Remarks by ONDCP Director Michael Botticelli
Remarks by ONDCP Director Michael Botticelli
The Road Back from the Opioid Crisis:
Lessons for State Leadership
Crystal City Doubletree, Arlington, VA
September 17, 2015
Thank you for the opportunity to be here today, and thank you, Rob, for that kind introduction. I appreciate having your support and leadership on this journey.
As Rob will attest, during my time on the NASADAD Board, I never missed an opportunity to politely remind our Federal colleagues of the critical role that States play: how States were the incubators of innovation not the federal government, and how important it was to have time with my colleagues in other States to hear about their challenges and successes. Your presence here along with your presentations reflect the role that States have played and will continue to play in addressing this epidemic. Whether distributing naloxone , using provisions of the ACA and Medicaid expansion for service and delivery redesign, integrating treatment into primary care settings, responding to infectious disease outbreaks associated with injection drug use, passing state legislation on prescriber education, Good Samaritan laws and overdose prevention, or bridging the gap between an overdose and treatment, State-level action will continue to help inform our Federal actions. As a State director I was also shameless about stealing programs from other States and this meeting also provides an excellent opportunity for you to learn from each other to replicate innovative and effective programs.
During my time at ONDCP I have travelled to many States, met with governors, senators, prevention and treatment providers, researchers, people in recovery and parents whose loved ones have been affected by this epidemic to ensure that we are doing everything we can at the federal level to be responsive to this epidemic and to state and local needs.
I particularly want to thank Secretary Burwell for making this issue a priority for HHS and convening this meeting and to her staff at HHS as well as all of the other government employees here today working on this issue.
Finally, I want to thank all of the invited speakers, like Mr. Alcantara, who just told an inspiring story about his own recovery journey.
I want to spend a few minutes reviewing the Administration’s response on this issue and the work ahead of us.
My office by statute, annually engages in three primary efforts to guide drug policy; each year we:
• Publish the National Drug Control Strategy, a comprehensive plan to reduce illicit drug use, the availability of drugs, and the consequences of drug use in the United States;
• Develop a consolidated National Drug Control Program Budget to implement the Strategy; and
• Coordinate and oversee the implementation by Federal Drug Control Program Agencies of the policies, goals, objectives, and priorities established for the National Drug Control Program and the fulfillment of the responsibilities of such agencies under the Strategy.
These three activities guide the Administration’s efforts to reduce drug use, manufacturing and trafficking, drug-related crime and violence, and drug-related health consequences.
Many Federal departments and agencies play a role in drug policy. The Obama Administration is committed to restoring balance to U.S. drug policy efforts by coordinating an unprecedented government-wide public health and public safety approach to reduce drug use and its consequences.
In 2010, the year when drug poisoning deaths surpassed the historically most lethal cause of preventable injury – traffic crashes – ONDCP published the Obama Administration’s Inaugural Strategy. In addition to our 2010 National Drug Control Strategy, the Administration released its Prescription Drug Abuse Prevention Plan in 2011. This blueprint was the result of a joint Federal partner and stakeholder process to establish our best options for addressing the Nation’s overdose and overprescribing crises.
Since then, working with our Federal partners and stakeholders, we have made progress toward many of the goals established under each of the Plan’s four pillars – education, monitoring, drug disposal, and enforcement.
Education is the first pillar.
Educating parents and prescribers.
Parent education is vitally important for our prevention efforts. Parents should understand the importance of talking to their children, and safely storing medications they have in the house.
And most critically it is vitally important to our efforts that we train health care providers in proper opioid prescribing.
In four years of medical school, students receive on average only 11 hours of pain medication training. And virtually none on the treatment of substance use disorders. I do not believe that after almost 10 years of escalating consequences due to the over-prescribing of prescription pain medications that it is a burden to ask prescribers to have a minimal amount of education on safe opioid prescribing. It is an obligation.
A number of continuing education training programs have been developed to teach prescribers skills such as how to start a conversation with patients about their substance use; managing pain appropriately; and treating patients using opioids more safely.
Various Federal agencies are leading the way by making certain that their workforce is properly trained. It is incumbent that our federal prescribers model what we want all providers to do. To this end:
• Prescribers at the NIH Clinical Center take continuing education on safer prescribing when they are hired.
• Over 1,000 providers have been trained by the Indian Health Service on pain, diversion, screening for substance use disorder, and alternatives to opioids for pain.
• In the Department of Justice’s Bureau of Prisons, virtually all of the supervisory medical staff and dentists have completed an online training program.
• Many prescribers in the Department of Defense have been exposed to training through the Military’s “Do No Harm Training,” and DOD has a policy requiring this training for prescribers in all branches.
The Food and Drug Administration (FDA), through its voluntary Risk Evaluation and Mitigation Strategy (or REMS), provides a training program on extended-release/long-acting opioids. Thousands have taken this program.
But does prescriber education work?
Researchers in Massachusetts recently published an evaluation of a REMS program produced at Boston University called “Scope of Pain.” The evaluation showed knowledge gains after the program. More important, 86 percent of providers reported implementing changes in their clinical practice when asked about it two months later.
We know that there is significant variation in state prescribing behavior as well as a significant correlation between the number of prescriptions and overdose deaths. Continuing to promote mandatory training should be a priority for all of us.
Today, ten states (Connecticut, Delaware, Iowa, Kentucky, Massachusetts, New Mexico, Nevada Tennessee, Utah, and West Virginia ) have passed legislation mandating training for prescribers.
Our second pillar concerns expanding and improving prescription drug monitoring programs (PDMPs). At the beginning of this Administration, there were 30 states with PDMPs.
Today all but one state – Missouri – has a PDMP. PDMPs are databases that allows prescribers to check on drug-interactions and alerts them to early signs of opioid use problems or diversion.
Kentucky, New Jersey, New Mexico, New York, Oklahoma, and Tennessee are some of the states that require their prescribers to use their state’s PDMP. In Tennessee, where the requirement to check the PDMP went into effect in 2013, there was a drop in the number of high utilizers of opioid pain relievers from the fourth quarter of 2011 to the fourth quarter of 2013.
But it is vitally important that PDMPs are adequately resourced so they are easy to use and data can be shared across state lines.
We are pleased that today at least 30 states have some ability to share data with other states. And HHS and DOJ are working to expand data sharing capability.
PDMP administrators are also working to better integrate these systems into other health IT programs so providers can integrate them into their daily workflow.
In 2014, the VA finalized a rule authorizing VA physicians to access state PDMPs in accordance with state laws and to develop mechanisms to begin sharing VA prescribing data with state PDMPs.
Since then, the VA has developed and installed software to enable VA pharmacies to transmit their data to PDMPs. As of April 2015, 67 VA facilities were sharing information with PDMPs in their respective states. VA providers have also begun registering and checking the state databases.
Although PDMP reporting is not required by Indian Health Service (IHS) facilities, many tribal nations have declared public health emergencies and elected to participate with the PDMP reporting initiative. Currently, IHS is sharing its pharmacy data with PDMPs in at least 19 states and negotiating data-sharing with more states.
The third element of our plan is disposal. We all know that the majority of individuals who begin misusing prescription drugs get them from family and friends, therefore, we must make it easier to dispose of unused medications.
From September 2010 through September 2014, the Drug Enforcement Administration (DEA) partnered with hundreds of state and local law enforcement agencies and community coalitions, as well as other Federal agencies, to hold nine National Take-Back Days.
And these events have been successful both at removing prescription drugs from the home and increasing public awareness of the dangers posed by unused prescription drugs in the home.
DEA collected and safely disposed of more than 4.8 million pounds of unneeded or expired medications. DEA has scheduled its next National Take-Back Day for September 26, 2015.
In September 2014, DEA published the final regulations on controlled substance disposal. Now ONDCP and our Federal partners and stakeholders are informing the public about the regulations and looking at ways to stimulate local disposal programs in partnership with pharmacies and law enforcement.
The rule allows for many options, including mail-back programs, which may help with unique state situations that would otherwise require a legislative solution.
The Plan’s fourth pillar focuses on improving law enforcement capabilities to reduce the diversion of prescription opioids. Federal law enforcement, including our partners at DEA, is working with state and local agencies across the country to reduce pill mills, prosecute those responsible for improper or illegal prescribing practices, and make it harder for unscrupulous registrants (including pharmacies) to remain in business.
ONDCP and the Department of Justice are leading a heroin task force that includes our public health partners. In the interest of time, I won’t go into detail concerning all the Federal activity focused on keeping heroin out of the United States. But we are working closely with our partners at the Departments of State and Homeland Security and with the international community to address supply reduction and interdiction.
Despite the progress we have made on the Prescription Drug Abuse Prevention plan, I am reminded every day of how far we need to go to make things better for individuals and families affected by a substance use problems. You just heard a brave young man discuss his recovery journey. No matter where I go, I hear about the role that shame and stigma continue to play in keeping people from seeking care. I know that some of your State plans have actions to address this issue. Having access to treatment is inconsequential if people are too ashamed to ask for help. I talk publicly about my story because I believe that those of us who have lost loved ones or who are in recovery from substance use disorders must speak up to defy the stereotypes and strike down the stigma that keeps too many people from obtaining help and moving to long-term recovery.
Part of our work at ONDCP and part of the Secretary’s initiative is expanding and improving access to both naloxone and treatment, especially Medication-Assisted Treatment (MAT), our best hope for making a difference. Naloxone is needed to stop the overdose deaths. Medication Assisted Treatment, when combined with other treatment and recovery supports, has been shown to be most effective for treating opioid use disorders. Medication Assisted Treatment saves lives while increasing the chances a person will remain in treatment and learn the skills and build the networks necessary for long-term recovery.
The President’s 2016 Budget Request includes millions of dollars in additional funding for treatment and overdose prevention efforts. In addition, HHS recently announced $100 million in supplementary grants to support medication assisted treatment expansion in Community Health Centers. And the Substance Abuse and Mental Health Services Administration is providing an additional $11 million this year to support medication assisted programming. HHS is also supporting naloxone in rural communities alongside a program for other lifesaving equipment for first responders.
We have strengthened federal contracting language to ensure that that there is access to medication assisted treatment and people who or on medications are not categorically excluded from federally-funded services. I would encourage all of you to follow the example that other States have implemented in using their contracting and licensing authority to do the same.
As part of our collective efforts, we must do a better job of early identification and intervention, integration with mainstream medicine, and collaboration with law enforcement.
All across this country, I have heard from federal, state and local law enforcement that we cannot arrest and incarcerate our way out of this epidemic. I have seen unprecedented partnerships between public health and safety. From one small police department in Quincy Massachusetts, we now have thousands of police officers and other first responders saving lives on a daily basis. Police want to work together to not only reverse overdoses but to help people get into and stay in care. Law enforcement wants to be part of solution and I have been astounded by law enforcement’s commitment.
Law enforcement and other first responders have an important role to play, but the medical community must remain engaged in treating heroin users as well as prescription opioid users. Every day, overdose victims appear in our emergency rooms. We are seeing promising models from the states to use an overdose as an intervention opportunity and to assist in getting people into treatment.
Right now, we are waiting to treat most people until they present of their own accord or are referred by the criminal justice system with only a small percentage of people being diagnosed and referred from the larger health care. People with diseases, including substance use disorders, should not have to diagnose themselves, which creates an expectation that people have to hit bottom. We do not do this with any other disease.
You all play critically important roles in finding solutions to our Nation’s drug problem. We all know that there is no silver bullet to this problem. That this requires a multifaceted approach and requires participation and coordination with our public health and public safety partners. Every sector of our communities has a role to play. It requires action by federal, state and local partners.
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