Opioid Commission: Declare a State of Emergency, Mr President

Alicia Ault

July 31, 2017

The White House commission charged with advising the Trump administration on the country's opioid epidemic is calling on President Donald J. Trump to declare a state of emergency to quickly and aggressively address this crisis.

Some 142 Americans die every day from a drug overdose, said Chris Christie, chairman of the President's Commission on Combating Drug Addiction and the Opioid Crisis, in a press briefing.

The declaration of a national emergency is "the single-most important recommendation," Christie said.

The commission's interim report, addressed to President Trump, said such a declaration would "empower your cabinet to take bold steps and would force Congress to focus on funding and empowering the Executive Branch even further to deal with this loss of life."

The report, released July 31, had been expected earlier, but Christie said it was delayed by the need to sift through some 8000 comments that were received after the commission held its first public meeting in mid-June.

The report made a number of recommendations, including some that would mandate physician education. Others would encourage and boost medication-assisted treatment (MAT) and increase availability of the overdose reversal agent naloxone.

The commission also urged an immediate change in Medicaid policy — one that would essentially require the federal government to pay for more addiction treatment, at a time when Congress has been looking at paring back Medicaid.

The healthcare community will play an increasingly crucial role in addressing the opioid epidemic, commission member Bertha Madras, PhD, told reporters.

"We are going to need an evolution or even a revolution in how the health care system addresses substance use issues," said Dr Madras,  professor of psychobiology at Harvard Medical School, Boston, Massachusetts.

"Revolutionary" Approach Needed

Physicians need much more training in identifying people with substance use issues and to learn how to manage those individuals, she said. The healthcare system also frequently overlooks the fact that mental health problems are what she called a "massive contributor" to substance use disorders.

"If there isn't an integration of mental and physical health in a revolutionary new way, we aren't going to be able to address the entirety of the problem in a systematic and coordinated fashion," Dr Madras said.

The report's recommendations call for mandatory training for those who prescribe opioids, which includes understanding risk factors for substance use disorders. This, the commission says, could be accomplished by amending the Controlled Substances Act to require all Drug Enforcement Administration (DEA) registrants to take a course in "the proper treatment of pain."

The report urged adoption of the American Society of Addiction Medicine's (ASAM) suggestion that all clinicians who apply for DEA registration to prescribe controlled substances be required to demonstrate competency in safe prescribing, pain management, and substance use identification.

Christie said the commissioners agree with the ASAM proposal and that it should also be applied to clinicians who seek renewal of their DEA registration.

The American Medical Association has repeatedly said that prescriber education should be voluntary, not mandatory.

The President's commission is also recommending that states allow naloxone dispensing via standing orders and that clinicians be required to prescribe the overdose antidote along with high-risk opioid prescriptions.

The commission further recommends the US Department of Health and Human Services (HHS) Secretary be granted the ability to negotiate reduced pricing on naloxone so that the drug is available to all governmental agencies and law enforcement.

In addition, it directed HHS and other federal agencies to find a way to identify individuals who have overdosed and been revived with naloxone, so that their primary care or other healthcare providers can be identified.

Mandatory Use of PDMPs

Christie said the Commission also believes clinicians should be required to check a state's prescription drug monitoring database before prescribing an opioid.

Currently, 49 states have prescription drug monitoring programs (PDMPs). But the information in those databases is of no use if doctors aren't required to use them, Christie said.

The commission also recognizes that databases are not as useful as they could be because currently states share information. The report urges the president to direct Veterans Affairs and HHS to lead an effort to have all state and federal PDMPs share information by July 1, 2018.

Information should also be shared among clinicians and families, the commission said. It recommended that patient privacy laws be amended to ensure that a patient's substance use history can be shared by clinicians with other healthcare providers and family members. 

"Sharing this information is appropriate in light of the crisis we are suffering," Christie said.

One of the Commission's top recommendations was to rapidly expand treatment capacity, by allowing states to immediately seek waivers from a regulation that prohibits Medicaid reimbursement for services provided in inpatient facilities that have more than 16 beds.

"This is the single fastest way to increase treatment availability across the nation," the report said.

The report also urges the Trump administration to find a way to create a federal incentive to boost access to MAT. All FDA-approved modes of MAT should be offered at every licensed MAT facility, and the decision should be based on what's best for the individual, "not on what is best for the provider," the report notes.

The commission called for the federal government to find a way to reduce reimbursement hurdles for MAT.

The commission's other recommendations include:

* That President Trump direct the Department of Labor to aggressively enforce the Mental Health Parity and Addiction Equity Act. Penalties should be levied on violators.

* That more funding and manpower be provided to Customs and Border Protection, the Federal Bureau of Investigation, and the DEA to quickly develop ways to detect fentanyl, and that legislation be supported to stop opioids from being trafficked through the United States mail.

The five-member commission was established by executive order and signed by President Trump on March 29. The panel is due to issue a final report in October.

That report will focus on creating addiction prevention strategies and will take a close look at patients' "satisfaction with pain" measure, which the federal government currently uses as a means of evaluating physicians.

"We believe this may very well have proven to be a driver for the incredible amount of prescribing of opioids," said Christie.

He noted that in 2015 enough opioids were prescribed so that every American could be medicated for three weeks. "It’s an outrage," said Christie.

For more news, join us on Facebook and Twitter


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.