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

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.

Cuts that Hurt: What the President’s FY18 Budget Proposal Means for HIV services and people of color

 

 

 

 

 

President Trump’s FY18 budget proposal included several cuts that would directly impact people of color (POC) living with or vulnerable to HIV. It is important to remember that the President’s budget recommendations are only the start of the budget process. Congress makes the final decision on funding for the government.

YOU CAN HELP: It is very important that our elected officials hear from us to save our services for HIV prevention and care. Please join us for this year’s HIV/STD Action Day on September 6 2017, the day before the start of the 2017 United States Conference on AIDS, and speak to your Member of Congress directly or organize an effort in your own local district.

Secretary’s Minority AIDS Initiative Fund (SMAIF)

The President’s FY18 budget request eliminates funding at this critical time in the SMAIF’s existence. Each year, the SMAIF provides over $50 million to support a wide range of activities designed to support communities of color (including, but, not limited to projects that: (1) get and keep people of color in care; (2) build leadership among people of color at the local level who are either living with or affected by HIV, and (3) address Hepatitis C in those living with HIV).

  • POC  IMPACT:  The  proposed  elimination  of  the  SMAIF  would  remove  a  key  resource  that promotes innovative and cost-­effective programs specifically tailored for communities of color and that influence HIV related programs across the entire Department of Health and Human Services.

Cuts to the Ryan White HIV/AIDS Program will
↑ Increase health inequities
↓ Reduce support services for persons living with HIV

Although  praised  by  the  Administration,  the  President’s  FY18  budget  request  decreases funding for the Ryan White program by $59 million (eliminating funding for  the  AIDS  Education  and  Training  Centers  (AETC)  which  train  medical  professional and Special Projects of National Significance (SPNS) programs).

  • POC IMPACT: The proposed cuts to the AETCs will reduce access to important training programs that help the healthcare workforce prepare to meet the needs of clients seeking HIV-related services – particularly, people of color.
  • POC IMPACT: The proposed cuts to the SPNS will stall: (1) evaluation of treatment models; (2) dissemination and replication of successful interventions; (3) capacity-­building in the health information technology systems of the Ryan White program.

Cuts to HIV Prevention will likely cause
Community-­Based Organizations (CBOs) near you to lose funding or close
+30,000 more Americans will become HIV-­positive
‐ 1,000,000 fewer HIV tests will be performed

The President’s FY18 budget request reduces the Centers for Disease Control and Prevention (CDC) funding for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Infections and Tuberculosis by $186.1 million. The proposed cuts to CDC would scale-­down local HIV prevention activities  that  have  just  started  to  reach  communities  of  color,  including  support  for  pre-­exposure  prophylaxis (PrEP) as well as efforts around treatment as prevention which would deeply harm the communities most vulnerable to HIV.

  • POC IMPACT: The proposed cuts to CDC threaten the existence of CBOs as cuts to their HIV prevention funding would greatly reduce services including testing, linkage services, prevention campaigns, and health education programs. Thousands more people will be unaware of their HIV status and those who need care will not be linked to life‐sustaining services.

Cuts to Medicaid will likely cause Millions to lose their Medicaid Coverage

The President’s FY18 budget request cuts $610 billion (over 10 years) to this joint federal/state program that provides healthcare services for people with limited income and resources. Medicaid remains one of the largest payers of insurance for people living with HIV.

  • The proposed cuts to Medicaid would especially impact communities of color and put their health and well-­being at-­risk since they will lose their access to HIV prevention and treatment services.

Cuts to National Institutes of Health (NIH) will Adversely impact the Office of AIDS Research (OAR)

The President’s FY18 budget request reduces funding by nearly $5.8 million. Such a large cut would likely harm researchers’ ability to find new prevention strategies and to make sure treatment options meet the needs of those on treatment.

  • POC IMPACT: The President’s FY18 budget request proposes the elimination of the Agency for Healthcare Research and Quality (AHRQ). With an emphasis on health disparities experienced by persons of color when they access healthcare services, AHRQ produces the annual National Healthcare Quality and Disparities Report as well as periodic updates on the National Quality Strategy.
  • POC IMPACT: The proposed cuts to NIH greatly undermine current long­‐term research on HIV vaccines and the hunt for a cure for HIV. Both Black and Latinos continue to be disproportionately affected by HIV and in need of HIV-­related services.

Cuts to the Housing Opportunities for Persons with AIDS (HOPWA) Program will likely cause more than 33,000 homeless People Living with HIV (PLWH) to lose housing support services

Despite being praised by the Administration, the President’s FY18 budget request proposes cutting HOPWA by approximately $26 million dollars.

  • POC IMPACT: The proposed cuts to HOPWA would reduce funding to below FY16 levels (although the 2016 levels were deemed inadequate and the HOPWA formula was updated by the Housing Opportunity through Modernization Act (HOTMA) in 2016).
  • POC IMPACT: The proposed cuts to HOPWA would reduce funding to below FY16 levels (although the 2016 levels were deemed inadequate and the HOPWA formula was updated by the Housing Opportunity through Modernization Act (HOTMA) in 2016). Several thousand fewer homes will be available for homeless or housing unstable PLWH.

Cuts to the Substance Abuse and Mental Health Services Administration (SAMHSA) will
‐ Reduce the SAMHSA Minority AIDS Initiative Funds by $17.7 million

The President’s FY18 budget request decreases SAMHSA funding by $374 million.

  • POC IMPACT: The proposed cuts to SAMHSA would directly impact communities of color since, in 2015, 65% of those who identified injection drug use as the mode of HIV transmission were people of color.
    • Specifically, the SAMHSA Minority AIDS Initiative Funds will reduce the resources available for substance use-­related HIV prevention and treatment programs focused on engaging people of color.

GOOD NEWS→

The President’s FY18 budget proposal is just a recommendation to Congress and only the first step in the Federal Budget Process:

Step 1: The President’s Budget Request

  • The President submits a detailed budget request for the coming fiscal year, which begins on October 1.

Step 2: The Congressional Budget Resolution

  • Congress usually holds hearings to question Administration officials about federal agency funding requests
  • Congress usually holds hearings to question Administration officials about federal agency funding requests
  • The federal House and Senate Budget Committees then develops its own budget resolution (which are supposed to be filed by April 15th)
  • The full House and Senate then vote on its own budget plan (only a majority vote is required to pass)

Step 3: Enacting Budget Legislation

  • The federal House and Senate Appropriations Committees determine program-­by-­program funding levels in 12 separate bills
  • The federal House and Senate Appropriations Committees determine program-­by-­program funding levels in 12 separate bills
  • Most HIV related programing is determined in the Labor­-Health and Human Services­-Education and Related Agencies appropriations bill

TAKE HOME MESSAGE→ The final distribution of funds is ENTIRELY in the hands of Congress