President Trump’s Opioid Emergency Not Official

Source: | September 1st, 2017
On August 10, President Trump announced that the opioid crisis was a national emergency, which was the priority recommendation in the preliminary report submitted by his Commission on Combating Drug Addiction and the Opioid Crisis issued in July.  However, the president hasn’t yet signed a formal declaration and sent it to Congress. “Relevant monies won’t be released until such a thing is signed,” said Northwestern University law professor Eugene Kontorovich. A White House spokesperson did not say when a signature could be expected. “The president recently instructed his administration to take all appropriate measures to confront the opioid crisis,” the spokesperson said. “Right now, these actions are undergoing an expedited legal review. In response to the delay, Senators Durbin (IL), Brown(OH), Manchin (WV), Booker (NJ),  King (ME), Portman (OH),  Capito (WV), and  Collins (ME) urged President Trump to lift the Medicaid Institutions for Mental Disease (IMD) Exclusion for residential substance use disorder treatment as part of his opioid emergency declaration. In May, the senators introduced the bipartisan Medicaid Coverage for Addiction Recovery Expansion (Medicaid CARE) Act, which would modify the IMD Exclusion – a policy created in 1965 that limits Medicaid coverage for substance abuse treatment to facilities with less than 16 beds. The Medicaid CARE Act would expand it to 40 treatment beds. Additionally, the Medicaid CARE Act establishes a new $50 million youth inpatient addiction treatment grant program to fund facilities that provide services to underserved, at-risk Medicaid beneficiaries’ younger than 21, with an emphasis on rural communities. The bill would also increase flexibility for pregnant and postpartum women who are seeking treatment.

Impact of Dropping Out of School

Source: | August 25th, 2017
A new SAMHSA report reveals that substance use was more likely among 12th grade aged dropouts than among 16 to 18 year olds who were still in school. “The impact of dropping out of high school is profound” said Frances M. Harding, Director for SAMHSA’s Center for Substance Abuse Prevention. “Substance abuse prevention efforts can reduce the risk of individuals dropping out of school which greatly increases their likelihood of future positive employment, financial and health outcomes.”  Several SAMHSA and NIDA resources are available:

Source: SAMHSA

Online guides and tip sheets for youths that address the risks of initiating use across a wide variety of substances, including:

Trump Declares the Opioid Crisis a National Emergency

Source: | August 11th, 2017
“The opioid crisis is an emergency, and I’m saying officially right now,” Trump said. “We’re going to spend a lot of time, a lot of effort and a lot of money on the opioid crisis.” Trump, speaking after a security briefing at his golf club in Bedminster, N.J. on Thursday, said his administration is preparing the paperwork for the declaration. Doing so was the most urgent recommendation coming from President’s Commission on Combating Drug Addiction and the Opioid Crisis interim recommendations. This executive action would make the epidemic a top priority and allow the Cabinet to take “bold steps” toward combating drug abuse according to the Commission’s letter. Declaring a national emergency removes some barriers and places urgency behind waiving some federal rules such as the IMD Exclusion rule which prohibits the use of federal funds for Medicaid patients in residential mental health or substance-use disorder treatment centers with more than 16 beds. It would also put pressure on Congress to provide more funding and enhance the administration’s ability to make grants and conduct investigations.
Source:  Fox News

President’s Commission on Combating Drug Addiction & the Opioid Crisis

Source: | August 5th, 2017
The President’s Commission on Combating Drug Addiction and the Opioid Crisis has issued its interim recommendations.  The first and most urgent recommendation is for the President to declare a national emergency under either the Public Health Service Act or the Stafford Act. The Report states, “With approximately 142 Americans dying every day, America is enduring a death toll equal to September 11th every three weeks. Your declaration would empower your cabinet to take bold steps and would force Congress to focus on funding and empowering the Executive Branch even further to deal with this loss of life.”
  • Grant waiver approvals for all 50 states to quickly eliminate barriers to treatment resulting from the federal Institutes for Mental Diseases (IMD) exclusion within the Medicaid program.
  • Mandate medical education training in opioid prescribing and risks of developing an SUD by amending the Controlled Substance Act to require all Drug Enforcement Administration (DEA) registrants to take a course in proper treatment of pain
  • 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.
  • Provide model legislation for states to allow naloxone dispensing via standing orders and require the prescribing naloxone with high-risk opioid prescriptions; equip all law enforcement in the United States with naloxone to save lives.
  • Prioritize funding and manpower to the Department of Homeland Security’s (DHS) Customs and Border Protection, the DOJ Federal Bureau of Investigation (FBI), and the DEA to quickly develop fentanyl detection sensors and support federal legislation to staunch the flow of deadly synthetic opioids through the U.S. Postal Service (USPS).
  • Provide federal funding and technical support to states to enhance interstate data sharing among state-based prescription drug monitoring programs (PDMPs).
  • Align patient privacy laws specific to addiction with the Health Insurance Portability and Accountability Act (HIPAA) to ensure that information about SUDs be made available to medical professionals treating and prescribing medication.
  • Enforce the Mental Health Parity and Addiction Equity Act (MHPAEA) with a standardized parity compliance tool to ensure health plans cannot impose less favorable benefits for mental health and substance use diagnoses verses physical health diagnoses.
The final report, due in October, will include a full-scale review of federal programs, regulations, laws, and funding mechanisms targeted toward addressing addiction and a more thorough examination of the following issues:
  • Development of a national prevention strategy using “big data analytics” to devise targeted prevention messages that employ cutting-edge methods of marketing and communications.
  • Evidence-based prevention programs for schools, and tools for teachers and parents to enhance youth knowledge of the dangers of drug use, as well as early intervention strategies for children with environmental and individual risk factors (trauma, foster care, adverse childhood experiences (ACEs), and developmental disorders).
  • The need for satisfaction with pain level as a satisfaction criterion through which health care providers are evaluated by HHS.
  • Workforce access and training needs within the treatment community nationally, with a focus on the regions of the country with the highest overdose deaths.
  • Improvements in treatments programs, based on adherence to principles of evidence based treatment, continuum of care, outcome measures, and patient education on quality treatment.
  • Research initiatives and opportunities to combat the epidemic and enhance treatment options, including alternative pain management strategies, and treatment for vulnerable populations such as pregnant women, and substance-exposed infants.
  • Opportunities to further the practice of substance use screenings and referrals through CMS quality measures.
  • Opportunities for patient protections providing better information about the risks and benefits of taking prescription opioids.
  • Supply reduction of heroin, fentanyl analogs and counterfeit pills through coordinated federal and state law enforcement initiatives.
  • Targeted data collection and analytics needed to identify most effective prevention and treatment strategies, quality treatment access programs, reimbursements, and aid to law enforcement activities. The possibility of a behavioral health surveillance system run through CDC that tracks prevalence rates, treatment modalities, and comorbidities with other illnesses in real-time.
  • Regulatory or statutory changes to reduce commercial insurance barriers to MAT, such as dangerous fail-first protocols and onerous and frequent prior authorization requirements.

The Oil Rush Again is Bankrolling Market for Illegal Drugs

Source: | July 26th, 2017
Law enforcement officials say drug trafficking, drug abuse and drug-related crimes have spiked in recent years, evidence that energy’s boom-and-bust cycles have had enormous social consequences in West Texas. While the U.S. opioid epidemic has captured national attention, the drug of choice in West Texas is methamphetamine which is increasingly supplied through Mexican drug cartels, according to law enforcement officials. An analysis of data from the Texas Department of Public Safety and the Houston oil field services company Baker Hughes found a strong correlation between the rise of drilling activity and the number of crystal meth seizures and CRS Diagnostic Service, a drug-testing company in Odessa, found the number of local workers who tested positive for methamphetamine in the first half of this year was more than three times higher than in the first half of 2009, shortly before the so-called shale oil revolution got underway. For the oil industry, increased drug abuse in West Texas has exacerbated the struggle to find workers as they rebuild labor forces after widespread layoffs during the recent downturn. In the first six months of this year, more than 1,000 people working or applying for jobs in the oil-producing business failed urine-based drug tests, double the pace of failures last year. “Meth is booming,” said Craig Smith, a senior vice president at CRS Diagnostic Service.

 

Attorney General Jeff Sessions Addresses Addiction Policies

Source: | July 13th, 2017
  • Attorney General Jeff Sessions is poised to announce a major law enforcement action cracking down on fraudulent claims in the treatment industry-possibly today. Fraud investigations are not new but have typically focused on Medicaid and Medicare. Many of the planned arrests target people who’ve made fraudulent claims against major private health insurers, including Anthem Inc., Cigna Corp. and companies that sell insurance under the Blue Cross Blue Shield brand. People who run drug addiction treatment centers that have filed bogus claims and those who have filed reimbursement claims for drugs they then sell illegally are among those to be charged, according to Bloomberg. Arrests will be carried out in cities including Miami, Chicago, Detroit, Los Angeles, and scores of arrests are expected in southern Florida. Source:  Bloomberg
  • Attorney General Jeff Sessions was in Texas this week speaking at the 30th D.A.R.E. International Conference in Grapevine about the opioid epidemic. He called for harsher sentences for drug cases, holding drug companies accountable and cracking down at the border to keep drugs from crossing into the U.S. from Mexico. Sessions hearkened back to the D.A.R.E. program’s founding in the 1980s by Los Angeles Sheriff Darryl Gates and its nationalization as a signature program of first lady Nancy Reagan stating, “The DARE team is ready to meet this new challenge, just like you did in the 80s and 90s”. He lashed out at what he called lax attitudes towards drug use and put much of the blame on the Obama Administration’s the effort to curb “mass incarceration” by directing federal prosecutors not to charge the most serious offenses that would carry certain minimum sentences, mandatory sentences. Source:  Dallas News

Senate ACA Repeal and Replace Legislation Revealed

Source: | June 23rd, 2017
The much anticipated Senate-version of Obamacare’s repeal and replace legislation was revealed yesterday (June 22). Called the Better Care Reconciliation Act of 2017, it maintains many of the House provisions and the overall impact impact is similar. Both bills roll back many of the SUD coverage advances gained under the Affordable Care Act (ACA) and gives the states more flexibility to make state-level decisions.

A Senate vote is planned for the end of next week. Senate Majority Leader Mitch McConnell has been widely criticized about the closed-door process he used to draft the bill and rushing the vote without adequate input opportunities or review time. If it passes, it would need to be reconciled with the House’s bill before going to President Trump’s desk. Below is a general summary of ACA changes proposed in the House and Senate bills.

  • Essential Health Benefits (EHBs): The ACA advanced access to SUD services by requiring all health plans sold on the Market place to provide MH and SUD coverage and comply with federal parity law. While there are subtle structural differences, both the House and Senate bills would allow states to opt out EHB requirements and define their own list of benefits. Health plans will likely want to reduce aspects of the current SUD benefit requirement and it will require dedicated state-level advocacy to maintain strong coverage requirements. Also affected is the prohibition against applying annual or lifetime caps to essential health benefit coverage. The proposed legislation allows States to opt out the ban.
  • Medicaid: Currently Medicaid is an entitlement program with open-ended, matching federal funds for anyone who qualifies. The payment ratio in Texas is currently a 60 Fed / 40 state split. Both the House and Senate Bills restructure the Medicaid program into a block grant based on a fixed per capita amount. That means when the number of Texas Medicaid enrollees grows, Texas would not receive any Federal dollars to help with increased costs as it does now. The state budget will have to cover costs for enrollment growth which includes a 22% population growth estimate and long term care costs for the aging baby boomer population. Under the Senate bill the cuts to Medicaid will be deeper because per capita increases rise more slowly than in the House.

    Another significant provision under the ACA is the eligibility expansion that allows states to cover childless adults making up to 138 percent of the federal poverty level under Medicaid with the Feds picking up a significant portion of the cost. Under both GOP reform bills, the Medicaid expansion would be phased out. Since Texas chose not to expand Medicaid, the impact of this reversal will not have the same impact as it will have for other states. The Senate bill did provide a more favorable block grant formula for those states that did not expand Medicaid.

  • Pre-Existing Conditions: One of the more popular aspects of the ACA is the prohibition against increasing premiums or denying coverage based on preexisting conditions. The House and Senate both modify this provision. The House creates a new Patient and State Stability Fund allocating $130 billion over 10 years for high risk insurance pools and other programs to help insurers cover the costs of sick and expensive patients. The Senate maintains the insurance ban on increasing premiums or denying coverage based on a pre-existing condition, but permits states to allow an insurer to deny costs associated with some conditions. Under this option, states could limit covered SUD services depending on how the federal parity law is applied. The Senate also establishes a new Stability fund for $112 billion over 10 years which is aimed at reimbursing insurers who take big losses.
  • Affordability: The federal subsidies that help people afford insurance would change in both the House and Senate versions. The ACA calculates subsidies based on income (400 percent of poverty or about $47,000 for an individual) and a mid-level coverage plan. The House bill would base subsidies mainly on age and phase out funding at an income of $75,000 for an individual. The Senate bill calculate subsidies based on a low-level plan and funding would no longer be available to those above 350 percent of the poverty level ($42,000 for an individual). Insurers would be able to charge older customers up to five times as much as they charge younger customers compared to 3X under ACA.
  • Other Changes made in the House and Senate Repeal and Replace legislation:
    • The individual and employer mandates are eliminated.
    • Removes cost-sharing subsidies for insurers to help some customers cover deductibles and co-payments.
    • States are given the option of requiring some Medicaid recipients to work or pursue job training.
    • People can contribute more to pretax health savings accounts than under the ACA which is capped at $3,400 for individuals and $6,750 for families
    • A provision of the ACA that allows young adults can to stay on their parents’ health insurance plan until they’re 26 years old is upheld.
    • Taxes that were charged to raise more Addiction treatment was a $21 billion business in 2003, and is expected to double to $42 billion by 2020 — a growth rate some three times faster than inflation, according to federal health and census data.

U.S. Heroin Use Costs Society More Than $51 Billion

Source: | June 9th, 2017
According to the World Drug Report 2016 from the U.N. Office on Drugs and Crime, heroin use has reached the highest level in 20 years in the U.S. and is the deadliest drug worldwide. UIC pharmacoeconomists led by Simon Pickard and Ruixuan Jiang created a cost-analytic model to determine how heroin impacts society using several variables: number of imprisoned heroin users and their crimes; treatment costs of heroin abuse; chronic infectious diseases contracted through heroin abuse (HIV, Hepatitis B and C, and tuberculosis), and cost of their treatments; cost of treating newborns with medical conditions associated with heroin; lost productivity at work; and heroin overdose deaths.  On average, the societal cost per heroin user per year is $50,799. An estimated 1 million people are active heroin users in the United States, putting the total societal cost at approximately $51 billion, said Simon Pickard, professor of pharmacy systems, outcomes and policy. The cost per user is significantly higher than for patients suffering from other chronic illnesses, such as chronic obstructive pulmonary disease ($2,567 per patient in 2015 dollars, or $38.5 billion for 15 million patients) and diabetes ($11,148 per patient in 2015 dollars, or $248.59 billion for 22.3 million patients).
Source:  Science Daily

Trump Proposed Budget/Restores Drug-Free Community Funding

Source: | May 26th, 2017
Richard Baum, Acting Director of National Drug Control Policy, announced drug-related requests in the Trump Administration’s Fiscal Year 2018 Budget this week.  The President’s Budget supports $27.8 billion in drug control efforts including prevention, treatment, and law enforcement.
Source:  White House
  • $12.1 billion for treatment and prevention efforts, and a $15.6 billion request for law enforcement, interdiction, and international initiatives.
  • $10.8 billion in treatment funding, which is an increase of nearly 2% from annualized FY 2017 continuing resolution levels. This includes $500 million in State grants authorized in the 21st Century CURES Act to reduce opioid misuse and improve access to treatment, prevention, and recovery services.
  • The budget request also secures our borders by investing $468.6 million in drug-related funding to support the President’s request for high-priority tactical infrastructure and border security technology to stem the flow of people, drugs, and other illicit material illegally crossing the border.
  • A $246.5 million request for ONDCP’s High Intensity Drug Trafficking Areas (HIDTA) program and a $91.9 million request for its Drug-Free Communities Support program – both are the highest funding amounts ever requested.

Trump Diminishes ONDCP Through Budget Cuts

Source: | May 12th, 2017
The Trump administration is moving to gut the office of the White House “drug czar,” according to a preliminary budget document and an email message the acting director has circulated to agency staff. The proposed $364 million cut would leave a budget of just $24 million and eliminates its two major grant programs: 1) high-intensity drug-trafficking area program, and 2) drug-free communities program. The document is a preliminary White House proposal for the drug czar’s office that was leaked to the Associated Press. The White Hose wouldn’t confirm the drug czar’s office is on the chopping block.
Source:  NPR