Public Policy Priorities to Combat the Opioid and Heroin Epidemic The expanded availability of prescription painkillers and heroin, known as opioids, has created a public health crisis that demands attention from our government and across our communities nationwide. As the nation’s leading nonprofit provider of drug and alcohol addiction prevention, treatment and recovery services, the Hazelden Betty Ford Foundation has an important responsibility, and is uniquely qualified, to comment on public policy opportunities that could help reduce the enormous impact of opioid misuse and addiction, which we see every day at our 17 locations across the United States. As such, we are pursuing the following advocacy priorities: Educate and Prevent Training for dentists, doctors, nurses and pharmacists We support the aggressive expansion of education and training for health care providers about the dangers of overprescribing opioids; safe pain management alternatives; screening for, recognizing and monitoring the signs of addiction to alcohol and other drugs; managing risk for addiction and promoting protective factors, just like they do for other highly prevalent and damaging diseases; appropriately intervening when problems are suspected; and referring to specialty care when needed. Public education We support national education and prevention campaigns that target youth and their parents, older adults and the general population to dispel myths, provide facts and resources, and reduce stigma. One idea we support is to provide educational literature for consumers, included with their opioid prescriptions. Another would be to add a “penny a pill” or similar surtax to prescription opioids, with proceeds to fund public education campaigns. School-based prevention Our education systems should develop the capacity to identify adolescents and young adults who engage in any form of substance use—including alcohol and marijuana use—and route them to intervention programs. That starts with providing young people with age-appropriate, evidence-based education and skill-building opportunities while they are still healthy and free from all substances. To protect against later opioid misuse and addiction, prevention must target entire populations; emphasize the relationship between alcohol, cigarette and marijuana use and health problems like addiction, other drug use and death; include robust training for our educators, and start from the earliest years of a child's education, continuing into young adulthood. Promotion of non-medication pain management therapies We encourage public and private organizations to embrace healthy approaches to pain management that do not rely so heavily on pain medications. We also urge state medical boards to include diverse pain management guidelines in their policies. A survey we commissioned supports this priority, finding that 80 percent of respondents are willing to reduce or eliminate their current chronic pain medications and try alternatives instead. We are especially supportive of the new opioid prescribing guidelines issued by the Centers for Disease Control and Prevention (CDC) and encourage their implementation nationwide. Limits on medication We support legislation, such as measures enacted by Massachusetts, that forbids doctors from writing opioid prescriptions for more than a seven-day supply. Lawmakers in other states are considering similar laws, which would go a long way toward reducing the excess supply in consumers’ medicine cabinets and limiting expectations regarding length of use. A ban on direct marketing of opioids The Food and Drug Administration (FDA) should forbid the makers of opioids from marketing them to doctors and the public. Responsible medication approvals and labeling We urge the FDA to refrain from approving new high-dosage opiate painkillers, especially those easily crushed and therefore more prone to misuse and diversion, unless the painkillers are clearly safer than existing products. We also encourage the FDA to further enhance opioid medication labels so that approved uses are appropriately limited and patients are fully aware of the risks and the availability of alternatives. It’s important that consumers understand opioids are addictive drugs that—while useful when taken as prescribed for acute pain—have a similar effect on the mind and body as heroin. We also believe natural painkillers such as “kratom” should be investigated for possible inclusion on the U.S. Drug Enforcement Administration’s (DEA) controlled drug schedule. Kratom, derived from a plant, has properties of amphetamine and opioids, and is marketed as a “natural painkiller.” It doesn't show up on drug screens, which means people with opioid use disorders can use it without being detected. Those selling it are doing so publicly without consequences, as it remains legal in spite of its addictive qualities. The FDA banned the import of kratom under its authority to keep out substances strongly suspected to be harmful. The DEA has also listed kratom as a “drug of concern” but not a controlled substance. Four states have independently banned it, and the U.S. Army has forbidden its use by soldiers. Effective Prescription Drug Monitoring Programs (PDMP) We support establishing a national PDMP and mandating its use by all prescribers PDMPs help prescribers see what prescriptions their patients may be getting from other prescribers, identifying problematic drug-seeking early on. State-level PDMPs are often voluntary, and the information is usually not shared across state lines. Short of a national system, we encourage more efforts to strengthen state PDMPs, including mandated utilization, appropriate funding and coordination of PDMPs across state lines. Mandated utilization is especially key, since studies show that in states where it is not mandatory, the PDMP is used only a third of the time. The addition of naloxone revival as an item tracked by PDMPs We also think prescribers need to know if their patients ever had to be revived from an overdose. A study in the Annals of Internal Medicine found that too many individuals who are revived are then prescribed opioids again. Effective law enforcement We support strong sentences for the criminal overprescribing of opioids as well as schemes intended to supply the illegal drug market. We also support closing loopholes in the U.S. postal system to stop dangerous synthetic opioids such as fentanyl and carfentanil from being shipped through our borders to drug traffickers in the U.S. Real-time surveillance systems Combatting any public health crisis requires real-time data. Unfortunately, there is typically a two- to three-year lag between when an opioid-related death occurs and when it is published by national data systems. Surveillance of morbidity and mortality empowers decision-makers to understand the effectiveness of policies put in place to combat the opioid crisis, as well as shift or expand resources to manage the problem. Surveillance cannot be used as intended if it is outdated. Disposal of Unused, Unneeded Medications We support the U.S. Drug Enforcement Administration’s regulations governing the safe and secure disposal of prescription medications at authorized collection locations. We also support the DEA's National Prescription Drug Take-Back Day and urge communities to vigorously promote their authorized collection locations with other community-wide Prescription Drug Take-Back Days. Such efforts facilitate continued public education about the dangers of keeping excess medications in the home or workplace. Availability of Overdose “Rescue Drugs” We encourage expanded access to the opioid antidote naloxone We also support “Good Samaritan” laws, which encourage people to call 9-1-1 when they witness a drug overdose, without fear of being arrested themselves for drug possession or being under the influence. States such as New York have trained thousands of first responders and lay individuals to recognize and respond to opioid overdoses using naloxone, and many have companion “Good Samaritan” laws. We encourage similar policies nationwide. Immediate intervention for people revived from an opioid overdose We believe health care providers should adopt a "standard of care," or recommended protocol, for helping people after they have been revived from an opioid overdose with naloxone. Such a standard or protocol would help ensure that overdose survivors are thoroughly evaluated, educated and referred to addiction treatment and/or community-based support resources. Too often people are revived and sent home without further care. They are at extreme risk to use and possibly overdose again. We believe trained peer recovery coaches, integrated into hospital and emergency responder protocols, can play a valuable role in helping overdose survivors make the transition to treatment and recovery support. We also encourage more study of civil commitment laws, which if appropriately circumscribed, could potentially help professionals and family members initiate care for an individual whose life is in immediate danger due to severe opioid addiction. Accessible Evidence-based Treatment for Opioid Addictions Longer-term comprehensive care Research and the experience of our opioid addiction treatment program, Comprehensive Opioid Response with Twelve Steps (COR-12™), show that engaging patients longer, and addressing all forms of substance use as well as mental health concerns, improves the chances for sustained recovery. While the level of care (i.e., residential, intensive outpatient, etc.) is best determined by clinicians using American Society of Addiction Medicine (ASAM) criteria, we support an emphasis on longer-term, comprehensive care. Public funding and insurance policies should support access to the most effective treatments. Safe, responsible use of medication to assist addiction treatment when appropriate, with abstinence as the long-term goal We support the use of certain medications in combination with adjunctively with therapy and recovery support to minimize risks and maximize treatment benefits. Our COR-12 program is a model. To that end, we believe primary care doctors who prescribe medications for opioid addiction need to also “prescribe” therapy, regular drug screens and recovery support resources. Current regulations suggest but do not require such measures. At minimum, we’d like to see weekly drug screens and at least one hour of counseling a week required for patients receiving medications for opioid addiction. In addition, we encourage doctors to consider naltrexone or its extended-release version—Vivitrol—as a viable alternative to Suboxone in some cases, and to consider both of those options as the safest alternatives. To ensure thorough consultations are possible between primary care doctors and their patients with opioid addiction, we also urge that existing limits be maintained on the number of patients to whom a doctor can prescribe Suboxone; at the same time, we would like to see more doctors certified to prescribe the medication. We know from years of experience that abstinence is a realistic goal for people with opioid addiction, and we urge all professional caregivers to pursue that goal. We also urge that public funding be used to encourage access to the most effective, life-improving treatments. Access to insurance coverage We support bipartisan action to retain and improve access to addiction treatment coverage. Any reforms to public and private health insurance policy should include no denial of coverage for those with pre-existing conditions; coverage for young adults on their family health plans through age 26, as addiction starts most often at a young age, when the brain is still developing; continued Medicaid coverage for those who need it; creative solutions to help individuals purchase insurance and help states fill coverage gaps; and the maintenance of substance use coverage, at parity, as an essential health benefit. We also support changing the outdated IMD Exclusion, which limits Medicaid coverage for substance use treatment to facilities with less than 16 beds, to allow coverage for up to 40 treatment beds, or more, at larger facilities. Parity enforcement to guarantee that insurance companies are not arbitrarily discontinuing coverage for treatment at a certain time Our organization was at the forefront in supporting the 2008 parity law. We still see “fail-first” violations, though, whereby patients are forced to fail at lower levels of care before receiving the appropriate level of care. The parity provisions also are inconsistently adhered to by insurance companies, something our staff contends with daily. We firmly believe that insurers and other payers should be required to disclose their medical management criteria and how they employ them. The parity regulatory guidance called for under the 21st Century Cures Act on non-quantitative treatment limitations and other issues should be issued as soon as possible. Addiction care that is integrated with the broader health care system, with support for this chronic condition beyond the acute care stage When screening, assessment, intervention and care are coordinated between general health systems and specialty addiction treatment programs, both systems benefit, improving effectiveness and efficiency of care and reducing costs. One key to integration is reforming the outdated 42 CFR Part 2 privacy regulations, which have become a barrier to access and deprive patients of the full benefits of modern services. At a minimum, Part 2 requirements should be aligned with the HIPAA requirements that allow the use and disclosure of patient information for treatment, payment and health care operations. Criminal justice reform We strongly support the expansion of drug courts and similar sentencing alternatives that are more rehabilitative than punitive and that have been proven to reduce crime, save money, ensure compliance and restore families. We also believe legislative efforts such as the Second Chance Act can help those convicted of drug offenses to get back on their feet through treatment, re-entry programs and employment training. We further support efforts to reform draconian mandatory sentencing laws, restore the voting rights of recovering drug offenders and provide them with more and better sober housing options. Funding We need a full-throated, comprehensive public health response to address the current opioid overdose epidemic and a long-term commitment to fighting addiction. We support full funding for the Comprehensive Addiction and Recovery Act, the 21st Century Cures Act and other programs and initiatives essential to addressing this long-neglected public health problem. Support Expanded infrastructure for community-based recovery Addiction is a chronic illness, and we need to think of recovery as we do cancer remission—something that needs close attention and support for up to five years. That doesn’t mean we need five-year-long treatment programs, but rather support mechanisms that help connect recovering people so they can support one another in the community context and be a magnet for others in their community who might seek recovery as well. While recovery often begins with addiction treatment, it is sustained in the community, and people with addiction benefit substantially from long-term recovery engagement. We support grants and targeted efforts to establish recovery community organizations, expand and improve sober housing, and promote collegiate addiction recovery programs and recovery high schools. Loan forgiveness for licensed addiction counselors who practice in high-need areas There is a huge need for treatment beds and addiction counselors to staff them, with a projected 31 percent employment growth rate by 2022 for these jobs. In fact, more than 21,000 new counselors will be needed, according to the Bureau of Labor Statistics. We can encourage prospective counselors to go into the field, and fill a need in the country, by offering targeted loan forgiveness for those who commit to practicing in certain high-need areas, for a specified period of time, similar to what’s been implemented for doctors in rural areas, for example. One specific way to do this is to make addiction treatment facilities eligible for the National Health Service Corps (NHSC) student loan repayment and forgiveness program. Telehealth and other remote supports We support federal and state legislation that would make it more feasible for health care organizations such as ours to provide care remotely using telehealth technologies. The greatest challenges are obtaining provider licenses across multiple state lines and accessing insurance reimbursements for care delivered in this manner. This is relevant because patients on medication assistance for opioid addiction require continuing care services that support their long-term journey to abstinence, and it is difficult to engage them long term without doing so remotely. Telehealth technologies could also help bring therapy resources to locations where primary care doctors are able to prescribe Suboxone but unequipped to provide follow-up addiction counseling. That is a clear need expressed by participants at our Addiction Medicine for the Primary Care Provider Conferences. Native Americans, military veterans and residents of rural areas, for example, would benefit greatly from greater access to care.