(Originally written for the Hazelden Betty Ford Institute for Recovery Advocacy: Robert D. Ashford, BSW & Jeremiah Gardner)
It appears more likely than ever that both sides of Congress will soon follow through with a response to America’s addiction crisis.
That’s the good news.
The other news: While the bill that was approved 407-5 Friday by the U.S. House represents important progress in the federal approach to addiction, it does not accomplish all that it could, or all that is needed.
We sent emails to House and Senate offices late last week with information and resources on the topic of opioids—the class of drugs that includes heroin, fentanyl and prescription pain medications, and that has fueled an epidemic of overdose deaths. In the messages, we expressed support for the conference committee report on the Comprehensive Addiction and Recovery Act (CARA). Recognizing the revised bill’s shortcomings, we also alluded to future Congressional work on this issue, which we hope to see.
While many advocates are celebrating the bill’s passage by the House, others have decided to oppose the current version of CARA—encouraging the President and members of the Senate to reject the bill unless it is strengthened.
Indeed, CARA presents a classic political conundrum. Support something that falls short of the ideal? Or, voice opposition that could contribute to the worst-case scenario—getting nothing passed at all?
If it is enacted—especially on the heels of the Mental Health Parity and Addiction Equity Act and the Affordable Care Act, both of which significantly expanded access to treatment for substance use disorders—we should recognize how far we have come in a short amount of time
We remain supportive, seeing a do-nothing stalemate as a substantially greater risk than an insufficient bill.
That said, just to get them on the table, here are a few disappointments in the final bill:
It no longer includes an important provision related to Prescription Drug Monitoring Programs (PDMPs). Only eight states require doctors to check a patient’s medication history in the PDMP before writing a prescription for opioids or other addictive drugs. As a result, utilization of these databases is low, making it difficult for prescribers to spot certain signs of misuse and addiction. For example, if someone is “doctor shopping”—or getting prescriptions from multiple doctors—it is much harder to detect in a state where PDMP use is not required. We have been advocating that Congress incentivize PDMP utilization by restricting federal grants to those states that require it. Unfortunately, that significant common sense reform was stripped from the bill in the conference committee.
The bill no longer authorizes any new funding for recovery community organizations, and supports recovery high schools and collegiate recovery programs only by including them in a long list of possible purposes for limited state grants. We know that recovery from substance use disorders only begins during treatment and that robust community and educational support structures are essential to people staying well—every bit as essential as treatment. Even so, public investments have been traditionally minimal when it comes to community-based recovery supports, and yet, unlike treatment, they have limited revenue potential. In other words, recovery supports are not only direly needed in our public health infrastructure, but they also require public assistance.
While the bill authorizes no funding for some provisions, it authorizes inadequate funding for others, and does not include emergency funds to fulfill any of its authorizations. Opioids alone killed almost 30,000 people in 2014, and the death toll has shown few signs yet of letting up. In our view, the opioid epidemic is certainly a national emergency that warrants potent investments in all of CARA’s provisions and the certainty of emergency funding. However, Congressional leaders have rejected emergency spending in favor of funding the bill through the regular appropriations process, i.e. via separate spending bills, meaning CARA programs and grants will compete with other federal priorities as lawmakers divvy up available budget dollars. That’s not to say the regular appropriations process won’t result in increased spending to fight addiction. Key Congressional leaders have pledged to fund CARA’s $187 million in authorizations. But the appropriations process is always vulnerable to political fights that can gum up even the most bipartisan of efforts. And, unfortunately, a more significant investment—certainly anything resembling the President’s $1.1 billion proposal, which would have greatly expanded access to opioid use disorder treatment—is no longer on the table.
While it appeared some Members of Congress were willing to vote against the bill in the absence of emergency funding, the almost unanimous House vote signals that Senate passage is now more likely.
We and our fellow advocates—the millions around the country impacted by substance use and related problems, and knowledgeable about the promise of prevention, treatment, recovery and criminal justice solutions—must continue to lend our voices in the coming weeks, months and years.
It’s worth remembering that this bill has received overwhelming bipartisan support at every stage where a vote has been taken. Prior to each nearly unanimous committee and floor vote, debate has centered on funding—with one camp wanting a huge billion dollar investment, and the other less sure that more money is the answer and wanting to consider funding in the context of other federal priorities. Whichever side of the fence you fall on, those are all legitimate views. And most Americans probably fall somewhere in the middle. So, it is reasonable, in a divided government, to expect a compromise such as that of the final CARA bill. Indeed, most of us have been pining for more compromise among our policymakers. To reject CARA, in our view, would be to reject the idea of collaborative compromise.
Still, the President has not tipped his hand, and with at least some vocal advocates ready to back up a veto decision, it’s possible he may withhold his signature.
We don’t think he should.
If the legislation gets to the President, he should sign it for these reasons:
- We are reasonably confident that Congressional appropriators will approve the funding needed to fulfill most, if not all, of the $187 million in CARA’s new authorizations.
- The $187 million will fund important new efforts, including community-based drug crisis response coalitions, state-based opioid crisis response programs, expanded availability of opioid overdose reversal drugs, some strengthening of state PDMPs, expanded use of incarceration alternatives, public safety/public health partnerships, expanded access to evidence-based opioid treatments that include medication assistance, expanded opioid misuse prevention and treatment programs for youth, the continuation of coordinated drug take-back days, and more addiction treatment for pregnant and postpartum women. To reject CARA is to deny all of those critical initiatives.
- One grant, authorized to the tune of $12 million a year, would help states, tribes and local governments not only train police and first responders on how to use opioid overdose reversal drugs but would help them “establish processes, protocols and mechanisms for referral to appropriate treatment, which may include an outreach coordinator or team to connect individuals receiving opioid reversal drugs to follow-up services.” This grant will help states address a huge gap we’ve been talking about all year—how to provide care and support to people after they’ve been revived from an overdose. To reject CARA would be to reject this critical grant program.
- Even if funded insufficiently now, and even if some of its provisions include no new immediate funding, CARA establishes an important grant structure for further funding in the future.
- The bill includes a number of needed reforms that have nothing to do with funding. For example, the entire last section overhauls Veterans Administration policies and practices regarding the treatment of pain and the use of opioids. To reject CARA means to reject these important sections too.
- The bill sets an important new precedent for thinking about addiction in terms of public health. For many years, federal spending and dialogue on drug-related issues has focused on keeping illegal drugs out of the country, telling kids not to use, and arresting those that do. In other words, we’ve looked at it primarily from a criminal standpoint, with questionable results. Now, the conversation has expanded to include more on prevention, treatment, recovery and even law enforcement/public health collaborations. CARA would codify that shift in dialogue by addressing addiction from multiple angles.
- Let’s not forget that the federal government already spends several billion dollars a year on substance use related issues, funding things like the Drug Enforcement Administration, treatment and prevention block grants to states, and research by the National Institute on Drug Abuse (NIDA). There’s no doubt that the balance of spending is still skewed, with almost half of addiction-related spending going to law enforcement, while recovery supports, for example, get almost no funding. But CARA, while it still falls woefully short on the recovery side of things, makes progress in retraining our eyes on a broader solution set. It sets us in the right direction, and that is significant.
For all of these reasons, and more, we are eager to celebrate CARA’s enactment into law and hope the Senate and President make that possible.
At the same time, the need for advocacy is far from over. We and our fellow advocates—the millions around the country impacted by substance use and related problems, and knowledgeable about the promise of prevention, treatment, recovery and criminal justice solutions—must continue to lend our voices in the coming weeks, months and years.
It starts with getting CARA two more steps to the finish line, with Senate passage and the President’s signature. And then we need to press appropriators to fully fund all of the authorizations in CARA, without cutting back on the existing programs and funding we continue to need to fight this addiction crisis. Legislation without funding is merely a Band-Aid on the substance use crisis. To truly move forward, we must ensure that the funds to implement lifesaving practices are put into place.
Much of the appropriations work is likely to be done by the respective Senate and House Appropriations Subcommittees on Labor, Health and Human Services, Education and Related Agencies, each of which has already begun to draft appropriations plans for 2017.
CARA is worth celebrating. If it is enacted—especially on the heels of the Mental Health Parity and Addiction Equity Act and the Affordable Care Act, both of which significantly expanded access to treatment for substance use disorders—we should recognize how far we have come in a short amount of time. It will be an important occasion for people in recovery, those seeking recovery and the allies and family members of our communities as well. Even as we prepare to celebrate, though, it is clear that we must continue our work.
Soon, it will be time to pick up where this legislation left off and fell short.
We have unfinished business.