Congress’s new spending deal commits more money to combat an opioid epidemic that’s led to hundreds of thousands of drug overdose deaths since the late 1990s. But while experts and advocates welcome the funding, there are a few reasons for caution.
The omnibus bill adds $3.3 billion to address the opioid and mental health crisis in fiscal year 2018, with a focus on public health efforts. Here are some of the big programs:
- $1.4 billion will go to the Substance Abuse and Mental Health Services Administration, including $1 billion for a new State Opioid Response Grant program and a $160 million increase in the Mental Health Block Grant
- $500 million for the National Institutes of Health for more opioid addiction research
- $350 million to the Centers for Disease Control and Prevention (CDC) for opioid overdose prevention, surveillance, and improving state prescription drug monitoring programs
- $415 million for the Health Resources and Services Administration to, among other efforts, improve access to addiction treatment in rural and other underserved areas
- $100 million to the Administration for Children and Families to help children whose parents misuse drugs
- An additional $299.5 million to the Department of Justice’s anti-opioid grant funding
- An additional $500 million to the Department of Veterans Affairs for mental health programs
- An additional $94 million to Food and Drug Administration efforts to inspect mail for illicit drugs
All of this is on top of the $500 million in fiscal year 2018 approved in the 21st Century Cures Act to combat the opioid epidemic.
The concern here, as usual, is that even this large commitment of money is not enough. When Congress first announced its spending deal — to add $6 billion over two years to combat the opioid crisis — earlier this year, Sarah Wakeman, the medical director at the Massachusetts General Hospital Substance Use Disorder Initiative, told me that “[i]t’s hard to imagine $6 billion being enough, especially when you think about the annual budget for other illnesses like HIV, which is $32 billion.”
Any increase is, of course, welcome. But when dealing with one of the worst public health crises in history, Congress will have to go really big — and it’s just not there yet.
The opioid epidemic demands big, sustained funding
It’s difficult to overstate the scope of the opioid crisis, which is now the deadliest drug overdose epidemic in US history. Nearly 64,000 people died of drug overdoses in the US in 2016, and at least two-thirds of those deaths were linked to opioids such as fentanyl, heroin, and prescribed painkillers. The total drug overdose deaths were higher than the number of deaths linked to guns, car crashes, or HIV/AIDS during any single year in America. Based on preliminary data from the CDC, 2017 was even worse.
This, advocates say, requires a massive solution. To put it in context, the New York Times recently asked 30 experts how they would spend $100 billion over five years to address the epidemic — a number comparable to how much the US spends domestically on HIV/AIDS. That sounds like a lot of money, but some experts cautioned that even that amount of cash may not be enough.
The good news is we have a fairly good idea what that money would go to: more treatment (particularly opioid addiction medications like methadone and buprenorphine), more harm reduction (such as better access to the opioid overdose antidote naloxone), fewer painkiller prescriptions (while ensuring the drugs are available to those who really need them), and policies that can help address the root cause of addiction (like mental health issues and socioeconomic despair).
One of the key issues to address is lack of access to treatment in the US. According to a 2016 report by the surgeon general, about 10 percent of people in the US with a drug use disorder get specialty treatment. And even when treatment is available, other federal data suggests that fewer than half of facilities offer opioid addiction medications like methadone and buprenorphine, which are considered the gold standard of treatment and studies show cut mortality among opioid addiction patients by half or more.
Fixing this will require more money — but just as crucially, it will require sustained funding. Over the past few years, Congress has approved one-off boosts to funding for the opioid crisis with few guarantees that the money will be there in the next spending deal. That’s a problem: It’s going to be harder to justify building a clinic if you don’t know if you’ll be able to keep it open the next year.
“I used to work in the local level, and sometimes we wouldn’t even ask for federal grant funding because we had no way of funding these programs after a year or two,” Regina LaBelle, who served in the White House Office of National Drug Control Policy during the Obama years, told me. “That’s a serious concern for states that have limited budgets.”
To deal with this, Dr. Leana Wen, the health commissioner of Baltimore, has suggested “a Ryan White for the opioid epidemic” — a reference to the program, launched in the 1990s, that created a health care safety net for people with HIV and communities hit hardest by the disease. The idea is to create a source of funds that officials on the ground know they would be able to rely on for years to come.
Congress needs a bigger, bolder strategy
Besides the budget deal, Congress is also working on a slew of bills that attempt to tackle the opioid crisis. There is enormous variety in these efforts — they can focus on treatment, regulating opioid painkillers, finding non-opioid alternatives to treating pain, education and awareness efforts, and more. (For a sampling of the House bills, check out the official list.)
While all of these efforts, including the new budget deal, are welcome, some experts and advocates have complained that this all seems to be a scattershot approach rather than a coherent plan.
“There’s no strategy here,” LaBelle said, noting that this is an area in which some leadership from the White House would help. “These can be hard things to do. You need to start with a plan.”
The concern is that the opioid crisis is now so far-reaching — and has exposed such major problems in how America deals with addiction treatment — that federal lawmakers really should be discussing broader reforms instead of one- or two-year funding boosts and one-off tweaks.
Wen drew a comparison to past disease scares, such as Ebola and Zika. These crises led hospitals and doctors, with government support, to retrain and restructure so they were properly built to handle any patients that came in with potential problems related to these diseases.
“We are now dealing with an epidemic of opioid overdose and addiction,” Wen said. “Why shouldn’t we require all doctors and all hospital systems to treat the disease of addiction?”
For example, hospital systems could require that a certain percentage of doctors are trained to prescribe buprenorphine. Methadone treatment could be provided on-site or nearby. Every opioid painkiller prescription could be paired with a naloxone prescription.
There are also comprehensive models that states could adopt, such as Vermont’s hub and spoke system, to really integrate addiction treatment into the rest of health care.
This goes much further than just putting one or two years of funding toward the problem or, as one in-the-works House bill recommends, helping hospitals set up discharge protocols for opioid overdose patients. It’s about fundamentally changing how health care systems work to mitigate the risk of opioid overdose and addiction at every level and ensure patients have readily available care options — just as we expect patients to be able to go to a hospital and quickly get full care if they have, say, problems with diabetes or heart disease.
Consider the counterfactual: What if, like addiction, only 10 percent of people with diabetes or heart disease got treatment? It’d be widely considered a public health disaster — and it’d demand a huge revamp of America’s approach to health care.
Experts argue that Congress needs to start thinking of the opioid epidemic on this bigger scale. Once it does, the more sweeping reforms and bigger, more sustained funding plans should naturally follow. Until then, what federal lawmakers do on the crisis may help, but it will ultimately fall short.
For more on the solutions to the opioid epidemic, read Vox’s explainer.