July 14th, 2016
The US Senate yesterday voted 92-2 to pass the long-awaited opioids bill—S. 534, or the Comprehensive Addiction and Recovery Act (CARA)—which will now be signed by President Obama and become law. The US House approved CARA 407-5 last week.
Haggling over the bill saw Republicans deny large amounts of the $1.1 billion in funding requested by the Obama Administration, and the administration’s statement in reaction to the vote was accordingly lukewarm.
“The Administration has consistently said that turning the tide of the prescription opioid and heroin epidemic requires real resources to help those Americans seeking treatment get the care that they need,” said White House Press Secretary Josh Earnest. “We continue to believe this bill falls far short … Every day that Republicans stand in the way of action to fund opioid treatment means more missed opportunities to save lives: 78 Americans die every day from opioid overdose. While the President will sign this bill once it reaches his desk because some action is better than none, he won’t stop fighting to secure the resources this public health crisis demands.”
Indeed, there are plenty of things not to like about the bill—not all of them aspects the Obama Administration would recognize—but a number of significant positive steps, too.
To start with the unequivocally good, more people should now be able to receive medication-assisted treatment (MAT) with drugs like methadone and burprenorphine (Suboxone). MAT is the evidence-based standard for opioid use disorders, and quite simply keeps more people alive than abstinence-only treatment.
Doctors’ cap on how many patients they can prescribe buprenorphine, previously set at 100, is being raised to 275 (for physicians who have prescribed buprenorphine to 100 patients for at least one year). Allowing nurses and physician assistants to treat patients with buprenorphine and methadone, not just doctors (who cost more, giving treatment providers a disincentive to use them) is another plus.
Authorizing grants for prisons, where so many people inject opioids without protection, to use methadone and buprenorphine to keep their charges safer is also extremely welcome. CARA should also, very importantly, keep more people who use opioids out of jail in the first place. Programs like Law Enforcement-Assisted Diversion (LEAD) can save people from the criminal justice system—although neither the coercive, law enforcement-led means of providing “alternatives” nor, in many cases, the alternatives themselves are anywhere near ideal. These two steps are some of the few in the bill to receive concrete funding, with $100 million set aside over the next five years.
Vitally, naloxone, the lifesaving opioid overdose reversal drug, will be made more widely available. This one should be a no-brainer. Now, people who work in schools and community centers will have more access, and pharmacists will be encouraged to provide repeat prescriptions for people who are particularly likely to need the drug.
Drug policy reform advocates are largely welcoming the new legislation. “CARA promotes many evidence-based interventions that have the potential to more effectively address opioid and heroin dependence and save lives,” said Grant Smith, deputy director of national affairs for the Drug Policy Alliance. “Lawmakers in Congress now must deliver on promises to fully fund CARA if we are to realize its potential.”
Lack of ring-fenced funding is one failing. Another is that CARA operates under some disease-model assumptions around opioids, in many places working with the idea that we’re simply aiming for people in all kinds of different situations to not use them.
The bill, for example, encourages states’ adoption and expansion of prescription drug monitoring programs—a questionable priority when only a small fraction of problematic or risky opioid use results from prescriptions, as Influence columnist Stanton Peele recently elaborated in covering Prince’s death. Such policies arguably create a climate in which people who need pain relief find it harder to get. There are better ways to spend time, effort and money.
The bill will also see more people diverted into abstinence-only treatment, while doing nothing to clean up the US treatment industry’s widespread corrupt and ineffective practices, such as those detailed here by Influence columnist Maia Szalavitz. It will see more people subject to coerced treatment—the “alternatives to incarceration” that people are referred to from the criminal justice system. Treatment that is coerced is less effective, as well as unethical.
Nonsensical limits on lifesaving drugs like burprenorphine and naloxone remain. And of course, prohibition itself, which drives people to use non-quality-controlled drugs secretly and unsafely, and sees many opioid users’ fates determined by law enforcement or non-medically-qualified drug court judges, remains. Some enlightened ideas like those proposed on The Influence by harm reductionist Meghan Ralston—such as candid education about how to use drugs more safely—are underemphasized or ignored.
CARA represents an incremental net positive, not a destination.