On Tuesday, October 20, the House Energy and Commerce Subcommittee on Health held the second half of the hearing on “Examining Legislative Proposals to Combat Our Nation’s Drug Abuse Crisis”. The first half of the hearing was held on Thursday, October 8 with a panel of federal witnesses, including Michael Botticelli, the Director of National Drug Control Policy, Richard Frank, Assistant Secretary for Planning and Evaluation for Health and Human Services and Jack Riley, Deputy Administrator of the Drug Enforcement Administration. The panel of witnesses for the second half of the hearing consisted of specialists and physicians from the field of addiction medicine. Among them was Dr. Corey Waller, Chair of the Legislative Advocacy Committee, who testified on behalf of ASAM.
Dr. Waller and Rep. Sarbanes
The subcommittee is reviewing seven pieces of legislation that address the current opioid epidemic. The panel of witnesses spoke to these bills, in particular the issues of access to evidence-based treatment and proper training of physicians who prescribe controlled substances. The seven bills being considered by the subcommittee are:
ASAM has endorsed the TREAT and Co-Prescribing to Reduce Overdoses Acts.
Alongside Dr. Waller was Dr. Paul Halverson, Dean of Indiana University’s School of Public Health, Dr. Allen Anderson, President of the American Orthopedic Society for Sports Medicine, Dr. Kenneth Katz from the Department of Emergency Medicine of Lehigh Valley Health Network, and Dr. Chapman Sledge, Chief Medical Officer of Cumberland Heights and another ASAM member.
Dr. Waller’s testimony emphasized three main facts: addiction is a chronic disease of the brain that leads to characteristic biological, psychological, social and spiritual manifestations; addiction involving opioid use can be successfully treated with a combination of medications and psychosocial interventions; there are significant barriers to access these effective medications, resulting in a significant addiction treatment gap in our country.
“In recent months my practice has had to turn away many patients due to the 100 patient limit for buprenorphine. This includes pregnant patients as well as the children of my friends and has resulted in at least two overdose deaths. If I am out of town or unavailable, my physician assistants are unable to see the patients who need an urgent intake, due to the restrictions on PAs and NPs writing for buprenorphine, which exists even if they are under the guidance of a physician who is board certified in addiction,” Dr. Waller told the subcommittee.
Dr. Waller stressed that patients with addiction are no different than patients with other chronic diseases, such as hypertension and diabetes, which are the result of a combination of biological and environmental factors. Addiction can be successfully treated through long-term management and the combination of evidence-based treatments and psychosocial services.
Dr. Waller discussed the history of use and effectiveness of the three FDA-approved medications - methadone, buprenorphine and naltrexone - which are prescribed to treat opioid use disorder. He explained that all of these medications have proven to be clinically effective and literature on the efficacy of these medications show that they reduce illicit opioid use, cravings, criminal justice involvement, unemployment, HIV risk behavior and mortality, while improving psychosocial outcomes.
Dr. Waller also mentioned that ASAM has released a clear and comprehensive guideline for how to use these medications effectively in the clinical care of patients with addiction. The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use is the first guideline to address all the FDA-approved medications available to treat addiction involving opioid use and opioid overdose – methadone, buprenorphine, naltrexone and naloxone.
However, despite strong evidence that these medications help patients with addiction, there is an enormous treatment gap in this country between those who need treatment and those who actually receive it. According to the Centers for Disease Control there are 2.3 million people with opioid addiction who need treatment, and a recent study published in JAMA found that 80% of Americans with opioid addiction don’t receive treatment. On top of that, Dr. Waller pointed out that less than 30% of treatment programs offer medications to treat addiction and less than half of eligible patients in those programs receive medication. While recent legislation, such as the Drug Addiction Treatment Act (DATA) of 2000, has helped expand access to treatment by integrating it into the general medical setting, there are still barriers to access. Provider willingness, limited insurance coverage and patient limits on physicians prescribing buprenorphine have created the treatment gap we see today.
Dr. Waller laid out ASAM’s recommendations for the gradual and limited lifting of the patient limits under DATA 2000. This was an important point, as many of the questions from the subcommittee were on the risk of diversion and insufficient prescriber education. In response to a question on increased diversion if restrictions on treatment were eased, Dr. Waller explained that the limits should be lifted for specialists and physicians with additional training who are subject to quality checks by SAMHSA and take required training on diversion control techniques such as call-backs, pill counts and urine drug screens, as well as comprehensive education on psychosocial supports. Asked whether addiction medicine should be incorporated into medical school curriculum, Dr. Waller added that pain and addiction education should be required curriculum in medical school and mandatory continuing medical education throughout an addiction physician’s career. The other panelists agreed.
What was made clear during the hearing was that the current model of care in our country does not work. As opioid overdose rates continue to increase and the treatment gap grows, we can no longer expect patients to recover after a brief treatment in withdrawal management or rehabilitation programs. Resources need to be provided to communities and health care systems to adequately treat this disease. The stigma around those who suffer from addiction and using medication to treat it needs to be eliminated. Dr. Waller touched upon this when he was asked by a subcommittee member whether the use of medication was just substituting one drug for another. “Rather than considering whether or not a patient still needs medication to manage his or her illness,” Dr. Waller said, “we should be looking for treatment outcomes like reduced incidence of infectious disease, increased employment, housing stability and reduced involvement with the criminal justice system, among other indicators of a return to physical, mental, social and spiritual health.” Dr. Waller’s complete testimony is available here.