WASHINGTON — The House and Senate have reached agreement on a big package of measures to address the opioid epidemic. The legislation, backed by leaders of both parties, is a rare bipartisan achievement that lawmakers are eager to have in hand when they go home to campaign for the midterm elections.
The 653-page bill contains a mix of law enforcement and public health measures, including one that aims to block deadly fentanyl from being imported through the mail and one that will allow more nurses to prescribe medication for opioid addiction. Another provision could make it easier for Medicaid recipients to get inpatient care for substance abuse over the next five years.
“While there is more work to be done, this bipartisan legislation takes an important step forward and will save lives,” a group of Republican and Democratic committee leaders said in a statement.
But addiction experts say that while many of the measures will help incrementally, the investment remains meager and scattershot compared with what is needed, and with what the government spent to stem the tide of AIDS-related deaths in the 1990s.
With 72,000 overdose deaths in 2017, including nearly 50,000 involving opioids, members of Congress are eager to wield the bill as a substantive policy achievement amid the drama surrounding the fates of Judge Brett Kavanaugh, President Trump’s Supreme Court nominee, and Rod Rosenstein, his deputy attorney general.
Both chambers still need to vote on the compromise bill. The House could vote as soon as Wednesday night, before its members adjourn to hit the campaign trail, and the Senate could take it up next week.
The Congressional Budget Office has yet to score the new bill and estimate its cost, but an earlier Senate version would have cost an estimated $8 billion over five years.
Improved access to treatment
One of the most expensive provisions — which had been a sticking point between the two chambers — will repeal an obscure rule that blocks states from spending federal Medicaid dollars on residential addiction treatment at centers with more than 16 beds.
The rule was originally intended to discourage warehousing of people with mental illnesses in psychiatric hospitals, which was far more common when it was written in 1965. More recently, the rule has limited the number of beds available for low-income patients suffering from addiction, although there were several ways for states to circumvent it.
Some addiction specialists worry that the bill’s expansion of inpatient care will eclipse the importance of longer-term outpatient programs that focus on medication-assisted treatment, which researchers consider the gold standard for treating opioid addiction. Many residential programs for opioid addiction still don’t offer such treatment as part of their protocol, and the bill does nothing to address that.
“The evidence for residential stays is very thin in terms of science,” said Dr. Ken Duckworth, medical director for behavioral health at Blue Cross Blue Shield of Massachusetts. “I’m not against the residential model, but the linchpin is that with it, you have to have exposure to medication-assisted treatment.”
The opioids bill that the House passed in June limited the expansion of inpatient treatment only to patients with cocaine and opioid addiction; the Senate version left the old rule in place. The compromise bill lifts the rule for all substance use disorders for residential treatment lasting up to 30 days.
The bill also permanently allows nurse practitioners and physician assistants to prescribe buprenorphine, an anti-addiction medication that requires a special license and extra training. Only about five percent of the nation’s doctors are licensed to prescribe it, and shortages are especially acute in rural regions. The bill further aims to increase access to the medication by allowing nurse anesthetists, nurse midwives and clinical nurse specialists to prescribe buprenorphine for the next five years.
Blocking mail orders of illegal drugs
The bill includes a provision to help stop the flow of illicit opioids into the country by mail, especially synthetic fentanyl and its analogs, which are fueling the rise in overdose deaths. The provision was pushed by Senator Rob Portman, Republican of Ohio, whose state has been especially hammered by the opioid epidemic.
It will require the United States Postal Service to start collecting information on international mail shipments, just as private carriers like Fed Ex and DHL already have to do. By the end of this year, the Postal Service will need to provide the name and address of the sender and the contents of the package, as described by the sender, for at least 70 percent of including all of those from China. It will have to provide the information on all such shipments by the end of 2020.
The Postal Service could block or destroy shipments for which the information is not provided.
Alternatives to opioids
The bill would provide funds for researching and developing new nonaddictive painkillers. It would also allow the Food and Drug Administration to require that certain opioids be dispensed in packaging that limits their abuse potential — for example, in blister packs that provide only a few days’ supply.
What’s not in the bill
Missing from the final bill is a contentious provision that had nothing to do with opioids but that the pharmaceutical industry had pushed hard for. It would have softened a requirement that drug manufacturers start providing larger discounts next year to Medicare beneficiaries whose spending on prescription drugs falls in a coverage gap called the “doughnut hole.” The measure, which would have cost the federal government $4 billion, met with fierce opposition from consumer advocates and some members of Congress.
Also missing, according to many addiction treatment providers and researchers, is the vastly larger investment needed to truly stem the tide of overdose deaths and provide effective treatment on demand. As a model, they point to the Ryan White Care Act, a bipartisan bill that Congress passed in 1990, which has allowed for billions of dollars in treatment and other support for people with H.I.V. and AIDS, including antiretroviral drugs for anyone without insurance.
Senator Elizabeth Warren of Massachusetts and Representative Elijah Cummings of Maryland, both Democrats, have proposed legislation modeled on the Ryan White Act that would provide $100 billion over 10 years for addiction treatment and other supports. But the proposal has gone nowhere.
“Compared to how we responded to AIDS, it’s a failure,” said Keith Humphreys, a Stanford professor who advised both the Senate and House on their earlier bills, of the new version. “The Republicans didn’t want to spend, so they agreed on every second-tier issue they could.”
Still, he added, “If you look at it in terms of the incredible dysfunction of Congress on everything, it’s actually one of the few things they’ve been able to do together as parties.”
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