In the wake of a March report from the Centers for Disease Control and Prevention (CDC) that drug overdose deaths climbed to a record 106,000 for the 12 months ending November 2021 (last November the agency reported 100,000 overdose deaths for the 12 months ending April 2021), the White House Office of National Drug Control Policy published a National Drug Control Strategy today.

On the positive side is ONDCP’s new appreciation for the benefits of harm reduction for reducing the risk of death and disease from using drugs obtained in the dangerous black market. The strategy includes a renewed emphasis on making the opioid overdose antidote naloxone more widely available. Unfortunately, the White House stops short of ordering the Food and Drug Administration to reclassify naloxone from prescription-only to over-the-counter, as I have written about here and here. As my colleague David Hyman and I spelled out in a Capitol Hill Briefing in October 2019, it is well within the power of either Congress or the Executive to make this happen.

The National Drug Control Strategy also calls for expanding evidence-based harm reduction strategies such as syringe services programs, and distributing drug testing devices such as fentanyl test strips.

Unfortunately, state-level drug paraphernalia laws are the big obstacle to the creation of syringe services programs and the distribution of testing devices. Many states still have laws that prohibit or severely curtail such programs despite the fact they are not federally illegal. Therefore, state lawmakers should repeal drug paraphernalia laws to clear the way for these proven harm reduction strategies.

The National Drug Control Strategy call for expanding Medication Assisted Treatment programs that use methadone or buprenorphine to treat addiction. But federal regulations stand in the way.

Congress can repeal the so-called “X‑waiver” that doctors must obtain in order to prescribe buprenorphine, and it can pass legislation permitting primary care providers to prescribe methadone on an ambulatory basis to treat addiction (as is done in the U.K., Canada, and Australia since the 1970s). I discussed these reforms in detail in a Statement for the Record I submitted to the Subcommittee on Health of the House Energy and Commerce Committee last April. Alas, the new drug control strategy makes no call for such reforms.

Another action that the federal government can take, but was not mentioned in the White House report, is for Congress to repeal the so-called “Crack House Statute,” so that local communities can establish Safe Consumption Sites—a time-tested means of reducing overdose deaths, in use throughout the developed world (there are 38 such sites in Canada alone), but federally prohibited in this country.

On a negative note, the remainder of the new report calls for doubling down on interdiction, border control, and other law enforcement measures aimed at curtailing the supply of illicit drugs—as if repeating the same failed strategies of the past half century, only with more gusto, will somehow work.

Oregon voters recently decided to try a new approach, and decriminalized all drugs within its borders while redirecting drug war resources to harm reduction strategies. Lawmakers in other states are watching Oregon closely and considering similar approaches.

While the new National Drug Control Strategy is an improvement over previous strategy, it would have been groundbreaking and visionary if the report had encouraged states to establish decriminalization pilot programs and allow the 50 “laboratories of democracy” to find ways toward a more realistic and humane drug policy.

After being nearly absent in 2020 and 2021, influenza cases are making a comeback. In fact, cases are up-ticking unusually late in the year. The Centers for Disease Control and Prevention (CDC) reported on April 15 that the majority of cases are H3N2, “antigenically different from the vaccine reference viruses.” This explains why the latest flu vaccine is only 16 percent effective in reducing the chances of a moderate to severe infection. As of April 15, the CDC reported at least 4.3 million flu illnesses, 42,000 hospitalizations, and 2,500 deaths from the flu.

Public health experts attribute the rise in flu cases to the resumption of pre-COVID social activity. People are crowding in public places with less social distancing along with less mask-wearing. While the former undoubtedly is a contributing factor, the latter is more uncertain. Although debate continues over the efficacy of wearing face masks for COVID, prior to 2020 most public health researchers agreed masks have no proven efficacy, whether N95 or surgical, for preventing influenza.

However, another factor not receiving enough attention is the phenomenon called viral interference. This is where two or more viruses compete for the same host. When the 2009 H1N1 pandemic hit continental Europe, an ongoing rhinovirus infection in France delayed the H1N1 influenza virus from impacting that country for several months. Similarly, the more contagious Delta variant of COVID outcompeted and replaced its predecessor Alpha variant and then was replaced by the more contagious Omicron variant. And the BA.1 Omicron subvariant is being replaced by its more contagious cousin, the BA.2 subvariant. It is likely that a combination of increased socialization and reduced competition from a now-waning COVID-19 pandemic is responsible for the re-emergence of the influenza virus. In fact, one might view the return of influenza as a sign that the COVID virus’s presence is declining.

People with symptoms of an upper respiratory infection are, understandably, testing themselves for COVID. When they test negative, some seek professional medical attention and, if they test positive for influenza, many are then prescribed the antiviral Tamiflu. Tamiflu works best if taken during the first two days of the illness.

Unfortunately, unlike the COVID tests, the Food and Drug Administration (FDA) has only approved at-home, self-administered influenza tests that require the patient to send in the specimen to a lab, and they get results in a couple of days—often too late to take Tamiflu. On the other hand, a doctor’s office or urgent care center can perform flu tests that give an answer in 15 to 30 minutes. Because many people don’t want the expense and inconvenience of a visit to the doctor’s office or urgent care center, many don’t bother to get tested for influenza—they just tough it out without the benefit of Tamiflu. This also means the CDC is likely undercounting influenza cases.

In response to the COVID emergency, the U.S. Department of Health and Human Services recommended that states permit pharmacists to perform COVID tests without a doctor’s supervision, and most states followed suit. This past March the Biden Administration implemented “test to treat,” where patients can bring their at-home, self-administered positive test result to a designated pharmacy and the pharmacist will then prescribe one of the new and effective COVID antiviral pills. One problem is that the only pharmacies designated to participate are those that house pharmacy-based clinics. This severely limits patients’ options and many are unable to take advantage of the “test to treat” program. The administration should let all pharmacists—not just those working in pharmacy-based clinics—to prescribe the antivirals.

Yet people with influenza currently get less access to diagnosis and treatment than people suspected of having COVID. There’s no “test to treat” program for influenza. Policymakers should apply the lessons learned from the COVID pandemic and allow patients to purchase, and use at home, the same self-administered rapid result influenza antigen tests that health care practitioners use. Patients with positive tests should then be able to purchase Tamiflu directly from pharmacists.

In 1971, Faraday labs began direct-to-patient marketing of the same urine pregnancy test it had marketed to physicians. The FDA objected but lost a federal lawsuit when it demanded Faraday cease direct-to-patient sales. Unfortunately, this led Congress, in 1976, to pass the Medical Device Amendment (MDA) to the Food, Drug, and Cosmetic Act of 1938. As attorney Shelby Baird wrote, and Professors Nita A. Farahany and Jessica Flanigan discussed at an online Cato Institute policy forum in January, 2021, the FDA has abused the MDA to infringe on the fundamental right of individuals to test themselves for medical conditions.

Many states have expanded their scope of practice laws to take advantage of pharmacists’ expertise. Some allow them to prescribe hormonal contraceptives, HIV pre- and post-exposure prophylaxis, and perform most vaccinations. And during the COVID pandemic, most states permitted pharmacists to perform COVID tests. Yet only one state, Idaho, permits pharmacists to perform influenza nasal swab tests and prescribe Tamiflu to patients who test positive. Other states permit pharmacists to test and treat, but only if they have “collaborative practice authority” (CPA) from a physician. CPAs are agreements that physicians and pharmacists negotiate that expand pharmacists’ scope of practice. The pharmacists agree to being supervised by a physician in the community or state. While a step in the right direction, this still restricts patients’ options and access to affordable care. Pharmacists should be allowed to practice to the full extent of their training without requiring CPAs with physicians. As Courtney M. Joslin and I wrote here, states should greatly increase pharmacists’ scope of practice to improve health care access and affordability.

When policymakers removed many of the regulatory obstacles to COVID testing and treatment to address the public health emergency, they tacitly recognized how federal and state regulations block patients from quick, convenient, and affordable health care. Policymakers should avoid tunnel vision. Quick, convenient, and affordable health care should not be restricted to COVID patients—or to people with the flu, for that matter. It should be available to everyone.

On November 11^th and 12^th, 2022, the Cato Institute will host its inaugural Junior Academics Health Policy Symposium, a paper workshop for pre-doctoral academics on topics relating to health policy.

The symposium seeks to encourage participants to approach health policy questions from a market-based perspective. Through a competitive selection process, Cato will offer up to 12 junior scholars the opportunity to present and receive feedback on research from their peers and distinguished academics.

Papers should be original and journal-article length. The symposium will focus on presentations, discussion, and feedback from peers and reviewers, with the expectation that authors will seek publication or build on these ideas in future research.

Paper topics may include but are not limited to the effects of competition in insurer and provider markets, long-term insurance contracts, moral hazard, and government rate-setting, including risk-adjustment.

The workshop will take place in-person at the Cato Institute in downtown Washington, D.C. Please note that COVID-19 related protocols may apply. Cato will provide participants with a stipend of $500 and cover reasonable travel and accommodation costs.

To apply, submit an abstract of no more than 500 words detailing your research project to aperez@​cato.​org by July 1^st. A curriculum vitae should accompany the abstract. Candidates must have completed at least one year of graduate study in health policy, economics, public policy, or a related field by the workshop’s date. We will notify all candidates of the status of their application by July 29^th, and their papers will be due on October 21^st.

In 1969, Denmark became the first country to legalize pictorial and audiovisual pornography, so it is acutely painful to see its government take a new puritanical turn.

The Health Ministry has already set the goal of raising the alcohol drinking age from 16 to 18. And last month, Denmark’s health minister announced plans to ban the sale of tobacco and nicotine products to anyone born after 2010. This way, the Health Ministry hopes to gradually phase out the use of all tobacco and nicotine products in the country. The Health Ministry took this action to address the 13,600 annual deaths from smoking-related cancer in the country.

Currently, such sales are banned for people under age 18. A Danish government survey found 31 percent of 15- to 29-year-olds smoke. This means that the black market is already serving a significant number of 15- to 18-year-olds. Does the Health Ministry think banning the sale of tobacco products to people born any time after 2010 will not cause a surge in underground sales—and all the side effects (from adulterated tobacco products to violent crime) that entails?

Not surprisingly, the Danish Health Ministry finds that two-thirds of 18- to 34-year-olds are OK with the proposed ban. They were all born before 2010.

While it was the first country to legalize porn, Denmark was not the first country to phase in tobacco prohibition. New Zealand announced last year that, beginning in 2022, it plans to ban the sale of tobacco products to anyone born prior to 2008 and to gradually raise the minimum age for adults to buy tobacco products every year beginning in 2023.

It’s one thing to ban the sale of certain products to minors and another to prohibit sales to adults. Prohibition violates adults’ right to ingest or otherwise consume into their bodies whatever they choose, assuming any risk that comes with it. Prohibition is also a money maker for black marketeers as well as a jobs program for the law enforcement industry required to enforce it.

H.L. Mencken humorously defined puritanism as “the haunting fear that someone, somewhere, may be happy.” Putting puritanism into policy has not-so-humorous consequences.

John Oliver made an excellent case for shifting from a war on drugs to a war on drug related deaths on the March 27, 2022 edition of Last Week Tonight on HBO. You can view it here.

In a little over 15 minutes, Oliver explained the rationale behind the harm reduction strategy: realism. Harm reduction advocates understand we will never attain a drug-free society, and that it therefore makes sense to make illicit drug use safer.

Oliver called for the Food and Drug Administration to make the opioid overdose antidote naloxone an over-the-counter drug, as I have been saying since 2018. In 2019, Cato adjunct scholar David Hyman and I conducted a Capitol Hill Briefing to make the case to congressional staff, which included a naloxone training session.

Oliver debunked the myth, popularized on TV dramas, that even close proximity to fentanyl can cause an innocent bystander to die from an overdose.

He mentioned the benefits of syringe services programs, also referred to as a “needle exchange.” In January 2020, then-Surgeon General Jerome Adams and University of Southern California Medical School Professor Ricky D. Bluthenthal addressed a Cato audience supporting that strategy.

Oliver discussed the benefits of safe consumptions sites and how the so-called “Crack House Statute” prevents them from saving lives in the U.S. I moderated an excellent panel discussion on that subject at a harm reduction event in Cato’s Hayek Auditorium in 2019, featuring Darwin Fisher, the Program Manager of Insite in Vancouver, B.C. (the oldest safe consumption site in North America), former Pennsylvania Governor Edward G. Rendell (a principal of Safehouse, a privately-funded organization attempting to set up a safe consumption site in Philadelphia), and Cato Senior Vice President for Legal Studies Clark Neily.

The U.S. lags well behind much of the developed world in employing harm reduction strategies. (Of course, the ultimate harm reduction strategy would be to end drug prohibition.) But harm reduction is finally beginning to gain acceptance in this country, and hopefully John Oliver added momentum to the cause. As I watched his monologue I almost shouted at the screen, “You complete me.” Instead, I’ll opt for, “You had me at over-the-counter naloxone.” 

h/​t Jerry Maguire.

Here is a poor, unsuccessful letter I sent to the editor of Health Affairs.

Kudos to Y. Tony Yang and Diana J. Mason [“COVID-19’s Impact On Nursing Shortages, The Rise Of Travel Nurses, And Price Gouging,” Jan. 28] for shining a light on the growing problem of hospitals recognizing the value of nurses and paying them accordingly.

Congratulations also to Minnesota, Illinois, and Massachusetts for enacting legislation to ban this practice.

Without such advocacy on behalf of hospital administrators, nurses might start getting funny ideas about their worth.

During his State of the Union Address last week, President Biden announced a plan to make it easier for people to get access to the new antiviral drug Paxlovid. This drug, if taken during the first 3 to 5 days of a symptomatic COVID infection, is 89 percent effective in preventing the case from progressing to hospitalization or death. Under the plan, dubbed “test to treat,” people with symptoms may go to a designated pharmacy, community health center, nursing home, or supermarket, where a pharmacist can perform the test for COVID and, if it returns positive, prescribe the antiviral drug to the patient at the same time. This is a positive move.

As Josh Bloom of the American Council on Science and Health and I wrote last January, when the Food and Drug Administration granted Emergency Use Authorization to the drug, it required patients to get a prescription for the drug from a health care practitioner once they test positive on a COVID test. It can be very difficult for patients to get the test result and the doctor appointment within the critical 3 to 5 day window after symptoms commence in order to ensure the drug will work. By allowing patients “one stop shopping” where they can get the test and the prescription from a pharmacist, the new policy works around that problem.

Unfortunately, the American Medical Association (AMA) poured cold water on the idea in a statement it released on March 4:

The AMA is pleased the administration is ramping up supply of antivirals so in the near future they will be broadly available. But, in the meantime, establishing pharmacy-based clinics as one stop shopping for COVID-19 testing and treatments is extremely risky. Pharmacy-based clinics typically treat simple illnesses such as strep throat. Yet, COVID-19 is a complex disease and there are many issues to consider when prescribing COVID-19 antiviral medications. Leaving prescribing decisions this complex in the hands of people without knowledge of a patient’s medical history is dangerous in practice and precedent. We urge patients who test positive for COVID-19 to contact their physician to discuss treatment options. COVID-19 is not strep throat—it is a complicated disease that has killed nearly 1 million people in the United States.

The AMA understandably worries about “scope creep,” i.e., expansions in the scope of practice of the various adjunct and/​or competing licensed health professions. For example, state chapters of the AMA frequently fight attempts by nurse practitioners and physician assistants to deliver primary care and other services to patients. They always claim to be concerned about patient safety but are arguably concerned about the competition as well. As I have written here and here, it is in the best interest of patients for states to expand the scope of practice of the various health professions to enable them to practice to the full extent of their training. This gives patients greater choice and access to health care.

The AMA points out that Paxlovid can interact with many other drugs a patient may be taking. For example, Paxlovid can interact with statin drugs (used to treat high cholesterol) and several sedatives and blood thinners. The AMA claims people should consult a physician if they get a positive test.

As a doctor, I don’t want to discourage people from consulting physicians for medical advice. But pharmacists are experts at recognizing and avoiding drug-drug interactions. In fact, we doctors frequently consult pharmacists for that very reason when we prescribe medications to patients who are taking multiple other medications. And it is not uncommon for prescribing physicians to get phone calls from pharmacists informing them that a drug they prescribed interacts with another drug their patient is taking and suggesting an alternative medication. Pharmacists have the training—and the software—to identify drug-drug interactions.

Multiple states permit pharmacists to prescribe oral contraceptives and pre-and post-exposure prophylaxis for HIV. Every state permits pharmacists to give vaccinations for various illnesses. I wrote this policy analysis with Courtney Joslin of the R Street Institute that argues for expanding pharmacists’ scope of practice to greatly improve access to and the affordability of health care for millions of consumers.

Sadly, at times, the goals of the AMA don’t align with the goals of patients. Its continuing battle against “scope creep” can be seen as just another form of protectionism.