Amid federal uncertainty, states confront opioid crisis

State lawmakers have considered about 1,000 measures in the past year aimed at confronting the mounting opioid epidemic, as heroin use spikes and overdoses claim thousands of lives across the country.

At the same time, states — and members of Congress — are worried that a draft Republican bill to repeal and replace the Affordable Care Act would cut hundreds of millions of dollars from Medicaid programs aimed at addiction treatment and prevention.

The scale and scope of the opioid addiction crisis has startled lawmakers in recent years, even as crime tied to the illegal drug trade has fallen to all-time lows. The Centers for Disease Control and Prevention reported in January that more than 52,000 Americans died from a drug overdose in 2015, and nearly two-thirds of those cases involved opioids.

{mosads}Northeastern and Southern states have been hardest hit: More than 3,000 residents in Ohio and Pennsylvania died from drug overdoses in 2015, the CDC reported. And nearly half of all Americans, 49 percent, said they know someone who has been addicted to prescription painkillers, according to a November tracking poll by the Kaiser Family Foundation.

In response, states have begun tightening restrictions on access to powerful painkillers and mandating more reporting by doctors and pharmacies. Last year, legislators in 47 states considered 536 bills related to prescription drug abuse prevention. This year, 434 bills have been introduced in 46 states, according to the National Conference of State Legislatures.

In 2016, nine states, led by Massachusetts, limited opioid prescriptions to seven days. In the opening months of 2017, four states passed limits on the number of pills that can be prescribed, and 16 other states are considering similar legislation.

Last year, seven states implemented new rules requiring doctors to check state-run databases, known as Prescription Drug Monitoring Programs, before they prescribe an opioid. Lawmakers in 37 states have introduced 109 measures to strengthen those monitoring programs.

Forty-nine states and the District of Columbia have a version of the program, and the 50th — Missouri — is considering several measures to implement its own.

Kate Blackman, a senior policy specialist who tracks health legislation for the National Conference of State Legislatures, said there is evidence that monitoring programs can reduce the number of opioids that fall into the wrong hands.

“It’s not a hard thing anymore to connect every pharmacy together, so if someone fills a prescription for opioids, it shows up,” said Colorado Gov. John Hickenlooper (D), whose state will consider both tighter restrictions on prescriptions and more stringent reporting requirements.

Some states are considering working with neighbors to share prescription information across state lines, to crack down on doctor-shopping and pill mills. Virtually every state is racing to find ways to curb the crisis.

Alaska Gov. Bill Walker (I) this week rolled out an opioid reform package that would update his state’s database of opioid prescriptions more regularly. New Hampshire Gov. Chris Sununu (R) plans to introduce his package of reforms later this month, while Nevada Gov. Brian Sandoval (R) will ask his legislature to limit prescriptions to seven days, too.

In Maryland, Gov. Larry Hogan (R) signed an executive order last week declaring the epidemic a state of emergency and allocating $50 million in new funding. 

“This is a problem that’s been a long time in the making, and one that’s been swept under the rug,” said Howard Dean, a physician and former Democratic governor of Vermont. “It’s probably the biggest public health crisis in the country.”

Vermont has long been at the center of the opioid crisis. During his term in office, Dean removed one of the first opioid drugs, OxyContin, from his state’s Medicaid formula, because he said he believed it would lead to a spike in heroin usage. In 2014, then-Gov. Peter Shumlin (D) devoted his entire State of the State address to what he called a “full-blown heroin crisis.”

This year, Gov. Phil Scott (R) said he would hire a director of drug prevention policy. In his inaugural address, Scott called the epidemic “one of the most significant challenges we face.”

But as states look for solutions, they worry that the House GOP’s plan to replace the Affordable Care Act could put a massive dent in addiction treatment services. Health experts at Harvard University and New York University wrote in The Hill that repealing the ACA would cost 2.8 million Americans with substance abuse disorders some or all of their insurance coverage.

“Changes to Medicaid could impede states’ ability to provide treatment,” said Kelly Murphy, director of the Health Division at the National Governors Association’s Center for Best Practices.

In a letter to Senate Majority Leader Mitch McConnell, Sens. Shelley Moore Capito (R-W.Va.), Rob Portman (R-Ohio), Lisa Murkowski (R-Alaska) and Cory Gardner (R-Colo.) said they worried that Medicaid cuts could impact money that funds substance abuse treatment.

“As the largest payer of mental health and substance use services in the United States, it is critical that any health care replacement provide states with a stable transition period and the opportunity to gradually phase-in their populations to any new Medicaid financing structure,” the senators wrote.

Many states have increased access to naloxone, a drug that counters the effects of heroin overdoses. Some, such as Nevada, have made naloxone available over the counter. Others have expanded the number of healthcare and law enforcement professionals who can administer the drug in order to save lives. And states such as New Jersey and Washington are taking steps to get law enforcement professionals more involved in what they view as a public health crisis.

“We’re seeing a lot more synergy between what maybe were traditionally more siloed, things like health and criminal justice,” Blackman said.