How Should We Spend Any Opiate Settlement Funds?
The “tobacco settlement” was reached in 1998 after five years of litigation. Tobacco manufacturers agreed to change some business and marketing practices, and to pay over $200 billion spread over 25 years (with continued payments thereafter) to reimburse 46 states for their expenses in treating tobacco-related illnesses.
There are now hundreds of opiate cases pending. The case against manufacturers is based on how opiates were marketed. Opiates can be more harmful than the marketing suggested. The case against drug distributors is based on the implausibly high numbers of pills that were made available to “patients” in specific localities, suggesting that massive amounts of medication were diverted from prescribed to other uses. Based on the tobacco settlement we could expect that the outcomes from opiate cases would involve both changes in business and marketing practices, and money. Some smaller opiate cases have already been resolved, for payments on the order of millions or hundreds of millions of dollars. However, with so much litigation still undecided, and opiate profits in the tens of billions, opiate manufacturers and distributors will presumably in time be making, for their roles in the opiate overdose crisis, large payments (billions) to state governments and possibly others.
In May, 2018, a federal judge in Cleveland began the attempt to organize a settlement ahead of a March, 2019 trial date. How many of the pending cases would join this settlement (if it occurs) is unclear. Nevertheless, we are within sight of an “opiate settlement.”
How is the addiction and recovery field responding?
Among other efforts, four leading addiction and recovery organizations (Center on Addiction, Legal Action Center, Public Health Management Corporation, and Partnership for Drug-Free Kids) have created The Addictions Solutions Campaign consortium. This consortium, in addition to focusing on improving enforcement of the Mental Health Parity and Addiction Equity Act, has made the foresighted effort to suggest spending priorities for any opiate settlement funds.
This document begins by suggesting that “we already know what to do to stem the opioid epidemic” (pg. 2, emphasis in the original) because what is needed and summarized in the document is “taken from scientific reviews and consensus documents developed by panels of experts” (pg. 2). In addition to being based on science, the document’s recommendations were also selected to be capable of being deployed quickly, likely to be acceptable to the public, and financially sustainable after opiate settlement funds are expended.
The recommendations fall into three broad categories:
1) Enhance public and professional education; Create informed demand for effective policies and interventions.
2) Implement evidence-based prevention and early intervention strategies to reduce substance misuse and related harms.
3) Expand access to evidence-based addiction treatment services, integrated with mainstream healthcare (pg. 5).
My background most closely aligns with the third priority, so I will focus on it. This section begins with a history of US substance treatment, and how it was established in the 1960s and 70s as separate from mainstream healthcare. The separation created problems:
The prevailing views of addiction had little provision for physicians, medications, information systems, professional therapies, or most of the prominent features of modern healthcare. The decision to focus treatment only on the severely addicted left few provisions for detecting or intervening clinically with the far more prevalent cases of early-onset, mild, or moderate substance use disorders. By the 1980’s we began an ineffective ‘war on drugs’ that disproportionately harmed people of color and perpetuated ill-informed racial biases about drug use. Because addiction was not accepted as an illness, medications were considered inappropriate or unnecessary by many providers and insurers — thus not profitable to develop by most pharmaceutical companies (pg. 10).
One thing is certain — adding more funding to perpetuate existing, conceptually antiquated and culturally segregated prevention and treatment policies and practices simply will not work (pg. 10).
Rather than funding a broken system, we should modernize addiction treatment by integrating it into mainstream healthcare [emphasis in original, pg. 11).
Even with sufficient training primary care practices will not be able to manage the most severely and chronically affected among the addiction patient population. Thus, true specialty addiction care will certainly continue to play a critical role. To enhance and expand this type of care, Opioid settlement funds could be used to promote and incentivize expansion of evidence-based specialty treatment and clinically functional organizational linkages between healthcare systems and better addiction treatment programs [emphasis in original; pg. 11).
The proposed action steps, for localities and states, emphasize the provision of medical care:
- Increasing treatment capacity [by adding more medical providers]
- Increasing the availability of medication-assisted treatment (MAT) for opioid addiction
- Using Payment Models to Promote Quality Treatment
- Using licensing requirements to drive quality
- Ensuring your state medical association adopts best practices for the design and implementation of Prescription Drug Monitoring Programs
- Educating and training physicians, nurses and other prescribers in safe prescribing of opioids for chronic pain
- Providing educational incentives for physicians, nurses and other prescribers to take the 8-hour SAMHSA course in Medication Assisted Addiction Treatment
- Authorizing state Medicaid and Block Grant funds to enhance reimbursement for certified evidence-based addiction treatment
- Supporting conversion to electronic health records for addiction treatment providers
- Reviewing state Medicaid and Block Grant guidelines to assure there are no undue restrictions of availability of and reimbursement for FDA-approved medications to treat addictions
- Invest in ongoing peer and family recovery service development and implementation (pp. 12-13)
This document accomplishes its stated intent. Its recommendations for responding to the opiate crisis are based in science, and seemingly not too far removed from current practice and political will, such that the recommendations might actually be implemented. Further, establishing only three broad themes is sensible. By comparison, Congress is now considering dozens of opiate bills, but apparently with little sense of an overall foundation or strategy. Perhaps the drafters of legislation will review this document as they consider revisions to their bills.
Unfortunately, although seemingly not radical, the document’s recommendations run substantially counter to much of US opiate treatment practice (as this document notes). Will the industry actually change, or will it need to be replaced? Most people do not let go of their jobs willingly. It is easy to imagine large struggles ahead.
If this document is widely recognized as a useful description of the new opiate treatment system we need to have, I believe it would need to be supplemented in two ways. In only 13 pages it is impossible to specify the transitional steps needed to go from where we are to the system this document envisions. Much further work is needed on transitional steps. This document is a great beginning.
Secondly, given that the focus here is on how to spend funds from an opiate settlement, we can expect a focus on MAT. However, these recommendations would do much less for other substance problems, and are not suitable as a template for changing the entire US substance treatment system. In particular, at least three treatment system issues are not adequately addressed: loss of privacy, psychosocial care, and treatment of sub-clinical, mild and moderate substance problems.
The loss of privacy in using an electronic health record for all substance problems seems unlikely to be acceptable to many clients, particularly those not on an addiction medication. We are likely to have stigma about behavioral health for a long time. One solution to the stigma challenge is to focus on bringing healthcare principles into the addiction treatment system, as much as bringing addiction clients into healthcare. Again, will the industry actually change, or will it need to be largely replaced?
Throughout the document, there is little mention of psychosocial care. If MAT is provided, additional psychosocial care may not be needed. Of course, hopefully, the MAT is provided with concern for the basics of good psychosocial care. However, for clients without addiction medication, psychosocial care is often the foundation of the change process. Good psychosocial providers (preferably licensed mental health professionals), not just good physicians, are needed in an effective and comprehensive treatment system.
The document clearly indicates that “addiction is not the same as substance misuse” (pg. 6). The document might also have emphasized how substance misuse may collectively create more problems than the severe cases we call “addiction.” Nevertheless, there is little mention of how to address substance misuse, which can even occur with opiates. Not all problematic opiate users need MAT.
Finally, there is no mention of the broader and deeper changes that could almost certainly make even larger changes in US substance problems: reduction in income disparity, decriminalization of substance use (or even legalization, if we want to stop funding the drug cartels), and a national healthcare system that provides treatment to almost everyone without regard to ability to pay. Unfortunately, a reasonable objection to these last three ideas is that, even though there is significant evidence in support of each, they are rather far from mainstream ideas in the public discourse. Perhaps the authors chose not to state these ideas because it may be difficult enough to get support for the ideas they have proposed, without introducing ideas even more likely to raise objections. However, I believe it is important that everyone concerned about substance problems in the US keep these three ideas in mind, and await a more promising time to act on them.