The President’s Commission: Headed in the Right Direction?

The President’s Commission on Combating Drug Addiction and the Opioid Crisis has released its initial draft recommendations. A bipartisan commission of policy makers and scientists, this commission has been tasked with the development of a national plan of action to stem the opioid epidemic. While their recommendations are sensible, very little in the report is innovative or new to advocates in the arena.

First and foremost, the Commission recommends that the president declare the opioid epidemic a national public health emergency, under either the Public Health Service Act or the Stafford Act. This would allow the federal government to draw upon the national Public Health Emergency Fund to address the problem. Unfortunately, the fund’s balance in mid-2016 was only $57,000 (Kodjak, 2016). The House of Representatives has requested $1.7 billion for a different, new fund for FY 2018, but even if the entire amount were spent on the opioid epidemic, it would not even be enough money for a single state to fully meet demand (HHS, 2017). 

Some in the advocacy community support the president taking such action, but there are drawbacks as well. Addiction is a chronic disease, and a problem that will not go away in the short term. No one can deny that even if several billion dollars are poured into treatment, the problem will not be eradicated any time soon. Long-term solutions could be far more beneficial than an emergency declaration, which exists to handle short-term public health emergencies that can be dealt with through fast actions and reactions.

Perhaps the most impressive recommendation is in regards to the IMD exclusion. In an effort to expand treatment capacity, the commission recommends that CMS grant waiver approvals for all fifty states to quickly eliminate barriers to treatment resulting from the federal Institutes for Mental Diseases (IMD) exclusion within the Medicaid program. This would, according to the commission, “immediately open treatment to thousands of Americans in existing facilities in all fifty states” (Baker et al., 2017). While this is a worthwhile pursuit, the waiver application process is long and arduous, and the results may come in time, but certainly not “immediately.” The Commission stated that legislation would be necessary to repeal the exclusion in its entirety, which might be true, but legislation would not be needed to exempt substance use disorder (SUD) inpatient treatment facilities from the rule. That could be done independently by CMS.

There is also a recommendation that could be considered controversial, pertaining to 42 CFR 2 and HIPAA regulations. The Commission believes it is possible to better align, through regulation, patient privacy laws specific to addiction with the Health Insurance Portability and Accountability Act (HIPAA) to ensure that information about SUDs be made available to medical professionals treating and prescribing medication to a patient. The commission has branded 42 CFR 2 “a particular hindrance to comprehensive health care,” citing the difficulty providers have in sharing information, which leads to ill effects on patients in both physical and behavioral health settings, by restraining physicians’ ability to make informed health care decisions (Baker et al., 2017).

The commission makes several other recommendations, almost all regulatory in nature. These include a wider availability of naloxone, proposed advances in prescription drug monitoring programs (PDMPs), and tighter border security (Baker et al., 2017). There are very few recommendations for improving clinical practices or the clinical workforce. However, ONDCP leadership has stated that this is only an interim report, and the final report will be more detailed on several fronts. Finally, we are obligated to cite that in November 2016, former Surgeon General Vivek H. Murthy completed his report on addiction and SUDs, and reached many of the same conclusions that this commission did (Murthy, 2016). The current administration has ignored this report, spending several months gathering data and input that had been previously compiled and disseminated in an official manner. We cannot overlook that we have lost precious time that could have been spent taking action, rather than reinventing a very complex wheel.