In county with 75% on Medicaid and 12.4% unemployed, Salyersville mayor ponders Medicaid's new work rules

Kentucky's new Medicaid plan requires some of its recipients to work or volunteer will be phased in, with poor areas last, but some are worried that finding work there won't be easy, and that enforcing the new requirement will cause some to lose their coverage.

"I would not be truthful if I didn't say it's a big challenge," Kristi Putnam, the Medicaid waiver program manager for the state, told Miranda Combs of Lexington's WKYT-TV.  "It's a big project. There are a lot of moving parts and lots of partnerships."

Kentucky was the first state the federal government allowed to require some of its Medicaid recipients to work, volunteer or get job training 80 hours a month to keep their health insurance. This requirement will largely affect those who gained coverage through the expansion of the program, under federal health reform, to those with incomes up to 138 percent of the federal poverty level.

Combs compared unemployment and Medicaid numbers and found that "the latest unemployment rate numbers were above the state average in each of the 10 counties with the highest percentages of Medicaid recipients," making many wonder where these people are going to work.

Screenshot of WKYT interactive map with percentage of population on Medicaid 
The top 10 Medicaid counties have between 58 percent to 82 percent of their population on the program, and have unemployment ranging from 5.2 percent to 12.4 percent. The statewide unemployment rate is 4.4 percent.

Combs talked to Salyersville Mayor Pete Shepherd about how 75 percent of the people in Magoffin County ended up on Medicaid.

"We got here because the federal government decided in the 1960s to give food stamps and welfare to everybody that was under a certain threshold," Shepherd said, adding that the loss of coal jobs added others to the rolls.

"We had a lot of people that went off good-paying jobs to nothing," Shepherd said. "It's not their fault, and a lot of them would work if there were jobs available."

Shepherd, who said he needed more guidance from the state on the program, also voiced his concern about the new work rules, saying, " You can't make jobs if there's nothing there to have for jobs."

Putnam told Combs that the state will help people meet the  new requirements, which won't be rolled out in Magoffin County until November.

Putnam estimated that about 239,000 people in Kentucky will have the "community engagement requirement," and that half of them already meet it. "It's really intended to help connect people to resources so that they aren't in the multi-generational poverty situation where they depend on benefits," she said.

Opponents of the plan are concerned that the lock-out periods for failure to meet work requirements, pay premiums, or report changes or renew coverage in a timely manner will result in Kentuckians losing their health coverage. The Bevin administration recognizes that many will lose their coverage, estimating that there will be 95,000 fewer Kentuckians on Medicaid in five years than without the program, partly because of "non-compliance."

Three nonprofit groups representing 16 Kentuckians have sued the federal government to block Kentucky's Medicaid waiver. The Trump administration and Gov. Matt Bevin want the case to be heard in federal court in Frankfort.

30 more Kentuckians die from flu, raising season total to 128

Thirty more people died from influenza in Kentucky during the week ended Feb. 10, the last one for which figures have been compiled. That was 10 more deaths than the previous week, and nine more than the highest weekly toll of 21, recorded in two consecutive weeks in January. The flu is now known to have killed 128 people in Kentucky during the current flu season, four of them children.

Kentucky had 1,023 new laboratory-confirmed flu cases from Feb. 4 through 10, a big increase from the 660 confirmed cases in the previous week. The total for the season is 6,287. Of that number, 5,125 have been Type A and 1,144 have been Type B.

All regions of the state except Lexington and Lake Cumberland reported increased flu activity during the week. Here is the state's detailed weekly report:

Bill to de-privatize Medicaid drug benefits and help independent pharmacists is moving, despite cost; some seek transparency

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky.  –  A bill to put the state back in charge of its Medicaid drug program is heading to the full Senate, but likely faces a "winding road" to its final passage, its sponsor says. The main obstacle appears to be cost, but that is countered by desires to open up the shadowy process in which a few companies make millions handling Medicaid prescriptions.

State Sen. Max Wise
"While it feels like every lobbyist in Frankfort has been hired to work against Senate Bill 5, local communities have stepped up their support," Republican Sen. Max Wise of Campbellsville told the Senate health committee Feb. 14, adding that community leaders all over the state have sent letters of support for the bill and its main lobby, independent pharmacies.

Wise said the problem is that pharmacy benefit managers, or PBMs, hired by Medicaid managed-care organizations, aren't fairly reimbursing independent pharmacies, putting them at risk of closing.

In addition to not paying a fair price for drugs, Wise said the PBMs are only paying independent pharmacists a "professional dispensing fee" of 85 cents per prescription, despite recommendations from the Centers for Medicare and Medicaid Services that says the fee should be around $10.64.

Rosemary Smith, a Beattyville pharmacist who co-owns six drug stores in Eastern Kentucky called Jordan Drug, said in a telephone interview that the low payments from the PBMs are "simply not sustainable."

"We have claims that we aren't even getting the cost of the drug, let alone any professional dispensing fee that would keep our stores in business," Smith said. "We've seen the reimbursement go down and down and now a lot of our prescriptions are being reimbursed at a low cost, with a 35 cent fee."

One of six pharmacies Rosemary and Luther Smith own (website photo)
Smith is co-founder of the Kentucky Independent Pharmacist Alliance, which represents the more than 500 independent pharmacies in the state. She said all they are asking for is a "level playing field."

"It's not Ace Hardware versus Walmart," she said. "We're not selling hammers. We're not selling nails. We are taking care of patients."

For example, she sees a conflict of interest with CVS Caremark, a PBM that is part of a company that operates a chain of pharmacies. CVS has contracts with four of the five Medicaid managed-care organizations in Kentucky.

"They are our competition and they are setting our prices," she said. "And what they are doing is, we call it a 'squeeze and buy' -- they are trying to squeeze us so we either go out of business or we have to sell to them."

CVS disagreed, saying in an e-mail that it is committed to providing its PBM members with a broad network of pharmacies that includes local, independent pharmacies.

"We reimburse our participating network pharmacies, including the many independent pharmacies that are valued participants in our network, at competitive rates that balance the need to fairly compensate pharmacies while providing a cost-effective benefit for our clients," said Christine Cramer, the senior director of corporate communications for CVS Health. "We also have a well-established appeals process for network pharmacies regarding reimbursement, and our responses to those appeals comply with all applicable laws."

Wise said at the Feb. 14 committee meeting that Medicaid in Kentucky spent $1.68 billion on pharmacy benefits last year, with about $1 billion of that going to pharmacies. He said the difference in the amounts went to pharmacy benefit managers, which have no obligation to report how they spent the money.

"PBMs currently set all the rules with little to no government oversight whatsoever," Wise said. "As a state senator, taxpayer, I don't think that's right." He said he has asked the Cabinet for Health and Family Services, which houses the Department for Medicaid Services, how that $1.68 billion is being spent, but has been unable to get an answer.

From left, Deputy Medicaid Commissioner Anne-Tyler Morgan, Chief of
Staff Eric Clark and Commissioner Stephen Miller address the committee.
Medicaid Commissioner Stephen Miller warned that if Wise's bill passes, it would cost Kentucky taxpayers an additional $36 million a year. That was his agency's official estimate of the bill's cost, attached to it as a "fiscal note."

Wise said the bill shouldn't cost the state any money, and asked Miller, "If the Department of Medicaid Services can't tell me how much PBMs are receiving, how can they come up with a fiscal note?"

Sen. Ralph Alvarado, R-Winchester, brought up a separate study by Optum that says the state would have a potential savings of up to $348 million if Wise's bill becomes law. A physican, Alvarado said that knowing what he knows, "I tend to believe this more."

After some back and forth with several committee members about the fiscal note, Miller said, "We still stand by our numbers."

Miller explained that because managed-care organizations are required to spend 90 percent of their monies on direct patient services, leaving 10 percent for administrative fees and profit, they haven't been concerned about the PBMs because the business model encourages MCOs to keep their costs low.

"So they are going to pay the PBMs as little as possible to provide the services, and then the PBMs are going to squeeze out the independent pharmacies to maintain their profit margin," said Sen. Danny Carroll, R-Paducah. "When you get to the crux of it, that's what happening,"

Miller suggested that an alternative would be to renegotiate contracts with managed-care organizations to require PBMs to pay pharmacies a higher dispensing fee, but he cautioned that for  every $1 the state increases the fee, it would cost $6 million of state money.

It was also suggested that there needed to be more competition among PBMs.

The bill passed the health committee with two members casting a "pass" vote, including its chair, Sen. Julie Raque Adams, R-Louisville. "We have a 36-million-dollar fiscal note attached to this bill and that's significant to me," she said. "That plays a role in everything else that we do relative to budgetary decisions. Those are real dollars and they are going to impact real people."

Sen. David Givens, R-Greensburg, also passed, but told the cabinet officials, "We're not pleased with your inability to adjudicate fairness." He noted that the problem is a national issue. West Virginia recently decided to manage its own pharmacy benefits, and Ohio and Arkansas are considering it.

Casey Ross of Stat, the health-and-science service of The Boston Globewrites in an in-depth article that Washington lawmakers are also concerned about PBMs. The President's Council of Economic Advisers released a report on drug prices last week that raised alarms about PBM consolidation, and calls for policy changes to encourage competition.

"PBMs say they are saving money for insurers and their members, but their contracts with drug makers and other parties are secret, so no one knows how much of that money is being passed on to consumers," Ross writes. "Furthermore, their ability to extract higher payments creates an incentive for drug makers to further raise their list prices, which leaves many consumers, especially the uninsured, facing higher out-of pocket costs. . . . People who work in the pharmacy benefit business argue the only way to reform it is to eliminate the secret discounts that allow these middlemen to thrive."

Jim Waters, president and CEO of the Bluegrass Institute for Public Policy Solutions, a libertarian, free-market think tank, writes that Wise's bill is indicative of a "sledgehammer-to-ant syndrome." He calls for more transparency from PBMs, suggesting that they be required to reveal their reimbursement rates for prescriptions, including how much they pay manufacturers, insurers, employers and pharmacists.

"If such transparency reveals monopolistic-like conflicts of interest or unholy alliances between the PBMs and big pharmacies, then – like a policy MRI – perhaps it will be clear where surgery is needed. Even then, a scalpel will be much-more effective than a sledgehammer." Waters writes.

Wise said he is open to other solutions, but said the managed care organizations and PBMs weren't likely to offer them unless "we show we're serious about moving legislation forward."

"Don't let the MCOs and PBMs win by withholding that information from us," Wise told his colleagues. "Rather, let's send a strong message that this committee and the Senate is going to stand up for local pharmacies and for small businesses, to keep the pressure up on those groups to offer alternative solutions."

Other business: The committee also passed Senate Bill 112, sponsored by Alvarado, which develops policies around telehealth payments and the oversight of telehealth providers, and would require physicians to be licensed in the state to be reimbursed. This bill is expected to increase healthcare access and savings to the state.

Advocates for heart health urge raising cigarette tax by $1 to reduce smoking, a major cause of heart disease

Representatives and volunteers with the American Heart
Association and the state chapter of the American College
of Cardiology rallied in Frankfort on Valentine's Day to urge
lawmakers to raise the cigarette tax by $1 for heart health.
By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- At a Feb. 14 rally in the state Capitol, advocates for heart health urged lawmakers to raise Kentucky's cigarette tax as a way to reduce smoking, a known cause of heart disease.

"We are here on Valentine's Day, the day which celebrates love, to ask our legislators and governor to do something that will have a profound and long lasting impact on the health of all of us Kentuckians," said Dr. Andy Henderson, president of the American Heart Association's Central Kentucky Board of Directors. "We are asking them to protect the hearts of all Kentuckians by raising the tax on cigarettes by at least $1 per pack."

Smoking kills about 9,000 Kentuckians every year, with about one-third of those deaths from heart disease caused by smoking or second-hand smoke, according to the AHA. It is also responsible for many other heart related diseases, including stroke and chronic obstructive pulmonary disease (COPD), of which Kentucky has the second highest rate in the nation.

Republican Sen. Ralph Alvarado, a Winchester physician, told the advocates that "the message is starting to soak in" with legislators, especially this budget year that is trying to address such a huge deficit. He noted that this tax, which would raise $266 million, could help to fill a half-billion-dollar gap.

Alvarado, who has sponsored several anti-tobacco bills, pointed out that support for raising the cigarette tax by $1 is backed by 70 percent of Kentuckians, the Kentucky Chamber of Commerce, medical groups and the education system.

"We've got to do something to help reduce our youth smoking [rates], which are the worse in the country, and adult smoking rates and this would help us get there," he said."Continue to be advocates, contact your legislators and let them know what your stance is, advise them on how they could use those funds to help us with the current budget crisis."

Henderson, who is also the CEO of Lexington Clinic, reminded the crowd that Kentucky has some of the highest smoking rates in the nation for both teens and adults. He said raising the cigarette tax by $1 a pack would not only keep teens from smoking, but would cause an estimated 2,900 smokers to quit, saving the state an estimated "millions and millions of dollars in health care costs year after year." The Campaign for Tobacco-Free Kids estimates that raising the tax by $1 would result in 23,200 fewer Kentucky teens smoking.

Henderson said that he primarily supported this measure for its many health benefits, but added that there was no denying it would bring new revenue to a state that sorely needs it.

Withrow wields cigarette (Melissa Patrick photos)
"I've heard our leaders say they don't want any new taxes. This is not a new tax and no-one is being forced to pay the tax. If you don't want to pay it, don't smoke. It's that simple," he said.

While holding a huge mock-up of a cigarette, Dr. Patrick Withrow of Paducah, the 2018 governor-elect of the Kentucky chapter of the American College of Cardiology, also called on the state's lawmakers to raise the tax, noting that at 60 cents a pack, Kentucky has one of the lowest cigarette taxes in the nation. The national average is $1.72 per pack.

"The cigarette smoking tax is a win-win-win," said Withrow, a long-time volunteer of the American Heart Association. "It will improve the health of Kentuckians. It will reduce tobacco use. It will lower health care cost and it will help businesses -- and it will improve the coffers."

The rally was the fourth in a series sponsored by the Coalition for a Smoke-Free Tomorrow, which comprises nearly 150 organizations that support efforts to decrease smoking in the state, including the tax hike. The other rallies have focused on smoking and pregnancy, teenagers and behavioral health. The next rally, set for 11 a.m. Feb. 21 in the Capitol rotunda, will focus on smoking and cancer.

With nearly nine in 10 Kentucky adults wanting schools to be tobacco-free, will this be the year for a statewide law?

By Melissa Patrick
Kentucky Health News

Most Kentucky adults, by far, want schools to be tobacco-free -- and bills to do just that have been introduced in the Senate and the House.

The latest Kentucky Health Issues Poll, taken Oct. 24 to Dec. 2, found that 87 percent of Kentucky adults favor tobacco-free campuses. Support was strong across party lines, with 89 percent of Democrats, 87 percent of Republicans and 82 percent of independents. The poll also found strong support among those with and without children in their homes: 90 percent and 85 percent, respectively.

The poll has shown consistent support for tobacco-free school policies since 2013, but only 39 percent of the state's school districts (with 55 percent of the state's total students) are covered by comprehensive tobacco-free school policies, according to the state Department for Public Health's Tobacco Prevention and Cessation Program.

Smoke-free school policies are decided by local school boards, but that would change with enactment of Senate Bill 51 or House Bill 318, which would prohibit tobacco products on school properties and at school events. Both bills are still in each chamber's education committee.

The Kentucky School Boards Association told Kentucky Health News in November that it would support any legislation that proposes a statewide tobacco-free school law in the 2018 legislative session, because 81 percent of their members support it.

Last year, the Senate bill's main sponsor, Republican Sen. Ralph Alvarado of Winchester, introduced a bill that passed the Senate but died in the House Education Committee.

Alvarado said Senate leaders have told him that the bill needs to pass out of the House first this year, and if it does, he said he thinks it will pass in the Senate.

"My question is, who are the 13 percent who don't support this?" he asked."That's what it comes down to."

Rep. Kim Moser, R-Taylor Mill, who is sponsoring the House version of the bill, said in an e-mail that she has asked Education Committee Chair Rep. John "Bam" Carney, R-Campbellsville, if she can get HB 318 heard, but hasn't heard back from him.

According to the 2017 Youth Risk Behavior Survey, 26 percent of Kentucky high school students regularly (defined as at least one day during the past 30 days) use either cigarettes, electronic cigarettes, cigars or smokeless tobacco, with about 14 percent each using using cigarettes and e-cigs. The numbers are much higher, 40.5 and 44.5 percent, respectively, when students are asked if they have "ever" used e-cigs or cigarettes. The survey found that 45.8 percent of Kentucky high-school students who used any kind of tobacco product, including e-cigarettes, said they had tried to quit. Research shows that strong tobacco-free school policies can discourage youth from smoking and can also help those who want to quit.

Recent studies also show that e-cigarette use among youth can lead to smoking cigarettes.

"We were making great headway in reducing youth smoking until e-cigarettes made tobacco use somewhat socially acceptable again," said Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, which co-sponsored the poll. "It is imperative that we send the message to Kentucky's youth that using tobacco of any kind is dangerous. We can reinforce that message by ensuring that students don't see their peers, teachers and role models smoking and using tobacco on school grounds."

The poll, co-sponsored by Cincinnati's Interact for Health, interviewed 1,692 Kentucky adults by landlines and cell phones. The margin of error for each result is plus or minus 2.4 percentage points.

In a state thick with cancer, leaders of screening and research organizations targeted for cuts make cases for state money

Mammograms are a screening for breast cancer. (WTVQ image)
By Melissa Patrick
Kentucky Health News

Gov. Matt Bevin's proposed budget for the next two fiscal years calls for cuts to five cancer research and prevention programs, including screenings for breast, colon, cervical, lung and ovarian cancer, and for research on lung cancer, all of which plague the state.

The programs are included in a list of 70 that Bevin proposed to eliminate to save the state $85 million, or less than 1 percent of the overall budget. He has said these cuts are necessary to help fund the state's ailing pension system.

Dr. Whitney Jones, a Louisville gastroenterologist and founder of the Kentucky Cancer Foundation, which provides funds for colon-cancer screening, said he recognizes the challenges of balancing a state budget, but hopes the state will reconsider eliminating the colon cancer screening and prevention program. He said of Bevin, "We hope this is just his first position."

Jones, who also founded the Colon Cancer Prevention Project in Louisville, called the state's improvement from 49th to 19th for colo-rectal screening in the past 15 years, "the best public health story" in Kentucky.

He added that this was only possible because the state offered screenings to uninsured and under-insured Kentuckians, expanded Medicaid to those who earn up to 138 percent of the federal poverty level, and has a unique, multi-partner screening program -- all of which he said makes Kentucky "the envy of most states in the nation."

But he also said there is still work to be done, because Kentucky still leads the nation in colon cancer and remains in the top 10 for colon-cancer deaths.

Doug Hogan, a spokesman for the state Cabinet for Health and Family Services, said the state's screening programs, including those for colon, breast and cervical cancer, are no longer needed because they are now covered by all insurance plans with no deductibles or co-payments.

Jones acknowledged that the program needs to be restructured because of the Medicaid expansion, but argues that it is still necessary for several reasons. He said Kentucky still has a large number of people without health insurance; the federal law that requires almost all Americans to have insurance or pay a tax penalty will be repealed at the end of the year; the coming work requirements and premiums in Medicaid will lead to some people going without coverage; and there will be a continuing need for education and outreach about cancer and screening.

"There has to be a better way to cut out the bad and support or maintain the good," Jones said. "And I would just suggest that the Kentucky Colon Cancer Screening Program is the baby, and not the bathwater."

Lung cancer research targeted in a state that has the most of it

Another program set to lose about $5 million is the Lung Cancer Research Grant Program, a collaboration between the University of Kentucky and University of Louisville that is funded by funds from states' 1998 settlement with cigarette manufacturers. UK's portion is $2.4 million, spokesman Jay Blanton said.

Dr. Mark Evers of UK's Markey Cancer Institute said this statewide initiative seeds a number of pilot projects and "spans the gamut" from new lung-cancer therapies and treatments to new clinical trials and prevention strategies, such as lung-cancer screening. He said such pilot programs are often used to help get larger grants from the National Institutes of Health and other sources.

Evers noted that the Kentucky Lung Cancer Education Awareness Detection Survivorship Collaborative (the Kentucky LEADS Collaborative for short), now funded by a $7 million Bristol-Myers Squibb Foundation grant, is a great example of how a pilot project from this research grant program was able to get a larger grant to further its work.

"It really is a valuable mechanism for us to provide pilot funding for investigators to get the initial data so that they can carry that forward in larger extramural grants," Evers said.

He also noted that the research grant program is responsible for the Kentucky Clinical Trials Network, which he described as another joint venture with U of L that "pushes out" clinical trials for lung cancer, which have been conducted in about 90 percent of Kentucky's counties.

Asked if the program could survive without the state funding, Blanton, who sat in on the telephone interview with Evers, said, "We're just trying to get our arms around the numbers right now."

Asked why the program is important, Evers pointed to the state's high smoking rate, second in the nation, and its No. 1 rank in number of lung-cancer cases. "We've got a terrible problem with this in the state," Evers said.

When Kentucky researchers made a pitch to the National Cancer Institute, Evers said, "The first words out of their mouth were, 'What are you guys doing about your smoking problem?' So, it's really incumbent upon us to be able to have the resources to attack this by screening, prevention and treatment."

While Kentucky LEADS is on Bevin's list of programs that would get no state funding in the next two fiscal years, it has never received any, said Jamie Studts, a UK professor of behavioral science and the lead investigator for the collaborative. He said it had been slated to get $10,000 in each year of the current budget, but that Bevin had "red-lined" the allocation.

Studts said that the cut "doesn't directly affect us in terms of dollars, but indirectly it does send a message that the governor and this administration is not interested in making those kinds of efforts to address Kentucky's burden of lung cancer."

Breast and cervical cancer: state squeezes local health departments

As for the screening programs for breast and cervical cancer, Hogan said that in addition to these screenings now being covered by insurance, they are also operated by federal funds, so elimination of any state funds would not impact them.

Allison Adams, president of the Kentucky Health Department Association, said that while it's true that the breast and cervical screening programs have not received any state dollars for several years and get some federal funds, most of their funding for these programs come from local tax dollars.

For example, she said that in the fiscal year that ended in June 2017, local health departments received about $607,000 in federal funding for breast and cervical cancer screening, and the rest came from $2.3 million in local dollars. The programs serve about 20,000 patients a year.

Adams said the real challenge for health departments to continue such programs, or any of the other initiatives that involves direct patient care, is that Bevin's budget has added $38.5 million to their annual pension liability. She said that will force the departments to provide programs that focus on overall health, safety and prevention and look for ways to spend $1 to affect 10 people, instead of $10 to affect one.

"Local health departments need to be working on the prevention piece, and less on the treatment and intervention," Adams said, but they "will have to do their own prioritization and determine which programs have the absolute most health benefit for all of Kentuckians. We really have to make some tough decisions of where we are going to spend our money that's going to have the greater impact over the health of Kentucky."

The Ovarian Cancer Screening Program is also slated to be cut. Linda Blackford of the Lexington Herald-Leader reports that this UK program offers free vaginal ultrasound screenings to women for ovarian cancer and has provided nearly 50,000 free screenings since its creation 30 years ago.

Blackford notes that the Pediatric Cancer Research Trust Fund, established in 2015 by Sen. Max Wise, R-Campbellsville, has been approved to receive $2.5 million in each year of the biennium to fund pediatric brain cancer research at UK and U of L. Bevin's budget calls for each of the universities to provide a minimum of $1.2 million a year for the program.

After decades of addiction and legal action, OxyContin's maker says sales staff won't visit doctors' offices to market the opioid

Photo by The Associated Press
Purdue Pharma, the manufacturer of OxyContin, says it will no longer market its opioid drugs with visits to doctors' offices and its halving its sales force. The move comes "after years of criticism and mounting lawsuits . . . claiming its sales practices are partly responsible for the opioid epidemic," reports Ben Poston of the Los Angeles Times.

"It's pretty late in the game to have a major impact," Brandeis University researcher Dr. Andrew Kolodny, a longtime critic of the pharmaceutical industry's role in the opioid epidemic, told Poston. "The genie is already out of the bottle. Millions of Americans are now opioid-addicted because the campaign that Purdue and other opioid manufacturers used to increase prescribing worked well. And as the prescribing went up, it led to a severe epidemic of opioid addiction." The drug went on sale in 1996; in 2007, in federal court in southwest Virginia, Purdue paid $635 million in fines to end an investigation by the U.S. Department of Justice.

Poston writes, "One remaining question is whether other opioid makers will follow suit and cease marketing the drugs to doctors, said Kolodny, executive director and co-founder of Physicians for Responsible Opioid Prescribing."

"In an attempt to stem the abuse of OxyContin, Purdue spent a decade and several hundred million dollars developing a version of the painkiller that was more difficult to snort, smoke or inject," Poston notes. "Since those 'abuse-deterrent'  pills debuted seven years ago, misuse of OxyContin has fallen and the company has touted them as proof of its efforts to end the opioid epidemic. But a study released in January 2017 found that rather than curtail deaths, the change in OxyContin contributed heavily to a surge in heroin overdoses across the country and that, as a result, there was 'no net reduction in overall overdose deaths'." States with the most OxyContin abuse rates had the largest increases in heroin deaths. Kentucky is among them.