President Trump’s drug commission says the opioids epidemic has become a national crisis that requires aggressive federal action to improve treatment and collect better data. Those conclusions line up with the views of many health policy researchers.
After missing its deadline twice, Trump’s Commission on Combating Drug Addiction and the Opioid Crisis on Monday presented an interim report of policy recommendations for handling the nation’s opioid epidemic. The commission’s preliminary recommendations are largely in line with those of many public health advocates: The report emphasizes treatment over law enforcement; backs the use of medical alternatives to heroin such as methadone; and makes no mention of Trump’s border wall, which the president has often touted as a way to stop the flow of drugs into the country. Perhaps most significantly, the commission called on the president to declare a national emergency under either the Public Service Health Act or Stafford Act. Doing so would give the government the power to respond more aggressively to the crisis, including by modifying requirements for health care programs like Medicaid and Medicare to make it easier for patients to seek treatment for addiction.
“I think finally this is a high-level message to say we are in a crisis, that we’ve moved beyond epidemic to a crisis,” said Daniel Ciccarone, who is a professor at the University of California, San Francisco’s medical school and studies heroin use. “The commission clearly understands that and clearly wants to send the signal to the president to concur with them.”
The commission, which Trump established through an executive order in March and which is led by New Jersey Gov. Chris Christie, was initially scheduled to release its first report in June. The process was delayed, however, after the commission received more than 8,000 comments at its first public meeting. The commission said those comments helped inform its recommendations.
“With approximately 142 Americans dying every day, America is enduring a death toll equal to September 11th every three weeks,” the commission wrote in its report. Declaring a national emergency, the report went on, would “awaken every American to this simple fact: if this scourge has not found you or your family yet, without bold action by everyone, it soon will.”
The report also made several more specific recommendations. Here are a few that are supported by most public health advocates:
Provide more access to medication-assisted treatment
Research shows that medications like buprenorphine and methadone are proven to be some of the most effective interventions for opioid disorders. These medications can relieve the physiological cravings of opioids without the negative effects of the drugs and are often combined with therapy to help users recover from addiction. But there is often a stigma against swapping out one drug for another, and only 10 percent of drug treatment facilities in the country provide so-called medication-assisted treatment, according to the commission’s report. The commission calls for an expansion of this treatment for people who have opioid use disorders and calls for the Centers for Medicare and Medicaid Services to require all qualified federal health centers to mandate that staff — including physicians, physicians assistants and nurse practitioners — obtain waivers that allow them to prescribe buprenorphine. The commission’s report notes several barriers to the use of this kind of treatment that those seeking treatment face, including the public perception that it isn’t equal to a step toward sobriety, despite the research supporting it. Ciccarone said the commission is right to emphasize medication-assisted treatment.
“It’s not that we don’t want people to go for full abstinence or full sobriety,” Ciccarone said. ”It’s just opioid substitution programs work, and that’s why they’re advocated for.”
Broaden access to (and ensure lower prices for) naloxone
Research has supported the use of naloxone, a powerful drug that can reverse the effects of an overdose. There’s a body of evidence that shows the drug, also known by the brand name Narcan, can save lives when administered by properly trained and educated first responders. But communities dealing with the worst of the epidemic are finding Narcan and other forms of naloxone prohibitively expensive — Narcan can run as high as $150 per dose. The commission report says that by declaring a national emergency, the administration can provide the Department of Health and Human Services with the power to negotiate for reduced pricing of the drug for government officials. The commission also recommends that law enforcement officials in all states be equipped with naloxone and suggests state legislation requiring the drug to be prescribed in combination with high-risk opioids such as Oxycontin. Ciccarone agreed that access to naloxone should be expanded for the population of prescription opioids users — but said the same should happen for heroin users as well.
Improve data sharing
Most states have established prescription drug monitoring systems, electronic databases that track prescriptions of certain drugs. The federal government has promoted these systems as a way to make prescription opioids safer by helping identify patients who misuse the drugs and the doctors who enable them. Research suggests that the programs can be effective in reducing “doctor shopping” by people misusing opioids (visiting multiple physicians to obtain several prescriptions) and can discourage doctors from over-prescribing opioids. But information on the programs’ overall effectiveness is limited because the systems vary from state to state. According to the commission report, 49 states have drug monitoring systems but many are not sharing information. The commission recommends that all state and federal monitoring systems be sharing information by July 1, 2018.
Drug policy researchers have complained about the lack of good data on the opioid epidemic and have advocated for better sharing of data. But they say sharing drug monitoring data alone might not be enough. They have called for additional data collection and surveillance from hospital emergency departments. And they want state standards for coroners on toxicology reports; they say that knowing the composition of the drugs that are leading to overdoses is key to understanding the scope of the epidemic.
Along with these recommendations, the commission highlighted the importance of enforcement. In particular, the report called on the Department of Homeland Security and Customs and Border Protection to develop better strategies to detect fentanyl, a synthetic opioid that is more deadly than heroin and other types of opioids. Despite the rhetoric from both Trump and Attorney General Jeff Sessions calling on border enforcement to curb the opioid epidemic, the commission report notes that fentanyl “defies detection at our borders,” in part because such small amounts are so potent. Instead of focusing on Mexico, as Trump often has, the commission calls for this to become a major diplomatic issue with China, which it said is the source of much of the fentanyl entering the U.S.
The interim report focuses on immediate steps the federal government can take to combat opioid addiction. (A final report, set to be released in October, is meant to provide a more comprehensive review of federal funding and initiatives.) What isn’t yet clear is whether Trump and the rest of the administration will follow through on the commission’s recommendations. Sessions has frequently emphasized law enforcement over treatment and has called for restoring tough prison sentences for drug crimes. And Trump’s proposed budget would cut funding for drug treatment programs, though it would add funding in other areas.