WASHINGTON — A top mental health and addiction treatment advocate here wants behavioral health on the ballot in 2020.
It’s a winning issue, according to Chuck Ingoglia, the president and CEO of the National Council for Behavioral Health, a D.C. nonprofit that represents thousands of community mental health providers. According to a presidential primary poll the organization released last month, large majorities of New Hampshire voters believe the federal government isn’t doing enough to address the nation’s addiction and mental health challenges.
After Congress passed a sweeping addiction treatment package in 2018, lawmakers have largely turned their focus to other health care issues, like high prescription drug prices and “surprise” medical bills. But Americans still need more, Ingoglia said in an interview this month. He spoke with STAT days prior to a National Council presidential forum that featured 2020 candidates including Rep. Tulsi Gabbard (D-Hawaii) and two former Massachusetts governors: Democrat Deval Patrick and Bill Weld, one of President Trump’s few challengers in the Republican primary.
Beyond 2020, Ingoglia discussed the changing treatment landscape for opioid addiction, why there’s not much pharmaceutical industry investment in other forms of addiction treatment, and what legislation he’d like to see from Congress in the coming years. And he acknowledged some progress in stemming the country’s emerging suicide epidemic — namely the federal government’s designation of the three-digit number 988 as a new suicide-prevention hotline distinct from 911.
The following conversation has been edited for length and clarity.
Congress passed a big addiction treatment bill in 2018, but we haven’t heard much about the issue since then. Are people less enthusiastic about addiction and mental health issues than they used to be?
Congress has this history of passing legislation and or funding based on whatever the “substance of the year” is. It’s like a glass half-empty, glass half-full kind of story, right? We released some polling results back in June that showed Americans really want Congress to pay more attention to mental health and addiction issues. I think the SUPPORT Act in 2018 was encouraging, and I just hope that we can keep it up.
One of the good things about my job is I get to travel around the country and talk to our members all over the place. One of the things I keep hearing is: It’s great that Congress is paying attention to opioids. But there are other problems that we need them to pay attention to. Everything from alcohol to stimulants — you know, in some parts of the country, meth never went away. And certainly it’s resurfaced.
Given the massive uptick in hospitalizations and deaths related to substances like methamphetamines and cocaine, and the constant crisis of alcohol use, why do you think Washington was so eager to latch onto opioid use, specifically, as a policy issue?
And we’ve have had multiple phases of the opioid epidemic. People have been most fixated on the first one, which was started by prescription drugs. The fact that you were “innocent,” that you got this prescription from your doctor, and then you became addicted — I think that’s compelling. Another thing is that the deaths happen so much more quickly, right? You usually die from alcohol over a long period of time. There’s not the sudden onset. The third part is that the opioid crisis hit a very wide swath of America.
And the fourth part is that Congress paid attention because every time they went home and had a town hall, they were hearing about this. They were hearing about it from people that they know. I don’t know that people feel as comfortable talking about the alcohol addiction or methamphetamine use in their families. Principally because it doesn’t seem as “innocent.”
There’s a debate in addiction treatment circles about whether anyone who wants addiction medication should have it, or whether those prescriptions should be conditioned on having patients enter into psychosocial counseling, coupled with the medication. What’s your position?
These are complicated illnesses, right? It would be great if you could have psychosocial interventions. But what makes opioids different from alcohol is if you relapse on alcohol, you don’t necessarily die, whereas if you relapse on opioids, the chances of dying are much, much more significant. That’s what why people are willing to say: If all you’re willing to do is to take medication, that’s OK for now because our goal here is to keep you alive until you’re willing to do to do other things.
What about proposals to eliminate training requirements for doctors who want to prescribe buprenorphine, the drug to treat opioid addiction — essentially allowing any doctor who prescribes opioids for pain to prescribe buprenorphine for addiction, too?
When our public policy committee unanimously endorsed this legislation, I thought there might be a little more debate. The practitioners in the room really thought that it made sense.
How about proposals to end “prior authorization” — the practice of forcing doctors to get permission from insurance companies before they can prescribe addiction treatment drugs?
We’ve not had a formal discussion, but my sense is that this is something that we would support, for two reasons. One, you want to make sure when people are ready, that they get the treatments that they need. Two, our members already struggle with, you know, all of the administrative hurdles that managed care has. If you’re lucky enough to have a physician or a nurse, having them stay busy filling out paperwork is not the best use of their time. So it doesn’t make a lot of sense to us.
The Trump administration considered a policy this year that would have allowed Medicare plans to exclude coverage for certain drugs — including drugs used to treat mental health conditions — if price increases for those medicines exceeded the rate of inflation. Did you support that change?
We had no idea what the practical impact was, and what has been the history of price increases for these medications. In general, we’re fans of the six protected classes policy. Part of the reason is 40% of the clients we serve are dual eligible [for both Medicare and Medicaid.] So trying to make sure that people have access to their medications is something that our doctors strongly feel strongly about.
In a broad sense, to what degree do you think that patients in your space are touched by the larger debate about drug prices?
Not so much, right? Because our members serve primarily folks who are indigent and or on Medicaid and Medicare. Indigent, it’s going to depend on where you are. Many of our members have full-time staff who are working with patient assistance programs and other free drug programs to make sure people have access. So very little of that cost is actually borne by the patient.
We talk a lot about drugs to treat opioid addiction, but not so much about medicines to treat addiction to alcohol, meth, cocaine, and other substances. Why do you think that is?
Look at the changing landscape in the pharmaceutical world related to central nervous system disorders. Most of the big companies have gotten out of CNS. My sense is it’s because it’s been so hard, R&D is so expensive, and it’s been so hard to find effective therapies. Whether it’s Alzheimer’s or mental illness, you don’t see as much investment.