Letters from readers on schools and bird flu, opioid ‘overprescribing,’ and more

“Preparing schools for the H5N1 bird flu they’re likely to face,” by Mario Ramirez

Having been a school nurse during the Covid pandemic I can tell you that most superintendents will only require what the education department in their state recommends. The leaders at the table in schools are not clinical people. Rarely is a nurse included in such discussion and most were not during the last pandemic.

School administrators follow the politics and not the science, which was slow and lacking during Covid. Having schools governed by an education department during times of a health crisis is a systems failure. School health should fall under public health departments, as is the case in Massachusetts. This will allow for stronger recommendations, better communication and perhaps even requirements.

Currently and historically children come in to school sick every day. And it should be noted that many schools do not have a school nurse. Those that do grossly underpay school nurses and minimize their ability to be a crucial part of the team regarding both physical and mental health issues. Those in public health have felt demoralized and disregarded.

School nurses are on the front lines of public health and typically are not even seen or respected by other medical professionals, no matter how hard they try. The system of health is broken nationally, and in individual school districts. Rather than focus on schools, why not focus on creating a system of feedback loops in real time and provide funding for all of this? Education for adults in infectious disease should occur regularly so that lasting systemic change can begin. The CDC told us that children do not spread Covid. That’s when I shifted to the WHO for information. Anyone who has worked with children knows that they spread disease readily in schools because they are in close contact, work in poorly ventilated buildings (some that are often cold or hot), have poor hand and cough hygiene, cannot verbalize and sometimes even identify how they feel and have young immune systems. I like the suggestions that the author has, but the reality of working in a school is vastly different than the private sector and a clinical setting. Real change needs to come from a national systemic approach that is not recommended but required.

— Sharon Stathoplos, recently retired school nurse

“Doctors ‘overprescribing’ opioids isn’t the cause of the overdose epidemic — and it never was,” by Richard A. “Red” Lawhern

Claiming that “overprescribing” of opioids is not and never was a cause of the overdose epidemic solely based on “misclassification” of deaths due to prescription versus illicit drugs is a gross oversimplification.

Studies have shown that prescription opioid use can lead to addiction, which can, therefore, eventually lead to death by an illegal opioid (Wilson et al., 2021; Chua et al., 2021). In 2022, the Congressional Budget Office cited a rise in opioid prescribing as a primary contributor to the crisis. They describe how increased prescribing results from reinforcing factors such as “aggressive promotion efforts by pharmaceutical factors, greater emphasis on assessing patients and treating it medically, and changes in incentives in the health care system.” They further state how guidelines by the Federation of State Medical Boards encouraged the use of opioids for such pain and “discouraged the use of disciplinary action for physicians prescribing opioids.” They also cite how studies have found that some providers overprescribed opioids due to feeling pressured to avoid lower patient satisfaction scores tied to reimbursement.

There have also been successful state-level prescriber interventions that have reduced opioid use in Ohio, Kentucky, Florida, New York, Tennessee, and Oregon. Further, the Justice Department’s criminal and civil investigations into Purdue Pharma found that it engaged in a conspiracy to promote the prescription of opioids “…to health care providers it knew were prescribing opioids for uses that were unsafe, ineffective, and medically unnecessary, and that often led to abuse and diversion.” They also were found to have paid doctors “ostensibly” to provide “educational talks to other health care professionals and serve as consultants, but in reality to induce them to prescribe more OxyContin.”

The opioid crisis is also considered to have started in the mid-1990s when OxyContin was approved by the Food and Drug Administration, causing the first wave of deaths linked to the use of legal prescription opioids. Therefore, there is significant evidence that prescription opioids are a direct cause of the overdose epidemic starting in the 1990s. To address this crisis, we thus need to address the root cause of the crisis in prescription opioids while maintaining that those in pain are well cared for and treated adequately. Ignoring the role of prescribing in the opioid epidemic only serves to perpetuate the crisis that has already gone on too long.

— Casey Heely, Brandeis University

“Senate, FTC cracking down on pharma patent shenanigans,” by Dick Durbin and Lena M. Khan

In their July 2 op-ed, Senator Dick Durbin and Federal Trade Commission Chair Lina Khan misrepresent the function and purpose of the FDA’s “Orange Book” list of drug patents. As the former directors of the U.S. Patent and Trademark Office under Presidents Obama and Trump, we feel obliged to clear up the confusion.

Durbin and Khan write that “when a patent is listed in the Orange Book, the drug’s manufacturer can delay approval of a generic competitor for 30 months” and assert that “some companies have taken advantage of the system, overloading the list with improper, trivial patents . . . to box out competitors and keep prices inflated.”

Those claims are misleading for several reasons.

First, the number of patents listed in the Orange Book pertaining to any given drug is irrelevant. A pioneer company can only initiate a single 30-month stay on a forthcoming generic competitor, regardless of how many patents it has listed in the Orange Book. In other words, listing extraneous or “trivial” patents wouldn’t give a drug company any additional opportunity to request a stay.

Second, the Orange Book doesn’t delay generic competition — just the opposite. Drug companies are required to list every relevant patent in the Orange Book to make it easier for generic companies to know which medicines are patent-protected, and which ones are fair game. These exhaustive listings help generic companies avoid being blindsided by lawsuits for infringing patents they didn’t know existed.

Generic companies operate on thin margins. Forcing their often small legal departments to proactively search through patent databases to avoid potential infringement issues, before those companies can even embark on a new generic product line, would increase their costs and deter competition.

Third, the 30-month stay protects generic companies. Without it, a generic company would be forced to launch a competing drug in order to contest a brand-name manufacturer’s patents if its challenges are unsuccessful, putting it on the hook for hundreds of millions, even billions, of dollars in financial damages. The 30-month stay allows patent infringement litigation to play out before infringement, while the stakes are comparatively small, thereby protecting both innovators and generic companies.

America boasts the highest rate of generic drug utilization in the world — nine in 10 prescriptions are filled with generics. Simply put, the system is working. Let’s get our facts straight when discussing it.

— Andrei Iancu (served as the Undersecretary of Commerce for intellectual property and director of the USPTO from 2018 to 2021) and David Kappos (served as the Undersecretary of Commerce for intellectual property and director of the USPTO from 2009 to 2013). Both serve as board co-chairs of the Council for Innovation Promotion.

“The ethical implications of Elon Musk’s unorthodox approach to medical science,” by Anna Wexler

You speak of Musk’s ethics surrounding Neuralink without once mentioning the ethics around Musk’s Neuralink company pre-human experiments with torturing and murdering chimpanzees who we share 98% of our genetics with. At least mention it as it’s a huge ethical issue.

— Jacqueline Hall 

“Empathy should guide responses to reported vaccine injuries,” by Kizzmekia S. Corbett-Helaire

I really appreciated this article in regards to having more empathy and listening ears for people who feel they were injured by the vaccine. I myself am not necessarily anti vaxx, however, have always been a skeptic as to its efficacy. This is in regard to personal experience in regards to my mother having an adverse reaction to the flu vaccine when I was a kid. To this day she still suffers from numbness in her legs that was triggered by an annual flu vaccine.

In response to this article, I believe while it does raise important ideas on how to respond to people’s individual concerns over their own reaction to the vaccine and a request for more data, I also feel it imperative to question the narrative that created an environment where people felt not only completely confident in its efficacy, but publicly shamed those who did not feel certain of its safety. As more data comes out and people come forward, I think it is absolutely necessary to start to question the government organizations and scientists that promoted it for people to take. And not only take once or twice, but over and over again.

These people who feel they were injured should be heard, but in regards to hearing them properly, I feel we need to question the ways that people were coerced to trust a product that has now been scientifically shown to be much less effective and has caused people harm.

— Steve Spiegel, Beat-ALS.org

“Psychiatrists aren’t fulfilling the social contract that subsidized their training,” by Richard Frank

I have held Dr. Richard Frank, now director of the Brookings Institution’s Center on Health Policy, in great esteem, learned much from him, and once had the privilege of working with him regarding Medicare payment for hospital psychiatric care.

But I must part ways with him regarding his criticism of U.S. outpatient psychiatrists who no longer accept payment from Medicare and/or Medicaid. As Dr. Frank points out, their requirement for out-of-pocket payment further limits access to services by psychiatrists, except for a limited number of patients and families who can afford them.

The refusal to accept the underpayments, huge and needless burdens, and dismissal of professional (medical diagnosis and treatment) decisions is one of the methods left to physicians who ethically cannot endure the ravages of what has been called the “corporatization of American health care,” packaged as if it were for our own good. “Evil only succeeds by disguising itself as good.” (Thomas Aquinas)

The ethos of corporate and investor profits before patients is festering the professional burnout and moral injury driving the continuing exodus of doctors and nurses from patient care. There is no negotiating with the kudzu of for-profit control over the health care of all Americans, rich and poor, old and young, and smacking of racial and ethnic inequities. We are beyond the talking/negotiating phase of attempting to regain medical quality and access, or to control the ever-increasing costs of American healthcare.

Do we want and can we bear the consequences of physicians becoming modern day Neville Chamberlains?

It is too late for negotiation and petty changes. I see three disruptive strategies (which I describe in this 4:41 video) available to you and your families, doctors and nurses, and the hospitals now being trampled by the corporate practice of medicine.

As the adage goes, “We make the path by walking it.”

— Lloyd I. Sederer, M.D., adjunct professor of the Columbia/Mailman School of Public Health, and former Commissioner of Mental Health for the City of NY and former chief medical officer of the New York State Office of Mental Health.

“Medicare should wait on approving coverage for Wegovy,” by Alissa S. Chen

Considering that obesity is the cause of so many diseases and deaths in our country today and the Insurance Companies are not covering the cost of the medications is insane! It will ultimately cost them more to cover the impact that obesity will cause for us. I’ve read many articles about how much it costs the manufacturers to provide the medications that help people with obesity to improve their health. It’s time for the Insurance Companies to wake up and realize that they will eventually be paying more for the impact of obesity!

— Cathy Mesimer, currently taking Ozempic

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Making policy based on just the author’s worries about her father would be wrong. I for instance have been taking Zepbound for 5 months and it is working. I spent two years dieting and walking four miles daily then adding resistance training three to four days a week to lose thirty pounds then gained ten pounds back after a year of weight loss plateau. I continue my training and with the aid of the drug I will get to desired weight. My doctor is monitoring my muscle mass. This month I am eligible for Medicare but will have to stay on my wife’s health plan because Medicare won’t yet cover the drug. Our hands are tied enough with cost and lack health coverage. Author’s concerns have merit but let’s not prohibit the masses from help when a trained doctor and patient should make these decisions.

— Tim Hert