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The Opioid Crisis in the United States: Expanding Medicaid to Addiction Treatment

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1. Introduction

a) Background on the opioid crisis

In 2015, drug overdoses have killed 52,404 Americans. The same year, car crashes have killed 38,022and guns 12,9791. While all these numbers are high, the first one is off the charts. Nevertheless, in spite of the number of casualties caused by drugs, policies prove to be fairly inefficient in dealing with the situation. Interestingly enough, while one might assume that the emergency is mainly caused by illegal traffic of substances, the crisis we observe today has started because of a legal drug: opioids. The NIH defines opioids as a class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, and many others’2.

b) Methodology

This policy paper will operate a literature review of current or past policies used to deal with the opioid crisis and try to capture why they have mostly been failing. From there, it will present different alternatives which could be implemented while showing why, while presenting advantages, one option is more reasonable than the others. Our research indeed leads us to the conclusion that we need policy which will treat addiction as what it is – conversely to what has been done so far –, namely a health issue and not a moral one.

2. Framing the issue

a) Review of past or current policies

The opioid crisis has led to many attempts regarding regulation. Policies have somehow focused on primary prevention through education in schools and communities. Most often, regulations have been related to crisis management, through the distribution of naloxone to drug users, paramedics, or bystanders as a way to deal with overdoses. However, globally, the set of policies which have been implemented are mainly aggressive. The initiative Stop Opioid Abuse of the Trump administration is a good illustration of this point. It is threefold: reducing the demand and over-prescription and cutting down the supply of illicit drugs by cracking down on the international and domestic drug supply chains and finally setting up support services3. However, it appears that enforcement has been largely focused on the first two elements rather than the third one. For instance, President Donald Trump has argued the rationale of building a wall at the United States frontier as a way to fight the opioid crisis and the drug-related emergency through a tweet, thus clearly showing that current policies are directed towards aggressive moves rather than providing services4.

b) Why does not it work?

i. We have focused on deterrent policies aiming at decreasing the availability of prescription drugs, which has had unintended effects Knowing that the crisis has been sparked by the legal prescription of painkillers, a logical solution was to simply try and decrease the availability of prescription drugs or to make the access more difficult. However, there is some evidence that such policy has actually increased the number of overdose deaths related to heroin. First, there has been a shift in the paradigm regarding the demographics of users. Indeed, in the 1960s, over 80% of the people who began using opioids started with heroin. However, in the 2000s, 75% of the people who began using opioids started with a prescription pain reliever5. Some research now demonstrates that the use of prescription opioids is actually increasing the risk of heroin use. But why is that? Well, this transition from opioids to heroin can be perceived as the normal evolution of the disease for certain users. Researchers conducted interviews of people with a heroin use disorder6 and came to the conclusion that the structure of the market, notably the accessibility, the cost, and the powerful effects of heroin are all reasons for transitioning from prescription opioids to heroin. Moreover, certain people who face a dependance toprescription opioids can find them increasingly hard to access to, mainly because their original providers do not ensure access anymore. This combined with the fact that obtaining opioids legally is very costly, some people decide to transition to heroin because it is cheaper and easier to get. But the real issue lies in the fact that heroin presents greater risks of overdose than legal opioids, simply because the purity of the drug is less controllable. More specifically, the drug can be contaminated by other drugs, notably Fentanyl which is used in clandestine labs. Public policies obviously need to decrease the prescription of opioids, but reducing it will not solve the problem, simply because it would require to stop the initiation of prescriptions so that people would not become dependent and turn to illegal and more dangerous opioids once they are denied legal access. However, there might be better policies to implement, as it will be discussed in part 3.

ii. Every attempt is hindered by the one true issue: morality and subsequent stigmatization Addiction stands as a very unique disease, notably because it is not perceived as such. People suffering from addiction are often considered as responsible for their situation and not worthy of help. Clearly, individual sense of what is moral has hindered the ability to fight the opioid crisis. Indeed, drug control is shaped by what can be referred to as ‘morality policies’7. As a clear example, some programs that are known to help fight the subsequent effects of the opioid crisis have actually been shut down because of moral views. It is the case for needle exchange programs. When we talk about subsequent effects, we mean addiction, heroin use, and thus the risk of spreading infectious blood-borne diseases such as hepatitis and HIV. What needle exchange programs do is providing people with clean syringes, not only as they also allow to direct users to services they need like addiction treatment or vaccinations. These programs thus recognize that people use drugs and aim at providing them with help. However, because addiction is seen as a criminal justice problem and not a public health concern, many believe that addiction requires punishment and not help. Consequently, many of these life-saving programs have been shut down and needle exchanges have been banned in 15 states. An Indiana county shut down a program quoting morals and the Bible. Commissioner Rodney Fish actually said word for word: ‘It was a moral issue with me. My conclusion was that I could not support this program and be true to my principles and my beliefs’8. As a consequence, the reason why policy responses to the opioid crisis fail becomes clear: the belief that this crisis is not a health issue, but a moral one and the subsequent stigmatization of the people who are sick with addiction. Our policy proposal aims at changing that by going to the roots of the issue and suppressing stigmatization by treating addiction as what it is, namely a public health crisis.

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3. Proposing a solution

a) Evaluating possible alternatives

i. Taking away the illegality to take away the stigma: why it would not work Our reasoning is simple: finding a way to treat the opioid crisis as what it is, a health issue, and subsequently erasing stigmatization. As such, a first reasoning may come to mind: considering the option of legalization of hard drugs. However, here is why we believe it would not work. Many of overdoses are indeed linked to illegal drugs (heroin, fentanyl). However, when considering the opioid crisis, what actually started the epidemic were legal drugs, namely opioid painkillers. Indeed, firms were able to produce a dangerous and highly addictive product, to use marketing meansto sell it, and to spend millions of dollars on lobbying regarding tax rules. In this context, the part played by the government was fairly ambiguous. Indeed, the government mostly worked along with these firms, notably because of the involvement of drug companies in lobbying and campaign funding. As such, the opioid crisis unveils the inability of the United States to regulate and manage drugs in a legal environment, mainly because drug industries are too involved in policymaking. One simple number is needed in order to understand this involvement: in the last decade, drug companies have spent more than 880 million dollars in lobbying to get laws and policymakers to drop new regulations while also asking them to give easier access to painkillers. To give a comparison, that is eight times as much as what was spent by the gun lobby9. Kevin Sabet actually summed up pretty well the issue when he stated: ‘If we were a country with a history of being able to promote moderation in our consumer use of products or promote responsible corporate advertising or no advertising, or if we had a history of being able to take taxes gained from a vice and redirect them into some positive areas, I might be less concerned about what I see happening in this country. But I think we have a horrible history of dealing with these kinds of things ’10. As a consequence, poor regulation tradition might just be what would await if legalization of hard drugs was to happen in the United States. However, we should still be careful. Indeed, saying that legalization would not work does not mean that a framework of prohibition advocating for punishment would either. This is why a compromise could be found.

ii. Finding a compromise: the potential channel of decriminalization If the legalization process appears thorny in the United States, that of decriminalization could be a potential compromise. Some countries such as Portugal have actually implemented such a policy and have gained encouraging results. In Portugal, drugs were indeed decriminalized when it comes to personal use, meaning that people cannot be sent to jail if they possess or use such substances. However, it still remains illegal for companies to produce and sell them and thus make a profit out of a health crisis. Nevertheless, if this policy has allowed for a decrease in drug-related death or incarceration, Portugal is still facing more long-term issues related to drug use such as hepatitis C, liver cancer, or cirrhosis11. Consequently, it seems that even if decriminalization can stabilize the crisis, it does not deal with it at its roots. As a result, we will now review another policy proposal which we believe to be the best option out of all presented alternatives.

b) Policy proposal

i. The policy: expanding Medicaid to addiction treatment The policy we advocate for is one that will consider addiction as what is it: a health issue. It is a policy aiming at shifting from a blame-the-person punitive framework to one going at the roots of the issue, namely the stigmatization of sick people as a result of moral views. In the United States, one in seven people is likely to suffer from a substance use disorder in the course of their life. However, only 10% of those suffering from addiction to a substance get treated for it12. The reason for such a small amount is that local treatments either do not exist or are not accessible. A simple comparison would allow us to grasp the extent of the issue: what if 90% of Americans suffering from heart disease were left to deal with this without healthcare and even die. What if, when going to the ER after a heart attack, they were told that treatment was unavailable at the moment or might never be available? The conclusion is simple: addiction is not treated as a health issue when it should be. Consequently, our policy proposal to make sure that addiction is treated as a health issue and not an amoral one is the following: expanding Medicaid to addiction treatment programs. Why not use private insurers? Simply because it is a well-known fact that addiction treatment is highly underpaid by health insurers, meaning that we need to go through the large health plan that is Medicaid in order to foster reimbursement rates regarding addiction treatments. At the moment, here are some of the criteria to benefit from Medicaid in order to treat addiction. You need to be one of the following to be eligible: over 65 years old, under 19 years old, pregnant, a parent, and within a specified income bracket. However, it is clearly stated on the official website: ‘Even if someone meets these requirements, they may not be eligible for Medicaid. Each state has its own rules for Medicaid eligibility’13. As a consequence, we want to expand the eligibility criteria and have a medication approach to what is a medical problem. It means expanding the accessibility to buprenorphine and methadone which are the two ‘gold-standard’ drugs that treat addiction. Many studies have indeed shown that these two drugs decrease the mortality rate of opioid addiction patients by over half and are way more efficient than non-medication approaches. For instance, in France, policymakers expanded in 1995 the ability of doctors to prescribe buprenorphine. Consequently, overdose deaths decreased by 75% from 1995 to 199914. We would thus want to replicate this model in the United States.

ii. Steps towards implementation One State in the United States has started to try out this policy and has had really encouraging results. Virginia used Medicaid and implemented a program called Addiction and Recovery Treatment Services(ARTS) in 2017. Thanks to ARTS, the number of Medicaid beneficiaries with an opioid use disorder enrolled in treatment increased by 29% between April and December 2017 compared to the same period but in 2016. What interests us the most here is that, in the same period, the visits to emergency rooms related to opioid use decreased by 31% (while this reduction was only of 15% for all state Medicaid members during the same period)15. This policy is obviously all new and necessitates deeper research and more data. However, in order to get it, we have to try. The implementation steps are fairly simple to capture: we need a federal movement using Medicaid as a tool to get people (especially low-income people) into addiction treatment so we can finally deal with it as what it is: a public health emergency. A first and logical step would simply be to expand the budget dedicated to Medicaid. Nevertheless, such a policy would be met with a lot of resistance within the political realm. We could also operate a shift in how the current budget is being used. Indeed, at the moment, about two-thirds of all Medicaid budget is dedicated to the elderly and disabled persons, who only represent one in four enrollees16. However, we observe through the opioid crisis the increasing importance of the rising costs of prescription drugs and the necessity of behavioral health facilities such as rehab clinics. In spite of this, States keep on restricting Medicaid costs while the federal government provides them with flexibility in how they wish to administer Medicaid, meaning that not much is done to expand the program. As a consequence, executive and legislative representatives need to fully back up the Medicaid substance use disorder system transformation by directing the budget towards addiction programs.

4. Conclusion

As a conclusion, this policy paper aimed at firstly reviewing policies that have been used to deal with the opioid crisis. The research has led us to discern a punitive framework mostly based on criminal justice and processes of blaming the addict. Moreover, if some policies did have positive effects, they also had unintended ones such as the increase of heroin-related overdoses. More importantly, these policies seem to be failing because they do not treat addiction as what it is, namely a health issue. Indeed, measures taken so far appear to be hampered by moral views and stigmatization of people suffering from a substance use disorder. As a result, we need to find a solution which will correct the negative effects. Some policies could be considered in order to take away the stigma. As such, legalization could be envisioned. However, the tradition of poor regulation of drugs in the United States as well as the obvious involvement of drug companies in policy-making renders it thorny. A subsequent compromise could then be found through decriminalization, as it has been done in other countries such as Portugal. However, if we are to solve the issue, we need to take a medication approach. This means using medical means and more precisely expanding coverage by using Medicaid in order to get low-income people into addiction treatment. Virginia has slowly started implementing some points of this policy and has had encouraging results. As such, we need a federal injunction which would fund this extension and transformation of Medicaid while giving directives to States in order for them to manage Medicaid in a way that would benefit people suffering from opioid addiction.

5. Bibliography

  1. “President Donald J. Trump’s Initiative to Stop Opioid Abuse and Reduce Drug Supply and Demand.” The White House, The United States Government, www.whitehouse.gov/briefings-statements/president-Donald-j-trumps- initiative-stop-opioid-abuse-reduce-drug-supply-demand-2/.
  2. Talbot, Margaret. “Trump Says That His Wall Will Stop Opioids-Two High-Profile Legal Cases Suggest That He’s Wrong.” The New Yorker, The New Yorker, 23 Jan. 2019, www.newyorker.com/news/daily-comment/trump-says- that-his-wall-will-stop-opioids-two-high-profile-legal-cases-suggest-that-he’s-wrong.
  3. Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers – United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013;132(1-2):95-100.
  4. Cicero, Theodore J. “Changing Face of Heroin Use in the United States.” JAMA Psychiatry, American Medical Association, 1 July 2014, jamanetwork.com/journals/jamapsychiatry/fullarticle/1874575. & Mars, Sarah G, et al. “‘Every ‘Never’ I Ever Said Came True’: Transitions from Opioid Pills to Heroin Injecting.” The International Journal on Drug Policy, U.S. National Library of Medicine, Mar. 2014, www.ncbi.nlm.nih.gov/pubmed/24238956.
  5. Ferraiolo, Kathleen. “Morality Framing in U.S. Drug Control Policy: An Example From Marijuana Decriminalization.” World Medical & Health Policy, John Wiley & Sons, Ltd, 21 Dec. 2014, www.onlinelibrary.wiley.com/doi/pdf/10.1002/wmh3.114.
  6. Maggie Fox. “Some Just Can’t Stomach the Idea of Needle Exchanges.” NBCNews.com, NBCUniversal News Group, 18 Oct. 2017, www.nbcnews.com/storyline/americas-heroin-epidemic/indiana-county-stops-needle-program-meant-stop-hiv-n811741.
  7. Lurie, Julia, et al. “Opioids Are Ravaging the Country. These Lobbyists Want to Keep the Drugs Flowing.” Mother Jones, 23 June 2017, www.motherjones.com/politics/2016/09/opioid-lobbying-pharmaceutical-companies/.
  8. Kevin Sabet quoted in Dufton, Emily. Grass Roots: the Rise and Fall and Rise of Marijuana in America. Basic Books, 2017.
  9. Ferreira, Susana. “Portugal’s Radical Drugs Policy Is Working. Why Hasn’t the World Copied It?” The Guardian, Guardian News and Media, 5 Dec. 2017, www.theguardian.com/news/2017/dec/05/portugals-radical-drugs-policy-is-working-why-hasnt-the-world-copied-it.
  10. Seelye, Katharine Q. “Fraction of Americans With Drug Addiction Receive Treatment, Surgeon General Says.” The New York Times, The New York Times, 17 Nov. 2016, www.nytimes.com/2016/11/18/us/substance-abuse-surgeon-general-report.html.
  11. “Paying for Addiction Rehab with Medicaid and Medicare.” AddictionCenter, www.addictioncenter.com/rehab-questions/medicaid-and-medicare/.
  12. Auriacombe, Marc, et al. “French Field Experience with Buprenorphine.” The American Journal on Addictions, U.S. National Library of Medicine, 2004, www.ncbi.nlm.nih.gov/pubmed/15204673.
  13. “Department of Medical Assistance Services.Medicaid for Virginia.” Department of Medical Assistance Services.Medicaid for Virginia., www.dmas.virginia.gov/#/arts.
  14. Rudowitz, Robin, et al. “Medicaid Financing: The Basics.” The Henry J. Kaiser Family Foundation, 21 Mar. 2019, www.kff.org/medicaid/issue-brief/medicaid-financing-the-basics/.
  15. Auriacombe, Marc, et al. “French Field Experience with Buprenorphine.” The American Journal on Addictions, U.S. National Library of Medicine, 2004, www.ncbi.nlm.nih.gov/pubmed/15204673.
  16. Cicero, Theodore J. “Changing Face of Heroin Use in the United States.” JAMA Psychiatry, American Medical Association, 1 July 2014, jamanetwork.com/journals/jamapsychiatry/fullarticle/1874575.
  17. “Department of Medical Assistance Services.Medicaid for Virginia.” Department of Medical Assistance Services.Medicaid for Virginia., www.dmas.virginia.gov/#/arts.
  18. Dufton, Emily. Grass Roots: the Rise and Fall and Rise of Marijuana in America. Basic Books, 2017.
  19. Ferraiolo, Kathleen. “Morality Framing in U.S. Drug Control Policy: An Example From Marijuana Decriminalization.” World Medical & Health Policy, John Wiley & Sons, Ltd, 21 Dec. 2014, www.onlinelibrary.wiley.com/doi/pdf/10.1002/wmh3.114.
  20. Ferreira, Susana. “Portugal’s Radical Drugs Policy Is Working. Why Hasn’t the World Copied It?” The Guardian, Guardian News and Media, 5 Dec. 2017, www.theguardian.com/news/2017/dec/05/portugals-radical-drugs-policy-is-working-why-hasnt-the-world-copied-it.
  21. Lurie, Julia, et al. “Opioids Are Ravaging the Country. These Lobbyists Want to Keep the Drugs Flowing.” Mother Jones, 23 June 2017, www.motherjones.com/politics/2016/09/opioid-lobbying-pharmaceutical-companies/.
  22. Mars, Sarah G, et al. “‘Every ‘Never’ I Ever Said Came True’: Transitions from Opioid Pills to Heroin Injecting.” The International Journal on Drug Policy, U.S. National Library of Medicine, Mar. 2014, www.ncbi.nlm.nih.gov/pubmed/24238956.
  23. “Paying for Addiction Rehab with Medicaid and Medicare.” AddictionCenter, www.addictioncenter.com/rehab-questions/medicaid-and-medicare/.
  24. “President Donald J. Trump’s Initiative to Stop Opioid Abuse and Reduce Drug Supply and Demand.” The White House, The United States Government, www.whitehouse.gov/briefings-statements/president-donald-j-trumps-initiative-stop-opioid-abuse-reduce-drug-supply-demand-2/.
  25. Rudowitz, Robin, et al. “Medicaid Financing: The Basics.” The Henry J. Kaiser Family Foundation, 21 Mar. 2019, www.kff.org/medicaid/issue-brief/medicaid-financing-the-basics/.
  26. Seelye, Katharine Q. “Fraction of Americans With Drug Addiction Receive Treatment, Surgeon General Says.” The New York Times, The New York Times, 17 Nov. 2016, www.nytimes.com/2016/11/18/us/substance-abuse-surgeon-general-report.html.
  27. Maggie Fox. “Some Just Can’t Stomach the Idea of Needle Exchanges.” NBCNews.com, NBCUniversal News Group, 18 Oct. 2017, www.nbcnews.com/storyline/americas-heroin-epidemic/indiana-county-stops-needle-program-meant-stop-hiv-n811741.
  28. Talbot, Margaret, and Margaret Talbot. “Trump Says That His Wall Will Stop Opioids-Two High-Profile Legal Cases Suggest That He’s Wrong.” The New Yorker, The New Yorker, 23 Jan. 2019, www.newyorker.com/news/daily-comment/trump-says-that-his-wall-will-stop-opioids-two-high-profile-legal-cases-suggest-that-hes-wrong.

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The Opioid Crisis in the United States: Expanding Medicaid to Addiction Treatment. (2022, September 27). Edubirdie. Retrieved February 3, 2023, from https://edubirdie.com/examples/the-opioid-crisis-in-the-united-states-expanding-medicaid-to-addiction-treatment/
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