21st Century Cures Act:
A Boon to Mainstream Medicine; A Threat to Drug Treatment*
In December, President Obama signed the 21st Century Cures Act authorizing $6.3 billion for an array of medical research and healthcare initiatives. The National Institute of Health gets $4.8 billion over 10 years – including $1.8 billion for its cancer “moonshot” – and the FDA secures $500 million to accelerate development of new medicines and medical devices. Finally, the Act earmarks $1 billion to combat the nation’s escalating epidemic of opioid addiction. Recall that earlier, Congress passed the Comprehensive Addiction and Recovery Act (CARA), which featured similar anti-opioid strategies but lacked the Cures Act’s funding commitments. Here are the highlights:
• States receive $1 billion in new funding for existing and supplemental programs to expand access to abuse prevention programs, improve treatment facilities and services, and train healthcare professionals.
• The money, distributed in block grants of $500 million for the 2017 and 2018 fiscal year, targets states, underserved communities and vulnerable populations hardest hit by the opioid crisis.
• Congress must approve appropriations each fiscal year, but funds for the opioid epidemic are already authorized from approved cuts in the Prevention and Public Health Fund and sales from the Strategic Petroleum Reserve.
That’s the good news, but other provisions of the act threaten the future of free-standing substance abuse programs and the very nature of drug abuse treatment as it has evolved over the past fifty years.
• The ACT will advance a key feature of CARA, the prioritization of medically assisted treatment (MAT) for drug abuse, which is increasingly implemented during today’s crisis either with none of the behavioral therapies required by SAMHSA guidelines or with only minimal behavioral services.
• Echoing the surgeon general’s recent call to merge substance abuse treatment with mainstream medicine, a stated goal of the Cure Act is to “heal the fracture” and “bridge the gap” between physical and behavioral healthcare.
• In this union, substance abuse is considered a mental health issue and not the unique challenge that we who treat it recognize it to be. Although treatment for substance abuse seeks self-awareness, as does mental health treatment, treating drug abusers requires not only the active participation of patients, but also the insight, trust, and support that patients give each other.
• In its effort to strengthen the mental health workforce, the Act provides support for recruitment and training of mental health practitioners at almost every level and venue. But the Act singles out for inquiry “peer support specialists” in drug treatment programs, calling for a study of federally-funded peer support programs, focused on the qualifications of specialists.
• As for to what has become federally mandated destigmatizing nomenclature, the Act dictates the use of “mental health and substance use disorder” in place of the simple, straightforward description of “substance abuse.”
The Opioid Epidemic and:
Rural White Women
No population group has been harder hit by the opioid epidemic than white, middle-aged women in rural areas of the country. The Washington Post crunched national health and mortality statistics, finding that death rates for this group spiked an alarming 48 percent between 1990 and 2014. It’s part of a broader trend of “decaying health” for white women across the country, but is much more pronounced for white women aged 30 to 44 who live in small towns and less urbanized areas, the Post reported. By comparison, the death rates for women in the same age group in urban areas remained flat or grew by only 1 to 3 percent.
For white men in the same rural demographic, the death rate rose between 9 and 12 percent. While that is also unexpectedly high, the increase is still below what the paper called “the most extreme changes in mortality” for white rural women. Multiple factors are to blame for the rising death rates, the paper says, including an increase in alcoholism, suicide and obesity. But the biggest risk factor was clearly the scourge of opioid and heroin overdoses that has been “particularly devastating in working-class and rural communities.”
As the opioid epidemic sweeps through rural areas of the country, hospital neonatal units are struggling to treat the growing number of drug-dependent newborns, the New York Times reported at the end of 2016. Quoting JAMA Pediatrics, the paper noted a sevenfold increase in the number of drug-dependent newborns in rural hospitals between 2004 and 2013 compared to a fourfold rise in drug-dependency among urban infants during this time period (7.5 per 1,000 newborns in rural areas compared to 1.2 per 1,000 previously; and an uptick in cities to 4.8 per 1,000 from 1.4 per 1,000).
The rising rates mirror the widening use of opioids among pregnant women, the researchers reported. In Utah, for instance, nearly 42 percent of pregnant women on Medicaid were prescribed opioids, mostly to treat back or abdominal pain. Maternal use and misuse of drugs such as oxycodone and illegal narcotics leads to neonatal abstinence syndrome, including breathing problems, seizures and difficulties breastfeeding. The problem of drug dependent newborns, the paper grimly concluded, has “grown more quickly than realized and shows no sign of abating.”
The number of youngsters removed from parental custody and placed in foster care or with relatives is increasing in tandem with opioid-related drug use and deaths across the country. More than 80,000 first-time foster care cases were related to parental drug abuse in 2015, the Wall Street Journal reported. Not surprisingly, the numbers are rising in states worst hit by the crisis, including a 19 percent increase in Ohio; 40 percent in Vermont; and 24 percent in West Virginia. Several states, such as New Hampshire and Vermont, have changed laws to make it possible to take children out of homes where parents are addicted and are budgeting more for social workers to help deal with the crisis, according to a Pew Charitable Trusts report.
Teen Drug Use Falls- But Not Pot
The good news from monitoring the Future’s latest school survey is the overall drop in 8th, 10th , and 12th grade drug use this past year. Use of tobacco and alcohol also hit new lows. Among other positive finding of the survey conducted annually by the University of Michigan for NIDA is declining use of amphetamines like Ritalin and Adderall and non-medical use of prescription narcotics. Use of these opioids fell from 9.5 percent among 12th graders in 2004 to 4.8 percent in 2016 with no corresponding increase in heroin use. The bad news, however, is the absence of marijuana from the general decline. Although 8th grade use did fall, 10th grade use showed no significant change, and past month use for 12th graders rose from 21.3 percent to 22.5 percent (up from 18.7 over the past decade).
What may be the most troubling finding of the latest survey is the dramatic decline in student awareness of marijuana dangers. Long before current research revealed the drug’s threat to the adolescent brain, the overwhelming majority of teens recognized the danger of regular marijuana use. In the early Nineties, roughly 80 percent of students in all three secondary school grades saw great risk in regular use. But the latest survey found just 57.5 percent of 8th graders now see great risk, only 44 percent of 10th graders do, and no more than 31 percent of seniors.
According to the 2016 survey, past year use of marijuana by 12th graders in states with medical marijuana continues to be higher than it is in states without such those laws—38.3 percent of seniors in states that have medical marijuana used the drug during the past year compared to 33.3 percent of seniors in states that do not have it. As for teens in states that have legalized recreational use, they are more likely to eat their pot than teens in states that have not legalized—40.2 percent of legalized state seniors reported using edibles, while only 28.1 percent of non-legalized state seniors are snacking on pot.