Go One Step Further: The 529 ABLE For Recovering Opioid Abusers…?

Posted December 13, 2018

ground group growth hands
Photo by Pixabay on Pexels.com

Can the 529 ABLE account be expanded to include Opioid Use Disorder as a qualified disability?  It is worth considering.

Prior to June 2018, the Whatcom County Sherriff’s office had a policy of denying individuals suffering from opioid use disorder (OUD) medications that treat opioid addiction.  Inmates were required to go “cold turkey” during their time in custody.  An exception was made for pregnant inmates.  The Americans With Disabilities Act forbids discrimination against disabled individuals; a public entity cannot deny the benefits of the services programs, or activities of the public entity based upon a disability for which reasonable accommodations for access to the benefits can be made.  Individuals suffering from OUD are considered disabled.  The ACLU of Washington’s position in the class action civil rights lawsuit filed against Whatcom County and the Whatcom County Sherriff was that MAT or “medically assisted treatment” medications (which include buprenorphine and morphine) are “clinically appropriate medications” and are on par with other medications for people suffering from other medical ailments (e.g., heart or diabetes medicine).  OUD is a “chronic” condition, effects brain chemistry and can require the use of MAT on a regular basis…even for the remaining years of the addict’s life.  MAT helps addicts achieve better outcomes through their recovery journey, which may include reduction in unnecessary physical suffering, chance of relapse, and overdose.  To deny incarcerated addicts suffering from OUD access to MAT is to single out a group of people deemed disabled by the ADA, which is discrimination and prohibited.   The U. S. District Court in Seattle ruled that the Whatcom County Jail was, indeed, in violation of the ADA.  OUD is a protected disability under ADA.

What is a qualified disabled person according to the Americans with Disabilities Act, Title II?

According to Title II, Section 201 of ADA, a “qualified individual with a disability” is a person with a disability who, “with or without reasonable modifications to rules, policies, or practices, the removal of architectural, communication, or transportation barriers, or the provision of auxiliary aids and services, meets the essential eligibility requirements for the receipt of services or the participation in programs or activities provided by a public entity.”  Explicitly, ADA addresses public transportation, vehicles, construction and access to facilities.  However, there is the idea that the services provided by the public entity (state or local government, department, agency, district, instrumentality, or commuter service) are to be available for all qualified individuals and the disability itself is to have no bearing on their qualifications to receive the service offered.

The plaintiffs in the ACLU of Washington case were entitled to receive the same medical services that other inmates received in Whatcom County Jail because OUD was a medical condition that required medication.  Previous trouble with the law or the fact that they were not pregnant did not absolve the jail from treating the inmates fairly by offering medications to treat a chronic, debilitating and deadly condition.

What is a qualified disabled person according to the Social Security Administration?

The federal government has a very strict definition of disability.  A recipient of benefits must not be able to work; the condition must be severe, significantly hindering ability to do basic work activities such as lifting, standing, walking and remembering.  Blindness, in severe, non-correctable cases is a condition that warrants SSA benefits under the strict federal definition of disability.  In addition, the condition must be expected to last more than one year or result in death.  There is a five-step process when determining whether or not a person meets the criteria of qualified disabled person that addresses the following:

  1. Employment status and earnings
  2. Severity of condition
  3. Is the condition included on the listing of impairments? (“medically equal” conditions, similar in severity to listed impairments, are also considered)
  4. Ability to do work within or related to current/previous profession
  5. Ability to do ANY gainful work

What is a qualified disabled person according to the requirements of a 529 ABLE account?

On December 19, 2014, President Obama signed The Stephen Beck, Jr. Achieving a Better Life Act of 2014 into legislation to facilitate a way for blind and disabled individuals to save money in tax advantaged accounts for the purpose of ensuring a better quality of life.  Qualified disabled persons are individuals with a physical or mental disability (not necessarily limited to sight or hearing) that functionally limits their ability to be employed or substantially limits one or more life activities (walking, speaking, breathing, learning, or working.)  In order to be qualified, the individual must meet the requirements set forth by title II or XVI of the Social Security Act.

According to the ABLE National Resource Center in Washington DC, qualified expenses are “any expenses related to the designated beneficiary’s blindness or disability that assist him/her in increasing and/or maintaining their health, independence and/or quality of life. These may include expenses related to education, housing, transportation, employment training and support, assistive technology, personal support services, health care expenses, financial management and administrative services and other disability related expenses that the beneficiary might incur as a result of having a disability.”  Some of the noteworthy characteristics of ABLE accounts are:

  1. Can be set up for qualified individuals that became disabled prior to age 26. It is possible to open the account at any age.  The ABLE Age Adjustment Act was introduced in the Senate on April 4, 2017, which aims to increase the age threshold to 46.
  2. Only one account may be set up per qualified disabled individual (beneficiary). The beneficiary is the owner; however, it is possible to designate a parent, guardian or power of attorney to have signing authority on the account for the benefit of the beneficiary.
  3. If a beneficiary of a 529 Education Savings Account, which can be established specifically for qualified education related expenses, becomes disabled, then the education account funds can be “rolled over” to a 529 ABLE account, however there are some limitations on amounts.
  4. For 2018, the annual contribution limit is $15,000. Multiple individuals can contribute to the account up to the annual limit.  The beneficiary can contribute a portion of their own compensation to the ABLE account, subject to some limitations.
  5. Money used from the account for “qualified expenses” will not be included in the beneficiary’s gross income. This means that others can contribute to the account, but the owner gets the benefit of using the funds for their health and well-being without incurring an extra tax burden.  There are direct deposit and debit card features.
  6. The funds deposited in the 529 ABLE account are not subject to the $2000 maximum personal asset limit required to qualify for public benefits like Medicaid and Supplemental Security Income. However, if the account balance grows to over $100,000, SSI benefits will be suspended.
  7. Funds within the 529 ABLE grow tax free…AND…as long as the distributions are for qualified expenses, there are no taxes due on the growth when the funds are withdrawn!
  8. Set up of a 529 ABLE account is relatively simple, without the expense, complexity or IRS filing requirements of trust accounts that are used to meet the same general objectives of providing funds for individuals with special medical/health and welfare needs.
  9. The ABLE act authorized states to establish the accounts, however, establishment was not required. Each state has unique characteristics that pertain to additional tax savings and the treatment or reimbursement of state benefits upon the death of the beneficiary.
  10. According to the ABLE National Resource Center, as of August 2018, 29 states established ABLE programs with a cumulative of $100,000,000, in 20,000 accounts, with an average of $5000 of savings per account.

Opioid Overdose DeathsAs calamitous as the graph above appears, in December 2017 the National Institute on Drug Abuse published an overview of the results of the Monitoring the Future survey, a large-scale federal survey described as a continuing study of American youth.  Two of the several highlights of the survey were:  1) while adult opioid use rates remain relatively high, the data shows that teen misuse is less frequent than ten years prior;  and 2) teens reported that narcotics other than heroine were not as easy to acquire as they used to be in the past (In 2017, 35.8% of 12th graders felt they were easy to obtain, versus 54% in 2010).[i]   View commentary by Dr. Nora Volkow, Director of the National Institute of Drug Abuse here.

However, the graph displays number of opioid deaths, not number of people “living in hell” per se.  Those that are still struggling through the addiction contend with the economic and social barriers to recovery on a daily basis.  Consider the Bureau of Labor Statistics Job Outlook for substance abuse, behavioral disorder and mental health counselors.

Behavior Health Career InfoEmployment of substance abuse, behavioral disorder, and mental health counselors is projected to grow 23 percent from 2016 to 2026, much faster than the average for all occupations. Employment growth is expected as people continue to seek addiction and mental health counseling services.

Demand for substance abuse, behavioral disorder, and mental health counselors is also expected to increase as states seek treatment and counseling services for drug offenders rather than jail time. In recent years, the criminal justice system has recognized that drug and other substance abuse addicts are less likely to offend again if they get treatment for their addiction. As a result, sentences often require drug offenders to attend treatment and counseling programs. In addition, some research suggests that these programs are more cost-effective than incarceration and states may use them as a method to reduce recidivism rates. In addition, there will be a continued need for counselors to work with military veterans to provide them the appropriate mental health or substance abuse counseling care. [ii]

A premise of “Thief” is that the opioid epidemic is systemic.  “Thief – Overcoming Economic and Social Barriers to Recovery” dealt with some of the social, political, legal and financial planning issues that planners and clients must contend with during human capital recovery.   On the road to recovery, opioid use disorder patients receive financial, social and emotional support in the form of pooled funds for groceries, transportation, educational and vocational experience expenses, dual diagnosis medication payments, rent payments, behavioral health therapy, and several iterations of treatment.  The SSA List of Impairments identifies conditions that are severe enough to prevent gainful activity or to cause severe functional limitations that are permanent or will result in death—a tall hurdle that currently applies to 529 ABLE accounts.  Recovery from OUD is very possible with support systems that provide long-term proactive management of the recovery with appropriate medication and supportive social and professional networks willing to create an environment for change.  There are no easy, standardized solutions, but society, as a collective, can provide the tools to help families and communities help themselves by:  1) providing the ability to pool assets from several people in a tax advantaged manner ; and 2) accountability for expenditures.  The 529 ABLE could be expanded to be such a tool in the midst of the opioid epidemic by not only increasing the age qualification limit, but also including OUD sufferers with documented dual diagnosis treatment as qualified disabled persons.

The plaintiffs in the ACLU of Washington case against Whatcom County and the Sherriff’s Department were teenagers when they became addicted to opiates and suffered from OUD for at least ten years prior to the incarceration that prompted the lawsuit.  BLS statistics indicate that the need for behavioral health professionals will increase dramatically between now and 2026.  Behavioral health professionals and the criminal justice system are adjusting their approach to counseling, diagnosis and incarceration.

The 529 ABLE account is not meant to transfer and preserve wealth.  Families on the economic margins engage in a form of financial planning by pooling extremely limited resources for the benefit of a beneficiary.  Why not expand the reach of an account type that is meant to (according to Section 101 of the ABLE Act of 2014):

1)     Encourage and assist individuals and families in saving private funds for the purpose of supporting individuals with disabilities to maintain health, independence, and quality of life; and

2)     Provide secure funding for disability-related expenses on behalf of designated beneficiaries with disabilities that will supplement, but not supplant, benefits provided through private insurance, the Medicaid program under title XIX of the Social Security Act, the supplemental security income program under title XVI of such Act, the beneficiary’s employment, and other sources.

…for the most vulnerable, for the sake of OUD beneficiaries and contributors?

It is worth considering.

Terry

[i] Kaiser Family Foundation, Opioid Overdose Deaths By Age Group, State Health Facts Tool, https://www.kff.org/other/state-indicator/opioid-overdose-deaths-by-age-group (visited December 12, 2018)

[ii] Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Substance Abuse, Behavioral Disorder, and Mental Health Counselors,
on the Internet at https://www.bls.gov/ooh/community-and-social-service/substance-abuse-behavioral-disorder-and-mental-health-counselors.htm (visited November 22, 2018)

Thief – Overcoming Social and Economic Barriers to Human Capital Recovery

Posted November 29, 2018

“My life was a raging dumpster fire!” – Anonymous, after two weeks at a residential drug rehabilitation treatment center.

So, how does the practitioner or client engage in financial planning while the client is driven to desperately and surreptitiously feed their addiction or fearfully concede to a dependence on opiates?  When abused, opiates morph into a swarm of locusts feeding on human capital. For an addict, or those individuals supporting the recovery efforts of an addict, human capital recovery starts by the client:

1)     recognizing and acknowledging the reality of the client’s situation;

2)     educating himself on options available for recovery;

3)     determining a personalized course for recovery with the help of trusted personal and professional support systems;

4)     Investing in himself by implementing a plan for recovery; and

5)     pro-actively taking care of himself on an ongoing basis by attending therapy, living a healthy lifestyle, and rebuilding the parts of his life that may have been neglected during the darkest hours of dependence or addiction.

While developing a five-step plan may seem intuitive to some, there are challenges that must be acknowledged directly.  Some of the challenges have to do with access to and affordability of treatment facilities, as well as the pharmaceutical industry’s and prescribing medical practitioners’ continued use of oxycodone.  It is also important for patients to advocate for themselves—for their very own best interests from a position of power; knowledge is power.

Recent news, developments and perspectives…

The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, also known as the SUPPORT for Patients and Communities Act was signed into law on October 24, 2018.  https://www.youtube.com/watch?v=2geQ0d3WsMY#action=share.  This legislation is holistic in nature.  It specifically addresses and provides guidance on opioid crisis issues such as Medicaid and Medicare provisions, detection and monitoring systems for synthetic opioids, behavioral health, opioid safety education, promotion of research to respond to the threat of the crisis itself, illicit drug importation, safe disposal of unused medication, treatment for veterans, support for grandparents caring for grandchildren, prescribing guidelines, support for mothers and care for infants suffering from neonatal abstinence syndrome and much, much more.  See the text of the SUPPORT for Patients and Communities Act at the following link:  https://www.congress.gov/bill/115th-congress/house-bill/6/text.  The above list of areas covered by this Act is a mere fraction of the sweeping legislation.

The Drug Enforcement Agency (DEA) appears to be on the mission and engaged in the battle against illicit opioid distribution and prescribing practices.  On November 15, 2018, Serio Juana Devoe was sentenced to 10 years in prison and eight years of supervision for attempting to distribute fentanyl and methamphetamines.  The Anchorage Police Department and the Drug Enforcement Agency (DEA) cooperated on the case which was prosecuted as a result of the United States Department of Justice Project Safe Neighborhoods (PSN) program.  PSN is a federally funded initiative that promotes nation-wide multi-agency efforts to reduce gun violence.[1],[2]  On October 31, 2018, the acting administrator of the DEA Diversion Control Division, denied the DEA Certificate of Registration for Edward A. Ridgill, MD, effective immediately.[3]  In August 2016, Dr. Ridgill was one of two doctors in Lynwood, CA that was arrested on federal drug charges for issuing prescriptions without a medical purpose.  He issued more that 21,000 prescriptions for hydrocodone (Vicodin or Norco), codeine (for example, promethazine with codeine cough syrup, street name purple drank), alprazolam (Xanax), and carisoprodol (muscle relaxer).   According to the investigation affidavits, there was evidence that the two doctors were large-scale suppliers for gang members.[4]  In December 2017, Dr. Ridgill was convicted of 26 counts of unlawful distribution of controlled substances.[5]

The US Department of Health and Human Services maintains the National Practitioners Data Bank (NPDB).  The NPDB was established by Congress in 1986 and serves as a web-based repository of reports and data that contain information on medical malpractice payments and adverse actions pertaining to health care professionals (practitioners, providers and suppliers).  An analysis of the most recent data reveals that between 1990 and 2017, there were a total of 3848 DEA Adverse Action Reports and 635,125 state licensure adverse reports[6].    Below is a chart of the most relevant categories for the purposes of this report.

DEA

Adverse Action Reports

State Licensure Adverse Action Reports

Physicians, MD

2699

4408

Pharmacist

0

1270

Dentists

341

1058

Physicians, DO

318

511

Advanced Practice Nurses

240

226

Physician Assistants

134

329

 

The below is a graphic representation of the number of reports issued each year for the specific practitioners listed in the table above.  Clearly, the number of reports issued by the DEA and state licensing organizations on an annual basis significantly increased after 2008.

Number of DEA Adverse Action Reports; 1990 – 2017[7]

Number of state licensure Adverse Action Reports; 1990-2017[8]

In May 1986 the medical journal Pain published a research report by Drs. Russell K. Portenoy and Kathleen M. Foley entitled “Chronic Use of Opioid Analgesics in Non-malignant Pain:  Report of 38 cases.”  The doctors re-examined up to 7 years of data collected on 38 pain patients that were undergoing some form of opioid analgesic pain management for non-malignant conditions.  After retroactively examining factors such as dosage, pain relief, toxicity, time in pain management therapy, and personality factors of 38 patients, Portenoy and Foley concluded “that opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse.”[9]  This study was used as the touchstone for the mass marketing of opioids as a go-to narcotic for pain relief…moderate to severe.  As early as 1998, researches at the University of British Columbia in Vancouver published research that directly contradicted Purdue and FDA claims that OxyContin was safe to prescribe, in that there was a low probability that patients would become dependent on or addicted to the narcotic in a “time release” formulation.  Purdue Pharma was aware of the research study published in the Journal of the Canadian Medical Association.  The study revealed that on the streets of Vancouver, abusers learned to peel away the time release coating and crush the pills; they were called “peelers”, and one 30 milligram pill had a street value of $40.  The very same pill sold for $1 at the pharmacy.[10]  It is against this backdrop that some pharmaceutical companies, distributors and medical professionals claim that they have no responsibility for the current opioid contagion.   Consider:

  • Purdue Pharma has paid several hundreds of millions of dollars in government penalties and civil litigation over the last decade or so, however they are currently facing more than a thousand lawsuits brought by cities, states, and Native American tribes. In August 2018 the company hired restructuring lawyers in response to mounting law suits that claim several pharmaceutical companies mislead the public about the addictive nature of their opioid painkillers.  The plaintiffs hope to recoup some of the costs of battling the epidemic.   According to an October 2018 Wall Street Journal article, Purdue Pharma along with other drug manufacturers claim they did not cause the opioid crisis and want plaintiffs to show how the companies were to blame by presenting specific numbers of prescriptions and identifying specific residents (both data points in the hundreds) that were harmed by the opioid prescriptions.
  • In a 2012 Wall Street Journal interview, Dr. Portenoy stated the following:

Did I teach about pain management, specifically about opioid therapy, in a way that reflects misinformation? Well, against the standards of 2012, I guess I did…We didn’t know then what we know now.

My patients are on very high doses, and I have patients who are executives in companies, hedge fund managers, hospital executives…I think that some of the literature that has emerged is not balanced…

What we are now dealing with in the United States is a movement of the pendulum back toward a level of concern and fear that is driving some policy decisions, that in my opinion, are very likely to harm the public health by reducing access to these essential drugs.[11], [12]

View the video-taped interview here:  A Pain-Drug Champion Has Second Thoughts

  • On November 2, 2018 the FDA approved Dsuvia (sufentanil), a synthetic opioid analgesic to be used in “acute pain settings”, such as emergency rooms and on the battlefields. It must be administered by a health professional in a “certified medically supervised healthcare setting”, not to be taken for more than 72 hours.[13]  AcelRx Pharmaceuticals has approval to sell this opioid analgesic that is 10 times stronger than fentanyl and 500 to 1000 times stronger than morphine.  The projected annual sales are $1.1 billion. [14]

Dumpster Fire

“My life was a raging dumpster fire!” – Anonymous, after two weeks at a residential drug rehabilitation treatment center

 

 

The financial and human capital costs for treatment

The cost to treat substance abuse disorders is substantially less than the cost associated with battling the societal ills the abuse produces.  Criminal justice, Neonatal Abstinence Syndrome, increased growth- rates and incidences of infectious diseases, injuries sustained while intoxicated and lost productivity are a few of the areas that increase the costs associated with the opioid epidemic.  According to an article published in the Medical Care section of the American Public Health Association Journal, in 2013 only 3.6% of the $78 billion dollars spent on opioid use disorders in the United States was spent on treatment.[15]  United States Department of Defense estimates for substance abuse treatment are as follows:

  • $6552 per year for methadone treatment, including medication and integrated psychosocial and medical support services (assumes daily visits)
  • $5980 per year for opioid treatment facilities that provide buprenorphine (includes medication and two meetings per week, stable patient)
  • $14,112 per year for opioid treatment facilities that administer naltrexone and related services.

To place these expenditures in context, average annual expenditures for diabetes mellitus is $3560, and $5624 for kidney disease patients.[16]  However, even more context is needed.

Residential substance abuse treatment programs that offer counseling, group therapy, psychological evaluations, medication, education about the addiction (remember, knowledge is power), psychosocial or behavioral interventions, family programs, relapse preventions programs, and sober housing referrals can be cost prohibitive for many of the would-be patients.  The cost for these programs can be $15,000 to $30,000[17] per year…or higher.  In accordance with the Affordable Care Act, mental health and substance abuse services are considered essential health benefits.  It is important to review individual plans to determine the specifics of individual coverage, however pre-existing conditions are covered and there can be no annual or lifetime dollar limits on essential health benefits.[18]  Some insurance companies will require patients to attend and fail an out-patient program before approving a holistic residential program.  Therefore, even after the addict triumphs over the barriers of facing the reality that they are suffering from an opioid use disorder and facing the fear of giving up the pills and potentially suffering from chronic pain that has been dulled by the opioid use, there can be confusion about costs and which treatment options will be successful and affordable.  Because the addiction is chronic, treatment and self-care in the form of individual and group therapy, medications (especially in the case of dual diagnosis treatment), healthy living, and measured, deliberate re-entry into the work place are critical and require structured processes.  All of this adds up to ongoing costs that do not even address the financial burdens amassed by the nuclear and extended family in the forms of child support, divorces, lost capital assets and destroyed careers.  The primary concern is to get better physically, emotionally, and psychologically…which means that finding work is not a primary concern, even in the face of the mounting financial burdens.  For a period of time, the recovering addict will need to acknowledge and deliberately, where practical,  tackle the realities of the dumpster fire that consumed jobs, family relationships, friendships, health and assets.  Everyone touched by the addiction is in recovery.

Creating Peace Of Mind Waypoints and course corrections…

Consider integrating the following life planning waypoints into your overall financial planning process to help mitigate the risks associated with opioid dependency or addiction.

  1. Get CPR/Overdose training. Vice Admiral Jerome Adams, the U.S. surgeon general issued an advisory; In an April 2018 interview with NPR host Rachel Martin, he urged Americans to carry naloxone (commercial name Narcan), a medication to be administered in case of an opioid overdose.   Not only do first responders carry the medication, households are encouraged to have the medication as part of home first aid kits.  When asked why “ordinary Americans” should be prepared to use Narcan, he responded that “Over half of the overdoses that are occurring are occurring in homes, and so we want everyone to be armed to respond. We should think of it like an EpiPen or like doing CPR on someone.”[19]  The Veterans Administration includes naloxone in defibrillator cabinets.  A simple internet search reveals where you can purchase the medication without a prescription.  Check your local pharmacy for an over-the-counter dose of this opioid overdose antidote.  Emergency care is still necessary after an overdose, however if administered after oxycodone is injected or snorted, naloxone will counteract the effects of the opioid.  As mentioned in previous posts, there are “good Samaritan” laws to protect individuals that administer naloxone and encourage vital medical attention after the medication is administered.  Some states require school nurses to carry the antidote and many have used it; our high schools are the front line.  Sadly, this is the new norm…be prepared.
  2. Proactively seek accountability when oxycodone is prescribed. Medical practitioners advise that it is important to manage pain after procedures that result in significant discomfort.  In layman’s terms, patients can better tackle the healing process if they can follow post procedure directions for recovery without the distraction of pain that may make them hesitant to follow discharge directions.  The law requires that patients complete specific documents acknowledging that they will receive oxycodone during recovery and that they understand how it will be prescribed, when it will be prescribed, under what conditions refills will be given, and what will happen if patients violate the contract pertaining to the use of the oxycodone narcotic.  Show and discuss copies of the document you sign with at least one or two trusted friends or family members that will help during the recovery process.   Ask about alternative pain medications.  Federal guidelines, as of 2016, dictate that opioids be prescribed for no more than three to seven days.
  3. Know how to dispose of unused medication and do so immediately. Recently, Hollywood actress Jamie Lee Curtis revealed her struggle with opioid addiction; she became addicted after receiving a prescription for painkillers after plastic surgery.  She admits to stealing pills from friends and family when she no longer had her own prescriptions re-filled.  The U.S Food and Drug Administration website[20], [21] lists several options for disposal of used medicines, to include:
    • National Prescription Drug Take-Back events – temporary medicine collection events; provide education on drug abuse. The Diversion Control Division section of the DEA website has a search tool; enter your zip code to find dates and times of local take back events.
    • DEA registered collectors – safely and securely collect and dispose of pharmaceuticals containing controlled substances and other medicines. Locations can be retail pharmacies, hospital or clinic pharmacies, and law enforcement facilities or collection receptacles/drop boxes.
    • Guidance on how to dispose of prescription medications that must be flushed immediately or disposed of in household trash.
  4. Get estate planning documents in order. Estate planning is not only for the wealthy.  While estate planning primarily addresses ownership and transfer of assets, it is also about protecting family and determining a process for using assets as efficiently as possible before and after the estate owner’s death.   Seek advice from an estate planning professional to address some of the potential human capital and financial issues that may arise as a result of opioid addiction, and the tools available to manage healthcare and assets.  The documents below allow an individual to designate trusted “agents” to manage assets and medical decisions to varying degrees.  These documents “starting points”, relevant in sickness and in health and part of a holistic planning processes.  Once again, my premise is not that your financial trusted advisor or estate planning professional is a behavioral health professional; do not expect behavioral health advice.
    • Power of attorney (POA) – Grants permission for someone else (an attorney in fact) to act on behalf of the principal (the person creating the POA). The attorney in fact can make legally binding decisions.  The POA can include limitations on scope and length of time.
    • Durable Power of Attorney (DPOA) – Similar to a POA, however, if the principal becomes incapacitated, the POA is no longer binding; DPOA remains in effect after the principal is incapacitated. In the event of incapacity, a trusted individual can be designated to manage assets and make financial decisions.  If it is a “springing” DPOA it will become effective at the time of incapacitation.  A durable power of attorney for healthcare (DPOAHC) is always “springing” and the scope is limited to medical decisions, not property decisions.  A DPOAHC is not only appropriate for situations in which the principal might be terminally ill, but also if the principle is unable to give consent for medical procedures or decisions;
  5. Execute a plan for recovery.  In general, any planning process includes:  gathering information, analyzing the information, developing a process to reach clearly articulated goals, implementing the process with a sense of purpose, and remaining accountable by periodically measuring the rate and amount of progress toward the stated goals.  Then start over.  With recovery from opioid addiction, research shows that, in general, this process never ends.  In his book Overcoming Opioid Addiction, author, Dr. Adam Bisaga provides a list of ways to earn “recovery capital” or a “build up of positives in life.”  As a review, a suggested format for a way forward in the human capital recovery process for an addict, or those individuals supporting the recovery efforts of an addict are to:
    1. Recognize and acknowledge the reality of the opioid abuser’s situation;
    2. Seek education on options available for recovery;
    3. Determine a personalized course for recovery with the help of trusted personal and professional support systems;
    4. Invest in self by implementing a plan for recovery; and
    5. Pro-actively taking care of overall health on an ongoing basis by attending therapy, living a healthy lifestyle, and rebuilding the parts of the opioid abuser’s life that may have been neglected during the darkest hours of dependence or addiction.

As the recovery plan takes shape, consider integrating “recovery capital” in the following ways, which are listed in Dr. Bisaga’s book, which include, but are not limited to:

Participate in treatment and continuing care

Take advantage of therapy even if you have been doing well for a long time

Actively engage with a mutual self-help community

Encourage your partner and family to support your recovery

Support others in their recovery

Choose to live in an environment that is free of drugs

Finish education; find a stable and fulfilling job

Clear all past legal problems…and much more.[22]

Preemptive and proactive life and financial planning are tools that can be used to help overcome social and economic barriers to recovery There are no guarantees but being prepared is a plus.  The process for recovery is unique for each person, however it includes having an awareness of current developments and perspectives, quantifying the cost of medical treatment, and planning for successful redemption of human capital with the help of planning professionals and trusted personal advocates.  The SUPPORT for Patients and Communities Act is comprehensive, law enforcement and licensing agencies are engaged, communities are developing educational programs and partnerships to save lives, and estate planning tools are available to assist in the planning process.   A systemic problem requires comprehensive, innovative solutions.  Not all are listed here.  Everyone touched by the contagion is in recovery–all hands on deck to encourage and support our loved ones as they douse the “dumpster fires.”

–Terry

[1] Herraiz, Domingo S. “Project Safe Neighborhoods: America’s Network Against Gun Violence.” U.S. Department of Justice Office of Justice Programs Bureau of Justice Assistance,  https://www.ncjrs.gov/pdffiles1/bja/205263.pdf, accessed on 11/24/2018.

[2] Underwood, Jodie. “Anchorage Man Sentenced for Fentanyl Trafficking” U.S Drug Enforcement Agency,  https://www.dea.gov/press-releases/2018/11/15/anchorage-man-sentenced-fentanyl-trafficking , accessed on November 12, 2018

[3] US Department of Justice, Diversion Control Division, DEA Decision Order, https://www.deadiversion.usdoj.gov/fed_regs/actions/2018/fr1120_3.htm   [Federal Register Volume 83, Number 224, Tuesday, November 20, 2018.

[4] Department of Justice, US Attorney’s Office Central District Of California, “Two Doctors Face Federal Charges of Illegally Writing Prescriptions for Addictive Narcotics Connected to Gang’s Drug Trafficking.”  https://www.justice.gov/usao-cdca/pr/two-doctors-face-federal-charges-illegally-writing-prescriptions-addictive-narcotics.  Augutst 29, 2016, accessed on 11/24/2018.

[5] https://www.deadiversion.usdoj.gov/fed_regs/actions/2018/fr1120_3.htm

[6] Singh, Harnam. National Practitioner Data Bank. Generated using the Data Analysis Tool at https://www.npdb.hrsa.gov/analysistool.

[7] Singh, Harnam. National Practitioner Data Bank. Generated using the Data Analysis Tool at https://www.npdb.hrsa.gov/analysistool.

[8] Singh, Harnam. National Practitioner Data Bank. Generated using the Data Analysis Tool at https://www.npdb.hrsa.gov/analysistool.

[9] Portenoy, R. K. and K. M. Foley, “Chronic Use of Opioid Analgesics in Non-malignant Pain:  Report of 38 Cases.”  Pain, May 1986, https://www.ncbi.nlm.nih.gov/pubmed/2873550, accessed on 11/24/2018.

[10] Sajan MD, Amin, Trevor Corneil, MD and Stefan Grzybowski, MD, MClS.  “The Street Value of Prescription Drugs,”  from the Department of Family Practice, University of British Columbia, Vancouver, BC , CMAJ 1998, volume 159, pgs. 139-42 .  www.cmaj.ca/content/cmaj/159/2/139.full.pdf, accessed on 11/24/2018.

[11] Catan, Thomas and Evan Perez. “A Pain-Drug Champion has Second Thoughts.” Wall Street Journal, Dec 15 2012, Eastern edition ed. ProQuest. 11/25/2018, accessed on 11/24/2018.

[12] Catan, Thomas and Evan Perez

[13] “Dsuvia Approval History.”  Drugs.com, reviewed by J. Stewart on 11/13/2018.  https://www.drugs.com/history/dsuvia.html, accessed on 11/25/2018.

[14] “FDA Approved new Opioid Drug Called Dsuvia.” https://abcnews.go.com/GMA/Wellness/video/fda-approved-opioid-drug-called-dsuvia-58940799, 11/3/2014, accessed on 11/13/2014.

[15] Florence CS, Zhou C, Luo F, Xu L. “The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States.” Med Care. 2016;54(10):901-906. doi:10.1097/MLR.0000000000000625.  Accessed 11/13/2018.

[16] “Medications to Treat Opioid Use Disorder.” National Institute on Drug Abuse, https://www.drugabuse.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-much-does-opioid-treatment-cost, accessed 11/24/2018.

[17] Adam Bisaga, MD, Overcoming Opioid Addiction, (New York:  The Experiment, LLC, 2018) 177.

[18] “Mental Health and Substance Abuse Coverage.”  Healthcare.gov, https://www.healthcare.gov/coverage/mental-health-substance-abuse-coverage/, accessed on 11/27/2018.

[19] “Surgeon General Urges More Americans to Carry Opioid Antidote.”  Soundbite of Sleep Dealers “The Way Home,” NPR Morning Edition, hosted by Rachel Martin, 4/5/2018.  https://www.npr.org/templates/transcript/transcript.php?storyId=599538089, accessed on 11/24/2018.

[20] “Disposal of Unused Medicines:  What You Should Know.”  U. S. Food and Drug Administration.  https://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm, accessed on 11/25/2018.

[21]“Prescription Drug Take Back Day.” US Drug Enforcement Agency Diversion Division, https://www.deadiversion.usdoj.gov/drug_disposal/takeback/index.html, accessed on 11/27/2018.

[22] Bisaga 208.

 

Thief!

Posted November 14, 2018

Something is stealing your human capital.

Human capital is intangible collective resources possessed by individuals and groups within a given population. These resources include all the knowledge, talents, skills, abilities, experience, intelligence, training, judgment, and wisdom possessed individually and collectively, the cumulative total of which represents a form of wealth available to nations and organizations to accomplish their goals.[1]

As a financial planner explaining this idea of human capital to someone, I define it as everything that you as an individual bring to bear for the benefit of yourself, your family and your community.  Everything includes knowledge, wisdom, life experiences, sense of community, love for your culture, support of family, spirituality… and yes, it of course includes earning power.  The list goes on.  The important takeaway is that human capital is not only the amount of financial capital your very existence generates, but also everything about you that adds to the greater good of everything your existence touches.  There is a recognition that we do not live our lives in a vacuum; we also recognize that just because human captital is intangible, that does not mean it is of no value.  In many cases, human capital, when quantified, may be more valuable than capital assets.

In the mid-1990s OxyContin became a “go-to” narcotic to alleviate the suffering of chronic pain.  In his book Pain Killer:  An Empire of Deceit and the Origin of America’s Opioid Epidemic, Pulitzer Prize nominated investigative reporter Barry Meier describes OxyContin as “a gateway drug to the most devastating public health disaster of the 21st century.”  Oxycodone was historically used to provide immediate relief for moderate to severe pain after surgery and to alleviate pain during the final stages of chronic illnesses that result in death.  OxyContin was first marketed by Purdue Pharmaceutical Company in 1996.  The appeal was that it was pure Oxycodone prescribed at a higher dosage, but with a time release coating.  The appeal of such a formulation and the marketing “hooks” were that pain relief could be provided over an extended period of time and there was a reduced chance of abuse because the full effects of the narcotic were not immediately felt…something addicts desired.  Doctors prescribed pain relievers derived from Oxycodone (as well as synthetic versions of this narcotic) in doses that “titrated to effect” to make life bearable for those suffering from chronic pain.  As patients’ bodies adapted to the relief provided by the narcotics, higher dosages were required and willingly prescribed by some doctors in known increments to provide the relief desired.  The term opiophobia, the irrational fear about the addictive powers of opioids, was a label ascribed to doctors that were reluctant to use the powerful narcotics to treat pain.  In the 1990s opioid advocates within the medical and pharmaceutical fields supported a decrease in prescription monitoring.  During the same time period, pain level was designated the fifth vital sign; the first four vital signs measured and monitored by health care professionals are pulse, blood pressure, temperature and respiration.  The fifth sign is a subjective “qualitative” measurement that is quantified by the level of misery indicated on a scale of stick diagram- like smiley faces.  By the early 2000s, the abuse and diversion of prescribed OxyContin and similar narcotics derived from the poppy plant were rampant, and OxyContin became known as “hillbilly heroin.”  Approximately 20 years after designating pain level as the fifth vital sign, several delegates at a 2016 American Medical Association meeting strongly supported no longer monitoring pain as a fifth vital sign.[2]

The Opioid Crisis is a systemic risk to human capital and by extension, a systemic risk to financial life planning.  Why systemic?

  1. In 1998, Dr. Frank Fisher wrote 46% of all prescriptions for OxyContin in the state of California. The prescriptions were written for patients in a state program specifically designed for low income healthcare recipients.  He was arrested and charged with murder.  A nearby pharmacy filled four times as many oxycodone type painkillers as any other pharmacy in the United States.[3]
  2. By 2002, only six years after it was introduced to the market, $1.5 billion of OxyContin was sold to the public[4]
  3. Between 2007 and 2012, 780,000,000 pain pills with oxycodone or hydrocodone were prescribed in West Virginia. That amounts to 433 pills per person.  1700 people died from fatal overdoses of prescription opioids.[5]
  4. Neonatal Abstinence Syndrome (NAS) is a postnatal drug withdrawal syndrome in newborns caused primarily by in utero exposure to opioids. In the United States, the incidence of NAS increased 383% during 2000–2012.[6] In April 2018, the West Virginia Department of Health and Human Resources issued a press release that stated the incidence rate of NAS was over 5% of for live births.  Bill J. Crouch, West Virginia DHHR Cabinet Secretary believes the state is in the “midst of a child welfare crisis.”[7]
  5. In 2015 Americans were 5% of the global population, however they were consuming 80% of oxycodone and hydrocodone opioids produced globally; they accounted for 30% of all prescriptions.[8]
  6. In 2016, 64,000 people died from overdoses; 42,000 attributed to opioids.[9]
  7. On April 19, 2016 the Ensuring Patient Access and Effective Drug Enforcement Act became law. The law defined the phrase imminent danger to the public health or safety as “due to the failure of the registrant (distributers of prescription medications/middlemen) to maintain effective controls against diversion or otherwise comply with the obligations of a registrant under this title or title III, there is a substantial likelihood of an immediate threat that death, serious bodily harm, or abuse of a controlled substance will occur in the absence of an immediate suspension of the registration” (emphasis added).  This change, along with other changes to verbiage in the original Controlled Substances Act, made it more difficult for the Drug Enforcement Agency to thwart the flood of opiates to prescribers and pharmacies when the Agency suspected a pipeline of prescription painkillers resulted in higher rates of diversion or abuse.[10],[11],[12]
  8. In July of 2016 Adapt Pharma made a donation of 50,000 doses of naloxone (brand name, Narcan), a nasal spray that reverses the affects of heroin and prescription pain killers, to high schools through the state departments of education, community organizations and first responders.[13], [14]
  9. By 2017 OxyContin sales were over $31 billion.[15]
  10. Emergency rooms report treating an average of 1000 people per day for opiate abuse.[16]
  11. While prescriptions for OxyContin have decreased over the years, illicit use of Fentanyl is driving up death count.[17]
  12. Beginning in 2017, several states, towns, cities and Native American tribes filed class action lawsuits against pharmaceutical companies and distributors for downplaying, deceiving or outright concealing the risk of addiction.
  13. By 2018 over 250,000 people died from prescription painkillers.[18] This statistic addresses deaths, but not lives destroyed.
  14. By 2018, although domestic sales of OxyContin decreased, the narcotic is still marketed overseas.[19]
  15. Today 40 states and the District of Columbia have “Good Samaritan” laws that protect individuals that report or experience overdoses. In order to save lives and provide follow-up care for Naloxone use, immunity is offered to varying degrees for individuals that call 911 in “good faith” to report over-doses.[20]

What used to be thought of as a potential problem for patients experiencing chronic pain is now a mainstream epidemic that grips loved ones; the reach of the Opioid Epidemic is likely governed by less than six degrees of separation.  Who do you know that has been trapped by the downward spiral of opiates?  Have you ever diverted funds in your budget from a retirement account or vacation to help someone receive treatment?  Has jewelry gone missing?   Do you have a neighbor that buys clean hypodermic needles at the local pharmacy so that their adult child can get high safely?  Is there an increase in crime in your local area because drug rehabilitation centers are filled to capacity, pharmacies are being robbed, abandoned properties are now drug houses, the unemployment rate is higher than average (even at recession levels) and homelessness is rampant?  On October 24, 2018 the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, also known as the SUPPORT for Patients and Communities Act was signed into law.  The breadth of the bill informs us of the extent and reach of the crisis into our lives: it covers issues of support across the demographic spectrum.  The Act can be reviewed at https://www.congress.gov/bill/115th-congress/house-bill/6/text.

pexels-photo-313690.jpeg
Photo by energepic.com on Pexels.com

Individuals that are personally affected by or provide financial assistance to family members that are affected by this contagion are highly encouraged to address the issue with their financial planning professional. My premise is not that your financial trusted advisor is a behavioral health professional; do not expect behavioral health advice. However, if helping yourself, a family member or a friend results in unexpected financial and emotional burdens that effect your ability to navigate your financial planning waypoints, seek your planner’s support in your efforts.  Seek your planner’s objective support as you work together as a team to determine whether your planning objectives and goals must be modified or re-ordered on your priority list.  Client comfort level dictates how much information is shared.  One recovering OxyContin and heroin addict described the epidemic as “our national treasure being ‘squalored’ away on this affliction… (It is about) human capital, financial capital, overall production… as well as time and destruction of the family structure that can span generations!”  When developing personalized financial planning waypoints and developing financial planning legacies, we build them on a foundation strengthened by what we love, what we value and priorities.  One look at the list above, which is a tip of the iceberg that tells the story of the damage our families, friends and country contend with, compels us to recognize that diversion, dependence and addiction to opioids is a strain on: newborns and adults; private and public organizations; individual high school students and several generations within the same household;  the poor and the wealthy; and law enforcement and community outreach programs.  It is not a stretch of the imagination to conclude that the intangible elements of human capital (knowledge, talents, skills, abilities, experience, intelligence, training, judgment, and wisdom) are diminished, if not eliminated, by misuse of narcotics.

people sitting on green grass
Photo by Markus Spiske temporausch.com on Pexels.com

Human capital is a part of your life planning portfolio.  Be sure to consider it as you cherish the present and plan for your future.  Everything about you and the important people in your life that add to the greater good of everything your existence touches is worth redeeming if stolen by, what I believe has become, the systemic thief that keeps on thieving:  opioid abuse.   Subsequent posts will cover costs of and barriers to recovery, to what extent opioid addiction has been considered a disability, corporate social responsibility, and much more.

-Terry

[1] Richard Huff, “Human Capital”, Last updated October 4, 2018, www.britannica.com/topic/human-capital
[2] Adam Bisaga, MD, Overcoming Opioid Addiction, (New York:  The Experiment, LLC, 2018) 1.
[3] Huff 135
[4] Meier 175
[5] Meier 175
[6]Ko JY, Patrick SW, Tong VT, Patel R, Lind JN, Barfield WD, “Incidence of Neonatal Abstinence Syndrome — 28 States, 1999–2013”,  2016, https://www.cdc.gov/mmwr/volumes/65/wr/mm6531a2.htm    .
[7] West Virginia Department of Health & Human Resources. “DHHR Releases Neonatal Abstinence Syndrome Data for 2017”, 4/11/2018    https://dhhr.wv.gov/News/2018/Pages/DHHR-Releases-Neonatal-Abstinence-Syndrome-Data-for-2017-.aspx.
[8] Bisaga 2
[9] Meier, x
[10] Ensuring Patient Access and Effective Drug Enforcement Act of 2016, https://www.congress.gov/bill/114th-congress /senate-bill/483/text.
[11] Bill Whitaker reporting, “How the DEA’s Efforts To Crack Down on the Opioid Epidemic Were Derailed” 60 Minutes,  S50, air date October 13, 2017, https://www.cbs.com/shows/60_minutes/video/K1vW4pnExDfDERlpajr8qds9Vm38rRpb
/how-the-dea-s-efforts-to-crack-down-on-the-opioid-epidemic-were-derailed/.
[12] Scott Higham and Lenny Bernstein,”The Drug Industry’s Triumph Over the DEA”, The Washington Post, October 15, 2017, http://www.washingtonpost.com/graphics/ 2017/investigations/dea-drug-industry-congress/?utm_term=.22fbe7ea4f76.
[13] Kimberly Leonard, “Coming to a High School Near You: Drugs that Reverse Heroin Overdoses” January 25, 2016, https://www.usnews.com/news/articles/2016-01-25/overdose-reversal-drug-naloxone-offered-free-to-high-schools.
[14] Donna Shalala, “Clinton Foundation Programs at Work”,   September 1, 2016, https://stories.clintonfoundation.org/clinton-foundation-programs-at-work-fda2ba0cf84c.
[15] Meier 174
[16] Meier 172
[17] Meier 173
[18] Meier 172-175
[19] Meier 175
[20] National Conference of State Legislators, “Drug Overdose Immunity and Good Samaritan Laws”, June 5, 2017, http://www.ncsl.org/research/civil-and-criminal-justice/drug-overdose-immunity-good-samaritan-laws.aspx.