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.