Washington Comes Together to Tackle Opioids

In a rare move that underscores the severity of the US opioid crisis, President Trump signed into law legislation with strong bipartisan support that provides multiple measures to more aggressively address what has become a steady and growing epidemic over decades.

“While there’s much more work to be done at every level of government and society, it’s nice to see a rare moment of unity on a life-and-death issue that is affecting every corner of America,” said Jeremiah Gardner, MA, LADC, director of communications and public affairs, Hazelden Betty Ford Foundation, Center City, MN. “We applaud policymakers for recognizing the need to address this public health problem in a bipartisan manner. It’s a bipartisan illness, after all.”

By all measures, the numbers of people misusing opioids and deaths caused by such misuse has made the opioid issue one of the leading public health concerns in this country. In 2017, drug overdoses accounted for more than 72,000 deaths in the United States, with provisional data showing that over 49,000 of these were attributed to deaths involving opioids, according to the National Institute on Drug Abuse. Among the sharpest increase in overall drug overdoses for 2017 were 30,000 deaths related to fentanyl and fentanyl analog (synthetic opioid) use.

Common among people who misuse opioids are those prescribed opioid pain relievers who then go on to become addicted to opioids. The numbers of people who have died from overdoses of prescription opioid pain relievers (not counting nonmethadone synthetics, a category in which illicit fentanyl dominates) grew 1.9-fold between 2002 and 2011. When looking at the number of overdose deaths attributed to synthetic opioids, predominately fentanyl, there was a 22-fold increase in the total number of deaths from 2002 to 2017.

Although the number of overdose deaths seems to have leveled off, the many more individuals who live with opioid addiction contribute to the toll of this epidemic on individuals, families, and communities all across the United States.

Most experts agree that the bill just signed into law—the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act—is a good step toward reducing these numbers and to address what many see as an ongoing health care issue. However, some experts and policymakers question whether the level of funding is sufficient and say that the bill fails to acknowledge the scope of the issue. More than an acute crisis, they say, it is a long-term problem that will require not only ongoing funding but also a fundamental change in how addiction and pain is managed.

SUPPORT for Patients and Communities Act

SUPPORT for Patients and Communities Act includes an array of provisions that address public health and law enforcement measures. The Table lists a number of policy changes included in the law.

Keith Humphreys, PhD, department of psychiatry, Stanford University, Stanford, CA, who worked with congressional staff on the bill, told PBS News Hour that a couple key benefits of the bill include leveraging Medicare and Medicaid and making them “part of the addiction treatment infrastructure. That means Medicaid is going to cover more residential care … [and] Medicare is going to cover treatment for people who are addicted to opioids. That’s more important than a lot of people realize. The stereotype is, everyone is young who have this problem, but, in fact, a number of senior citizens suffer from it as well.”

Another important provision is allowing for more types of health care providers, such as Certified Registered Nurse Anesthetists (CRNAs), to administer drugs like buprenorphine that ease withdrawal symptoms and improve treatment outcomes, according to Garry Brydges, DNP, CRNA, president, American Association of Nurse Anesthetists, Park Ridge, IL.

“This legislation will allow CRNAs to fully engage in combating the opioid crisis,” he said, adding that CRNAs are the primary providers of anesthesia care in rural America. “In some states, CRNAs are the sole anesthesia professionals in nearly 100 percent of rural hospitals,” he said. “Wait times, travel times, and access to care are critical barriers to patients that CRNAs confront daily.”

For Mr Gardner, the bill demonstrates the bipartisan commitment by Congress and the White House seen over the past several years to address the country’s opioid overdose epidemic as well as the broader addiction crisis as well. “Those of us working on the front line of this public health problem are grateful and hope the sustained federal focus will continue,” he said. “It needs to.”

Need for Sustained Focus and Funding

Although the bill provides many important measures, many experts and policymakers think it is too underfunded to make a real and lasting impact on reducing the opioid crisis. “The bill will make a positive difference, but it’s not sufficient to turn back the opioid crisis due to the lack of extensive funding provided,” said Dr Humphreys in an email interview with First Report Managed Care. “What is missing from the bill is a commitment to permanently integrate quality of care for addiction and chronic pain into the US health care system.”

The Trump administration has secured $6 billion in new funding over 2 years to tackle the opioid problem. Some experts and policymakers, however, say the funding needs to be much higher—in the range of $100 billion over 10 years—to truly treat the opioid crises as the public health emergency that President Trump declared it to be a year ago. 

As communications director for one of the leading addiction centers in the country, Mr Gardner emphasized the need for continued funding and sustained effort to address addiction. “Continued funding for the states is critical,” he said. “That’s where we’re seeing these innovations and systemic changes beginning to happen.” Among the recent advances he cited are greater collaboration among health care and corrections professionals, expanded use of medications alongside clinical therapy and peer support, new emergency room protocols, expanding insurance coverage, slow-but-growing use of telehealth and other technologies, more robust linkages to community-based recovery supports, accountability reforms within the specialized addiction treatment field, and more education on addiction for mainstream health care providers.

He also highlighted that the addiction crisis is not new but decades old in the United States. “It tends to morph from one drug to another,” he said. “The opportunity arising from this tragedy is to advance our entire, long-neglected addiction care system so that we are not so susceptible to the next crisis and the historical swings from one crisis to another.”

Dr Humphreys also emphasized this need in his PBS interview. “I would like us to stop thinking of this as a crisis, meaning a short-term issue that will be resolved by a couple of years of hard work, and instead just be realistic that addiction is part of the fabric of population health,” he said. “What we need to do is bite the bullet, go into programs  like Medicaid and Medicare, adequately reimburse treatment, make a big investment in training, because we need physicians and nurses and psychologists and other professionals trained in this, taking care of this disorder, and just accept this will be part of what the health care system does from here on out, because, right now, it’s opioids.”

“Payers are in a unique position to help addiction treatment progress through alternative payment arrangements that support better outcomes through evidence-based practices and solid continuums of care,” said Mr Gardner.

He also underscored that new grant funding is providing the opportunity to encourage the development of integrated care systems through collaborations with primary care and specialty providers.

Mr Brydges encouraged managed care providers to use the expertise of CRNAs as reducing opioid addiction is at the core of their training and education. “Managed care providers should reach out to CRNAs and ask about the mechanisms of chronic and acute pain, addiction, and the role that CRNAs play,” he said. “In many cases, a CRNA may be on your doorstep without you knowing it.”