In Arizona, it allowed state officials to get daily reports on overdoses. In Alaska, it allowed officials to expand naloxone use. In Massachusetts, it led to new prescription monitoring guidelines and even a controversial ban on a specific painkiller.
But at the national level, Health and Human Services Secretary Tom Price said Tuesday the Trump administration did not yet think it was necessary to declare a state of emergency regarding the opioid crisis. And it is still unclear what invoking such powers would mean for an epidemic that is touching every corner of the country and will likely endure for the foreseeable future.
Most national emergency declarations, which grant the government temporary new powers with little in the way of oversight, have come in response to natural disasters or the spread of infectious diseases like the H1N1 virus. They allow the federal government to redirect military personnel or to relax certain rules so, for example, hospitals can treat diseases off site.
Those powers might not meaningfully help advocates fighting the opioid crisis, who instead acknowledge the accompanying media spotlight may be the most tangible effect of the declaration.
“I think the question really becomes, not that you just say it, but what are the actions behind it? What are the series of actions that you’re going to take as a result of that declaration?” asked Michael Botticelli, who ran the Office of National Drug Control Policy under President Obama. “There is some merit to it, but only if that brings along with it real meaningful action.”
Others went further.
“It’s a PR stunt if it doesn’t come with money, and doesn’t come with a total government commitment to give people the best access to health care to resolve this issue,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “Unless you do that, all you’ve done is made a statement.”
But some states have successfully used the same idea — of a disaster or emergency declaration — to take more purposeful aim at the battles they’re waging on a local level. Six states — Maryland, Massachusetts, Alaska, Arizona, Virginia, and Florida — have declared some form of public health emergency in recent years to implement new guidelines for prescribing, tap into funding reserves, and expand access to naloxone, the overdose reversal medication.
Each state has taken a different approach, based on their local laws and varying levels of coordination with state legislatures, governors, and local providers. Because they are so recent, experts say, it’s difficult to assess whether they’ve measurably improved access to treatment.
In Arizona, a June emergency declaration allowed officials to tap a public health emergency fund for additional resources. The state has since trained 1,000 law enforcement officers how to use naloxone and improved their tracking so they get daily reports of overdoses and cases of babies born dependent on opioids, instead of relying on numbers that are six to 18 months old.
“This is data we haven’t been able to have in a real-time capacity,” said Dr. Cara Christ, Arizona’s health director.
In Alaska, the state issued a disaster declaration in February because the crisis mirrored what happens during a disaster — a loss of life, a threat to property (in this case from an increase in crime), and limited capacity from local agencies. The announcement came after health officials realized they did not have the legal authority to issue a standing order for naloxone, essentially a blanket prescription to make it available to the public.
“This seemed like the best approach,” said Dr. Jay Butler, Alaska’s public health director.
The disaster declaration expired after 30 days — and after the standing order was implemented. But the declaration also inspired state agencies to team up on a more coordinated response, Butler said, and that work has continued.
Former Massachusetts Gov. Deval Patrick, whose March 2014 declaration was the first of its kind in the country, used his emergency powers most broadly — and instituted a ban on the sale of a new painkiller, although it was ultimately overturned in court.
The order also made mandatory a previously voluntary prescription monitoring program for physicians and pharmacies, and let first responders carry and administer naloxone. Some of those policies were later codified by the state legislature.
The Massachusetts Medical Society said the drug monitoring program had a “dramatic effect,” pointing to a 24 percent drop in the number of people being prescribed opioids in the state between 2015 and 2017.
Fewer prescriptions “may mean that we are helping to prevent new cases of substance abuse disorder among patients,” the group said in a statement. “However, with roughly 2,000 lives lost to overdose in Massachusetts last year, we know that this crisis is still far from over.”
In each jurisdiction, the declarations trained even more public attention on the growing crisis. In Virginia, for example, authorities declared opioid addiction there a public health emergency right before Thanksgiving, hoping it would prompt families to discuss the problem over the holiday.
A federal declaration is an entirely different animal — and one that may not readily achieve the goals opioid advocates have pressed for.
In interviews this week, advocates identified few new policy solutions that would only be possible if an official, nationwide emergency is declared. Major hospital groups couldn’t easily point to specific rules they might need relaxed to help them address the problems in their communities, the way they did during the H1N1 epidemic.
Instead, advocates pinned their hopes on funding that might accompany an order.
The White House’s commission on combatting the opioid epidemic seemed to acknowledge as much when it made its recommendation to declare an emergency last week. Many of the steps outlined in its interim report would require congressional action or are steps that governmental agencies can already take, from changing Medicaid rules for addiction treatment to tweaking patient privacy laws to encourage information sharing among providers.
But the report intimates that such a declaration would rouse a sweeping response, even if it just meant stirring officials to act with authorities they already have.
“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 wrote to the president. “It would also awaken every American to this simple fact: if this scourge has not found you or your family yet, without bold action by everyone, it soon will.”
“It’s a PR stunt if it doesn’t come with money, and doesn’t come with a total government commitment to give people the best access to health care to resolve this issue.”
Dr. Georges Benjamin, American Public Health Association executive director
New Jersey Gov. Chris Christie, who is leading the commission, reinforced that point on CNN on Sunday, arguing that given how pervasive and damaging the problem is — with 142 people dying each day — then how could it not be an emergency?
“If that’s not a national health emergency, I don’t know what is,” Christie said.
Though an emergency declaration might open up some limited federal resources through the Disaster Relief Fund, any major spending injection would have to come from Congress.
And money isn’t easy to come by in Washington. Lawmakers traditionally spend months or longer bickering about such spending decisions, and in recent years, their willingness to authorize big sums has declined. Though they allocated $7.7 billion for H1N1 in 2009, they offered up $5.4 billion to address Ebola in 2014, and then just $1.1 billion for a response to Zika last fall.
Outside of the spotlight a declaration could train on the crisis, it’s difficult to predict other tangible effects.
In its report, for example, the commission said that a state of emergency would enable federal health officials to negotiate a lower price for naloxone, the overdose reversal medication. But a spokesman for Christie declined to offer further details about how that negotiation would proceed or why it could only be done under an emergency declaration.
A federal declaration might also enable the Trump administration to send public health officials or other federal personnel to local and state agencies overwhelmed by whatever crisis has struck — something that providers in particular say is badly needed.
“To get psychiatrists, counselors, to get primary care providers who are trained in medication assisted treatment is really challenging,” said Louise Reese, the head of the West Virginia Primary Care Association. “If there was one thing that could help West Virginia get out of this situation, it would be some sort of program that would … get more providers into West Virginia. Whether that’s some sort of bonus or expanded loan repayment program, we just really have a significant shortage.”
But not every advocate agrees that a federal disaster declaration would be a positive step.
“Would this administration use a declaration of a national emergency to further an agenda that places at its center health-based solutions, or would it then turn around and say, we have an emergency, we need draconian legislation like sentencing laws, or crackdowns on people who use or misuse opioids?” asked Grant Smith, deputy director at the Drug Policy Alliance. “The latter would be more in line with how the administration has handled its drug policy to date, more than the former.”
One challenge with this crisis is that, no matter the response, it will remain a problem for years to come, experts said. That complicates the process of declaring some sort of emergency because they are often defined by law as short-term bursts of action that require measurable outcomes to determine success. Emergencies are typically single events — a tornado or earthquake — or even a disease outbreak that might take months to control, but not something that researchers can’t envision the end of.
“Frequently when a declaration is being considered, one of the first questions is, how will we know when it’s over?” said Dr. Marissa Levine, Virginia’s health commissioner. The opioid crisis “is a very different type of emergency.”