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As Drug War Rages, Most People Who Need Treatment Don’t Get It

A focus on drug-supply reduction and aggressive law enforcement is undermining addiction treatment.

Pill Man, a skeleton made from artist Frank Huntley's oxycontin and methadone prescription bottles, is seen on Pennsylvania Avenue, on August 30, 2019, in Washington, D.C.

The war on drugs persists under President Trump. In fact, critics say the administration’s continued focus on drug-supply reduction and law enforcement could undermine the public health approaches to the opioid crisis that the government funnels billions of dollars into every year.

On Thursday, the Trump administration announced the release of $1.8 billion in state grants for combating opioid addiction and the overdose epidemic. The money was allocated by Congress, which has put billions of dollars toward the opioid crisis annually since the Obama administration. Although Congress is responsible for the grants, Trump has attempted to take credit for them because opioid funding is included in his budget requests, along with billions of dollars for law enforcement-based anti-drug efforts.

Alex Azar, the secretary of Health and Human Services (HHS), which distributes federal opioid response funding from Congress, said a $932 million will be distributed to states for addiction prevention and treatment programs as well as efforts to distribute naloxone, the drug that reverses opioid overdoses. HHS regularly releases federal opioid funding in chunks through a grant program at the Substance Abuse and Mental Health Services Administration (SAMHSA).

“Starting with the initial grants last year, however, we did impose one requirement: that treatment providers funded by these grants must make available medication-assisted treatment, which is the gold standard of treatment for opioid addiction,” Azar told reporters on Wednesday.

As Truthout has reported, medication-assisted treatments (MAT) such as methadone and buprenorphine are indeed considered the gold standard for treating opioid addiction, because they act like opioids in the brain to relieve cravings and withdrawal symptoms. A push to expand access to MAT began under the Obama administration, when the overdose epidemic spread to wealthier, whiter communities and forced policymakers to embrace a public health approach to opioids after decades of failed strategies rooted in the war on drugs.

MAT is more available today than it was a decade ago, but barriers to access remain, especially for low-income people and those criminalized for drug use. Today, nearly half of the estimated 2 million people in the United States living with opioid addiction are not receiving medication-assisted treatment, according to SAMHSA and HHS data. Critics say this data may not be accurate, because it excludes data on houseless and unstably housed people, as well as those who are incarcerated or hospitalized — all groups that are disproportionately impacted by opioids.

Of course, opioids are not the only type of drug that people use. In 2018, 84 percent of people in need of treatment for any kind of illicit drug use did not receive it, according to an annual survey recently released by SAMHSA.

While public health advocates may applaud Azar’s public commitment to MAT, researchers and advocates on the front lines of the crisis say the administration’s embrace of law enforcement as a solution to addiction could undermine the same effort.

“A clash between public health and law enforcement is pretty common … but in this current time of this so-called public health response to the crisis, there’s this slightly more hidden effort by law enforcement to broaden its powers to take a war on drugs approach,” said Jeremiah Goulka, a senior fellow at the Health in Justice Action Lab at the Northeastern University School of Law.

Last week, SAMHSA proposed relaxing privacy rules for federally funded clinics that provide MATs such as methadone and buprenorphine, and gave advocates, patients and health care providers a shortened, one-month window for public comment. Part of the proposal would make it easier for law enforcement to obtain a MAT patients’ medical records and surveil MAT providers, and critics worry that relaxing privacy protections could scare doctors away from the field of addiction treatment and prevent people living with addiction from seeking treatment in the first place.

Publicly, Azar and HHS focused on other parts of the proposal that would make it easier for health care providers, government programs and researchers to access an addiction patient’s medical records, changes that health care groups say would help different providers coordinate and streamline addiction and mental health services if implemented properly. However, a coalition of harm reduction groups and MAT providers are opposed to weakening longstanding privacy standards for patients who could be criminalized for using drugs.

“In the midst of the worst opioid epidemic in our nation’s history, we cannot afford to have patients fearful of seeking treatment because they do not have faith that their confidentiality will be protected,” said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence.

Since the 1970s, the SAMHSA has enforced special privacy protections for patients at methadone clinics so they can receive treatment without worrying about being outed publicly as living with addiction or investigated by the police. The administration’s proposal would weaken these protections, making it easier for police to obtain medical records with a court order to investigate “serious” crimes, including drug trafficking, even if the patient is not a suspect. The proposal would also allow undercover agents inside a MAT clinic for up to 12 months at a time and link clinics into controversial Prescription Drug Monitoring Programs (PDMP), which are frequently used by the police in criminal investigations.

“Turning over patients’ medical records to law enforcement, even when they are not suspected of a crime, is completely unethical,” said Lindsay LaSalle, director of public health law and policy at the Drug Policy Alliance. “Steps like this erode trust between patients and providers and may discourage people from seeking care altogether. This is just the latest example of how people who use drugs are criminalized, even when trying to get help.”

SAMHSA claims police would not be allowed to use a patient’s medical records to prosecute the same patient, but it’s unclear whether police could use the records as part of an investigation and bring charges based on additional evidence. Even the rumor of changes to the privacy rulings can have a chilling effect on people recovering from substance use disorders who may be considered criminals under the nation’s drug laws.

“Patients are already anxious about the proposed new rule and the threat of opioid treatment programs sharing their sensitive health information through their state Prescription Drug Monitoring Programs, which may be accessible to entities like law enforcement who could then use the information to prosecute patients,” Parrino said.

The Trump administration wants to loosen the privacy rules so federal law enforcement can investigate “drug trafficking” from clinics that provide methadone and buprenorphine, according to the proposed regulation. While these drugs are considered opioids, they do not provide the same high as painkillers or street drugs like heroin and fentanyl. Instead, they are generally used to ease withdrawal symptoms. Even as Azar hails MAT as the “gold standard” for treating addiction, federal law enforcement is claiming that doctors and drug dealers are contributing to the opioid epidemic by diverting these therapies to people on the street — people who are likely in need of treatment in the first place.

“At root, a lot of folks in law enforcement and particularly in drug law enforcement view methadone and buprenorphine as quote ‘narcotics’ themselves, and are deeply uncomfortable with their existence or use for therapeutic proposes,” Goulka said.

Under Trump, there have been a number of raids on MAT clinics across the country, and the Justice Department took a major buprenorphine manufacturer to court and won a $1.4 billion settlement. While some doctors who appeared to be putting profits before their patients have been arrested, a number of well-known and respected addiction physicians have had their offices investigated or raided but were never charged with crimes.

There has long been a dearth of MAT providers because of social stigma surrounding addiction patients and federal restrictions on prescribing drugs like buprenorphine. Goulka said the Trump administration’s crackdown is not helping.

“It’s the kind of thing that could definitely scare [doctors] off from wanting to provide necessary services, which was already an existing problem,” Goulka said.

This is the other side of the Trump administration’s opioid strategy, and you won’t be hearing about it from health officials like Azar. It’s called “supply reduction,” and it’s been central to the war on drugs for decades. As the role of prescription painkillers in the opioid epidemic has come to light, federal law enforcement has made high-profile busts on “pill mills” across the country. New restrictions on painkiller prescriptions and PDMPs have also reduced supply as public awareness of opioid addiction increases. The number of people misusing painkillers was down 11 percent last year, according to SAMHSA.

But supply reduction can have unintended consequences, especially when it comes to addictive drugs like opioids. It’s well known that many people who became addicted to prescription painkillers turn to street drugs like heroin once they are cut off. The administration has aggressively pursued international drug traffickers, who have turned to fentanyl because it is generally more potent than other opioids and can be smuggled in smaller packages. Fentanyl rapidly increased the potency of street drugs across the country, causing a terrifying increase in overdose deaths.

George Shultz, who served as secretary of state under President Reagan, argued in a recent op-ed that the “supply-oriented war on drugs has failed.” He joined activists and public health advocates everywhere who argue treating drugs as a criminal issue makes them more dangerous and fuels mass incarceration. A steady supply of opioids remains, despite aggressive enforcement. The government has never succeeded in eliminating the supply of opioids or any other drug. Instead, drug interdiction makes the black market more irregular and dangerous.

Meanwhile, treatment providers have been unable to keep up with levels of opioid misuse, and rates of opioid overdose remain sky-high. The number of people accessing MAT for opioid addiction may be slowly growing thanks in part to federal funding, but the number of people in need of addiction treatment generally is increasing nationwide. From 2017 to 2018, the number of people in need of treatment for a substance use disorder related to illicit drugs of any kind increased from 80 to 84 percent, according to SAMHSA’s own data.

That means the vast majority of people in the U.S. in need of drug treatment are not receiving it for one reason or another. In a country where possessing even small amounts of drugs is a criminal offense and people living with addiction are often charged as drug traffickers, advocates argue that putting addiction treatment clinics under police surveillance effectively shoots a public health strategy in the foot.

“Here you have an effort to do something that can only create a chilling effect on the treatment they need,” Goulka said. “If used robustly, it can only result in things getting worse and more people dying.”

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