How to Fight the Opioid Crisis

Photo

Most people agree that the federal government should tackle public health crises, and there is a particular consensus about the current epidemic involving opioids. The White House announced last fall that President Trump was “mobilizing his entire administration to address drug addiction and opioid abuse by directing the declaration of a nationwide public health emergency to address the opioids crisis.”

Yet as of today, there is no permanent head of the Drug Enforcement Administration. The president’s nominee for “drug czar” to run the White House Office of National Drug Control Policy withdrew from consideration in October and no replacement has been named. The acting chief of staff and general counsel for that office was dismissed last month. All this as overdose deaths continue to rise faster than ever, killing some 64,000 people last year, making the opioid epidemic a top national priority.

We need to rethink how the federal government carries out this mission. The Food and Drug Administration, in approving new opioid drugs, puts more opioids in the marketplace because these drugs meet the standards for safety and efficacy in treating certain forms of pain. But the more opioids there are in the marketplace, the greater the opportunity there is for abuse. The D.E.A. tries to curb the amount by limiting the number of pills that can be manufactured, but when the agency cracks down on one form of the drug, opioid addicts move to other forms to sustain their addiction. Playing Whac-a-Mole is hardly a strategy.

White House czars are largely ineffective because they do not control the agency heads who are legally responsible for carrying out the various congressional mandates of the czars. Historically, the relevant agency heads don’t pay much attention to czars. There is a world of difference between someone whose authority is to coordinate and someone who has the true authority to impose change. Moreover, the president’s drug control policy office has been more heavily focused on law enforcement than on public health strategies.

The many federal agencies that work on this crisis live largely in their own worlds. Funding for opioid-related activities is under the control of multiple departments, including the Department of Health and Human Services and the Justice Department, both of which are criticized as operating with blinders with respect to coordination and accountability.

The task of educating physicians and health professionals about opioids has been spread across multiple agencies: the Centers for Disease Control and Prevention, which established primary physician practice guidelines; the National Institute of Drug Abuse; the Substance Abuse and Mental Health Administration; the Food and Drug Administration; and the Office of the Surgeon General.

None of these agencies has much clout when it comes to the budget for addiction services. Steep cuts have been proposed for Medicaid, the largest single insurance program covering opioid addiction treatment, which will further impede access to substance abuse treatment.

Unfortunately, no one in the federal government has taken the lead to support the testing of new approaches to this epidemic. Such an effort would include new ways to prevent the illicit use of prescription drugs and to establish methods of treating addiction. The President’s Commission on Combating Opioid Drug Addiction and the Opioid Crisis has come up with nearly 60 recommendations that are thoughtful and useful, but responsibility falls across so many federal agencies that little progress is likely to result.

In times of crisis, major change can happen. But this requires central leadership. The administration needs to put under one authority all of the programs and funding sources focused on drug abuse now spread among more than a dozen agencies. These include the D.E.A., the F.D.A.’s addiction and review and enforcement activities, the National Institute of Drug Abuse, the Substance Abuse Mental Health Administration and those portions of the Centers for Medicare and Medicaid Services that fund addiction treatment centers.

With current workplace technology, the programs need not relocate. The H.H.S. secretary and the attorney general, along with other cabinet officials, can have input. But they need to be part of a centralized effort commanded by a new cabinet member who will have explicit, unambiguous authority over these programs, now in the hands of many others, and see to it that we effectively treat those who are addicted and prevent the next generation from becoming addicted. My conclusion is based on my six years as the F.D.A. commissioner during the administrations of George H. W. Bush and Bill Clinton.

We need to change how we as a country view addiction and to change how medicine deals with this epidemic. The programs necessary for treatment and prevention will cost tens of billions of additional dollars. We are currently paying far more than that in dealing with the consequences of this very American problem. Without centralizing responsibility and finding the right leadership, many of our citizens will be lost.