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Demand for repayment of bankrupt hospital loan could bankrupt county
Commissioner says forcing county to pay Erlanger $8.7 million in full now would be "catastrophic"

Commissioner Shannon Whitfield has said that if Walker County were forced to pay back — immediately and in full

— a nearly $9 million debt to Erlanger Health System it would break the county.

"To pull $8.7 million out of our budget to pay Erlanger in a year would be catastrophic to our county," Whitfield said Thursday, Dec. 7.

Erlanger, in motions filed Dec. 5 in U.S. District Court for the Northern District of Georgia Rome Division, demands the full amount now.

"If we are forced by a federal judge to do so, the state may have to step in and take over," the commissioner said. "We will not have the money to operate, or either we will have to shut down aspects of our county government, because we would not be able to sustain the balanced budget that we have put in place, which is already tight."

In its filing, Erlanger argues that the county has the money on hand and is simply refusing to pay.

"That's far from the truth," Whitfield said. "We have no problem with providing the evidence that we are operating on borrowed money and that we do not have the cash to pay them this debt (in full and now)."

The commissioner said if the federal court ordered the county to pay the $8.7 million in full at this time, the county would have to amend its budget by cutting every department a minimum of 30 percent.

Whitfield said an emergency meeting would have to be called to make this happen.

Whitfield added that given the department heads are already saying they are struggling with the current budget cuts to operate under, to cut it again by 30 percent would be catastrophic. It would place citizens in need of services, including police, fire and emergency services to name a few, in jeopardy.

Whitfield said most offices would have to move to a reduced hourly schedule and

the county would not be able to afford to operate at a 40-hour-per-week schedule and services offered would have to be cut back substantially.

"It would be ugly," he said.

County doing its best

Whitfield said the county is moving as quickly as it can to pay off the debt.

Tax bills were sent out Oct. 13, earlier than normal, and are not due until Dec. 20, Whitfield said.

Some of that money, Whitfield said, has begun to trickle in and the county hopes by the first of the year to have some money to make a payment on the debt.

"This is going to be a three-year process. We are not going to have the money to pay them all at one time," Whitfield said.

"If we had taken and imposed the taxes that it would take to settle this in one year, we would put many of our citizens into bankruptcy and you would see many businesses in Walker County having to close, because they are not able to pay their taxes," Whitfield said.

Whitfield said the county's expenses have already been cut by $2.5 million. There were $2 million in requests from departments and other elected officials that the county was not able to accommodate. The county is already working with a very "reduced, tight budget," he said.

"Even paying it over three years is going to be very painful — financially — for the citizens of Walker County to be able to pay this that fast," Whitfield said.

Negotiations between the two parties ceased some time ago, but Whitfield said the county hopes to be able to negotiate an out-of-court agreement with Erlanger.

"There has not been any court date set — to my knowledge — at this point," Whitfield said. "We are still hopeful we can settle something out with this. There is still time to do that we feel, but they are going to have to be realistic on what our abilities are financially. We don't have a problem in providing them information and data to show them what our financial ability is."

Whitfield said his administration has been very transparent with Erlanger, even more so than the past administration. Whitfield took office in January.

Asked if Erlanger is aware of the financial distress the county is in, Whitfield said Erlanger is smart enough to read the county's financial audits, which show the county has $70 million worth of debt and a negative net position of $7.5 million.

Government shut down?

The commissioner said it is unclear how the state of Georgia would react to stepping in to run the county if the county was financially unable to run itself.

"It would be very sad that a hospital — a Tennessee-based hospital authority that was put into place by the authority of the state of Tennessee — would actually come in and cripple a neighboring state and county over 35 months of paying out a debt," Whitfield said. "That Erlanger is so narrow-focused in the dominate position that they are taking to not allow us the additional 35 months to work through this debt."

Whitfield said it is getting to the point that the leadership of Tennessee and the leadership of the governor's office in the state of Georgia will obviously have to get involved.

Asked what citizens would expect in this possible scenario, including the fear it could raise the cost of services or even do away with them, Whitfield said there is already a tax increase in place. The only other options the county would have at this point would be to start shutting down different aspects of the government if the state doesn't step in first.

Whitfield said if there was a federal court order to impose a second round of tax increases, that would all be at the hands of the CEO of Erlanger and it would not be anything he would do unless the county was ordered to do so.

"All of the hard work that we have done over the last 11-plus months in putting a plan together to be able to systematically and mathematically pull Walker County out of the financial ditch would all be — potentially — thrown out of the window with Erlanger's attempt to bulldoze their way into North Georgia," Whitfield said. "I'm beginning to believe this is more about them positioning themselves with new facilities versus doing the right thing and coming to a compromise on a debt that I inherited from the previous administration."

Legalizing medical marijuana: An empty promise for Georgians' legal treatment

Rep. Katie Dempsey

Patients and caregivers find the legalization of the possession and use of low THC oil in Georgia is of no use when they cannot find a legal way to purchase the drug.

Harley Gambrell's son Hayden is 13, stocky and very strong. He's also autistic, and the Floyd County businessman doesn't always know when a "bad moment" will come.

"We have situations when we go into a store and I have to restrain him," Gambrell said. "He may think it's funny to knock over a rack or, if he's having a bad day, he might bite or scratch me."

Hayden is "functioning," his father says, although his doctor has classified his case as severe. His son is a good boy, Gambrell said, but his bad moments are bad.

"He bangs his head on the wall, bites his fingertips, hits concrete walls ... I've been with him, fortunately, but some parents are desperate," Gambrell said.

Autism is among the six conditions the Georgia General Assembly cleared this year for treatment with medical marijuana. As of September, 109 autistics had been issued cards that allow them to have up to 20 fluid ounces of low-THC cannabis oil, according to Donna Moore, director of the Georgia Public Health Vital Records Department that oversees the program.

Hayden's doctor has registered him and Gambrell has the card. But the treatment remains untested because it's still illegal to buy or sell low-THC oil in Georgia.

"Also, you're not allowed to bring it over the state line," Gambrell said. "The whole thing is pointless. We don't have any options unless we break the law."

That's one of the "challenges" noted by state Rep. Allen Peake, R-Macon, who chairs the Medical Cannabis Working Group. Members, including Rep. Katie Dempsey, R-Rome, met last week to review the situation before the legislature convenes in January.

"Once people get the card, I hear, "What do I do now, where do I get this oil?" ... That continues to be a challenge, that we don't provide access," Peake said.

It's also an issue at schools, for students who need to take the oil several times a day but find zero-tolerance policies ban it from campus, he said. And Moore — in her testimony to the committee Tuesday — said some people have removed themselves from the registry because their employers have warned them they'll be fired if they fail a drug test.

"We were silent about that on the law when we wrote it, on purpose," Peake said. "But we will have to address it."

What's new

The General Assembly approved use of the oil in 2015 to treat eight conditions. With this year's additions, the list covers 14 conditions plus patients in hospice care. The oil, which does not get people high, must be in a prescription container listing the percentage of THC on the label.

Moore said that, as of September, there were 453 physicians registered to request cards for their patients. They are certified through the Georgia Composite Medical Board and must submit semi-annual reports tracking the patient's progress.

"Any doctor can enter into the database... so the patient's existing doctor, who they already have a relationship with, can enter them into the registry," she said.

Caregivers also can get cards — a little over 2,700 have them — and there were 2,682 patients enrolled.

Moore said 55 percent of the patients are treating seizures or end-stage cancer with the oil. Another 25 percent have severe or endstage multiple sclerosis, peripheral neuropathy or Crohn's disease.

Other conditions approved for the treatment are severe or end-stage amyotrophic lateral sclerosis, mitochondrial disease, Parkinson's disease, sickle cell disease, Tourette's syndrome, autism, epidermolysis bullosa, Alzheimer's disease and AIDS.

Forty percent of the patients on the registry are ages 50 and older, with another 31 percent in the

range of 25 to 49 years old.

"So most of these are adults, which is a little surprising," Moore said. "We had expected more children."

Gambrell may have an answer for that. He said he's been contacted with offers of illegal oil and he's sure others have too. Some may be buying it, he said, but many parents turn it down.

"No way would we do it," Gambrell said. "It's not regulated. Would it kill my son? But there are people who are desperate."

What's frustrating is that, in many cases, the drug works.

Moore shared some stories from grateful patients and physicians whom, she said, don't have too many people to talk about the treatment with other than her registry team members.

"The patients who are carrying these cards are just so touched ... It brings back appetite, it brings back quality of life, it brings back the lack of nausea," she said.

But there's more than anecdotal evidence, according to Dr. David Bradford, the chair of public policy at the University of Georgia. Bradford told the working group about some of the latest research findings.

"The results are really quite remarkable," he said.

Just this January, Bradford said, the National Academy of Sciences issued a report saying there is conclusive evidence that medical cannabis is effective in treating nausea and spasticity.

"Conclusive evidence is a technical term; it means it's very compelling," he said. "And there's moderate evidence it's effective for sleep disorders and various sorts of pain."

The report follows an examination of more than 10,000 research papers.

Bradford said 29 states and Washington, D.C., now have laws recognizing the benefits of "whole-plant," botanical cannabis and Georgia is among several others allowing variations such as low- THC oil.

"It's no longer just a coastal, northeastern phenomenon. It is widely accepted around the country, " he said.

Still, the underlying problem is that the federal government still classifies marijuana as a Schedule I drug, a category reserved for substances that have no medical use and a high potential for abuse.

Gambrell says he doesn't care about the politics of the issue, he just wants a change in Georgia.

"We're talking about the oil, not about people smoking pot," he said. "As a controlled substance available from a licensed pharmacist, there could be substantial tax revenue, too.

"Maybe there's a down side," he added, "but I'm just not seeing it. But I'm living with Hayden every day."

As kratom use surges, states enact bans Available in Georgia, not in Tennessee

CARRBORO, N.C. — On a sunny November afternoon in this quiet college community, a steady stream of customers walks through the doors of a local cafe called Oasis for a cup of an increasingly popular herbal beverage. The menu offers coffee, black tea, beer, wine and pastries, but nearly everyone opts for a $5 mug of kratom (pronounced KRAYdum).

A powder ground from the leaves of an indigenous Southeast Asian tree related to the coffee plant, kratom (Mitragyna speciosa) offers pain relief and mood enhancement, similar to prescription painkillers.

Advocates say the substance, which does not depress the respiratory system and therefore presents little to no overdose risk, could help reduce the nation's reliance on highly addictive and often deadly prescription painkillers. Some addiction experts also argue the plant could be used as an alternative to methadone, buprenorphine and Vivitrol in medication-assisted therapy for opioid addiction.

Used for centuries to fight fatigue, pain and anxiety in Indonesia, Malaysia, Myanmar, Papua New Guinea and Thailand, kratom was rarely taken in the United States until recently.

Now, with growing concerns about the dangers of prescription painkillers, an estimated 3 million to 5 million people are using kratom and reporting positive results, based on information from retailers. But worries that the unregulated plant product could be abused for its mild euphoric qualities and users could become addicted are spurring federal officials to issue public health

warnings — and a handful of states and cities to impose bans.

Alabama, Arkansas, Indiana, Tennessee, Vermont, Wisconsin and the District of Columbia have banned kratom, along with at least three cities — Denver, San Diego and Sarasota, Florida. Legislation was considered last year in at least six other states — Florida, Kentucky, New Hampshire, New Jersey, New York and North Carolina.

Animal studies have shown that kratom use may lead to addiction. But user surveys indicate that although the herb can be habitforming, withdrawal symptoms are no worse than those encountered when quitting coffee, sugar or certain herbal supplements. Withdrawal symptoms, which typically last three to four days, include muscle aches, cravings, a runny nose, restlessness and mood swings.

The Drug Enforcement Administration last year said it intended to classify the herbal supplement as an illegal Schedule 1 drug, along with heroin, LSD and marijuana. But after public demonstrations, letters from Congress and a petition with more than 142,000 signatures, the agency put the proposal on hold.

Last month, Food and Drug Administration chief Scott Gottlieb issued a public health warning, citing 36 deaths in which kratom was present, but not necessarily the cause. About 50,000 Americans die of drug overdoses each year. In addition, the FDA, which has been seizing imports of kratom at U.S. ports since 2013, stepped up import enforcement.

The agency also cited a 10-fold increase in kratom-related calls to poison centers between 2010 and 2015 — from 26 calls to 263, out of roughly 2.2 million calls a year. And Gottlieb warned about the unknown risks of using kratom to treat opioid addiction, saying he fears some kratom may have been laced with opioids, and that the FDA needs to conduct more study on the plant's potential benefits.

In response, the American Kratom Association, a Coloradobased advocacy and lobbying organization, issued its own analysis of FDA data on adverse drug events, calling the kratom numbers "incredibly insignificant in the broader context" of drug-related deaths and adverse reactions.

All Kinds

At Oasis, no one seems concerned about the hubbub in Washington. Owner Robert Roskind says the controversy has only improved business by focusing attention on what he says is still a little-known plant with huge benefits and few drawbacks. "Except for the rare upset stomach or lightheadedness, it has helped nearly everyone," he said. "And it's cheap. I have about 300 customers and most come here several times a week. Some buy take-home packages."

With subdued lighting, soft music and mystical artwork, Oasis has a peaceful vibe. Customers are happy to talk about their reasons for taking kratom, and they vary widely.

A group of University of North Carolina students from nearby Chapel Hill sit on floor pillows in a corner, reading and working on laptops. Kratom sharpens their focus when they need to study for an exam, one student said. "It's like coffee without the jitters."

A 27-year-old tattooed chef from Brooklyn said he started drinking kratom to relieve withdrawal symptoms after he decided to quit heroin on his own three months ago. A conservatively dressed 22-year-old fraternity brother said kratom has helped him stop binge drinking.

A woman in her 40s, recovering from brain cancer therapy, says it relieves her anxiety and improves her sense of well-being. Two women who work with preschoolers say it lowers their stress level. And a 29-year-old construction worker says it keeps his fibromyalgia symptoms, including pain and fatigue, at bay so he can get up and work every day.

Even among the diverse crowd here at Oasis, Bob Whyte, a well-dressed 80-yearold businessman from Chapel Hill stands out. A self-described straight-laced "boy scout," he said he's been drinking kratom three times a day to relieve severe back pain from failed surgery.

"I'd been taking tramadol and hydrocodone consistently for two years when I found out about kratom," he said. Whyte said his doctors didn't want him to keep taking the highly addictive prescription painkillers, and they had no objections when he told them he was switching to kratom.

At first, Whyte said he was a little fearful about trying the plant-based medicine. Roskind gave him a kratom brownie and suggested he eat half of it at home.

"I picked a day when I wouldn't be driving and sat on the front porch and had half a brownie. I waited a half-hour and felt fine, so I had the other half. That's when I had a little happy moment there on the porch," he said sheepishly.

Since that July morning, Whyte said he's figured out what dose is best for him — enough to bring his pain down to a tolerable level without feeling drowsy. Now he says he's telling everyone he knows about kratom.

Research Needed

Despite rave reviews from kratom users, most physicians and researchers argue that research using human clinical trials is needed to accurately determine the leaf powder's potential harms and benefits. They also insist that oversight of commercial sales of the plant is needed to ensure consumers are getting high-quality, uncontaminated products.

But scientists and other stakeholders differ about whether sales of the plant should be curtailed in the meantime.

The American Society of Addiction Medicine argued in comments to the DEA last year that the whole botanical product, like the powder sold at Oasis, should be made illegal to prevent people with addictions from trying to use it to recover. Since three FDA-approved medications exist that have proven safe and effective, using kratom to treat opioid addiction presents an unnecessary risk for people with addictions, the group said.

At the same time, they recommended that what appears to be the plant's primary active ingredients, mitragynine and 7-hydroxymitragynine, should remain legal so they can be researched for their pain relief and addiction treatment potential.

Oliver Grundmann, an associate professor of medicinal chemistry at the University of Florida College of Pharmacy, has surveyed kratom users and found that very few report becoming addicted and most use it to treat chronic pain, mental health conditions and drug addiction.

"I'm questioning whether we are doing any good by banning kratom," Grundmann said. If states and the federal government make kratom illegal, he said, it would not only slow the progress of research, but it would also leave many kratom users no choice but to switch back to painkillers or heroin.

Stateline focuses on four topics that are key to state policy: fiscal and economic issues, health care, demographics, and the business of government.