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What a public health emergency on opioids means

At this point in the nation’s opioid epidemic, fighting back is mainly about quickly making money available: Money for treatment. Money for the overdose antidote naloxone. Money to hire more people to help overwhelmed cities and states battle a crisis that killed an estimated 64,000 Americans last year.

President Donald Trump’s declaration of a public health emergency Thursday did not come with any big new sources of funding. But his official pronouncement helps the government speed any available resources to communities, where the epidemic is playing out on the streets every day, and will eliminate some obstacles that stand in the way of providing assistance.

According to the White House, 175 people will die of a drug overdose today and every day until the crisis is curbed. So the government may start with the most basic need: Keeping alive more than 11.5 million people taking prescription opioids for nonmedical uses plus 1 million people using heroin.

“Unless you keep people alive, you can’t get them into treatment,” said Elizabeth Van Nostrand, an assistant professor of health policy and management at the Graduate School of Public Health at the University of Pittsburgh.

That means more naloxone in communities – a lot more – and more money to train people how to use it. Gary Mendell, who founded the activist group Shatterproof after his son’s death, said the nation will need naloxone “everywhere there is a fire extinguisher.”

Naloxone, which is administered in several ways, can be expensive; Baltimore Health Commissioner Leana Wen said that city is paying $70 to $90 for a two-dose pack. It often takes several injections or nasal sprays to revive a single victim, especially if the individual has overdosed on the powerful street drug fentanyl. Police and paramedics sometimes need to carry naloxone for themselves, in case they come in contact with fentanyl. A few are carrying it for their drug-sniffing dogs.

The emergency allows the federal government to speed more people and resources to the streets where naloxone is needed. Acting Health and Human Services Secretary Eric Hargan could negotiate lower prices for government agencies. And he could put out model instructions for states and cities to issue “standing orders” that make the antidote more readily available in pharmacies around the country, as jurisdictions such as Baltimore already have done.

Barriers to treatment

The greater need is for treatment. Only one in 10 of the 21 million people with a substance abuse disorder receives any kind of specialized treatment, according to the commission established by Trump to recommend responses. Barriers include a federal policy that prohibits Medicaid from paying inpatient facilities with more than 16 beds. The emergency declaration would allow HHS to grant waivers to any state requesting one.

“This is the single fastest way to increase treatment availability across the nation,” the commission wrote in July.

Opioids aren’t the only problem, though. The country is also battling abuse of benzodiazepines, cocaine and other drugs. But opioids – from prescription painkillers to heroin and fentanyl – cause more than half the overdose deaths each year.

Research shows that medication-assisted treatment (MAT) with drugs such as methadone and buprenorphine is the most effective approach. It reduces overdoses, keeps people in treatment and cuts the number of relapses (a particularly difficult problem in opioid abuse), the president’s commission said. But only 10 percent of drug treatment facilities are offering it.

Part of the problem is the outdated belief that such treatment merely substitutes one addictive substance for another. But Medicare doesn’t cover MAT. And in some places, such as Veterans Affairs and Indian Health Service facilities, there is a shortage of trained providers. Under the emergency, the HHS could more quickly make temporary hires of people and send them where they’re needed, including hard-hit parts of the country such as Appalachia, the Midwest and New England. The president’s declaration also will allow people in remote areas to receive treatment by telemedicine.

On Wednesday, FDA Commissioner Scott Gottlieb called for wider use of medication-assisted treatment and said his agency would issue new guidance to manufacturers to promote the development of novel therapies, including ones that treat a wider range of symptoms.

The government also may be able to take a role in encouraging doctors and others to get better training in prescribing opioids; fewer than 20 percent of the more than 1 million professionals licensed to provide controlled substances have training in how to prescribe opioids safely, the commission noted.

The administration will call on the Department of Labor to provide grant money, if available, to states that create job-training programs for people in recovery. It can often be difficult for recovering addicts to find work because of criminal records or gaps in their employment history.