White House Opioids Summit Highlights Plans to Fight Crisis

Damian McNamara

March 02, 2018

Attendees at a White House Opioids Summit on Thursday — including President Donald J. Trump, cabinet members, and the surgeon general — detailed programs and voiced ideas to fight the opioid epidemic.

"It's a problem that is growing," Trump said. "People go into the hospital with a broken arm and they come out addicted, and they don't even know what happened."

His administration plans to roll out new policy over the next 3 weeks, and it will be "very, very strong," Trump said.

He suggested the option of the death penalty for drug dealers, although that is not an item in any official policy.

"We have pushers and drugs dealers, they are killing hundreds and hundreds of people," Trump said. "If you shoot one person, they give you life, they give you the death penalty. These people can kill two thousands, three thousand people and nothing happens to them."

Legal action against the opioid manufacturers is another possibility. Trump acknowledged similar lawsuits filed by states and said he saw no reason the federal government could not do the same.

Regarding the multiple, ongoing challenges of the opioid epidemic, "We're with you 100%, and we're going to win," he told summit attendees gathered in the East Room of the White House.

"Everyone in this room knows our country is in the middle of an opioid crisis," said First Lady Melania Trump in opening the summit. She is proud of the work that has been done so far by the administration, she said, adding, "We all know there is still much work still to be done."

Melania Trump was referring, in part, to the administration's declaration of a public health emergency regarding the opioid epidemic in October 2017. Actions taken since the declaration include a doubling of annual funding for the Department of Health and Human Services (HHS) to promote opioid addiction prevention, treatment, and recovery. The proposal in Trump's budget would increase funding from $500 million to $1 billion.

Department of Health and Human Services Response

"This year and last, we're issuing $500 million in targeted response grants to state governments, which cover prevention and treatment but also recovery support," HHS Secretary Alex Azar said during a panel discussion at the summit. "We are also working on a $150 million grant program for rural treatment," he noted.

"We know we need to treat addiction as a medical challenge, not as a moral failing," Azar said. "That informs HHS's position across all three areas we're here to discuss today: prevention, treatment, and recovery."

Promising trends in opioid prescribing patterns are encouraging, Azar said, but he echoed the theme that more needs to be done. "Prescribing is down noticeably from 2010 to 2015, but it's still three times what it was in 1999," he said.

Azar emphasized the importance of evidence-based medication-assisted treatment of opioid addiction. However, only one third of US treatment facilities offer medication-assisted therapy. "That's unacceptable — it's an evidence-based approach."

Two forthcoming guidelines from the US Food and Drug Administration will expand and accelerate medication-assisted treatment, Azar announced. "One will help the development of long-acting depo formulation, like the monthly shot approved this last fall. The other will open up new ways of assessing medication-assisted treatment effectiveness by looking at...alternative endpoints besides achieving complete abstinence."

In terms of solutions, Azar said HHS has solicited states to request waivers to support substance abuse treatment. Since the public health emergency declaration, the department has approved waivers for five states. During the summit, Azar publicly invited more states to participate.

HHS organized an opioid "code-a-thon" in December that brought data science experts from Yale, Stanford, and Johns Hopkins universities and top technology companies. Use of data to identify troublesome trends in opioid abuse and to target resources was among the goals. "The programmers spent the day coming up with new tools for prevention — like apps that use existing datasets to monitor risky opioid prescribing and to help providers assess their own prescribing levels to see if they are out of the norm."

Veterans Affairs Action

The US Department of Veterans Affairs (VA) took an unprecedented step about 2 months ago, said David Shulkin, MD, secretary of the VA. "We now publish, publically, all our opioid prescription rates for every VA medical center across the country," he said.

The highest rate in the country is in Roseburg, Oregon, at 20% of all prescriptions; the lowest is in Cleveland, at 3%. "We're the only health system in the country that does this," Shulkin said. He hopes that VA's approach will serve as a model for others.

"I have three points I want to share with you," Shulkin continued. "The first is that I do believe, I'm optimistic, that we can make a difference."

As the country's largest health system, he said, the VA recognized the devastating effects of the opioid epidemic early. "We started focusing on this in 2011. In 2012, we launched the Opioid Safety Initiative that has put in more than $300 million toward prevention and treatment," he said.

The initiative also aimed to promote appropriate prescribing. "Since 2012, we've reduced the number of opioids used in the VA by 41%," he said. Part of the success, he explained, comes from a 90% reduction in new opioid prescriptions and from considering alternative methods of pain management.

His second point concerned the importance of sharing best practices from around the country in addressing the opioid epidemic. "We have a lot to learn from each other," he said.

His third point concerned the principles that helped the VA realize a 41% drop in overall opioid prescribing. He presented the following STOP PAIN acronym:

Step care model to pain management — Opioids are not considered first-line therapy.

Treatment alternatives — "We've really focused on integrative medicine, nonmedicinal options, and the medication-assisted treatments."

Ongoing monitoring and usage — Data are used to show bumps in high opioid usage rates.

Practice guidelines — The Department of Defense, the VA, and the CDC have published joint guidelines.

Prescription monitoring — "I am still a practicing internist, and I can go to the state database to see if other doctors have prescribed opioid medications," Shulkin said.

Academic detailing — VA pharmacists train their doctors on how to appropriately prescribe opioids.

Informed consent — Patients have a shared responsibility in countering opioid abuse.

Naloxone distribution — The VA has distributed more than 100,000 naloxone kits to first responders and veterans. "We know that saves lives," he said.

Housing and Urban Development's Role

US Department of Housing and Urban Development (HUD) Secretary Ben Carson, MD, was also a member of the panel. "At HUD, the human cost of opioids is all too familiar. Drug addiction lands at the intersection of health, housing, and economic opportunity," he said.

In fiscal year 2017, 67,000 persons, or approximately 25% of those served in the HUD's Continuum of Care Program, reported having problems with substance abuse, Carson said. "That's a lot of folks.

"It's not just a crisis of health, it's a crisis of hope," he added.

During a question-and-answer session at the summit, an attendee who struggled with opioid addiction spoke of the difficulty in accessing treatment and recovery programs.

Carson said, "As a society we have to recognize that until it becomes as easy to get treatment as it is to get the drugs, we're not going to win the battle."

"No state has been spared, and no demographic group has been untouched," said Kelleyanne Conway, counselor to the president and summit moderator. "For the courageous family members who have suffered loss and for those individuals currently suffering...we hear you and see you."

Office of National Drug Control Policy

"This is one of the president's greatest priorities," said Jim Carroll, who started serving 1 week ago as acting director of the Office of National Drug Control Policy. "I've seen how this tears families apart," he said.

Carroll made a personal revelation at the summit. He explained that Kathryn Helgaas Burgum, the First Lady of North Dakota, noted that 1 in 7 residents of her state know a family member, friend, or neighbor who is affected by the opioid epidemic.

"For the first time publicly, I want to tell you that I am that '1 in 7,' " Carroll said. He explained that opioid addiction affected one of his family members. "So it's a great honor for me to take this on. This is a professional and personal challenge for me, for the president, and for every member of this administration."

Another Personal Story Shared

As part of a video presentation of personal stories of people affected by the opioid epidemic, US Surgeon General Jerome M. Adams, MD, MPH, shared a personal story as well.

"I'm a physician. I have a master's degree in public health, and I'm the US Surgeon General. My family is suffering from substance use disorder. My brother is in prison because of crimes he committed to support his addiction," he said.

This has affected his entire family "emotionally, medically, and financially," Adams said.

"As a trauma anesthesiologist, I have seen things that would make the average person cringe. But nothing has shaken me quite like seeing the barbed wire and the thick metal bars when I first visited my little brother in the state prison.

"I'm hopeful that by sharing my story, it will help people understand addiction touches every family, and they are not alone," Adams said. "For me and for all too many Americans, stopping the opioid epidemic is not only pressing, it's personal."

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