By SANDHYA RAMAN, ANDREW SIDDONS and MARY ELLEN McINTIRE
Congress faced a startling public health and political problem throughout 2016 as the number of people dying from opioid addiction climbed. The number of Americans succumbing to drug overdoses more than tripled between 1999 and 2015, affecting a whiter and more geographically diverse population than previous drug crises. Lawmakers ultimately approved some modest policies aimed at curbing prescription drug abuse and provided $1 billion to support state efforts.
Two years later, the situation is more dire and the political imperative to act even more intense. Drug overdose deaths rose another 12 percent from October 2016 to October 2017, according to Centers for Disease Control and Prevention data.
The 2018 debate mirrors the earlier effort in many ways. 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.
Experts say the piecemeal approach falls short of the systemic changes needed to address the scourge of addiction and prepare the United States for future needs.
“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.
“They’re just not getting that next step,” Waller said.
Watch: Congress’ Proposals on Opioids Aren’t Keeping Up With Epidemic
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.
The Senate is writing an opioids bill that includes more than 40 proposals, ranging from advancing research to finding a nonaddictive painkiller to detailing ways to dispose of unused medication. The Senate Finance Committee has hinted at an upcoming markup to discuss about 22 additional bills on topics including telehealth and medication-assisted treatment.
The House is pursuing dozens of similar separate bills.
Energy and Commerce Chairman Greg Walden, an Oregon Republican, is pursuing an aggressive timeline, aiming for June floor action. The Senate will likely follow suit later in the summer.
“We’re committed to getting these bills done,” Walden said. “It’s the biggest package of bills ever before the committee, and they’re bipartisan, almost all of them. I just think it’s really important public policy at a time when a thousand people a day are ending up in emergency rooms overdosing on opioids.”
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 political pressure to act is high. The problem of opioid addiction plagues virtually every congressional district.
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.
That law sought to address several issues, mostly through authorizing new grants for things like residential treatment programs for addicted pregnant women or overdose-reversal drugs.
The focus on prescription drugs is seen in the law’s requirement that the Food and Drug Administration more deeply scrutinize applications for new prescription opioids.
The law also created a pain management task force meant to help federal agencies develop best practices for opioid prescribing. It required the National Institutes of Health to intensify research into the causes of pain and its treatments. It expanded federal funding for state-based prescription drug monitoring programs, and required Medicare to more closely track patients at risk of abusing prescriptions.
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.
“We have crossed the paths of where the illicit side is now the leading problem. Fentanyl, heroin and other adulterants out there are our problem,” Robert Patterson, the acting head of the Drug Enforcement Administration, said in May.
Yet lawmakers remain most fixated on doctor-prescribed drugs. Of the 57 House bills that Energy and Commerce marked up in May, almost half — 24 bills — seek to limit exposure to prescription opioids specifically.
One bill would provide the NIH the ability to spend money more easily on its research into nonaddictive pain medications. Another would establish a program meant to test how to limit the use of opioids in emergency rooms. Similarly, nearly half of the provisions in the Senate bill focus on limiting exposure to prescription opioids.
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.
“If you have places where the treatment system is more robust, if someone can no longer use their OxyContin to get high, they’ve got two choices,” said Bradley Stein, a physician and RAND Corporation policy researcher. “They can say, ‘Well, I can get treatment, or I can go for heroin.’”
Other RAND researchers in recent years published papers examining how the reformulation of OxyContin — which made it more expensive, less accessible and harder to abuse —increased the use of heroin.
Public data also suggest this trend. 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. U.S. Customs and Border Protection seized 564 pounds of the drug entering the country in 2016, with that number growing to 1,370 pounds in 2017 — enough to poison around 200 million people.
To be sure, lawmakers are starting to tackle drugs besides those prescribed. Aspects of the House and Senate bills could make it easier to detect fentanyl in overdose deaths and give authorities more power to stop it from coming in from other nations. Congress will also likely pass a DEA-backed bill to help law enforcement pursue the makers of illicit synthetic drugs. But the effort is still largely focused on prescription opioids.
Congress did take some steps in 2016 that expanded treatment for those suffering from opioid use in general, not exclusively prescription pills. In the 2016 law, Congress expanded prescribing rights for an addiction treatment, buprenorphine, so that nurse practitioners and physician assistants can prescribe it as well as doctors — but only until 2021. Now, lawmakers want to extend the prescribing authority indefinitely. Experts caution there is a risk in focusing too narrowly on the treatment for a single disease such as opioid abuse.
“We’re building up a workforce and a capacity to treat only one addiction that is not malleable enough to rotate over to the other ones, because it’s focused on medicine and not the whole package of addiction treatment,” Waller said.
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. He recalled a meth-fueled triple homicide last summer. Montana saw more than a 400 percent increase in meth violations from 2010 to 2015, Daines’ office said.
For methamphetamine, there is no drug like buprenorphine to temper the addiction, and medication-assisted treatment for alcohol abuse is not commonly used. What’s needed, experts say, is the support of addiction medicine as a medical specialty and a focus on the underlying causes of addiction.
What’s happening in Congress in part reflects getting as many members involved as possible in an important piece of election-year legislating.
Just as nearly every committee that oversees opioid-related issues is considering how to legislate the problem, candidates around the country are raising it.
“You can’t hold a town hall meeting, you can’t move up and down Main Street in any part of the district without running into some person whose family has been scarred by it,” said 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.
“I’m not seeing many things that unite Congress as much as this stuff,” Cole said.
Some candidates highlight what they have done on the issue — or how their own lives were touched by substance abuse.
Democratic Sen. Tammy Baldwin of Wisconsin released an ad last month discussing her mother’s addiction to prescription pills.
Candidates in the West Virginia Senate race between Democratic incumbent Joe Manchin III and Patrick Morrisey, the state’s attorney general, are also focusing on the issue. A Democratic super PAC released an ad promoting Manchin’s work on legislation to require providers to be aware of a patient’s opioid abuse history.
Similarly, Morrisey has campaigned on his record, including a $47 million settlement with pharmaceutical distributors.
Brendan Kelly, seeking to oust GOP Rep. Mike Bost in Illinois’ 12th District, highlights how he was the first state attorney there to sue pharmaceutical manufacturers for their role. In an ad earlier this year, he said drug companies’ donations to lawmakers keep the industry out of the spotlight, though manufacturers did appear before a House committee last month. Bost, whose seat is rated Leans Republican by Inside Elections with Nathan L. Gonzales, says he’s also focusing on the issue and holding events.
Whether those ultimately sway a voter’s mind is yet to be determined. “I’m glad that my opponent is out there having these. I’m having just as many,” he said.
Despite the concerns about the 2018 package of opioid bills, it could affect the opioid epidemic more than what Congress achieved in 2016.
The American Society of Addiction Medicine’s 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 proposals could positively affect the addiction health care system at large rather than only opioid-abuse treatment. Both the House and the Senate want to extend federal loan repayment benefits to a wider range of addiction treatment professionals, which could bring more providers into the workforce.
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. Sixteen senators, led by Democrat Debbie Stabenow of Michigan, asked Health and Human Services Secretary Alex Azar in April to find a way to cut its cost. Leana Wen, health commissioner for the Baltimore City Health Department, also believes reducing naloxone’s cost will help. “We need the ability to scale up the interventions that we need to be effective,” she said. Some legislators expressed concerns that these bills simply chip away at a larger problem.
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.
Warren and Democratic Rep. Elijah E. Cummings of Maryland introduced bills that are unlikely to become law, although they were endorsed by several experts. The Warren-Cummings bill would provide $100 billion in federal funding over 10 years to areas with the greatest need, following the model of the Ryan White Comprehensive AIDS Resources Emergency Act, the nation’s federally funded program for Americans with HIV or AIDS.
“They’re grasping the nettle of how serious this problem is,” said Keith Humphreys, a Stanford University drug policy expert, while acknowledging that it will be difficult to pass a bill with no Republican co-sponsors.
“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 isn’t alone. “The United States during the AIDS epidemic made a decision that if someone was HIV-positive, they should have access to treatment,” said Andrew Kolodny, senior scientist at the Institute for Behavioral Health at the Heller School at Brandeis University and co-director of the Opioid Policy Research Collaborative.
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.”