The Biden administration’s sweeping plan to quell rising drug deaths in the U.S. could face roadblocks as treatment specialists grapple with limitations in tracking overdoses and varying state regulations.
Harm reduction, recovery support, evidence-based treatment, and primary prevention are the four tenets of President Joe Biden’s government-wide strategy for fighting an addiction crisis that has evaded policymakers since the Obama era. But tackling a hodgepodge of state policies, diverging treatment approaches, and funding restraints will be key to getting the administration’s efforts off the ground, health policy experts say.
“You can’t just make the announcement. It’s critically important that the funding is behind these things, that the additional attention to regulations or other policies that may serve as barriers are addressed,” said Bradley Stein, director of the RAND Corporation’s Opioid Policy Center.
“Some of that the federal government can do. Some the states can do,” he said.
The Department of Health and Human Services announced the overdose prevention strategy just one day before the Senate confirmed Rahul Gupta as the new director of the Office of National Drug Control Policy. Gupta, the first physician to hold the role and who previously led the opioid response in West Virginia, will have authority over dozens of agencies that deal with drug addiction and enforcement.
Gupta, along with the Centers for Disease Control and Prevention and other agencies, will be tasked with addressing overdose numbers that have surged during the coronavirus pandemic. The CDC estimates that over 100,000 individuals died from a drug overdose between April 2020 to April 2021, marking a 28.5% increase from the previous year.
“As we continue to make strides to defeat the COVID-19 pandemic, we cannot overlook this epidemic of loss, which has touched families and communities across the country,” Biden said in a Wednesday statement.
The new strategy is unfurling across the administration, with the HHS and other agencies supporting needle exchange programs that provide clean needles to reduce disease transmission; strips to test drugs for fentanyl, a pain treatment increasingly linked to overdoses; and other novel methods long praised by experts but only slowly gaining acceptance from the broader public.
“Getting away from that model where we need to punish people to get them to change or make them feel the pain of going through withdrawal to change is taking some time, and attitudes are shifting,” said Brenna Greenfield, a University of Minnesota professor who works on equity issues in addiction treatment.
Beyond public acceptance, policy experts note that adequate funding, along with having an accurate picture of how many people are suffering overdoses in order to target those funds, is paramount.
In its fiscal 2022 budget plan, the administration proposed $11.2 billion in funds across the HHS to broaden access to substance use treatment efforts, according to the department’s website.
The HHS’ plan pays particular focus to data collection efforts, highlighting a national framework dubbed the Drug Overdose Surveillance and Epidemiology System that contains information on overdose-related emergency department visits. The data accrued is seen as especially important in the pandemic climate.
“These last two years, with Covid, we’ve seen how important it is to get current data, and this is a particularly important concern with overdoses, as the data is often delayed,” said Magdalena Cerdá, director of New York University’s Center for Opioid Epidemiology and Policy.
CDC provisional data on U.S. overdose deaths cuts off at April 2021—slightly over one year into the pandemic. Provisional data is only based on available information that passes a certain quality hurdle, CDC says, and there’s a longer lag in data for overdose deaths than other causes.
Having a lag makes it difficult to respond to the overdose crisis in “a nimble way,” Cerdá said.
Part of the data issue lies with the states. Different jurisdictions have different ways of documenting overdoses, Cerdá says. In some states, it’s done by a medical examiner testing for toxicology. In others, she says, it may be done by a coroner, who has less training and might not do toxicology.
“That lack of standardized data collection makes it difficult to have comparable data,” Cerdá said. The CDC and states have done much to try and address the problem, and more work on this front is “hugely positive.”
Differing state policies pose challenges to other aspects of the plan, including its focus on boosting harm reduction services, or those that cut down on the consequences of drug use, treatment professionals say.
Denis Antoine, director at Johns Hopkins’ addiction services clinic, said that while harm reduction has been “practiced more and more in different states,” there “probably needs to be more evidence generated to make sure it will be effective for long term substance-use related outcomes” in various locations based on each state’s rules.
For example, all 50 states have laws facilitating public access to the overdose reversal drug naloxone, but who is “legally allowed to access it and how” varies across jurisdictions, Cerdá said.
About 35 states have “some mechanism” that allows for naloxone distribution without a prescription, Cerdá said. Among those states, though, some only allow distribution by pharmacies, while others allow distribution by other entities, such as community organizations.
Cerdá also noted that “states and local jurisdictions vary in the extent to which they allow for the operation of syringe service programs,” marking another barrier for the administration.
Use of buprenorphine to treat opioid addiction could face barriers by location, too. The Biden administration removed training requirements for medical professionals to be able to prescribe the drug, an opioid approved by the Food and Drug Administration as a medication-assisted treatment for opioid use disorder. But Stein said some states “impose additional restrictions” while Tennessee doesn’t allow physician assistants and nurse practitioners to prescribe buprenorphine at all.
The Biden administration’s guidelines, released in April, say health practitioners who are licensed and possess a valid registration from the Drug Enforcement Administration can prescribe buprenorphine without certification in training, counseling, and other ancillary services like psychosocial sessions.
Andrew McWilliams, CEO of the treatment provider American Addiction Centers, says that Biden’s most recent plan hits the right notes at the “macro level,” but some detail still needs to be ironed out.
“We need to put just as much effort and funding into medication-assisted treatment programs as we do for injection sites,” McWilliams said. Harm reduction “has a place, but it is not a solution. Without additional clinical programming, it’s essentially kicking the can down the road.”
Treatment specialists generally welcomed the HHS’ plan as a step in the right direction, rooted in science rather than dated views on substances and those suffering from addiction.
Still, “the issue of stigma” around “evidence-based treatment with effective medications” in place of the criminal justice system remains, Stein said.
“The more leaders and public figures both speak about treatment and public health rather than punishment is an important step,” Stein said. “Actions to change the culture of institutions and their policies are also needed.”
Stein pointed to New York state, which this year passed legislation making medication for treating opioid use disorder available for people who are incarcerated.
“Those types of actions change not just the treatment available to individuals suffering from opioid use disorder, but more broadly change the way many people think about the issue,” Stein said.
Effectively addressing the overdose rate may go beyond the confines of the plan as well.
“It is a multi-pronged approach” that “also involves investment in social benefits like unemployment benefits, eviction moratoriums, supportive housing policies, and supplements for working families,” Cerdá said. “All of those things will be important in addressing the overdose crisis.”