The Washington Post reports that President Donald Trump will announce today the creation of a federal opioid commission. New Jersey Gov. Chris Christie will be the chair, and the rollout will feature a who's who of federal bureaucrats, from Attorney General Jeff Sessions, to acting Drug Czar Richard Baum, to Florida Attorney General Pam Bondi.
Drug policy reformers would prefer to see a commission like this chaired by a harm reduction expert, but Christie is not the worst choice in a Trumpian world. He signed a Good Samaritan law in 2013 that protects drug-possessing bystanders from arrest in the event they report another person's overdose. It also provides some legal protection for people who administer the overdose-reversal drug naloxone in a life-threatening situation. The law would've been better if it had provided immunity to drug dealers who reported overdoses, but Christie vetoed that version of the bill. He has also allowed New Jersey pharmacies to sell naloxone without a prescription. (I wouldn't normally applaud that kind of executive inaction if not for Maine Gov. Paul LePage vetoing a bill that would have allowed pharmacies in his state to do the same.)
Christie's biggest move on opioids–a comprehensive bill he signed in February–is a little more complicated. The American Journal of Managed Care says it contains "the nation's strictest treatment mandates for opioid addiction." It requires:
health plans to offer 6 months of treatment, including an initial 28-day period in which health plans cannot deny inpatient care. After that, health plans can do concurrent review no more than every 2 weeks to guide the location of care.
Less-noticed, but groundbreaking, parts of the bill require health plans to go out-of-network, if necessary, to ensure that people seeking help are placed within 24 hours. The law, as written, will extend to other forms of substance abuse, not just opioid and heroin addiction.
The measure also includes education requirements for licensed professionals who dispense opioids, from physicians, to dentists, to midwives. Patients with cancer or those in hospice care are exempt from the initial [five-day] pill limit.
So, we have a five-day pill limit for people who aren't dying, and a requirement that insurance companies pay for six months of care. New Jersey Sen. Gerald Cardinale, a dentist, objected to both facets, saying that the pill limit was too strict and the length of treatment too short.
The bill also requires insurers to cover medication-assisted treatment (see: methadone) if a physician, psychologist, or psychiatrist recommends it. According to the Drug Policy Alliance, the Centers for Disease Control, and the Substance Abuse and Mental Health Services Administration (SAMHSA), medication-assisted therapy dramatically reduces mortality among opioid users. Maia Szalavitz, who's not shy about calling bullshit on bad opioid policy, has encouraged drug court operators to make medication-assisted therapy an option for people whose substance use has ensnared them in the criminal justice system.
But as Jason Cherkis reported in his fantastic piece for the Huffington Post, far too many treatment programs are dangerously enamored with abstinence-only pseudoscience. The founder of one of those 12-step programs will be at today's commission announcement. More tragic still, pretty much anyone can set up a 12-step program, while regulatory obstacles to offering medication-assisted therapy all but guarantee very few doctors will ever provide it.
Unlike with most schedule II drugs, healthcare providers must ask the federal government for permission to provide medication-assisted therapy. If approved, they can provide the treatment to only 30 patients at a time in their first year, and 100 patients at a time in their second year. In 2016, the Department of Health and Human Services finalized a rule permitting doctors with extensive credentials in addiction medicine to treat as many as 275 patients at a time, but only if they'd been at the 100-patient limit for at least a full year. These ceilings are obscenely low considering that even SAMHSA concedes lifelong methadone use is better than having someone relapse into opioid abuse. Violating these rules has already earned several doctors visits from the Drug Enforcement Administration.
If Christie wants to do something significant to reduce opioid deaths in the near term, he should look at ditching the rat's nest of regulations preventing doctors from offering medication-assisted therapy to people who will otherwise die. Putting some harm reduction experts and doctors on the commission would help.