Absolute must-watch: 60 Minutes on how pharmaceutical distributors fueled the opioid crisis

In a blockbuster investigation carried out along with the Washington Post, 60 Minutes’ Bill Whitaker looks into allegations that powerful pharmaceutical distributors helped advance the current opioid crisis by fulfilling patently suspicious orders for prescription opioids. The piece cites one example where a pharmacy in a West Virginia town with a population of several hundred ordered and received millions of opioid pills.

The main source for the piece is Joe Rannazzisi, former head of the Drug Enforcement Agency’s Office of Diversion Control. Rannazzisi charges that as his office was planning to prosecute some of these distributors, a bill passed by congress — and signed by President Obama — neutered any power the DEA had to pursue these cases. He notes that many of the legislative and agency workers involved in crafting the bill have exited through the revolving door into lucrative positions as lobbyists and industry lawyers. Rep. Tom Marino of Pennsylvania, who introduced the bill, has recently been nominated by President Trump for the position of Director of the Office of National Drug Control Policy.

Absolutely essential viewing. To read the accompanying Washington Post story, click here.

Tox Tunes #111: Girl on LSD (Tom Petty)

Although this Tom Petty song is somewhat obscure, I’m embarrassed to say I hadn’t know about it until an article in The Cannabist after the singer’s death last week brought it to my attention. The song appeared as the B-side to “You Don’t Know How It Feels” and was scheduled to be on Petty’s 1994 album Wildflowers, but the record company (Warners) objected because of its content.

The New York Times has posted a guide with links to 14 essential Petty tracks. By the way, in a brilliant cold open to “Saturday Night Live” yesterday following the mass shooting tragedy in Las Vegas, Jason Aldean covered Petty’s “I Won’t Back Down” — a song that for some unfathomable reason was left off the Times‘ list:

 

 

ACMT Position Statement: Toxicology Issues in Determining Brain Death

4 out of 5 stars

ACMT Position Statement: Determining Brain Death in Adults After Drug Overdose. Neavyn MJ et al. J Med Toxicol 2017;13:271-273.

Full Text

The American Academy of Neurology guidelines on determining brain death in adults states that the clinician can not make such a determination unless he or she can  “[e]xclude the presence of a CNS-depressant drug effect by history, drug screen, calculation of clearance using 5 times the drug’s half-life (assuming normal hepatic and renal function), or, if available, drug plasma levels below the therapeutic range.”

Excluding drug effect in these cases is not at all straightforward, and this position statement — developed by the American College of Medical Toxicology and endorsed by both the American Academy of Clinical Toxicology and the Society of Critical Care Medicine — discusses the crucial nuances that must be considered.

The authors note that a drug screen can neither exclude intoxication nor establish a clinical significant depressant effect. They also point out that while a period of 5 half-lives in generally considered time enough for a drug to be essentially eliminated from the system, in overdose situations all bets are off. In overdose, standard assumptions about rates of drug absorption and elimination go out the window. In addition, with massive overdose, the amount of drug remaining in the CNS can still be clinically significant. For example, although baclofen has a half-life of 2 -4 hours, one reported case of baclofen-induced coma mimicking brain death lasted for 7 days.

Although determination of brain death is an extremely complex matter, there are 3 essential components:

  1. establishing a clear, irreversible and proximate cause
  2. demonstrating lack of brain function, and
  3. eliminating reasonable possibility toxic etiology

In a 2013 column in Emergency Medicine News, I reported on a case from Syracuse NY where a 41-year-old woman was declared brain dead and sent to the operating suite on her 5th hospital day so that her vital organs could be harvested. Just as the surgical procedure was beginning, she opened her eyes and began to look around at the OR lights. Afterwards when she was able to give a history she admitted taking a massive overdose of baclofen. When the case was reviewed, it was determined that the clinical team had neither established a clear alternative explanation for brain death, nor established lack of brain function. If the principles stressed in this brief position statement had been adhered to, this near catastrophe could have been avoided.

Related Posts:

TPR Podcast #4: Poisoning and the diagnosis of brain death

Official report about overdose patient who awoke in OR just before surgeons
harvested her organs

Hospital fined after overdose awakes just before surgeons harvest her organs