A congressional conference committee is currently hammering out a bill to combine separate legislation recently passed in the House and Senate addressing the growing opioid crisis, as the number of Americans addicted to and overdosing on heroin and prescription painkillers has dramatically increased in recent years.
There is still a question of what specific initiatives in the Senate’s Comprehensive Care and Recovery Act and the 18 different bills passed by the House will make their way through the conference committee, though it seems likely the final bill will heavily focus on expanding access to medication-assisted treatment (MAT) programs for those addicted to opioids. Over 90 percent of addiction treatment in America is abstinence-based, but a growing number of experts in the field say peer-reviewed research shows combining behavioral therapy with medication such as buprenorphine (the main component of Suboxone) is a more effective way to break opioid addiction and prevent a relapse that leads to an overdose death.
At a political event in Louisville this week, Kentucky Sen. Rand Paul discussed one of this own legislative initiatives that would expand access to MAT, which he hopes will be included by the conference committee.
Paul is co-sponsor of the TREAT Act, which would significantly increase the amount of patients to whom a doctor could prescribe Suboxone. Currently a physician who receives a federal waiver can treat up to 30 patients at a time in their first year prescribing the medication, and 100 patients in the following years. Paul’s legislation would significantly increase those limits, as many parts of the country have few providers able to prescribe Suboxone and patients wanting help are often put on waiting lists.
At the event on Monday in west Louisville, Paul called the existing federal limits a “stupid rule” and touted the effectiveness of Suboxone over abstinence-only treatment.
“It’s almost impossible to stop heroin or Oxycontin or any of these drugs cold turkey,” said Paul. “We replace them with something that doesn’t get you high, but allows you to stabilize off the drugs. But there’s 1 million people waiting for treatment… There just aren’t that many doctors involved in (medication-assisted) treatment. So why in the world would we limit how many patients they can see?”
The TREAT Act passed a Senate committee and has not been voted on in the full chambers, but similar legislation was passed in the House, and Paul told IL there is a “very good chance” it will be included by the conference committee.
“I’ve talked to the members of the conference committee and asked them if they’ll include it,” said Paul. “I’d say (there’s) a better than 50 percent chance that it will get included.”
Even without this legislation, the Suboxone/buprenorphine caps may be lifted later this year, as the Obama administration recently announced a proposed rule to raise such limits to 200 patients. Paul — a fierce critic of Presdient Barack Obama — even gave him rare praise for doing so.
“The president, on his own, lifted the number recently because I was bugging him to do it,” said Paul. “I’m not opposed to complimenting the president, we don’t always agree, but I will compliment him on this…. Now we need to make it part of the law so hopefully we can save some lives.”
As for the full bill that comes out of the conference committee, another big question is whether Congress will actually provide the funding needed for it to have the intended impact. The Obama administration has asked for $1.1 billion to combat opioid addiction, and Senate Democrats have called for $600 million in emergency funding, though new fears over the Zika virus and Republicans’ calls to cut spending may lead to a much lower amount.
Asked by IL if Congress will provide enough funding for the legislation to have an impact, Paul says the Congressional Budget Office recently scored such legislation as costing $2 billion, but says that figure is inflated because they did not factor in the savings that fighting addiction and reducing overdoses would provide.
“If you’ve ever seen someone who is comatose (after overdosing), that can be $1 million, $2 million, they could be in the hospital for months with kidney failure, all of that,” said Paul. “If you save that cost, there’s got to be a savings. They weren’t putting any savings in for the preventative treatment of getting people before they become comatose or overdose, so we’re trying to get them to look at the scoring on it. That is a problem, because it costs money and we have to figure out how to pay for it.”
Democratic Congressman John Yarmuth of Louisville told IL that finding bipartisan agreement on the policies to fight opioid addiction was the easy part, but appropriating the funds needed to make it work as intended will be a very difficult challenge.
“(The Senate) bill authorizes $600 million, but you can authorize it and they can then come back and appropriate $50 million out of the $600 million authorization, which makes it essentially impotent,” said Yarmuth. “And that’s going to be the real test, is whether we can get any money actually appropriated for these policies.”
Yarmuth noted that the appropriations process in the House appears to have completely broken down, which will make providing funds for the legislation difficult. There are currently open rules for appropriations bills in which anyone can offer an amendment to attach a policy rider to a bill, which are often controversial and prevent the full bill from passing. He added that many Republicans also want to return to the lower sequestration-level of total spending and would vote against any appropriations bill exceeding that level.
“Unless (Paul) Ryan changes the policy about open rules on appropriations, I don’t think they’re going to be able to get any appropriations bill passed,” said Yarmuth. “So I think it’s highly unlikely that individual appropriations bills containing funding for these programs will end up getting passed, which means it would all go into an omnibus spending bill at the end of the year. And we’ll see whether it gets appropriated or not.”
Yarmuth said that parts of the legislation before the conference committee should cost little to no money, but both chambers will ultimately have to vote for or against one unified bill that provides a significant amount of funding in order to succeed — largely grants to states to expand MAT programs.
One initiative before the committee costing little money is one that Yarmuth co-sponsored: providing incentives to companies for manufacturing opioids in a way that cannot be diverted and abused. He also supports the elements of Paul’s TREAT Act, which he says would not be costly.
“I understand the reason for the (buprenorphine patient) limit at the beginning, you didn’t want to encourage pill mills,” said Yarmuth. “But now this makes it harder for people to get treatment.”
Medication-assisted treatment combining behavioral therapy with Suboxone has been touted as an effective way to prevent a deadly relapse for heroin addicts by a diverse group of medical experts, from federal agencies such as the National Institute on Drug Abuse and the Substance Abuse and Mental Health Services Administration, to organizations like the American Medical Association and the American Society of Addiction Medicine. Suboxone also has critics, including some law enforcement officials who cite the common diversion and abuse of the medication, and abstinence-only 12-steps recovery centers who view buprenorphine as another harmful addiction to replace heroin or prescription painkillers.