The federal government isn’t totally incapable of doing anything. Faced with the worst drug epidemic in US history, the Obama administration and Congress are moving to act — not with harsher anti-drug criminal justice penalties, as federal lawmakers have done with previous drug epidemics, but with initiatives focused on public health.
Over the past week, Congress passed a major bill to combat the the opioid painkiller and heroin epidemic — and President Barack Obama is expected to sign it into law. The news also followed new actions announced by the Obama administration earlier this month, focused on providing more treatment options to people with opioid abuse disorders.
The epidemic is very serious. In 2014, more Americans died of drug overdoses than any other year on record: more than 47,000 deaths in just one year, roughly two-thirds of which were linked to opioids, according to federal data. That’s far more than the nearly 34,000 who died in car crashes, the almost 34,000 who died due to gun violence, and the more than 43,000 who died due to HIV/AIDS during that epidemic’s peak in 1995.
There’s just one problem: It’s not clear if Congress will allocate the hundreds of millions of dollars needed to fight the epidemic. But the White House is forging ahead in the meantime, hoping to make some forms of treatment more accessible even if Congress ultimately doesn’t act as it would prefer.
Congress passed a big bill, but a lack of funding could hold it back
Over the past week, the House and Senate passed a compromise bill that merged several pieces of legislation passed by each chamber of Congress to combat the opioid epidemic. Among a long list of measures, it expands access to medication-assisted treatment, boosts prescription training for doctors, and creates grant programs to help fund more overdose-related training for first responders (including for the overdose antidote naloxone) and alternatives to incarceration for opioid users.
But as the Obama administration has pointed out, the bill is currently missing a big piece: more funding. Democrats and the White House insist that funding should be attached to the bill now to significantly boost access to treatment and prevention programs, but Republicans say the funding will come later, when Congress passes its spending bills as part of the federal budget process.
More money for drug abuse treatments is truly needed. According to 2014 federal data, at least 89 percent of people who met the definition for a drug abuse disorder didn’t get treatment, largely due to stigma and financial barriers. Patients with drug abuse disorders also frequently complain of weeks- or months-long waiting periods for care — most often due to a severe lack of resources to match demand.
In response, the Obama administration has repeatedly asked for $1.1 billion in new spending over two years, with a focus on increasing access to opioid abuse treatment options, particularly in states like West Virginia and New Hampshire that have been hardest hit by the epidemic:
- $920 million to states, based on the severity of their epidemic and strength of their strategy, to help them expand medication-assisted treatment for opioid use disorders and make it more affordable
- $50 million to expand access to substance use treatment providers, which would help approximately 700 providers
- $30 million to evaluate the effectiveness of medication-assisted treatment under real-world conditions
- $90 million in new spending across the Department of Justice and Department of Health and Human Services for an array of programs that emphasize treatment and prevention
Congressional Democrats have asked for a smaller sum. But exactly how much money, if any, is allocated for treatment programs may not be decided until the budget process later this year.
Whatever action Congress takes, it’s long overdue. The opioid epidemic has been ravaging various parts of the country for years, and its origins go back decades.
The Obama administration is boosting treatments for opioid addiction
The Obama administration, meanwhile, has pushed the limits of its executive authority to accomplish as much as it could while Congress debated its bill. While the White House readily admits that all the actions it’s taken aren’t enough, officials estimate that they should improve access to treatment and care for people addicted to opioids.
One of the biggest steps taken by the White House is the move to improve access to buprenorphine. Also known as Suboxone, buprenorphine is an opioid that eliminates someone’s cravings for opioids and withdrawal symptoms — to help avoid relapse — without producing the kind of euphoric high that heroin or traditional painkillers can. It is similar to methadone, another opioid used to treat opioid addiction. But buprenorphine is offered in take-home doses, while methadone is, for people with drug abuse disorders, usually administered once a day in a clinic.
These two drugs, used in what’s known as medication-assisted treatment, have been well-vetted: Decades of research have deemed them effective for treating drug abuse. The Centers for Disease Control and Prevention, the National Institute on Drug Abuse, and the World Health Organization all acknowledge their medical value.
But the drugs were previously very limited: Each doctor could prescribe the drug to only 100 patients. With a regulatory change, the White House expanded the cap to 275. The administration estimates that the change should make the drug available to about 10,000 to 90,000 more patients in the first year.
The change comes alongside an array of other measures pushed by the White House in recent years. It stepped up general spending on treatment and prevention programs over the past few years. It dedicated $2.5 million in 2015 to fight heroin abuse. The Department of Health and Human Services also unlocked more than $100 million for drug abuse treatment in 2016. And the administration helped launch a combination of federal, state, local, and private efforts in 2015 to provide better prescriber training and improve access to addiction treatment.
"We have to turn the tide of this epidemic," Health and Human Services Secretary Sylvia Burwell said in a press conference on Tuesday.
But as it takes these steps, the White House has pushed for Congress to do far more. Without set funding, it’s not clear just how much the bill passed by Congress will accomplish.
The opioid painkiller epidemic goes back to the 1990s
Back in the 1990s, doctors believed — and many still do — in the need to treat pain as a serious medical issue. There’s a good reason for that: About 100 million Americans suffer from chronic pain, according to a 2011 report from the Institute of Medicine.
Pharmaceutical companies took advantage of this concern. Through a big marketing campaign for doctors and by backing advocacy groups, they got doctors to prescribe products like OxyContin and Percocet in droves — even though the evidence for opioids treating long-term, chronic pain is fairly weak, although the drugs are effective for acute, short-term pain. The drugs proliferated, landing in the hands not just of patients but also teens rummaging through their parents’ medicine cabinets, other family members and friends of patients, and the black market.
As a result, opioid painkiller deaths skyrocketed. In 2014, nearly 19,000 Americans died from overdoses linked to opioid painkillers — sometimes opioids alone, other times involving other drugs like alcohol and benzodiazepines, which are typically prescribed to relieve anxiety.
Seeing the rise in opioid abuse and deaths, doctors, clinics, and governments began to crack down on prescriptions for painkillers. Law enforcement, for instance, threatened doctors with incarceration and the loss of their medical licenses if they prescribed the drugs unscrupulously.
Ideally, doctors should still be able to get painkillers to the many patients who truly need them — after, for example, evaluating whether the patient has a history of drug abuse. But doctors who weren’t conducting even such basic checks are being told — not just through the crackdown but by health-care organizations and public education campaigns — to give more thought to their prescriptions.
But many people who lost access to painkillers were still addicted, so they looked for other ways to satisfy their habit. So some who could no longer access prescribed painkillers — or perhaps could no longer afford them — turned to a cheaper, more potent opioid: heroin.
Not all painkiller users went this way, and not all heroin users started with painkillers, but statistics suggest many did: A 2014 study in JAMA Psychiatry found many painkiller users were moving on to heroin, and a 2015 CDC analysis found people who are addicted to prescription painkillers are 40 times more likely to be addicted to heroin.
So heroin abuse increased, as did overdoses: In 2014, more than 10,000 deaths in the US were linked to heroin.
That doesn’t mean cracking down on painkillers was a mistake. It appeared to slow the rising number of painkiller deaths, and may have prevented doctors from prescribing the drugs to new generations of potential addicts. So the crackdown did lead to more heroin deaths, but it will hopefully prevent future populations of drug abusers, who could have suffered even more overdose deaths.
But ultimately, the likely solution is to get opioid addicts into treatment to ensure they don’t resort to even more dangerous drugs if painkillers are restricted. So the Obama administration is asking for more funding for treatment programs. Some states have also talked up treatment programs, although others, like Louisiana and Indiana, have taken a "tough-on-crime" approach that focuses on incarcerating drug traffickers.
The Obama administration and Congress’s approaches so far are notable in that they have by and large resisted the "tough-on-crime" approach. But whether the measures will be enough — or will even be funded — remains to be seen.