opioid

Opioid Epidemic and Drug Addiction Crisis Require Bold Action, but Also a Huge Amount of Money

By M2|2019-07-12T17:35:29+00:00August 9th, 2017|Health care spending, Uncategorized|

Opioid Epidemic and Drug Addiction Crisis Require Bold Action, but Also a Huge Amount of Money

On March 29, 2017, President Donald J. Trump signed an Executive Order establishing the President’s Commission on Combating Drug Addiction and the Opioid Crisis. The Commission is led by New Jersey Governor Chris Christie (R), and will issue a final report with its findings and recommendations by October 1, 2017.

The commission issued an interim report July 31, 2017, and many news headlines focused on either what the commission called “the first and most urgent recommendation,” which was to urge the President to declare a national emergency (which U.S. Health and Human Services Secretary Dr. Tom Price told reporters on August 8, 2017, the President has no plans to do immediately), or, some of the more alarming facts about drug addiction, for example:

“Only 10 percent of the nearly 21 million citizens with a substance use disorder (SUD) receive any type of specialty treatment.”
“With approximately 142 Americans dying every day, America is enduring a death toll equal to September 11th every three weeks. (Emphasis in original).

In addition to some key findings, the interim report included areas for further consideration (to be included in the final report) and nine key recommendations, summarized as follows:

Declare a national emergency.
Rapidly increase treatment capacity.
Mandate prescriber education initiatives.
Immediately establish and fund a federal incentive to enhance access to Medication Assisted Treatment (MAT).
Improve access to naloxone.
Prioritize funding and manpower to quickly develop fentanyl detection sensors.
Enhance interstate data sharing among state-based prescription drug monitoring programs (PDMPs).
Ensure that information about SUDs be made available to medical professionals.
Enforce the Mental Health Parity and Addiction Equity Act (MHPAEA).

The 10-page report includes a broad range of ideas, as it should, considering the process the commission used:

“In addition to conducting phone calls with Governors and their teams in all 50 states, we also held a listening session with bi-partisan members of Congress, and key cabinet members of your Administration. Individual Commission members have organized “listening sessions” and solicited recommendations from treatment providers, addiction psychiatrists and other physicians, data analysts, professional medical and treatment societies, medical educators, healthcare organizations, pharmacoepidemiologists, and insurance providers. Outreach also has been made to scientists with broad expertise in pain, addiction biology and treatment.”

“The first public meeting of the Commission was held on June 16th at the White House, and was a great success. The Commission members heard comprehensive public testimony by nine leading nonprofits, and have received more than 8,000 comments from the public, including comments from at least 50 organizations.”

It makes sense the commission was able to access so many voices of experience. There are lots of experts out there, and lots of previous recommendations, including one of the most recent, the 413-page Surgeon General’s Report on Alcohol, Drugs, and Health, Facing Addiction In America, published in 2016 under the Obama administration.

Show Me the Money

Ideas aren’t really the problem though. The real sticking point is money. How much money is needed to address what is likely a national emergency?

The Obama administration, the Trump administration, and our current Congress have all proposed some numbers.

The Obama administration’s President’s FY 2017 Budget included more than $1 billion over two years just for “expanding access to treatment for prescription drug abuse and heroin use.”

President Trump’s first budget, for FY 2018, proposed nearly $30 billion for drug control efforts, including for treatment and prevention efforts.

In the middle of negotiating Obamacare repeal and replace this summer, the Senate made changes to the Better Care Reconciliation Act that went from providing $2 billion to $45 billion over 10 years for substance abuse treatment and recovery.

And yet another estimate for caring for those who are already addicted was pegged at $183 billion over 10 years by Dr. Richard G. Frank, a Professor of Health Economics in at Harvard Medical School.

Addressing the opioid epidemic and drug addiction crisis can’t be about the politics of the Obama budget versus the Trump budget, or President Trump’s commission versus former President Obama’s Surgeon General’s Report on Alcohol, Drugs, and Health, Facing Addiction In America.

“If this scourge has not found you or your family yet, without bold action by everyone, it soon will,” exhorts the interim report.

We have plenty of ideas. We know what we need to do in order to save lives. But what we need to do won’t come cheap. The sooner we get to that conversation, the sooner we will be able to act boldly.

Coverage Drives Treatment: The Case of Pain

Last week Congress decided not to move forward with repealing and replacing the Affordable Care Act with the American Health Care Act of 2017. This doesn’t mean health reform is over in the U.S., though.

Patient access to care and the costs of that care are still hot topics in Washington, D.C. and statehouses across the country. As we move forward in reform, I would propose a close look at the opioid epidemic and ways we can push for payers to cover treatment that is patient-centered and evidence-based. Seems straightforward, but it isn’t.

A USA Today op-ed from last fall had a subtitle on the opioid epidemic that said it all: “There are other ways to manage chronic pain, but insurance companies won’t pay for them.”

In the summer of 2016 the U.S. Surgeon General sent a letter to physicians in the U.S. basically saying they haven’t been properly trained to manage pain and they could do better to manage patients with pain than just handing over a prescription for an opioid. Dr. Vivek Murthy was more eloquent, writing, “We often struggle to balance reducing our patients’ pain with increasing their risk of opioid addiction. But, as clinicians, we have the unique power to help end this epidemic.”

Prescriptions for painkillers vary dramatically by state, further supporting the argument that prescribers may not be following a standard of care for treating pain.

Source: CDC, Policy Impact: Prescription Painkiller Overdoses

It is true that clinicians are uniquely situated to address responsible opioid use and pain management, but that will be difficult to do without support from health insurers. Dr. Robert Bonakdar, the author of the USA Today piece and the Director of Pain Management at the Scripps Center for Integrative Medicine, and immediate past president of the Academy of Integrative Pain Management, succinctly explained the entire U.S. health care system’s approach to pain management:

… many well-established non-pharmacologic treatments like biofeedback and cognitive behavioral therapy (CBT), endorsed [by Murthy], are routinely denied by insurance companies. As an ironic example of the campaign’s shortcomings, on the same day I received the surgeon general’s letter, I received one of the standard insurance denial letters for the biofeedback I had requested for a patient’s headache.

Government agencies and other advisory organizations are coming together to acknowledge that addressing pain is not as simple as writing a script – which is clearly what the system pays for right now.

The National Pain Strategy reminds health care providers and policymakers (and anyone else who will read its 72 pages) that, “Chronic pain is a biopsychosocial condition that often requires integrated, multimodal, and interdisciplinary treatment, all components of which should be evidence-based.”

The Principles of Chronic Pain Treatment prompt health care providers who are treating patients with pain to “use nonopioid therapies to the extent possible,” but also to “identify and address co-existing mental health conditions (e.g., depression, anxiety, PTSD)” in patients in order to best define their treatment needs.

The health care system needs to move in the direction of covering what works. Like other examples we have covered in the Pondering Policy blog, opioids are no exception to the rule.