The COVID-19 pandemic is just one of two public health crises the new Biden administration will confront. The addiction crisis is the other. The opioid epidemic has already killed more Americans than World Wars I and II combined. And it is but the most visible sign of a broader population health challenge that includes methamphetamine, cocaine, benzodiazepines, and alcohol. This article presents practical legislative and executive actions that are required for addressing these challenges. The authors focus on two broad policy challenges: (1) improving financing and delivery of treatment for substance use disorders, and (2) reducing population exposure to addictive and lethal substances. Through both of these channels, a portfolio of well-implemented, evidence-informed policies can save many thousands of lives every year.
The COVID-19 pandemic is just one of two public health crises President Biden and the new Congress face now that they have been sworn into office. Addiction and opioid overdoses have accelerated during the past year (AMA 2020; Shover et al. 2020). The opioid epidemic has already killed more Americans than World Wars I and II combined. It is also but the most visible sign of a broader population health challenge that also comprises methamphetamine, cocaine, benzodiazepines, and alcohol (Lembke, Papac, and Humphreys 2018; O'Donnell et al. 2020; Spillane et al. 2020).1
Even if one excludes tobacco, addiction's toll on America rivals COVID-19's in morbidity and mortality and exceeds it in terms of unemployment, community violence, and family dissolution (CEA 2017; SAMHSA 2016, 2018).
An effective federal response must improve accessibility and quality of addiction care while reducing population exposures to addictive drugs (e.g., through effective regulation of legal drugs such as OxyContin and alcohol and law enforcement responses to illegal markets, such as in fentanyl). Through both of these channels, a portfolio of well-implemented, evidence-informed policies can save tens of thousands of lives every year.
This article presents practical legislative and executive actions required to accomplish these tasks. We focus on two broad policy challenges: (1) improving financing and delivery of treatment for substance use disorders (SUDs) and (2) reducing population exposure to addictive and lethal substances.
Improving the Financing and Delivery of Addiction Treatment in Mainstream Health Care, Particularly in the Financial Hydraulics
In this section we discuss strategies to improve the quality and accessibility of SUD treatment. The first challenge is to integrate the financing of SUD treatment within mainstream public and private insurance programs to establish a politically and financially durable structure of care. SUD treatment is largely set apart from the payment arrangements, accountability standards, and regulatory mechanisms of modern health care systems. The separation of addiction treatment from other health care arises in part from the history of assigning the treatment of these conditions to the criminal justice system, social welfare agencies (e.g., the Salvation Army), and state and local government, where they are frequently subdivided between specialty addiction programs and criminal justice institutions (SAMHSA 2016, 2018; White 2014). Much of the funding relies on direct annual budget allocations (e.g., police funding) or grants and contracts supported by federal (primarily block grant) and state dollars.
These mechanisms are largely detached from mainstream health care financing, accountability, and quality assurance. The result is a system with inadequate and unstable funding to meet prevention and treatment needs and a delivery system that fails to serve many people who need addiction treatment and too often provides low-quality care (SAMHSA 2016, 2018).
Candidate Biden promised greater investment in addiction treatment and prevention (Biden-Harris 2020). That is welcome and necessary. Yet, if that new money follows tradition and takes the form of targeted set-aside grants, it will not promote the long-term investments in treatment infrastructure America needs. Nor will these investments improve a system that falls short of using what is known to improve patients' health and well-being.
A better treatment financing strategy would align federal, state, and private interests by channeling most new federal dollars through enduring, mainstream funding mechanisms that support the rest of health care: Medicaid and Medicare and the funding of federal health care systems, namely the Veterans Health Administration (VHA), Military Health Care System (MHS), Indian Health Service (IHS), and Community Health Centers.
More money, by itself, will not address the failure to deliver evidence-based treatment; nor will it ensure the quality of addiction services. Financing of each of these systems must incorporate robust mechanisms for accountability and quality improvement. When such “pull” funding mechanisms (IOM 2010) are implemented, states, localities, and indeed treatment providers themselves will have incentives to invest in infrastructure, as they do for services to address other health problems. None of these actors will make the same long-term investments in response to fragile, time-limited, and targeted grants.
Implementing a financially durable response to the opioid epidemic in the public and private sector would particularly improve the accessibility and quality of opioid use disorder (OUD) care. Done properly, this strategy will enhance our capacity to meet other public health challenges, including the rise of stimulant addiction and heavy alcohol consumption.
The Mental Health Parity and Addiction Equity Act (MHPAEA) has been an important element in expanding financial support treatment of SUDs. Reenergizing parity enforcement and extending the principle of parity by building more robust accountability systems in SUD care will complement public financing policy described earlier.
MHPAEA has greatly improved coverage. Yet compliance with MHPAEA's benefit design requirements (cost sharing, treatment limits) has been much stronger than the compliance with provisions that regulate the management of care (Goplerud 2013; Horgan et al. 2016; US Department of Labor 2016). Expanded enforcement of “parity” laws and associated regulations that govern private insurers—including those that participate in Medicare and Medicaid—promotes greater care access, better financial protections for patients, and improved quality. More complete MHPAEA implementation further integrates behavioral health into mainstream public and private insurance programs in the US. It may also help to reduce stigma that accompanies both addiction and addiction care.
Several specific steps would enhance existing enforcement efforts:
Direct the White House Domestic Policy Council to conduct a rapid review of progress made toward all recommendations of the 2016 Obama-Biden mental health and substance use parity task force and present the president with legislative and executive options for advancing recommendations that have yet to be fully implemented.
Create a high-level DOL-HHS-Treasury fusion center dedicated to parity enforcement across all types of insurance plans. The center will be responsible for educating and monitoring insurers and developing clear criteria for auditing plans on network adequacy, use of preauthorization procedures, utilization review, medical necessity standards and guidelines, appeal processes, patient out-of-pocket costs, and adequacy of provider reimbursement. The fusion center will expand technical support and training for DOL inspectors, state insurance commissioners, and other officials responsible for enforcing parity laws.
Direct HHS, in alliance with leading mental health and substance use stakeholders, to launch a national campaign educating employers, patients, families, and health care providers regarding consumer rights under the parity law and encouraging them to file complaints with the appropriate agencies for violations of the law.
Our systems of addiction treatment, oversight, and financing are not fully equipped to realize the principle of parity, in the sense of making access to high-quality behavioral health care similar to what is found in health care overall. Accomplishing parity as an everyday reality requires addressing incentives to underserve people with behavioral health conditions and to skimp on quality.
People with addictive illnesses are particularly costly to insure. Most health plans do not receive additional payments for enrolling people with addiction, and if they do, those adjustments fall short of the additional expected costs. Health plans can thus profit by avoiding such enrollees or by stinting on their care. Such discrimination is enabled and worsened by the absence of quality indicators for addiction in most quality measurement systems.
To address this reality, accountability systems must be bolstered to measure and monitor the quality of behavioral health services. Failure to meet standards must also carry meaningful consequences. That means improving performance measurement, including sufficient measures to monitor behavioral health performance into core measure sets, establishing rewards and penalties that promote access to quality care.
We must also reduce or neutralize incentives for insurers to avoid enrolling and serving people with mental illnesses and SUDs. One concrete step would be to improve the behavioral health components of existing risk adjustment systems that are used in Medicare, the Health Insurance Marketplaces, and some Medicaid programs (Montz et al. 2016).
Policy can increase use of evidence-based treatment in a large segment of addiction treatment providers. The Biden administration should lead the way by committing to expand the use of evidence-based addiction care within federal health care programs, with a particular focus on medications for opioid use disorder (MOUD).
Medicaid provides insurance coverage for more than 72 million people, including many Americans at high risk for OUD. How Medicaid sets standards and pays for addiction treatment influences almost every aspect of SUD care. Medicaid-issuing guidance to end administrative restrictions on FDA-approved MOUD can thus promote widespread use of this set of evidence-based treatments.
One incentive for greater use of MOUD could involve increasing Medicaid's Federal Medical Assistance Percentage (FMAP) for states that adequately reimburse addiction treatment providers—clawing back funds from states that do not raise reimbursement levels. This increase would require new legislation.
Within Medicare, the Biden administration can work to eliminate access barriers to MOUD within Part D drug plan formularies. Likewise, Medicare Advantage health plans must be prohibited from creating barriers to evidence-based SUD care.
The Biden administration could also take administrative actions to improve treatment access and quality for services paid for or provided by an array of other federal agencies, including the VHA, MHS, IHS, and Community Health Centers. New funding should tightly focus on expanding SUD care, for example providing resources to guarantee that all Federally Qualified Health Centers and IHS facilities have in-house addiction care expertise and that every patient with OUD in every federally overseen health care system has access to all FDA-approved MOUD.
The White House Office of National Drug Control Policy (ONDCP) has the authority to audit all drug control–related agency requests. It should be tasked with guiding those requests through its interagency consultation process. It should use its authority to reject agency budgets that fail to request sufficient resources to adequately expand addiction treatment. ONDCP's authority could be strengthened by President Biden issuing an executive order mandating universal access to addiction care within all federally overseen health care systems and requiring the relevant secretaries to submit budget requests for achieving it.
The federal government should expand MOUD treatment within the criminal justice system, including upon jail and prison release.
The attorney general could restore the Obama administration's directive that no federal funds be provided to drug courts that fail to offer participants all three FDA-approved MOUD. The Justice Department could also direct the Federal Bureau of Prisons to provide MOUD to all incarcerated individuals who have opioid use disorder. The Biden administration and Congress should consider supporting legislative proposals to have Medicaid reimburse addiction treatment beginning 30 days prior to release from incarceration (e.g., the Medicaid Reentry Act). Finally, the Center for Medicare and Medicaid Services should work with states to limit participation of private insurance plans in Medicaid Managed Care programs and Medicare Advantage to those that cover all MOUD. Medicaid could also reimburse Critical Time Interventions and other services for returning citizens with behavioral health concerns.
The federal government, American households, and private insurers currently pay billions of dollars for SUD treatments that do not reduce the toll of addiction. Some are even harmful to those treated. The federal government must adopt policies that stop paying for care that does not work.
Too often, the regulation and financing of SUD care provide weak accountability that allows treatment providers to supply services that actively discourage use of evidence-based treatment—promoting services that in some cases increase overdose and mortality risk upon discharge. Recent “secret shopper” studies show that 39% of residential SUD programs do not offer MOUD with an opioid agonist; 21% actively discourage admission of patients being treated with MOUD using an opioid agonist (Beetham et al. 2020). There is also continued reliance on inpatient detoxification programs that are not closely connected to community-based continuing care. Discharge after detoxification from opioids without follow-up increases the risk of overdose and death relative to evidence-based care—and may even attain higher mortality risk than no treatment at all (Strang et al. 2003).
The American opioid epidemic is significantly grounded in inappropriate medical practice (Alpert et al. 2019). Inappropriate prescribing of pain medications remains disturbingly common to this day. Federal policy must support efforts to improve nonpharmacologic pain treatment and expand access to such care.
Patients who experience chronic pain require effective treatments without the risks that accompany long-term opioid use. Expanded provision of cognitive-behavioral therapy (CBT), physical therapy, and occupational therapy would give patients and clinicians more care options than they often currently have in a system overly reliant on prescription medications alone. The VHA's Opioid Safety Initiative has shown that, when scaled up, such alternatives are accessed by many patients (Gellad, Good, and Shulkin 2017). The Obama-Biden administration's National Pain Strategy detailed other effective approaches to reducing the population burden of pain and should be revisited in a Biden-Harris administration (NIH 2019). The Biden administration's reappointment of Vivek Murthy as surgeon general should reenergize these and related proposals laid out in a report on addiction presented at the close of the Obama administration (SAMHSA 2016).
People with OUD face particularly high risks of overdose and death upon release from jail or prison. It has been estimated that fewer than 5% of people referred through the criminal justice system to specialty OUD care received either methadone or buprenorphine (Krawczyk et al. 2017). The President's Commission on Combating Drug Addiction and the Opioid Crisis (Christie et al. 2017) noted important barriers to MOUD provision within the criminal justice system. Measures such as expanded distribution of overdose rescue drugs and syringe support services (SSPs) provide important complements to MOUD treatment in protecting the health and well-being of people who use drugs.
Naloxone (also known as Narcan) is sold for as little as $0.75 per vial and as much as $200 per dose in an electronically facilitated injection device. The federal government has substantial purchasing power to negotiate for lower prices, and it does so for some programs (e.g., within VHA). Unfortunately, the government is legally forbidden from doing so for the 50 million Medicare Part D enrollees.
President-elect Biden has proposed to eliminate the noninterference clause in the Medicare Modernization Act that would allow for negotiation over naloxone and other drug prices. That requires legislation (e.g., H.R. 3). A more immediate path would involve the president invoking such authorities through the declaration of a public health emergency under the Public Health Service Act or Stafford Act. President Trump declared such an emergency but then did not use most authorities available to him (US GAO 2018).
Although opioid overdose is the main killer of people who use drugs, HIV and other blood-borne diseases remain public health threats. SSPs thus have a critical public health role in protecting people who inject drugs. Although such services are often placed in opposition to or contrast with SUD treatment, such programs are more-fruitfully considered as complementary. SSPs can engage and retain people who are not otherwise receiving addiction treatment services. Conversely, addiction treatment providers can provide linkages to syringe support services for patients and clients who continue some level of injection drug use.
The Biden administration has particular opportunities to strengthen services for criminal justice populations, who face extremely high risks of overdose, HIV seroconversion, and other poor outcomes. Through Medicaid and other policies, the administration can support treatment providers and correctional institutions to provide comprehensive health and social care services to all patients, clients, and detainees, and to provide improved service linkages when individuals exit jails and prisons. NIDA's Justice Community Opioid Innovation Network (JCOIN) provides one source of evidence-informed strategies in these efforts.
Reducing Population Exposure to Addictive Drugs
Basic public health principles encourage removing pollution from the air, bacteria from drinking water, and viruses from shared surfaces. In like fashion, an effective public response to addiction requires constraining population exposures to addictive substances. Several steps are central to such a response.
First, restore the value of the federal alcohol tax. No drug competes with alcohol as a contributor to violence, arrests, and incarceration. This toll rises as the real cost of alcohol declines (e.g., Cook 2007). Flat federal excise taxes on alcoholic beverages were set almost thirty years ago and have declined in real terms every year since. Adjusting these for inflation would save thousands of lives annually.
Second, restore international partnerships to reduce the flow of fentanyl and other drugs. Publicly denigrating the governments and populations of other nations may be the least effective approach to reduce the flow of drugs into the United States. Building a border wall is likewise ineffective when most illicit substances arrive through legal points of entry. Acting alone, America cannot address the challenges posed by fentanyl and other substances. Effective international control of fentanyl and other opioids requires bilateral and multilateral partners. The US also has much to offer, including as the home base for some pharmaceutical companies aggressively pushing prescription opioids overseas using tactics now outlawed in the United States (Humphreys, Caulkins, and Felbab-Brown 2018).
Mexico should be the highest initial priority, given the large drug trade across the US-Mexico border. Collaboration on supply control and rule of law can be complemented by exchanges on public health issues, including increased availability of evidence-based treatment for Mexicans with SUD and support for Mexican drug treatment courts and other alternatives to incarceration for nonviolent offenders who often are sent to poorly maintained jails.
America is also well-positioned to assist Mexico (and other partners) in addressing other public health challenges, particularly COVID-19. Such cooperation offers compelling opportunities to earn our partners' trust in addressing our own opioid epidemic, and to save lives.
The Biden administration can also make fentanyl a top priority in dealings with China. Controls imposed for synthetic opioids produced within its borders have evidence of translating into reduced deaths in the US (Jalal and Burke 2020).
Third, the Biden administration can step-up enforcement against misconduct by opioid distributors. Legislators with longstanding pharmaceutical ties led passage of the Ensuring Patient Access and Effective Drug Enforcement Act of 2016, stripping most of DEA's power to respond to distributors making and failing to report suspicious opioid shipments. This law should be repealed or reformed. The Biden administration should take a page from the tobacco history by taking steps to prevent American drug manufacturers from pursuing unethical sales practices overseas that effectively export the opioid epidemic to developing countries.
Fourth, curtail industry promotion of controlled substances to prescribers. Another useful concrete step would be to remove the tax deductibility of pharmaceutical product promotion for opioids and other drugs with addiction/misuse potential. US pharmaceutical industries spend more than $25 billion per year marketing medications to prescribers and directly to consumers.2 These expenditures are currently tax deductible against firms' income. It is not clear why the public should subsidize activities that foster greater opioid prescribing and harms during an opioid epidemic (Hadland et al. 2018). De-incentivizing such promotion through removing the tax deduction thus has importance far beyond the revenue it would bring. The Biden administration can support the End Taxpayers Subsidies for Drug Ads Act, introduced by Senator Jeanne Shaheen, to reform these practices.
The Biden administration faces many policy challenges. None—including the immediate threat from COVID-19—is likely to take more lives than opioids during the full Biden presidency. As noted above, no single policy or intervention will halt or dramatically reduce the ongoing death toll from the opioid epidemic. A portfolio of well-implemented, evidence-informed policies can nonetheless save many thousands of lives every year.
For reasons of space, we do not consider tobacco control within this article.
Direct-to-consumer advertising increases prescribing beyond the advertised drug. For example, ads for medications that help with opioid side effects (e.g., constipation) are indirectly opioid ads.