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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.

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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.

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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.

  • Kratom is a useful tool to help mitigate opiate withdrawal symptoms and lessen cravings for opiates. Especially for people in rural areas, who don’t have access to doctors, clinics and counseling. Kratom can be delivered right to their door.

    #51- the FDA lifts their import alert on kratom products. In addition, the FDA regulates kratom so it is ensured to be safe, unadulterated and free from contaminates. Adults who want to use kratom in their recovery are free to do so without a threat of a ban.

    #KratomSavesLives

  • Observation for Charlie: actually, no. Although there was certainly false advertising by profit-obsessed Big Pharma companies, they didn’t “create” the opioid crisis. There is very little relationship between rates of doctor prescriptions and rates of opioid mortality. What happened instead is that major intermediary distributors like McKesson routed huge volumes of prescription drugs to pill mills in zip codes where there was no possible medical market — and the DEA let them do it, knowing that something was haywire. DEA prosecutors refused to aggressively go after the distributors, on “grounds” that the lawsuits might drag on forever without resolution. There is reason to believe that some of those DEA and DoJ prosecutors were bribed by promises of cushy jobs following departure from government service, as lobbyists for the companies they didn’t prosecute.

    • This is also for Charlie. Yes, Cannabis does help some people who live with pain, but not all. I’ve been on the program for years, have spent thousands of dollars trying to find a strain that will work for me and have yet to find a single one that can help elevate even a minute amount of relief. In my state it took 5 years for topicals to become legal and only two dispensaries that are 90 minutes apart can offer them. I use the topicals now but because I have pain in all my bones, muscles, nerves, and joints I have to spread it over my entire body but they only last a few minutes, not long enough to sustain relief to enable me to go out and walk around a mall or even a single store. When one has pain levels everyday between 8-10, Cannabis doesn’t touch it. So Charlie, Cannabis can be the answer for some, but again, one size does not fit all.

  • First, it is not an Opioid Crisis, it is a “Heroin/Fake Fentanyl Crisis,” Write 50 ways the Senate can change the CDC mandating of 90 MME for chronic pain patients. Here, I will start the list 1) It has been proven over and over that legally prescribed opioid patients have the lowest percentage of addictive behavior 2) the CDC should not try and override what trained Pain Management doctors prescribe for chronic pain patients 3.) There are close to 100 million Americans who either live in chronic pain or have at some point in their lives 4) Stop all the false propaganda that has spread like wild fires with inaccurate facts about legally prescribed opioids for patients 5) Start listening to the patients instead of the DEA/FDA/CDC about what it is like to have your pain ignored and forced to go into withdrawal because doctors have closed their doors on us out of fear. 6) The prevention of over 20 suicides a day due to chronic pain where the patient has been denied the medication regimen he/she have been on for years and can no longer handle the pain for which they were once treated 7.) One size of medication does not fit all because there are so many diseases that cause chronic pain. Some people may only have one disease but in most cases patients (like me) have several diseases all of which cause chronic pain. 8) Get the facts straight that the Fentanyl is coming into this country from China and Mexico and is being mixed with the who knows what type of ingredients and are able to reach the wrong hands in the US and is then mixed with Heroin. This is the deadly combination causing this epidemic not our legal prescriptions 8) Stop calling this crisis as an Opioid Crisis and call it “A Heroin Epidemic 9) stop the forcing of withdrawal because the pharmacist has decided to not fill a prescription to a patient who has been on the same medication, going to the same pharmacist for years and are now suddenly turned away. 10) Stop the unnecessary “no questions asked” raids by the DEA of Doctors who are helping chronic pain patients that other doctors have turned away. Now I’ve given you 10 things to bring to the senate. Do your research and give us, the chronically ill/chronic pain community some type of quality of life instead of the needless suffering we are forced to endure everyday caused from all the false reporting propaganda that is constantly making news on TV, radio and all over social media. Do your homework, get your facts straight and stop the suffering of innocent people who are dying because the pain is more than any human can or should have to endure 24/7/365.

    • Lisa Hess is the only person I’ve read who has it exactly right. I’ve been affected severely by the CDC’s back room deal along with their false reporting. Doctors for the most part know what is right for their patients with chronic illness, so the government should go after the cartels not the doctors who are just doing what is best for their patients. Patient suicide has risen because of the CDC and don’t be surprised by patients harming their doctors as well for what they are forcing on them. Unwarranted discontinuance forcing severe withdrawals can do much harm to patients, making them unstable and very angry. Let doctors be doctors and keep crooked politicians and lobbyists out of our waiting rooms.

    • We have an opiod epidemic created by big Pharma. They pushed prescribing opioids for every complaint of pain possible. And doctors obliged. Now, many people are addicted and using heroin as an alternative. This isn’t a Mexico/ China problem. Fortunately, so many people are saying, fuck big Pharma’s poison. Cannabis will get the vast majority of people through their pain with no danger or side effects. Next we will be dealing with the over prescribing of antidepressants and anti anxieties.

    • APPLAUSE to Lisa!! Folks, after living in Severe Chronic Pain for 32 years after 6 failed back ops resulting in a RUINED SPINE, it is Awesome to hear someone who hits it Dead On The Head!! To our US Govt…THERE IS NO PRESCRIPTION DRUG CRISES. Please let DOCTORS who are TRAINED to treat patients like us ALONE!!!! GOLLY! Don’t you ppl have enough to do..

  • Doctor Oller’s 51 points are almost all directed to expanding treatment and prevention programs for addicts. That may be useful. But a voice is missing from this discussion: where are the programs for management of chronic pain in both addicts and people who have never abused opioid analgesics?

    We now know that medically managed opioids prescribed to valid pain patients contribute almost nothing to our public health crisis with opioid addiction and morality. Statistics published by the CDC itself prove this reality beyond any reasonable contradiction. Seniors over age 50 are prescribed opioids 250% more often than kids and young adults. But death rates by opioid overdose have skyrocket among youth over the past 17 years, while rates among seniors have remained stable for this entire period. If exposure to medically managed opioids was a significant cause of addiction, we’d be seeing more opioid deaths in older people. But we aren’t.

    The assumption that physician over-prescribing is a cause of our public health crisis is wrong. The demographics don’t work. And they never have. Doctors and their patients aren’t at fault, and it’s past time to stop stigmatizing and punishing pain.

    Likewise, Congress may need to embrace two more dimensions of treatment for people with addiction: sober housing for addicts in recovery, and job training and community reintegration programs to provide alternatives to pushing drugs as a way to survive.

    At its heart, our opioid “epidemic” is a crisis of despair, not medical exposure to opioids. If we fail to deal with the despair and disintegration of our communities, then we’ll see no end of drug addiction and death.

  • I’m a chronic pain patient. My opioid pain med was discontinued in order for me to try supplements instead. The prescription costs 13$ a month. The supplements will cost over 50$ a month. I’ve wasted money on non opioid meds that did not work if I could afford them. I’ve had physical therapy, 2 epidurals, gone to a chiropractor and have been prayed over which I don’t believe in, but when you’re desperate you’ll try anything. I’m not using the supplements bcuz I can’t afford them. My pain management Dr will probably d/c me because of this. BUT if I was an addict and od’d 5 times in one week I’d be given narcan every time.

  • This is so typical of the medical community. Doctor, there is only one answer to the opiod epidemic. Cannabis. Using cannabis in lieu of prescribing opioids is the answer. You, and big Pharma created this mess for profits. Cannabis will fix it.

    • This is another part of the problem, people using these venues to advertise everything from cannabis to alternative medicine. The lack of a fact based scientific response to this debacle, turned the deaths into a ghoulish multi level marketing morass on social media.
      The For Profit so called “free market” healthcare system created this, and in 20 years has done nothing but attack sick people, peddle fake “cures,” and use platforms like this to promote their business. No one in the Medical Industry added any facts to the discussion. They fiddled while people died.

  • They should have done some of these years ago. Unfortunately this ongoing crisis has been really profitable for the parasites at Pharma, the Medical Industry, and even the insurance companies. Absent is any mention of American with Chronic Pain who have been stigmatized, criminalized and forced to give up their lives and relationships due to this lop sided coverage. There is plenty of blame to go around, form the A.M.A who told their members that diagnosing pain, or addiction could lead to liberality. Then there are the psychologist who rewrote the DSMV to conflate chronic pain with addiction, and hysteria, these unscrupulous liars made a of money too. Many American with long term intractable chronic pain were initially misdiagnosed, and endured surgeries with no pain relief, which added to the severity of their long term pain. Many of these individuals are traumatized, yet the industry censored these fact based stories.
    This is like the Mad Hatters Tea Party, they ignored the DEA, while the FDA. CDC, and FTC ignored the Facts, and allowed the profiteering Lawbreakers continue to cash in. We have the worst healthcare in the developed world, and anyone that believes otherwise is delusional.
    In Post Fact America, the press and Hospital Public Relations Departments, are still misleading the public about “Drug Addicted Infants” in order to keep the public deceived. The old people with multiple screwed up hip surgeries (from Devices the FDA approved for a price) are being tortured because of addiction, they are not allowed pain relief.

    No one is asking how many Suicides have been falsely attributed to Opiate Use Disorder. It was a convenient label for patients who were butchered in failed spinal surgeries, or sold devices that had to be removed. Perhaps they should start with defining “Addiction.”

  • As a patient with acute chronic pain who needs opioids to survive, I am so tired of all the focus on the addicts which leads to punishing legitimate patients, most of whom are too sick and too weak to fight back. My pain manager just told me about the new CDC rule, effective Jan 1, which will severely restrict the amount of opioids which doctors can prescribe – with no consideration to the needs of any individual patient. Combine this with the Trump Admin’s war on medical marijuana — a substance incapable of killing people via overdoses — and pain patients are in for a horrible near future. many will be forced to become criminals to obtain the pain relief they need; others will commit suicide.
    I wish that articles like this would remember that addicts are not the only people with opioid-related problems.
    The past lack of proper regulation has led to over-regulation in far too many instances, and this is only getting worse.

  • What about chronic pain patients who are not addicts, that have tried every non narcotic pain relief method available including surgeries and implants, who only have some semblance of a life without being in agonizing pain because of opiates? Chronic pain patients are now the casualties in this epidemic, having pain management taken away due to addict behaviors. The suicide list of pain patients denied pain management grows daily. People who have used the same dosage of pain meds for years judiciously and responsibily. Don’t those lives matter too? It doesn’t seem like it the way things are being handled! Suffering dogs are currently treated better in this country!

    • I can’t agree with Misty more. I tried to write my own comment on that same topic, but for some reason, got a message that it would not be published.
      But she did forget the non-suicide options for pain patients — buy drugs illegally and risk arrest and prison, or move to another country. All great options for really sick people.

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