The package of 70 Senate bills costs $8.4 billion and creates, expands and renews programs across multiple agencies. It’s ambitious in scope, aiming to prevent the deadly synthetic drug fentanyl from being shipped through the U.S. Postal Service as well as allowing doctors to prescribe more medication designed to wean addicts off opioids, such as buprenorphine.
“It doesn’t include everything all of us want to see but it has important new initiatives and it’s a step in the right direction," said Sen. Rob Portman (R-Ohio), who has advocated several measures that are part of the package.
“Congress is committing itself to actually putting politics aside. It’s not just bipartisan -- I think it’s nonpartisan."
Yet many public health advocates and experts say it doesn’t offer the one thing truly needed: The massive amount of funding needed to fully combat a crisis that deeply affects rural and urban communities across America.
Sarah Wakeman,the medical director for Mass General Hospital’s Substance Use Disorders Initiative, said really targeting the depth of the opioid epidemic would require an infusion of federal dollars on par with the more than $20 billion a year spent on HIV/AIDs.
“We have historically not thought of addiction as a medical issue and so our health care and public health system are woefully unprepared to respond in a robust way,” she said.
The House passed a similar measure in June, and the two chambers will need to negotiate a few differences before sending the package to Trump’s desk.
The biggest difference between the House and Senate measures involves an obscure, decades-old rule known as the Institutions for Mental Diseases exclusion rule, or “IMD exclusion,”prohibiting federal Medicaid reimbursements for inpatient substance abuse treatment in centers with more than 16 beds whose patients are mainly suffering from severe mental illness. Many people with substance abuse disorders also have a mental illness, and this rule means they are unable to get treated for their addiction when in a large mental health facility.
The House bill partially overturns the IMD exclusion for mental-health patients who also have an opioid use disorder, which the Congressional Budget Office says would cost nearly $1 billion over the next 10 years. The Senate bill makes some changes to the IMD rule, including making sure pregnant and postpartum women continue receiving Medicaid-covered services administered outside such facilities, such as prenatal care. But it doesn’t allow Medicaid to pay for addiction treatment in bigger facilities.
While addictions to opioids are declining, heroin overdose deaths are rising. That’s not because more people are using heroin, but because the drug is being laced with fentanyl - an incredibly potent, inexpensive and synthetic opioid. The Centers for Disease Control estimates that of the 72,000 overdose-related deaths in 2017, 30,000 were caused by synthetic opioids.
The Senate bill addresses the ease with which synthetic opioids are shipped from overseas, typically from China. A provision from Portman requires the postal service to screen packages coming from overseas and receive electronic data about the packages' content -- something that as of now only commercial carriers have to do. The House legislation contains similar language.
Additionally, the Senate bill seeks to increase access to treatment for people with substance abuse disorders, particularly through a grant for recovery centers where people getting over their addictions can find temporary housing, job training and other assistance during that transition.
It provides loan repayments to behavioral health providers practicing in substance-abuse disorder facilities in areas of the country where there’s a shortage of mental-health professionals; expands a program that gives first responders the ability to administer naloxone, the life-saving antidote to opioid overdose; and would allow the Federal Drug and Administration to require drug manufacturers create blister packs where opioids are administered in a limited three to seven day supply.
Jessica Hulsey Nickel, president of the Addiction Policy Forum, is an advocate of the bill.
“I think it’s an important moment of new resources and better policies to address the opioid epidemic,” she said. “It’s a historic bill that treats addiction like the disease it is.”
But others in the industry are less impressed.
Daniel Raymond of the Harm Reduction Coalition said it's hard to tell a city losing its citizens to drug overdoses that help is coming in the form of a competitive grant pilot program that it may or may not receive.
“This is an election year bill to show they are doing something. That’s not always a bad thing, but I do think to some degree it’s a political document,” Raymond said last week. “When you drill down into it, it’s not that there aren’t good ideas, but it doesn’t reach the level of, this is what our nation needs right now.”
(Correction: Jessica Hulsey Nickel’s name was misspelled in an earlier version of this story.)