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What it does 

HR 994 establishes the framework to assess the capacity and availability of America’s opioid treatment infrastructure, as well as to identify areas of needed infrastructure in addressing the escalating opioid epidemic.

The bill tasks the US Government Accountability Office with evaluating and reporting to Congress, within two years of the bill’s enactment, on the following:

  • The capacity of residential or inpatient detoxification programs (i.e., “detox”);
  • The capacity of inpatient clinical stabilization, transitional residential support (i.e., “holding,” a short-term place to stay before entering longer term treatment), and residential rehabilitation (i.e., “rehab”) programs and services;
  • The capacity of demographic-specific residential or inpatient treatment programs (e.g., those designed for women or children);
  • The availability of treatment options that rely on scientific evidence, including the use of medication-assisted treatment (MAT) with Food and Drug Administration (FDA)-approved medications and evidence-based non-pharmacological therapies;
  • Measures of geographic disparities in residential or outpatient treatment options;
  • An assessment of the need for residential or outpatient treatment options;
  • The availability of residential or outpatient treatment options for American Indians and Alaska Natives through an Indian health program; and
  • An assessment of the barriers at the federal, state, and local levels to real-time reporting of de-identified drug overdose statistics, as well as suggestions to overcome those barriers.
Relevant Science 

Opioids are a class of drugs that bind to opioid receptors in the brain, producing pain-relieving and euphoric effects. Opioids are either derived naturally from the opium poppy plant (e.g., morphine and codeine, commonly referred to as opiates), partially synthesized from opium (e.g., heroin, oxycodone, and hydromorphone), or fully synthesized to mimic the effects of opium (e.g., fentanyl and methadone.) Medically, these drugs are primarily used for their analgesic (i.e., pain-relieving) properties, but are often misused, overprescribed, and abused given their propensity for dependence.

Rates of opioid dependence have significantly increased in the United States over the past two decades, resulting in a drastic increase in overdose deaths nationwide. Prescription medications, such as oxycodone (commonly marketed as OxyContin), are viewed as a primary catalyst in the spike of opioid use. After prescriptions run out, patients may turn to illicit opiates, such as heroin. In 2013, the Substance Abuse and Mental Health Services Administration estimated that over 1.8 million people suffer from opioid use disorder. The Center for Disease Control estimates that over 33 thousand people died from opioid overdoses in 2015 alone; half of those deaths resulted from prescription opioids.

Treatment for opioid use disorder comes in many forms; this bill only deals with treatments that rely on medically- and clinically-provided services. These can include:

  • Residential or inpatient addiction treatment, or what is commonly known as “detox” or “rehab,” where patients remain in residential facilities for a given period of time in order to allow their bodies to detoxify from drug dependence, to spend time away from their previous environments, and to explore various behavioral support systems;
  • Counseling and behavioral therapy, which provides a variety of psychological tools to assist in recovery and reduce the risk of relapse; tools include skill building, adherence to a recovery plan, group therapy for social reinforcement, and professional/educational outcomes assessments. These services are often provided in residential treatment facilities in tandem with medication-assisted treatment; and
  • Medication-assisted treatment, which involves the provision of various drugs to combat withdrawal symptoms, to mitigate cravings, and to prevent relapse. Specific to opioid use disorder, there are several drugs involved in MAT:
    • Methadone is a slow-acting opioid agonist, which mimics the effects of opioids, thereby reducing withdrawals and cravings. It is only available once daily at methadone clinics;
    • Buprenorphine is a partial opioid agonist, which produces similar effects to opioids but in diminished effect. It is proven to be effective at combating withdrawal symptoms and cravings; and
    • Naltrexone is an opioid antagonist, which does not have the effects of opioid drugs. Naltrexone binds and blocks the opioid receptors, preventing the feeling of getting “high” when users take opioids on the medication. It is available in pill form or a monthly intramuscular injection.

There are many different goals and measures regarding the effectiveness of various treatments used in different fields. Public health officials often cite statistics regarding disease transmission or overdose deaths. Economists look to statistics on employability, or conduct cost-effectiveness comparisons of providing treatment versus either not providing treatment or using punitive approaches. The criminal justice field often measures crime rates or recidivism. Notably, the National Institute of Drug Abuse does not consider relapse a measure of treatment failure, even though it claims that treatment reduces drug use by 40 – 60%.

Relevant Experts 

Nicole Schramm-Sapyta, Ph.D., is an Assistant Professor of the Practice in Duke Institute for Brain Sciences.

Relevant publications:

  • Schramm-Sapyta, Nicole, Q. David Walker, Joseph M. Caster, Edward D. Levin, and Cynthia M. Kuhn. 2009. “Are Adolescents More Vulnerable to Drug Addiction Than Adults? Evidence from Animal Models.” Psychopharmacology 206(1): 1 – 21. doi: 10.1007/s00213-009-1585-5
Endorsements & Opposition 

At present, there have not been any publicly reported endorsements of or opposition to this bill.

Status 

HR 994 was introduced in the House on February 9, 2017, and referred to the House Committee on Natural Resources and the House Committee on Energy and Commerce. On February 10, 2017, the bill was referred to Energy and Commerce’s Subcommittee on Health. On February 24, 2017, the bill was referred to Natural Resources’s Subcommittee on Indian, Insular, and Alaska Native Affairs.

Sponsors 
Primary Author 
Sean Riley, MA
Editor(s) 
John Matthews, JD Candidate; Nicole Schramm-Sapyta, PhD; Andrew Pericak, MEM
Citation 

Duke SciPol, “Examining Opioid Treatment Infrastructure Act of 2017 (HR 994, 115th Congress)” available at http://scipol.duke.edu/content/examining-opioid-treatment-infrastructure-act-2017-hr-994-115th-congress (date posted to site).