President Trump may have underscored the gravity of the opioid epidemic by declaring a public health emergency, but he failed to put forth any new resources or actions that would make a significant and immediate impact on the trajectory of the worst health crisis of our time.
Instead of putting the full weight of the federal government behind fighting the crisis, Trump ignored many of the most compelling recommendations from his own Commission on Combating Drug Addiction and the Opioid Crisis. Those of us on the front lines of this scourge — which is already claiming more American lives each year than motor vehicle crashes and gunshot homicides — hoped to see a more precise, thoughtful, and aggressive strategy, one that would include the rapid allocation of federal funding that such a crisis deserves.
As Congress and the commission consider what impact the declaration will have, and what is still needed, there are certain approaches that should not be overlooked, starting with expanding the capacity of the health care system to treat people with opioid addiction and making sure they have access to that care.
The best strategy we can embrace on the treatment access front is to fight to preserve the Affordable Care Act, particularly Medicaid and Medicaid expansion. According to the most recent National Survey on Drug Use and Health, only 10 percent of the nearly 21 million citizens with a substance use disorder receive any type of addiction treatment. One of the primary reasons people who seek treatment are not able to get it is lack of insurance coverage or insurance that does not provide an adequate substance use disorder treatment benefit.
Medicaid expansion under the Affordable Care Act — adopted by 31 states — has played a crucial role in increasing treatment access in states that have been hit hard by this epidemic. If the president really does believe that this is a public health emergency, he should drop his effort to repeal the ACA and eviscerate the Medicaid program.
Access gaps arise again in the use of medications to treat addiction. According to the president’s commission, medication-assisted therapy can “reduce overdose deaths, retain persons in treatment, decrease use of heroin, reduce relapse, and prevent spread of infectious disease.” Only about 10 percent of conventional drug treatment facilities in the United States provide medication-assisted therapy for opioid use disorder, and significant barriers exist to getting it among certain populations, such as those in rural parts of the United States and those in the criminal justice system. The commission called for the immediate establishment of, and funding for, a federal incentive to enhance access to these medications yet no such funding is included in the emergency declaration.
We must also better support those who are in recovery, so they will stay in recovery. According to the National Institute on Drug Abuse, relapse rates for people with addiction and other substance use disorders are similar to rates for other chronic medical illnesses such as diabetes or hypertension. Yet resources for the supports people need to stay in recovery are typically not covered by insurance. These include peer recovery coaches, transportation and child care, as well as community resources such as housing and employment. States need additional resources to build up not only treatment programs but support services that are essential for people to maintain their recovery.
Funding is also needed for first responders to purchase naloxone, the most effective antidote to overdose deaths. Yet this medication is becoming an increasingly exorbitant line item for public safety and community health budgets. With the price of naloxone increasing dramatically, and multiple doses needed to reverse fentanyl-related overdoses, many state health departments, as well as state and local law enforcement departments, simply cannot meet current demand without additional resources.
Also missing from Trump’s declaration is the mandated prescriber education that was recommended by his opioid and addictions commission. “While we acknowledge that some of this inappropriate overprescribing is done illegally and for profit, we believe the overwhelming percentage is due to a lack of education on these issues in our nation’s medical and dental schools and a dearth of continuing medical education for practicing clinicians,” it concluded. Again, the president’s declaration fell short of mandating prescriber education initiatives.
One of the most effective strategies to promote safer prescribing is the use of state-based prescription drug monitoring programs to better track patient-specific prescription data. Numerous studies have shown these programs to be highly effective at reducing problematic prescribing and reducing overdose deaths. Essential to this effort is sharing data across state lines. But to do so, we need federal funding and technical support to enhance interstate data sharing and to ensure that federal health care systems, including the Department of Veterans Affairs hospitals, participate in state-based data sharing.
Trump was at least correct to identify the opioid crisis as a “public health emergency.” Any future efforts should be focused on a more robust health response, not a law enforcement response. While law enforcement efforts are a vital part of the overall strategy, this country and many local law enforcement agencies have begun to finally move away from arrest and incarceration as the foundation of our response. In acknowledging this as a public health crisis, the president should also nominate someone well-respected within the public health community to lead his Office of National Drug Control Policy, a post that remains vacant nine months after his inauguration.
The urgency of this epidemic cannot be overstated and needs to be matched by actions and resources that will make a difference. Many of policies and programs put in place by previous administrations are already showing promising results. We need make sure they are fully resourced and implemented.
As with most epidemics, this one continues to evolve. We need to continue to put forward new strategies, such as those in the interim report from the Commission on Combating Drug Addiction and the Opioid Crisis, and act on them with the sense of urgency that this epidemic demands.
Michael Botticelli is the executive director of the Grayken Center for Addiction at Boston Medical Center. He served as the director of the White House Office of National Drug Control Policy from March 2014 until January 2017.
I guess I wonder why the test strips for fentanyl, that are less than a penny each, aren’t readily available to the public? Not to say it’s a solution to the crisis, but at least it would be a way to slow down the deaths. I believe most addicts would use them to keep from dying. I just find it very odd that no one’s ever talked of them, suggested them or even acted like it was something that could be had. The overall impression that’s always been given to the public is that there was no way at all for people that used heroin to know if it had been laced with fentanyl. (OH my they lied)
What’s most shameful is there are many things that could’ve been done to slow this thing down, save many, hundreds even, of lives, yet it’s almost as if no one really gave a damn…until (and I hate to even imply this BUT) rich white kids and housewives starting droppin then they cared, then they sat up and got wide eyed. But they really still have yet to grasp how bad it can still get. The answers to this has been right in front of them since the beginning, but until everyone gets on board with the, “They aren’t criminals, it’s a sickness”, it will continue to spiral and folks will die.
Does anyone think that a housewife would’ve bought heroin laced with fentanyl and died if she would’ve known all she had to do was go get on MAT and she could’ve been home that night, cooking dinner and tucking those kids in bed. IF she would’ve known. It’s too bad when there are answers but because the people that have them feel that it’s not treatment that they agree with so…in essence…screw em, let them die. These are not addicts like we’ve been brought up to believe addicts are, these are the victims of not only their own doctors but of big pharma and our own congress (congress that let them sell/market the drugs) that got them hooked, while all the while saying it was safe, these are the people they hid the MAT from when they took away their pain relief. Instead of giving them a bit of information that absolutely would’ve saved their lives, those pain doctors just cut them off, knowing what it would do to them. It’s so sad but most of all, besides being sad…it’s all so eff’ing shameful.
When will logic and proportion overtake the propaganda and hysteria of
the drug war? Currently, our policy enriches our terrorist enemies if
they are brave enough to grow the flowers we forbid. Drug war empowers
barbarous cartels to overthrow governments and kill tens of thousands
each year. This prohibition gives reason for more than 30,000 violent
gangs to exist, prowling our neighborhoods with high powered weapons,
enticing our children to lives of crime or addiction to the primitive and contaminated black market drugs.
Even if we can somehow discount the 45 million arrests, the trillions spent fighting this war and the more than ten trillion flowing into the pockets of
criminals world wide, this drug war has never stopped even one
determined child from getting their hands on their drug of choice.
Considering the horrible blowback of believing in this decades old folly
of drug war I must ask, what is the benefit? What have we derived from
this policy that even begins to offset the horrors we inflict on
ourselves by continuing to believe. From this reporters perspective it
is obvious that those who believe in drug war do not believe in public
safety.
Mr. Botticelli, given that you run an addiction treatment facility, it is not surprising that the financial bias your position creates compels you to advocate for more money for the treatment of addiction, Unfortunately, the various strategies employed by most addiction treatment facilities and the doctors employed by them, have failed miserably. Furthermore, the cost of programs like yours are incredibly expensive. Therefore, it’s impossible for this physician to see much merit in your arguments.
Medication Assisted Therapy (MAT) is horribly misused by the medical community. Doctors prescribing daily doses of 16+ mg, often more than 32 mg of Suboxone, aren’t treating addiction, they are MAINTAINING addiction. And many are doing it for financial reasons. Doctors are using MAT in the same way they misused/misprescribed the opioids in the first place. They are using a “chemical dependency as a business model.” They get patients addicted and they keep them that way, because it guarantees a steady stream of income for years.
There’s just no money for these doctors in successfully treating addiction, therefore, we continue to see nothing but expensive, harmful, and failed strategies for the treatment of opioid addiction.
Doctors are responsible for the creation of most cases of opioid addiction. Therefore, allowing the same people that created the problem to solve it, without removing incentives for them to simply maintain addiction with a different and more expensive opioid like buprenorphine, makes no sense.
And please, don’t insult the intelligence of those of us that truly treat addiction, by pretending that anything but a vanishingly small percentage of the drug treatment programs do much of anything effective with acillary programs for counseling, cognitive behavioral therapies, etc. They don’t. They still do little more than herd 40+ addiction patients through their clinics everyday with a primary focus of maximizing income.
Until a solution removes the incentives for doctors to maintain patients on therapy for years, MAT will never free patients from addiction, save lives, or slow the unsustainable increases in spending for opioid addiction treatment programs.
Jim Meehan, MD
Bravo, Dr
Meehan!!!