The Food and Drug Administration announced Thursday that it will seek a ban on the sale of menthol-flavored cigarettes.

The announcement came as the agency officially released a detailed plan to also restrict the sale of flavored electronic cigarettes. It also wants to ban flavored cigars.

In a statement, FDA Commissioner Scott Gottlieb says the moves are aimed at fighting smoking among young people. Flavored e-cigarettes, menthol-flavored tobacco cigarettes and flavored cigars are all popular among teenagers.

“Today, I’m pursuing actions aimed at addressing the disturbing trend of youth nicotine use and continuing to advance the historic declines we’ve achieved in recent years in the rates of combustible cigarette use among kids,” Gottlieb says.

While cigarette smoking has hit a record low in the United States, vaping has been skyrocketing. That trend has raised concerns that a new generation of young people will become addicted to nicotine.

Gottlieb says the moves were prompted by new data showing a 78 percent increase in e-cigarette use among high school students and a 48 percent increase among middle school students, from 2017 to 2018.

“These data shock my conscience,” Gottlieb says.

The ban on menthol, in particular, has been long sought by public health authorities and antismoking advocates. The concern is that the flavoring masks the harshness of tobacco smoke, making it easier for people to start smoking.

“I believe these menthol-flavored products represent one of the most common and pernicious routes by which kids initiate on combustible cigarettes,” Gottlieb says.

Menthol cigarettes are especially popular among African-Americans, leading some to charge that tobacco companies have been using the flavoring to target minorities.

Several groups, including the NAACP, endorsed the FDA’s plan even before it was officially announced. “For decades, data have shown that the tobacco industry has successfully and intentionally marketed mentholated cigarettes to African Americans and particularly African American women as ‘replacement smokers,’ ” the NAACP said in a statement.

Several cigarette companies that market menthol cigarettes didn’t immediately respond to requests for comment. In the past, they have vigorously opposed any effort to ban menthol cigarettes.

“We continue to believe that a total ban on menthol cigarettes or flavored cigars would be an extreme measure not supported by the science and evidence,” said a statement from Altria Group Inc., maker of Marlboro Menthol.

The proposed ban will require a lengthy rule-making process by the FDA before it can go into effect.

Antismoking groups hailed the announcement.

“FDA’s decision to move forward with a ban on menthol cigarettes is one of the most significant public health actions that the FDA has taken in years and will have a greater impact on the death and disease caused by tobacco in the United States than almost any other single action,” says Matthew Myers, president of the Campaign for Tobacco-Free Kids.

“Menthol cigarettes are the single most important pathway to get kids to start smoking in the United States. It makes sense because what it does is coat your throat. It makes it much easier to get used to the harshness of tobacco smoke,” Myers says.

Some opponents of a menthol ban have argued that it could create an underground market for menthol cigarettes. But Myers and others dismiss that concern.

While Myers praised the FDA’s new restrictions on e-cigarette flavorings, he called for the agency to go further and completely ban the flavorings. According to the plan released Thursday, the FDA would continue to allow adults to buy flavored e-cigarettes.

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When she was in her early 20s, Nicole Veum says, she made a lot of mistakes.

“I was really sad and I didn’t want to feel my feelings,” she says. “I turned to the most natural way I could find to cover that all up and I started using drugs: prescription pills; heroin for a little bit of time.”

Veum’s family got her into treatment. She’d been sober for nine years when she and her husband, Ben, decided to have a baby. Motherhood was something she wanted to feel.

If she needed an epidural during labor, Veum told her doctor, she didn’t want any fentanyl in it. She didn’t want to feel high.

“I remembered seeing other friends,” she says. “They’d used it, and they were feeling good and stuff. I didn’t want that to be a part of my story.”

An epidural is a form of regional anesthesia given via an injection of drugs into the space around the spinal cord. It’s usually a mix of two types of medication: a numbing agent, usually from the lidocaine family, and a painkiller, usually fentanyl.

The amount of fentanyl in the mix is limited, and little passes into the bloodstream, anesthesiologists say. But if a woman doesn’t want the fentanyl, it’s easy to formulate an epidural solution without it. Doctors either use a substitute medication or boost the concentration of the numbing agent.

“There’s no medical reason why someone should be forced to be exposed to opioids if they don’t want to,” says Dr. Kelly Pfeifer, a family physician and addiction expert who now works as director of high-value care at the California Health Care Foundation.

Pfeifer says there’s another situation to be aware of: pregnant women who are taking methadone or suboxone to manage opioid addiction. During labor, anesthesiologists often prescribe certain narcotics to help manage pain, but some of those commonly used — like Nubain — can immediately reverse the effects of methadone or suboxone.

“Suddenly, you’re in the middle of labor — which is already painful — and now you’re in the middle of the worst withdrawal of your life,” Pfeifer says.

For Veum, it was the worst wildfire in California’s recorded history that interrupted her birth plan. She and her husband live in Santa Rosa, Calif., and she was in active labor when devastating fires ignited nearby on Oct. 8, 2017. What are now known as the “Wine Country wildfires” burned more than 5,000 homes and killed 44 people.

“There was a ton of smoke in the hospital,” Veum says. “Like you could visibly see it outside — and smell it.”

Nurses told her everybody had to evacuate. Veum was transferred to another hospital, 5 miles away. And the special instructions for her epidural got lost in the chaos.

“Then, when they went to change the drug, I saw the tube said Fentanyl on it,” she remembers. “And by that point I was starting to feel ‘the itchies’ ” — one of the familiar physical signs she would experience when starting to get high.

Most women without a history of addiction wouldn’t experience these sensations when given opioid anesthesia, says Dr. Jennifer Lucero, chief of obstetric anesthesiology at the University of California, San Francisco Medical Center. Anytime a woman who is not in recovery asks for an epidural without fentanyl (usually out of the mom’s concern for the baby), Lucero explains why it’s there.

Adrian Veum plays at home; Nicole Veum says she’s loving being his mom, and feels “reborn.”

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The fentanyl allows the anesthesiologist to balance out the numbing agent in the solution, she says, so women don’t have as much pain from the contractions, but can still feel the pressure and are able to move their legs a bit or shift in bed during labor.

Once she explains the trade-offs, and assures women that the opioid will have no effect on their fetus, most of her patients opt to keep fentanyl in the epidural solution.

But doctors have been trying to cut down on opioids in other ways during labor and delivery, namely in what they prescribe for pain after the birth.

For years, women who had a normal, vaginal birth were sent home with a 30-day supply of Norco, Percocet or another opioid, Lucero says.

“Some people would think they’re supposed to take them all,” Lucero says, while other women “would not use it, and it would just be sitting in the bathroom cabinet.”

While most people who get a bottle of pills when leaving the hospital won’t develop dependence or an addiction, some will. When a patient is prescribed opioids for short-term pain, the risk of chronic use starts to increase as early as the third day of the prescription, according to a 2017 report published by the Centers for Disease Control and Prevention. A 2018 study suggests that every week of opioid use increases the risk of misuse.

As recently as 2017, postpartum women were routinely being prescribed three- to five-day supplies of opioids — even after an uncomplicated vaginal delivery. A study published that year of 164,720 Pennsylvania women on Medicaid who gave birth vaginally found that 12 percent of them filled an opioid prescription after they gave birth — even though most did not have a clear medical need for a painkiller, such as vaginal tearing or an episiotomy.

Now obstetricians are issuing new guidelines to patients, Lucero says, and they’re trying to prescribe limited amounts of opioids, and only post-surgically, to women who have had a C-section.

Nicole Veum ended up being one of those women. After she was transferred to the second hospital during the wildfire evacuation, she spent another 12 hours in the early stages of labor, but it didn’t seem to be progressing much. She agreed to a C-section.

After the birth of her son, doctors sent her home with a bottle of Percocet — another opioid. They told her that if she was worried about being able to maintain her sobriety, she could have her husband or a friend hold on to the bottle and control the dosage.

Pfeifer, the physician and addiction specialist, says that in a situation like that, sending Veum home with just a few Percocet pills, or even suggesting she take just take ibuprofen would have been fine.

“Any parent will tell you there’s nothing more stressful than the first week of being a parent and having a baby and being in sleep deprivation,” Pfeifer says. “And here you have a little bottle of Vicodin that you used to turn to, to make you feel better when you’re stressed.”

First the fires. Then the fentanyl in her epidural. Then the Percocet. It was Veum’s first test in seeing how her sobriety and motherhood would line up.

She called a friend who was also in recovery. They talked it all through, and Veum was fine.

“I was OK. I was OK with it. It was just something that happened,” she says as her baby, Adrian, now a year old, plays with a new toy.

Veum is 32 now. She’s returned to school this fall to work toward her college degree, after a 14-year break. And she is loving being a mom.

“A lot of people, metaphorically, felt it as a baby coming out of the ash — the life coming from the ashes,” she says about her child born in the midst of the 2017 wildfires.

“And I feel that,” Veum says. “I feel like it was a big time for our community — and me personally — to be reborn in some way.”

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Roger Chui first learned about the mass shooting that killed 12 people in a packed bar Wednesday night in Thousand Oaks, Calif., when he woke up the morning after and turned on his phone.

“And I was like ‘Oh, that seems really soon after Pittsburgh and Louisville,’ ” says the software developer in Lexington, Ky. “I thought we’d get more of a break.”

Chui feels like these kinds of shootings happen in the U.S. so often now that when he hears about them all he can think about is, “Oh well, it happened again I guess.”

He’s not alone.

Ginger Ellenbecker, a high school biology teacher in Lawrence, Kan., has similar feelings.

“My immediate reaction was, ‘Another one. Here’s another one. This is terrible!’ But I’m not incredibly surprised,” she says.

Both Ellenbecker and Chui say they feel bad about their immediate reactions, but science suggests that their feelings are quite normal.

It’s a natural response called compassion fatigue, says Charles Figley, a psychologist and director of the Tulane University Traumatology Institute.

He says thinking too much about traumatic events, whether it’s a refugee crisis on the other side of the world or a school shooting in our own country, can make people too anxious or depressed to function in their daily lives.

“We of course think about ourselves being in such a place, in which someone would suddenly burst in and shoot things up,” says Figley. “But if we think about that too much, then it deteriorates our sense of confidence and our sense of trust and our sense of safety.”

Numerous studies have shown that human service providers — doctors, nurses, case workers, counselors — can experience compassion fatigue because of having to constantly address, deal with and think through tragedy. Figley says people in these professions have what’s called secondary trauma, which can build up and lead to compassion fatigue.

“Human service providers are wanting to help — that’s one of the reasons why we go into the field — but we recognize we can only do so much,” says Figley. “But if they’re not able to process that then they gradually begin to shut down in order to protect themselves.”

Another reason why people might find themselves feeling desensitized in the face of the latest tragedy is something called psychic numbing, which happens when the emotional response to a tragedy doesn’t increase when the number of victims does.

“The statistics of large-scale killing don’t convey emotion,” says to University of Oregon psychologist Paul Slovic, a leading researcher of psychic numbing. He and his colleagues demonstrated the phenomena in a recent study that found people are much more willing to donate aid to an identified individual than to an unidentified group of people.

Slovic says this is because the emotional circuitry in our brains is bad with numbers. “It can’t add and it can’t multiply, it reacts very strongly to one person or a small number of people that we can connect with and empathize with and we become emotionally connected,” he says.

But when more people are added attention and emotion get diffused, response starts to diminish, says Slovic.

For Audrey Cho, a teenager living in Grosse Pointe Woods, Mich., reports of school shootings really worry her. She says it’s hard not to think it could happen to her, but Cho consciously tries to not let it take over her life.

“This is very serious,” she says. “But you can’t allow it to be so detrimental that you can’t leave the house or something, because that’s impossible.”

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What do rural Americans say are the biggest problems in their communities? A new poll finds that the top challenges are drug and opioid abuse and economic concerns.

Indeed, a majority of rural Americans put opioid and drug addiction on par with the local economy as serious problems in their community. The poll found rural Americans largely hold negative views of their local economy, but nearly one-third have seen economic progress in recent years.

You can read the full findings of the poll, conducted by NPR, the Robert Wood Johnson Foundation and Harvard T.H. Chan School of Public Health, here.

What may help? A majority of rural Americans believe outside assistance will be needed to solve major community problems in the future, and many believe government will play an important role.

These and other issues related to life and health in rural America will be highlighted in an expert panel discussion Friday, Nov. 9, to be live-streamed here at 12 p.m. ET, as part of The Forum at the Harvard Chan School.

Convened shortly before National Rural Health Day and after the nation’s midterm elections, our panel will look at the economic and day-to-day social concerns of rural Americans.

We’ll discuss possible solutions to economic decline and the opioid/drug crisis, and point to positive signs and optimism revealed by our poll.

Joe Neel, deputy senior supervising editor on NPR’s Science Desk, will moderate the discussion with:

Katrina Badger, program officer, Robert Wood Johnson Foundation,

Robert Blendon, professor of health policy and political analysis, Harvard T.H. Chan School of Public Health and Harvard Kennedy School,

Ted Strickland, former governor of Ohio, and

David Terrell, executive director, Indiana Communities Institute and RUPRI Center for State Policy, Rural Policy Research Institute.

This webcast is part of an ongoing series, “Life and Health In Rural America.” The series is based in part on a poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health.

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For some older adults, private Medicare Advantage plans next year will include a host of new benefits, such as transportation to medical appointments, home-delivered meals, wheelchair ramps, bathroom grab bars, or air conditioners for asthma sufferers.

But the new benefits will not be widely available, and they won’t be easy to find, during this fall’s enrollment period.

Of the 3,700 plans across the country next year, only 273 in 21 states will offer at least one. About 7 percent of Advantage members — 1.5 million people — will have access, Medicare officials estimate.

That means even for the savviest shoppers it will be a challenge to figure out which plans offer the new benefits and who qualifies for them.

Medicare officials have touted the expansion as historic and an innovative way to keep seniors healthy and independent.

Despite that enthusiasm, a full listing of the new services are not available on Medicare’s web-based “plan finder,” the government tool used by beneficiaries, counselors and insurance agents to sort through dozens of plan options.

Medicare officials see the added benefits as a key to helping Advantage members prevent costly hospitalizations. Federal approval of new supplemental benefits is “one of the most significant changes made to the Medicare program,” said Seema Verma, the head of the Centers for Medicare & Medicaid Services, at an insurers’ meeting last month. She added that she expects plans to expand the number of services in coming years.

Medicare Advantage plans, which are an alternative to traditional Medicare, serve 21 million beneficiaries and limit their out-of-pocket expenses. But they also restrict members to a network of doctors, hospitals and other medical providers. They often offer benefits not available in traditional Medicare, such as dental and vision care, hearing aids and gym memberships. The federal government pays the plans to help cover the cost of each member.

Enrollment is underway now for choosing a Medicare Advantage plan, as well as for people in traditional Medicare who want to buy a policy for drug coverage. The deadline for both plans is Dec. 7.

Among the new benefits that some Medicare Advantage plans said they will offer are:

• Trips to the pharmacy or fitness centerin addition to doctor’s appointments for plan members, depending on where they live or their health conditions.
• A monthly or quarterly allowance for over-the-counter pharmacy products such as cold and allergy medications, eye drops, vitamins, supplements and compression stockings.
• Doctors or other health care providers who make housecalls, under certain conditions.
• A home health care aide for a limited number of hours to help with dressing, eating and other daily activities, sometimes including household chores and light housekeeping.

However, plans offering these services will likely have only some of the options and will have different eligibility criteria and other limitations. Advantage members will need a recommendation or referral from a health care provider in the plan’s network. Then they may need to have a certain chronic health problem, a recent hospitalization or meet other eligibility requirements.

Also, the same services likely won’t be available in every county the plan serves. For example, next year Humana Medicare Advantage members in Texas and South Florida in just two of the 43 states Humana serves will be able to get a free in-home personal care aide for up to 42 hours a year if they can’t be left alone at home. And more than half of the members in Cigna-HealthSpring Advantage plans will have access to free transportation services in all but five of the 16 states and the District of Columbia where the company sells coverage.

To find these supplemental benefits, seniors can go to the online plan finder. After they enter their Zip code and get a list of plans available locally, they can click on a plan name. That will take them to another page that offers more details about coverage, including a tab for health and drug plan benefits. That page might say whether the new services are offered.

But often the website will simply say that some benefits are available and advise consumers to contact the plan for more information.

“There is a lot of information on the plan finder, but there is a lot of information missing that requires beneficiaries to do more research,” says Deb McFarland, Medicare services program supervisor at the Southern Maine Agency on Aging.

There are also other variables to be considered when choosing an Advantage plan, such as which health care providers and pharmacies participate in a plan’s network, what drugs are covered and costs.

Where available, however, several insurers say the services will be free with no increase in monthly premiums.

“We certainly believe that all of the ancillary benefits we provide will help keep our members healthy which is good for them and it’s good for us in the long run,” said Steve Warner, head of the Medicare Advantage product team at UnitedHealthcare, which insures about 5 million seniors or one out of every four Medicare Advantage members.

Insurers are betting that services will eventually pay for themselves.

Dawn Maroney, consumer president at Alignment Healthcare, which serves eight counties in Southern California, says it’s much cheaper to give an air conditioner to someone with congestive heart failure to keep that patient healthy than to pay for expensive medical treatment.

But if the new benefits are such a good idea, they should be available to the majority of older adults in traditional Medicare, says David Lipschutz, a senior policy attorney at the Center for Medicare Advocacy.

Medicare Advantage plans have extra money to spend on benefits next year because the federal government increased its payments an average of 3.4 percent, seven times more than the rate of increase in 2018.

For free help with Medicare Advantage and drug plan enrollment, contact the Senior Health Insurance Information Program (www.shiptacenter.org) or the Medicare Rights Center (800-333-4114 or www.medicareinteractive.org). Find Medicare’s Plan Finder at www.medicare.gov/find-a-plan/questions/home.aspx or call 800-633-4227.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

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A ballot initiative that would have continued funding Montana’s Medicaid expansion beyond June 2019 has failed. But advocates say they’ll continue to push for money to keep the expansion going after that financial sunset.

“We now turn our attention to the legislature to maintain Montana’s bipartisan Medicaid expansion and protect those enrolled from harmful restrictions that would take away health insurance coverage,” said a concession statement Wednesday from Chris Laslovich, campaign manager with the advocacy group Healthy Montana, which supported the measure.

The initiative, called I-185, was the single most expensive ballot measure in Montana history. Final fundraising tallies aren’t in yet, but tobacco companies poured more than $17 million into Montana this election season to defeat the initiative. That’s more than twice as much cash as supporters were able to muster.

Most of the money in favor of I-185 came from the Montana Hospital Association. “I’m definitely disappointed that big money can have such an outsized influence on our political process,” said Dr. Jason Cohen, chief medical officer of North Valley Hospital in Whitefish.

The ballot measure would have tacked an additional $2 per-pack tax on cigarettes. It would have also taxed other tobacco products, as well as electronic cigarettes, which aren’t currently taxed in Montana.

Part of that $74 million in additional tax revenue would have funded continuation of Medicaid expansion in Montana.

Unless state lawmakers vote to continue funding the Medicaid expansion, it’s set to expire. If that happens, Montana would become the first state to undo a Medicaid expansion made under the Affordable Care Act.

In September, Gov. Steve Bullock, a Democrat, told the Montana Association of Counties that if the Medicaid initiative failed, “we’re going to be in for a tough [2019 legislative] session. Because if you thought cuts from last special session were difficult, I think you should brace, unfortunately, for even more.”

Republican State Rep. Nancy Ballance opposed I-185 and disagrees with Bullock’s position. “I think one of the mistakes that was made continually with I-185 was the belief that there were only two options: If it failed, Medicaid expansion would go away; if it passed, Medicaid expansion would continue forever as it was.”

Ballance, who didn’t receive money to campaign against the initiative, said Medicaid expansion in Montana can be tweaked without resorting to a sweeping new tax on tobacco products.

“No one was willing to talk about a middle-ground solution where Medicaid expansion is adjusted to correct some of the things that we saw as issues or deficiencies in that program,” she said. “I think now is the time to roll up our sleeves and come up with a solution that takes both sides into consideration.”

Ballance says conservatives in the Legislature want recipients of expansion benefits to face a tougher work requirement, and for means testing, so those with low incomes who also have significant assets like real estate won’t qualify.

In any event, Ballance said she suspects that if the initiative had passed, it would have immediately faced a court challenge.

North Valley Hospital’s Cohen said he hopes Montana will pass a tobacco tax someday. “We all know how devastating tobacco is to our families, our friends and our communities,” Cohen said. “And I think we also all know how important having insurance coverage is, and so I think people are dedicated to fighting this battle and winning it.”

This story is part of NPR’s reporting partnership with Montana Public Radio and Kaiser Health News. Montana Public Radio’s Edward O’Brien contributed to the story.

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Voters in three traditionally Republican states supported ballot measures to extend Medicaid benefits to more low-income adults.

The results highlight the divide between voters, even in conservative states, who generally support providing health benefits to the poor, and conservative politicians who have rejected the expansion, which is a central part of the Affordable Care Act.

With the approval of the measures in Idaho, Utah and Nebraska, about 300,000 low-income people will gain access to health care coverage, according to estimates from government agencies and advocacy groups in those states.

“People are enthusiastic about Medicaid expansion because they recognize that it’s both good for health care but it’s also a compassionate thing to do,” says Jonathan Schleifer, executive director of The Fairness Project, which worked to get the questions on the ballots of the four states. “And it’s a financially sound thing to do. It’s a fiscally responsible thing to do.”

The Fairness Project is funded by the SEIU United Healthcare Workers West, a California health care workers union.

Voters in Montana, however, appeared to reject a proposal to raise taxes on tobacco and e-cigarettes to continue funding the state’s expansion of Medicaid, which is set to sunset next year, leaving 100,000 Montanans at risk of losing coverage.

Before the Affordable Care Act, Medicaid, the government health insurance for the poor and disabled, was reserved mainly for pregnant women, children, low-income seniors and people with disabilities.

Since the law passed, 32 states, plus the District of Columbia, have expanded access to childless adults whose incomes are below 138 percent of the federal poverty level. That cutoff is $16,753 for a single person and $34,638 for a family of four.

Maine voters approved an expansion in 2017, but Gov. Paul LePage, a Republican, has resisted implementing the law, even vetoing a $60 million funding bill that passed the Legislature. LePage was barred by term limits from seeking another term. Democrat Janet Mills, Maine’s governor-elect, has pledged to expand Medicaid on her first day in office.

One person who stands to gain coverage in Utah is Grant Burningham, of Bountiful. “Most of us are ecstatic,” he said, referring to his friends who worked to get the measure passed. “We were all together and hugging and kissing last night.”

Burningham has spent the past several years working for this day. A former financial adviser, he became seriously ill after having a severe reaction to a medication in 2001, lost his job, his home and his health care.

Burningham now has a place to live, and hopes that access to health care will help him get back on his feet.

Still, he’s a bit wary that members of the Utah Legislature will try to do something to derail the results before the expansion of Medicaid can be implemented next spring.

“We had a win last night. But we still have the fourth quarter to go through,” he said. “A lot of us are deadly sick and we’ll still wait until April (after the state’s legislative session ends) to turn in our applications.”

Utah has come close to expanding Medicaid several times in recent years. But those efforts were blocked by conservatives in the state’s House of Representatives.

Burningham says it was necessary to put the question directly to voters “because so many of our politicians have been out of touch with their constituents.”

That’s why voters had to step in, says The Fairness Project’s Schleifer, who helped organize the campaign to put the measure on Utah’s ballot.

“This election proves that politicians who fought to repeal the Affordable Care Act got it wrong. Americans want to live in a country where everyone can go to the doctor without going bankrupt. Expanding access to health care isn’t a blue state value or a red state value; it’s an American value,” Schleifer said in a statement.

Utah will pay for its share of expansion costs by increasing the state’s sales tax by 0.15 percentage points to 4.85 percent, which works out to about 1.5 cents for every $10 residents spend on nonfood purchases. The federal government pays for 90 percent of the health care costs incurred by those who get Medicaid benefits through the expansion measures.

RyLee Curtis, campaign managers for Utah Decides, an advocacy group that campaigned for the expansion, says many of the 150,000 Utahans who will benefit are employed, and about a third are parents.

“They’re working one or more jobs and they’re unable to afford health care coverage,” she says.

Nebraska and Idaho also had Medicaid questions on ballots in their states.

In Nebraska, about 90,000 people are now eligible for coverage. And a study by two University of Nebraska professors, commissioned by the Nebraska Hospital Association, concluded that the expansion would cost the state about $148 million over three years but bring $1.36 billion in federal health funding into the state over the same time frame.

The Nebraska analysis is one of several that suggest expanding Medicaid can also help improve employment in a state by supporting health care jobs.

In Idaho, Gov. Butch Otter, a Republican, endorsed the expansion initiative a week before Election Day.

Montana, voters appeared to reject a ballot measure to continue that state’s expansion, which originally passed in the state’s legislature in 2015, but included a built-in expiration date.

The Montana measure would have continued funding for Medicaid expansion with a combination of taxes on tobacco and e-cigarettes. The tobacco industry strongly opposed the measure. Tobacco giant Altria, the parent company of Philip Morris, which makes Marlboro cigarettes, contributed about $17 million on cash and loans to Montanans Against Tax Hikes, which opposed the measure, according to the state’s Campaign Electronic Reporting System.

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The Food and Drug Administration has approved a potent new opioid painkiller, despite warnings from physician critics who say the drug will contribute to the addiction epidemic.

Dsuvia, a 3-millimeter-wide tablet of sufentanil made by AcelRx, came before an FDA advisory committee on Oct. 12. Such committees weigh in on the safety and efficacy of proposed products, and the FDA generally follows committee guidance in its decisions about drugs. The FDA’s Anesthetic and Analgesic Drug Products Advisory Committee voted 10-3 to recommend approval for the medication, and the agency approved the drug Friday.

“There are very tight restrictions being placed on the distribution and use of this product,” said FDA Commissioner Scott Gottlieb in a written statement Friday regarding his agency’s approval of Dsuvia. “We’ve learned much from the harmful impact that other oral opioid products can have in the context of the opioid crisis. We’ve applied those hard lessons as part of the steps we’re taking to address safety concerns for Dsuvia.”

But vocal critics, including the chair of the FDA advisory committee and the consumer advocacy group Public Citizen, had urged the FDA to reject Dsuvia.

In approving the drug, the agency skirted its normal vetting process, these critics say. Dsuvia is an unnecessary opioid, they say, and its size and potency will appeal to people looking to sell or misuse it.

“We have worked very diligently over the last three or four years to try to improve the public health, to reduce the number of potent opioids on the street,” says Dr. Raeford Brown, an anesthesiologist at the University of Kentucky. Brown chairs the FDA committee that, despite his disagreement, voted for Dsuvia’s approval. “I don’t think this is going to help us in any way,” he says.

Dr. Pamela Palmer, an anesthesiologist and co-founder of AcelRx, argues that the risk of diversion — when drugs end up with people who are not the intended patients — is low with Dsuvia because it will not be dispensed to patients at pharmacies. Instead, health care providers will only be able to use it in medical centers, she says, arguing that few people misuse drugs from those settings.

“It will not contribute to the large outpatient opioid crisis,” Palmer maintains.

While sufentanil is potent, the dose in Dsuvia is premeasured and small: 30 micrograms, or millionths of a gram. And Palmer says the product fills a unique need — health care providers put it under patients’ tongues, rather than injecting it or giving them a pill to swallow, which, she says, can take too long to offer relief.

“If you want to get on top of someone’s pain quickly, you have to come up with a different route than swallowing a pill,” Palmer says. She envisions providers using the tablet when finding a vein is difficult and time-sensitive — in emergency room patients who are morbidly obese, for instance.

The company projects $1.1 billion in annual sales, and hopes to have its product in hospitals early next year.

Palmer also says the Department of Defense helped fund the company’s research because Dsuvia could potentially be used on the battlefield instead of morphine.

Dr. Sidney Wolfe, senior adviser to Public Citizen’s Health Research Group, dismisses Palmer’s claim that Dsuvia meets a crucial need. Along with Brown, the group sent a letter to the FDA expressing concerns about the drug.

“It is not unique at all,” Wolfe says, adding that the drug wasn’t adequately tested in emergency settings, and that in tests, pain relief with Dsuvia was slow. In two of the company’s studies, Dsuvia patients only felt “meaningful” pain relief at 54 minutes and 78 minutes.

“We may find a niche for [Dsuvia] but it’s not like we need it, and for sure, at some level, it’s going to be diverted,” says Dr. Palmer MacKie, assistant professor at the Indiana University School of Medicine and director of the Eskenazi Health Integrative Pain Program in Indianapolis. “Do we really want an opportunity to divert another medicine?”

Though the advisory committee ultimately voted in favor of the drug, Public Citizen contends the FDA sought to “tilt” the vote’s outcome toward approval. Brown, the committee chief, who has been outspoken against certain opioids in the past, says he was unable to attend the advisory committee meeting on Oct. 12 because of a scheduling conflict that he had informed the FDA about months in advance.

Brown says the FDA decided to hold the meeting anyway — without him.

“I have strong feelings about the opioid crisis, as someone who lives in the Commonwealth of Kentucky, where we continue to have people die,” Brown says. “My forthright nature may have played a role in their decision about how the agency was going to manage this advisory committee.”

The October meeting also left out most members of another FDA committee — the Drug Safety and Risk Management Advisory Committee — who are often included in regulatory discussions of new opioid drugs. Public Citizen says members of that committee were not invited to attend.

In an email, an FDA spokesman wrote that drug safety committee members “could not attend due to scheduling conflicts.”

“That’s not the full story,” Brown says.

On Wednesday, ahead of the FDA’s final decision, four U.S. senators — Ed Markey, Claire McCaskill, Joe Manchin and Richard Blumenthal — sent a letter to Gottlieb, the FDA’s commissioner, echoing concerns from Brown and Public Citizen and asking the agency to deny approval to Dsuvia until Brown and the full drug safety committee were allowed to participate.

Ultimately, the FDA approved the drug anyway.

“There should never again be a meeting on opioids that doesn’t include drug safety,” says Wolfe. “The FDA really screwed up.”

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