Congress’ Focus on Opioids Misses Larger Crisis

Congress’ Focus on Opioids Misses Larger Crisis – By Sandhya Raman, ANDREW SIDDONS and Mary Ellen McIntire –  June 2018

Targeting prescription opioids puts Congress years behind the crisis, which is largely driven by illicit nonprescription drugs.

Congress faced a startling public health and political problem throughout 2016 as the number of people dying from opioid addiction climbed. 

Two years later, the situation is more dire and the political imperative to act even more intense.  

Both chambers of Congress will likely soon pass dozens of proposals to help combat the opioid epidemic in ways that most experts agree is an improvement over the 2016 effort. 

But they also suffer from the same shortcoming: They largely focus on how the problem began, not on how it’s evolved.

“We still haven’t built a functioning addiction treatment system,” said Corey Waller, who chairs the legislative advocacy committee of the American Society of Addiction Medicine.

“Because as soon as opioids are done, it’s marijuana, and it will always be alcohol, then now we have methamphetamine coming up.”

He and other experts say Congress needs to give America’s health care infrastructure a wholesale overhaul to prop up addiction treatment as a sustainable medical specialty.

While one of the most promising ideas frames addiction in the same way that Congress successfully handled the HIV/AIDS epidemic, it has almost no chance of passing.

Fighting the last war

The 2018 appropriations omnibus spending law provided about $4 billion to combat the epidemic, the largest amount to date. But some lawmakers argue it’s not enough.

Lawmakers in both parties agree on the small changes under consideration.

The package will ultimately represent a long list of mostly incremental ideas to change policies, authorize new grants and send states more money.

But partisan gulfs divide them over funding and the most consequential policy proposals.

The new effort to build on the 2016 law risks carrying on that statute’s tradition of tunnel vision by homing in on a narrow set of concerns rather than pushing for broader changes.

The 2016 law focused almost entirely on abuse of prescription drugs rather than addiction in general.

Even as most smart people understand the crisis is one of addiction, not a specific drug.

But prescribing rates already were dropping by 2016. The law barely addressed other poisonous drugs that caused overall drug abuse deaths to skyrocket to nearly 64,000 by the end of that year: heroin and illicit synthetic drugs like fentanyl.

While prescription opioids were involved in just over 17,000 overdose deaths in 2016, heroin was responsible for 15,500 overdose deaths that year, a 20 percent jump from a year before. Synthetic drugs caused 19,000 deaths — a 100 percent increase.

Yet lawmakers remain most fixated on doctor-prescribed drugs.

Because it’s easier, cheaper, and less dangerous to to after doctors and patients instead of the extremely powerful and dangerous drug cartels.

It’s also easier to “count success” by opioid milligrams than by taking down drug cartels.

Playing catch-up

Targeting prescription opioids puts Congress years behind the crisis, which is largely being driven by illicit nonprescription drugs.

In recent years, with opioid prescriptions on the decline, the lack of treatment infrastructure in place drove addicted people to more dangerous illicit drugs.

The Centers for Disease Control and Prevention reported last year that opioid prescribing rates increased from 2006 to 2010, but by 2015 fell back down to 2006 levels.

At the same time, the rate of deaths involving heroin was climbing, overtaking the prescription painkiller oxycodone as the most lethal drug in 2012. Fentanyl use is also rising

Legislative focus

To be sure, lawmakers are starting to tackle drugs besides those prescribed.

But the effort is still largely focused on prescription opioids.

Experts caution there is a risk in focusing too narrowly on the treatment for a single disease such as opioid abuse.

Even some lawmakers question whether the narrow focus risks leaving other addiction issues unaddressed.

“In Alaska, it’s alcohol,” the state’s senior Republican senator, Lisa Murkowski, said at a health panel hearing. “

I’m concerned that here in Congress, we’re so focused on opioids as the drug du jour, if you will, and that in five years or so when this crisis ends or abates, or tapers, that we’re going to have a bunch of federal programs that are specifically aimed at a problem that may not be as significant.”

Methamphetamine use is of concern for lawmakers from more rural western states.

“Meth is actually more of our issue,” Republican Sen. Steve Daines of Montana said at an Indian Affairs Committee hearing

Political dynamics

Oklahoma GOP Rep. Tom Cole, a former National Republican Congressional Committee chairman.

The issue compels congressional attention because of its public health effects. Cole said it’s also one of the only concerns that affects lawmakers from all corners, making it the rare issue that members from both parties agree needs action.

The additional $4 billion in opioid funding helped cement a budget deal that funded the government for the rest of the fiscal year, he noted.

Different approaches

The American Society of Addiction Medicine’s [not a recognized medical specialty -zyp] Waller favors a bill to require groups applying for grants to document that they are evidence-based.

“The first thing that you do to maximize how that money works is you stop paying for things that don’t work,” he said.

Experts oppose treatment like rapid detox, which can cause higher overdose rates. Instead, they favor medication-assisted treatment, which insurance does not always cover.

Some critics are calling for more action. While Congress tried to provide resources for states to buy the opioid overdose reversal drug naloxone, many want the federal government to negotiate and lower its cost.

Sen. Elizabeth Warren, a Massachusetts Democrat, said she wants a federal response to the problem that won’t “nibble around the edges.” Rep. Diana DeGette, a Colorado Democrat, agrees, saying the epidemic should be addressed more holistically like the HIV/AIDS crisis was.

“We can’t plan and develop infrastructure around treatment if there’s no sustained source of funding,” Wen said. “That’s what it’s going to take to resolve any major outbreak and this is a major illness that’s affecting every aspect of our country. We need the resources that are proportional to the severity of the disease.”

Wen is concerned about the relatively narrow focus of the current crop of opioid bills.

All the bills are tinkering around the edges.

They have important but short-term and small fixes that really will not address the epidemic in the way that we know is necessary,” she said.

“I’m concerned that the attention to getting these small fixes passed will result in people celebrating when actually the fixes in the short term are very small and not even being close to the scale of the epidemic.”

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