Posts Tagged ‘drugs’

For the latest Health Wonk Review, go see Joe

Friday, October 10th, 2014

Joe Paduda has posted this week’s Health Wonk Review at Managed Care Matters. In keeping with the overall mission of HWR, he says that there’s “lots of health policy stuff, all right here!
While at Joe’s blog, also check out his post on drug formularies . He makes the case that despite progress that payers and PBMs have made in curbing runaway opioid costs, new drug-related issues keep emerging (eg compounding) and tighter controls are needed.

Compensable Meningitis?

Tuesday, October 9th, 2012

The alarming crisis precipitated by contaminated steroids has implications for the workers comp system. In Framingham, MA, two towns over from where I write, the New England Compounding Center has been shut down, but not before it shipped over 17,000 vials of methylprednisolone acetate, each potentially contaminated by fungal meningitis. Across 23 states, eight people have died and over 100 others have been sickened. As Denise Gray writes in the New York Times, the incubation period appears to be between a few days and a month; the last doses of the tainted medications were administered on September 17, so there are literally thousands of people at risk for a potentially fatal illness.
Because the steroid is used for the treatment of back pain, this crisis intersects with the workers comp system. Lower back injuries are among the most prevalent in workers comp; across the country, injured workers are receiving all forms of treatment, ranging from physical therapy to surgery to injections. An unknown portion of those sickened by the tainted drugs will have been treated for work-related injuries. These unlucky few will require lengthy and costly treatment, along with extensive hospitalization. They will be eligible for long-term indemnity payments, including support for any qualified dependents. These claims will total hundreds of thousands of dollars. Should an injured worker suffer a stroke – one of the many side effects of the disease – the claim is likely to become a permanent total disability.
[NOTE to comp attorneys: New England Compounding is out of business. The prospects for subrogation are remote.]
Exposure: Limited But Deadly
The good news, if indeed there is any, is that the source of the contamination is highly specific: it involves only drugs shipped by New England Compounding. Thus any injured workers receiving lumbar injections over the past few months can know for sure whether they are at risk. But that – and the fact that most people exposed to the drug will not become ill – is the extent of the good news.
Anyone exposed to the fungus is advised to seek medical help immediately if they experience any of the following symptoms: severe headache, fever, stiff neck, dizziness, weakness, sensitivity to light or loss of balance. For those who have received tainted injections, just reading that list would probably give rise to real or imagined symptoms.
Early treatment is essential and might save a patient’s life. The untreated fungus can cause strokes. So logic might indicate that everyone exposed should receive preventive treatment. Unfortunately, the life-saving treatment itself carries risk: antifungal drugs must be administered for months and they can have serious side effects, including kidney damage. Thus those anxiously awaiting the first signs of illness can only watch the days tick by until they are beyond the incubation period. (Even if they do not become ill, individuals exposed to the risk might be tempted to pursue claims for PTSD, given the magnitude of the stress they are experiencing.)
Manufacture Versus Assembly
The Wall Street Journal points out that a 2002 Supreme Court ruling placed limits on any federal role in the oversight of drug compounding:

[The FDA] has been stymied by, among other factors, a 2002 Supreme Court decision. In the majority opinion, written by Justice Sandra Day O’Connor, the court struck down as unconstitutional the portion of a 1997 law setting out how the FDA would decide which compounding pharmacies it would regulate

.
The compounding – as opposed to manufacturing – of drugs is considered a pharmaceutical procedure, so the only oversight comes from the states. And given limited resources, states are not in a position to do the job thoroughly or consistently. As Representative Ed Markey (D-MA) put it, “compounding pharmacies currently fall into a regulatory black hole.”
Most of the people receiving the tainted medication will soon be able to resume their normal lives. For the relatively small number who become ill, or even die, the promise of relief from back pain has been transformed by a scandalously unregulated industry into a broken promise of life-altering proportions. For those wondering what role, if any, government should play in free markets, this surely is an example of a place where government belongs.

Annals of Compensability: Confusion and Death from an East Texas Cocktail

Monday, September 10th, 2012

We have been tracking the compelling issue of compensability in drug overdoses within the workers comp system. We have blogged drug-induced fatalities that are compensable (Tennessee) and non-compensable (Ohio and Connecticut). Given the prevalence – make that rampant over-use – of opioids in the workers comp system, prescription drug abuse is an issue with profound implications for injured workers, their employers and the insurers writing workers comp policies across the country.
Which brings us to the saga of Bruce Ferguson-Stewart. He was injured on May 25, 2004 while working for AltairStrickland, an industrial contracting firm in Texas. A bolt weighing several pounds fell from above, striking Ferguson-Stewart and injuring his shoulder and neck. The MRI showed “minor disc bulges” at three levels on his cervical vertebrae. His treating physician diagnosed him with a left shoulder contusion and prescribed hydrocodone as part of the treatment plan. The doctor also recommended surgery to repair the shoulder.
Denial and its Consequences
For reasons that are not clear from the trial documents, the claim was denied by Commerce & Industry Insurance, the employer’s carrier. The carrier lost the initial appeal and then lost again. The insurer then sought judicial review of the Division-level finding of compensability.
Meanwhile, with his shoulder untreated and in extreme pain, Stewart continued to take his prescribed Hydrocodone, known locally as an “East Texas cocktail.” At every level of appeal, the compensability of the claim was upheld, but the surgery was delayed – with apparently disastrous results. (The delaying tactics may have been related to Stewart’s alleged history of abusing prescription drugs.)
On October 3, 2004, while his worker’s compensation claim was still being contested, Ferguson-Stewart died from an overdose of hydrocodone. His blood contained a hydrocodone level of 0.38 mg/L, which is consistent with acute severe toxicity. The blood also contained carisoprodol, a prescription muscle relaxant, and marihuana.
Trial by Jury
Ferguson-Stewart’s widow filed for death benefits under workers comp, but the case was denied. The widow appealed.
At trial, Ferguson-Stewart presented two theories as to how and why Stewart might have unintentionally or unknowingly ingested a lethal dose of hydrocodone. First, in what CIIC describes as the “accidental overdose” theory, Ferguson-Stewart alleged that the overdose must have been accidental because her husband did not intentionally or knowingly commit suicide.
Tommy J. Brown, a forensic pathologist who performed an autopsy on Stewart, concluded that the cause of death was hydrocodone toxicity and that the manner of death was “accidental.” Brown’s testimony is right out of central casting:

Well, I–I see it a lot. I do autopsies on people with chronic pain a lot and
this–like before I see them, start out with their drugs and then they
increase the drugs, and then to try the [sic] alleviate the pain more, and pretty soon they’re taking more than prescribed, and pretty soon they will
overdose theirselves [sic] or they will overdose theirselves [sic], some
people do. And then they die and it’s usually in a low lethal range [like
that observed in Stewart]. So I consider that an accidental death because
they were overdosing due to the chronic pain.

With its pathos and illuminating detail, the widow’s testimony reads like a monologue from a Faulkner novel:

The day before or the day of–that he died. They say he actually died
early in the morning; so, I guess the day before. He was really disoriented. He was not acting normal or the way he had been acting since he was hurt. He wasn’t acting normal at all. His speech was slurred. He was stumbling and falling all over things. I remember–I think I remember one time he actually falling [sic] out of a chair and–in the yard
because he was trying to get up and he tripped over a root and he fell on
the shoulder he had injured. And that made it even that much more
painful for him. He was–he was very–he was crying about it. He really
had hurt himself.
. . . .
He was–in the last couple of days before he died, he was getting really
bad about forgetting that he had already taken his medicine and taking it
again; and you know, sometimes I would have to tell him, “Hey, you
already took it. You can’t take it again.” And usually he would agree with me; but there were times when he would say, “No. No. No. I didn’t take it. I’m sure I didn’t take it. I’m still hurting too bad, and I don’t remember taking it.” So, he’d take it again.
But especially the day of [his death], he was entirely too confused. He
wasn’t–like I said, he wasn’t himself at all.

The jury charge instructed that “[a] claimant’s death does not
result from medical treatment instituted to relieve the effects of his compensable injury if the death results solely from a claimant intentionally or knowingly failing to comply with his doctor’s instructions[emphasis added].” The jury concluded that Ferguson-Stewart’s death was unintentional, resulting from the treatment for his compensable injury. The widow was granted death benefits.
Intention, Confusion and Compensability
Under Texas law, compensability hinges on Ferguson-Stewart’s intent: was the death an intentional suicide or was it an accident? He had no intention of killing himself, so the death was compensable. In a somewhat similar Connecticut case (see above), the overdose was the result of the deliberate (and illegal) act of using a needle to ingest drugs. That case was denied.
Behind every death due to prescription drugs lies a story worth telling. Powerful and effective pain killers are transformed into instruments of death. When it comes to the compensability of these cases, disorientation and confusion are not limited to injured workers experiencing pain. The medical and workers comp systems struggle with the ambiguous legacy of medications: while opioids offer immediate, short-term relief from pain, the relief is followed all-too-often by a downward spiral of addiction and dependency.
I truly wish the testimony of Ferguson-Stewart’s widow could be played in the examination room of any doctor about to write a script for an “East Texas cocktail.” The doctor just might consider a more benign and less toxic alternative.

Opioids: Altered Minds and Bottom Lines

Wednesday, August 29th, 2012

In this era of data mining and predictive analytics, it’s really not that difficult to project which comp claims are headed for “catastrophic” levels. Just follow the meds. A new study entitled “The Effects of Opioid Use on Workers Compensation Claims Cost in Michigan” establishes a direct link between long-acting medications and the eventual magnitude of the claim. Where short-acting opioids are involved, the claim is 1.76 times more likely to break the $100K barrier; with long-acting medications, the likelihood increases to a whopping 3.94. The researchers, including Jeffrey Austin White and Jack Tower of Accident Fund Holdings in Lansing MI, demonstrate what has been long known anecdotally: the use of opioids is an “independent risk factor for development of catastrophic claims.”
The study examined over 12,000 claims that opened and closed between January 2006 and February 2010. (Had they included claims that were still open, the numbers may have been even more dramatic.) In an effort to isolate just how much opioids drove up the costs, the study accounted for other risk factors including sex, age, attorney involvement, the number of medical treatments and claim duration.
Pain and Dr. Sajedi
There is a relatively simple logic at work: injuries cause pain and opioids alleviate extreme pain. The question, naturally, is which injuries require extreme pain relief and which could be managed with lesser medications. Far too many doctors are too quick to prescribe narcotics, even as they fail to implement the most elementary safeguards to ensure that the drugs are used properly and for as short a duration as possible. (A comparable problem exists with the overuse of antibiotics; doctor training clearly needs more emphasis on pharmacology.)
Which brings us to Dr. Ebrahim Sajedi, 46, an internal medicine specialist in California who gets good reviews from his patients. Trained at the Rochester School of Medicine, Sajedi was busted on 12 felony counts of prescribing medications without a legitimate purpose. He provided scripts for Vicodin, Adderall, Klonopin and similar drugs to four undercover police officers without examining them and for no medical purpose. Why buy drugs on the street when you can get the good stuff from a certified specialist?
Bottom Lines
The prevalence of strong drugs in the comp system should come as no surprise. We live in a culture where we are supposed to live pain free, virtually forever, stimulated and distracted in every waking moment. We can hardly fathom the pain that mankind endured in every generation up until recent times. There is a complex, perhaps ultimately incomprehensible alchemy that takes place when pain relievers are introduced into the body. But this relief comes at great cost and even greater risk.
In workers comp, the cost is borne by the employer. The quick pain fix of opioids inevitably finds its way to the employer’s bottom line in the form of prolonged absence from work, higher costs, higher experience mods and bigger insurance premiums. We have long suspected that injured workers on opioids stay out of work far longer than is medically necessary and often find themselves in the downward spiral toward a permanent disability lifestyle. With this Michigan study, we have further documentation that the promiscuous use of drugs undermines the recovery of injured workers and the financial stability of their employers.

Of Pain Killers, Wilful Misconduct and Compensability

Monday, June 11th, 2012

The immortal Mae West once said that “too much of a good thing can be wonderful.” When it comes to pain relievers, however, too much of a good thing can kill you. Which brings us to the sad saga of Anthony Sapko, who died of an accidental prescription drug overdose in August of 2006. Sapko worked as a policeman for 21 years in New Haven, CT, and went on in the mid-1990s to become a state corrections officer. Beginning in 1999, he was treated for depression. He suffered four work-related injuries while working in corrections, the last being a back problem from which he never returned to work.
Sapko was treated with a cornucopia of medications: oxycodone, Zanaflex, Kadian, Celebrex, Roxicodone, Avinza, Lidoderm patches and Duragesic. When his depression deepened in 2006, his psychiatrist prescribed Seroquel. Two weeks later, Sapko was dead. The autopsy revealed a level of oxycodone 20 times normal, and of Seroquel at 5 times normal. The combination of the two over-consumed drugs proved both toxic and fatal.
Suicidal Intent Vs. Accident
Sapko’s widow filed for workers compensation death benefits. The claim was denied at the Commission level and again at the Appeals Court level. Sapko’s widow argued that the death was directly related to his workplace injuries, but the court found a disconnect: this was not a suicide (where such a link might be established), but an accidental overdose.
In a December 2011 blog, we made note of two similar cases: a compensable case in Tennessee and a denied case in Ohio. Fatal overdoses, in other words, may or may not be compensable, depending upon the specific circumstances and state-based precedents. But the over-arching issues are clear: the abuse of prescription narcotics has reached epidemic proportions in workers comp; some individuals are unable to properly self-manage the use of these medications; and doctors are all-too-too willing to prescribe very powerful drugs to alleviate pain.
Workers compensation is endlessly fascinating because it inevitably brings together pain (from workplace injury) and pain suppression (far too often, opioids). In Sapko’s foreshortened life, the combination of medications was toxic. In workers comp as a whole, the mixture of pain and drugs is proving to be a formidable problem.
No Will, No Way?
One of the interesting sidebars in this case is the concept of wilful misconduct: when an injured worker abuses prescription medication, is this a “serious and wilful” action that precludes compensability? Or is the pain so consuming and the drugs so powerfully addicting, that the concept of “wilful” disappears in a drug-induced haze? There are no simple answers. There is undoubtedly some link between Sapko’s depression, the work he performed and the injuries he suffered. But in the world of comp these links must be explicit and, unlike life itself, unambiguous. It would require a novelist to reveal the connections. Unfortunately for Sapko’s widow and children, the commissioners and judges in charge are simply not in a position to craft that kind of narrative.

Overdosing on Drugs: Compensable in Tennessee, Denied in Ohio

Monday, December 12th, 2011

Today we examine two court cases that trouble the dreams of claims adjusters: workers with severe injuries whose use of pain medication leads to their deaths. In one case, the accidental overdose is deemed compensable; in the other, the claim is denied. The devil, of course, is in the details.
Compensable Death In Tennessee
In November 2008, Charles Kilburn was severely injured in an auto accident while in the course and scope of employment. Fractures to his back and neck resulted in permanent total disability. Following surgeries, he still experienced severe pain. A pain specialist prescribed oxycodone. Fourteen months after the accident, Kilburn died of an accidental overdose. His widow filed for death benefits.
Kilburn’s employer believed that the death was the result of negligence, which would break the chain of causality with the original injury. Kilburn had ignored his doctor’s cautions to limit his intake of oxycontin to a specific maximum dose. The Supreme Court of Tennessee determined that the severe pain experienced by Kilburn might result in diminished faculties, which in turn might lead to taking more medicine than was prescribed. In their view, the chain of causality remained intact at Kilburn’s death and thus his widow was entitled to benefits.
Denial in Ohio
In Parker v Honda of America, the initial circumstances are similar, but the apparent “diminished faculties” lead to a very different result. John Parker suffered a severe back injury at work in 1988. He was prescribed OxyContin in March 1999. He eventually became addicted to the drug, along with cocaine, percocet and heroin. In March of 2006 he was found dead, a syringe in his arm, a spoon with a lethal dose of melted OxyContin at his side. In this case, the Ohio Court of Appeals found that his melting and injecting the drug, combined with his documented abuse of street drugs, broke the chain of causation linking the death to the workplace injury.
The court rejected his widow’s argument that the drug abuse was the result of a “severe disturbance of mind” and thus unintentional. It’s worth noting that if Parker had deliberately overdosed as an explicit act of suicide, the death may have been deemed compensable. But because the overdose was an acccident, workers comp benefits were denied.
The Big (and Not-So-Pretty) Picture
Pain is a constant factor in work-related injuries. The control of pain is a complex and widely misunderstood aspect of claims management. Because we live in a culture that relies heavily on powerful medications to control pain, and because the prescribing of these powerful drugs is neither well managed nor well monitored, we will see more and more cases of drug overdoses wending their way through the workers comp system. Some cases will be compensable, others will not. One thing is certain: the challenges of managing these situations will continue to haunt key players in the comp system: the doctors who prescribe the drugs, the adjusters who authorize bill payment, the families who suffer the consequences of loved ones in severe discomfort, and above all, the injured workers, whose every waking moment is compromised and consumed by a pain that just won’t go away.

Opioid Abuse in Florida: Who Controls Controlled Substances?

Monday, December 5th, 2011

Florida is famous for at least three things: citrus fruit, sunshine and pain pills. The citrus and sunshine are pretty much permanent, but it appears that the easy dispensing of opioids may be coming to an end. HB 7095, the state’s new law regulating opioid distribution, bans doctor dispensing of drugs and subjects pharmacies to inspection of prescription records. The state is determined to put an end to its reputation as the pill mall of America.
Now CVS, the giant pharmacy concern with over 700 stores in Florida, has stepped into the breach. They have notified a small number of doctors that they will no longer honor their prescriptions for opioids. CVS has analyzed prescription data and determined that these doctors are over-prescribing. As with so many issues involving insurance coverage, the data goes into a black box and a determination comes out the far end. What happens in the box remains a mystery. Our esteemed colleague, Joe Paduda, has strongly endorsed the CVS effort at his Managed Care Matters blog.
Feeling the Pain
It should come as no surprise that a key stakeholder in the use of opioids, the Florida Academy of Pain Medicine, is crying foul. The academy points out that the criteria for blackballing doctors is unknown and that doctors – and only doctors – should be allowed to determine who needs pain killers and for how long. As Jeffrey Zipper, chair of the Academy’s Medical Affairs committee puts it, “I don’t want to be subject to the scrutiny of CVS.”
Given the immense dimensions of the prescription drug problem in Florida, it’s clear that some doctors have long been abusing their power to prescribe medications. They need scrutiny and they need to be sanctioned. While CVS and other pharmacies are a key part of the distribution network, their leverage in this area is somewhat limited. To begin with, other pharmacies may choose to pick up the rejected business: we’re talking big bucks. In addition, CVS at some point will have to disclose the criteria used for rejecting the prescriptions written by certain doctors. Once this happens, doctors may attempt to manipulate their prescription practices to avoid detection and sanction.
In attempting to get its arms around this formidable problem, the State of Florida has reframed the question about who controls controlled substances. While it’s apparent that doctors no longer have sole discretion in the area, it remains to be seen how effective and how equitable the control exerted by pharmacies can be. The Insider will monitor with great interest this important experiment in substance abuse control.

Health Wonk Review & other news notes

Thursday, September 29th, 2011

Best of the healthcare blogosphere – Looking for your biweekly fix of health wonkery? Check out Health Wonk Review: Muppets Edition! – posted by Joe Colucci at The New Health Dialogue blog.
Health Care Costs – The Kaiser Family Foundation’s 2011 Employer Health Benefits Survey revealed that average annual premiums for family health benefits are up 9%, topping $15,000. According to the report, “Premiums increased significantly faster than workers’ wages (2.1 percent) and general inflation (3.2 percent). Since 2001, family premiums have increased 113 percent, compared with 34 percent for workers’ wages and 27 percent for inflation.” It’s pretty jolting, and even more so when you check the graphic depiction of rising costs. You can find additional report documents here.
Drug deathsLos Angeles Times reports that drug deaths now outnumber traffic fatalities in U.S.. Apparently, we’ve been so busy fighting “the drug war” that we’ve overlooked the creeping and insidious threat of the prescription pain and anxiety drug problem. Deaths related to these drugs now outpace deaths from heroin and cocaine combined.
Mark Walls pointed this article out and he has a discussion going on the LinkedIn Work Comp Analysis Group. He also links to several related resources – here’s a sampling: ACOEM – Comments to State WC Officials on Prescription Opioid Abuse in the U.S.; Joe Paduda – Understanding Opioid Abuse; and Mark Walls – It Starts with the Regulators
Safety tools – The Federal Highway Administration has a portal for Work Zone Safety. It includes some good highway safety tools and resources for you safety program.
Time Capsule – What was work life like in 1943? Check out The Ropes at Disney’s, an employee handbook from 1943. Pop quiz: How many current labor law violations can you spot?
And in another look back at days of yore, Oregon’s Willamette River Bridge Project posts an historic construction photo of the Willamette Bridge, inviting readers to spot the safety hazards. The answers are already posted, so if you want to play along, don’t peek at the comments.

Risk roundup, substance abuse, changing workforce, cool tool, & more

Wednesday, September 7th, 2011

Cavalcade of Risk – Emily Holbrook hosts this week’s Cavalcade of Risk at Risk Management Monitor – go check it out. If you are interested in risk and insurance – and presumably so if you are reading this blog — then RMM should be on your must-read blog list. If you aren’t familiar with it yet, take a few minutes to poke around the archives Emily and Jared consistently do a terrific job on an array of risk related matters. It covers everything from bedbugs to earthquake hotspots.
Substance abuse & WC – Roberto Ceniceros posts about a controversy over stats citing the prevalence of drug and alcohol use in workers comp accidents and claims. Merchants Information Solutions says they are a factor in 65% of all accidents and 50% of all claims. Peter Rousmaniere disputes this and puts his money where his mouth is. “And here is why Rousmaniere thinks potentially exaggerated claims about the prevalence of alcohol and drugs in workers comp claims is dangerous: he says it “perpetuates an unhealthy tendency to shift attention away from safe worksite policies and towards blaming the worker.”
Prescription drugs – Joe Paduda talks about the recent WCRI benchmark report on prescription drugs in Washington and explains why what works in Washington likely won’t work elsewhere.
Spinal Cord Injuries – Kelly Scott posts about spinal cord injuries, noting that September is spinal cord injury awareness month.
Changing workforce – Lots of good reading in The Atlantic recently. Well, more than recently, but a few caught our eye over Labor Day. Sara Horowitz makes the case that the freelance surge is the industrial revolution of our time, with a follow-on article about a jobs plan for the post-cubicle economy. And, also of note, a slide show on 7 Jobs that are making thousands of workers sick
Illinois – Ameet Sachdev of The Chicago Tribune charts changes to the workers compensation law.
Cool Tool – We just discovered OSHA’s $afety Pays Cost Estimator, an interactive expert system to assist employers in estimating the costs of occupational injuries and illnesses and the impact on a company’s profitability. Hat tip to the post at Safety Daily Advisor, which talks more about the tool.
bi-conference.JPGReminder: September 22 – If you haven’t signed up yet, head on over to Business Insurance and register for Virtual Advantage 2011 – Workers Comp Trends & Cost Control Strategies. We’re very pleased that our own Tom Lynch will be participating on a blogger panel with three other blog luminaries: Roberto Ceniceros, Joe Paduda, and Mark Walls. There will also be a keynote by NCCI’s Harry Shuford, an expert panel on pharmaceutical cost controls for worker’s comp – and more. It’s a one-day virtual conference – and best of all – there is no charge to attend.

Health Wonk Review and other news from the blogosphere

Thursday, April 30th, 2009

Health Wonk Review – Bob Laszewski hosts this weeks edition of the best healthcare posts on the Web! – check out this week’s Health Wonk Review.
Pharma – Joe Paduda discusses a planned FDA ban on certain medications which is likely to take a high toll on workers’ comp since they are “old stand-bys, drugs that have long been used to manage chronic and acute pain.” Joe notes: “The loss of these drugs will certainly drive up costs, may lead to adverse events as patients try other medications to replace their now-banned drugs, and may make it harder for patients to get medications.”
Ergonomics – A few ergonomics resources:
Call Center ergonomics: sit-to-stand work stations – if you have workers who spend the better part of their day on the phone or before a computer screen, sit-to-stand works stations might help to minimize repetitive stress injuries.
Exercises that protect against carpal tunnel syndrome – a four and a half minute video with tips from percussionist David Kuckhermann.
Thanks to Ergonmics in the News for the two links above – a great source for the latest news on the topic.
Work violenceHR Daily Advisor recently ran a pair of posts addressing workplace violence prevention. The posts are authored by Dennis A Davis, Ph.D., who notes that, “Because most people follow the rules, and because most violent people give ample signs before they act, employers can be successful at preventing workplace violence.” He offers six key steps for prevention. The first post is Workplace Violence Is Not Beyond Your Control and the second is Are Your Greeters Ready to Deal With a Violent Visitor.
Illegal immigrants – Peter Rousmaniere summarizes and links to A Portrait of Unauthorized Immigrants in the United States, the latest Pew Hispanic Center report on illegal immigrants.