trump opiod ignore advice

President Trump’s special Commission on Combating Drug Addiction and the Opioid Crisis released an interim report on July 31, 2017 that detailed its recommendations for dealing with the epidemic. In a letter to the President, the Commission stated,

“Our nation is in a crisis….Our citizens are dying. We must act boldly to stop it.”

It also declared that the “first and most urgent recommendation” of the Commission is for the President to declare a national emergency under the Public Health Service Act or the Stafford Act. This would free up funding and other resources to deal with this epidemic that is killing 142 Americans every day. The Commission’s letter went on to make a personal plea saying,

“You, Mr. President, are the only person who can bring this type of intensity to the emergency and we believe you have the will to do so and to do so immediately.”

Initially, President Trump failed to declare a national emergency. Instead, according to the Washington Post, he said,

{The} “best way to prevent drug addiction and overdose is to prevent people from abusing drugs in the first place.”

“If they don’t start, they won’t have a problem. If they do start, it’s awfully tough to get off,”

“So if we can keep them from going on—and maybe by talking to youth and telling them: ‘No good, really bad for you in every way.’ But if they don’t start, it will never be a problem.”

Yeah, right. That approach worked so well during Nancy Reagan’s War on Drugs that we really ought to try it again.

Thankfully, two days later Trump did declare the opioid crisis a national emergency. Hopefully, this will mean that the administration and Congress will work together to free up desperately needed resources and implement the Commission’s recommendations.

 

The Commission’s recommendations

The Commission made eight other recommendations for action:

  • Rapidly increase treatment capacity by eliminating the federal Institutes for Mental Diseases exclusion, a part of the Social Security Act, that prohibits using federal Medicaid funds to pay for inpatient mental health services including substance abuse in facilities with more than 16 beds. Every governor and many experts and advocates have urged that this barrier to treatment be rapidly removed by granting waivers for all 50 states. The report notes that “this is the single fastest way to increase treatment availability across the nation.”
  • Mandate prescriber education initiatives. Since “four out of every five new heroin users begin their addiction with non-medical use of prescription opioids,” the Commission felt such initiatives could help reduce the misuse of these drugs. I find this recommendation ironic since I was mandated to take an opioid prescribing course to renew my California medical license a number of years ago. At that time, the emphasis was on being less reluctant to use opioids because pain was being undertreated.
  • Immediately establish and fund a federal incentive to enhance access to Medication Assisted Treatment (MAT). According to the Substance Abuse and Mental Health Services Administration (SAMHSA), MAT in combination with counseling and behavioral therapies is effective in the treatment of substance abuse disorders and can help people to sustain recovery. Despite this, there are many barriers to accessing this type of treatment: There are too few trained and/or authorized providers. Insurers, including Medicare, may not cover some of the options (e.g., methadone). Even if offered, not all of the MAT options are covered. Finally, we need to facilitate the development of new, hopefully even better, MAT treatments. All of these issues are addressed in this recommendation.
  • Provide model legislation for states to allow naloxone dispensing via standing orders, as well as requiring the prescribing of naloxone with high-risk opioid prescriptions. This recommendation also calls for equipping all law enforcement in the United States with naloxone to save lives. I would go a few steps further and say that all opioid addicts and their families or friends ought to have access to naloxone to use in outpatient settings where they are most likely to overdose. This is important because some people will be reluctant to involve law enforcement when an overdose occurs. Further, there can be a delay in law enforcement getting to the scene in time to reverse the overdose. The one part of this recommendation that is controversial is the recommendation that primary care and other physicians be notified when someone in their care has overdosed and been revived with naloxone. Although the reason for this recommendation is said to be so the doctors can alter their prescribing habits, care must be taken to not infringe on privacy rights (see below for a recommendation on this).
  • Prioritize funding and manpower of various agencies (DHS, FBI, DEA) to develop fentanyl detection sensors. Fentanyl is more powerful than even heroin and is responsible for many drug deaths. It is coming into the country mainly via China, but our inability to detect it at borders and mail facilities “creates untenable vulnerabilities.” The commission again points out the important role the President could play in addressing this issue by stating that

“Only a presidential directive will give this issue the top level attention it deserves from DOJ, DHS, and USPS.”

  • Provide federal funding and technical support to states to enhance data sharing between state-based prescription drug monitoring programs (PDMPs). Addicted patients often doctor shop getting opioids and other drugs of abuse from multiple providers. On the other hand, there are some bad actors in the medical field who make a living providing prescriptions for drugs that can be abused to addicted people. PDMPs allow the identification of both. They are invaluable tools in the fight against drug addiction.
  • Better align, through regulation, patient privacy laws specific to addiction. The report notes that some privacy regulations act as a barrier to communication between providers and can make it difficult for family members to be involved with a loved one’s treatment. Alterations to privacy laws probably should be altered to eliminate these barriers but this needs to be done in a way that carefully balances the need for better treatment with respect for an individual’s privacy.
  • Enforce the Mental Health Parity and Addiction Equity Act (MHPAEA) with a standardized parity compliance tool. MHPAEA has been the law of the land since 2008, but compliance with its mandate that mental health and substance abuse (MH/SA) benefits must be on par with physical health diagnoses has been variable. Health plans can discriminate against people with MH/SA issues not only by limiting coverage, but also by having requirements that certain inexpensive, but less effective treatments be tried first or by having onerous prior authorization requirements. Treatment, also limited with the provider network, fails to include enough individuals with the knowledge and training to provide addiction treatment. Having been involved in reviewing health plan benefits during my career, I cannot emphasize enough how important the use of a compliance tool is to preventing discriminatory behavior on the part of insurers.

The Commission’s report has received praise from some surprising places, including media outlets such as FiveThirtyEight, whose headline declared somewhat incredulously, Trump’s Opioid Commission Listened To Public Health Experts. Let’s hope that the President and his minions will as well.


This post was initially published on 8/10/17 with the title”Trump Ignores His Opioid Commission’s Most Urgent Recommendation.” We were pleased to update this post after he changed his mind.

1 COMMENT

  1. Hopefully this will not lead to a physician witch hunt.
    Hopefully this will not lead to government dictating how physicians practice medicine.
    Hopefully this WILL lead to tort reform.

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