States Show the Way on the Opioid Epidemic

https://www.nytimes.com/2018/08/24/opinion/opioid-epidemic-states.html

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The opioid epidemic is far from contained — the national death toll from drug overdoses climbed to a record high last year. But some states and cities are bucking the trend and showing how governments can get a grip on the worst drug crisis in American history.

In 2017, overdose deaths in the United States jumped 10 percent, to about 72,000, the Centers for Disease Control and Prevention said last week. The new data show that people are dying from opioids that are more potent and more dangerous than were available in years past. The C.D.C. also found that many people who overdose are simultaneously using multiple drugs like heroin, fentanyl, cocaine, methamphetamines and benzodiazepine, an anti-anxiety medicine, and that the crisis has spread across the country, from rural and suburban areas to cities.

Given all this grim news, the areas where overdose deaths are decreasing — Hawaii, Massachusetts, North Dakota, Oklahoma, Rhode Island, Utah, Vermont and Wyoming, per the C.D.C. — stand out. Some of these states have taken a more thoughtful approach to helping people who suffer from what experts call opioid use disorder and have worked to prevent more people from becoming addicted to prescription pain pills. Along with some cities, like San Francisco, these states have been at the forefront of increasing access to the anti-overdose medicine naloxone and to anti-addiction medicines like buprenorphine and methadone, which experts say can help people who are dependent on opioids live relatively normal lives.

The successes on these fronts can be attributed in part to efforts to boost rates of insured individuals — people who are dependent on drugs often struggle financially and cannot afford treatment without health coverage. Massachusetts and Vermont, where overdose deaths are falling, have expanded Medicaid under the Affordable Care Act and have helped people sign up for private insurance. In 2016, just 2.5 percent of people in Massachusetts were uninsured and only 3.7 percent lacked health insurance in Vermont, compared with 8.6 percent for the country as a whole.

It’s no surprise, then, that most people with opioid use disorder in those states — more than 60 percent of them — received medication-assisted treatment, according to a Blue Cross Blue Shield Association report. By comparison, less than 30 percent of people with the disorder received treatment in Florida, Georgia and Texas, which have not expanded Medicaid and where the uninsured rate was more than 12 percent.

This disparity highlights how important it is for state governments to take advantage of the health care act, and how wrong it is that the Trump administration and Republican lawmakers have been doing everything they can to weaken that law and reduce the number of people who benefit from it. One of Mr. Trump’s biggest supporters, Gov. Paul LePage of Maine, for example, has refused to expand Medicaid even though a sizable majority of his state voted to do so last year.

Access to health insurance is only part of the answer when it comes to tackling the opioid crisis. Most areas also desperately need more doctors who are licensed to prescribe buprenorphine, also known by the brand name Suboxone. In the United States, doctors are required to go through eight hours of training before they can prescribe the medicine, and then are only allowed to treat up to 275 patients per year with it.

The federal government could potentially save many lives if it significantly eased those requirements. But the Trump administration and Congress have been slow to act. Many lawmakers and health officials seem to believe that the use of buprenorphine and other anti-addiction drugs merely replaces one addiction with another, since patients may have to take the medicines indefinitely. This idea persists even though scholars have documented that greater availability of buprenorphine helped France reduce overdose deaths by nearly 80 percent.

“We want to believe that if you work hard enough you can overcome this,” said Dr. John Brooklyn, a psychiatry professor at the University of Vermont who has pushed to expand access to addiction treatment through a statewide network of clinics. “But this is not a disease that you overcome with willpower.”

State officials and addiction specialists in Vermont made a big push in recent years to encourage primary care doctors to get training so they can prescribe buprenorphine. They also used state funds and federal grants under the health care law to hire nurses and social workers to follow up regularly with patients, make sure they are taking their medicine, and make sure they have the support they need to get back on their feet. A recent Vermont Department of Health report found a sharp drop in drug use and overdoses among people in opioid addiction treatment.

Massachusetts has found success in pairing access to treatment with the use of recovery coaches — people who have been through addiction treatment themselves — to guide and support patients. In recent years, the state upgraded the prescription monitoring system that doctors are required to use before prescribing opioids and restricted new opioid prescriptions to just seven days. Opioid prescriptions have dropped 30 percent in the state since 2016.

Other states and cities are trying similar strategies to get people into treatment. Rhode Island has expanded access to treatment in state prisons, for example. In the public Highland Hospital in Oakland, Calif., emergency room doctors have begun giving buprenorphine to people suffering from withdrawal symptoms. And city health workers in San Francisco are offering the treatment to addicts who are homeless.

These successful local and state efforts show what it would look like if the United States as a whole got serious about tackling the opioid epidemic. Namely, effective addiction treatment would be made available to anyone who needed it, regardless of their health insurance status or ability to pay. Congress would need to set aside billions of dollars a year to fund such an effort, but the approach wouldn’t be unprecedented — the nation used similar tactics to fight the AIDS epidemic in the 1980s and 1990s.

Some lawmakers and administration officials have introduced bills and ideas to address the crisis, but they’ve tended to be small-bore proposals. What the nation needs is bold action from Congress and from President Trump — who campaigned heavily on addressing the opioid crisis. But Congress and the president have failed to muster the ambition necessary for this moment.

State and local governments are showing the way. Too many lives are at stake for federal officials and lawmakers not to follow their lead.

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