In November 2021, provisional data from the Centers for Disease Control and Prevention (CDC) showed that the U.S. surpassed 100,000 drug overdose deaths from April 2020 to April 2021. This record-setting number follows the previously reported figure of 93,145 overdose deaths in 2020 (roughly 30% higher than in 2019). The recent rise in overdose mortality rates has been exacerbated by increases in fentanyl and polysubstance use, and complicated by an accompanying long-standing stigma regarding addiction. Furthermore, the COVID-19 pandemic has intensified the conditions leading to overdose; people with substance use disorders (SUD) were greatly affected by the pandemic’s disruption of daily life and reduced access to treatment services.
Drug overdose mortality rates in minority populations have disproportionately increased recently, with Black and Native American mortality rates increasing by 81%, and Hispanic mortality rates increasing by 65% between 2019 and 2021; by comparison, for whites, mortality rates increased by 40%. Since the start of the COVID-19 pandemic, the South and West regions have seen 57% and 67% increases in drug overdose mortality, respectively, versus an 18% increase in the Northeast and a 37% increase in the Midwest.
In response to this crisis, Congress has maintained opioid-related discretionary spending at over $6 billion per year from fiscal year 2018 through fiscal year 2020. The COVID-19 relief funds have added an additional $2.5 billion in funds targeting SUD. It is important to note that these discretionary dollars are dwarfed by mandatory spending; Medicaid alone spent approximately $23 billion in 2019 on treatment for opioid use disorder.
While considerable attention has focused on the drivers of the opioid crisis, policymakers in Congress remain unsure whether federal investments in opioid-related programs over the past several years have yielded improved patient outcomes, as treatment remains out of reach for the vast majority of Americans with SUD, and overdoses remain high.
Building on its previous 2019 and 2020 reports, BPC launched the Opioid Crisis Task Force to develop recommendations for Congress and the Biden administration to optimize mandatory and discretionary spending and improve opioid-related population health outcomes. The recommendations fall into four policy areas: mandatory spending that could be more fully leveraged; discretionary spending with a focus on “smarter” spending that is evidence-based and coordinated; data reporting and metrics that could be more uniform, frequently reported, and actionable; and governance and leadership to best ensure executive branch-wide coordination and accountability.
The recommendations are as follows:
Recommendation #1: Ensure Parity and Expand Coverage for SUD Services
- The HHS Secretary and CMS, Alongside DOL and the IRS, Should Coordinate With State Insurance Commissioners and State Medicaid Agencies to Exercise Their Authority to Enforce Parity Rules for SUD Treatment.
- The HHS Secretary Should Direct CMS to Work with Section 1115 Waiver Recipients to Ensure That Funds Are Used Primarily to Finance Evidence-based OUD Interventions.
- The HHS Secretary Should Direct CMS to Promote Medicaid Section 1115 Waivers for Evidence-based Nonmedical Recovery Services.
- CMS Should Promote Medicaid Section 1115 Waivers for Incarcerated Individuals.
Recommendation #2: Increase Medicaid and Medicare Reimbursements for OUD/SUD Treatment
- The HHS Secretary and CMS Should Educate Providers on Recently Added SUD-specific Billing Codes.
- The HHS Secretary and CMS Should Adopt Alternative Payment Models Incentivizing Patient-centered OUD Care.
Recommendation #3: Ensure Qualified Health Providers Can Bill for OUD/SUD Treatment (In-person and via telehealth as appropriate)
- Congress and CMS Should Consider Expanding Provider-type Eligibility for OUD Treatment (e.g., SUD counselors, peer support specialists).
- Maintain Flexibilities for Eligible Behavioral Health Providers to Provide Care Across States (In-person and via telehealth).
- Congress and the DOJ Should Ease Prescribing Restrictions for In-person and Telehealth OUD/SUD Services.
Recommendation #1: Optimize the SOR and SABG grant programs
- Congress Should Reexamine the Formula for the SOR Program.
- Congress Should Enact Multiyear Authorizations for the Formula Grant Programs.
- Congress and the HHS Secretary Should Direct SAMHSA to Work With SOR and SABG Grantees to Ensure That Funds Are Used to Finance Evidence-based OUD Interventions and Promising Innovations.
- The HHS Secretary Should Direct SAMHSA to Promote Funding of Evidence-based Recovery Services.
Recommendation #2: “Braid,” or Coordinate, Federal Funding Streams Thematically
- States Should Be Encouraged to “Braid” Discretionary and Mandatory Funding Streams.
- Congress and the White House, Working With Executive Branch Departments, Should “Braid” Discretionary Funding Streams by Directing Similar Opioid-related Programs to Formally Collaborate.
Data Reporting and Metrics
Recommendation #1: Establish a Set of Evidence-based “Core Metrics” Tied to Surveillance and Health Services Delivery
- ONDCP Should Guide Executive Branch Departments in Establishing “Core Metrics.”
- ONDCP Should Work with the HHS Secretary Who Would Direct SAMHSA to Replace Its GPRA Measures With “Core Metrics” Using an Existing OMB Waiver.
Recommendation #2: Collect “Core Metrics” for OUD/SUD Surveillance and Health Service Delivery More Frequently and Undergo Relevant System Updates
Recommendation #3: Create an OUD/SUD Data Dashboard to Improve Data Sharing and Policymaking While Maintaining Privacy
- HHS Should Create a New Data System Modeled After HHS Protect for OUD/SUD Data.
- HHS Should Establish Anti-discrimination and Privacy Protection Policies for SUD Patient Data Sharing.
Recommendation #1: Reorient ONDCP’s Role to Focus More on Policy Leadership and Federal Coordination
- Congress Should Restore Cabinet-level Rank of the ONDCP Director and Consider the Appropriate Placement of the HIDTA and DFC Programs.
- The HHS Secretary and ONDCP Should Improve Intradepartmental and Interdepartmental Collaboration.
- ONDCP Should Operate as a “Center of Excellence” for Drug Control Policy and Federal Coordination.
Recommendation #2: Provide Expert Technical Assistance to States
- Congress Should Fill Existing Vacancies at SAMHSA to Enhance State-level Training and Technical Assistance Efforts.
- The Federal Government Should Provide States with Technical Assistance to Direct Opioid Settlement Funding.
Recommendation #3: Leverage ONDCP’s National Drug Control Strategy for Congressional Oversight
All the recommendations included in this report can assist in optimizing federal spending and the federal response to address the opioid crisis. Stronger federal leadership and actionable metrics will more strategically direct money from discretionary and mandatory funding streams, which can then be used to save lives through evidence-based prevention, treatment, harm reduction, and recovery interventions. With so many preventable lives lost to the opioid crisis to date, it is of high national interest to target funding in a sustainable manner and overcome regulatory and legislative barriers to address the needs of vulnerable populations affected by opioid use disorder.
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