A reality check on Obama’s billion-dollar opioid addiction plan
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WASHINGTON — President Obama wants to spend $1 billion over two years to tackle the nation’s opioid epidemic. That’s a big commitment, and many in the addiction field are highly encouraged.

But for the plan to make a dent in a crisis that’s now killing nearly 30,000 Americans a year, it will have to overcome several big hurdles. Here are five of them.

The stigma against treating drugs with drugs persists

Many in the so-called recovery community are wary of treating an opiate addiction by prescribing another opiate.

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Obama’s plan puts most of the funding toward getting opioid abusers on medication, typically methadone and buprenorphine. Those drugs aren’t heroin, but they can be abused. There’s also a risk that the medications will be diverted and sold to other addicts.

For those skeptics, “abstinence is the treatment of choice,” said Dr. Hilary Connery, clinical director of the alcohol and drug abuse treatment program at McLean Hospital in Belmont, Mass. “Replacing one drug with another drug, that’s not what they consider the goal of recovery.”

An endorsement from the White House is one way to reverse this stigma. But there’s no getting around the fact that the administration is putting most of its resources behind a treatment that still hasn’t won over everybody in the field.

“The knee-jerk response is to not really think about medications because we want to do things as ‘natural’ as possible,” said Dr. Joseph Lee of the Hazelden Betty Ford Foundation, which has treatment centers across the country.

However, Lee said, “the evidence is pretty overwhelming that being on a medication can save lives compared to not being on medication.”

There aren’t enough doctors to prescribe the medications the White House is pushing

Just 30,000 doctors across the United States are certified to prescribe buprenorphine. That’s not a lot, considering that an estimated 2.1 million Americans are addicted to opioid painkillers and another half million are addicted to heroin.

“Are they going to train the workforce? If people aren’t comfortable prescribing, that’s a problem,” said Dr. Alexander Walley, medical director of the Narcotic Addiction Clinic at the Boston Public Health Commission and an attending physician at Boston Medical Center.

In October, the White House announced a commitment by leading provider groups to double the number of doctors who are certified to prescribe buprenorphine in the next three years. This week’s budget request also included $10 million for a panel to explore allowing nonphysicians to prescribe the treatment.

The administration is also revisiting regulations that limit the number of patients each doctor can write prescriptions for.

But updating any policy involving opioids is a delicate proposition. The Centers for Disease Control and Prevention has stirred a lot of controversy with its efforts to revise opioid painkiller prescription guidelines. The Food and Drug Administration has run into similar trouble. It’s unclear whether the White House will have more luck.

It’s not just about medication

Experts say medication treatment works best in tandem with therapy. Traditional inpatient treatment is always going to have an important role for acute crises, too.

In other words, just bumping up the number of methadone prescriptions won’t be enough.

“We can’t look at these as separate issues,” Connery said. “These medications do not work on their own.”

Many doctors don’t feel comfortable prescribing medication treatment unless they know the patient will have adequate social and emotional supports, Connery said.

It’s vital for patients, too, because “somebody who’s using is not engaging in normal life skills behavior,” said Colleen LaBelle, who helps run the treatment program at Boston Medical Center. “We want to help them figure out how to put their lives in order. Going to therapy gives them some direction.”

The president’s budget included a reference to more spending for “recovery support.” The success of the plan could hinge on what, exactly, that means.

There are big gaps in insurance coverage

Taxpayer dollars aren’t enough. Experts want to see better coverage for addiction treatment, particularly medications, from private insurance.

As things now stand, some insurers don’t cover buprenorphine, restrict its use, or require prior approvals that can make it difficult to get patients into quick treatment.

Both the Mental Health Parity Act of 2008 and the Affordable Care Act were supposed to ensure that health plans would cover mental health treatment, including substance abuse treatment, as thoroughly as other health care.

But implementation remains a work in progress. Enforcement is spotty at both the state and federal level. And the provider problem rears its head again: Just because substance abuse care is covered doesn’t mean patients can find a doctor in their network who will prescribe medication treatment.

Congress may not approve the spending

Maybe we should have started with this one.

A president’s budget is just a proposal. Congress has to appropriate the money. And this particular Republican-controlled Congress has said — in an unprecedented move — that it will not even hold hearings on Obama’s budget. That’s hardly a good omen.

On the other hand, key members like Senator Lamar Alexander of Tennessee have signaled a willingness to work with the administration on substance abuse. It is also a big issue for Senate Majority Leader Mitch McConnell.

And last year’s government spending bill included a $100 million funding increase, to $400 million, for efforts to combat the opioid crisis. So there is a precedent for opening the purse strings, at least a little.

The bottom line on the president’s billion-dollar bet?

“There’s a lot of things that can go wrong with so many moving pieces,” Lee said. “But that’s not to say … it’s not a step in the right direction.”

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