Recent Federal Responses to the Opioid Crisis
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With opioid-related deaths reaching an all-time high, evidence shows that multiple approaches are needed to address the opioid crisis. In a newly released Congressional Budget Office (CBO) report, we have identified strategies that the federal government has employed in three recently enacted laws: the Comprehensive Addiction and Recovery Act of 2016 (CARA), the 21st Century Cures Act, and the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act.1
Strategies to Address the Opioid Crisis
The three laws aim to address the crisis through strategies focused on reducing demand, supply, and harm. Policies focused on reducing the demand for opioids include expanding prevention efforts — such as training health care practitioners on best practices for prescribing opioids and pain management — and expanding eligibility for federally subsidized insurance to increase access to treatment for opioid use disorder (OUD). Policies focused on reducing the supply of opioids for misuse include increasing oversight of prescription opioids among patients and prescribers as well as curbing the supply of illegally produced opioids. Last, policies focused on reducing harm include enhancing access to overdose reversal drugs.
CBO’s role in the legislative process is to provide budgetary and economic analysis. In the present article, we examine two ways in which Congress has addressed the crisis via the budget process: (1) through authorizations of appropriations (with funds only becoming available to federal programs if appropriated in subsequent legislation), and (2) through mandatory spending on benefit programs such as Medicare and Medicaid. The laws mentioned above authorized the appropriation of $8.1 billion between 2017 and 2023 to address the opioid crisis (and substance use disorder more generally). Provisions aimed at reducing the demand for opioids were estimated to always increase mandatory outlays. In contrast, provisions aimed at reducing the supply of opioids were estimated to increase spending in some cases (for example, by providing technical assistance to providers who prescribe opioids in larger quantities than their peers) and to reduce spending in other cases (for example, by allowing partial prescription fills).
CBO estimated that, on net, opioid-related provisions in CARA will reduce mandatory spending by $187 million over the 2017–2026 period, reflecting a $54 million increase in spending from provisions related to reducing the demand for opioids as well as a reduction of $241 million in spending from provisions related to reducing the supply of prescription opioids subsidized by the federal government. In contrast, the estimated $2.7 billion net increase in mandatory spending stemming from the SUPPORT for Patients and Communities Act over the 2019–2028 period results from a $2.9 billion increase in spending from provisions related to reducing the demand for opioids and an estimated $205 million reduction in spending from provisions aimed at reducing the supply of opioids.
Health care professionals can help to address the opioid crisis by encouraging the use of evidence-based strategies, including those that have been supported at the federal level. For example, the laws mentioned above increased eligibility for treatment with medications for OUD and funded the development and expansion of prescription drug monitoring programs. In addition, the laws expanded access to overdose-reversal drugs to help keep people with OUD alive until they are ready to seek treatment.
The Opioid Crisis and the Pandemic
To address the opioid crisis during the pandemic, the federal government made policy changes and Congress appropriated additional funds. Medicaid emergency authorities resulted in expanded eligibility for and access to treatment and naloxone beginning in March 2020. The federal government eased restrictions on methadone dispensing by allowing take-home doses for a 14- to 28-day period instead of requiring observed daily doses at federally regulated opioid treatment programs. Last, the use of telemedicine to treat patients with OUD remotely was expanded. The American Rescue Plan Act of 2021 appropriated $1.5 billion in block grants for the prevention and treatment of substance use disorder and $30 million for community-based funding of harm-reduction services, including naloxone distribution and syringe services programs.1
Opioid-related deaths continued to increase after the three federal laws were enacted — initially more slowly than in preceding years, but then more rapidly during the pandemic. The annual increase in opioid-related deaths averaged 6% from 2017 to 2019, which was smaller than the 19% per year average increase from 2014 to 2016.2 The laws probably contributed to that slowdown through channels such as the increased use of naloxone to reverse opioid overdoses and the use of medication to treat OUD. After 2019, there was a dramatic increase in opioid-related mortality during the pandemic. In 2020, 68,630 opioid-related fatalities occurred, a 38% increase from 2019.2 Preliminary data for 2021 indicate that the trend of increases in the number of opioid-related deaths continued.3
Several factors may have contributed to the increase in opioid-related deaths during the pandemic. Opioid use may have increased because of increased anxiety, depression, and social isolation stemming from measures intended to reduce the spread of the coronavirus, concerns about contracting the virus, and pandemic-related job losses and economic insecurity. In addition, disruptions in in-person treatment and social supports may have led to relapses among some people who were in recovery.4 At the same time, a temporary disruption in the availability of less-potent opioids because of pandemic-mitigation measures, such as lockdowns, may have exacerbated the shift toward the use of fentanyl. Last, solitary use of opioids increased because of social distancing measures, which may have reduced opportunities for bystanders to administer naloxone in the event of an overdose.
Changes in the Racial and Ethnic Composition of the Opioid Crisis
As the crisis evolved, so has the racial and ethnic composition of those affected by it. The early waves of the crisis had a disproportionate effect on non-Hispanic white people, while opioid-related deaths during the pandemic were more common among other racial and ethnic groups (Figure 1). In fact, the number of opioid-related deaths per capita among non-Hispanic Black and Native American or Alaska Native people first surpassed the number for non-Hispanic white people in 2020. Dramatic increases in the number of deaths involving opioids per capita also occurred among Hispanic people and Asian or Pacific Islander people.2
The increase in deaths involving opioids among different racial and ethnic groups is due, in part, to disparities in access to treatment and differences in the provision of treatment. According to one study, patients with OUD who are Black are half as likely to obtain a follow-up visit for treatment following a nonfatal opioid overdose encounter in the emergency department than patients who are white.5 Treatment for OUD with methadone is also more common in Black and Hispanic communities, whereas treatment with buprenorphine is more common in white communities. Although both treatments have been approved by the Food and Drug Administration (FDA), buprenorphine might be associated with less stigma and easier access because it is prescribed by an office-based provider and is acquired at a pharmacy. In contrast, methadone is typically administered under supervision in certified opioid-treatment programs.5 Health care professionals can reduce racial and ethnic variations in opioid-related mortality by ensuring that all subpopulations have equal access to treatment for OUD, including all medications that have been approved by the FDA.
Looking Ahead
Several policy approaches are available to Congress. Some provisions in the three recently enacted federal laws have lapsed, and others are scheduled to lapse in the coming year. Authorizations of appropriations in CARA expired in 2021, and authorizations in the SUPPORT for Patients and Communities Act will expire in 2023. In addition, the SUPPORT for Patients and Communities Act included two provisions to increase treatment capacity on a temporary basis. One provision gave states the option to expand access to treatment for residential services in institutions for mental diseases through September 30, 2023. The second established a requirement for Medicaid to cover medications to treat OUD through September 30, 2025. Options under consideration by policy makers include strategies that are similar to those used in the three federal laws as well approaches that differ from them. As policy makers consider their next steps, the opioid crisis does not show signs of abating.
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