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Tag: opioid prescribing

  • Is The Opioid Lobby Behind Attacks On The CDC Prescribing Guidelines?

    Is The Opioid Lobby Behind Attacks On The CDC Prescribing Guidelines?

    “Opioid manufacturers stand to lose substantial profits with the widespread adoption of the CDC guideline. Public health, however, benefits from the guideline, and attacks on it bear industry’s fingerprints.”

    Since the Centers for Disease Control and Prevention (CDC) issued guidelines around prescribing opioids in 2016, there has been controversy over whether the recommendations are appropriate. One group believes that this skepticism is being fed by a coordinated effort by the pharmaceutical industry to undermine the guidelines.

    Writing for STAT News, Dr. Adriane Fugh-Berman, Judy Butler and Ben Goodwin point out the many ways that the pharmaceutical industry has influenced organizations that have spoken out against the CDC guidelines.

    The authors are all associated with PharmedOut, an initiative from Georgetown University Medical Center that aims to bring awareness to pharmaceutical marketing and promotes evidence-based prescribing.

    The authors point out that no one has disputed the crux of the CDC guidelines.

    “Criticism of the guideline follows a consistent pattern: no evidence provided to refute any statement in the guideline and no evidence provided for the critics’ claims,” they write.

    Yet, the constant criticism points to a coordinated effort.

    “The eerily similar attacks on the guideline, and the subsequent spinning of the CDC’s we-meant-what-we-said responses to critics as some kind of admission of error or inadequacy, raise the question of whether this is a coordinated attempt by opioid manufacturers to use third parties to undermine, discredit, and smear the guideline,” the authors wrote.

    Groups including the American Academy of Pain Management and even the American Cancer Society Cancer Action Network, which spoke out against the guidelines, received funding from industry groups, the authors note.

    In fact, a 2017 analysis found that “opposition to the guidelines was significantly more common among organizations with funding from opioid manufacturers than those without funding from the life sciences industry.” It also found that no groups disclosed their opioid-related funding when formally submitting comments on the CDC guidelines.

    The authors also pointed out that a 2019 letter against the recommendations drafted by Health Professionals for Patients in Pain and signed by 300 providers received extensive press coverage, while a similar letter in support of the guidelines drafted by PharmedOut received very little coverage.

    Even chronic pain patients can have their stories hijacked for the bottom line of opioid manufacturers, the authors said.

    “It is essential that we not abandon patients on long-term opioids—but it is also important that we not create more of them,” they wrote.

    Ultimately, the CDC guidelines will cut down on profits, and that has the industry fighting against the guidelines, the authors wrote.

    “Opioid manufacturers stand to lose substantial profits with the widespread adoption of the CDC guideline,” they said. “Public health, however, benefits from the guideline, and attacks on it bear industry’s fingerprints.”

    View the original article at thefix.com

  • Medical Schools Rethink Training Amid Opioid Epidemic

    Medical Schools Rethink Training Amid Opioid Epidemic

    Some medical schools around the country have begun to change the conversation around pain management.

    Medical schools are rethinking how they train doctors in pain management and addiction treatment, in hopes of graduating a generation of medical professionals that are better able to serve the needs of patients living amid the opioid epidemic. 

    In a recent role-play exercise at the Warren Alpert Medical School of Brown University, students talked to a patient about her back pain, and learned to ask an important question: “Have you ever taken any medications that weren’t prescribed to you?” 

    “To be perfectly honest I stopped buying the Percs because they were too expensive, and I started buying heroin, because it was cheaper. I’ve been doing the heroin for the past 5 months,” the woman playing the patient replied. 

    Dr. Paul George, associate dean of medical education at Brown, told WBUR that the exercise is a realistic representation of what pain doctors may face. “The point of that workshop is for the students to work together to show it really does take a team to care for folks who are using substances inappropriately,” he said. 

    Recently, Brown and the University of Massachusetts (UMass) were both recognized by the Association of American Medical Colleges for their proactive approaches to teaching medical students about pain management and addiction. 

    At UMass, Jill Terrien teaches graduate-level nursing students to talk to their patients about pain. Rather than treating pain as the fifth vital sign and aiming to mitigate it, Terrien encourages nurses to tell patients that they should expect some pain after undergoing major procedures like surgery. 

    “In our curriculum now, we’re more deliberate about [telling patients] ‘you’re going to have pain,’” she said. “That way patients don’t expect that a) they’re going to get opioids because that’s what they’ve always gotten, and b) that might not be the best treatment for them.”

    In addition to changing the conversation around pain management, UMass and Brown both provide all medical students the training they will need to prescribe buprenorphine, a medication commonly used for medication-assisted treatment.

    Currently, under 7% of doctors hold the waiver needed to prescribe buprenorphine, and the medical schools feel that needs to change. 

    “They can prescribe Oxycontin, they can prescribe morphine. It seems almost unfair they can’t prescribe a medication that is used to treat some of the consequences of prescribing opioids,” said Sarita Warrier, associate dean of medical education at Brown.

    Paul Wallace, who recently graduated from medical school at Brown, agreed. 

    He said, “It helps dispel the notion that treating opioid use disorder is purely the domain of addiction specialists or primary care doctors, when truly all different types of physicians are going to encounter patients with opioid use disorder, whether it’s an emergency physician seeing a patient after an overdose or an obstetrician working with a patient with opioid use disorder.”

    View the original article at thefix.com

  • Doctor Receives 20-Year Sentence For Reckless Opioid Prescribing

    Doctor Receives 20-Year Sentence For Reckless Opioid Prescribing

    The Manhattan doctor was convicted on 10 counts of unlawful distribution of oxycodone without legitimate medical purpose.

    A family doctor based in Manhattan’s Upper East Side was sentenced to 20 years in prison on Tuesday (April 30) for recklessly prescribing opioid painkillers that played a role in one patient’s fatal overdose.

    Dr. Martin Tesher, 83, was convicted in July of 10 counts of unlawful distribution of oxycodone without legitimate medical purpose to five patients, including 27-year-old Nicholas Benedetto.

    In March of 2016, two days after visiting Tesher and receiving prescriptions for oxycodone and fentanyl patches, Benedetto fatally overdosed on the drugs.

    According to SILive.com, one month before his death, Benedetto’s mother called Tesher asking him to stop giving her son prescriptions because he needed treatment. She told authorities that her son was smoking the fentanyl patches.

    Tesher prescribed oxycodone and fentanyl patches to Benedetto and four other patients “after he learned, or had reason to believe, that these patients were addicted to drugs,” according to the Justice Department.

    An expert witness testified that none of them “had verified medical conditions that would require the prescription of Schedule II opioids.”

    Benedetto, while under the doctor’s care, tested positive for cocaine, heroin, morphine and methadone in addition to the oxycodone and fentanyl prescribed by Tesher.

    Twenty years was the minimum sentence Tesher faced for his crime. The maximum was life in prison.

    “In the midst of an unprecedented opioid epidemic, Dr. Tesher used his medical skills to harm, not heal and in doing so he cost a young man his life,” said U.S. Eastern District Attorney Richard Donoghue. “Such criminal conduct is an utter betrayal of the trust our society places in doctors and it warrants the severe sentence imposed today.”

    The DOJ has recently cracked down on health care providers and drug companies accused of playing a role in fueling the opioid crisis.

    Also last month, 60 people were indicted for the illegal prescribing of painkillers including doctors, pharmacists, nurse practitioners and other licensed medical professionals.

    According to the Washington Post, the indictment included “doctors who prosecutors said traded sex for prescriptions and a dentist who unnecessarily pulled teeth from patients to justify giving them opioids.”

    View the original article at thefix.com

  • Oklahoma Lawsuit Against Purdue Pharma Settles For $270 Million

    Oklahoma Lawsuit Against Purdue Pharma Settles For $270 Million

    The bulk of the settlement will go to Oklahoma State University to fund an addiction treatment center and addiction treatment medicine.

    The first lawsuit of around 2,000 filed against Purdue Pharma and other drug manufacturers/distributors has settled for $270 million, Reuters reports. The money which will go toward mitigating the opioid crisis.

    The lawsuit was filed by Oklahoma Attorney General Mike Hunter and would have gone to court in May.

    It accused pharmaceutical companies Purdue Pharma (the maker of OxyContin), Johnson & Johnson, and Teva Pharmaceutical Industries of deceptive marketing that fueled the national opioid epidemic.

    The $270 million settlement is with Purdue Pharma only, so Johnson & Johnson and Teva are still expected in court on May 28 of this year.

    According to Reuters, the state of Oklahoma was seeking a total of $20 billion in damages caused by opioid addiction and overdose. The bulk of the $270 million from the settlement will be granted to Oklahoma State University to fund an addiction treatment center and addiction-fighting medications.

    $12.5 million will be given to local governments to help them recover from the opioid epidemic, and $60 million will be paid in legal fees. Members of the Sackler family who own Purdue Pharma will pay an additional $75 million to the university.

    This settlement has been encouraging news for critics of drug companies who believe this is a sign of more settlements to come. Purdue Pharma had been considering bankruptcy as a way to halt the roughly 2,000 lawsuits against it.

    However, it appears that Purdue may instead be opting for a far-reaching settlement across the many similar lawsuits. This is how the legal battles against the tobacco industry ended in 1998—with a $246 billion settlement, Reuters noted.

    University of Connecticut School of Law Professor Alexandra Lahav believes that the Purdue settlement “may be the start of the dominoes falling” for the company.

    According to the White House Council of Economic Advisers, the opioid epidemic has caused over $500 billion in economic damages across the U.S. in the year 2015 alone.

    That number likely rose in 2016, when the total number of deaths from opioid-related overdoses jumped from 33,091 to over 42,000.

    Between deaths, the costs of treating overdose cases and addiction, missed work by those affected, and crime related to illicit opioids, the crisis has been economically devastating to communities across the nation.

    Purdue Pharma and members of the Sackler family have continued to deny its alleged role in fueling the opioid epidemic, stressing that prescription opioids come with FDA warnings about addiction and overdose. This argument, however, has proved to be an ineffective deterrent. 

    View the original article at thefix.com

  • Dentists Need To Make Sweeping Changes To Opioid Prescribing

    Dentists Need To Make Sweeping Changes To Opioid Prescribing

    Dentists have decreased the amount of opioid prescriptions they write by nearly 500,000—but some believe it’s not enough.

    Three years ago, P. Angela Rake decided to make a major change at her oral surgery practice.  

    “After the loss of Prince, I just drew a line in the sand that I’m going to change my prescribing practices,” Rake said, according to The Chicago Tribune. In just two years, she reduced the amount of opioids she was prescribing by 70%. 

    It wasn’t just the death of the superstar that moved her. Rake had also seen her own brother get hooked on opioids that he was given during cancer treatment. Having seen firsthand the dangers of opioid addiction, she knew that she couldn’t continue to prescribe opioids to her patients in the usual manner. 

    Today, she only prescribes opioids when absolutely necessary. The patients who do need opioids get few pills and lower doses. Rake now says she feels like the opioid industry deceived her. 

    “When these drugs came into being routinely prescribed, the industry-funded message we were being told was that the risk of addiction was less than 1 percent. We were misled.”

    The truth is that the risk of addiction for young people given opioids after oral surgery is closer to 6%. Now, more dentists are becoming aware of the danger of these pills for the youngest patients, said Andrew Kolodny, co-director of opioid treatment research at Brandeis University.

    “Dentists and oral surgeons are the No. 1 prescribers of opioids to teenagers. What’s so disturbing is that it’s so unnecessary. These are kids who could have gotten Advil and Tylenol,” he said. “It’s almost a rite of passage in the United States having your wisdom teeth out. The aggressive prescribing of opioids to adolescents may be why we’re in an epidemic.”

    Dentists have decreased the amount of opioid prescriptions they write by nearly half a million, from 18.5 million in 2012 to 18.1 million in 2017. However, that’s a far cry from the 70% reduction that Rake made, and some within the industry say it is not enough. 

    Romesh Nalliah, who teaches at the University of Michigan School of Dentistry and has studied opioid prescribing among dentists, said that dentists are concerned about customer satisfaction, and sometimes that relies on doling out opioids. 

    “Dentists are also business owners. They don’t want patients to say, ‘Dr. Nalliah did my extraction, and now I’m in agony,’” Nalliah said. Despite that, he has now changed the way that he prescribes opioids, and urges others in the field to do the same. 

    He said, ”I don’t want to be responsible for someone becoming addicted to opioids. I personally think we can cut opioid prescribing in dentistry to less than half of what we do now.”

    View the original article at thefix.com

  • Doctor Accused Of Prescribing Pills Linked To Overdose Deaths

    Doctor Accused Of Prescribing Pills Linked To Overdose Deaths

    The doctor’s prescription writing was allegedly so extreme that a local CVS stopped accepting prescriptions he wrote. 

    There’s a lot of attention on the so-called “third wave” of the opioid epidemic, synthetic opioids, but the arrest of a California doctor this week for allegedly illegally distributing prescription pills shows that medications are still a dangerous part of the epidemic.

    Orange County doctor Dzung Ahn Pham, 57, who owns Irvine Village Urgent Care was arrested on Tuesday for allegedly providing prescriptions to patients whom he never actually examined, according to a press release issued by the U.S. Attorney’s Office.

    He is facing two charges of illegally distributing oxycodone. At least five people who reportedly received medications from Pham overdosed, and another man who was allegedly using pills from Pham was involved in a fatal car accident.  

    “This case clearly and tragically illustrates the dangers of drug dealers armed with prescription pads,” United States Attorney Nick Hanna said in the press release. “This doctor is accused of flooding Southern California with huge quantities of opioids and other dangerous narcotics by writing prescriptions for drugs he knew would be diverted to the street. Prosecutors in my office, working with their law enforcement partners, will tirelessly pursue everyone involved in the trafficking of opioids as part of our persistent and ongoing efforts to stop the trail of misery that follows these dangerous drugs.”

    Pham’s prescription writing was allegedly so extreme that a local CVS stopped accepting prescriptions he wrote. 

    According to an affidavit, Pham provided medications including Adderall, oxycodone, tramadol, sSuboxone, norco, soma, alprazolam, and hydrocodone bitartrate-acetaminophen to patients who requested them via text message. At least 84 patients had prescriptions within a day or two after sending texts. 

    Last summer, undercover agents from the Drug Enforcement Administration also reportedly received pills from Pham, including a “Holy Trinity, [which] is the combined use of an opioid (such as hydrocodone), a benzodiazepine (such as Valium), and carisoprodol (a muscle relaxer like Soma),” according to the press release. The doctor then reportedly sent the undercover agent to a specific pharmacy that still accepted his prescriptions. 

    The pill mill operation was reportedly lucrative for Pham, who is believed to have deposited more than $5 million into personal accounts over the past five years. He also reportedly deposited $1.7 million into a business account. Investigators say he was charging $100-$150 per visit; it’s not clear how patients who requested prescriptions via text were charged. 

    William D. Bodner, DEA Los Angeles Associate Special Agent in Charge, said that targeting doctors who write prescriptions irresponsibly is a priority. 

    “This arrest should serve as a warning to any physician who utilizes their position to traffic opioids,” he said.

    View the original article at thefix.com

  • New Opioid Laws Seek To Curb Overprescribing

    New Opioid Laws Seek To Curb Overprescribing

    Though there is no hard evidence of the effectiveness of the laws yet, some professionals see the numbers as heading in the right direction.

    As the opioid epidemic has continued to claim lives, more than two dozen states have put laws in place in the hope of limiting the damage.

    Of those two dozen, the most recent states to take action are Florida, Michigan and Tennessee, according to Harvard Health Publishing. The new rules put in place set limits for the amount of opioids medical professionals can prescribe for pain relief from surgery, injury or illness. 

    Opioid laws vary from state to state, according to Harvard Health. While most states limit first-time opioid prescriptions to seven days, some states, such as Florida, Kentucky and Minnesota, have shortened it to three days unless a medical professional can give reason for a week-long supply.

    “For almost all acute pain problems, including after surgery, a week is usually sufficient,” Dr. Edgar Ross, senior clinician at the Pain Management Center at Harvard-affiliated Brigham and Women’s Hospital, told Harvard Health. 

    Additionally, some states have put procedures in place that require doctors to take more steps when prescribing. In Florida, both physicians and pharmacists are required to take courses about prescribing practices. They must also search a drug database to make sure doctors aren’t doubling up on prescriptions for patients.

    Massachusetts has a similar procedure in place, but some medical professionals say it’s not as simple as it sounds. 

    “We have the ability to check the registry to see who else has prescribed it, but it’s not integrated with electronic records,” Dr. Dennis Orgill, a surgeon at Harvard-affiliated Brigham and Women’s Hospital, told Harvard Health. “If you have someone who needs opioids over the weekend, you can imagine the logistics of that.” 

    Another new law, this one in Ohio, allows doctors to override and refill acute pain prescriptions, but only after a patient has gone through the first prescription.

    According to Harvard Health, patients will typically have to return to the doctor to get a prescription rather than getting a refill on the phone. If for some reason a refill is made over the phone, Harvard Health states patients will end up visiting the pharmacy more often and making more copays as a result.

    If doctors do not follow the new laws, they may face consequences. As a result, Harvard Health states some patients that need prescriptions for chronic pain are not getting them.

    “Many doctors now refuse to prescribe any opioids because of the fear of sanctions,” Ross told Harvard Health. “I have had several cancer patients whose pain was not well managed because of incorrect perceptions.” 

    Although there is no hard evidence of the effectiveness of the laws yet, some professionals see the numbers as heading in the right direction.

    “Massachusetts’ opioid legislation was signed into law in March of 2016. The overdose death rate then decreased by 8.3% in 2017, the first decrease since the beginning of the opioid epidemic,” Dr. Karsten Kueppenbender, an addiction psychiatrist at Harvard-affiliated Massachusetts General Hospital, told Harvard Health. “While it’s impossible to say the law caused the decrease, it’s certainly a welcome association.” 

    View the original article at thefix.com

  • Doctors Will Be Required To Check Prescription Database In California

    Doctors Will Be Required To Check Prescription Database In California

    The state’s monitoring system has been historically underused by healthcare providers. 

    Beginning on October 2, doctors in California will be required to check the state’s prescription monitoring database before writing a new prescription, in an attempt to provide better care and correct years of underutilization of the system.

    “California created the first system to track prescriptions of the strongest painkillers, but our state fell behind as the opioid crisis grew,” state Sen. Ricardo Lara, who drafted the legislation in 2015, told the Los Angeles Times. “I wrote SB 482 to require that doctors and others consult the CURES system before prescribing these powerful and addictive drugs. This tool will help limit doctor shopping, break the cycle of addiction and prevent prescriptions from ever again fueling an epidemic that claims thousands of lives.”

    California’s monitoring system, called The Controlled Substance Utilization Review and Evaluation System, or CURES, provides a list of patients’ prescriptions, the doctors who prescribed the medication and the pharmacies that filled them. The system was overhauled in 2016 to make it easier for doctors to use, and the new legislation will now require them to do so.

    Under the law, healthcare providers will need to check CURES every time they write a new prescription, or every four months for patients who have an ongoing prescription. There are exceptions, including for emergency room care and hospice patients.

    The legislation is meant to cut back on so-called doctor shopping, as well as ensure that doctors and patients are aware of any risky combinations of medicines that a patient is taking.

    “I think people make the mistake of thinking it’s just for doctor shopping,” said Dr. Roneet Lev, chief of emergency medicine at Scripps Mercy Hospital in San Diego. “Using CURES just makes you a smarter, better doctor.”

    Although some doctors balk at the amount of time that it will take to consult CURES, other believe that using the system will soon become second nature.

    “I think it’s going to be one of those things that a year from now is going to be second [nature] to them,” said Kimberly Kirchmeyer, executive director of the Medical Board of California. “It’s just the first round of it gets hard for them. Any additional administrative task for physicians in the world they live in is difficult for them, and we completely understand that.”

    However, if the requirement helps to protect patients, doctors say that they are willing to spend time using the CURES system.

    “I think every doctor in California will gladly do it as long as there’s a pot of gold at the end of the rainbow,” said Dr. Jason Toranto, chief of plastic surgery at Senta Clinic in San Diego. “As long as the patient is going to do better, that’s what it’s all about.”

    View the original article at thefix.com

  • "Death Certificate Project" Helps Identify Doctors Who Overprescribe

    "Death Certificate Project" Helps Identify Doctors Who Overprescribe

    The crackdown has spooked physicians, including some who say they’re now less inclined to treat complex patients. 

    Hundreds of California physicians are under investigation for their prescribing habits, as the state medical board cracks down on overprescribing.

    Under the “Death Certificate Project,” the Medical Board of California is trying to take a proactive approach to identifying overprescribing behavior.

    The board, a state agency that licenses/disciplines physicians, has reviewed death certificates that list a prescription opioid (or more) as the cause of death, then identify the provider(s) who prescribed the controlled substance to the patient “within three years of death, regardless of whether the particular drug caused the death or whether that doctor prescribed the lethal dose,” MedPage Today reports.

    Prescribers were matched to patients through California’s prescription drug database, CURES (California Controlled Substance Utilization Review and Evaluation System).

    “Our goal is consumer protection… (to) identify physicians who may be inappropriately prescribing to patients and to make sure that those individuals are educated (about opioid guidelines), and where there are violations of the Medical Practices Act, the board takes (disciplinary) action,” said Kimberly Kirchmeyer, the medical board’s executive director.

    So far, 462 physicians have been identified as “warranting an investigation of patients’ files,” according to MedPage. Of these cases, 223 have been closed for either insufficient evidence, no violation, their license was already revoked/surrendered, or the physician has died.

    Nine physicians have been targeted in opioid-related prescribing accusations filed by the state Attorney General; four of them were already under scrutiny on “unrelated charges.”

    The state’s crackdown has spooked physicians, including some who say they’re now less inclined to treat complex patients.

    “When you hear a bunch of doctors all at the same time all getting the same letter, and you realize they’re going through the same thing, you see why some are saying [to patients], ‘Sorry, if you have a lot of medical conditions, we’re not going to take care of you,’” said Dr. Brian J. Lenzkes, a San Diego internist and one of the targets of the Death Certificate Project.

    Last December, Lenzkes received a letter from the state medical board notifying him that there had been a “complaint filed against you” about a patient who had died of a prescription drug overdose in 2013.

    According to Lenzkes, the patient’s severe condition required him to take a regimen of prescription drugs including painkillers.

    After receiving the letter, however, Lenzkes says he’s more wary of taking on pain management, saying that he’ll refer patients to pain specialists instead. “I’m not taking any more. That’s just how I feel,” he said.

    View the original article at thefix.com

  • Could Informing Doctors Of Patients' Opioid Deaths Curb Prescribing?

    Could Informing Doctors Of Patients' Opioid Deaths Curb Prescribing?

    How are doctors’ prescribing behavior affected when they’re notified of their own patients’ opioid-related deaths?

    Some California doctors have recently received letters that changed how they prescribed opioids, according to new research.

    The letters informed doctors of the deaths of patients to whom they had prescribed opioids, according to the Washington Post. Such letters were part of a study conducted by researchers at the University of Southern California and published Thursday (August 9) in the journal Science.

    The letters were sent by the San Diego County Medical Examiner Office to hundreds of doctors who, in the past year, had prescribed opioids to a patient who later died.

    “This is a courtesy communication to inform you that your patient [name, date of birth] died on [date]. Prescription drug overdose was either the primary cause of death or contributed to the death,” the letters read. “We hope that you will take this as an opportunity to join us in preventing future deaths from drug overdose.”

    According to the Post, the idea behind the study was to close the gap between a doctor’s care and a doctor’s knowledge about the potential consequences of prescribing opioids.

    While many doctors are aware that opioid use disorder is a widespread issue, they may believe that the consequences affect other doctors’ patients rather than their own, the Post noted. 

    According to the results of the study, doctors who learned of a patient’s death at the hands of opioids were 7% less likely to prescribe opioids to new patients. Doctors who received a letter also had a tendency to prescribe fewer high-dose prescriptions within the next three months  of receiving the letter. The total amount of opioids these doctors prescribed decreased by 9.7%. 

    “What’s particularly interesting to me is the personal nature of it,” Alexander Chiu, a surgeon at Yale New Haven Hospital who was not involved in the study, told the Post. “Depending on what field you’re in, [the opioid epidemic] can feel a little remote. If you’re not a pain doctor or a primary-care doctor, it’s not quite as common to know or see your actions having a negative impact, which is what this is showing—it makes it very real. As evidence-based as we are as a profession, sometimes anecdotes can be really powerful.”

    Lead researcher Jason Doctor, director of health informatics at the University of Southern California’s Schaeffer Center for Health Policy and Economics, tells the Post that while doctors have knowledge of facts, they are still human.

    “One of the takeaways I’d like people to have is that doctors learn a lot of clinical facts, but when it comes to clinical judgment and decision-making, they fall prey to the same biases that we all do,” he said. 

    According to Doctor, San Diego County plans to continue sending these letters, and other counties have also said they are interested in doing something similar.

    View the original article at thefix.com