Accelerating the federal response to the opioid epidemic

The opioid crisis—really, tragedy—continues to grow exponentially in the United States. The starkest reflection of this crisis is the large and growing annual number of related deaths. In 2014, more than 29 thousand accidental deaths occurred as a result of prescription opioids or heroin. This number translates into more than 80 deaths every single day.

Opioids come in the form of prescription medications from the family medicine cabinet, prescription medications sold illicitly on the streets, or as illicit heroin. Users range from young children to the elderly, and every demographic group and geographic region of our country. Clearly, we are in the midst of an unprecedented opioid epidemic.

Very fortunately, President Obama recently has made the federal response to the opioid crisis a top priority of his administration. Earlier this year, the president asked Congress to appropriate $1.1 billion in new funding to help every American with an opioid use disorder who wants treatment get the help they need.

Similarly, Department of Health and Human Services (HHS) Secretary Sylvia Burwell has made the departmental response to opioids her signature initiative, and USDA Secretary Tom Vilsack has taken impressive steps to address opioids in rural communities. The Food and Drug Administration and the Centers for Disease Control and Prevention (CDC) have made very important strides in the recent release of an opioid safety document and opioid medication guidelines, respectively.

March 29 was a watershed day for all of these initiatives. That day, the president spoke at the National Rx Drug Abuse & Heroin Summit in Atlanta. At the same time, the administration announced a dramatic series of important actions designed to address this problem directly. These actions are summarized below.

Expanding access to treatment

To expand access to buprenorphine and prevent diversion, HHS is issuing a proposed rule to increase the current patient limit for qualified physicians who prescribe this medication to treat opioid use disorders from 100 to 200 patients.

Earlier this month, HHS awarded $94 million in new funding to 271 community health centers to increase substance use disorder treatment services, with a specific focus on expanding medication-assisted treatment (MAT) in underserved communities. As many as 124,000 new patients may receive treatment in these health centers.

Up to 11 states will share in some $11 million in SAMHSA funding to expand their MAT services. The agency is distributing 10,000 clinical pocket guides containing a checklist for treating opioid disorders using medication, as well as non-pharmacologic therapies. In states with the greatest need, SAMHSA will help boost the number of physicians qualified to prescribe buprenorphine.

1. Establishing a Mental Health and Substance Use Disorder Parity Task Force: The president has directed the creation of an interagency task force, chaired by the Domestic Policy Council, to improve access to behavioral health treatment; promote compliance with best practices in parity implementation; and develop additional agency guidance, as needed. The task force, which spans federal departments and stakeholder organizations, has an October 31, 2016, deadline.

2. Implementing Medicaid Mental Health and Substance Use Disorder Parity: HHS is finalizing a rule to strengthen access to mental health and substance use services for Medicaid and CHIP enrollees by requiring that these benefits be offered at parity, comparable to medical and surgical benefits. These protections are expected to benefit more than 23 million people in the two programs.

3. Preventing Opioid Overdose Deaths: SAMHSA is releasing a new $11 million grant opportunity enabling States to purchase and distribute naloxone, and to train first responders and others on its use, as well as with other overdose prevention strategies.

4. Expanding Public Health-Public Safety Partnerships to Combat the Spread of Heroin: The Office of National Drug Control Policy is expanding its heroin initiative among regional High Intensity Drug Trafficking Areas (HIDTAs), adding Ohio and Michigan to the effort. These states will join the Appalachia, New England, Philadelphia/Camden, New York/New Jersey, and Washington/Baltimore HIDTAs in accelerating local law enforcement/public health partnerships to combat heroin use and overdose.

5. Investing in Community Policing to Address Heroin: The Department of Justice is announcing a $7 million grant program—the COPS Anti-Heroin Task Force Program—to advance public safety and to investigate the distribution of heroin, unlawful distribution of prescription opioids and unlawful heroin and prescription opioid traffickers. Grants will be made directly to law enforcement agencies in states with high rates of treatment admissions for heroin and other opioids.

6. Tackling Substance Use Disorders in Rural Communities: The USDA’s $1.4 million Rural Health and Safety Education Grant Program to enhance the quality of life in rural areas through health and safety education projects has been expanded to include a focus on substance use disorders in rural communities.

7. Implementing Syringe Services Programs: HHS is issuing guidance for HHS-funded programs regarding the use of federal funds to implement or expand syringe services programs for people who inject drugs. The bipartisan budget agreement signed by the president last year revised a longstanding ban on these programs, allowing communities with a demonstrated need to use Federal funds for operational elements of syringe services programs.

New private sector commitments

1. Medical School Opioid Prescribing Education: More than 60 medical schools are announcing that, beginning in fall 2016, they will require their students to take some form of prescriber education, in line with the newly released CDC Guideline for Prescribing Opioids for Chronic Pain, in order to graduate.

2. Naloxone Pharmacy Distribution/Pharmacist Training: Rite Aid has trained over 8,400 pharmacists on naloxone and is dispensing naloxone to patients without needing an individual prescription in 10 States, with plans to expand to additional States. Kroger currently dispenses naloxone without an individual prescription at its pharmacies in 7 States with plans to expand to at least 12 more by the end of the year. AmerisourceBergen/Good Neighbor Pharmacy will provide educational materials to encourage their 4,000 independently owned and operated retail pharmacy locations to provide naloxone without an individual prescription.

Updates on earlier actions

In October 2015, as part of his visit to West Virginia to discuss the prescription opioid abuse and heroin epidemic, President Obama announced a series of public/private initiatives, including a requirement that federal departments develop plans to address barriers to opioid use disorder treatment in federal programs. Since that time, many other steps to expand access to opioid use disorder treatment, including MAT, have occurred:

1. Tricare: Department of Defense issued a proposed rule to implement parity protections in Tricare, including expanding mental health and substance use disorder treatment to include coverage of intensive outpatient programs and treatment of opioid use disorders with MAT. An estimated 15,000 to 20,000 Tricare beneficiaries have an opioid use disorder and, under current benefits, cannot access MAT.

2. Federal Employees Health Benefits Program (FEHBP): The Office of Personnel Management released a letter to health plans participating in FEHBP that makes opioid use disorder treatment a priority and urges plans to improve access to MAT by 2017.

3. Medicare: The Centers for Medicare and Medicaid Services (CMS) released a letter to Medicare Part D (pharmacy benefit) plans reiterating the priority on reducing the unsafe use of opioids and making clear that Part D formulary and plan benefit designs that hinder access to MAT for opioid use disorder will not be approved.

4. Medicaid: CMS released a document to states identifying best practices for addressing prescription opioid overdoses, misuse and addiction, including effective Medicaid pharmacy benefit management strategies, steps to increase the use of naloxone, and coverage expansion options for and access to opioid use disorder treatment.

5. Health Insurance Marketplaces: Recently, CMS finalized a 2017 marketplace payment notice clarifying that essential health benefits requirements and Federal mental health and substance use disorder parity requirements apply to qualified health plan coverage of medications to treat opioid use disorder. Additional guidance is forthcoming.

6. Drug Enforcement Administration (DEA): The DEA will hold its 11th National Prescription Drug Take-Back Day on Saturday, April 30, 2016, providing a safe, convenient, responsible way to dispose of unneeded prescription drugs. Local communities also are establishing ongoing drug take-back programs.

7. In the Private Sector: More than 40 health care provider groups announced a commitment to ensure that more than 540,000 health care providers will complete training on appropriate opioid prescribing in the next two years. In the first five months of this initiative, the provider coalition reports that more than 75,000 providers have completed prescriber training. Further, over 2,200 additional physicians have committed to completing training to prescribe buprenorphine as part of the coalition's effort to double the number of buprenorphine prescribers in the next three years.

8. The National Association of Counties, National Governors Association, National League of Cities and United States Conference of Mayors, in collaboration with the U.S. Communities Purchasing Alliance and Premier, Inc.: These groups announced they had secured discounts on naloxone and MAT drugs through their purchasing program for state, county, and local agencies.

9. Walgreens: The drug store chain announced it will install safe medication disposal kiosks in more than 500 drugstores across the country, primarily at locations open 24 hours. The program will make the disposal of medications - including opioids and other controlled substances - easier and more convenient while helping to reduce the misuse of medications. Walgreens also will make naloxone available without needing an individual prescription at its pharmacies in 35 states and Washington, D.C. throughout this year.

10. CVS Health: The drug store chain has worked to increase access to naloxone by establishing standing orders or collaborative practice agreements. By the end of March 2016, CVS Pharmacy locations in 23 states were able to dispense naloxone to patients without needing an individual prescription, increasing to 35 States by the end of 2016 as part of its program expansion announced at the October 2015 event. CVS Health also has launched a drug use prevention program called Pharmacists Teach, which brings CVS Pharmacists into schools across the country to educate students about the dangers of drug use. To date, more than 30,000 students have participated in the program.