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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.

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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.

What’s not

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.

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  • Sometimes the devil is in the details. The Senate bill includes the following section:

    501. Study on prescribing limits

    Not later than 2 years after the date of enactment of this Act, the Secretary, in consultation with the Attorney General, shall submit to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives a report on the impact of Federal and State laws and regulations that limit the length, quantity, or dosage of opioid prescriptions. Such report shall address—

    (1) the impact of such limits on—
    (A) the incidence and prevalence of overdose related to prescription opioids;
    (B) the incidence and prevalence of overdose related to illicit opioids;
    (C) the prevalence of opioid use disorders;
    (D) medically appropriate use of, and access to, opioids, including any impact on travel expenses and pain management outcomes for patients, whether such limits are associated with significantly higher rates of negative health outcomes, including suicide, and whether the impact of such limits differs based on clinical indication for which opioids are prescribed;

    (2) whether such limits lead to a significant increase in burden for prescribers of opioids or prescribers of treatments for opioid use disorder, including any impact on patient access to treatment, and whether any such burden is mitigated by any factors such as electronic prescribing or telemedicine; and

    (3) the impact of such limits on diversion or misuse of any controlled substance in schedule II, III, or IV of section 202(c) of the Controlled Substances Act (21 U.S.C. 812(c)).

    =======================
    The main question here is “why take two years?” This sounds to me like a get out of jail free card for the CDC. We already know that unjustified restrictions on opioid therapy are killing patients and destroying lives. It is time to outright withdraw the CDC opioid prescription guidelines for a major re-write.

    Call your Senators and demand that they rewrite Section 501 to be accomplished in 90 days.

  • Please “ Say it sin t so” that the Senate is not going to allow Medicare to pay for methdone treatment! Methadone is the only reason I’m alive and productive today! I am 70 yrs old and have been in methadone treatment at the same clinic for 23 yrs. it now costs me $600 per mo and I only receive $1200 a month of SS benefits. I guess I should have not worked all my life and then Medicaid would have paid for my treatment, as they re doing for 75-80% of the addicts here. I don t want to be forcibly detoxed from here , but that is becoming an option that will probably kill me. Senators; please help me!!!

  • The response so far has been unscientific and nearly Genocidal. A lot of those funds will be sent to faith based treatment, instead of programs that work. At least this article mentioned chronic pain patients, they have been kept out of the discussion. This debacle was started by Pharma Greed, and they are still allowing the creators of the so called opiate epidemic, profit from their so called cures. These are the same ghouls that took money from Pharma to allow them to peddle get around federal laws and illegally distribute opiates.

    What we have here is the best lackluster, half baked solution, a bunch of industry funded, amoral, willfully ignorant, and misinformed ghouls can create. We have witnessed the end of science and reason, while these people profited from the deaths. We are in Post Fact America, where nonsense, propaganda, and lies have replaced facts. They even gamed the death toll, and used it to market more deadly pharma products.

    • I was injured at 16. Wasn’t supposed to reach 35. I have, but kniw I’m on borrowed time. I had a short leg cast put on too tight and it killed the nerves, and cut off the circulation. My leg was allowed to remain on too long and the damage went to my spine. 4 sympathectomies ( 2 lumbar, 2 brachial), my sympathetic nervous system is not properly functional. My organs are being shut down, one by one and it will eventually kill me. Every single second, of every minute, hour, day month and year, for 39 years now- my body feels like somebody is holding a torch to it. Sharp shooting electrical jolts that shoot through my limbs and make them jerk uncontrollably.
      My limbs are so deep down cold that nothing warms them. I have been on my deathbed far more times than I like to think about.
      I have had 200+ surgeries, sepsis, blood clots, pulmonary embolisms, osteomyletis (10 times), my bones are so brittle that nothing can be done to prevent my spine from collapsing more than it has already. 3 amputations. 1 artificial hip and need a replacement of the other side, as well as my right knee. But, its too risky for the surgery.
      I know self hypnosis, biofeedback, and have had years upon years of therapy (physical and psychological).
      I know other methods of trying to deal with the CRPS, TRIGEMINAL NEURALGIA, (Full body w/ complications due to earlier procedures).
      10 + years bedridden, to where I cannot take care of myself.
      And those are my good days!
      During a flare up, I am in excruciating pain with all symptoms greatly intensified.
      Any breeze, clothes, sheets, change in the weather, sets it off
      A touch of a loved one, someone trying to help.. And I feel like I am being electrocuted from the inside out from the inside out.

      I was on a maintenance dose of opiates, for ~ 30 years. Never failing to jump through the required hoops, pass the tests, or pill counts. IN FACT, it was a constant struggle within me when it came time to take my medicine. I DID NOT WANT TO HAVE TO TAKE ANY MEDICINE!
      I want MY RIGHT TO CHOOSE!
      IT’S MY LIFE, MY BODY.
      My medications were stopped cold turkey by pain management, due to the CDC “guidelines ” that are being acted upon as if they are law.

      I am terminal, just not a terminal cancer patient. ALL NON TERMINAL CANCER PATIENTS, WERE TURNED AWAY! NO WARNING. NO TAPERING. NO DISCUSSION.
      CDC GUIDELINES SAY,” FIND OTHER METHODS… OVER 5 MILLION PEOPLE HAVE DONE JUST THAT- NOW THIS IS BEING THREATENED AS WELL, AS BIG PHARMA ISN’T PROFITING.
      SINCE WHEN HAS IT BECOME AN AMERICAN WAY TO PURPOSEFULLY TORTURE AND COMMIT GENOCIDE OF THE AMERICAN PEOPLE?

      THE fordruggingamericans collection of future big pharma workers of america, do NOT have our BEST INTEREST OR HEALTH IN MIND!
      #FollowtheScience!
      #LeafItBe
      #ticktockticktock…

  • Politics! It’s the people who need help not politicians who want to advance their personal political schemes. I see this problem from two sides of the coin.
    Side #1: I am a stage 3 breast cancer survivor. I had very aggressive chemotherapy. I am blessed to be 71 years old now. But the chemo did quite a bit of physical damage to my body that can’t be fixed and leave me in chronic pain 24/7. Excruciating bone pain, muscle pain and nerve pain. Until my doctor was able to get my pain under control to help me I wondered which was worse, the cancer or the pain I now face..not saying anything about the depression and no quality of life. He has managed this severe pain with an opioid medication for the past 10 years. Now it’s old age creeping in that limits some of my activities, not that horrible pain. For anyone or any government to deny or in any way interfere with a patients comfort and quality of life is not acceptable.
    Side #2: People addicted to drugs need a full range of help to become sober, not just detox! The reason many don’t go for rehab is because no matter how badly they want to quit there’s no help! Oh sure if you’re fortunate enough to have insurance or rich family it can be done. There’s a real reason people become addicted in the first place that was never treated. So the drugs take the place of that void that develops. Our people need to have HELP to become sober and live a productive life. There’s so many that want help, yet it’s no where to be found. And for the few that do get a state grant for rehab they get booted when a bed is needed for someone with insurance!
    Instead of spending millions of dollars on “special” agencies or groups to look into this or that, just do it. Use those millions and millions to help these neglected human beings. They’re our people. Our brothers, sisters, sons, daughters, parents, friends! Yes, Medicaid and Medicare need to step up and help.
    For those of us who suffer chronic pain, leave us alone. We’re not bothering anyone.
    My son was an addict for 10 years and has been clean for 7 months now. He uses methadone treatment and must go to get his med in person by bus and walking. He’s committed to not using whether walking in rain, sleet, hail or 100 degree temperature. These addicts suffer everyday of their lives..they can’t find a way out. They need everyone’s honest help. They are desperate to live life but just can’t do it alone. Some people just need help. Not some self glorified politicians playing them like a game of chess! I could go on and on but I think I’ve dumped enough on you all. Thanks for listening.

  • Facts are rolling in that the CDC, FDA, DEA have miscalculated that fentanyl and heroin are the actual issue, and not opiate perscriptions for Chronic Pain patients. They are off by 50% on the percentages of fentanyl overdoses, and chronic pain sufferers. Horrible suffering is exactly what is happening right now, all over our country as doctors, pain centers, and most of all patients, are being bullied and threatened into compliance, to taper down or off of medicine that has helped patients have some quality of life. All in anticipation of a bill passing. It hasn’t even passed yet, and it has already raised the suicide rate, instead of helping. What is going on is inhumane, and against the oath that doctors take.

  • I m a 70 yr old methadone client with a monthly SS benefit of $1200. Of this I must pay $600 per month for my methadone. I’ve been clean and productive for 23 yrs. why is it that a lot of these addicts at the clinic , who have barely worked in their lives are covered by Medicaid? Why can’t the senators see the damage they re doing by denying Medicare coverage for methadone treatment?

  • Stage 4 Cancer should not have ANY of these rules! I need my Fentanyl patch and Dilaudid to manage my bone pain caused by stage 4 terminal cancer.

  • This government makes me SICK!!!! First they blame doctors for “over prescribing” when it’s clearly not happening, now they are blaming the most of this “opioid crisis” on illegal fentanyl…(which I totally believe is true). So leave our prescribing physicians ALONE!!!!!!! THEY ARE NOT THE CAUSE OF YOUR SUPPOSED “OPIOID CRISIS” !!!!!!! CDC, RETRACT YOUR STATEMENT THAT BREWED THIS DISASTOR ON CRONIC PAIN PATIENTS IN THE FIRST PLACE!!!!!!!!!!OUR FEDERAL GOVERNMENT HAS NO BUSINESS PUSHING MY LAW ABIDING DOCTOR’S RX WRITING PEN!!!!!
    #FEDUPWITHLIES

  • Again why is the goverment involved in medical decisions .How well did the prohibition go for alcohol ? And alcohol is far more deadly than people in chronic pain.get real folks

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