Congress is hyperfocused on opioids. Is it focusing enough on addiction?

Controversy over one bill that could fragment care for people with substance use disorder raises serious questions.

Still life. Oxycodone. Oxycodone is a narcotic pain reliever. Oxycodone has a high abuse potential and is prescribed for moderate to high pain relief associated with injuries, bursitis, dislocation, fractures, neuralgia, arthritis, and lower back and cancer pain. OxyContin, Percocet, Percodan, and Tylox are trade name oxycodone products. (Photo by: Education Images/UIG via Getty Images)
STILL LIFE. OXYCODONE. OXYCODONE IS A NARCOTIC PAIN RELIEVER. OXYCODONE HAS A HIGH ABUSE POTENTIAL AND IS PRESCRIBED FOR MODERATE TO HIGH PAIN RELIEF ASSOCIATED WITH INJURIES, BURSITIS, DISLOCATION, FRACTURES, NEURALGIA, ARTHRITIS, AND LOWER BACK AND CANCER PAIN. OXYCONTIN, PERCOCET, PERCODAN, AND TYLOX ARE TRADE NAME OXYCODONE PRODUCTS. (PHOTO BY: EDUCATION IMAGES/UIG VIA GETTY IMAGES)

Congress is trying to pass legislation that addresses the opioid crisis in an election year, so they’re moving fast, passing a bill through committee Thursday that would free up Medicaid dollars for opioid addiction treatment in institutionalized care. But it could be more harmful than lawmakers realize.

Rep. Greg Walden (R-OR) is aiming for the House to take up legislation in June. So to keep with schedule, the House Committee on Energy and Commerce — on which Walden serves as chairman — advanced 32 bills on Thursday, after unanimously advancing another 25 bills last week. The Senate health committee passed its legislative package in April

While lawmakers agree it’s critical to address an epidemic where more people died of a drug overdose in 2016 than the aggregate of the Vietnam War, they don’t always jibe on how.

A question some lawmakers and journalists often ask is whether Congress is too closely targeting opioids, as the epidemic is a problem of polydrug misuse. Bloomberg’s editorial board warned “lawmakers need to take benzodiazepines seriously, before it’s too late.” (Overdose deaths associated with benzodiazepines are fewer than opioids, but still eight times what it was in 1999.)

“I’m concerned that here in Congress we’re so focused on opiates as the drug de jure, if you will, and that in five years or so when this crisis ends or abates or tapers that we’re going to have a bunch of federal programs that are specifically aimed at a problem that may not be as significant,” said Sen. Lisa Murkowski (R-AK) in April.

This point was raised again on Thursday when House members debated, largely along partisan lines, whether to advance the bill to allow Medicaid dollars to be used for opioid addiction treatment in certain treatment facilities.

“With 115 Americans dying each day, we have to focus on the opioid crisis,” said Rep. Mimi Walters (R-CA), the bill’s sponsor. “While we agree that all substance use disorders are important, we’re prioritizing our resources to address the opioid crisis.”

Walters was immediately met with resistance from Democrats.

“I’m troubled that this bill would expand treatment only to people with opioid use disorder as opposed to those with other substance use disorders like alcohol, crack-cocaine, methamphetamine,” said Rep. Jan Schakowsky (D-IL). “This bill is not only blind to the reality faced by people suffering from substance use disorder but it’s also discriminatory.”

Given that the bill exclusively helps those struggling with opioid use disorder, lawmakers are making it clear they only care when white constituents are dying, said Rep. Bobby Rush (D-IL).

“Too often, Mr. Chairmen, this committee and this House have paid attention to issues only when they affect the majority — the majority of the white population,” said Rush. “This leaves too many Black Americans behind.”

The measure would partially and temporarily repeal Medicaid’s Institutions for Mental Disease (IMD) exclusion, meaning it would allow federal Medicaid dollars to pay for opioid use disorder treatment up to 30 days in facilities with more than 16 beds. It would only repeal the ban until December 2023.

Currently states seek federal permission, by waiver, to relax the IMD exclusion for substance use disorder (SUD) treatment. Ten states have these waivers, with California being the first in 2015 to get the okay from the Obama administration.

“We don’t yet know what the utilization of this service looks like, as the program is so new, but it’s worth noting that the IMD exclusion exemption in California’s program is just one piece of a larger system,” said senior program officer at the California Health Care Foundation Catherine Teare, who worked extensively on the state’s waiver. “It’s not specific to opioids or any other particular substance, and it’s embedded within a system that provides access to a full continuum of evidence-based SUD services — based on the American Society of Addiction Medicine criteria.”

Sometimes that care is residential, and sometimes it’s not. People might start their recovery process in inpatient rehab, but then need community-based services to maintain sobriety. In 11 California counties, Medicaid not only pays for residential treatment but a host of other services:

Screenshot of The Drug Medi-Cal Organized Delivery System Pilot Program
SCREENSHOT OF THE DRUG MEDI-CAL ORGANIZED DELIVERY SYSTEM PILOT PROGRAM

It also forced relationship-building between primary care, mental health, and substance use treatment providers.

This is another reason why health experts are wary of Walters’ bill.

“I’m fine with paying for the residential component of care, but only if linked to an enduring care plan, such that a person would get more than that,” said Keith Humphreys, a drug policy expert at Stanford University. “Otherwise I think we’ll just spend a lot of money on expensive inpatient stays that don’t have any follow-ups, and the history of that is it’s actually worse than nothing because a person loses their tolerance and they’re even at a higher risk for overdosing than they were when they started.”

It just doesn’t work to build a system where people cycle in and out of institutions, Humphreys added.

Various Republican lawmakers pointed out during the hearing on Thursday that it took months for states to get the federal government to approve their waivers — which is concerning given how many people die a day on average from drug overdoses. For example, West Virginia applied in December 2016, but didn’t get approved until October 2017. For that, Republicans reasoned it just makes sense to lift the ban altogether.

But it’s also important to remember that Congress only has a limited amount of money dedicated to this drug crisis, and IMD repeal could be expensive.

“The cost of inpatient care typically ranges from $6,000 for a 30-day program to $60,000 for 90-day programs, while community-based outpatient services cost around $5,000 for three months of services. That means that any repeal of the IMD would require significant offsets,” according an analysis by the Center on Budget and Policy Priorities (CBPP). Experts at CBPP don’t support a repeal.

Hannah thank you for saying like it is.

Hannah Katch@hannahkatch

Repealing ‘s restriction against payment for institutional care, known as the “IMD exclusion,” would not solve the epidemic — it would risk worsening care for people who need treatment. @JudyCBPP and I explain: https://www.cbpp.org/research/health/repealing-medicaid-exclusion-for-institutional-care-risks-worsening-services-for 

Repealing Medicaid Exclusion for Institutional Care Risks Worsening Services for People With…

Opioid use caused over 42,000 deaths in 2016, and drug overdose deaths rose by statistically significant amounts in 27 states that year, according to the Centers for Disease Control and Prevention….

cbpp.org

The Congressional Budget Office is reportedly working on a score for the bill, but a GOP committee aide told Modern Healthcare that the agency has said repeal is in the “low single digit billions.” IMD exclusion for both mental health and SUD services without day limits would cost up to $60 billion over 10 years.

The worry is money will go to measures that further fragment care for people with substance use disorder, rather than investing in the continuum of care model. Alternatively, for states to secure a SUD waiver, they need to show how inpatient and residential care will supplement community-based services. This can work really well, just look at Virginia.

The House Committee on Energy and Commerce did pass several measures that seem small, but could do a lot of good. Some even addressed fentanyl, which is now the dominant cause for drug overdoses, with fentanyl-laced cocaine potentially becoming the next wave of the opioid crisis. For example the STOP Fentanyl Deaths Act of 2018 authorizes grants for federal, state, and local agencies to create or operate public health laboratories to detect the illicit, synthetic opioid.

Humphreys’ advice: Congress should pass targeted bills addressing the supply side of opioids — but aim for more comprehensive bills when it comes to treatment.

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After a Big Buildup, the Trump Administration’s Drug Pricing Plan Doesn’t Deliver

 

Last Friday, President Trump and Secretary of the Department of Health and Human Services Alex Azar unveiled the administration’s plan to lower prescription drug prices, but health policy experts are warning that the proposals fall short of the promises he made on the campaign trail and will do little to address the root causes of the issue. The plan received criticism for being too easy on pharmaceutical companies for their role in the seemingly exponential recent rise in drug prices. President Trump, who once accused the pharmaceutical industries of “getting away with murder” sang a more sympathetic tune last week. Several central tenets of his plan actually support the industry by aiming to increase competition and negotiating power – though not, however, directly for Medicare Part D, as then-candidate Trump touted as his plan during his campaign.

Secretary Azar further clarified the President’s plans in a speech Monday, focusing mostly on the role of Pharmacy Benefits Managers (PBMs), companies that act as middlemen in drug negotiations between insurers and manufacturers. Azar will seek to restrict how much and from where PBMs can collect revenue during their negotiations. The lack of action regarding pharmaceutical manufacturers comes as no surprise to most, considering Secretary Azar’s history as a former industry leader himself.

Also as a part of the administration’s overall efforts to decrease drug prices, the Food and Drug Administration released new data on Thursday about which pharmaceutical companies were potentially “gaming” the drug pricing system by blocking access for other corporations to develop generic (and cheaper) versions of their products.

This national conversation about drug pricing is one that has been ongoing in the HIV community for years, from the creation of the AIDS Drug Assistance Program to subsidize exorbitant HIV medication costs in the 1980s to the prohibitively high cost of one of the only FDA-approved PrEP drugs, Truvada. Most people living with and at risk for HIV are able to get the medications they need thanks to what HIV activist Tim Horn terms the “patchwork of coverage” in place to pay for HIV-related treatments; however, AIDS United will continue to monitor any legislative or regulatory changes proposed by this administration regarding drug pricing and will work to ensure access to these lifesaving drugs is only increased.

Register for the 2018 CME/CNE Competition!

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Elevating Trans Voices

I am Joi-Elle White, and I work at Positive Impact Health Centers (PIHC). I am an HIV Educator and soon will become a Prevention Specialist. I’ve been at PIHC for a year but have been in this field for 16 years. I started out as an outreach volunteer for Hudson Pride Connections in New Jersey when I was going to their transgender group called G.L.I.T.Z. (Girls Living in the Trans Zone).

My lived experiences got me involved in this work. I faced rejection, discrimination, sexual and physical assault, homelessness, and other bumps in my journey. And some of my experiences I would not wish on anyone, let alone the younger generation. I can’t stop any of that from happening and we all will have to come across them. So my plan was to learn a way to help the youth through whatever life can throw at us.

I was so excited to be put on the Transgender Leadership Initiative project at PIHC, where I was part of creating applications, policies, and curriculums, as well as facilitating an eleven-session leadership program called TRANSitioning to Leaders Academy (T2L). I was part of recruiting twelve transgender ladies to compete the academy.

T2L’s goal was to help bring the leadership skills out in these ladies so the transgender community can have a voice on the HIV planning council and anywhere else their voices can be heard. T2L was unique because it was “for us, by us.” Three transgender women and a cisgender woman created the curriculums and facilitated the sessions.

We need as many voices and people as possible to help us get rid of the stigma, myths, discrimination, lack of Medicaid coverage, and, last but not least, lack of education. Those are a few of the barriers we face. It’s important for us to keep talking about HIV to educate society. I would like people to get tested and learn their status. Knowing your status is the first step towards reducing the risk of spreading HIV. G.I. Joe said it best: “Knowing is half the battle.”

Additionally, we need to create our own platforms, forums, and panels all over on TV screens, radios, and magazines. It’s also important for organizations to hire transgender people. Not only will it give the transgender community a friendly face of someone who has walked in their shoes, it also gives us an opportunity to be part of the change we want to see.

I believe what keeps me motivated is every time I hear or see a law that has changed to benefit the transgender community and seeing more transgender people joining the fight. Hearing a transgender male or female say to me, “I am working,” or “I got my keys to my apartment,” knowing that they reached their goal – that motivates me.

Joi-Elle White is an HIV Health Educator in Atlanta, Georgia. Through Positive Impact Health Centers, a grantee of AIDS United’s Transgender Leadership Initiative, Joi-Elle and her colleagues created a leadership course for transgender individuals to increase participants’ HIV knowledge and to improve HIV service delivery, health and social justice outcomes for their peers. Joi-Elle has been doing HIV work for over fifteen years. 

Doing It banner.  A woman at a café bar sipping coffee next to an old fashion espresso machine. I’m Doing It. Testing for HIV. Testing is Fast, Free & Confidential. cdc.gov/DoingIt #DointIt HHS, CDC, Act Against AIDS

In Congress’s Rush to Pass Opioid Legislation, Funding Falls by the Wayside

Over the past week, committees in the House and Senate have advanced large swaths of legislation aimed at addressing the opioid crisis that has become one of the most pressing issues on Capitol Hill as of late. Keen to show the American public that there is indeed a sense of urgency in Congress to tackle rising levels of problematic substance use that took the lives of 63,600 Americans in 2016, both the Senate Health, Education, Labor and Pensions (HELP) Committee and the House Energy & Commerce Health Subcommittee advanced an overwhelming amount of opioid-related legislation, with 56 bills advancing in the House alone.

In contrast to some of President Trump’s more punitive approaches to ending the opioid crisis, the legislation advanced this week in Congress was largely public health-centered and addresses a number of very real needs. Included in the raft of bills that were advanced this week is legislation that would ensure that all CHIP plans fully cover mental health and substance use treatment, revamp the way the federal government distributes grants to focus on the areas hardest hit by the opioid epidemic, and partially repeal the Institutions of Mental Disease exclusion that prevents Medicaid from reimbursing for substance use disorder treatment in facilities with more than 16 beds.

Unfortunately, any joy there is to be gleaned from the quantity of bills that have been put forward this week and their individual merits is more or less snuffed out by the absence of any new funding in the House and Senate legislative packages. With only about 1 in 10 Americans who are in need of substance use disorder treatment being able to access it and a series of temporary and insufficient fixes like the 21st Century Cures Act that only provide funding for 1 or 2 years, no amount of regulatory change will be able to end the opioid epidemic. As Rep. Kathy Castor (D-FL) put it earlier this week, “We’re tinkering around the edges — we’re not tackling this public health crisis.”

The primary alternative to the legislation being offered by the Senate HELP Committee and House Energy & Commerce Health Subcommittee is the Comprehensive Addiction Resources Emergency (CARE) Act of 2018, which has been submitted by Senator Elizabeth Warren (D-MA) and Representative Elijah Cummings (D-MD 7). The overall structure and intent of the CARE Act of 2018 should be very familiar to HIV advocates, as it is modelled on the Ryan White CARE Act and looks to emulate the tremendous success it has experienced in providing comprehensive, effective, wrap-around care for people living with HIV in America.

The CARE Act of 2018 would provide an additional $100 billion in opioid response funding over 10 years to states and localities to help them institute evidence-based strategies to reduce fatal overdoses, increase access to substance use treatment, and address the infectious disease consequences of the opioid crisis. More so than any previous piece of opioid-related legislation, the CARE Act of 2018 fully embraces and champions the kinds of community-based harm reduction programs that are so vital to any effective response to this issue.

AIDS United strongly endorses the CARE Act of 2018 and will keep you up to the date on all of the latest news regarding the bill, as well as other opioid-related legislation in Congress.

Why Are Older Adults with HIV at Increased Risk for Multimorbidity

NMAC

 

 

Advocacy and Education Webinar Series
Please join us for our next webinar!
Why Are Older Adults with HIV at Increased Risk for Multimorbidity?
By Dr. Stephen Karpiak
Friday, April 6th, 2018 – 3:00 PM to 4:00 PM EST
Registration URL: https://attendee.gototraining.com/r/1280203559206296322
(After registering you’ll receive a confirmation email with information about joining the training.)
As people living with HIV experience longer lives, healthcare providers are spending less
time managing HIV-related issues and more time managing age-associated illnesses.
Multimorbidity refers to several serious health conditions that cannot be cured to any
great extent, occurring in an older person and engendering functional and/or cognitive
debility. Join us as we explore this topic with national expert on HIV and aging, Dr.
Stephen Karpiak from ACRIA.
Stephen Karpiak PhD is the Senior Director for Research at the ACRIA Center on HIV &
Aging at GMHC, where he launched ROAH, the seminal Research on Older Adults with HIV,
and supervised clinical trials for HIV drugs. He is a member of the Einstein-Rockefeller-Hunter
Center for AIDS Research, Editorial Board HIV-AGE (www.HIV-AGE.org) American Academy of
HIV Medicine, the American Geriatrics Society, and, the UN Aging Committee. Dr. Stephen is on
faculty at NYU and has published over 150 peer reviewed scientific papers.
Website: http://www.SEKPhD.com

Omnibus Fails to Invest Adequately in Eliminating Opioid Related Infectious Diseases

 

In the $1.3 trillion omnibus spending bill, H.R. 1625, Congress failed to secure an additional $100 million to the viral hepatitis programs at the Centers for Disease Control and Prevention (CDC) to address opioid crisis-related infectious diseases. Although the viral hepatitis programs will receive an additional $5 million, it is insufficient for addressing the infectious disease consequences of the opioid crisis.

Congress has been holding a series of hearings on bills to address the opioid crisis response, with an eye on passing a legislative package ahead of Memorial Day. Among those under consideration are two newly-introduced, bipartisan-supported bills that reauthorize surveillance and education regarding infections associated with injection drug use – in particular, viral hepatitis and HIV – by the CDC. Rep. Leonard Lance (R-NJ)’s office is responsible for drafting the Eliminating Opioid Related Infectious Diseases Act of 2018 (H.R.5353/S.2579), which amends the Public Service Act to fund such activities at $40 million per year, from 2019 – 2023.

AIDS United strongly supports any effort to increase funding toward the prevention of infectious diseases spread by injection drug use. The Eliminating Opioid Related Infectious Diseases Act of 2018 is an important step toward our community’s request for an additional $100 million to the viral hepatitis programs, and we urge Congressmembers to support this legislation.