White House Establishes New Opioid Commission

Alicia Ault

March 31, 2017

The Trump administration has established a White House-level commission to examine the US opioid epidemic, with an eye to determining where the federal government can have the biggest impact. The commission's full membership and responsibilities are still in the works.

The President's Commission on Combating Drug Addiction and the Opioid Crisis was established by executive order and signed by President Trump on March 29. The panel is due to issue a final report to Trump in October.

"I think the first order of priority is to see what at the federal level is out there currently," Bertha Madras, PhD, a professor of psychobiology in the Department of Psychiatry at Harvard Medical School, Boston, Massachusetts, told Medscape Medical News. That includes gathering data on the dollars the federal government spends on prevention and treatment and interdiction of illegal opioids, and then consulting with experts who can help better guide the resources, said Dr Madras. She said that although she has not been officially named, she believes she "will have a seat at the table."

Dr Madras believes physicians have played an outsized role in creating the opioid crisis. In an editorial published online March 29 in JAMA Psychiatry, Dr Madras notes that prescription opioid sales has risen 300% in the past 20 years, with more than half written for chronic pain.

"This shift in practice norms created a risk for diversion, use disorder, and overdose deaths," she writes. "It was fuelled by acceptance of low-quality evidence that opioids are an effective, relatively benign remedy for managing chronic pain," said Dr Madras, who went on to decry the creation of a "fifth vital sign" of pain.

In a statement, Trump notes that the Commission chairman Gov. Chris Christie (R-NJ) "will be instrumental in researching how best to combat this serious epidemic and how to treat those it has affected," and that "he will work with people on both sides of the aisle to find the best ways for the federal government to treat and protect the American people from this serious problem."

Christie recently signed the most restrictive limit on opioid prescribing in the United States, and has made substance use prevention and treatment a priority in his administration. His final term as governor ends this year.

The commission is also directed by the order to to the following:

  • assess the availability and accessibility of drug addiction treatment services and overdose reversal throughout the country and identify areas that are underserved;

  • identify and report on best practices for addiction prevention, including education for healthcare providers, the evaluation of prescription practices, and the use and effectiveness of state prescription drug monitoring programs;

  • review the literature evaluating the effectiveness of educational messages for youth and adults with respect to prescription and illicit opioids;

  • identify and evaluate existing federal programs to prevent and treat drug addiction for their scope and effectiveness and make recommendations for improving these programs.

Listening Session

A "listening session" at the White House on March 29 kicked off the effort. Dr Madras was one of those in attendance. She said she was not sure why she was invited, although she notes that she is a former deputy director for Demand Reduction in the White House Office of National Drug Control Policy (ONDCP). She held that position, which required Senate confirmation, from 2006 to 2008.

The new commission will operate under the auspices of the ONDCP, which will fund its operation. Trump has yet to appoint someone to head the ONDCP. Initial reports were that the office was being axed in the fiscal 2018 budget. But in the "blueprint" issued March 16, the ONDCP was no longer on the list of independent agencies that would be eliminated.

Richard Baum, the acting ONDCP director, was at the listening session, as was Secretary of Education Betsy DeVos, Secretary of Veterans Affairs David Shuklin, Attorney General Jeff Sessions, Homeland Security Secretary John Kelly, Drug Enforcement Administration Chief Chuck Rosenberg, and Acting Assistant Secretary for Health Don Wright.

All or most of those federal officials will be on the opioid commission.

Surgeon General Vivek Murthy, MD, who issued a seminal report on addiction in Fall 2016, did not attend the meeting because the US Department of Health and Human Services was already represented, a spokeswoman for Dr Murthy told Medscape Medical News.

Other attendees included Pam Garozzo, whose son died of an overdose, and A. J. Solomon and Vanessa Vitolo, who are both in recovery. All spoke at length about their efforts to cope with addiction and its fallout.

Pam Bondi, the attorney general of Florida, and former New York Yankees pitcher Mariano Rivera, representing the Mariano Rivera Foundation, also were at the meeting.

"We want to help people like A. J. and Vanessa, who struggled through the dark depths of addiction. Not easy. Not easy," said Trump in opening remarks.

He said his administration would also focus on law enforcement.

"Drug cartels have spread their deadly industry across our nation, and the availability of cheap narcotics – the cheap narcotics – some of it comes in cheaper than candy – has devastated our communities. It's really one of the biggest problems our country has, and nobody really wants to talk about it," he said.

Dr Madras said she did not believe the commission would focus too much on law enforcement and that conclusions about prevention and treatment would be based on solid evidence, not opinion.

"Evidence-based science should be driving this," said Dr Madras. From her observations at the White House meeting, the commission will be "committed to hearing as many voices as possible, with as many perspectives as possible." She said she does not yet know if the commission"s meetings will be public.

"There are so many areas in the entire process that have to be improved," said Dr Madras.

"Our prevention strategies in the country are abysmal," she said, adding that there are still too many opioids being prescribed and that people taking the medications don't know all the risks.

Greater Access to Naloxone

Physicians need greater education and knowledge to identify and treat addiction and help people get the right treatment, she said. Doctors can take more responsibility through brief and early screening for substance use disorder and by helping motivate people to seek treatment, said Dr Madras.

Few individuals with opioid use disorder are referred to treatment by a healthcare professional; at least half self-refer, she said. "It would be helpful to attenuate the problem before it progresses to a point of a cry in the night or an overdose."

Making naloxone more widely available and training more to use the rescue drug is a good goal, but it's not helpful to rescue someone and just walk away, she said.

"You have to have programs in place that can offer people seamless entry into treatment if they're rescued and they want to be," said Dr Madras.

The American Medical Association (AMA) said it welcomed the new commission.

"We are poised to offer guidance in areas of effective public health approaches, best practices, clinical tools, medication-assisted treatment, and barriers to effective treatment," said AMA Board Chair Patrice A. Harris, MD, in a statement.

In an interview conducted before the executive order was issued, Dr Harris told Medscape Medical News that the AMA has some concerns, including the possibility that some policies might adversely affect patients with chronic pain.

The group welcomes the opportunity to "get together to discuss the remaining questions that must be asked and answered to be sure there are not any unintended consequences on patient access to care," said Dr Harris.

The AMA also supports increased access to naloxone and medication-assisted treatment, she said. "It is vital that there is increased access to treatment in general," she added.

Federal Response "Awful"

Nitin S. Damle, MD, MACP, president of the American College of Physicians (ACP), said in a statement that the ACP also was encouraged, and urged the commission to "consult with the AMA Opioid Task Force, of which ACP is a member.

"Substance use disorders are treatable, chronic medical conditions, like diabetes and hypertension, that should be addressed through expansion of evidence-based public and individual health initiatives to prevent, treat, and promote recovery, rather than excessive reliance on criminalization and incarceration," Dr Damle added.

Andrew Kolodny, MD, codirector of opioid policy research at the Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, said he was not sure how a commission could solve the opioid problem, but that coordination is "desperately needed" among the federal agencies that are involved the crisis.

"President Obama really neglected the opioid epidemic until his last year in office," Dr Kolodny, executive director of Physicians for Responsible Opioid Prescribing, told Medscape Medical News. "The federal response to the opioid epidemic has been awful," he added.

Billions of dollars in federal investment, much of it to be given to the states, will be required, he said, adding that he's not sure the Trump administration will spend that kind of money.

In addition, Dr Kolodny is concerned that measures to prevent addiction will mean running afoul of the pharmaceutical industry — at a time when the Trump nominee to lead the US Food and Drug Administration, Scott Gottlieb, "is someone who's been involved in advocacy for the opioid lobby," he said.

Dr Madras serves on the scientific advisory board of RiverMend Health, is a consultant for Guidepoint, and recently served on a panel organized by the Vatican Pontifical Academy of Sciences, which was unfunded. Dr Kolodny has disclosed no relevant financial relationships.

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