As overdose deaths from opioids and other drugs continue to rise — they are up almost 7 percent from the previous year — the U.S. Senate has a choice to make. It can change the course of this crisis or let the country continue to lag behind in addressing this public health emergency.
One of the Senate’s many tasks this session is to craft a bill that addresses the opioid crisis using the scaffolding set by the SUPPORT for Patients and Communities Act (H.R. 6), which passed the House of Representatives in June. SUPPORT is an important starting point, but is limited in its scope and lacks essential provisions that would lower barriers for patients struggling with addiction to get help. SUPPORT may look good on the resume of a congressperson running for reelection, but to a physician like me who treats patients with addictions, it looks uninspired and inadequate.
If the Senate wants to fundamentally change the lives of people struggling with addiction, I offer 50 ways they can improve the bill.
There are only three medications that I and other health care providers can recommend to patients with opioid use disorder that are proven to save lives: methadone, buprenorphine, and naltrexone. Methadone can be administered only at federally sanctioned treatment facilities, and doctors must get a special waiver to prescribe buprenorphine. This limits the treatment options of patients in rural counties where the crisis has hit especially hard. To address this, 1) allow doctors who have earned the waiver to prescribe buprenorphine to also prescribe methadone in their clinics, 2) provide grants to institutions willing to start such clinics, 3) create incentives for researchers to develop a long-acting formulation of methadone that carries a lower risk of being abused, and 4) create penalties for employers who discriminate against workers on methadone.
Only one in 10 individuals with substance use disorders receive care for their disease. To increase access to care, 5) allow any primary care provider or 6) emergency room physician to prescribe buprenorphine to a set number of patients without a special license and 7) make it possible for doctors-in-training to have their own panel of patients on buprenorphine under the guidance of a specially trained physician. Allow 8) pharmacists in rural communities to provide buprenorphine to patients with remote assistance from addiction medicine providers, 9) change unwieldy privacy laws to allow physicians delivering addiction care to communicate more freely with patients’ primary care providers, and 10) make the depot version of buprenorphine (the medication is injected under the skin and is released slowly over several weeks) available to incarcerated individuals with opioid use disorder, who are at extremely high risk of overdose when released back to their communities.
For patients already taking these life-saving medications, 11) create financial penalties for skilled nursing facilities that refuse to accept these patients, 12) require drug makers to submit proposed price increases to a state board to avoid sudden, unexpected expenses for patients in recovery, and 13) allocate funds to ensure that veterans of the armed services do not have to pay a dime for a medication that works for them.
Prevention, counseling, and management of other behavioral health issues are just as vital as medications to recovery and remission. Create grants to support the work of peer support specialists, also known as recovery coaches, 14) in high schools, 15) colleges, 16) emergency rooms, and 17) primary care clinics. Develop loan repayment programs for 18) behavioral health workers with graduate-level training in addiction medicine who are willing to practice in underserved areas, and 19) do the same for licensed clinical social workers dedicated to caring for these patients.
In rural areas 20) establish a national addictions community health worker program with funding to allow these individuals to lead meetings of 21) Alcoholics Anonymous, Narcotics Anonymous, and SMART, as well as to oversee 22) overdose prevention groups and 23) clean syringe programs. Create incentives for 24) employer-sponsored peer support meetings and 25) worksite counseling. Increase 26) funding for research to develop new medications to control cravings for drugs often used with opioids, such as methamphetamine, cocaine, and alcohol.
For individuals who relapse, help them get treatment earlier by 27) providing hospitals with incentives to offer medications for addiction treatment while the patient is hospitalized and 28) increase how much hospitals are reimbursed for in-hospital addiction consultations. Expand the use of 29) Medicaid health homes for patients with opioid use disorder, a successful care delivery model piloted in Vermont, Rhode Island, and Maryland.
SUPPORT’s proposed grant program to increase addiction medicine and pain management training in medical schools is a start, but 30) more robust addiction medicine curricula is needed for the future gastroenterologists who will be treating patients’ hepatitis C or future cardiologists who will be managing patients’ heart valve infections. As long as the rate of overdose deaths is still increasing, 31) forgive the student loans of physicians willing to work for four years in communities with the greatest need for evidence-based addiction treatment, or 32) pay for the medical school education of future doctors who are willing to make this commitment.
Expand 33) loan repayment programs and 34) online addiction medicine training to individuals providing primary care in rural settings — they are at the front lines of this crisis.
To accelerate their entry into the workforce, allow doctors-in-training who will go into addiction medicine to 35) fast-track through the initial phases of their training in two years instead of three and enter a certified addiction medicine fellowship in their third. Require institutions offering advanced training in pain medicine to also offer 36) addiction medicine fellowships.
Long-term recovery and remission ultimately require patients to re-form frayed bonds with family and find work that gives their lives meaning. Support paid family leave for 37) parents or close family members caring for a loved one after an overdose or 38) after a severe complication of addiction. Provide 39) telehealth and 40) on-the-ground support for rural doctors providing care to infants of mothers who are in early recovery to avoid separating moms from their babies.
Streamline 41) training and certification processes for individuals in recovery to become peer support professionals. Tie 42) increases in financial incentives for existing federal hiring programs at farms and manufacturing facilities to the percentage of individuals in recovery they employ.
When no addiction treatment seems to help, 43) allow specially trained doctors to observe patients in their home when they inject drugs, providing guidance to avoid infection and monitoring for overdose. When patients and family members ask for overdose reversal medications like naloxone to have on hand at home, 44) protect them from increased health insurance premiums.
I know that the Senate can’t just create programs. It must also figure out how to pay for them. How can it do that? Expanding 45) public-private partnerships and treatment programs is essential; it also benefits employers by improving the health of their workers. Increase 46) fines to physicians who break prescribing rules and 47) aggressively prosecute drug companies that deliberately mislead prescribers and consumers. Raise taxes 48) on families like mine in upper tax brackets — I’d much rather pay more in taxes than see another 20-year-old patient of mine die of a fentanyl overdose.
If the Senate took up these bipartisan proposals, it would go a long way to resolving the opioid crisis. But even if it doesn’t, I ask Majority Leader Mitch McConnell and Minority Leader Chuck Schumer to at least follow my last two recommendations: 49) establish a patient and family advisory panel made up of individuals affected by this crisis to guide the Senate in its lawmaking and 50) listen to them.
Devin Oller, M.D., is a primary care physician who cares directly for patients with opioid use disorder and is also an assistant professor of medicine at the University of Kentucky. The views and opinions expressed here are his own, and do not represent those of the University of Kentucky.
I want to see a doctor
All over the internet and in our mass media the misinformation continues. A popular Scince Magazine Mind, the author relates how “opiates have no benefit for people with chronic pain. https://www.scientificamerican.com/article/too-good-to-be-true-a-nonaddictive-opioid-without-lethal-side-effects-shows-promise/
At the same time the Author overstates and over sells the hype around this “Breakthrough.” The use of hyperbole and outright lies has not saved any lives, nor reduced the numbers of the addicted. The willful ignorance surrounding Chronic Pain, considering the numbers of American affected, is leading to more deaths.
A few years ago, the Psychologists, in order to increase their role in prescribing and interfering with the practice of Medicine, made a calculated “Mistake” in their bible the DSMV. They deliberately conflated addiction and Dependence. This was so they could target people with pain, as addicts, which dehumanized the millions of Americans with Chronic Pain, often the result of work injuries or repetitive stress injuries. At the same time the media painted a picture of injured blue collar workers as junkies. They did the same thing at the VA, instead of looking at facts, they decided pain was no longer a symptom. The rates of Suicide were all explained away by clever psychologists, working to undermine the credibility of injured service people.
The VA did the same thing with the soldiers exposed to Burn Pits, they got their Psychiatrists to claim the resulting illness was a Personality Disorder. That same tactic worked with Sex Abuse cases too, soldiers that reported Rape were suddenly diagnosed with various pernicious Psychiatric Disorders.
Like all of the other thoughtful replies about dealing with this industry created crisis, this industry funded, and well meaning guy refuses to look at the facts. In our dysfunction healthcare system, this has not only been allowed to go on for over a decade, they failed time and again to do anything that was not profitable for an industry insider.
This is supposed to sound realistic or sensible. Their failure to act for all of these years, or look at the impact of Pharmaceutical Marketing, corrupt well paid politicians, and even the peddling of profitable “Faith Based Cures.” Marijuana, and Battlefield Acupuncture.
I post fact America, even this is a Gas Light. They still refuse to look at History, and Facts, or even bother to follow the money.
No one is asking why the ACA was not even minimally effective at reining this in. The AMA was instrumental in obstructing sensible prescribing, and refusing to educate physicians. This Epidemic has been really profitable, and appears to be Genocidal. The alternate fact propaganda has not diminished the death toll one bit. It was really clever how the propaganda was not used to treat addiction, but to increase the profits of ineffective treatment providers, spread Faith Based Ideology, and blame sick people instead of corporate criminals.
The abject failure to address this so called Crisis, is proof the current Market Based System has failed. They are still avoiding the facts and pretending their might be common sense here. The Senate just like the rest of our Politicians took unlimited money from the death dealers.
What does it take for such authors to focus in on the real issue here, and take off the gloves, remove their tin foil hats and blinders so they can cut through the BS and explicitly get their hands around the real issues here? That would include:
1) Until Congress removes the feedbag around its neck to collect every possible campaign dollar from Big Pharma and its expansive army of lobbyists, nothing will change.
2) Congress should reverse the FDA ruling in 1997 that allowed the flood of advertising by Big Pharma to pitch its prescription drugs to the common man around the clinician. This should be regarded no differently than when tobacco advertising was banned.
3) When does Congress and the DOJ figure it out and prosecute Big Pharma for pushing the edge of the envelop:
a) Violating anti-trust by paying-off generics not to come to market to allow a longer, and more expensive window for branded drugs; splitting profits.
b) Harassing generics with expensive litigation to delay or prevent introduction of their drugs; or creating false new and improved patents to delay expiration of the brand.
c) Creating coupons to sustain branded drugs at the expense of the generic-at a higher cost to insurance (e.g., Lipitor).
4) Medicare fraud should be prosecuted to include for prison and fines the C- Suite and Board.
5) Congress and the FDA should ensure that drugs can be purchased from Canada without the false claim of Big Pharma re pirates, placebos, etc.
6) Congress should move immediately to stop the distortion in our health care that allows Big Pharma to peg its pricing to maximize its profits at the expense of our citizens:
a) Require Treasury/CMS to establish a market basket (monthly; quarterly?) that secures drug pricing and profit percentage from Switzerland, UK, EU, Australia, and Canada.
b) The U.S. will take an average of those prices and profits and declare how that will then be set for the U.S.
c) As the U.S. remains the largest market for Big Pharma, Congress, the public, the media, and providers should not blink when confronted with Big Pharma’s threat to pull R&D. Actually, the recent Harvard study delineating how Big Pharma R&D is significantly more of covering lobbying and marketing costs. Where has Congress and CMS been on this position?
In essence, Big Pharma should not be tolerated to create such an ironclad monopolistic sector in a free market; to throttle generics; to push demand for their drugs through advertising.
Perhaps if our government had the guts to prosecute the aberrant business model of Big Pharma, we would have been saved from the opioid crisis. Instead of plea deals, when do they start going to prison to make license plates? Indeed, the question is, however, what is the next impending crisis in drug overuse and consumption promoted by Big Pharma..?
Excellent article. So many of the suggestions are long overdue. I especially support any changes to current laws that would allow doctors with a special training, waiver, etc, to prescribe methadone. It (methadone) literally saved me and allowed me to drastically change my life. I have been clean now for over 20 years, no arrests, greatly improved health, etc. But having no options except to attend a specific clinic remains a big strain and difficulty for me, especially at age 64. My thinking on this is to perhaps continue to require a person needing methadone maintenance to attend a clinic during the first 5 years (or some other period of time) and if their drug screens are clean to then get their medication from a primary care physician with special training, waiver, etc. This would not really affect the private clinic industry so much, while providing much more fair and accessible treatment for those who have proven themselves. Thanks again for this insightful article.
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