Beto’s Plan to Address Substance Use Disorders and the Opioid Epidemic
Our country knows all too well the devastating effects that opioid overdose and opioid use disorder have had on our families and our communities. Each day, more than 130 individuals die after overdosing on opioids and in 2017, the last year for which data is available, over 47,000 Americans died as a result of opioid overdose, which includes not only prescription drugs, but heroin and fentanyl. 68% of those overdoses occurred among men. It has also been reported that from 2015 to 2016, African American men, Latino men, and African American women saw an increase in opioid death rates. Overdoses involving benzodiazepines have also been steadily increasing from 1,135 in 1999 to 11,537 in 2017.
As President, Beto will:
- End the stigma around substance use disorders, focusing on public awareness.
- Ensure access to treatment to enable long-term recovery, providing access to medication-based recovery and supporting at risk populations, including rural Americans, veterans, Native Americans, and incarcerated individuals.
- Ensure that individuals with chronic pain for whom proper usage of opioids are life-sustaining pharmacotherapy are not denied access to these medications.
- Target the supply chain by tackling the illegal importation of fentanyl and holding the medical profession and the pharmaceutical industry accountable.
- Ensure those recovering from substance use disorder, opioid use disorder, and alcohol use disorder have economic stability.
End the Stigma and Discrimination Around Substance Use Disorders.
Beto will treat substance use disorder and opioid use disorder as the public health concerns they are. These are not criminal justice issues that warrant punishment. Beto understands that these are chronic brain diseases with the potential for both recovery and relapse. An O’Rourke Administration will respond appropriately by prioritizing prevention efforts and access to services and long-term recovery for individuals with opioid use disorder and substance use disorders. Outside of cost, the stigma surrounding substance use and opioid use disorders is considered the largest barrier to treatment, and an O’Rourke Administration will not only employ the appropriate terminology, but will fight discrimination against those seeking health care and recovery for substance use disorders.
- Support Public Education Campaigns, to the scale of awareness raised around tobacco. The Tobacco Master Settlement Agreement of 1998 resulted in $246 billion over 25 years, paid out to states. The Settlement provided for $300 million annual spending for five years to create a foundation dedicated to public education around tobacco, including the truth campaign, which employed culturally relevant references and leveraged significant cultural moments (like awards shows) to engage with youth on the dangers of tobacco use. Beto will call for a similar funding level, paid to states, to educate the public on prevention, risks, interventions and recovery related to opioid use disorder and substance use disorders.
Ensure Access to Health Care and Interventions that Promote Long-Term Recovery.
- Prevent overdose and expand access to medication-assisted recovery. Use of these medications also reduces the risk of individuals dying from effects related to opioid withdrawal, including dehydration.
- Beto will enact Medicare for America, which will ensure universal, guaranteed, high-quality health care that includes mental health care. This will eliminate barriers to medication-assisted recovery, including coverage by insurance of FDA-approved maintenance medications, also referred to as medication-assisted recovery, including buprenorphine, methadone and Suboxone. He would also allow clinicians to prescribe buprenorphine without having to undergo an invasive process. Clinicians are currently required to undergo training, receive an additional license, and submit patient records to the DEA.
- Buprenorphine is considered the most effective drug in preventing overdose. A study found that after France adopted this model in 1995, expanding access to the drug, they saw an 80 percent decline in opioid overdoses. It is estimated that a similar decrease in the U.S. would mean 37,000 fewer deaths. In addition, expanded access to methadone and Suboxone (buprenorphine and naloxone) as part of medication-assisted recovery has been proven to offer effective reduction of opioid cravings while mitigating withdrawal symptoms. Both Suboxone and methadone activate opioid receptors in the brain, thereby staving off withdrawal symptoms and desire to use.
- Beto will also ensure enforcement of the Mental Health Parity Act and Addiction Equity Act, which prevent insurance companies from offering less favorable benefits for mental health or substance use disorders when compared to other medical coverage. Beto will ensure that mental and behavioral health, as well as substance use health care and services as outlined in the Affordable CareAct, are components of every health care plan. Through enforcement, Beto will ensure individuals with mental health disabilities and substance use disorders are not denied these critical benefits and life-saving interventions, medications, and care.
- Crack down on methadone’s for-profit industry. Expand Medicare and Medicaid, until a system of universal health care is put in place under Medicare for America, to cover methadone treatment, and allow doctors to prescribe methadone, allowing individuals to maintain their treatment without the barriers of transportation, clinic availability, and bad weather.
- Address struggles with substance use disorder beyond opioids. There has been an eightfold rise in mortality for benzodiazepines, often identified as anti-anxiety medications, between 1999 and 2016, with a particular impact on women. For women between the ages of 30 and 64, mortality rates increased 830% between 1996 and 2017. When co-prescribed with opioids, these drugs can increase the risk of overdose. There have also been documented increases in the use of methamphetamines. In 2017, more than 10,000 individuals died of causes related to methamphetamines, up from over 500 individuals in 1999, and an increase of nearly 7.5 times from 2007 to 2017. Beto will fund research for medically assisted treatment (MAT) for methamphetamines — such products do not currently exist, though experts have indicated doctors are considering trials with Chantix, a tobacco cessation drug. He will also direct the Food and Drug Administration to closely monitor the production of new products used to treat pain.
- Provide additional grants to states and localities to support harm reduction programs with $100 billion Substance Use Disorder Fund consisting of grants to states and localities to address this public health crisis. To receive funds, governments will be required to develop comprehensive, multi-year plans to prevent, intervene, and support long term recovery efforts related to substance use disorder and opioid use disorder, while rigorously evaluating the effectiveness of these plans and programs. Funds will be allocated based on need, use of best practices and evidence-based strategies, and proposals with promising new strategies to build the evidence base of what works well. The $100 billion comes from an increase in the Affordable Care Act’s Branded Prescription Drug Fee. Uses of funding will include:
- Expanding access to evidence-based substance use disorder and opioid use disorder treatment and recovery programs, including those that specialize in co-occurring psychiatric and substance use disorders
- Tackling the shortage of mental health and substance use treatment professionals by improving the pipeline to employment through investments in education and training programs — recognizing the need to staff additional acute care, outpatient, and long-term recovery-targeted programs;
- Expanding access for individuals and families to medications that prevent overdose through increased supply, and ensuring first responders, law enforcement and public spaces have naloxone, also known as Narcan, onsite, in addition to training public employees on its administration. The Denver Public Library system was able to save 14 lives in 2017 because of readily available Narcan.
- Creating needle exchanges and supervised consumption sites where people can consume drugs they have obtained elsewhere in a controlled setting, under the supervision of trained staff, and with access to sterile injecting equipment;
- Implementing innovative models for health care and interventions related to substance use disorder such as that used in Portugal, particularly mobile vans that travel to areas of high consumption to distribute medicines or needle exchanges, where individuals caught with drugs are sent to treatment instead of jail;
- Supporting state foster systems straining under the influx of children who have lost parents to the epidemic, with uses that can include prevention to families at risk of entering the foster system, recruiting foster families, and collaboration across systems (including the criminal justice system). In West Virginia, the number of children in the state system have doubled over the past decade, and officials estimate 80% of children in the state’s care have been impacted by the opioid epidemic.
- Support caregivers for children exposed to substance use disorders. Approximately 1 in 8 children have one or two parents suffering from substance use and alcohol use disorder. Beto will work with Congress to sign into law the bipartisan Help Grandfamilies Prevent Child Abuse Act, expanding the Child Abuse Prevention and Treatment Act (CAPTA) to ensure resources reach grandparents, and other caregivers to children whose parents are absent due to substance use disorders, require CAPTA resources go to prenatal care, particularly pregnant women. Beto will also support continued implementation of the Family First Prevention Services Act, to increase access to Title IV-E reimbursement for prevention services, thereby allowing children to remain with relatives.
- Ensure access to treatment for at risk populations, including rural populations:
- Veterans: Allow doctors at the Department of Veterans Affairs to prescribe medicinal cannabis and non-opiates as a pain treatment medication alternative. In his plan to support Veterans, Beto called for standing up interdisciplinary pain management teams at every VA medical center, and supporting the compassionate use of medicinal cannabis as an effective remedy for many conditions.
- Native Americans: Double grant funding from $50 million to $100 million for the Tribal Opioid Response grant program, providing tribal nations with the resources to offer Medication-Assisted Recovery (MAR).
- Ensure that individuals released from prison have access to MAR by allowing inmates with substance use disorder in prison access to buprenorphine or methadone as part of long-term recovery plan, which has been shown to reduce death in the first four weeks after release by 75%. These individuals are often at increased risk of overdose in the first four weeks after incarceration, when formerly incarcerated individuals attempt doses their bodies can no longer accept. A 2018 report by the CDC found that 10% of overdose deaths were those of individuals who had been released from an institutional setting in the month before the overdose
- Rural: Beto will expand access to telemedicine and increase support for providers to reduce the workforce shortage. Often, access to housing and training serve as the barriers to filling needed positions.
- As part of his commitment to expand the housing stock for both lower-income and middle class Americans, Beto will invest $60 billion in the Capital Magnet Fund.
- Beto will provide accelerated loan forgiveness for health care professionals willing to work in rural and underserved communities, forgiving all student debt after 5 years of service and 20% of principal for each year of service.
- Beto will also fully fund the Public Health Service Corps debt forgiveness programs, which support individuals working in Health Professional Shortage Area (HPSA), and double the funding of the National Health Service Corps Substance Use Disorder Workforce Loan Repayment Program, to benefit individuals working at substance use disorder treatment sites with a qualifying HPSA score.
- Improve the quality and reduce the cost of treatment by tackling abusive practices of the substance use disorder treatment industry. There is currently no entity within the federal government regulating facilities that oversee treatment for substance use disorder, and much of the U.S. substance use disorder treatment industry does not provide evidence-based, effective care consistent with long-term recovery. The Centers for Medicare and Medicaid Services (CMS) has over 4,000 quality measures, but there are zero for substance use and opioid use disorder programs. An O’Rourke Administration will:
- Under Medicare for America, tie Medicare reimbursement to adherence to clinical-based guidelines and outcomes compared to other programs -just as we do for other types of health care interventions.
- Use Federal Trade Commission (FTC) and CMS authority to shut down centers that deceive and over-bill patients. The FTC should pay particular attention to illegal lead generation practices.
- Task the FTC with cracking down on “product hopping” which allows pharmaceutical companies to make a minor change to a drug (such as switching from capsules to tablets) to generate a new period of exclusivity and then heavily promote it to convince physicians to switch to the more expensive drug without generic competition.
Ensure that individuals with chronic pain for whom proper usage of opioids are life-sustaining pharmacotherapy are not denied access to these medications
- Demand Appropriate Opioid Prescribing. Direct the CDC to improve the guidelines offered to primary care doctors, clinicians, and other specialists who are issuing opioid prescriptions, increasing research, and mirroring that guidance with respect to benzodiazepines. These guidelines must also ensure that individuals in need of opioids for treatment of chronic pain are not deprived access to these medications through arbitrary dosage and supply limits, and that individuals perceived to be at risk for opioid use disorder are connected with the appropriate information about available services and interventions for opioid use disorder.
Target the Supply Chain
- Demand accountability from the pharmaceutical companies through tighter government regulation and oversight. In Oklahoma’s recent case against Johnson & Johnson, the judge ordered that the company must pay the state $572 million, the amount of money necessary to implement the first year of the state’s abatement plan to combat the opioid crisis. This plan will include opioid and substance use disorder treatment and services, non-opioid pain treatment alternatives, and neonatal abstinence syndrome treatment, among other provisions. To ensure accountability outside of litigation, Beto will direct his Administration to:
- Demand accountability from the owners of pharmaceutical companies, not allowing them to hide behind the corporate framework and reversing the “Marino” bill, which limited the Drug Enforcement Administration’s (DEA) ability to hold drug distributors accountable for suspicious shipments by raising the legal standard under which distributors would be required to stop a shipment to “a substantial likelihood of an immediate threat” and allowing distributors to submit “corrective actions” before the agency can take action against them.
- Require prescription drug manufacturers and distributors’ CEOs, Board Chairs, and major investors to certify that their sales and marketing policies, procedures, and implementation complies with federal law and are not designed to oversell prescription drugs. Individuals who certify in bad faith will be subject to civil or criminal penalty.
- Extend SEC bad actor disqualification to include violations committed by drug companies during the opioid crisis, making it harder for companies that played a role in the crisis to raise capital.
- Revise FDA regulations to allow individuals to bring a case against a company, despite FDA approval of the drug. This will remove threat of preemption.
- Combat the presence of fentanyl within the United States. Beto will work to curb the flow of fentanyl into the United States — a drug that is 50 times stronger than heroin — and has contributed to the majority of synthetic-opioid-related deaths between 2013 to 2018, taking the lives of approximately 98,000 individuals. He will do this by:
- Applying pressure on China to stem the flow of this drug into the United States, which US officials believe to be the main source of illegal fentanyl, much of it coming through the mail. This would include requiring China to increase its monitoring of fentanyl as a condition of ongoing trade negotiations and bi-lateral discussions. Beto will also cooperate with China, under licensing agreements. to develop and increase access to portable sensors that detect fentanyl.
- Ensuring that the U.S. Postal Service has the resources needed to improve its ability to monitor packages coming from China.
- Ensuring the U.S. Customs and Border Patrol, a partner to the Postal Service in the screening of mail, has the resources necessary to conduct the required searches at ports of entry, and will reallocate CBP staff that have been sent to the border, to focus instead on drug trafficking.
Ensure those recovering from substance use disorder, opioid use disorder, and alcohol use disorder have economic stability.
Beto recognizes that individuals with opioid use disorder have difficulty finding and holding good paying jobs. The CDC estimates that the economic burden of the opioid epidemic is $78.5 billion per year, factoring in the cost of healthcare, lost productivity, and the cost to the criminal justice system. We know that opioid use disorder is not limited to one region of the country. The Midwest saw a 70% increase in overdoses between June 2016 and September 2017, while large cities in 16 states have seen a 54% increase in opioid overdoses. To ensure individuals have the support they need to find employment and/or re-enter the workforce, Beto will:
- Support Individuals Transitioning Back Into Their Communities: Beto will triple federal investment in grant funding for re-entry programs that address homelessness, access to substance use disorder long-term recovery, mental health services and supports, disability, and unemployment. He will also expand post-release job placement and training programs, including access to peer support specialists to aid in the transition process.
- Invest in Paid Training: Beto will create 5 million paid apprenticeships over ten years. Grants will be awarded competitively based on the quality of the training program, industry wages, prospects for career growth, and plans to recruit marginalized groups and displaced workers. Marginalized groups will include Americans recovering from substance use disorder, opioid use disorder, and alcohol use disorder.