The Politics of Addiction: How a Group of Cities and Counties Shaped the Federal Response to the Opioid Crisis

By Joe Pritchard, CEO, Pinnacle Treatment Centers

On October 26^th, 2017, the President of the United States convened a press conference in the East Room of the White House and made an announcement eagerly anticipated by many people in the mental health and substance use treatment community:

“The opioid epidemic is a national health emergency. Nobody has ever seen anything like what’s going on now. As Americans, we cannot allow this to continue. It’s time to liberate our communities from this scourge of drug addiction. We can be the generation that ends the opioid epidemic.”

Following the announcement, the White House unveiled a three-part initiative to address the opioid epidemic:

1. Reduce demand, reduce over-prescription, and educate citizens about the dangers of opioid misuse.
2. Disrupt the supply of illicit opioids through increased domestic and international law enforcement efforts.
3. Expand evidence-based treatment and access to recovery support services for all citizens.

A year later, the U.S. Congress passed the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, a.k.a. The SUPPORT Act. The SUPPORT Act is the largest piece of legislation ever passed by Congress to address a drug crisis.

The President’s announcement, subsequent initiative, and the ensuing passage of federal legislation got a lot of national press. As it should have. But like most things that reach the federal level and get the attention of the Office of the President and the advantages of the bully pulpit, the plan to end the opioid crisis did not start at the very top.

Nor did it start in the offices of Senators or House Representatives.

It started small.

It started local.

The entire effort started with concerned representatives from a group of counties and cities in the U.S. joining together and saying,

“Enough is enough. It’s time to do something.”

A Joint Task Force

In August 2016, the National Association of Counties (NaCO) and the National League of Cities (NLC) formed a joint task force to address the growing opioid crisis in America. The ongoing task force, chaired by Judge Gary Moore of Boone County, Kentucky, and Mayor Mark Stodola of Little Rock, Arkansas, includes representatives from 11 counties and 11 cities around the country.

Participating Counties

• Boone County, Kentucky
• Weber County, Utah
• Ross County, Ohio
• Erie County, Pennsylvania
• Laporte County, Indiana
• Florence County, South Carolina
• Kern County, California
• Erie County, New York
• Mercer County, West Virginia
• Anne Arundel County, Maryland
• Multnomah County, Oregon

Participating Cities:

• Little Rock, Arkansas
• Covina, California
• Boston, Massachusetts
• Fort Lauderdale, Florida
• Greenbelt, Maryland
• Atlanta, Georgia
• Tempe, Arizona
• Dayton, Ohio
• Manchester, New Hampshire
• Wichita, Kansas
• Huntington, West Virginia

They convened their task force in response to the alarming increase in opioid-related health issues plaguing their constituents. The statistics they cited at the formation of the task force painted a dire picture:

Overdose deaths.

Between 2000 and 2017, the number of deaths due to opioid overdose increased at unprecedented rates:

• 6,242 deaths in 2000
• 12,991 in 2005
• 19,687 in 2010
• 32,500 in 2016

Over-prescribing.

Americans consume 80% of all prescription opioids in the world, and the number is rising:

• 1991: 76 million people received prescriptions for opioids.
• 2011: 219 million people received prescriptions for opioids.
• 2016: In 12 states, the number of opioid prescriptions written was greater than the number of people in that state.
  • On an average day in 2016, medical professionals wrote over 650,000 prescriptions for opioids.

Illicit Opioid Use.

Prescription opioid use can lead to illicit opioid use when the prescription runs out. On an average day in 2016:

• 3,900 people initiated nonmedical use of prescription opioids.
• 580 people used heroin for the first time.
• 78 people died from opioid overdose.

Considering these facts, local city and county officials felt they could no longer sit by and do nothing. They formed their task force and met twice during 2016: once in Washington, DC, and once in northern Kentucky. The result of their collective effort was a comprehensive report and list of recommendations for city and county leaders to implement in order to combat the opioid crisis.

A Prescription for Action

The report they generated – A Prescription for Action – included the input of countless local officials not on the task force, public health directors, prosecutors, treatment providers, and law enforcement officials. The action plan addressed four key areas:

1. Leadership
2. Education and Prevention
3. Treatment
4. Public Safety

Here are the recommendations they made in each area:

Leadership

1. Involve local and community leaders in all aspects of the response to the opioid crisis. Local leaders should include behavioral health and substance use treatment professionals, elected officials, education officials, parent advocates, and faith leaders.
2. Set a compassionate and constructive tone in all conversations about opioid abuse. Normalize conversations about addiction and addiction treatment in order to reduce stigma and encourage people from all walks of life to understand the issues and seek help for themselves or their loved ones, if needed.
3. Encourage cooperation between towns, cities, and counties. While lateral, regional cooperation typically involves law enforcement, the opioid crisis demands coordination between regions on subjects of education and treatment, as well.
4. Speak up the chain of command. City and county officials should inform their state and federal counterparts about the effects of the opioid crisis on their communities. They should also communicate clearly – up the chain of command – about which initiatives offer the most practical support for their communities.
5. Include everyone. City and county officials should recognize that communities of color have been disproportionately impacted by current drug laws. New approaches to both law enforcement and substance use disorder treatment should focus on harm reduction and improved public health for all citizens.

Education and Prevention

1. Increase awareness. City and county leaders should leverage all forms of communication to educate their citizens on the dangers of opioids and the availability of treatment. Leaders should use town halls, advocacy events, Facebook, Twitter, Instagram, and any and all available means to spread knowledge and awareness about opioids and the opioid crisis.
2. Embrace Technology. This can occur on multiple levels. Communication with constituents is one, but the use of technology to collect current data to target treatment efforts is equally, if not more, important. For instance, local officials can mine data for information on the number and location of opioid prescriptions written and the number and location of opioid overdose deaths in order to target communities in most need of support.
3. Organize disposal and take back days. Cities and counties can ensure their citizens have access to safe disposal sites where they can get rid of their unneeded or unused prescription opioids and dispose of used needles. Getting opioids out of home medicine cabinets can help stop casual recreational use and accidental overdose, while getting dirty needles off the street can help stop the spread of HIV and hepatitis.
4. Educate children early both in and out of school. Data indicates that the earlier children learn real facts about drugs, the more likely they are to make informed, safe, and responsible choices when presented the opportunity to experiment with drugs. Education can happen in the classroom, in after-school programs, and in the home.
5. Advocate for opioid training in higher education. Students in all health-related fields – from medical school to nursing and pharmacy programs – should receive training on substance use disorders and pain management.

Treatment

1. Increase the availability of naloxone. Naloxone is a wonder drug: it’s a life-saving, non-addictive drug that can reverse the effects of an opioid overdose if it’s administered in time. Forty states currently allow pharmacists to distribute naloxone to individuals with opioid prescriptions. These states also allow pharmacists to dispense naloxone to individuals who support or act as caregivers to people with opioid use disorders. All 50 states should allow this, combined with a “warm handoff” program so that anyone who received naloxone can be referred to appropriate counseling and/or treatment.
2. Increase availability of Medication-Assisted Treatment (MAT). Policies and regulations that limit the number of patients to whom a physician can prescribe medications like Suboxone® (buprenorphine) are significant barriers to treatment. The same problem exists with methadone programs: current regulations are barriers to treatment. Rather than limiting the availability of these life-saving treatments by placing arbitrary restrictions on medical professionals, access to these programs should be expanded in order to reach more people.
3. Expand insurance coverage for the treatment of substance use disorders. City and county leaders can advocate that all health insurance plans cover addiction treatment and remove limits on reimbursement for treatment. In addition, city and county officials can ensure their local government health plans over treatment for substance use disorders. This is a bigger deal than it might seem: nationwide, city and county governments employ millions of people. If they’re all covered, that’s a big step in the right direction. Finally, all health insurance plans should cover MAT as part of substance use disorder treatment.
4. Increase availability of telemedicine. The advent of instant video-chat technology has expanded access to medical treatment. While initial visits should be in-person, rural patients with access to the internet can engage in treatment without traveling hours. Current insurance regulations limit the amount and types of treatment available through telemedicine: these restrictions should be eliminated in order to expand access to care.

Law Enforcement

1. Reduce supply. The Drug Enforcement Agency (DEA) has a State and Local Task Force Program with the capacity to combine the considerable resources available to federal officers with the detailed knowledge of local law enforcement officers. Coordination across agencies and regions leads to more effective drug enforcement. This is critically important now, as drug dealers have begun lacing street drugs such as heroin with additional, more dangerous substances like carfentanil, which drastically increases the chances of lethal overdose.
2. Look for alternatives to arrest. In the 1990s, we made a choice as a country: come down hard on anyone who has anything to do with drugs. People apprehended with small amounts of illegal substances were arrested and incarcerated under mandatory-minimum sentencing guidelines. This criminalized behavior largely driven by addiction. However, law enforcement officials now understand that arresting users for minor possession is not an effective method for changing behavior. According to the International Association of Police Chiefs, law enforcement officers should:

“…strive to create innovative partnerships with public health providers and rehabilitation experts to help line officers respond more effectively to substance abusers with an increased array of alternative solutions to incarceration.”

This means that instead of being forced to make arrests for low-level possession, local law enforcement officers should be given the discretion to refer people with addiction problems to local addiction treatment programs.

3. Institute drug courts and divert offenders from the criminal justice system. This is part two of “look for alternatives to arrest.” Many cities and counties across the country use drug courts to reduce drug use and criminal behavior related to addiction. Drug courts typically use teams of judges, prosecutors, corrections officers, social workers and treatment professionals to manage courts and provide appropriate treatment services.
4. Expand treatment in jails. Evidence shows that incarcerated individuals with opioid use disorders who receive little or no treatment while incarcerated are more likely to relapse and return to criminal activity when they’re released than those who receive appropriate treatment while they’re incarcerated. They’re also more likely to overdose shortly after being released. Jail-based programs should not only address substance use, but also help individuals develop healthy interpersonal relationships and improve their ability to interact positively and productively with family, employers, peers, and other members of their community.

The Results: Federal Legislation That Helps Local Communities

In addition to recommendations for local leaders, the Task Force took its own advice, and made recommendations up the chain of command. They told federal agencies what they could do to facilitate the implementation of all the initiatives mentioned above.

Specifically, they asked federal lawmakers to:

• Expand access to MAT
• Fund local efforts to battle the opioid crisis
• Coordinate with local law enforcement to stop the supply of illicit opioids
• Allow individuals to receive Medicaid benefits while awaiting trial, and if convicted, make it possible to immediately reinstate benefits upon release.

And guess what?

Federal lawmakers listened.

The SUPPORT Act contains all the recommendations included in the “Prescription for Action” report prepared and presented by the National Association of Counties and the National League of Cities. The law expands access to MAT by easing restrictions on all MAT programs and requiring Medicaid to cover MAT costs. The law expands telemedicine, allocates billions of dollars to local treatment efforts and national law enforcement initiatives, allows people to receive Medicaid while waiting for trial, and includes provisions to make it easier for people to receive Medicaid upon release from detention.

This entire process – from the formation of the task force to the passage of legislation – is an example of how local engagement is a critical element in battling the opioid crisis. The task force was made up of local officials: city council members, mayors, and county-level representatives. These people aren’t insulated from the day-to-day realities of their constituents. They live those realities right alongside them. The reality they saw was that the opioid crisis was slowly destroying their communities and literally killing their friends and family members.

So they took action.

They took action to help their neighbors, and the action they took now has the potential to help people across the country meet and defeat the opioid epidemic. Their action reinforces the well-known saying, attributed to anthropologist Margaret Mead:

“Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it’s the only thing that ever has.”

THE PINNACLE COMMUNITY PLEDGE

Pinnacle Treatment Centers is committed to addressing the opioid epidemic at the local level. With more than 70 locations in six states, we drive education, support, and treatment to the places and people who need it most. Every day, we join families in urban areas, rural areas, and everywhere in between to fight the opioid epidemic. Please check our locations page to find a treatment program near you, read our blog to learn more about the latest topics in treatment and recovery, and keep an eye on our news page to find out about our new locations, community events, and how our leadership team collaborates with state, local, and federal officials to heal and restore balance to the individuals, families, and communities impacted by the crisis.