Joe Biden has taken office amidst more instability than perhaps any president in recent history.
He must move quickly to address the public health emergency of the COVID-19 pandemic and the accompanying economic fallout. He must also address other situations like the broken immigration system and growing domestic terrorism threats. Even amidst all these issues, his administration cannot avoid its responsibility to deal with a crisis that’s been growing for decades and is now skyrocketing: the overdose epidemic.
Those of us affected by this epidemic have long known that overdoses are killing far too many people in our country, but the pandemic has worsened conditions further. Overdose deaths last year rose by over 18 percent, with the largest spike occurring after the US went into lockdown. For many Americans, the overdose epidemic is as bad or worse than the pandemic, and in some areas, overdoses may have outpaced pandemic-related deaths in 2020. As communities and businesses closed down to confront the pandemic, restrictions left more people impoverished, isolated, and unable to seek pathways to treatment and recovery. In September, 54% of community behavioral health care organizations (which include addiction recovery services) reported closing programs during the pandemic, while 52% of those same organizations reported an increase in demand for services.
While the Biden administration has already pushed a massive $1.9 trillion pandemic relief bill, it needs to do more. If Americans struggling with addiction do not receive expanded access to care and medication, the country will emerge from the pandemic to find itself overcome by the overdose epidemic.
In this article, we’ll take a look at what Biden and his administration have signaled regarding their stance on key policy issues related to the overdose epidemic. We’ll also examine bills in Congress that will affect the administration’s choices if they become law.
Background:
President Biden has a long political career with a mixed record on addiction-related policy, but his more recent positions demonstrate a firmer embrace of harm reduction-focused solutions to the overdose epidemic. He also has a family connection to addiction: his son Hunter is in recovery. While he’s faced the effects of addiction firsthand and ascended politically, Biden’s views on addiction seem to have changed as well.
In 1994, Biden championed the Clinton Crime Bill, which critics claim has accelerated unjust sentencing practices for people experiencing addiction, especially people of color. While this law is complex, its sentencing requirements clearly contributed to the criminalization of addiction. As a “tough on crime” senator, Biden at first supported policy that blocked people in recovery from getting the help they needed. Nevertheless, he later pivoted toward legislation that acknowledged and addressed the overdose epidemic.
As vice president, he served on an administration that was the first to signal a commitment to funding efforts to combat the overdose epidemic. Biden pushed for Congress to pass the 21st Century Cures Act, which included $1 billion in grants for states to fight the opioid crisis. His attention to this legislation showed a growing understanding that public health measures, not criminalization, are needed to address the overdose epidemic.
Shortly before announcing his candidacy for the 2020 election, Biden spoke at a forum devoted to the opioid crisis. He blamed greedy drug companies and overzealous doctors for causing the overdose epidemic, and he showed a desire for more Americans to understand “just how addictive” opioids are. While Biden spoke at length about traditional Drug War-esque ideas like shutting down trafficking routes into the US, he joined other panelists in agreeing that addiction is a disease and must be treated as one. Even immediately prior to becoming a 2020 candidate, Biden still showed an evolving perspective on addiction and came closer to embracing a harm-reduction approach.
Early in his presidency, Biden’s executive office for drug control policy has announced its priorities, which include “enhancing evidence-based harm reduction efforts.” This is the clearest evidence yet that Biden and his administration will take a modern approach to address the overdose epidemic, moving beyond criminalizing addiction to focus on expanding access to treatment that works. The policy announcement may also demonstrate the completion of Biden’s evolution on addiction policy, and the recovery community should be optimistic about the progress Biden’s made. Below, we’ll take a look at specific policies that Biden could focus on to realize his newfound priorities.
Ryan Haight Act:
As we’ve discussed before on the blog, the Ryan Haight Act of 2008 is a federal law that prohibits providers from prescribing controlled substances to patients before establishing an in-person relationship. The Act includes several exceptions to this requirement, including in the case of a “public health emergency.” The COVID-19 pandemic triggered this exception, meaning addiction recovery services have been able to prescribe medications like buprenorphine after seeing patients virtually since shortly after the public health emergency was declared. However, many recovery activists would like to see the Ryan Haight prohibition rolled back permanently for drugs prescribed for medication-assisted therapy (MAT), like buprenorphine. Recently, researchers found that 39% of US counties did not have a single buprenorphine prescriber. Removing barriers to treatment by permanently allowing MAT via telehealth would particularly help people living in these underserved areas.
While the Biden administration has not specifically committed to changing the Ryan Haight Act, the Biden campaign website lists the president’s priorities in this area as “removing undue restrictions on prescribing medications for substance use disorder” and expanding access and funding for treatment and recovery services, particularly MAT. This indicates that the administration may intend to make changes to Ryan Haight Act restrictions for MAT-related prescriptions, representing a huge win for the recovery community and treatment access nationally.
The Ryan Haight Act also permits those providers who have been granted “special registration” by the Drug Enforcement Administration (DEA) to prescribe controlled substances without an in-person appointment. However, the DEA never created a registration program for these providers. In 2018, a new law yet again directed the DEA to create a registration program. If the Biden administration is serious about expanding access to MAT and treatment services, it could put pressure on the DEA to finish this job, which would open a pathway for more providers to prescribe drugs that help people recover from substance use disorder.
X Waiver:
Another federal law with a massive impact on the overdose epidemic is the Drug Addiction Treatment Act of 2000 (DATA 2000), which established the “X Waiver” program to regulate access to addiction recovery medicine. The X Waiver is a permit granted by the Substance and Mental Health Services Administration (SAMHSA) to providers, allowing them to prescribe buprenorphine for substance use disorder. Currently, all providers must complete training before receiving the X Waiver.
In its final days, the Trump administration removed the X Waiver training requirements for physicians treating 30 or fewer patients. The Biden administration has decided to reverse course and keep these requirements in place for now, due to legal concerns about the Trump administration’s actions. To keep his campaign promise to remove barriers to addiction treatment, President Biden will need to take action to either reduce barriers for providers to prescribe addiction recovery medicine or expand outreach and enrollment into the X Waiver program so that more treatment is available.
Legislative Proposals:
While the Biden administration can make policy through executive action and promulgation of regulations, Congress is responsible for changing the laws that address the overdose epidemic. Several current bills could reshape the way America provides addiction medicine. We’ve highlighted them below:
- CARA 2.0 (Comprehensive Addiction and Recovery Act)
- Key Aspects: Increases investment in evidence-based addiction treatment programs and allows providers to prescribe MAT without an in-person visit. Removes limit on the number of patients a provider can treat with buprenorphine and methadone.
- Why It Matters: This bill would eliminate the Ryan Haight restrictions for MAT prescriptions, and it would also enable providers to meet the demand for MAT treatment in areas with high addiction rates.
- TREATS Act (Telehealth Response for E-prescribing Addiction Therapy Services Act)
- Key Aspects: Aims to expand access to telehealth services for addiction medicine and allow the prescribing of MAT after a video evaluation. Permanently eliminates the need for an in-person evaluation before prescribing MAT and allows providers to bill Medicare for audio-only services.
- Why It Matters: This bill would also eliminate the Ryan Haight restrictions for MAT prescriptions and expand care options for rural populations where broadband is less available.
- Telehealth Act
- Key Aspects: Includes the TREATS Act and loosens restrictions on covered telehealth services under Medicare, especially related to behavioral health and substance use disorder treatments through telehealth services.
- Why It Matters: This bill would dramatically increase the number of patients with insurance coverage of telehealth addiction recovery services. This would remove geographic and financial barriers for providers to provide high-quality addiction recovery care to those who need it most.
Each of these bills has the potential to reshape the way providers fight the overdose epidemic by changing the rules about who can practice addiction medicine and how. As we monitor how President Biden responds to the overdose epidemic, we must also watch the progress of these bills in Congress. To make significant progress toward reducing overdose deaths, Congress and the administration must leverage the bipartisan attention toward this issue and commit to sustained, cohesive action, starting with the policies outlined above.
Over the next four years, we can expect to see several changes in national drug policy based on the evidence above. Congress will likely pass legislation that makes substantial changes to Ryan Haight restrictions on MAT-related prescriptions. We can also expect Congress to expand telemedicine, especially for substance use disorder. We may also observe modifications or elimination of the X Waiver program, which will allow more providers to prescribe buprenorphine where it’s needed most. With a national drug policy focused on harm reduction, those familiar with addiction have every reason to hope that over the next four years the country will see policy evolve and create change that will allow our nation to experience relief from the spiraling overdose epidemic we are facing.
