I will never forget an interaction I had in Washington while serving as New Jersey’s health commissioner. A federal official addressed state health directors. I was initially pleased to hear her tone around opioid addiction, encouraging an approach that was more compassionate and treatment-focused.
But when I asked her about regulatory restrictions on the use of buprenorphine, the gold-standard medication for addiction treatment, she defended the fact that trained clinicians had to go through hours of additional training, only to find that the number of prescriptions they can issue is capped at 100 before having to recertify. I chimed in: Why is a medication that treats withdrawal and addiction harder to prescribe than opioids like OxyContin? What followed was an unsatisfying response about the complexity of the therapy, knowing full well that many more complex specialty drugs, with substantially greater risks, require no such federal certification.
Unfortunately, while the rhetoric of federal officials has changed, meaningful reform lags, mostly for political reasons.
Opioids killed more Americans last year than car accidents. How did we get to this point? Overprescribing is certainly a major part of our story, as well as synthetic opioids like fentanyl. Fentanyl is particularly problematic due to its more than 50-fold potency over morphine. On overprescribing, better use of evidence-based alternatives has allowed us to make progress. Having since moved on to the privilege of leading our state’s only public hospital, when I arrived I found that our emergency medicine team reduced prescribing out of our emergency room by 70%. Gov. Murphy has also bolstered hospital-based prescription reduction efforts with significant funding.
But for all of this progress, the root causes of the epidemic involve stigma, trauma, poverty, and institutional racism. Modern science also teaches us that substance use disorder is not an issue of depravity, but rather, a neurobiological disorder that fundamentally alters brain circuits involved in reward and self-control.
Unfortunately, federal policy retains vestiges of the shame that once shrouded public conversations around addiction. Federal laws, regulations, and funding decisions maintain structural barriers to effective drug policy at local levels precisely because they are politically tricky.
Ways to reduce harm
A first example is harm reduction through needle exchange. Clean needles prevent the transmission of HIV and hepatitis C. Studies evince that syringe exchange programs reduce overdose deaths, decrease new HIV and viral hepatitis infections, and increase entry into substance use programs. Despite this, federal appropriations law still bars states from using federal funds to pay for syringes. Critics continue to argue that these strategies encourage drug use. But evidence shows that they neither increase drug use nor crime. Federal lawmakers should fund syringe access directly, and more robustly.
Second, states need the help of federal regulators to reduce the price of naloxone, the antidote used to revive someone at the time of overdose. New Jersey estimates its need for naloxone at much greater levels, and the price point is limiting. The need is particularly stark in urban areas, where an average of only 25% of pharmacies carry the drug, versus closer to 70% in more affluent, suburban areas.
Third, the Drug Enforcement Agency should relax the regulations around prescribing buprenorphine, eliminating the special certification requirements and prescription limits. My conversation with the federal official reflected a different mentality rooted in stigma: that medications used to treat addiction are potential drugs of abuse themselves. However, evidence shows that buprenorphine is not abused and even when it is bought and sold on the black market, most take it to avoid withdrawal. Withdrawal is also the most important reason why folks refuse transport to the emergency room after being revived, which is why as health commissioner I authorized New Jersey paramedics to administer it in the field after an overdose, a first in the nation.
But widespread uptake of this life-saving therapy will, again, require federal action. That is why I joined 21 other state health directors in signing a letter to the federal government asking them to remove onerous certification requirements for buprenorphine. After taking similar actions to deregulate buprenorphine, France saw nearly an 80% decline in overdose deaths. Similar actions here would afford the United States 30, 000 fewer annual deaths from opioid overdoses.
Finally, just last month, recipients of federal grants from the Substance Abuse and Mental Health Services Administration received a letter from the agency warning that their funding is at risk if they — or any clinical organization within which they operate — use medical marijuana as part of a treatment regimen for opioid use disorder. The Murphy administration, along with several other states, added opioid use disorder as an eligible condition for medical marijuana for a reason.
Studies, including a recent systematic review, have found that symptoms across a spectrum of behavioral health conditions, including opioid use disorder, are more mitigated if medical marijuana is used in conjunction with other therapies. But simply pointing out that better evidence isn’t available yet, when the federal government itself puts up the very barriers that have led to this dearth of research on medical marijuana’s benefits, should not be reason enough to threaten states and organizations that are tired of waiting.
Federal policymakers will need courageous leadership to make these decisions. That means not waiting for the politics to be favorable around all evidence-based tools we have against the opioid epidemic. Allowing time for the controversial or politically tricky strategies to become more palatable will needlessly cost lives. We need political leadership that is willing to offend sensibilities for the sake of public health, and finally end this epidemic.