WASHINGTON -- The House passed more than a dozen bills last week aimed at thwarting the nation's opioid addiction crisis. The bills came not long after the Senate passing a single broad bill targeting opioid overuse back in March.
But can the Senate's , and the House's extended approach -- at least 17 individual bills -- effectively be integrated and made law? One physician and addiction specialist argued that yet another bill needs to pass the Senate before the House legislation can have any effect.
chair of the legislative advocacy committee for the American Society of Addiction Medicine (ASAM), said unless the Senate passes the (TREAT), up to 80% of the provisions presented in the House legislation could die without reaching committee.
Together the provisions of CARA and the TREAT bills mirror those included in the House legislation, but the latter "just did it in a bunch of smaller bills," he said.
Waller explained said that there has to be a match for everything in the House bills on the Senate side, but that accord isn't currently in place because only the CARA bill has passed.
CARA and TREAT
In February, President Obama pledged $1.1 billion to target the opioid epidemic. He earmarked the bulk of funding for medication-assisted treatment for opioid use disorder, but these funds have yet to be authorized. A month later, the Senate passed the CARA bill.
CARA would expand access to naloxone to first responders and law enforcement; support efforts to treat incarcerated individuals; expand drug take-back efforts; enhance drug monitoring programs and establish prescription opioid and heroin intervention programs.
Senate Republicans rejected an amendment to CARA that would have infused the bill with $600 million in emergency funding.
The TREAT bill would, after 1 year, allow qualifying physicians to prescribe "an unlimited number of patients" with maintenance therapies provided that physician meets certain requirement, including receiving 24 hours of education for treating patients with opioid use disorders. The bill would also expand the definition of a "qualifying practitioner" to include nurse practitioners (NP) and physicians assistants (PA) who are licensed by their state to prescribe relevant pain medications.
TREAT is currently awaiting a vote in the Senate.
House Steps Up
The House, feeling pressure from the Senate to tackle the opioid issue, passed a host of individual bills that would expand the type of providers able to prescribe medication-assisted therapy, increase education around opioid prescribing practices, and raise the limit on the number of patients that a single provider can prescribe MAT.
Three of the core bills to pass were the , the , and the .
The first of these creates grant programs to support provider training and the co-prescribing of naloxone whenever opioids are prescribed to high-risk patients. Programs would include training resources for healthcare providers and a tracking tool for monitoring these high-risk patients.
The second act would raise the cap on the patient limit for prescribing medication-assisted therapy to 250 patients after 1 year, and expand prescribing privileges to NPs and PAs. All providers would be required to receive 24 hours in opioid maintenance and detoxification and a series of related courses.
The third bill would allow the Attorney General to offer grants to expand treatment services by appropriating $103 million for each fiscal years from 2017 through 2021.
Other opioid-related bills passed by the House included:
- would require the Department of Veteran's Affairs and the Department of Defense to update their practice guidelines for managing opioid therapy and expand pain management training.
- would create a pilot program, including state grants, for this target group and reauthorize residential treatment.
- would allow grants to states for developing standing orders for pharmacies for opioid overdose reversal medications and expand provider education regarding their distribution.
- would require the FDA to hold advisory meetings prior to approving opioids except under certain circumstance, and require panels to discuss labeling of opioids intended for pediatric use.
- would makes it easier for the government to prosecute drug lords without revealing classified information.
The House also passed individual bills to establish an interagency task force that would examine and update best practices for pain managment and pain medication prescription; to raise awareness and education around the safe care of infants born affected by illegal substances; and to require the Government Accountability Office to track and report on the capacity for inpatient and outpatient treatment for opioid abuse disorders.
Providers Respond
Asked whether he was hopeful about a comprehensive bill being made law, Waller said, "It's more likely than anything else that's been on the docket for the last 8 years ... lawmakers understand that this is a life and death decision that they're making for the highest cause of death in the United States right now."
He said he also does not anticipate any major disputes while in conference, except for some potential debate around the precise number for the "patient limit" -- the number of patients each provider can prescribe medication-assisted therapy -- which differs across the two chambers' bills.
, president of the American Association of Family Physicians (AAFP), said she's pleased that the new bills would raise the limit on the number of patients each provider can prescribe maintenance therapies to. "We were asking for 200. I don't think anybody thought we could get higher than that," she said.
Filer also said she is not opposed to allowing NPs and PAs to provided medication-assisted therapy.
But Waller pointed out that the scope of practice for all NPs and PAs would still be governed by the state, such as a state-mandated supervisory requirement that federal legislation could not override that.
Mandatory education, which would be a requirement for prescribers who wish to treat patients with medication-assisted therapy or raise their "patient limit," is another sticking point.
While ASAM is in favor of mandatory education, the AAFP has not traditionally supported it, Filer said.
Filer said there isn't a lot of evidence to establish the benefits of mandatory education, and for some physicians, prescriber education is not relevant. However she cited "a dramatic upswing" in the last 5 years in physician self-directed learning, specific to opioids and pain management. She also expressed concern that mandatory learning modules would require physicians to spend more time on paperwork, rather than caring for patient.
"I think that the question is this broad brush may not be the best way to do it. There's been a lot of work in a lot of different ways to mandate all sorts of different [continued medical education] and there's absolutely no evidence that it works," Filer said.
Waller disagreed. "It baffles me, to be honest, that people would argue, knowing that we have a deficit of knowledge in an area such as addiction medicine, and then somehow fighting against becoming knowledgeable. I mean it's the opposite of intellectualism," he said. "I think it actually goes a long with showing that there's still a large amount of bias towards this [opioid overuse] in the healthcare community."