Yesterday Secretary of Health and Human Services Alex Azar used his emergency powers to override the restrictions that 22 states place on pharmacists vaccinating children over age 3.

As I noted in a previous post, a dangerous side effect of the COVID-19 pandemic is that many parents have not been bringing their children to the doctor’s office for their scheduled vaccinations. There are multiple contributing causes. In some cases, parents may be concerned about the expense. In others, they may be concerned that they or their children may get exposed to the virus. The timing of certain immunizations in children can be crucial and, for that reason, pediatricians and primary care practitioners have taken steps to provide immunizations in a safe, socially-distanced environment.

Despite an encouraging report from the Centers for Disease Control and Prevention that, as COVID-19 cases have declined in New York City, childhood vaccinations have increased, a rebound in vaccinations has not yet been detected in other parts of the country.

Pharmacists receive training and certification to perform immunizations in the course of their education. As far back as the late 1800s, pharmacists assisted physicians with smallpox vaccinations. While it wasn’t always this way, today all 50 states plus the District of Columbia and Puerto Rico allow licensed pharmacists to vaccinate patients. Some states require patients to hand the pharmacist a doctor’s prescription before they can be immunized. Twenty-two states don’t allow pharmacists to perform many vaccinations on children over age three, and three states—Connecticut, Florida, and Vermont— prohibit pharmacists from vaccinating any children.

Most pharmacists do not receive training to perform immunizations on children below age 3, and Azar’s emergency order only applies to children above that age.

Unsurprisingly, the American Academy of Pediatrics believes the emergency action is unnecessary while the American Pharmacists Association welcomed it.

The COVID-19 pandemic provides a lesson in how health care practitioner “scope of practice” laws don’t let health care professionals practice to the full extent of their training and thus restrict patients’ choice and access to health care.

While he should have done it sooner, Secretary Azar was right to issue this emergency order. State lawmakers should see this as an opportunity to permanently expand pharmacists’ legal scope of practice.

There is no link between nicotine in e‑cigarettes and E‑cigarette of Vaping Product-Use Associated Lung Injury (EVALI). EVALI cases have been traced to vitamin E acetate, used as a solvent for THC in black market vaping products. Flavored vaping products are preferred by adults who switch from combustible tobacco smoking to vaping. Yet none of these facts prevented a federal ban on flavored vaping products from going into effect last February. Not satisfied with a ban on flavored products, vaping opponents are now trying to leverage fear of COVID-19 infection as a means of preventing many adults from choosing to engage in an activity they find pleasurable.

A study published in the Journal of Adolescent Health looked at a national sample of adolescents and young adults and concluded:

“The findings from a national sample of adolescents and young adults show that electronic cigarette use and dual use of electronic cigarettes and cigarettes are significant underlying risk factors for coronavirus disease… Being diagnosed with Covid-19 was five times more likely among young people who have used e‑cigarettes ever.”

“…who have used e‑cigarettes ever.” Does that mean that if a person tries an e‑cigarette at a party and never does so again, that person is still at greater risk of contracting COVID-19?

Bear in mind that it has been illegal to sell vaping products to persons under age 18 since 2016.

Michelle Minton of the Competitive Enterprise Institute complained to Filter Magazine that the e‑cigarette users in the study had three times the COVID testing rate of 13 to 24-year-olds:

“Had the authors calculated risk based on testing rates, it would have shown no difference in COVID-19 cases between e‑cigarette users and non-users. But, that’s not how the authors chose to report their results.”

Leading Greek vaping researcher Konstantinos Farsalinos tweeted, “The study suggests that approx 40% of all diagnostic tests for COVID until May 14 were performed in 13–24 year olds.”

As soon as news of the study reached Congressman Raja Krishnamoorthy (D‑IL), a big opponent of vaping, he sent a letter on behalf of the House Subcommittee on Economic and Consumer Policy to Food and Drug Administration Commissioner Stephen Hahn that stated:

In view of this national study proving our worst fears, I respectfully reiterate my call on FDA to clear the market of all e‑cigarettes for the duration of the coronavirus crisis. It is the only responsible path forward.

The Subcommittee requests that you confirm, in writing, by August 18, 2020 whether or not the FDA will temporarily clear the market of all e‑cigarettes, and assuming it will, provide a written description of the FDA’s plan to do so.

We’ve seen this movie before. As with “reefer madness” and other drug war hysterics, vapophobia and e‑cigarette prohibition will only fuel a nascent and growing underground market. It will also deprive tobacco smokers of an effective means of harm reduction as they try to quit that decidedly unhealthy activity.

The story of one man’s stand on principle and the patients who were saved, from Jewish family weekly Mishpacha via Ira Stoll:

Early on, a talmid called with a complicated question. As an operator of several nursing homes, he was being forced to accept residents who’d tested positive for the virus as they were released from hospitals that no longer wanted them. Despite the clear danger to their current residents and staff, the nursing homes were being given no choice.

Rav Shmuel told him unequivocally that to accept these patients was a form of retzichah, murder, since it put the other residents at serious risk. But then, on a conference call, the governor informed all nursing home operators that failure to accept the patients would mean losing their licenses.

The talmid called Rav Shmuel again. Lose your license, the Rosh Yeshivah ruled, but you can’t put your elderly residents in danger.

The nursing home operator listened to his rebbi.

Weeks later, he stood tall as the only major nursing home operator in the state of New Jersey who didn’t lose a single resident to Covid-19.

The full article, a profile of Rav Shmuel Kamenetsky, is here.

Two weeks ago, a federal appeals court upheld the freedom of consumers to purchase health plans that are exempt from the Affordable Care Act’s costly regulations; that consumers can purchase year-round; and that can cover enrollees for a full year—including during the 10-month period that the ACA prohibits consumers from purchasing ACA plans. Short-term, limited duration insurance (STLDI) plans offer consumers additional choice. Since they are exempt from the ACA, they cost dramatically less than ACA plans and often offer greater choice of health care providers.

Last week, I published an oped in The Hill praising the appeals-court ruling. I noted that the lead plaintiff in the case is a lobbying group—the Association for Community Affiliated Plans—that represents private insurance companies who sell ACA plans. The group asked the courts to impose a rule that would throw STLDI enrollees out of those health plans after just three months. Insurance regulators at the National Association of Insurance Commissioners have warned such a rule would strip coverage from sick patients, leaving them uninsured for up to an entire year. As it turns out, the regulators were right: when that rule was briefly in place during 2017, it stripped Arizona resident Jeanne Balvin of her STLDI plan, leaving her with $97,000 in hospital charges and no coverage. The court agreed that the rule ACAP desires would create situations where sick STLDI enrollees “could be denied a new policy ‘based on preexisting medical conditions.’”

ACAP admitted in court both that it is seeking that rule because STLDI plans are cutting into its members’ revenues, and that it wants the courts to throw STLDI enrollees out of their plans after three months because that would improve its members’ revenues. I wrote:

Complaining that STLDI plans were cutting into their business, ACAP asked federal courts to remedy that “injury” by reinstating this heartless rule.

To be clear: ACAP is asking federal courts to improve its members’ bottom lines by stripping coverage from their competitors’ enrollees after three months, because doing so will frighten consumers into enrolling in ACAP members’ plans. ACA plans must not be very attractive if the insurers who sell them feel they cannot compete unless the government actively punishes people who choose their competitors’ plans.

Today, The Hill published an equal-length rebuttal by Margaret A. Murray, the head lobbyist for ACAP. The oped is heavy on rhetoric. It labels STLDI plans “junk insurance,” for example, a phrase that appears an average of once per paragraph. (More about junk insurance in a moment.) Worse, the oped gets crucial facts wrong.

It claims, incorrectly, that ACA plans neither deny coverage for preexisting conditions nor impose lifetime caps on benefits. On the contrary, for 10 months every year, ACA plans do both. In effect, and with few exceptions, the ACA prohibits enrollment in ACA plans except during a narrow window in November and December. During the other 10 months of the year, the ACA effectively offers a benefit limit of $0. As any honest ACA supporter will tell you, the purpose of that restriction is to block people with preexisting conditions from enrolling in coverage during those 10 months.

For 10 months every year, therefore, STLDI plans offer more comprehensive coverage than ACA plans. You can see for yourself: call up one of the insurance companies Ms. Murray represents and one STLDI issuer, tell them you would like to enroll in one of their health plans right now, and see how much coverage each insurer offers you.

ACA plans deny coverage to people with preexisting conditions in other ways as well. Last week, the Cato Institute held a forum exploring the case of seven-year-old leukemia patient Colette Briggs. ACA-participating plans have repeatedly dropped coverage for Colette’s cancer treatment. Colette’s parents have had to fight with insurance companies, plead with Congress, and go to the media to get ACA plans to cover Colette’s care. They often failed.

ACA plans are treating Colette this way for the same reason economists have found ACA plans are getting increasingly worse for patients with other expensive illnesses: the ACA literally rewards insurers who discriminate against such patients in these ways. Chances are extremely high that ACAP’s members are doing the same. (Who’s selling junk insurance now?) If both ACA and STLDI plans have downsides, why not let consumers decide which they prefer?

There are plenty of other problems with Murray’s oped. It claims STLDI plans engage in misleading marketing, yet it neither substantiates that allegation nor acknowledges the ACA owes its existence to misleading marketing. (Sprechen Sie, “If You Like Your Health Plan, You Can Keep It”?) It derides measures that protect consumers and insurers from fraud as if they were some evil plot. It fails to recognize that when STLDI plans offer less coverage than ACA plans, they are reflecting consumers’ preferences.

But the biggest problem with Murray’s oped is its refusal to take responsibility for ACAP’s actions. Insurance regulators and a federal court have warned ACAP’s desired rule will strip coverage from, and deny care to, sick patients. ACAP has admitted in federal court that it is pursuing that rule in order to improve its members’ bottom lines. Murray’s oped blames everyone else in sight for the damage everyone knows her organization’s actions would cause in the pursuit of more money for its members.

In the most recent issue of Public Health Reports, the official journal of the U.S. Public Health Service, Surgeon General Jerome Adams restated his strong support of syringe services programs (SSPs). While most people know of them as “needle exchange programs,” “syringe services programs” more accurately describes them because they actually provide a much wider array of services in addition to providing clean needles and syringes to people who inject drugs.

As Dr. Adams pointed out when he spoke at the Cato Institute last January, such programs distribute opioid overdose antidote naloxone, offer screening tests and treatment referrals for HIV and hepatitis C, and have brought many users with substance use disorder into rehab programs. With the advent of the COVID-19 pandemic SSPs can also provide COVID-19 testing.

Dr. Adams’ commentary in Public Health Reports detailed the long and proven track record of SSPs in reducing the spread of HIV and hepatitis. Now that they are distributing naloxone, they are likely to reduce overdose deaths.

The federal government does not prevent states from legalizing SSPs, and the Surgeon General along with the National Academy of Sciences, Engineering and Medicine are encouraging states to allow them to proliferate. Unfortunately, state-based drug paraphernalia laws make them illegal in 20 states. My state of Arizona is one of them.

Hopefully, if the Surgeon General continues to promote them, lawmakers in the holdout states will soon come to their senses.

The COVID-19 pandemic has placed another stumbling block in the way of the Drug Enforcement Administration’s futile effort to reduce the country’s drug overdose rate through quotas on the manufacture of all forms of prescription opioids.

The DEA’s annual quotas have brought production levels more than 50 percent below 2016 levels. But, in response to the COVID-19 pandemic, the agency increased this year’s quota by 15 percent, to allow drug makers to respond to pandemic-induced shortages. Intravenous opioids such as fentanyl are valuable tools used to manage patients on ventilators—as well as inducing general anesthesia—and the DEA recognized the pandemic would likely increase demand for such drugs. Unfortunately, the agency conflates prescription opioid pills used in the non-hospital setting with intravenous opioids like fentanyl and morphine, almost exclusively used in hospitals, when it adjusted the manufacturing limits.

This has generated a shortage of intravenous opioids, causing many hospitals to cancel or delay necessary procedures and has jeopardized the management of patients on ventilators, according to a July 22 report from the hospital policy group Premier.

This is not the first time that DEA opioid production quotas caused a critical shortage in hospitals. I wrote here about the shortage the agency helped create in 2018.

While hospitals and patients suffer from the DEA’s war on opioids, fentanyl and other IV opioids are plentiful on the street. We learned last week in a preliminary report by the Centers for Disease Control and prevention that drug overdose deaths increased from 67,367 in 2018 to 70,980 in 2019. And deaths attributable to fentanyl increased by 15 percent, from 31,529 in 2018 to 36,509 in 2019.

Policymakers continue to believe that reducing the prescribing of opioids will somehow lead to a reduction in their non-medical use, addiction, and overdose deaths. This false hope persists despite the fact that data from the CDC and the National Survey on Drug Use and Health show no association between prescription volume and non-medical opioid use or addiction.

The drug overdose crisis is caused by non-medical users accessing drugs in the dangerous black market that is fueled by drug prohibition. But drug prohibition doesn’t only harm non-medical drug users. It harms patients as well—including critically ill patients in hospitals.

National Public Radio released an investigative report today showing that doctors and dentists are still prescribing opioids for pain management at “rates widely considered unsafe.”

This persistent focus on the number of pills doctors prescribe defies justification in light of the fact that data from the Centers for Disease Control and Prevention and the National Survey on Drug Use and Health consistently reveal no association between prescription volume and the non-medical use of prescription opioids or addiction.

And despite the overall prescription volume coming down dramatically since 2012 (the year the volume peaked), overdose rates continue to climb. In fact, the overdose rate climbed as prescription rates came down. We learned this week that overdoses in 2019 are up considerably over the previous year and the situation this year is exacerbated by the COVID-19 crisis.

Meanwhile, what prescription amounts that are “widely considered safe” is a matter for debate. The CDC in 2019 issued a memo claiming policymakers were misapplying and misinterpreting the opioid prescribing guidelines they published in 2016, and reminded policymakers that they were meant to be suggestive, not prescriptive. Around the same time a Department of Health and Human Services Pain Management Best Practices Inter-Agency Task Force issued a report calling for the individualization of pain management practices, deferring to practitioners to weigh the risks and benefits when recommending medications and dosages to their patients. And the American Medical Association in June came out against governments imposing prescription and dosage limitations.

NPR should take note of the developments over the past nine to ten years since the press and policymakers adopted the mantra that opioid prescriptions must be brought down to end the overdose crisis and change its focus to the real cause of the overdose crisis: drug prohibition.