A doctor on the front lines describes Medicaid’s role in the opioid crisis

Dr. Leana Wen describing Naloxone, the opioid overdose reversal drug, at a public town hall. Credit: National Press Foundation

For decades, the residents of Baltimore, have been dying from opioid overdoses and have been incarcerated due to addiction.

“There’s no doubt that the opioid epidemic is worse than before, but it’s not a new problem,” says Baltimore City Health Commissioner Dr. Leana Wen. “I do think there are elements of racial inequalities, racial disparities, racial discrimination, and that needs to be taken into account.”

Baltimore has been a leader among localities when addressing the epidemic, likely due to its history with addiction and overdose. Since 2015, Wen has been serving as the health commissioner. She’s testified before Congress and spoken before President Barack Obama about opioid addiction, intervention and treatment, and her city’s public health approach to mitigating a national crisis.

Nationwide, about 33,091 people died from overdosing on opioids in 2015, according to the Department of Health and Human Services data. The public health crisis is worsening annually as more people become addicted to heroin and prescription painkillers, including oxycodone, hydrocodone, and fentanyl. And Baltimore is among the most affected cities nationally. Between 2007-2016, 2,912 Baltimore city residents died of overdoses, according to the Maryland Department of Health. For comparison, that’s nearly a third of all Maryland residents who died from overdosing during the same amount of time. 

In many places, like Baltimore, Medicaid is helping people get the treatment they need, says Wen.

“When someone has an opioid addiction, we know what works: a combination of medication-assisted treatment, psycho-social counseling, and other services,” said Wen during an opioid-specific panel discussion. “We just need the resources to get there, and the more we focus on the lack of resources, that’ll be helpful.”

In Maryland, one in three people receiving treatment for addiction are on Medicaid. By no means is the social insurance program the only source of revenue or local assistance, but during a crisis, every bit is crucial. As the Kaiser Family Foundation has reported, nationally, Medicaid and the Children’s Health Insurance Program covers 3 in 10 people with opioid addiction. In 32 states, including Maryland, Medicaid covers all three recommended medication-assisted treatments. Medicaid also covers partial hospitalization in Maryland and 16 other states. This program provides limited counseling with nurses and physicians in a medical setting.

Most public health officials, including Wen, have asked President Donald Trump to declare a national state of emergency over the opioid epidemic. The White House Commission on Combating Drug Addiction and the Opioid Crisis also recommended he declare a national state of emergency and increase Medicaid spending. On Thursday, Trump said his administration was “going to draw it up and [they were] going to make it a national emergency” — but it’s still unclear whether this was an off the cuff remark or a formal declaration.

Wen spoke to ThinkProgress about Medicaid and the federal government’s role in the fight against the opioid epidemic. This interview has been slightly edited for grammar and clarity:

I take it you’ve listened to Trump and Health and Human Services Secretary Tom Price’s statements on the opioid crisis. What are some of your major takeaways?  

I was hoping that the president would declare a state of emergency on opioids. There are 142 people a day who are dying from overdose in our country. Imagine if there were 142 people dying from another infectious disease like Ebola or a natural disaster. There would be no question of a national state of emergency. How many people need to die before such a declaration is made?

I also heard the president’s statement where he emphasized the role of law enforcement and talked about the importance of prevention. The emphasis on law enforcement is important, but I worry that it is a call to return to the war on drugs, which has not worked, and has resulted in generations of poor minorities being incarcerated.

Here in Maryland, one in three of our patients who have substance abuse disorders depend on Medicaid for treatment.

Focusing on prevention is important too. Certainly, in public health we believe that prevention is the best medicine. But what are we going to do for the millions who already have the disease of addiction? How can we make sure they maintain treatment so that we are not just simply fueling the demand for drugs? So I hope the president heeds the rest of the commission’s recommendations— in fact his own commissions recommendations.  

I latched on to the Secretary’s comments on Medicaid: “Nobody is interested in cutting Medicaid.” How do you see Medicaid’s role in addressing the opioid epidemic?

The role of health insurance coverage could not be understated. Here in Maryland, one in three of our patients who have substance abuse disorders depend on Medicaid for treatment. We also need to make sure that essential health benefits, covering addiction and mental health treatment, remains part of insurance plan.

We should not be pricing people out of the ability to pay for these services at a time of a public health epidemic. For people who have the disease of addiction, there is no margin of error. If they were to lose their insurance today, the only option would be maybe go out in the streets and overdose and die. We should be doing a lot more to expand health insurance coverage. The last thing we should be doing is to cut services and cut health insurance such as Medicaid, and steps to repeal the Affordable Care Act (ACA) and basic social services.

You don’t expect that someone with diabetes is going to be cured by throwing them in jail.

It’s also important to note that the block grant purposed–including in the ACA repeal and replacement plans, the block grants are helpful but they cannot be dependent on such a widespread disease. We do not treat any other diseases through block grants alone. It would be preposterous to say we were going to treat diabetes with block grants alone. We need to make sure there is full coverage and reimbursement for addiction and substance abuse disorder treatment. Especially for a time in of a public health epidemic.  

How does stigma around the opioid crisis and the Medicaid program work against providing treatment?

There is profound stigma around addiction treatment. Science shows that it’s unequivocal that it is a disease. But many individuals still understand addiction as a choice. Therefore, if someone is incarcerated or dead, it’s a choice. It’s a moral failing on their part.

The stigma prevents people from seeking treatments treatments when they need it. The stigma results in individuals being incarcerated and expecting to get better, to get cured of a disease through jail, which is not what we would do with anything else. You don’t expect that someone with diabetes is going to be cured by throwing them in jail. And that’s another reason why we shouldn’t return to the war on drugs mentality. That will further stigmatize other individuals and potentially result in more people being scared to receive needed treatment.

You mentioned too that there is stigma on other services, including Medicaid. And I think that stigma is pervasive because there is stigma around seeking treatment in the first place. And so these are all issues that must be addressed.

In Baltimore, we have public education. We have initiatives like our “Don’t Die” campaign. We also have a focus on hiring people who are in recovering programs themselves to be outreach workers and case managers, which are certain steps to reduce stigma and to actually fight stigma with science.

President Barack Obama speaks at the National Rx Drug Abuse & Heroin Summit at AmericasMart in Atlanta, Tuesday, March 29, 2016. From left are, Baltimore City Health Commissioner Dr. Leana Wen, Crystal Oertle of Ohio, Young People in Recovery President and CEO Justin Riley and the president. (AP Photo/Jacquelyn Martin)

Traditionally, you think of Medicaid dollars being used to provide access to treatment. Could you talk about creative ways Medicaid dollars are being used to combat this crisis? I’m thinking about how Los Angeles uses Medicaid dollars for public housing. 

Expanding Medicaid has been helpful because it allows states to expand their coverage to other vulnerable populations. You mentioned before the use of Medicaid dollars for housing, which is also important because housing is health care. We also hope that there will be coverage for other wraparound services and for reimbursements for folks like the peer recovery or outreach works such as the peer recovery specialists that I referenced. Whether that’s done through Medicaid, through grants, through other processes, these are important services that must be provided. But that is all contingent on our safety net not being further cut. Efforts to slash Medicaid should be the last thing that we need at this time.

I’ve heard you say the issues of addition tie into every part of Baltimore, from health disparities to unemployment. Could you talk about the limitations of addressing this crisis as just a public health crisis?

The opioid crisis is complicated in terms of how we got here and in terms of how we go to address it. There are critical components: supply and demand. On supply side, it certainly requires a combination of law enforcement and public health approaches. We need law enforcement to stop the trafficking of drugs, to stop fentanyl from being let into this country, from being mixed in with other drugs, and killing people. And it also requires more doctors and pharmaceutical companies to step up and over prescribing of opioids that leads to a supply issue.

But the demand side is what we focus on. And it equally important if not more important than the supply side. We have millions of people in this country who need treatment for this addiction. Yes, it’s important to focus on prevention but these are people who already have the disease of addiction, who are at risk for overdose every single day, and who will continue to fuel the supply side unless their addiction is properly being treated. That’s why it’s so important for us to take a public health approach as well.

We know people are dying every day and we have to make a calculated guess as to who’s most likely to die, and get the medication into people’s hands. Imagine having to do this for any other illness.

I understand Baltimore health officials are running low on naloxone. I understand to fill the gaps, residents are turning to pharmacies and the Medicaid program, which charges a dollar per dose. Can you talk about how Baltimore is still trying to get naloxone into the hands of every person?  

In the last two years, we have launched an aggressive outreach effort. That includes my having issued blanket prescriptions for naloxone for everyone one of our 620,000 residents in our city. By issuing this blanket prescription, we also added on an aggressive outreach. We do outreach on street corners, on markets, on public housing, in bus shelters. We have done over 23,000 trainees of everyday people. And as a result, everyday people have saved the lives of over 1,000 of their fellow residents, which is very significant. And these are 1,000 people whose lives are saved because of the work of their fellow residents. 

Unfortunately, we are limited by how much funding we have to purchase this life saving medication. We are having to ration our supply of naloxone. We have a certain number of units that will last us until July 2018. We have to ration out units by month. And we have to decide which individuals are most at risk.

This is heart-wrenching. This is what we do. We know people are dying every day and we have to make a calculated guess as to who’s most likely to die, and get the medication into people’s hands. Imagine having to do this for any other illness. If this were Ebola and there was a way for us to cure it, and we were letting people die everyday, we would never find this acceptable. We look to the federal government, including President Trump and commissioner, in assisting us to get Narcan through things like price negotiations.

Could declaring a state of emergency help obtain Narcan?

What the declaration means would be up to president. But potentially it could mean that more funding could be available. And potentially it could compel the federal government to take additional steps, including having them directly negotiate with manufacturers of naloxone. So that for those of us in local jurisdictions, who are priced out of the availability to save lives, we can provide these antidotes to our residents.