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Innovation and Progress in the Fight against Opioid Addiction

Alex M. Azar II
Milken Institute Future of Health Summit
October 23, 2018
Washington, D.C.

We already have the raw materials we need to win this war. Scientific innovation, private entrepreneurship, the strength of American communities—that is what will help us escape the storm of addiction and overdose we are fighting through today. Together, we can end this epidemic and lay a foundation for a healthier country that will never face such a crisis in the future.

As Prepared for Delivery

Thank you for that introduction, Ed [Greissing]. Good afternoon, everyone, and thank you to the Milken Institute for having me here today.

It’s appropriate that this summit, on the future of healthcare, has taken a holistic approach to the health challenges we face, including mental health treatment and our country’s opioid crisis.

Our nation’s epidemic of opioid addiction and overdose is one of the most significant health challenges we face: In 2016, American life expectancy dropped for the second year in a row, in large part because of rising numbers of drug overdoses.

In January, I identified the opioid crisis as one of my four priorities as HHS secretary, and it had already been a focus at HHS for some time. But President Trump has brought a new level of focus to the crisis, declaring a nationwide public health emergency late last year.

His leadership has focused the entire federal government on the crisis—really, this is something where every Cabinet department from Interior to Education is engaged.

It has also helped focus Congress—never an easy task—leading to the passage earlier this month of comprehensive opioids legislation, which the President will sign tomorrow.

We need a comprehensive response because the opioid crisis is such a multi-faceted issue. That is said so often in healthcare, but it especially applies to the opioid crisis. Every corner of HHS and our health system has to be involved in our response.

Today, I want to focus on two particular issues: preventing addiction by promoting healthy, evidence-based methods of pain management, and then supporting treatment and recovery services for those struggling with addiction.

In both of these areas, we do know a great deal about what works. But with a crisis of this scale, we also need new tools, and a better understanding of our existing tools, in order to prevail. On both pain and addiction, we need both scientific innovation and policy innovation.

I’ll start with pain management, because that is, after all, where the crisis began.

Simply put, America has prescribed, and still prescribes, a stunning amount of potentially addictive pain medications.

From 1999 to 2015, according to the CDC, the amount of opioids prescribed in America tripled. The problem of pain in America is a very real one, but it is safe to say it did not triple in 16 years.

The prescribing numbers in 2015 were actually a slight decrease from the peak in 2013. But even the 2015 number is four times what is prescribed per capita in Europe. The 2015 level was the equivalent of 640 milligrams of morphine for every man, woman and child in America—enough to keep someone medicated round the clock for three weeks with a Vicodin every four hours.

How did we get to such immense supply?

Part of the story is a revolution in how physicians were taught to treat pain: Where they once worried about the addictive potential of opioids, the conventional wisdom over the past several decades became that the risk of abuse was very low, and that physicians should get used to the idea of regularly prescribing opioids for all kinds of pain.

Compensation and quality-rating systems assessed how happy patients were with their pain treatment, adding pressure on doctors to overprescribe out of concern that their scores would be dinged.

This shift also undermined plenty of good work that was being done to treat pain holistically, through physical therapy, nutrition and other methods. In 1998, one assessment found that there were more than 1,000 multidisciplinary pain clinics across the country. By 2005, there were just 85.

Insurers stopped paying for these more holistic approaches to pain treatment when they realized how cheap an option pills could be instead. And then the pills kept getting cheaper, as generic versions made it onto the market.

Of course, as we’ve belatedly realized, these supposedly cheap pills can impose a tremendous cost. The majority of America’s heroin users started by misusing a legal opioid, whether one they were prescribed or one they bought or obtained from someone else.

I had a recent chance to hear about this firsthand: On a trip to Philadelphia with the First Lady, we met with mothers whose infants were born with neonatal abstinence syndrome, meaning they were born physically dependent on opioids. Some mothers came from backgrounds with a long, multigenerational experience of addiction.

But others were ensnared by treatment they got as part of common health procedures. One mother, from the suburbs of Philadelphia, started misusing opioids after she was prescribed them for a broken finger—a broken finger! Another ended up struggling with addiction after going home with 30 Percocets after getting her wisdom teeth out.

We badly need better ways to treat pain—not just non-addictive methods, but also more effective ones—and we need to support them in how our health system pays for care.

It’s important that we take the lead in Medicare and Medicaid, and that’s what CMS has done. We’ve had Medicare Part D plans aggressively monitor inappropriate prescribing of opioids. In 2017 alone, we saw a 40 percent decline in the number of Medicare beneficiaries receiving higher than the recommended amount of opioids from multiple doctors.

We’re also making sure that our policies are in no way encouraging overprescribing, so we’ve proposed an overhaul of the H-CAHPS survey, asked of Medicare patients after they leave the hospital, to ensure the questions asked about pain management aren’t driving over prescribing.

We’ve set an expectation that new opioid prescriptions for acute pain in Medicare drug plans be filled for a seven days’ supply, so that people don’t have extra pills and aren’t on them for longer than they need to be.

We’ve also opened up new ways to pay for non-addictive pain treatment: Starting next year, for instance, Medicare Advantage plans will be allowed to pay for therapeutic massage as a supplemental benefit.

HHS is supporting scientific research around pain and addiction, laying a base of knowledge and promising leads for new treatments—as it did in the early years of other public health crises, like HIV/AIDS.

Earlier this year, the National Institutes of Health launched its HEAL Initiative, a more-than-$1 billion effort that will study not just how to treat addiction, but also how to better treat pain. NIH’s work will involve going to the very roots of pain itself, studying patients who have acute pain associated with a surgical procedure and patients who have suffered acute trauma. This will help create a comprehensive data set that can help us predict which patients may develop long-lasting chronic pain.

NIH is also exploring the possibilities for new, non-addictive treatments for pain. For instance, researchers are working to engineer cell-based screening platforms, which can closely approximate the physiology of human pain and addiction, to identify leads for testing new drug candidates in humans. NIH is working in close partnership with private companies, all the way up through Phase II clinical trials, to advance new pain treatments.

HEAL—or Helping to End Addiction Long-term—will examine promising areas for addiction treatment. Some of you heard earlier today from Dr. Nora Volkow, head of our National Institute on Drug Abuse—perhaps the world’s leading expert on addiction. What Tony Fauci is to the flu, Dr. Volkow is to addiction—a very smart, and very dangerous, enemy for a health threat to have.

We already do know that medication-assisted treatment works, that overdose-reversing drugs are essential, and that we need to make them both more available. But as part of the HEAL Initiative, NIDA is working to improve these tools and expand our arsenal, including researching new formulations of medication-assisted treatment. They are also looking at the development of immunotherapies that can block entry of heroin or synthetic opioids to the brain, which could prevent overdose and relapse for individuals with severe addiction.

This work brings me to the current epidemic we face: the huge numbers of Americans misusing both prescription and illicit opioids, the tragic number of Americans we lose to overdoses each year, and the still-too-small number of Americans receiving the right treatment for these challenges.

This September, we disbursed a historic amount of grants to help support treatment and recovery services, secured by President Trump in this year’s government funding bill. More than $930 million in grants went out from the Substance Abuse and Mental Health Services Administration, SAMHSA, to state governments to support prevention, treatment and recovery, with a special new focus on supporting medication-assisted treatment. Another $396 million was disbursed to community health centers and behavioral health training efforts. Over the last year, under President Trump, we have approved waivers for 11 states to expand access to in-patient addiction treatment through their Medicaid programs.

We know these efforts to support treatment at the state, local and community level are having a real effect.

One of the key organizational decisions I made on opioid policy was to designate a single senior adviser to coordinate efforts: Adm. Brett Giroir, our assistant secretary for health. In September, he oversaw the updating of HHS’s comprehensive strategy for the epidemic, and he has also worked to ensure we are watching the latest data, to understand where efforts are having an effect.

We are seeing a number of positive signs. Since President Trump took office in January 2017, the number of patients receiving buprenorphine, one form of medication-assisted treatment, has increased by 21 percent, while the number of prescriptions for naltrexone, another form of medication-assisted treatment, has increased by 47 percent. In the same time, the number of naloxone prescriptions dispensed monthly has increased by 368 percent.

From 2015 to 2017, we have seen a statistically significant decline in the number of Americans who misuse prescription opioids. And from 2016 to 2017, the number of Americans initiating heroin use declined by a statistically significant margin as well.

Most important of all, we are starting to see more encouraging results in overdose trends.

The number of Americans dying from drug overdoses has risen steadily since 1999, and skyrocketed since 2010.

From 2016 to 2017, the number of Americans dying from drug overdoses rose from 64,000 to approximately 72,000.

But toward the end of 2017, through the beginning of 2018, the number of drug overdose deaths has begun to plateau.

According to provisional data from the CDC, the seemingly relentless trend of rising overdose deaths seems to be finally bending in the right direction.

Plateauing at such a high level is hardly an opportunity to declare victory. But the concerted efforts of communities across America are beginning to turn the tide.

Everyone involved in fighting this crisis should know: Your hard work is having results and saving lives.

We are so far from the end of the epidemic, but we are perhaps, at the end of the beginning.

I want to highlight a few ways now in which we are not just scaling up our support, but also trying to understand which efforts are working best.

One example is a unique initiative launched by NIH in collaboration with SAMHSA. This project, called the HEALing Communities study, will provide generous resources and comprehensive support for up to three communities with especially high rates of overdoses, helping them test an integrated set of evidence-based practices for prevention and treatment.

NIH doesn’t think small: Providing comprehensive support to these communities will cost hundreds of millions of dollars, and will provide an unprecedented level of knowledge about how integrated interventions work.

HEALing Communities is the most ambitious such undertaking in the history of the study of addiction. Never before has such a comprehensive intervention been attempted, let alone studied with the rigor that this one will be.

While expanding our base of knowledge, this project will save lives in some of the communities hardest hit by the opioid epidemic: The goal is to reduce rates of opioid use disorder while decreasing opioid overdose fatalities in these communities by 40 percent.

An integrated response like we envision will bring together all segments of a community. Earlier this year, some of us at HHS sat down with Sam Quinones, author of Dreamland, a book on the opioid crisis many of you probably know.

I asked him where, in his travels, he has seen the most encouraging signs. He said the best responses he’s seen are communities where everyone has come together to tackle this challenge: not just healthcare providers and families of those struggling with addiction, but schools, churches, businesses, law enforcement—every element of civil society. Through HEALing Communities, we can rigorously assess the best ways for such communities to approach this challenge.

It will build on the pioneering work NIH has already done to expand our understanding of addiction—the science that informs our everyday work.

From supporting drug courts to placing an emphasis on medication-assisted treatment, the Trump administration has been quite clear: We believe in evidence-based treatment, we believe in a public-health approach to this epidemic, and we believe in approaching addiction as a disease, never a moral failing.

Another place at HHS where we can improve care and simultaneously build our evidence base is the Centers for Medicare and Medicaid Innovation, or CMMI.

Today, I’m pleased to announce that CMMI is launching its first such model specifically devoted to helping address the effects the opioid crisis is having on mothers and infants.

The M-O-M model, for “Maternal Opioid Misuse,” will partner with state Medicaid agencies to integrate a wide range of services for pregnant and postpartum women struggling with opioid misuse, to ensure not only their health, well-being, and recovery, but protect the health of their children as well.

This model is also part of our efforts to move to value-based care, which will include focusing on prevention and the critical health needs of children, families and communities. It follows our recent announcement of the Integrated Care for Kids Model, the first child- and family-centered model to improve quality of care and decrease costs through an integrated framework.

Last week, as I mentioned, the First Lady and I traveled to Philadelphia, where we visited the first HHS national convening on neonatal abstinence syndrome, or NAS. National experts came together to provide their individual perspectives on a new HHS initiative to study and address the needs of infants born with NAS, a challenge we really don’t well understand.

Many of the efforts I’ve described today will be supported by the opioids legislation President Trump is signing tomorrow. It will help state Medicaid programs, for instance, support pediatric counseling centers, which have been at the forefront of treating NAS.

The bill also gives Medicare additional ways to provide care for beneficiaries struggling with addiction, including through expanded telehealth options. It will expand workforce training initiatives through SAMHSA that can expand access to medication-assisted treatment, and support FDA work to identify new pathways and endpoints for the approval of non-opioid pain relief.

The bill is truly a comprehensive approach. I spoke with Sen. Lamar Alexander yesterday about the bill, and he said he feels it will be the most important new healthcare law this year. It’s hard to disagree.

What I’ve discussed today are a number of initiatives, at the federal level or supported by the federal government, that will help tackle the opioid crisis across our country.

But this victory isn’t going to be won by the federal government.

I want to leave all of you with a call to action: Many of you have already joined this fight, whether through changing practices at your hospitals, directing research in your clinics, or supporting new treatment for pain and addiction. Please keep up the focus; keep up the good work. You have tremendous resources at your disposal: the world’s highest-quality healthcare system, the world’s greatest biopharmaceutical industry, and our country’s unique spirit of community and entrepreneurship.

We already have the raw materials we need to win this war. Scientific innovation, private entrepreneurship, the strength of American communities—that is what will help us escape the storm of addiction and overdose we are fighting through today.

Together, we can end this epidemic and lay a foundation for a healthier country that will never face such a crisis in the future.

Thank you very much for having me here today.

Content created by Speechwriting and Editorial Division 
Content last reviewed on October 23, 2018