Opioids

Donald Trump's Opioid Commission Is Stacked With Prosecutors and 12-Steppers

Will any drug policy experts sit on Trump's drug policy commission?

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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.

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40 responses to “Donald Trump's Opioid Commission Is Stacked With Prosecutors and 12-Steppers

  1. Fuck harm reduction, just legalize everything.

    1. Damn, SIV is right.

      1. He’s just hoping that one of the things that will be legalized will be the love that dare not cluck its name.

    2. The appetite suppressing effect of opium would reduce harm to Christie Creme’s arteries quite a bit.

    3. Bingo!

      If all presently illegal drugs were legal for recreation use tomorrow, I would still stick to the two legal ones I use (tobacco and caffeine). That said, the older I get the less convinced I am that the War on Drugs accomplishes anything remotely worthwhile, once you factor in the costs and fallout.

      Admittedly, I was never a fan.

      Any policy, no matter how well meant, that keeps a sufferer of chronic pain from getting the necessary pain meds, or significantly impedes the process, is barbaric. Drug Warriors who advocate such policies deserve to be impaled on a short stake, and left to shriek their excuses to the Gods.

      1. Maybe it’s a budget cutting proposal. Since people who have chronic pain tend to be considerably more expensive in their health and personal care needs, cutting us off might make a lot of people commit suicide rather than trying to live with the intolerable pain. Bingo – lowers heath care costs. Don’t even have to repeal Obamacare.

        We seem to go through one of these scares every 20 years or so, but this one is by far and away the worst I’ve seen. At least the last time around, even GPs were still allowed to use their own judgement for the lower level opioids, only really cracking down on those who ran “pill mills.”

        1. I once read a gloss of a study that asserted that the reason for the cyclic nature of drug ‘epidemics’ has most to do with the longevity of the users. People around the first wave of addicts see what the drug (and assorted additives) is doing to them and so they back off. The first wave dies, time passes, nobody remembers the last raft of horrid object lessons, next wave.

          Works for heroin, cocaine, crack, meth. Marijuana doesn’t tend to kill, so its numbers remain fairly steady.

          Does this hold water? Who knows. Sounds about right, though.

      2. Maybe it’s a budget cutting proposal. Since people who have chronic pain tend to be considerably more expensive in their health and personal care needs, cutting us off might make a lot of people commit suicide rather than trying to live with the intolerable pain. Bingo – lowers heath care costs. Don’t even have to repeal Obamacare.

        We seem to go through one of these scares every 20 years or so, but this one is by far and away the worst I’ve seen. At least the last time around, even GPs were still allowed to use their own judgement for the lower level opioids, only really cracking down on those who ran “pill mills.”

        1. Dang squirrels again. For days it wouldn’t post at all, now it’s too many.

    4. Well, sure, if we had a realistic choice between legalizing everything & harm reduction. But why not help push the train that’s actually moving?

    5. That would reduce a tremendous amount of harm!

  2. Is there any venue in which New Jersey Democrat Chris Christie isn’t an a-hole?

    1. Some years ago he told a bunch of rebellious legislators, who wanted to spend like usual in a budget crunch, “Yes, I know. All those programs would be nice. If we had the money. We don’t.”

      Sadly, he seems to have left those days behind him.

  3. Donald Trump’s Opioid Commission Is Stacked With Prosecutors and 12-Steppers

    Sort of like how a local city council meeting is stacked with pubsec union and affordable housing advocates?

    Hard to stack a meeting about doing something with people who don’t want anything done.

  4. Here’s hoping that Trump brings Christie up onto the dais when he announces that Tiffany will actually chair the commission.

  5. We don’t have an opioid crisis, we have a STREET opioid crisis. People aren’t dying from the 60 percocet they get after knee surgery. They are dying because they are forced to take street opioids (made in some dirty factory in China) with uncertain dosage and composition, after they violate their doctors Narcotic Agreement. The proof? Methadone overdoses have stubbornly refused to increase. Which makes sense; taking a prescription medication under a doctors care is much safer than eating pills you bought off a meth addict.

    Punishing all people with pain issues because some idiots like to get high, and some doctors want to chase them into the street to die, is insane. This crisis is going to get a hell of a lot worse, given the direction its going.

    1. This crisis is going to get a hell of a lot worse, given the direction its going.

      I don’t disagree, the example of the Philippines gives insight into how bad it can get.

      1. “Can” isn’t synonymous w “will”.

        1. Not implying it was.

  6. Appeared in the local paper today.

    http://www.stltoday.com/news/o…..a7eec.html

    Missouri does not have a prescription drug monitoring program.

  7. If health insurance is required to cover opioid addiction treatment, why wouldn’t it cover nicotine patches or vapes to stop people from smoking? Where does this line of thinking stop?

    1. I think it already covers patches. But vaping looks like smoking and is evil, so no.

      But yeah, covering “everything” is a recipe for disaster.

      1. Some insurance plans (like mine) explicitly exclude smoking cessation stuff. I’m not sure why. Maybe rates of success are too low.

        1. Patches and the like have about a 5% success rate. Far lower than switching to eCigs, yet that’s where they’re putting all the obstacles.

  8. If I were to set out crafting harm reductions, short of full legalization, the very first thing I would do is put an immediate end to violent drug raids. Needle-exchanges, medically assisted treatment programs, and the availability of naloxone are all well and good, but they only really affect a very small percentage of drug users. Violent drug raids, on the other hand, cause serious and sometimes lifelong damage to all drug users, their families, and innocent bystanders. And as a tool for seizing drugs, are both obscenely expensive and absurdly ineffective.

    1. Don’t violent drug raids also affect a very small percentage of users?

      What I think would be better would be ending undercover ops.

    2. Indeed, those approaches are incoherent, ineffective and aggressive. But I’m sure they know that, and put political expediency ahead of effectiveness. If it were about effectiveness, they wouldn’t be doing what they do.

  9. Or admit weed has its place?
    Oh wait; that does not require a huge government program with lots of jobs for my buddies! In fact it would reduce a lot of government things!
    Next thing you know, the government would just allow doctors to do their job.

  10. See… you should have voted for me. I would have appointed Tommy Chong as the chairman.

  11. And, not a one of them understands that the failure can only be remedied by thinking outside of the box. They just want to continue the same failed programs!

  12. Why don’t we end all government interference in the “substance” sector, and let people self-medicate as they please, and if they OD…..well, too bad!/s – or is it?

  13. 1. Rehab is a waste of money. At tens of thousands of dollars per patient with 95% relapse rate, the cost per successful treatment can reach hundreds of thousands of dollars. Government subsidized rehab, health insurance rehab mandates, and court ordered rehab makes even less sense, especially for people who don’t really want to quit.
    2. Opioid addiction fell dramatically in medical marijuana states. Legalize it, don’t criticize it.
    3. Educate doctors to prescribe other meds and/or recommend non-pharmaceutical strategies for chronic pain.
    4. Make naloxone OTC without a prescription.
    Almost every other strategy is useless.

    1. Get the government out of “educating” doctors. The decision to use opioids should be based on science and the patient, not the nanny state and a few yahoos that want to get high. Undertreated pain can lead to obesity and health problems, and is a high predictor for opioid abuse. The idea that people should live with some pain is, frankly, bullsh!t. Who cares if someone wants to take opioids for the rest of their life? Many people already do that with methadone.

      1. Agreed. The notion of “educating doctors” is quite laughable. There’s a reason why MDs spend a decade in school and then residency for a number of years. I certainly wouldn’t lecture an engineer or architect on how to design a high rise building, because I don’t know what I’m talking about.

  14. Obviously, eight years of Obama’s approach has been amazingly successful.

  15. This Victory Bay place linked in the 6th graf is not a 12-step program. It’s a for-profit treatment center. 12-step programs are non-profit 501(3)(c) lay fellowships that don’t take money, don’t own property, don’t claim to be providing psychiatric services, and don’t claim to have any scientific grounding. That the blog post author here, Mike Riggs, doesn’t know that reveals ignorance and a lack of curiosity that is, well, curious in a writer. I’m guessing, and maybe I’m off here, that Reason types are atheists who object to 12-step recovery because it is based on a spiritual experience and is thus not medical or scientific. They assume that everyone agrees that is an obviously bad thing. One gets the impression that they are perfectly happy to have people die enslaved by addiction, as long as they don’t recover and become whole through spiritual means.

    Certainly a lot of for-profit treatment facilities are sketchy, and provide “treatment modalities” that aren’t based in solid research. When people cry “We should TREAT them, not jail them!” and courts and government welfare agencies mandate treatment this is a predictable result. Alcoholism and addiction are very difficult problems that don’t really have an easy public health solution. Reason.com wonks have nothing to offer in this area but abstract speculation.

  16. Of course Chris Christie’s in charge. The preemptively ruining people’s lives method has worked worked soooo great in the past he’s gonna double down on it like meat on a deep dish pizza. Seriously, imagine how cheap and safe poppy products would have become by now without artificial impediments, but the wellbeing of addicts is very clearly not the point.

  17. Harm reduction is the obvious way to deal with issues like opioid addiction in the real world. I stress “real world” because we never see policy that deals with the reality of addiction, only pipe dream hardliner policy that has been tried over and over with a bigger sledgehammer each time, leaving more and more broken families and broken lives in its wake.

    Any government official that places marijuana in the same tier as heroin, cocaine and prescription drugs is obviously far too incompetent to make decisions that deal with real problems in the real world.

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