The opioid crisis needs a long-term national strategy

For the first time in years, there’s been a decline in the national number of drug overdose deaths, according to a new report from the Centers for Disease Control that looked at preliminary 2018 data.

That’s good news, but make no mistake: The opioid crisis is far from over. At the Bipartisan Policy Center (BPC), we recently tracked all 57 federal funding sources directed at the epidemic and found that they fall far short of the amount necessary to reverse the rate of overdose deaths, address the consequences of the epidemic, permanently reverse the rate of overdose deaths and build a comprehensive addiction treatment and recovery system.

Addiction is a multi-faceted, chronic condition and a national response must reflect the nature of the disease.

There are an estimated 2 million people with opioid use disorder, but the national addiction crisis is about more than just opioids. More than 20 million people in the United States have a substance use disorder. A recent study in “Science Magazine” demonstrated that the opioid crisis is only a part of a long-term increase in drug overdoses, beginning at least as far back as 1979. 

Although Congress has appropriated more than $3 billion in 2017 and more than $7 billion in 2018 in state opioid grants, these grants are subject to annual appropriations, making long-term planning by states difficult without a guarantee of long-term funding. Plus, it’s simply not enough money to tackle the epidemic.

Cost estimates for an effective opioid response vary. In the current trial pitting the state of Oklahoma against Johnson & Johnson, state experts estimate the cost of abating the epidemic in Oklahoma at $17.5 billion. Sen. Elizabeth Warren (D-Mass.) and Rep. Elijah Cummings (D-Md.) have introduced The CARE Act calling for $100 billion in funding over a 10-year period.

Our nation’s addiction prevention and treatment infrastructure has been underfunded for decades. Treatment services are funded through private insurance and public payers such as Medicaid. However, developing a comprehensive evidence-based system of care for people with substance use disorder will take ongoing funding over a sustained period.

The federal government’s funding source for the country’s prevention and much of the nation’s treatment system, the Substance Abuse and Mental Health Administration’s (SAMHSA) block grant, has suffered a 24 percent decrease in real funding due to a decade of level-funding. This shortfall should be remedied. However, building a system to address the social determinants of health, as well as the full continuum of care, will take billions more than are included in the president’s annual budget request or in congressional appropriations. 

A sustained funding source could be found by adopting an approach more often used in the environmental context — product stewardship. This means holding the manufacturer of a product responsible for as long as the product is on the market. Pharmaceutical manufacturers would pay a fee on their products to fund block grants to states. Bipartisan legislation has been introduced this year in both the Senate and House to do just that.

 We should also consider increasing the federal alcohol tax, which hasn’t gone up in almost 30 years. In fact, alcohol taxes in 2017 decreased by 16 percent over a two-year period in the Tax Cut and Jobs Act. Raising the tax on alcohol would generate enough money to fund an addiction treatment system and improve outcomes for people with all forms of addiction, including alcohol use disorder, which is linked to 88,000 deaths in the US each year. 

Private insurance, the Affordable Care Act (ACA), Medicare and Medicaid are each essential to ongoing treatment and recovery services. According to a Kaiser Family Foundation analysis, 38 percent of non-elderly adults with opioid use disorder in the United States are covered by Medicaid. However, considerable barriers to evidence-based treatments such as medications for opioid use disorder persist in Medicaid programs. These obstacles include: the need to obtain prior authorizations before prescribing medications for opioid use disorder; quantity or dosing limits; lifetime treatment limits; and step therapy (sometimes referred to as “fail first” policies). A 2018 Report to Congress published by MACPAC (Medicaid and CHIP Payment Access Commission), found that 40 percent of counties did not have an outpatient substance use disorder treatment program.

The ACA requires that treatment for substance use disorders be covered as an essential benefit, and private insurance companies must comply with The Mental Health Parity and Addiction Equity Act (The Parity Act). However, noncompliance with these requirements is well documented. A recent report from the Center on Addiction identified significant noncompliance with both The Parity Act and essential benefit requirements in state ACA plans. The Report found that 20 percent of states in 2017 offered ACA Plans that violated the Parity Act, and over half of the states offered ACA plans not in compliance with ACA essential benefit requirements.

Our findings indicate that sustainable sources of funding must be identified to address the opioid epidemic. However, this does not simply mean continued funding for one-time grants. Rather, the limitations on addiction treatment identified in mandatory programs such as Medicaid, the ACA, and private insurance coverage must be removed. 

In addition, a more thoughtful approach to funding and resource allocation is necessary to target resources to areas where the risk of addiction is greatest and services are limited.

The nation’s highway system was not created in an ad hoc manner but was developed as part of a national vision to connect the country. A similar comprehensive plan is needed today to address the opioid and addiction crisis. Our system of funding the addiction treatment system is scattershot and not targeted to areas of greatest need or coordinated across funding streams.   

Congress and the administration should prioritize the development of a national treatment system so resources are sustainable and spent more strategically, barriers to evidence-based care are removed, and health outcomes are improved.   

Regina LaBelle is Director of the Addiction and Public Policy Initiative at Georgetown University Law Center. She previously served as Chief of Staff and Senior Policy Advisor in the White House Office of National Drug Control Policy (ONDCP) during the Obama Administration, where she oversaw the Agency’s efforts to address the opioid epidemic and other drug policy issues, including overseeing implementation of the National Drug Control Strategy. William Hoagland is senior vice president of the Bipartisan Policy Center and former staff director at the Senate Budget Committee.