Policy Brief: Opioid Use as a Public Health Emergency

This is intended to be a short primer on the very complex topic of opioid use and overuse. The purpose is to update readers on the impact of the recent order to make this issue a Public Health Emergency. This paper will also provide some minimal context and potential resources for strategies. Since many readers will be familiar with the background, it is at the end of the document.

Current status

On October 26, 2017, President Trump declared that the opioid epidemic will now be an official Public Health Emergency. There were no funds attached to this announcement.

The Administration has made several rounds of grant awards this year, so far totalling almost $1 billion. These funds largely came from the Comprehensive Addiction and Recovery Act (CARA) and the 21st Century Cures Act, passed by Congress and signed by President Obama in 2016. Notably, at the end of 2016, the Obama Administration announced nearly $1 billion in available grants, that the current Administration has been awarding, under the 21st Century Cures Act funding. Many experts have concluded that at least an additional $40 billion is needed to effectively combat this urgent issue.

The White House announcement is expected to accomplish the following, according to senior Administration officials:

1. Allow states to shift federal HIV funds to address the opioid and heroin crisis, due to the likelihood of spreading HIV through sharing needles for drug use;
2. Open Public Health Emergency Fund (which only has $57,000);
3. Federal HHS can increase staff for this;
4. Expand the use of telemedicine for prescribing treatments under Medication Assisted Treatment (MAT) protocols;
5. Make the National Dislocated Worker Grants more widely available (currently apply to federal disaster areas); and
6. Work with Congress to find more funds.

The President’s announcement also revealed that the Administration plans to relax the prohibition on using Medicaid funds for certain Institutions for Mental Disease (IMDs). Known as the “IMD exclusion” in Medicaid, it is a statutory provision that prohibits federal money to be used in most IMDs.^[1] In 2015, the Obama Administration offered to grant section 1115 demonstration waivers in order to relax this exclusion. Subsequently, in 2016, the Obama Administration used the final regulations addressing Medicaid managed care and tried to relax the IMD exclusion as much as legally possible by allowing states to pay for IMDs for partial months through managed care entities. Since August 2017, HHS has been telling states that they would “make it easier” to get substance abuse disorder section 1115 waivers. It is unclear what additional measures the Trump Administration plans to take, as the statutory prohibition is law that needs to be changed by Congress.

The day prior to the Trump Administration Public Health Emergency announcement, on October 25, 2017, Senate Democrats (along with Angus King, Independent-Maine)^[2] introduced a bill that would spend $45 billion over ten years. The bill is titled the Combating the Opioid Epidemic Act and, as of this publication, has 18 co-sponsors.

The Public Health Emergency lasts 90 days, but can be repeatedly renewed. The last time one was declared was the 2009 H1N1 (so-called “swine flu”) epidemic.

Strategies and Best Practices

Under the Trump Administration, the U.S. Department of Health and Human Services has a five-point strategy for combatting the opioid epidemic:

1. Improving access to prevention, treatment, and recovery services, including the full range of medication-assisted treatments.
2. Targeting availability and distribution of overdose-reversing drugs.
3. Strengthening our understanding of the crisis through better public health data and reporting.
4. Providing support for cutting edge research on pain and addiction.
5. Advancing better practices for pain management.

In 2016, the National Governors Association Center for Best Practices released a set of recommended approaches for states to use. The tools and strategies in this document will help states develop a roadmap and strategically align stakeholders.

Also in 2016, the Center for Medicare and Medicaid Services (CMS) released a list of state Medicaid best practices. In July 2017, several states testified in a Congressional hearing about their challenges and best practices.

Background

People have been using various forms of opiates throughout human history. In the 1990s, drug manufacturers developed a number of opiate pain management prescriptions and heavily marketed them to doctors. The drug manufacturers promoted these prescriptions as being largely free from side effects. A multi-pronged movement for doctors engage more seriously in pain management, along with increased awareness of these pharmaceutical options, led doctors to feel pressured to prescribe pain management if a patient wanted it. Now the United States has — by far — the highest rate of opioid prescriptions in the world.

Over time, many opioid addicted individuals have moved to heroin or fentanyl, a synthetic heroin. For some, this is because they were unable to continue getting a prescription opioid, and for others, it was a way to get a more intense high. Sometimes heroin and fentanyl are cheaper than prescription opioids. Most opioid drug overdose deaths have been attributed to prescriptions, but many have also come from heroin and fentanyl.^[3]

According to HHS figures, in 2015 over 52,000 Americans died from opioid overdoses and that figure is expected to rise to 64,000 in 2016, once the data is finalized. Experts predict that over the next ten years, we will see 500,000 deaths related to opioid overdoses.

In the meantime, Medicaid plays an important role in the problem, but opioid use and addiction are a problem across all demographics. Roughly 30 percent of adults with an opioid addiction are covered by Medicaid and 40 percent are covered by private insurance. This is a slight distortion of the general population, where approximately a quarter of Americans are Medicaid or CHIP enrollees and a little over half are on employer-sponsored insurance. Notably, approximately 20 percent of people with opioid addictions are estimated to be uninsured.

Some have alleged that the Medicaid expansion offered through the Affordable Care Act exacerbated the epidemic. The allegation is that the rate of death and abuse correlated with the Medicaid expansion implementation, particularly in states like Ohio and West Virginia, since people could legally obtain new opioid prescriptions through Medicaid coverage. However, there is little evidence to support that claim and researchers have, in fact, shown that it is extremely unlikely.

Opioid deaths are highest among white males, however there is speculation that this trend could change. With such a small sample set (in spite of the magnitude of the problem), it is challenging to draw conclusions around trends. There are, however, excellent data from government agencies, showing the disparities of the past and existing population affected by this issue.

Resources

American Society for Addiction Medicine. “Opioid Addiction: 2016 Facts and Figures”. October 26, 2017.
https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf

Centers for Medicare and Medicaid Services. State Medicaid Director Letter #10-003. July 27, 2015.
https://www.medicaid.gov/federal-policy-guidance/downloads/SMD15003.pdf

Centers for Medicare and Medicaid Services. Frequently Asked Questions. August 17, 2017.
https://www.medicaid.gov/federal-policy-guidance/downloads/faq08172017.pdf

Centers for Medicare and Medicaid Services. Medicaid Managed Care Final Rule. April 25, 2016.
https://www.medicaid.gov/medicaid/managed-care/guidance/final-rule/index.html

Centers for Medicare and Medicaid Services. Informational Bulletin: “Best Practices for Addressing Prescription Opioid Overdoses, Misuse and Addiction”. February 2, 2016.
https://www.medicaid.gov/federal-policy-guidance/downloads/cib-02-02-16.pdf

Congress.gov. “S.2004 – A bill to increase funding for the State response to the opioid misuse crisis and to provide funding for research on addiction and pain related to the substance misuse crisis.” October 27, 2016.
https://www.congress.gov/bill/115th-congress/senate-bill/2004

Goodman-Baker, Andrew and Emma Sandoe. Health Affairs Blog. “Did Medicaid Expansion Cause The Opioid Epidemic? There’s Little Evidence That It Did.” August 23, 2017.
http://www.healthaffairs.org/do/10.1377/hblog20170823.061640/full/

Johnson, Jenna and John Wagner. Washington Post. “Trump Plans to Declare the Opioid Crisis a Public Health Emergency”. October 26, 2017.
https://www.washingtonpost.com/news/post-politics/wp/2017/10/26/trump-plans-to-declare-the-opioid-crisis-a-public-health-emergency/?utm_term=.7a0ba123bacf

Lopez, German and Sarah Frostenson. Vox. March 29, 2017.
https://www.vox.com/science-and-health/2017/3/23/14987892/opioid-heroin-epidemic-charts

National Association of Medicaid Directors. Newsletter. August 15, 2017.
http://medicaiddirectors.org/in-the-namd-newletter-we-cover-opioids-21st-century-cures-act-and-happenings-on-the-hill/

Social Security Act. Section 1905. October 26, 2017.
https://www.ssa.gov/OP_Home/ssact/title19/1905.htm

Substance Abuse and Mental Health Administration. Press Release. December 14, 2016.
https://www.samhsa.gov/newsroom/press-announcements/201612141015

U.S. Department of Health and Human Services, “The Opioid Epidemic, By the Numbers”. June 15, 2016.
https://www.hhs.gov/sites/default/files/Factsheet-opioids-061516.pdf

U.S. Department of Health and Human Services, Press Release, May 31, 2017.
https://www.hhs.gov/about/news/2017/05/31/hhs-announces-over-70-million-in-grants-to-address-the-opioid-crisis.html

U.S. Department of Health and Human Services. Press Release. September 15, 2017.
https://www.hhs.gov/about/news/2017/09/15/hhs-commits-144-million-in-additional-funding-for-opioid-crisis.html

U.S. Department of Health and Human Services, “Opioids: The Prescription Drug and Heroin Overdose Epidemic.” October 26, 2017.
https://www.hhs.gov/opioids/index.html

^[1] The IMD exclusion is based on the statutory language in section 1905(a)(B) of the Social Security Act, which states that federal financial participation, or medical assistance, will not be allowed for: “any such payments with respect to care or services for any individual who has not attained 65 years of age and who is a patient in an institution for mental diseases.” The Act names some specific exceptions to this, but then goes on to say: “No service (including counseling) shall be excluded from the definition of ‘medical assistance’ solely because it is provided as a treatment service for alcoholism or drug dependency.”

^[2] Please refer to this link for updated co-sponsors.

^[3] According to the American Society of Addiction Medicine (ASAM): “Drug overdose is the leading cause of accidental death in the US, with 52,404 lethal drug overdoses in 2015. Opioid addiction is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin in 2015.”