Trump administration begins to confront the opioid crisis

The Lancet

By: Susan Jaffe

As the Presidential Commission releases its recommendations, Trump moves closer to defining his policies against the opioid epidemic.

The death toll from drug overdoses in 2016 alone rose to an estimated 64 000 in the USA, more than the fatalities suffered during the nation’s nearly two-decade tumultuous involvement in the Vietnam War. Easy access to prescription pain medication and vastly more potent and illegal synthetic opioids pushed last year’s overdose death rate up by more than 17% compared to the previous year, according to Centers for Disease Control and Prevention. On Oct 26, President Donald Trump declared the opioid epidemic a public health emergency, although 2 months earlier he promised a national emergency declaration, which would have included additional funding to address the explosive problem. The decision was followed by a report from president’s bipartisan Commission on Combating Drug Addiction and the Opioid Crisis offering detailed recommendations for action.

“This is an attack from within”, said the commission’s chairman, New Jersey Governor Chris Christie at its fifth and final meeting last week. “We are killing ourselves and it is unacceptable from my perspective not to step up to the fight and…stop the dying and stop the suffering”.

“That doesn’t mean just throwing money at the problem”, he immediately added. “It means requiring accountability from everyone involved in this process to produce results.”

The commission did not put a price tag on its recommendations. Christie said the commission was not asked to estimate the cost, which would be the responsibility of Congress and the president to determine. He called on Congress to put money in the public health emergency fund without delay so it can be used to implement the commission’s proposals.

The commission’s recommendations address a wide range of problems that contribute to the opioid epidemic, including many steps aimed at federal health and law enforcement agencies and health research programs. A top proposal would create a nationwide multimedia public education campaign stressing the dangers of addiction. Another would establish “drug courts” in every federal court district offering medication-assisted addiction treatment and recovery services. Additionally, every US law enforcement officer would have naloxone, a medication that quickly reverses an opioid overdose (although the commission did not address its skyrocketing cost).

“We believe it provides an excellent roadmap for really increasing access to medication-assisted treatment for patients who have addiction disorders and highlights the need to eliminate barriers to accessing the full range and spectrum of pain treatment options”, said Patrice Harris, a psychiatrist based in Atlanta, GA, who heads the American Medical Association’s opioid task force made up of 25 national medical
societies, state organizations, and the American Dental Association. The task force supports wider use of such non pharmacological alternatives as physical therapy, acupuncture, and biofeedback but, Harris said, some health plans do not cover them—a problem the
commission also recognized.

“The cheapest way to treat pain is to write an opioid prescription”, said Bob Twillman, executive director of the Academy of Integrative Pain
Management, which advocates for reducing opioid use by treating pain in other ways. The recommendations on pain management “are on the mark”, he said, although the commission should have done more to pressure insurers to cover alternatives to opioids. “If patients can’t afford to pay for it out-of-pocket or they can’t access it because there are not enough providers around, what’s the point?”

But the recommendations also reveal a litany of unmet needs that have been allowed to accumulate for years.

Scott Gottlieb, Commissioner of the Food and Drug Administration (FDA), told reporters at the National Press Club in Washington, DC, last week that federal officials “failed to intervene hard enough perhaps at times when we might have had an opportunity to quell this epidemic—or at least stem its continued spread” for more than a decade. “Even as we tried to take measures to intervene in various ways, the epidemic was always five steps ahead of us”, he added. “Having failed to recognize how this epidemic was going to grow in proportion and take vigorous enough action, we need to be willing to be far more vigorous so we don’t continue with that mistake.”

FDA action

To reduce the risk of addiction, the FDA is considering changes in prescription requirements, including reducing the number of opioid
prescriptions and limiting the number of doses by requiring a short-term supply that could be packaged in a blister pack, like some antibiotic

Gottlieb said the agency recently asked Endo Pharmaceuticals to withdraw a drug “solely” because it was susceptible to illicit use, creating
“very unique risks”. Last month, the FDA told 74 companies it was requiring additional training for providers who prescribed their immediate-release opioid formulations which can carry a higher risk of overdosing. The training offers information on safe prescribing
and non-opioid alternatives.

“I think they [the Trump Administration] are serious but without resources, a lot of plans just get put on the shelf and never implemented”, said Regina LaBelle, former chief of staff for the White House Office of National Drug Control Policy during the Obama Administration and now a visiting fellow at the Duke-Margolis Center for Health Policy.

She suggested federal officials could begin by implementing policy changes that may not require substantial additional funding and welcomed the commission’s call for medication assisted treatment and community based recovery support services. But essential for those changes is retaining the Affordable Care Act and its expansion of the federal-state funded Medicaid programme for low-income families.

Under the Patient Protection and Affordable Care Act’s (ACA’s) online insurance marketplaces, more than 10 million people have gained health insurance, along with another 17 million who have enrolled in Medicaid. Trump and Republicans in Congress have promised to repeal the ACA, which the non-partisan Congressional Budget Office estimates would leave millions of Americans without health insurance.

“The only way we are going to wrap our arms around our fellow Americans who are suffering from this illness is to give them health insurance”, said commission member and former Rhode Island Representative Patrick Kennedy, an early champion of healthcare
reform, along with his father, the late Senator Ted Kennedy. “Then you have a chance to try to put the kind of services together that is going to help manage their chronic illness.”

But the ACA is still under assault, said Kennedy, who now leads the Kennedy Forum, a mental health and addiction policy think tank. And he said the budget bill recently passed by the House of Representatives for fiscal year 2018 would reduce Medicaid funding.

“You can’t expand insurance if you are cutting insurance”, he explained.

Providing medication-assisted opioid addiction treatment and counseling could cost US$10 billion annually, according to an estimate Kennedy cited by Richard Frank, a Harvard Medical School health economist.

In New Jersey, Governor Christie has allocated $200 million “just to tackle the opioid crisis”, Kennedy said. Christie’s commitment to the issue is one of the reasons Kennedy agreed to join the commission. Ohio, one of the states hit hard by the opioid epidemic, spent nearly $1 billion responding to it last year, according to Senator Sherrod Brown, an Ohio Democrat.

Representative Annie Kuster, a Democrat who represents part of New Hampshire—another state ravaged by the opioid epidemic—has cosponsored legislation to provide $500 million a year for 5 years to address the crisis. “It’s important that now President Trump and his administration work with Congress to appropriate funding so that those on the frontlines of this crisis have access to the necessary resources”, she said.

“It’s not always the amount of money [that matters]—it’s how you spend the dollars”, said Representative Andy Harris, a Republican from Maryland who is also an anaesthetist. He praised the commission’s call for better federal, state, and local coordination. “That’s very important because the federal government cannot solve this problem out of Washington, DC, these problems need to be dealt with at the
community level.”

LaBelle commended the commission’s support for medication-assisted treatment and community-based recovery support services. But she is disappointed it did not also endorse syringe exchange programs.

Kennedy was most enthusiastic about the commission’s strong recommendations to strengthen enforcement of the Mental Health Parity
and Addiction Equity Act; he was its lead sponsor in 2008. It requires health insurers to cover substance use and mental health disorders with financial requirements and treatment limitations that are no more restrictive than those applied to medical benefits. Many of the commission’s recommendations reflected problems exacerbated by a persistent scarcity of mental health parity.

“If our medical establishment considered these illnesses as medical illnesses—which of course they are— instead of calling it behavioral health, which somehow connotes that they are not medical, then we would be screening people for their risk factors”, said Kennedy. “Frankly that’s all we want—we just want to be in the house of medicine, treated like anyone else would be treated as opposed to waiting for the illness to essentially metastasize.”

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