July 31, 2017

Trump’s opioid epidemic commission wants the president to declare a state of emergency

The panel wants Trump and Congress to act quickly to address the deadliest drug overdose crisis in US history.


Vox Media

A commission created by President Donald Trump has asked him to declare a state of emergency over the nation’s opioid epidemic.

The recommendation, from a preliminary draft of the opioid commission’s report, comes in the midst of grueling statistics linked to the epidemic. In 2016 alone, drug overdoses likely killed more Americans in one year than the entire Vietnam War. In 2015, drug overdoses topped annual deaths from car crashes, gun violence, and even HIV/AIDS during that epidemic’s peak in 1995.

“With approximately 142 Americans dying every day, America is enduring a death toll equal to September 11th every three weeks,” the report argues. “After September 11th, our President and our nation banded together to use every tool at our disposal to prevent any further American deaths. Your declaration would empower your cabinet to take bold steps and would force Congress to focus on funding and empowering the Executive Branch even further to deal with this loss of life.”

The commission, which is chaired by New Jersey Gov. Chris Christie (R), Massachusetts Gov. Charlie Baker (R), North Carolina Gov. Roy Cooper (D), former Rep. Patrick Kennedy (D), and Dr. Bertha Madras, also makes several other recommendations. Here are some of the big ones:

  • Grant waiver approvals for all 50 states to eliminate existing regulatory barriers in the Medicaid program that exclude the federal Institutes for Mental Diseases.Under the Social Security Act, federal Medicaid funds can’t reimburse services from inpatient facilities that treat “mental diseases,” including addiction, with more than 16 beds. Eliminating this barrier would let states “immediately open treatment to thousands of Americans in existing facilities in all 50 states,” according to the commission.
  • Immediately set up and fund a federal program to improve access to medication-assisted treatmentThis is the gold standard of opioid addiction treatment, with research showing that it can reduce the all-cause mortality rate among addiction patients by half or more. But it remains inaccessible; only 10 percent of conventional drug treatment facilities in the US provide medication-assisted treatment for opioid use disorder, according to the commission. The report wants this treatment greatly expanded, from health care settings in prison to traditional drug treatment facilities.
  • Better enforce federal law that requires health insurers to provide equal access to mental health services, including addiction. Health insurers often create onerous barriers to mental health care, seeing it as expensive. Federal law technically outlaws this for the plans that cover behavioral health, but the law remains poorly enforced. The report recommends that the federal government, particularly the secretary of labor, better enforce the law.
  • Expand access to the opioid overdose antidote naloxone. Among other plans, the commission vows to provide model legislation so states can allow the dispensing of naloxone through a standing order. Baltimore Health Commissioner Leana Wen used such legislation in 2015 to let anyone in the city carry naloxone; she estimates that it’s saved more than 950 people from overdose over the past two years.
  • Mandate education initiatives, with the help of medical schools and by amending the Controlled Substances Act, to require better training for prescribers about the treatment of pain and addiction. The opioid epidemic began when doctors prescribed an enormous amount of opioid painkillers, causing the drugs to proliferate across the country. By getting doctors to prescribe opioids more responsibly, the commission aims to pull back the original source of the current drug overdose crisis.
  • Provide federal support for state-based prescription drug monitoring programs.These programs, which all 50 states now have, let doctors closely watch a patient’s prescription drug history — letting them see if, say, a patient is shopping around to obtain as many opioids as possible from different doctors, or if a patient has a history of misusing drugs. But these programs often aren’t very robust and don’t share data across state lines, which federal aid could help address.
  • Fund more research for non-opioid painkillers. The current drug crisis began in part as doctors sought to tackle another major medical problem: 100 million US adults suffer from chronic pain. Despite the lack of evidence for opioids’ effectiveness in treating chronic pain, doctors often responded with opioids. By finding non-addictive, effective painkillers, the commission wants to give doctors a better, safer option.
  • Step up efforts to interdict fentanyl. As the opioid epidemic has progressed, many people suffering from opioid drug use disorder have moved from painkillers to heroin. More recently, though, much of this heroin has been laced with the even more potent opioid fentanyl — often without the knowledge of the people buying the heroin. This fentanyl is synthetically manufactured, and it often comes from around the world, such as clandestine labs in China. Among other proposals, the report asks for greater support for law enforcement and US Postal Service efforts — through more manpower and better technology, for example — to catch fentanyl as it’s transported.

The commission’s report addresses both sides of the opioid crisis: what Stanford drug policy expert Keith Humphreys has described to me as the “stock” and the “flow.” On one hand, you have the current stock of opioid users who are addicted; the people in this population need treatment or they will simply find other, potentially deadlier opioids to use if they lose access to painkillers. On the other hand, you have to stop new generations of potential drug users from accessing and misusing opioids.

A full response to the opioid epidemic would address both of these issues. It would take steps to prevent opioid misuse — by, for example, limiting access to painkillers while keeping them available to patients who truly need them. And it would greatly increase access to addiction care.

A lot of work remains to be done, particularly on the drug addiction treatment front. According to a 2016 report by the surgeon general, just 10 percent of Americans with a drug use disorder obtain specialty treatment. The report attributed the low rate to severe shortages in the supply of care, with some areas of the country, particularly rural counties, lacking affordable options for treatment — which can lead to waiting periods of weeks or even months.

The preliminary report will soon be sent to the president. A final version with more recommendations and details will also be sent to the president later this year.

A big question is whether Trump and Congress will act on the recommendations. So far, the White House and Congress have taken little action on this issue. The only major bill passed regarding the opioid epidemic added just $1 billion to drug treatment over two years — which is far from the tens of billions experts estimate is necessary.

In fact, Congress, with Trump’s support, has worked against some of the recommendations from the commission by moving to repeal Obamacare, which expanded access to addiction treatment through increased insurance coverage and regulations that require equal access to mental health services.

The commission’s report, however, offers Trump and Congress a chance to turn the page on this issue. It now remains to be seen whether they will take it.

The opioid epidemic, explained

In 2015, more Americans died of drug overdoses than any other year on record — more than 52,000 deaths in just one year. That’s higher than the more than 38,000 who died in car crashes, the more than 36,000 who died from gun violence, and the more than 43,000who died due to HIV/AIDS during that epidemic’s peak in 1995.

This latest drug epidemic, however, is not solely about illegal drugs. It began, in fact, with a legal drug.

Back in the 1990s, doctors were persuaded to treat pain as a serious medical issue. There’s a good reason for that: About 100 million US adults suffer from chronic pain, according to a 2011 report from the Institute of Medicine.

Pharmaceutical companies took advantage of this concern. Through a big marketing campaign, they got doctors to prescribe products like OxyContin and Percocet in droves — even though the evidence for opioids treating long-term, chronic pain is very weak (despite their effectiveness for short-term, acute pain), while the evidence that opioids cause harm in the long term is very strong.

Painkillers proliferated, landing in the hands of not just patients but also teens rummaging through their parents’ medicine cabinets, other family members and friends of patients, and the black market.

As a result, opioid overdose deaths trended up — sometimes involving opioids alone, other times involving drugs like alcohol and benzodiazepines (typically prescribed to relieve anxiety). By 2015, opioid overdose deaths totaled more than 33,000 — close to two-thirds of all drug overdose deaths.

Seeing the rise in opioid misuse and deaths, officials have cracked down on prescriptions painkillers. Law enforcement, for instance, threatened doctors with incarceration and the loss of their medical licenses if they prescribed the drugs unscrupulously.

Ideally, doctors should still be able to get painkillers to patients who truly need them (and they can work for some individual chronic pain patients) — after, for example, evaluating the patient’s history of drug addiction. But doctors, who weren’t conducting even such basic checks, are now being told to give more thought to their prescriptions.

Yet many people who lost access to painkillers are still addicted. So some who could no longer obtain painkillers turned to cheaper, more potent opioids: heroin and fentanyl, a powerful synthetic opioid.

Not all painkiller users went this way, and not all opioid users started with painkillers. But statistics suggest many did: A 2014 study in JAMA Psychiatry found 75 percent of heroin users in treatment started with painkillers, and a 2015 analysis by the Centers for Disease Control and Prevention found that people who are addicted to painkillers are 40 times more likely to be addicted to heroin.

So other types of opioid overdoses, excluding painkillers, also rose.

That doesn’t mean cracking down on painkillers was a mistake. It appeared to slow the rise in painkiller deaths, and it may have prevented doctors from prescribing the drugs to new generations of people with drug use disorders.

But the likely solution is to get opioid users into treatment. According to a 2016 report by the surgeon general, just 10 percent of Americans with a drug use disorder obtain specialty treatment. The report found that the low rate was largely explained by a shortage of treatment options.

So federal and state officials have pushed for more treatment funding, including medication-assisted treatment like methadone and buprenorphine.

Some states, like Louisiana and Indiana, have taken a “tough on crime” approach that focuses on incarcerating drug traffickers. But the incarceration approach has been around for decades — and it hasn’t stopped massive drug epidemics like the current crisis.

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