendations and policies.”

The HHS office shortly after reaffirmed its dedication to medication assisted treatments and pointed out the HHS website’s link that helps individuals find medication assisted treatment.

Enforcement vs. Treatment

While Price focused on treatment during his visit, Attorney General Jeff Sessions focused on prevention and law enforcement.

Sessions emphasized prevention programs like the “Just Say No” program from the 80s.

“Illegal drugs are dangerous and deadly,” he told the crowd gathered at the University of Charleston. “Say no, don’t do it, it’s not right to do it. It’s wrong to do it. It’s wrong to help other people, lead them into drug use when they have no business doing so,” he said.

Boggs is critical of this old approach, saying while well-intended, the “Just Say No” program was not effective because it didn’t treat addiction as a disease.

“If I’m born with diabetes, I don’t have the ability to just say no,” he said. “So if folks can’t say no to drugs, then they need to be seeking treatment.”

But Boggs does like some of the initiatives put forth by the Trump administration. The creation of a task force led by New Jersey Gov. Chris Christie to develop best practices for addressing the epidemic is encouraging to him.

He would like for someone from West Virginia to be named to the task force as a representative to the unique needs and challenges the state faces in the epidemic. But it’s more important to him that President Trump follow through with the recommendations they make.

Boggs said in the meantime it is important for those working to combat the opioid epidemic to continue to make their voices heard.

“I think it’s important that we continue to advocate, we continue to talk about recovery. We’ve got to talk about prevention.”

Heart Of The Matter: Needle Drug Use Brings Spike In Heart Infections

The Ohio Valley’s addiction crisis has brought another health problem, as rising numbers of needle drug users are contracting a serious form of heart infection called endocarditis. The rate of endocarditis doubled in the region over a decade, and many patients require repeated, expensive treatment and surgery as they return to drug use and once again become infected.

According to the Centers for Disease Control and Prevention, annual Medicaid spending on endocarditis is more than $700 million, a number likely to rise if treatment does not change to also address the growing health impact of substance abuse.

Doctors at the University of Kentucky are creating a team approach to address endocarditis and the addiction contributing to it. It’s a challenge that has forced them to change traditional practices, break down walls between different medical practices, and get to the heart of the problem.

Sharing or even reusing syringes can build up the bacteria causing endocarditis.

An Emerging Problem

Endocarditis is a result of bacteria accumulating around and infecting a heart valve. It can appear initially as mild, flu-like symptoms or chest pains and extreme discomfort. Emergency surgery to replace heart valves is required in the most extreme cases, but standard treatment involves weeks of sustained doses of antibiotics to make sure the infection is completely cleared.

University of Kentucky researcher Jennifer Havens documented a spike in endocarditis cases.

Since 2008, University of Kentucky researcher Jennifer Havens has tracked the health of hundreds of addicts in Hazard, Kentucky. She said that in the last few years she’s seen a spike in endocarditis cases.

“They may or may not be sharing needles but they’re reusing the same syringes, which accumulates bacteria, which they’re basically shooting into their bodies,” she said.

Havens said traditional cardiac units aren’t designed to treat addiction so the patients frequently return to previous, dangerous habits.

“If you’re not treating their substance abuse issue in the hospital they can potentially go right back out and infect themselves,” Havens said.

According to the CDC, addicts with endocarditis are 10 times more likely than other patients to die or require a second surgery months after initially leaving the hospital. Research has also shown that addicts tend to leave the hospital more often before the weeks-long series of antibiotics that is necessary to complete treatment.

In many cases, the patients are in withdrawal from opiate addiction during treatment. The intense atmosphere of post-surgery care only amplifies the anxiety and pain of withdrawal from opiates, said UK infectious disease specialist Dr. Saritha Gomadam.

“It definitely affects us,” she said. “Our heart just goes out when we see a really young patient in their 20s crying that they want to quit.”

Overall, the median age of endocarditis patients is rising slightly. But at UK and other hospitals treating a large population with substance abuse disorders it is younger patients who are more often returning in need of multiple surgeries. Gomadam said the question of how to treat them most effectively “is something we talk about almost every time we are on service.”

“There is sort of a moment where you both sit there and you know you have to do something,” she said.

There are also physical limitations to how much the body can take.

“Any kind of surgery has its risks,” she said. “There comes a point where there’s only so many times that their body can be opened up.”

The scar tissue from repeated surgeries can make valve replacement difficult and dangerous.

Teachable Moment

When the patient comes into the hospital with endocarditis it offers an opportunity for the team to have a discussion about substance abuse treatment, said Dr. Laura Fanucchi, who specializes in internal medicine and addiction. She is working with Gomadam to create the new treatment method.

“I believe — and our data support this — that coming to the hospital being very sick from a complication from untreated substance abuse disorder or untreated opioid addiction can be a moment where we can really reach that patient and help them start positive changes,” said Fanucchi.

Dr. Laura Fanucchi said addiction treatment “has been siloed from general medical care.”

But addressing the social challenges around addiction requires skills outside of traditional endocarditis treatment.

“If we don’t work together we are not going to be successful because the patient has problems that my antibiotics will not cure,” said Gomadam.

Gomadam and Fanucchi are in the early stages of creating a unique team approach for endocarditis after seeing the same young, addicted patients again and again.

“We are working closely with internal medicine, cardiology, cardiothoracic surgery” Gomadam said, with each group bringing in a particular expertise.

Breaking Silos

Such an approach requires education for both patients and providers.

“A lot of patients with untreated addiction feel very stigmatized by the health care community,” Fanucchi said.

That distrust can result in patients being even reluctant to say they have a problem abusing drugs.

On the other hand, health providers often see the ravages of addiction but very few people in recovery. That takes its own toll, especially on health care providers.

“I think seeing for a long time the complications of untreated substance use disorder some health care professionals start to feel hopeless, and that will engender a culture of frustration,” Fanucchi said.

She said the answer lies in creating communication across medical and addiction services that have traditionally operated independently of each other.

“I think it’s long standing in treatment of addiction that it has been siloed from general medical care,” said Fanucchi. “It’s not historically been part of general medical education and residency. So we’re going to address that.”

The approach has been well received, she said, but it is a big shift that will take time.

Fanucchi said another key in finding the right treatment focus is recognizing the need for sustained medical intervention and recognizing relapse as a part of the disease process.

“Trying to be successful, particularly with opioids, with detox only or abstinence only is part of the reason that we are in this problem that we are in, unfortunately,” she said.

That means bridging the hospital stay with drugs that help with withdrawal, such as naloxone and buprenorphine, plus counseling or treatment.

“The analogy is that someone comes into the ER sick from diabetes and you send them home and tell them not to eat sweets but don’t give them any insulin,” she said. “And we wonder when they come back why their diabetes is a problem again.”

Students in Wheeling Provide Window into Middle School Experience

On this West Virginia Morning, we’ll hear more from eighth-grade students at Wheeling Middle School who teamed up with Northern Panhandle Bureau Chief Glynis Board to report and produce stories and commentaries about the issues that affect them the most.

We’ll also hear an update from The Ohio Valley ReSource about an effort in Congress to save retired miners’ benefits.

Hunger Gains: Budget Cuts Imperil Nutritious Food Aid

At a moment when food aid agencies are working to provide healthier food to the poor and the elderly, President Donald Trump has proposed a 21 percent cut in funding for the agriculture programs that support them.

It’s a move that advocates say is bad for people who need food and local farmers who provide it.

Food Insecurity

To understand why folks are worried is to understand Appalachia’s dependence on food programs. Research at West Virginia University found 15 percent of people there are food insecure. A study in Athens, Ohio, showed half of the families enrolled in Head Start couldn’t count on regular meals. And in Kentucky, where one fourth of children in poverty cope with hunger. God’s Pantry Program Director Danielle Bozarth struggles to keep up. She said it’s unclear what specific food-related programs might be hurt by budget cuts.

“Just dealing with the uncertainty of not knowing what is going to happen is kind of scary,” she said. She plans to meet with Kentucky Congressman Andy Barr soon to get some clarity on what God’s Pantry might be facing.

God’s Pantry provides food to 50 counties in central and eastern Kentucky. Its program to provide fruits and vegetables to senior citizens is one of the largest in the United States.

Development Director Rebecca Wallace said transportation costs take up much of her budget and God’s Pantry depends on a steady stream of volunteers to get the food packed for delivery.

Ric Roberts and a team of red-shirted members of the Bluegrass Buckeyes sort donated items at God’s Pantry’s massive Lexington warehouse. The fans and alumni of Ohio State University check expiration dates on baby food, stretch tape to repair packing and discuss the nuances of sorting food stuffs.

“Excuse me, what do you classify pickles as, condiment or vegetable?” he said, holding up a jar for examination.

The pickles go in the bin marked “extras” for bonus food, such as candy or barbecue sauce.

Traditionally, most donated foods were non-perishable items with a long shelf life. But Wallace said it’s especially galling that food programs are coming under threat at a moment when they are evolving to provide better nutrition. That means providing people with more fruits and vegetables.

“This year we will distribute right about 32 million pounds of food. That’s a lot of food,” she said. “When you think about how much food we are putting onto the tables of low income families, it also tells us we have an awesome responsibility to make sure that we’re not simply filling bellies but that we are nourishing bodies,” she said.

Farm Fresh

The 2014 the federal farm bill included the Food Insecurity Nutrition Incentive, or FINI. Through grants it links local farmers to food stamp recipients. In Kentucky the program is called Double Dollars: Spend $10 in food stamps on healthy food and you get a $10 voucher to double the buying power.

Andrea Maus, whose infant daughter, Sabali, was bundled up against the wind, used the program for the first time on a brisk weekend at the Berea Farmers Market. She didn’t know about the program at all until she spoke with Farmers Market Manager Margie Seltzer at an information table.

Shaun and Adrian Maus and their child Sabali, got their first Double Dollars at the Berea Farmer’s Market.

“If you are a low income family that doesn’t mean you have to shop at places with cheap and awful produce,” Maus said. With Double Dollars to spend at farmers markets and stores with healthy options, she said, “you can support local food and small businesses and still stay within your budget.”

She ended with a sigh, swayed a bit to calm Sabali, and then finished her thought. Access to healthy foods, she said, is a “right”. She and her husband, Shaun, recently moved to Kentucky and are renting a small farm in nearby Waco, where they hope to grow produce of their own to sell.

Obesity & Hunger

Martina Leforce, of Grow Appalachia, runs the summer feeding program in Berea. She said some people find it difficult to reconcile the region’s high rates of obesity with hunger. But, she said, too much weight can be a sign of malnutrition. People dependent on fast food, or cheap, calorie-dense food like chips or soda, aren’t getting proper nutrition. They get more calories than they need but they are the wrong kind for healthy living.

In fact, she said, Berea College is holding a conference on the nutrition and food insecurity later this month to explore issues surrounding nutrition and food insecurity.

Such meetings are part of a growing movement. Ashton Wright, Lexington’s Food Coordinator, is leading the effort to take Kentucky’s Double Dollars statewide. It is an effort made possible through a $1 million matching grant. The same thing is happening in Ohio and research for a similar program is underway in West Virginia.

Growing Support

“What’s so exciting about these Double Dollars programs is that it’s not only encouraging folks to eat and make those health behavior changes, it is also directly supporting our local food and farm economy,” Wright said. “So it is directly putting dollars into the pockets of farmers who often times are struggling”

At the Berea Farmers Market Seltzer meets with a constant stream of people asking questions, most wanting to know how they can get their products into the market or asking about Double Dollars. It is a festive atmosphere, with a guy teaching kids to juggle and little ones squealing and playing tag. One boy has subtle rainbow highlights in his brown hair.

Seltzer said cuts in food programs will be bad for local farmers as well as the food recipients.

Goods stored at God’s Pantry’s warehouse in Lexington. which serves 50 counties from central to eastern Kentucky.

A lot of smaller farms, like the ones selling eggs and baked goods at the market, have benefited from Double Dollars. They also operate on very thin margins, so any loss of revenue would be felt acutely. Seltzer said 1 out of every 20 dollars vendors make at the farmers market comes from Double Dollars.

“If you believe in the local farm economy, you’ve got to believe in food stamps,” she said.

FINI Finale?

The FINI support expires in 2018, so its future is unclear. A similar program serving the elderly – 12,000 of them in God’s Pantry’s 50 counties alone – is also at risk.

“It’s a very important program,” God’s Pantry’s Wallace said. “So many of the seniors we serve live on minimal income and get $10 a month for food stamps.”

Pantry director Bozarth said there are even questions arising about who will have access to SNAP, the Supplemental Nutrition Assistance Program, which is the largest program in the country’s hunger safety net. Some states, she said, are considering work requirements for people needing food assistance.

Those questions, coupled with the proposed cuts in the Trump budget, have brought a sense of anxiety to many working to feed the low income and elderly. But feedback from Capitol Hill indicates that the food programs may have some powerful friends. Several members of Congress, including the chair of the House Agriculture Committee, have voiced criticism of the White House budget proposal.

Black Lung Update: Federal Researchers Seek Allies in Appalachia

Federal health researchers are visiting health clinics and medical schools in the Appalachian coalfields to recruit allies in the fight a resurgence of black lung disease. The worst form of the disease may affect as much as 5 percent of experienced working miners in the region, and the researchers fear that rate could be even higher among retired miners.

Medical students filled an auditorium at the University of Pikeville, Kentucky, to hear the latest on this scourge of coal communities, a disease many think should be history by now.

“If we come to your town there’s generally something bad going on there,” said Dr. Scott Laney, an epidemiologist with the National Institute for Occupational Safety and Health, or NIOSH. He was part of a research team that identified a resurgence in the worst form of black lung disease in a study published late last year.

Pike County, Kentucky, Laney said, is “at the epicenter of one of the largest industrial medicine disasters that the United States has ever seen.”

Laney and his colleague Dr. David Blackley got word that a clinic here in Pike County had identified more cases of the advanced form of black lung than a national screening program had seen nationwide.

“We found only a few dozen complicated cases of black lung in the last several years,” Blackley said of the screening program. “But just in the last year-and-a-half, at one clinic in Pikeville, we saw 60 cases.”

Mackie Branham views a lung X-ray with Dr. James Brandon Crum, who was among the first physicians to note an uptick in black lung diagnoses.

In December, NPR and the ReSource obtained records from several black lung health clinics in the region, and found another 962 incidents of severe black lung. Blackley and Laney have been reaching out to clinics, hoping to create a more comprehensive count. Recently they visited facilities in Tennessee, Virginia and Kentucky to raise awareness in the local medical field, and also to find and encourage new collaborations.

“Many people think, ‘Oh, black lung, isn’t that something that went away in the 1970s?’ ” Blackley said. “So we really try to emphasize that this this is something that’s real, something that’s ongoing, and should be recognized as the tragedy that it is.”

The researchers only found out about the resurgence once they connected with a local physician, Dr. Brandon Crum, who told them about the new cases at his clinic in Pikeville. Crum said what’s troubling isn’t just the number of new black lung patients, it’s how quickly he’s seeing the disease progress in young miners.

“Being from a mining family and a miner myself, the thought was it would occur in your 70s and your 80s,” Crum said. “But with this new form, this aggressive form of the disease, we’re seeing it attack younger and younger miners with shorter durations of mining.”

Crum said he’s seen the worst form of black lung disease in miners who’ve spent as few as seven years working in coal mines. Crum and the federal researchers said that indicates how much work remains to be done.

“We plan on working on this issue for the foreseeable future, for many many years, until it’s remedied,” Blackley said.

Last week, a bipartisan group of legislators sent a letter to president Trump requesting $3.3 million in additional funding for black lung health clinics facing this resurgence in black lung disease.

After Obamacare: Ending Affordable Care Act Could Cut Addiction Treatment

The Road To Recovery

On a recent gray winter morning Tomas Green drove the rain slick streets of Ranson in West Virginia’s Eastern Panhandle. No matter the weather, Green helps transport clients working through addiction at the Jefferson Day Report Center get to their treatment sessions and meetings.

“If they need rides, I use my own personal transportation sometimes,” he said.

As a peer coach for the center, he strives to go above and beyond for the clients. Green can relate to his passengers: He’s in recovery himself.

His experience taught him recovery can be difficult. And now he wants to help others stay on the right path.

“For me, I share with everybody it’s good to have a good support system.”

But the support offered by the day report center faces an uncertain future as Congress considers repeal of the Affordable Care Act. Pending changes could have major consequences for the availability of substance abuse treatment in a region that has become the epicenter of the nation’s opioid addiction crisis.

Care Tied to the ACA

A lot of the funding tied to services offered by the day report center is tied to the ACA. And a repeal without replacement would be damaging.

“It would impact us negatively to the point where we would have to make tough decisions about the level of care that we could provide, even to the point where we might not be able to exist,” Executive Director Ronda Eddy said.

On the road to the Day Report Center. Transportation to regular treatment sessions is important to addiction recovery

Day report centers work with non-violent drug offenders referred by the court system. They offer medication assisted treatment, counseling and other resources aimed at rehabilitation.

Local law enforcement has embraced this approach to dealing with addiction.

Charles Town Police Detective Ronald Kernes said the center is a valuable tool in the system, as they can’t arrest their way out of the epidemic.

“We understand that people have problems and addiction is a disease,” he said. “It’s nice to have an outlet where people at least have a chance to try to better themselves, and kick the habit and become a productive member of society.”

Jefferson Day Report Center Executive Director Ronda Eddy would face tough choices without the ACA.

The day report center is in the infancy of offering services. They established the current facility just a few years ago.

Medicaid expansion under the ACA helped the center build on its early success.

“It certainly has expanded access to care, more behavioral health care, all of those things that support recovery,” Eddy said.

Expanding Treatment

Treatment centers across the Ohio Valley have used the additional resources in hopes of reducing the highest opioid addiction and overdose rates in the country.

Data from a Harvard/NYU study show that in Kentucky, Ohio, and West Virginia nearly 215,000 additional people were able to seek mental health and addiction treatment after the Medicaid expansion.

And that may be a low estimate. A report from Ohio’s Department of Medicaid claims their number is 50 percent higher than what researchers in the study found.

The waiting room at Jefferson Day Report Center in West Virginia.

Republican Congressional leaders are working to repeal the ACA but have yet to agree on its replacement. This is especially true for the ACA’s Medicaid expansion provisions; reform, reduction and elimination have all been proposed.

Cautionary Tales

In Portsmouth, Ohio, Lisa Roberts works with people struggling with addiction as a Public Health Nurse for the city’s Health Department. Scioto County –where Portsmouth is located– has one of the highest rates of opioid addiction in the state.

The department offers Vivitrol shots to treat addiction and counseling to help with recovery. They refer individuals to other treatment programs if it is a better fit.

This program and others would be gone with a full repeal of the ACA, according to Roberts

“There would be people who lose access to their Vivitrol injections, a lot of people that would lose access to their addiction treatment,” she said. “It could just be catastrophic.”

Portsmouth, Ohio, public health nurse Lisa Roberts saw what happens when addiction treatment abruptly ends. “It could just be catastrophic.”

Roberts has two examples of what happens when treatment is suddenly lost: one professional and one personal.

Federal and state authorities shut down Community Counseling and Treatment Services, an opiate treatment practice operating in Scioto and Lawrence Counties on September 25, 2014, during an investigation into Medicaid fraud and other allegations. No charges have been filed and no arrests made in the investigation, but Community Counseling and Treatment Services was never again permitted to accept Medicaid, and remains closed.

That forced Roberts and the Portsmouth Health Department to scramble to quickly find clinics that would accept Medicaid for around 1,200 people who suddenly lost treatment.

“We had to triage. We had to prioritize people,” Roberts said.

Other local facilities were overwhelmed and some people had to travel up to 100 miles for treatment. Long trips proved difficult for those who lacked the transportation or the time.

Some relapsed and had to resume treatment later. Others didn’t make it.

“We did experience a spike in overdoses and we also experienced a lot of fatal overdoses,” Roberts said. “It was actually the most lethal month that we’ve seen in Scioto County.”

Scioto County had no more than three accidental fatal overdoses in a month until October, right after the clinic closed, when they had six.

Close to Home

Roberts’ personal experience with the loss of coverage for addiction treatment came as part of her daughter’s struggle with addiction.

Vivitrol injections were what helped Roberts’ daughter sustain recovery. And she was covered under the Medicaid expansion.

But when her daughter moved to Tennessee –a state that did not expand Medicaid– she suddenly lost access to the shots.

Roberts stepped in.

“I would have to drive 400 miles to give her that injection,” she said. “And eventually she was able to get it there through the Affordable Care Act.”

Her daughter later returned to Ohio and continues recovery.

But Roberts understands that others may not be as fortunate.

She says the lessons for the ACA debate remain the same even if the circumstances of her experiences are different.

She and others fear repealing the ACA without a replacement could trigger a wave of similar events across the Ohio Valley.

Waiting and Working

As Congress continues its health care debate, the people Tomas Green drives to the West Virginia treatment center wait to see what will happen to their coverage.

To Green and others on the road to recovery, the journey is already a difficult one. But he says it comes with rewards.

”First comes the lessons and then the blessin’s.”

Rebecca Kiger contributed reporting for this story as part of her work with “100 Days in Appalachia.”