White House opioid commission calls for wide-ranging changes to anti-drug policies

President Trump's commission on the opioid crisis called Wednesday for a nationwide system of drug courts and easier access to alternatives to opioids for people in pain, part of a wide-ranging menu of improvements it said are needed to curb the opioid epidemic.

The commission, headed by Gov. Christie, called for expanding drug courts — an alternative system that tries to channel substance abusers accused of crimes into treatment — into all 94 federal court jurisdictions. Currently they are in fewer than half.

The more than 50 recommendations in the draft report also include requiring doctors and others who prescribe opioids to show they have received training in the safe provision of those drugs before they can renew their licenses to handle controlled substances with the Drug Enforcement Administration. The panel also wants to mandate that providers check prescription-drug-monitoring databases to ensure that users aren't "doctor shopping" for prescription drugs. They already are in certain cases in New Jersey and Pennsylvania, although not in all states.

The powerful American Medical Association has expressed concern that federally mandated "one-size-fits-all" training would conflict with state requirements for education and do little to speed the end of the crisis.

The commission specifically declined to endorse the use of marijuana for pain, despite some studies suggesting that access to marijuana may decrease opioid deaths. Christie said in his cover letter to the president that research by the National Institute on Drug Abuse "found that marijuana use led to a 2½ times greater chance that the marijuana user would become an opioid user and abuser." Christie said there is also "a lack of sophisticated outcome data on dose, potency and abuse potential for marijuana."

Nor did the commission endorse establishing safe injection sites like those in Canada, where intravenous drug users can inject drugs under the supervision of trained personnel who prevent them from overdosing. Mayor Kenney's own opioids task force recommended considering supervised sites in May, and, with more than 900 overdose deaths in the city last year, his administration is currently investigating the idea.

While no dramatic recommendations were released at the Christie commission's final meeting on Wednesday, several people spoke in strikingly personal terms about their own families' experiences.

Among them was Roxanne Schwartz of Lebanon, N.J., who told the commission how she and her family managed to gain treatment for her son's addiction to opioids only to spend $300,000 and hundreds of hours appealing insurance claim denials.

"Even when you have access to care, there are barriers to treatment," said Schwartz, adding that parity coverage for mental health issues was essential.

Christie said he found recent testimony from health insurance company executives "sickening," noting that they said "everything's going great and they're making great progress when it's simply not true."

The governor spoke passionately about ending the stigma surrounding drug addiction. He used the example of his mother, who was addicted to nicotine after smoking cigarettes for 55 years before she was diagnosed with lung cancer at 71. When that happened, he said, "no one told me she was getting what she deserved. No one told me they weren't praying for her."

Christie said he doubted that would have been true if his mother had been addicted to heroin.

"Stigma is real, and it's not something we can just talk about," he said.

Like Trump, who declared the opioid crisis a "public health emergency" six days ago, the President's Commission on Combating Drug Addiction and the Opioid Crisis identified no new funding for the drug crisis, which claims the lives of an estimated 175 people every day nationwide. But it called for block grants of substance abuse aid that would consolidate federal funding from a variety of sources and send it to cities and states that are fighting the battle on their streets.

Trump's emergency declaration, which the commission had urged along with eight other recommendations in its July interim report, allows the president to direct all federal agencies to speed aid to localities in the grip of what he called "the worst drug crisis in American history."

One important step he signaled was a decision to have the U.S. Department of Health and Human Services waive a 1960s-era policy that blocked Medicaid payments to inpatient treatment facilities with more than 16 substance-abuse beds. That should make treatment more widely available. Trump also said the Postal Service and the Department of Homeland Security are strengthening package inspections in an attempt to reduce the flow of the street drug fentanyl, much of which is synthesized in China, sent to the United States and mixed with powdered heroin by dealers. On Wednesday, the commission recommended stronger penalties for fentanyl trafficking.

Trump suggested that the federal government might file suit against companies he called "bad actors," presumably those in the pharmaceutical industry that have allowed painkillers to reach the black market. Private attorneys have already filed some lawsuits, and a coalition of 41 state attorneys general is investigating the role of some companies in the epidemic.

But the president was harshly criticized by activists and Democratic lawmakers for failing to put significant new funding into a battle that many say will require tens of billions of dollars, especially for treatment of the 21 million people with substance-abuse disorders. Only about 10 percent of them receive treatment of any kind.

Overdoses from prescription drugs have killed 200,000 people since 2000, and more than 500,000 have succumbed to overdoses of all kinds during the same period. Drug deaths are expected to exceed 60,000, a record, when final numbers are available for 2016. As the crisis has evolved, heroin and fentanyl are responsible for an ever-larger share of the deaths.

The recommendations also come almost a year after former U.S. surgeon general Vivek H. Murthy released a landmark report on addiction in the United States.

Modern treatments for addiction are effective, Murthy and other experts have noted, though relapse rates are comparable to those seen among people with other chronic diseases. For people trying to recover from an alcohol-abuse disorder, it can be four or five years before the chance of relapse drops below 15 percent.

In its interim report, Christie's commission called for a large expansion of medication-assisted treatment, which many experts have called the most effective approach and which Food and Drug Administration Commissioner Scott Gottlieb has endorsed. That therapy provides users with buprenorphine, methadone and naltrexone in an attempt to wean them off harmful addictions to heroin or prescription narcotics.

Wednesday, in its final report, the commission said the government must adjust the way insurance rates are set, saying these rates currently encourage doctors to use opioid painkillers rather than physical therapy or other treatments that do not involve drugs.

Similarly, it recommended that the Centers for Medicare and Medicaid Services eliminate questions about pain from satisfaction surveys that are used rate hospital performance. Physicians have said they feel pressure to treat pain aggressively, often with drugs, so they are not penalized on such surveys. The start of the opioid epidemic in the early 2000s is widely blamed on the overprescription of opioid medications.

Staff writer Don Sapatkin contributed to this story.