Some doctors were handing out opioids like candy. The Justice Department just shut them down. – Vox

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The US Department of Justice just took what it calls its biggest action against opioid-related fraud ever.

The department announced Thursday that it’s charged 120 people with opioid-related crimes. That includes doctors who were allegedly running pill mills in which they unscrupulously prescribed opioids to patients. It also includes fraudulent treatment centers, which attract customers with promises of treatment for their addiction and then offer shoddy, ineffective services — if any at all.

“Too many trusted medical professionals, like doctors, nurses, and pharmacists, have chosen to violate their oaths and put greed ahead of their patients,” Attorney General Jeff Sessions said. “Their actions not only enrich themselves often at the expense of taxpayers but also feed addictions and cause addictions to start.”

The news was part of the Justice Department’s annual announcement about its health care fraud work. In total, the Justice Department announced charges in more than 400 cases, totaling more than $1.3 billion in health care fraud — what the feds called the biggest health care fraud enforcement action ever taken by the Medicare Fraud Strike Force.

The opioid actions are meant to address a major public health crisis. It’s currently estimated that up to 65,000 people died of drug overdoses in the US last year alone — more than all the American casualties from the entire wars in Vietnam and Iraq. Most of those overdoses are believed to be tied to opioids. This is now the deadliest drug overdose crisis in US history.

The Justice Department’s latest work won’t come close to ending the opioid crisis. And there’s evidence it could actually make the crisis worse in the short term — if the actions leave addicted users without a reliable source of prescription painkillers, they may turn to more dangerous opioids like heroin, increasing their chances of overdose and death. But if the Justice Department’s work is paired with increased access to drug treatment, it may help.

The feds are shutting down pill mills

The opioid epidemic began in the 1990s, when doctors became increasingly aware of the burdens of chronic pain. Pharmaceutical companies saw an opportunity, and pushed doctors — with misleading marketing about the safety and efficacy of the drugs — to prescribe opioids. Doctors followed suit — in some states, writing enough prescriptions to fill a bottle of pills for each resident. With all this overprescribing, some patients became addicted to the drugs, while other patients left them out for their children to steal and misuse, gave away extra pills to friends and family, or sold them on the black market.

Some, but certainly not all, of the doctors doing this overprescribing have done it on purpose. Running what are called pill mills, these doctors tend to run clinics in which they give patients opioid prescriptions, typically for cash, with few questions asked. This allowed patients who were clearly buying the drugs either for misuse or to resell them to easily obtain opioids.

This is part of the problem the Justice Department countered in its latest action. According to the Washington Post, six of the doctors charged by the Justice Department allegedly ran a scheme in Michigan in which they doled out prescriptions to people who would often resell the drugs on the streets. Through this scheme, the doctors allegedly billed Medicare for $164 million in fraudulent claims.

The charges come on the heels of a report by the Office of Inspector General at the US Department of Health and Human Services that found almost 90,000 Medicare Part D beneficiaries (out of 43.6 million) are at “serious risk of opioid misuse or overdose,” yet managed to get the drugs from more than 400 prescribers.

By cracking down on these practices, the Justice Department hopes to not only take out existing pill mills but hopefully also deter future operations.

This is part of a broader effort from different levels of government to stem the supply of opioids in the US, which prescribes far more of the drugs than any other country in the world. The idea is simple: If you can cut off new patients who don’t really need opioids from getting the drugs, you will stop some of them from getting addicted — and potentially stop the crisis from getting worse.

In the past few years, these kinds of actions have worked to some extent: The number of opioid prescriptions has dropped every year since 2010, although the amount of opioids prescribed per person in 2015 was still more than triple what it was in 1999.

Ideally, doctors should still be able to get painkillers to patients who truly need them — after, for example, evaluating whether the patient has a history of drug addiction. But doctors, who weren’t conducting even such basic checks, are now being told to give more thought to their prescriptions.

The Justice Department also went after fraudulent treatment providers

Some of the other actions the Justice Department announced on Thursday focused on going after fraudulent drug treatment providers.

These kinds of operations, recently reported on by STAT and Politico, have essentially taken advantage of the opioid epidemic to make a quick buck. They work by recruiting people who are genuinely struggling with drug addiction, offering them the possibility of treatment as well as luxurious amenities. But when patients arrive, it turns out that the services provided are shoddy, if they even exist at all. And the people offering the services frequently have no proper training in dealing with addiction.

In some cases, these fraudulent treatment centers let their supposed patients use drugs in the facilities — and some even bought drugs for the patients. Meanwhile, they charged federal health insurance programs for the supposed care they offered.

David Armstrong at STAT gave an example:

A federal indictment alleges Eric Snyder fraudulently billed insurance companies for more than $58 million from 2011 to 2015. He owned a treatment facility, called Real Life Recovery Delray LLC, and a sober home where patients lived called Halfway There Florida LLC, also known as A Safe Place.

The investigation into Snyder’s facilities began in 2014.

Snyder allegedly employed a “junkie hunter” who recruited patients by paying hotel owners and front desk receptionists to call him if someone checked in who could be a potential treatment center client. One confidential witness alleged that a patient recruiter, Christopher Fuller, bought drugs for prospective clients.

The consequences were tragic. In Armstrong’s original story for STAT, 33-year-old Peter SanAngelo moved from Massachusetts to Florida, hoping to finally get the care he knew he needed so he could spend more time with his 4-year-old son. But he got pulled into an insurance scam, and after his insurance lapsed, he left his treatment facility. Three months after arriving in Florida, he died of a drug overdose.

The Justice Department’s actions must be paired with drug treatment

While the Justice Department’s actions may help slow the opioid crisis, there are limits to the law enforcement approach. In fact, there’s evidence that simply cutting back on the supply of opioids could make the crisis worse if it’s not paired with a boost to drug addiction treatment.

When a person is addicted to opioids, cutting them off from the drugs will make them go through painful withdrawal. Treatment, especially through medications like buprenorphine or methadone, can help avoid some of the worst effects of withdrawal.

But many patients don’t have access to treatment, perhaps because there are no clinics in their area or they don’t have the insurance coverage necessary to afford treatment. Rather than going through withdrawal alone in these cases, many drug users decide to go for opioids like heroin or fentanyl — which do avert withdrawal by satisfying opioid cravings, but can lead to even worse health outcomes, since both heroin and fentanyl are more potent and, therefore, deadlier than painkillers.

There’s good evidence this happened to many — but not all — prescription painkiller users: A 2014 study in JAMA Psychiatry found 75 percent of heroin users in treatment started with painkillers, and a 2015 analysis by the CDC found people who are addicted to painkillers are 40 times more likely to be addicted to heroin.

The fundamental problem is many of these patients didn’t get addiction treatment once they lost access to painkillers or before they progressed to heroin or fentanyl. Without the option of treatment, opioid users’ only answer to averting withdrawal becomes harder drugs.

That doesn’t mean that cracking down on pill mills is a mistake. By stopping doctors from unscrupulously prescribing the drugs, the feds potentially stopped these drugs from flowing to new users who didn’t really need opioids and could have developed addictions had they been allowed to get painkillers.

The problem, instead, is that addiction treatment remains inaccessible in America. A 2016 report by the surgeon general found that just 10 percent of Americans with a drug use disorder obtain specialty treatment. The report attributed the low rate to severe shortages in the supply of care, with some areas of the country, particularly rural counties, lacking affordable options for treatment.

One way to look at the problem, as explained by Stanford drug policy expert Keith Humphreys: There are essentially two populations with two different problems. On one hand, you have the current “stock” of opioid users who are addicted; the people in this population need treatment or they will simply find other, potentially deadlier opioids to use. On the other hand, not doing anything to stop new generations of potential drug users from accessing and misusing opioids would enable a new “flow” of people struggling with addiction.

So while the Justice Department’s actions are a positive step in stopping the crisis by addressing the “flow,” there’s another important issue — the “stock” — that needs to be addressed to stop the tremendous amount of death that’s come from this crisis.

But there’s no sign that lawmakers will actually address the “stock” problem anytime soon — and they may in fact make it worse. Experts widely believe the Republican health care bill currently in the works will actually make the crisis worse by cutting off people with substance use disorders from the insurance they need to pay for addiction treatment.