The Washington Post: The Health 202: Here’s what is in the Senate opioid bill—and what didn’t make the cut
Via The Washington Post.
The Senate’s response to the opioid epidemic — a sweeping package that contains 70 bills from Republican and Democratic lawmakers eager to be part of the solution to the nation’s greatest public health crisis — is expected to easily pass this week.
Reaction to the bill — and a similar measure passed by the House in June — has been mixed. The Chicago Tribune editorial board summed it up best Tuesday, writing: “The package is heartening and frustrating: heartening because it offers some positive steps, and frustrating because it doesn’t do more.”
Most public health advocates and experts say that while the bill tackled some important issues, it’s a relatively incremental effort. To really address an opioid crisis that, according to preliminary data released by the Centers for Disease Control and Prevention in August, killed more than 49,000 of the 72,000 overall deaths from drug overdoses in 2017, would require a considerable infusion of new funding for treatment programs and a long-term commitment from the federal government.
Daniel Raymond of the Harm Reduction Coalition said it’s hard to tell a city losing its citizens to drug overdoses that help is coming in the form of a competitive grant pilot program that it may or may not receive.
“This is an election year bill to show they are doing something. That’s not always a bad thing, but I do think to some degree it’s a political document,” Daniel told me. “When you drill down into it, it’s not that there aren’t good ideas, but it doesn’t reach the level of, this is what our nation needs right now.”
So, what’s in the bill? Mainly, a lot of narrowly focused ideas. There are measures directing agencies across the federal government to create programs, expand programs and study the potential for programs.
After speaking to several experts, here’s what could make an impact:
1. Stopping illegal fentanyl from entering the country
This piece of the package seems to be getting the most attention. Sponsored by Sen. Rob Portman (R-Ohio), it would take steps to stop the inflow of illegal synthetic opioids into the country, mostly from China.
While opioid deaths overall didn’t increase last year, fentanyl overdoses did. New overdose estimates from the Centers for Disease Control released in August show that fentanyl overdoses have surged. Our Post colleague Christopher Ingraham reported that “there were nearly 30,000 deaths involving those drugs in 2017, according to the preliminary data, an increase of more than 9,000 over the prior year.”
“A chief concern among substance abuse experts is the ubiquity of fentanyl, a synthetic opioid that’s roughly 50 times more potent than heroin. Because it’s cheap and relatively easy to make, it’s often mixed with other drugs such as heroin and cocaine,” Ingraham wrote.
The bill would close loopholes in the U.S. Postal Service that allow people to sneak fentanyl into the country through the mail. The USPS currently does not know what is in packages coming in from abroad. The bill would require that foreign packages reveal their contents and where and who they’re coming from.
2. Support for people in treatment and in recovery
Nearly everyone in the public-health sector agrees that access to treatment and recovery programs will be more successful than trying to stop the prescribing or trafficking of drugs. The bill does several things on this front.
It authorizes a grant program through the Substance Abuse and Mental Health Services Administration (SAMHSA) to allow organizations to develop opioid recovery centers in a community. It also requires the Department of Health and Human Services to determine best practices and then create a grant program implementing those policies or procedures, such as the use of recovery coaches, which has proven effective in Massachusetts.
It also authorizes HHS to develop grants to support people who are in recovery transition to independent living and jobs, as well as develop a pilot program to provide temporary housing for those recovering from substance abuse.
“What we know is that if treatment can continue whether its detox or medication or residential, whatever form you need, this continuation of treatment predicts that someone will stay in recovery,” Deni Carise of Recovery Centers of America told me.
The bill also loosens some guidelines around medication-assisted treatment. It lifts the cap on the number of patients to whom a qualified doctor can prescribe drugs like buprenorphine, a drug proven effective at limiting opioid cravings and easing withdrawal, from 100 to 275, and expands a grant program allowing first responders to administer medication-assisted treatments. A recent study out of Stanford found that “greater access to naloxone” is one of a few things that could reduce overdose deaths.
What’s not in the bill? There are two key provisions that made it into the House version, but not the Senate measure that and could be sticking points when the two chambers try to iron out the differences.
1. IMD Medicaid exclusion
The House repealed an obscure, decades-old rule known as the Institutions for Mental Diseases exclusion rule, or “IMD exclusion,” prohibiting federal Medicaid reimbursements for inpatient treatment centers with more than 16 beds whose patients are mainly suffering from severe mental illness. The Health 202 wrote about the issue in June.
The Senate bill makes some changes to the IMD rule, including making sure pregnant and postpartum women in an IMD facility continue receiving Medicaid-covered services administered outside such facilities, such as prenatal care. But it doesn’t allow Medicaid to pay for addiction treatment in bigger facilities.
2. Behavioral-health information sharing between health providers
The House allows doctors and other health professionals to more easily share behavioral health information, including a patient’s substance abuse history.
The Senate bill, however, directs the Health and Human Services Department to examine how to appropriately disclose confidential substance-use disorder medical records. There are issues of privacy that come up around sharing mental health or substance abuse between doctors, but advocates say doctors are still bound by professional ethics and that coordinated care is a key to treatment.
Meanwhile, a new study, obtained early by the Post, on the economic impact of opioid addiction, underscores the problem. Our colleague Leonard Bernstein writes for The Health 202:
An analysis by the conservative-leaning think tank American Action Forum found that two million people of prime working age were not in the work force in 2015 because of problems with prescription opioids. The loss of those workers slowed U.S. economic growth by 0.6 percent annually, according to the report by Ben Gitis, the organization’s director of labor market policy.
In states whose workforce was hit hardest by the opioid epidemic, Arkansas and West Virginia, Gitis estimates the real economic growth rate was reduced 1.7 percent annually by the absence of those workers. Prime working age is defined as 25 to 54.
Gitis said the problem is undoubtedly larger because illegal drugs such as fentanyl and heroin are exacting their own toll. But there is no way to accurately quantify the amount of those drugs used in the United States annually, he said.
Gitis said he hopes the data will encourage the business community to play a larger role in battling the drug crisis. With unemployment at its lowest in decades, employers in some sectors have complained about the difficulty of finding applicants who can pass drug tests.
Correction: An earlier version incorrectly said there was a physician cap on the drug naloxone. Thanks to reader Dr. Laura Fochtmann of Stonybrook University for alerting us to the mistake.
