The Commission on Combatting Drug Addiction and the Opioid Crisis appointed by President Donald Trump unveiled its initial recommendations on Monday. The recommendations indicate that the commission understands the need for a public health-based response to the opioid epidemic, although some important issues are not addressed. A few highlights:
Declaring the opioid epidemic a national emergency would improve federal response capabilities.
The commission recommended that Trump declare the opioid epidemic a national emergency. Doing so would purportedly give the executive branch and Congress greater freedom to quickly increase funding for and remove regulatory barriers to treatment. The commission suggested the president make the emergency declaration via either the Stafford Act or the Public Health Act; initial analyses indicate that the Public Health Act is better suited for dealing with the opioid problem. If declaring a national emergency would force action—and funding — to address the epidemic then it would be worthwhile, despite some concerns that an emergency declaration would conjure punitive policy responses such as those seen in the 1980s directed toward crack-cocaine use.
Access to treatment, especially medication-assisted treatment (MAT), should be expanded.
The commission recommended that drug treatment capacity be increased by eliminating regulatory barriers under Medicaid and Medicare. A particularly egregious limitation is that any inpatient treatment facility with more than 16 beds cannot be reimbursed by Medicaid or Medicare. This provision was initially created in the 1960s to prevent the warehousing of mental health patients, but the practical effect today is that there are many empty beds at the same time that people are being denied treatment. The commission recommended that states be granted waivers on this and other exclusionary regulations; this may be the quickest way to expand treatment capacity.
The commission also recommended that access to MAT be expanded. According to its report, MAT is only offered at 10 percent of treatment facilities, and few of these facilities offer all three MAT options (methadone, buprenorphine, and naltrexone). The commission rightly stressed the importance of tailoring MAT protocols to patient needs, rather than expecting patients to conform to the preferred methods of care providers or insurance companies.
The commission suggested that the Center for Medicaid and Medicare Services require medical staff at all health centers they work with to obtain waivers to prescribe buprenorphine. This would significantly increase the prescribing capacity for buprenorphine. But capacity is also limited by strict rules set by the Drug Enforcement Administration limiting doctors who are licensed to prescribe buprenorphine to 30 patients. This is especially problematic in rural communities with few doctors. The commission did not address these patient limits.
The commission also recommended that the National Institutes of Health work with pharmaceutical companies to facilitate testing of new MAT treatments. The commission said nothing of heroin-assisted treatment, a therapy proven to be effective for treating heroin dependence, or the possibility of researching how other substances, such as the therapeutic cannabidiol (CBD) found in the cannabis plant, may help treat opioid use disorders. The report also did not mention several harm reduction strategies, such as syringe-exchange programs and safe injection sites, both of which reduce overdoses and the spread of HIV/HepC, and put users in contact with important health services.
Naloxone must be made more widely available.
The commission also called for expanded access to naloxone, the opioid overdose reversal drug. It suggested this be done through state legislation requiring all law enforcement officers be equipped with it and mandating that it be given to patients in conjunction with any prescription painkiller. These are important steps to increasing naloxone availability.
But many overdoses occur out of view of law enforcement and with opioids not obtained from a doctor. Thus naloxone needs to be made more widely available to users and their families, who are more likely to be first witnesses to an overdose. Two simple ways to do this would be to give it to people exiting jails who have been identified as opioid users and to make it available at community service centers that come into contact with high-risk populations, such as homeless shelters, treatment facilities and sobering centers. A significant challenge to increasing naloxone availability is its price, which has increased exorbitantly. In the late 1990s, the cost for one dose of naloxone was less than two dollars; today a Narcan kit (a popular nasal spray form of naloxone) costs at least $110 for someone without insurance. The commission indicated that the national emergency declaration would allow for negotiation of reduced pricing for naloxone purchased by law enforcement, but the price needs to be reduced for other community service providers and the general public as well.
The medical community is a major player in the opioid response.
Several of the commission’s recommendations indicated an expectation that the medical community play a leading role in addressing the opioid epidemic. Specifically, the commission called for the implementation of education standards at medical and dental schools to educate providers on the risks of opioid dependence; legal requirements mandating that physicians educate patients on risks of opioid dependence before issuing prescription painkillers; and participation in prescription monitoring programs (PMPs) across state lines.
While the commission clearly recognizes the importance of increasing involvement of the medical community in response to the opioid epidemic, it did not address the workforce gap. Currently, there are not enough people specializing in addiction treatment to meet demand. Part of this is due to negative perceptions of working with the substance using community, which is indicative of the larger problem of negative stigma this population faces. But there may also be people who would like to specialize in drug treatment but are discouraged by the low reimbursements in this field compared to others. The federal government should adopt policies that encourage people to pursue careers in drug treatment, such as providing debt forgiveness programs for people who enter the drug treatment field and increasing reimbursements for doctors specializing in drug treatment.
The opioid epidemic is part of a larger crisis of medical care in the U.S.
Criticisms of how the U.S. has responded to the opioid epidemic cannot be separated from the larger problem of the severe shortcomings of the American health care system, especially for those who are poor or dealing with mental health or substance use issues. To this end, the commission called for enforcement of the Mental Health Parity and Addiction Equity Act. This law was passed in 2008, yet inequities in care for mental health and substance use disorders compared to standard medical care are common. Lack of care for mental health and substance use disorders is a major contributor to and perpetuator of the opioid epidemic; mental health and substance use issues frequently coincide and traditional medical care often fails to identify people at risk for these conditions. The commission’s recommendation for the Labor Department to enforce the Parity Act highlights the importance of ensuring access to care for Americans, and if followed would be an effective tool in addressing the current epidemic.
The commission’s final report is due in October. Despite some shortcomings, the initial recommendations give reason to be optimistic about the federal government’s response to the opioid epidemic. Bipartisan agreement on the need to “do something” to address the opioid problem offers hope that these recommendations may be adopted. At the same time, many of the recommendations, particularly those tied to the expansion of Medicaid, run counter to the agenda of many congressional Republicans, who have wanted to cut Medicaid spending and regulations. There is some indication that Senate Republicans and Democrats are now willing to work together to address shortcomings in the Affordable Care Act; how the president will respond and what that will mean for Medicaid funding and other funding measures to address the opioid epidemic remains to be seen.
Katharine Neill Harris, Ph.D., is the Alfred C. Glassell, III, Fellow in Drug Policy at the Baker Institute. Her current research focuses on state sentencing policies for drug offenders and the legalization of medical and recreational marijuana.