What Trump's National Opioid Emergency Should Look Like
The president should strip away the red tape preventing people from getting methadone or buprenorphine, which are proven to reduce opioid overdose.
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Last week, not long after Health and Human Services Secretary Tom Price said the Trump administration was not declaring a state of emergency over the opioid overdose epidemic, the president said he would do just that. It's not entirely clear what this will mean—if anything—in terms of increased funding for treatment, prevention, or law enforcement surrounding opioids in America. In six states, emergencies have already been declared, and so far, they have been used to allow greater access to the overdose-reversal drug naloxone, tighten pain prescribing rules, and increase funding for rehab.
But there is one way that a national declaration could do a tremendous amount of good. That's if it is used to rapidly and dramatically expand access to the only treatment shown to cut the opioid death rate by half or more: long-term use of either methadone or buprenorphine (Suboxone), a.k.a. maintenance medications. Currently, these drugs are only available in around 10 percent of addiction treatment centers—and even when they are used, time limits and other onerous restrictions are often placed on access.
The President's Committee on Combating the Opioid Epidemic actually made an excellent recommendation on this very point, arguing the government should:
Immediately establish and fund a federal incentive to enhance access to Medication-Assisted Treatment (MAT). Require that all modes of MAT are offered at every licensed MAT facility and that those decisions are based on what is best for the patient.
The committee also recommended fixes for restrictions on coverage of MAT in Medicaid, Medicare, the VA, and the abominable lack of access to it in the criminal justice system. These suggestions recognize that buprenorphine and methadone are wrongly stigmatized compared to a third and less rigorously studied medication option for those dealing with opioid addiction: extended release naltrexone (Vivitrol).
For any other disease, these kinds of policies would not be controversial. But in addiction, ideology and fear tends to prevail over data—a reality visible even in the way medication treatment for addiction is described. We don't, for example, have "medication-assisted" treatment for any other disease: We don't call antidepressant therapy using Prozac "Prozac-assisted treatment," nor do we call diabetes care with insulin "insulin assisted treatment"—even though in both cases, as with addiction, behavioral changes are usually also important to recovery.
In the case of MAT, the "assisted" part is even more absurd because research shows that requiring counseling and other hurdles like frequent urine testing adds little additional benefit beyond that of the medication itself. Even adding super-intensive services does not make a real difference: Fundamentally, what's most important is the medication, according to a Cochrane Review, a strict analysis of the data.
It's also important to bear in mind that the benefit from these drugs is huge. Over all, patients experience a reduction in relapse, mortality, HIV, and criminal behavior—none of which are seen to anywhere near the same degree from the basic counseling and urine testing regimes that the medication is supposed to be "assisting."
To make matters worse, the counseling and other non-medication requirements associated with MAT are often what limit access to it, both due to costs and regulations. To revisit the analogy with diabetes, it's as if, in order to get insulin, diagnosed patients were required to meet with dietitians—and the number of people allowed treatment was limited due to expense, as well as the oversight system ensuring no one who didn't meet with their dietician got meds.
So if the Trump administration wants to dramatically cut the death rate from opioid overdose, it should use its emergency powers to strip away the bureaucracy associated with obtaining methadone or buprenorphine. Methadone, for example, is probably the most regulated drug in the American pharmacopeia, and when used in the treatment of addiction, cannot be prescribed anywhere other than a licensed clinic. (In treating pain, on the other hand, any doctor can prescribe to as many patients as they please.) Buprenorphine, on the other hand, was deliberately FDA-approved in a way to make it less regulated—but even here, doctors must get special training and are limited to a maximum of 275 patients at any given time. (Again, when treating pain, a single doctor can have thousands of people on opioids). All of these restrictions should be dropped during the emergency.
Would it be dangerous to let people with addiction get these drugs without requiring them to take steps towards abstinence? Actually, it seems more dangerous not to do so: Being on these medications, even without counseling, cuts mortality by raising people's tolerance to opioids so that they are less likely to die of overdose.
Other countries around the world like the United Kingdom, Netherlands, and Canada already have what are known as "low-threshold" methadone and buprenorphine services. Basically, this means that other than giving their name so they can't get dosed more than once daily, people have regular access to these drugs if they don't want to use street drugs that day (or want to use less). Such programs reduce overdose, cut mortality, and can even lead to abstinence from street drugs.
Of course, this is not to say that people who want counseling and other intensive treatment focused on stabilizing their lives and eliminating street drug use should not be able to get it. It's simply that such services should be triaged to those who actually want them—and people who don't want should not be denied medication that could save their lives.
Health state of emergency declarations are designed to lift regulations that limit access to needed medications, like during epidemics of infectious disease. America should use this declaration the same way here. Republicans—including Trump—generally say they want to cut through bureaucracy and eliminate needless red tape. What could be more burdensome in all of American life than regulations that result in needless death?
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