A & U
Americas Aids Magazine
June 24, 2019

Money Talks
The hepatitis community wants more federal dollars; hep a cases rising fast
by Larry Buhl

Here’s the good news on federal funding for hepatitis research and treatment. In its 2020 budget proposal, the Trump Administration has requested a $53 million increase, from the current level of $5 million, to fund the infectious disease and opioids programs at the U.S. Centers for Disease Control and Prevention (CDC). The bad news is the budget for the response to all forms of hepatitis, including hepatitis A, B and C, is flat, at $39 million. That’s not nearly enough, according to Frank Hood, Senior Policy Associate at The AIDS Institute. He’s calling on Congress to allocate the additional $95 million requested by the hepatitis community for CDC’s viral hepatitis programs, and says that the CDC needs massive funding to expand its work in prevention, education, and testing for individuals at risk of hepatitis C, surveillance of outbreaks, and linkage to care for those who need it.
“President Trump has kept the same level of funding [for hepatitis] flat for three years,” Hood told A&U. “Any budget increases were due to Congress. And we hope that with a Democratic House, that budget item will be increased.”
Not only are cases of hepatitis C rising throughout the country, new populations are being impacted. In 2016, there were 41,700 new cases of hepatitis C, a twenty-two percent increase from the prior year. Between 2010 and 2016, there was a 350-percent increase in new infections. Unlike previous outbreaks that affected baby boomers, the biggest increase in infections today are among people under forty years old with more than seventy percent of cases the result of injection drug use.
“One reason we need increased funding is linkage to care, and this funding can be used for harm reduction,” Hood said.
On harm reduction there has been a shift in recent years, Hood added. “To our surprise, there is brief but well-worded support for syringe programs. There isn’t a fear of backlash around this and other harm reduction programs, but we want to make sure they get up and running, and again, we need resources for them.”
TO CONTINUE READING:   https://aumag.org/2019/06/24/hep-community-we-need-more-federal-dollars/

NATURE
NEWS 
28 JUNE 2019Researchers around the country are scrambling to understand these outbreaks, but lack solid data on case numbers.
Sara Reardon

Opioid addiction kills tens of thousands of people every year in the United States and the trend shows no signs of slowing. Now, public-health officials are worried about a surge in bacterial and viral infections linked to opioid abuse that threatens to compound the crisis.
This surge includes in unprecedented rise in bacterial infections — including those caused by Staphylococcus aureus, a bacterium that’s frequently resistant to antibiotics — and a spike in new cases of HIV and hepatitis associated with injecting opioids that threatens to undo decades of progress in corralling these diseases.
Research groups around the country are working to understand, identify and treat these outbreaks. But the lack of solid data on the number of new cases, and where they’ll crop up next, as well as stigma associated with drug use that can prevent people with infections from seeking early treatment, is hindering efforts.
“This is like HIV all over again,” says Judith Feinberg, an infectious-disease physician at West Virginia University in Morgantown, comparing the current crisis to the HIV epidemic that dominated US public health efforts in the 1980-90s. “People are stigmatized; they don’t feel they deserve to live. They hear people say it’s a lifestyle choice.”
Over the past 20 years, the use of opioids, including prescription pain medications, heroin and synthetic drugs such as fentanyl, has skyrocketed in the United States. As of 2017, there were roughly 15 opioid-overdose-related deaths per 100,000 people in the country, compared with 3 per 100,000 in 1999, according to estimates from the US Centers for Disease Control and Prevention (CDC).
TO CONTINUE STORY: https://www.nature.com/articles/d41586-019-02019-3

By Dan Levin
May 31st 2019, New York Times

Call them Generation O, the children growing up in families trapped in a relentless grip of addiction, rehab and prison.
PORTSMOUTH, Ohio — Layla Kegg’s mother, back home after three weeks who knows where, says she’s done with heroin, ready for rehab and wants to be part of her daughter’s life. But Layla has heard all of this before and doesn’t believe a single word.
Layla’s trust was broken long ago, after years of watching her mother cycle in and out of addiction and rehab. And now this latest discovery: “I found a needle in your purse the other day,” says Layla, seated at her grandmother’s kitchen table, her arms crossed. “And Mamaw found two more in the dryer.”
A pause, and then a fitful tumble of excuses from her mom: she doesn’t know why the needles were there; they were only syringes, actually, and not needles; she was keeping them for a friend.
Layla, 17, rolls her eyes and sighs.
“It’s almost like you want me to be using,” her mother pleads tearfully, in a voice children more often use with their parents. “Everything I do is never going to be good enough, so what’s the point.”

TO CONTINUE TO READ:https://www.nytimes.com/2019/05/31/us/opioid-children-addiction.html

By Abby Goodnough, New York Times, HEALTH
May 18, 2019

BALTIMORE -- Heroin has ravaged this city since the early 1960s, fueling desperation and crime that remain endemic in many neighborhoods. But lately, despite heroin’s long, deep history here, users say it has become nearly impossible to find.
Heroin’s presence is fading up and down the Eastern Seaboard, from New England mill towns to rural Appalachia, and in parts of the Midwest that were overwhelmed by it a few years back. It remains prevalent in many Western states, but even New York City, the nation’s biggest distribution hub for the drug, has seen less of it this year.
The diminishing supply should be a victory for public health and law enforcement alike. Instead, in cities like Baltimore, longtime users who managed to survive decades injecting heroin are now at far higher risk of dying from an overdose. That is because synthetic fentanyl, a deadlier drug that is much cheaper to produce and distribute than heroin, has all but replaced it.
The dramatic rise of fentanyl, which can be 50 times stronger than heroin, has been well documented. But its effect on many older, urban users of heroin, who had been able to manage their addiction for years, has been less noticed. The shift from heroin to fentanyl in cities has contributed to surging overdose deaths among older people and African-Americans and deeply unnerved many like William Glen Miller Sr., who first tried heroin as a 13-year-old in West Baltimore.
TO CONTINUE READING: https://www.nytimes.com/2019/05/18/health/heroin-fentanyl-deaths-baltimore.html?nl=todaysheadlines&emc=

APR 25 2019 • 12:15 AM EDT  UPDATED THU, APR 25 2019 • 10:49 AM EDT
Berkeley Lovelace Jr.@BERKELEYJR

KEY POINTS

• The nationwide opioid epidemic has led to a sharp increase in the death rate for overdoses by teens and young adults, according to a new study.
• Most of those deaths were from the use of opioids, both prescription and illicit, such as heroin, the researchers say.

HEALTH AND SCIENCEMore millennials, Gen Z are dying of opioid overdoses, researchers sayPUBLISHED THU, APR 25 2019 • 12:15 AM EDT  UPDATED THU, APR 25 2019 • 10:49 AM EDT
Berkeley Lovelace Jr.@BERKELEYJR
KEY POINTS

• The nationwide opioid epidemic has led to a sharp increase in the death rate for overdoses by teens and young adults, according to a new study.
• Most of those deaths were from the use of opioids, both prescription and illicit, such as heroin, the researchers say.

Attorney General Maura Healey hugs Paula Haddad, whose son Jordan died from opioids at the age of 26, as Healey entered the courthouse at Suffolk Superior Court in Boston for a status update on the Attorney General’s suit against Purdue Pharma on Jan. 25, 2019.
Suzanne Kreiter | Boston Globe | Getty ImagesThe nationwide opioid epidemic has led to a sharp increase in the death rate for overdoses by teens and young adults, according to a study published Thursday.
Death rates from drug overdoses for people ages 15 to 24 rose by 19.75% from 2006 to 2015, according to a study published in the peer-reviewed Journal of Studies on Alcohol and Drugs. Researchers at the nonprofit Pacific Institute for Research and Evaluation in Maryland reviewed millennial and Gen Z mortality data from the National Center for Health Statistics.
During the study period, 36,422 adolescents and young adults in the United States died of drug poisoning.
Most of the deaths from drug overdoses were from opioids, prescription and illicit drugs like heroin, the researchers said. Death rates from opioid use rose by an average of 4.8% annually over the same time period, with an even steeper increase of 15.4% a year between 2013 and 2015.

TO CONTINUE READING: https://www.cnbc.com/2019/04/24/more-millennials-gen-z-are-dying-of-opioid-overdoses-researchers-say.html

Erin C. Wilson ,Caitlin Turner ,Jess Lin ,Willi McFarland ,Katie Burk ,Henry Fisher Raymond

Posted on March 4, 2019Researchers assessed hepatitis C virus (HCV) prevalence among transwomen in San Francisco via performing a cross-sectional survey. Further, they assessed the indicators of engagement in HCV care. They interviewed a total of 315 transwomen who were then tested for HCV antibodies. Outcomes revealed an overall HCV seroprevalence of 23.6%. Transwomen who had injected drugs (48.2% vs 9.9%), smoked crack or methamphetamine (30.8% vs 12.5%), used intranasal drugs (28.4% vs 15.8%), and had been incarcerated (27.9% vs 9.9%) displayed significantly higher HCV seroprevalence. Overall, transwomen are at high risk for HCV infection, but many in San Francisco do have access to testing and treatment services, which may allow for HCV control and elimination.
Source:  MD LINX

​TO CONTINUE READING:https://onlinelibrary.wiley.com/doi/full/10.1111/jvh.13089
​

By Joel Wolfram August 13, 2018 WHYY Listen Live. Morning Edition

Addiction researchers at the University of Pennsylvania say it’s time to stop using “addict” and “alcoholic” when talking about people with substance use disorders. The recommendation comes out of a new study that found the terms are associated with a strong negative bias.
Researchers studied how people responded to several addiction-related terms including “addict,” “alcoholic,” and “substance abuser.” Those terms elicited the strongest negative biases of the lot, said lead study author Robert D. Ashford.
“Terms that seem to label the person — and invoke the negative attitudes toward the person rather than the disease — those are the ones that have the higher levels of bias,” said Ashford, a research assistant at the University of Pennsylvania and doctoral candidate in health policy at the University of the Sciences.
Participants were asked questions about their willingness to associate with people depicted in fictional vignettes who were described with such terms. But the study also used a word-association task to test whether any “implicit bias” was lurking in the language.
“So ‘implicit’ is … think of ‘subconscious,’ what’s going on in the recesses of my mind that I may not be consciously aware of,” Ashford explained.
TO CONTINUE READING:
​https://whyy.org/articles/dont-call-people-addicts-penn-researchers-say/?utm_source=facebook&utm_medium=social&utm_campaign=evergreen&fbclid=IwAR1uaN2nnPkP4blZs6BmG9WexQ4wDf-crGOnRVycSDKMLE6n4OUtJEe2frI

Known as the 'silent killer,' hepatitis C can cause serious damage to your liver without showing symptoms.

​US NEWS HEALTH
By Ruben Castaneda, Staff Writer March 14, 2019, at 1:43 p.m. 

WHILE MOST OF THE estimated 3.5 million people in the U.S. infected with hepatitis C are baby boomers, the virus is spreading at a greater rate among young people, according for the Centers for Disease Control and Prevention. Overall, the highest rate of new hepatitis C infections is among people between ages 20 and 29, according to a 2017 CDC press statement. Increasing IV drug use propelled by the opioid epidemic is the primary factor fueling this increase among young people, according to the CDC; sharing infected needles is a key mode of transmission. Research suggests the rate of hepatitis C infections is also rising among women of child-bearing age. Hepatitis C is associated with cirrhosis, which is potentially fatal, so it's important to get screened and treated.

If you should be diagnosed with hepatitis C, whatever your age, here are steps you should take:

• Don't panic.
• Don't obsess about when and how you were infected.
• Stop drinking alcohol.
• Talk about it.

TO CONTINUE READING:https://health.usnews.com/conditions/hepatitis-c/living-with-hepatitis-c

Arnold Doyle
Feb 10

​One in a Series of Commentaries on the US Healthcare SystemIf looking at this infographic gives you a headache, you’re not alone. A simplified rendering of the brand drug distribution chain, it’s still exasperatingly complicated. It also exemplifies the difficulty inherent in understanding how the distribution system works, who profits, and where along the chain there may be opportunities for reducing drug costs.
As mentioned in Part I, there is an array of middlemen who — literally or figuratively — touch a prescription drug before it gets to you. Each intermediary profits from this interaction. Therefore, drug companies pad the price of each drug up front so that this skimming along the way doesn’t lower a drug’s expected profitability for the company.
Drug companies make separate, confidential price discount or rebate agreements with each intermediary. Therefore, external parties (e.g., other companies, consumers, government agencies) do not know the amount of the discount nor how much profit each middleman earns per transaction. In an attempt to bring additional clarity to this process, the following is a description of the middlemen in the commercial (i.e., private, employer-sponsored and Medicare) insurance market, and how each profits from drug sales:

• Drug Wholesalers- these entities purchase product from the drug companies, and eventually sell them to pharmacies, hospitals and doctors that then dispense them to consumers. Wholesalers charge the purchasers a marginally higher price than what they paid for the drugs in the first place, thus making a profit.
• Insurers- your health insurer (e.g., Aetna, Cigna) processes claims when you visit a doctor, emergency room, etc. They determine how much the doctor gets paid and how much you must pay. However, when it comes to prescription drugs, most insurers hire a third-party entity, known as a pharmacy benefits manager (PBM), to process claims. Some insurers (e.g., Humana) own a PBM, and therefore do not need to hire externally. Insurers themselves can receive payments from drug companies in the form of drug rebates. The company may provide such rebates if the insurer confidentially agrees to make the company’s drug easier for patients to access than a competitor’s drug (e.g., not requiring physicians to obtain written prior authorization from the insurer before prescribing the company’s drug).
• PBMs- the initial purpose of PBMs was to process a rapidly growing number of prescription drug claims for insurers. PBMs, such as the largest, Express Scripts, have evolved to play a much more expansive and lucrative role that includes setting up an insurer’s pharmacy network, deciding which drugs the insurer will make available to consumers and negotiating drug company rebates. Drug companies provide rebates in order to gain preferential status — and therefore more sales — for their drugs through a PBM’s pharmacy network. PBMs make their profits by pocketing drug company rebates, instead of passing the savings on to consumers.
• Pharmacies- traditional brick and mortar pharmacies purchase drugs from wholesalers. When consumers come in with a prescription, they pay the pharmacy a co-pay that’s determined by their insurer’s PBM. The PBM reimburses the pharmacy for the dispensed drug at a negotiated rate — a rate that reflects a discount off the artificially padded price mentioned above. The PBM reimbursement plus the consumer co-pay, minus what the pharmacy paid the wholesaler, equals the pharmacy’s profit.

Outside this commercial system, drugs also flow to consumers who are beneficiaries of certain government-run programs that have tighter control over drug costs. For example, the federal government mandates that drug companies sell their products to Medicaid, a publicly-funded health insurance program for lower income and disabled people, at a lower cost than is available to commercial insurers. Most of the middlemen described above also profit from drugs bought and sold in this program.
Ultimately, an incredibly complex picture of the brand drug prescription pricing system emerges when looking at all the factors and players involved. Understanding this complexity is crucial as our lawmakers; drug company insurance and PBM lobbyists; physician and hospital associations; and consumer groups continue to debate drug pricing. As these discussions progress, here are a few key considerations drawn from what we know about the current system:
First, brand drug companies utilize a business model that results in ever-higher prices, not only for new drugs but for older brand drugs. The companies’ challenge will be to fundamentally alter this business model, while ensuring continued investment in new and truly innovative treatments. To date, companies have been reluctant to tinker with a system that has ensured them sustained growth and high profitability for so long. That said, I think even brand drug companies are recognizing that the current business model is unsustainable for political and socio-economic reasons. Their long-term business success may depend on their willingness and ability to change.
Second, any significant shift in drug company pricing practices will impact the distribution middlemen, and vice versa. Relatively speaking, wholesalers, pharmacies and physicians profit only marginally from brand drug sales. Among the intermediaries, PBMs have the highest financial stake in the current system. Altering their business practices could have the greatest — and potentially the most positive — impact on moderating drug costs. While PBMs do get drug companies to provide rebates, these “savings” are exactly what constitute PBM profits. And, rather perversely, higher initial drug prices also mean higher profits for PBMs. True, they may pass on some rebate dollars to the insurers who hire them, but consumers do not realize any meaningful savings.
Third, consumers (often called “patients” in the healthcare context) are usually at the bottom of the list of key considerations when it comes to reining in drug or other healthcare costs. While all the players claim that consumers are their №1 priority, many drug cost-reducing proposals — sometimes as an unintended consequence — may reduce patients’ access to the medicines that will help them the most. Consumer advocacy groups must have an equal voice at the table.
Finally, everyone who has a stake in this ongoing debate, especially our political leaders, should be wary of what seem like sweeping, easy fixes to the drug cost problem. There are no solutions that won’t require careful consideration and implementation; and there will always be trade-offs. In Part III of this series, we’ll look at a few current drug cost-containment proposals and their potential ramifications in the context of our larger, expensive but inefficient healthcare system.

One in a Series of Commentaries on the US Healthcare System
If looking at this infographic gives you a headache, you’re not alone. A simplified rendering of the brand drug distribution chain, it’s still exasperatingly complicated. It also exemplifies the difficulty inherent in understanding how the distribution system works, who profits, and where along the chain there may be opportunities for reducing drug costs.
As mentioned in Part I, there is an array of middlemen who — literally or figuratively — touch a prescription drug before it gets to you. Each intermediary profits from this interaction. Therefore, drug companies pad the price of each drug up front so that this skimming along the way doesn’t lower a drug’s expected profitability for the company.
Drug companies make separate, confidential price discount or rebate agreements with each intermediary. Therefore, external parties (e.g., other companies, consumers, government agencies) do not know the amount of the discount nor how much profit each middleman earns per transaction. In an attempt to bring additional clarity to this process, the following is a description of the middlemen in the commercial (i.e., private, employer-sponsored and Medicare) insurance market, and how each profits from drug sales:

• Drug Wholesalers- these entities purchase product from the drug companies, and eventually sell them to pharmacies, hospitals and doctors that then dispense them to consumers. Wholesalers charge the purchasers a marginally higher price than what they paid for the drugs in the first place, thus making a profit.
• Insurers- your health insurer (e.g., Aetna, Cigna) processes claims when you visit a doctor, emergency room, etc. They determine how much the doctor gets paid and how much you must pay. However, when it comes to prescription drugs, most insurers hire a third-party entity, known as a pharmacy benefits manager (PBM), to process claims. Some insurers (e.g., Humana) own a PBM, and therefore do not need to hire externally. Insurers themselves can receive payments from drug companies in the form of drug rebates. The company may provide such rebates if the insurer confidentially agrees to make the company’s drug easier for patients to access than a competitor’s drug (e.g., not requiring physicians to obtain written prior authorization from the insurer before prescribing the company’s drug).
• PBMs- the initial purpose of PBMs was to process a rapidly growing number of prescription drug claims for insurers. PBMs, such as the largest, Express Scripts, have evolved to play a much more expansive and lucrative role that includes setting up an insurer’s pharmacy network, deciding which drugs the insurer will make available to consumers and negotiating drug company rebates. Drug companies provide rebates in order to gain preferential status — and therefore more sales — for their drugs through a PBM’s pharmacy network. PBMs make their profits by pocketing drug company rebates, instead of passing the savings on to consumers.
• Pharmacies- traditional brick and mortar pharmacies purchase drugs from wholesalers. When consumers come in with a prescription, they pay the pharmacy a co-pay that’s determined by their insurer’s PBM. The PBM reimburses the pharmacy for the dispensed drug at a negotiated rate — a rate that reflects a discount off the artificially padded price mentioned above. The PBM reimbursement plus the consumer co-pay, minus what the pharmacy paid the wholesaler, equals the pharmacy’s profit.

Outside this commercial system, drugs also flow to consumers who are beneficiaries of certain government-run programs that have tighter control over drug costs. For example, the federal government mandates that drug companies sell their products to Medicaid, a publicly-funded health insurance program for lower income and disabled people, at a lower cost than is available to commercial insurers. Most of the middlemen described above also profit from drugs bought and sold in this program.
Ultimately, an incredibly complex picture of the brand drug prescription pricing system emerges when looking at all the factors and players involved. Understanding this complexity is crucial as our lawmakers; drug company insurance and PBM lobbyists; physician and hospital associations; and consumer groups continue to debate drug pricing. As these discussions progress, here are a few key considerations drawn from what we know about the current system:
First, brand drug companies utilize a business model that results in ever-higher prices, not only for new drugs but for older brand drugs. The companies’ challenge will be to fundamentally alter this business model, while ensuring continued investment in new and truly innovative treatments. To date, companies have been reluctant to tinker with a system that has ensured them sustained growth and high profitability for so long. That said, I think even brand drug companies are recognizing that the current business model is unsustainable for political and socio-economic reasons. Their long-term business success may depend on their willingness and ability to change.
Second, any significant shift in drug company pricing practices will impact the distribution middlemen, and vice versa. Relatively speaking, wholesalers, pharmacies and physicians profit only marginally from brand drug sales. Among the intermediaries, PBMs have the highest financial stake in the current system. Altering their business practices could have the greatest — and potentially the most positive — impact on moderating drug costs. While PBMs do get drug companies to provide rebates, these “savings” are exactly what constitute PBM profits. And, rather perversely, higher initial drug prices also mean higher profits for PBMs. True, they may pass on some rebate dollars to the insurers who hire them, but consumers do not realize any meaningful savings.
Third, consumers (often called “patients” in the healthcare context) are usually at the bottom of the list of key considerations when it comes to reining in drug or other healthcare costs. While all the players claim that consumers are their №1 priority, many drug cost-reducing proposals — sometimes as an unintended consequence — may reduce patients’ access to the medicines that will help them the most. Consumer advocacy groups must have an equal voice at the table.
Finally, everyone who has a stake in this ongoing debate, especially our political leaders, should be wary of what seem like sweeping, easy fixes to the drug cost problem. There are no solutions that won’t require careful consideration and implementation; and there will always be trade-offs. In Part III of this series, we’ll look at a few current drug cost-containment proposals and their potential ramifications in the context of our larger, expensive but inefficient healthcare system.
​https://medium.com/@slavcelt/drug-pricing-demystified-part-ii-the-intermediaries-d92