White House Opioid Commission Interim Report Ideas Out of Touch With Reality
The White House Opioid Commission’s Interim Report shines a bright light on America’s opioid epidemic; 142 people dying from drug overdose every single day. At The Center for Network Therapy, we estimated that the cost of the drug epidemic exceeds $1 trillion every year. (Read CNT's recent press release on this topic here.) As an Addiction Specialist and Medical Director at CNT, New Jersey’s first licensed outpatient detoxification facility, I fear that many of the recommendations may not help much and some may actually make the drug problem worse.
I have analyzed the interim report’s recommendations and explained why below:
Increasing inpatient treatment capacity constitutes an expansion of a failed model: The report recommends Medicaid limitations for inpatient treatment be removed. However, the drug epidemic is proof that the traditional inpatient treatment modalities have largely failed even people with private health insurance not subject to such limitations. I feel that more of the same may help on the margin at best, but supporting nascent addiction treatment modalities such as the Ambulatory (Outpatient) Detoxification is the key to delivering far better outcomes in an economic manner. The outpatient model incorporates an individual’s living environment into treatment, which helps deliver better results.
Increasing opioid prescriber education may not stop the creation of new addicts: I have seen that 65% of opioid pain prescriptions are written by Family Doctors and Nurse Practitioners, not pain management specialists. While educating these prescribers is important, a better alternative would be limiting the ability to prescribe opiate pain medications only to physicians with specialized training in pain management (such as surgeons, oncologists and orthopedic and pain management specialists). We need to stop creating addicts as a more comprehensive opioid curriculum is worked into the medical education system.
Medication Assisted Treatment (MAT) is not a panacea: MAT primarily consists of prescribing buprenorphine or methadone and, to some highly-motivated individuals, naltrexone in order to address cravings and withdrawal symptoms for individuals afflicted with the disease of addiction. In my experience, I feel that recklessly expanding the number of prescribers of these medications will only intensify the problem; these medications are only effective when accompanied by therapy to help encourage lifestyle changes, as well as monitoring to ensure these patients are not using other drugs concurrently. We are sure to find people with addiction issues leverage the easy availability of such prescriptions to detox themselves when they run out of money to buy drugs or use it as currency on the street to buy other drugs. Mixing these medications with other drugs or prescription medications could be dangerous.
Making Naloxone (Narcan) available to people addicted to opiates may encourage riskier behavior: Naloxone is an opiate overdose reversal drug used by first responders and other emergency medical care professionals. Requiring opioid prescriptions to be complemented by Naloxone prescriptions appears logical on the surface but it is a double-edged sword. I fear it may encourage people abusing opioid pain pills to chase a ‘higher high,’ as they have the antidote to overdose on hand. At Center for Network Therapy, we feel that while all emergency medical professionals and first responders should be equipped with Naloxone, handing it out to opioid pain medication abusers could actually increase the chances of overdose. Also, overdoses are not intentional and the ability to recognize and self-administer Naloxone at the point of overdose is questionable.
Development and deployment of fentanyl sensors will likely be futile: The opioid commission’s assumption is that Fentanyl is smuggled into the country as a finished product, but the reality is a little more complex. On shoring of Fentanyl is happening fast and drug dealers are importing base chemicals (that can be combined in home-size labs to make Fentanyl) and pill making machines (disassembled and shipped in separate packages) from China and making the fentanyl pills themselves. Therefore, screening for fentanyl is unlikely to yield optimal results. A better option would be to leverage our terror tracking apparatus to track orders of raw materials over the internet and the dark web.
Exploding demand for street heroin will not show in national prescription monitoring programs: Currently, most prescription monitoring databases are localized to one state and the opioid commission recommends a national database. It would definitely help identify ‘doctor shopping’ across state lines for prescription opiate pain medications. In my opinion, this may be similar to locking the stable door after the horse has bolted. Drug dealers are awesome competitors and street prices of heroin and heroin laced with fentanyl have fallen so much that opioid overdose deaths in 2015 continued to climb despite a significant decline in opioid pain prescriptions. Individuals addicted to opiates simply switched to cheaper and more potent street drugs. If the crackdown on legal prescriptions intensifies it will push more people to street drugs.
Enforcing the Mental Health Parity and Addiction Equity Act (MHPAEA) should be accompanied by support for newer treatment modalities: At CNT, I see patients every day whose health insurance provider either does not provide sufficient coverage for substance use disorders or they face a high deductible. Either way, many individuals suffering from substance abuse disorders are unable to access treatment. There is also resistance in the treatment community to innovative, higher efficacy and lower cost treatment models such as Ambulatory Detoxification, which I introduced in the state of New Jersey. The cost of traditional inpatient treatment is high and burdensome regulations play a big part in driving costs higher. In order to lighten the costs of treatment on society as a whole, lower cost modalities of care such as Ambulatory Detoxification should be strongly supported while enforcing MHPAEA.
Easing HIPAA regulations should help: While HIPAA was designed to protect the patient’s privacy, with substance use disorders it cuts both ways. In many instances, I find that sharing information with other care providers would greatly enhance the patient’s recovery as they could avoid receiving prescriptions addictive medications. But HIPAA is restrictive when the patient has not signed a release to share information. HIPAA actually serves to increase the relapse rate, so this recommendation could truly help, and may save lives in case of overdose.
Decriminalization of possession charges important, but not one of the recommendations: In 2015, there were roughly 1.5 million arrests for drug law violations and four out of five were for possession. Decriminalization of drug possession related violations may offer the biggest bang for the buck because, according to the U.S. Department of Justice, more than 50% of the costs tied to illicit drug use related to criminal justice and incarceration. I strongly believe it is time we utilize the ‘token economy’ modality of treatment that universally offers individuals a clean record upon successful completion of addiction treatment. This would cut criminal justice costs dramatically and also enable those in recovery to more easily re-integrate into the job market. This will also save money that can be utilized to fund other initiatives.