ASHINGTON — The Senate on Monday passed a wide-ranging opioids bill, one that aims to prevent illicit fentanyl trafficking, account for drug diversion in opioid manufacturing quotas, and improve access to addiction treatments via telemedicine.
Many senators, soon to campaign for re-election in states hard-hit by the epidemic, say the bill is enough. Many advocates for better addiction treatment beg to differ.
And, perhaps as importantly, many key policy differences remain between Senate and House versions of legislation to address the epidemic, leaving Congress plenty of work to do before the bill reaches President Trump’s desk. That effort is expected to begin in earnest after Election Day.
The Opioid Crisis Response Act, authored largely by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), contained dozens of proposals that are viewed as limited but commonsense steps toward a better nationwide system for preventing and treating addiction. As a result, the bill enjoyed bipartisan support and has been marred by relatively few controversies, especially compared to the House version.
The sole brief snag centered on a provision written by Sen. John Cornyn (R-Texas), the chamber’s No. 2 Republican, which would have awarded $10 million in yearly grants to advocacy organizations, largely to provide training and literature about improving treatment services.
Democrats protested that the language was so narrowly tailored that only the Addiction Policy Forum, a group run by a longtime lobbyist for the drug company Alkermes and funded largely by PhRMA, would be eligible for the funds. After multiple outlets reported on the controversy last week, Republicans agreed to remove the language.
Here’s a look at what else was in the bill, what policy ideas didn’t make the cut, and what ideas might be added back in the coming weeks and months.
What’s in the bill
Reduced quotas: The Senate bill gives the Drug Enforcement Administration more authority to reduce manufacturing quotas for controlled substances, including prescription opioids when the agency suspects diversion, building on a rule the agency issued itself earlier this year. The quotas spell out the volume of specific controlled substance classes manufacturers can produce in a given year.
Chronic pain patients, however, have expressed the concern that reduced quotas could make it more difficult for patients in need to access their medications, without reducing addiction and overdose rates. As the county’s addiction crisis has become more of a focus in Washington, chronic pain patients have increasingly warned policymakers about the pitfalls of otherwise well-intentioned efforts to reduce opioid oversupply.
Telemedicine: The bill instructs the Department of Health and Human Services to issue regulations allowing doctors to remotely prescribe medication-assisted treatments. Buprenorphine and methadone are both controlled substances, meaning in-person prescriptions and referral requirements can pose an obstacle to patients seeking treatment in rural areas.
Mail security: The “STOP Act,” penned by Sen. Rob Portman (R-Ohio) and included in the Senate bill, aims to prevent the illegal importation of illicit fentanyl via the international mail system. The bill will bolster digital tracking data on 70 percent of international packages arriving in the U.S. by the end of 2018 and 100 percent by 2020.
As Portman and other backers point out, the entry of illicit fentanyl into the county’s drug supply has resulted in an explosion of overdose deaths. In 2016, illicit synthetics including fentanyl were involved in more overdose deaths than prescription opioids.
More methadone treatment: The House’s opioids bill included language to close a coverage gap for methadone-based addiction treatment in state Medicaid plans, beginning in 2020. The Senate bill did not include such language.
Prescription limits: Some versions of the legislation, including one authored by Sens. Portman and Sheldon Whitehouse (R-R.I.), included hard limits on first-time opioid prescriptions for acute pain. Numerous states have already enacted such legislation, but groups including the American Medical Association have resisted efforts to legislate prescribing practices at the federal level. Other advocates opposed to the limits decried those versions of the legislation as messaging tactics.
Parity enforcement: Like the House bill, the Senate’s package does little to improve enforcement of parity laws mandating that employers and insurers comprehensively cover treatment for behavioral health conditions, including addiction. Parity was a key focus of a Trump White House commission that issued a sweeping list of recommendations last November.
What might get added back in conference
A controversial patient privacy law: Advocacy groups that normally agree on addiction treatment policy are split on a House provision that gives health providers more freedom to share information about a patient’s history with substance use and non-fatal overdose with families, caregivers, and other health professionals
The Senate package, however, does not extend the same authority to providers. Sources familiar with the House legislation said Rep. Greg Walden (R-Ore.), the chairman of the House Energy and Commerce Committee, is unlikely to walk away from a conference process without ensuring the House version, which he helped author, makes it into the final package.
IMD exclusion: Trump’s commission also recommended that the federal government waive the so-called “IMD exclusion,” which prohibits Medicaid payments to addiction treatment facilities with more than 16 beds. Advocates say the exclusion limits the nationwide capacity for inpatient addiction treatment.
The House version included a limited version of the provision, which could greatly expand treatment options but which could also cost the Medicaid program billions of dollars. The Senate included no version at all. Nonetheless, Portman has said he hopes the House version can be improved upon in negotiations following the Senate vote.
This story was updated to reflect passage of the bill.