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What it does 

HR 993, comprised of six distinct provisions, intends to curb opioid abuse and misuse by requiring the establishment of various grants and mandating certain regulatory actions. This legislation, and other similar measures, are part of a larger effort to curb the escalating opioid epidemic.

First, the bill requires the Department of Health and Human Services (HHS) to dispense grants to states for one-year pilot programs that will develop standardized peer-review processes and methodologies for evaluating the prescribing and pharmacy dispensing patterns of schedule II and III substances. These reviews, in reviewing the states’ Prescription Drug Monitoring Programs, would identify and investigate questionable dispensing methods. In order to qualify for the grant, states must make any information regarding controlled substances available to state regulators and licensing boards.

Second, the bill directs HHS to establish grant programs for the following:

  • Training programs to teach healthcare providers about patient screening and treatment techniques (e.g., interventions or referrals) to prevent drug abuse;
  • Evaluations of the prospects of allowing state health professional boards to expand prescribing authority of drug abuse treatment pharmaceuticals to qualified nurses (e.g., advance practice nurses) and physician assistants; and
  • The development of continuing education criteria and review processes to allow state health professional boards to certify appropriate training and education regarding the informed and safe prescribing of schedule II and III drugs.

Third, the bill tasks the Department of Justice (DOJ) with requesting that practitioners and pharmacies who dispense scheduled drugs screen patients for drug abuse before prescribing schedule II or III drugs.

Fourth, the bill tasks the Food and Drug Administration (FDA) with assessing whether naloxone (a drug used to reverse opioid overdose) should be made available without a prescription.

Fifth, the bill tasks HHS with convening an interagency working group to assess ways to:

  • Encourage state and local governments to increase opportunities for opioid disposal; and
  • Reduce opportunities for opioid abuse, such as by instituting opioid dispensing limits at hospital emergency departments.

Finally, the bill stipulates that the US Government Accountability Office (GAO) reviews opioid and heroin abuse programs, relevant federal policies, and best practices enacted in the states. The GAO must submit a report, to include findings and recommendations to reduce drug abuse, to Congress within 18 months of the bill’s enactment.

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.

Prescription Drug Monitoring Programs are state-level databases designed to store and track information about the prescribing and dispensing patterns of various health care providers. They are designed to flag any potential over-prescription or illegal diversion of drugs as well as to ensure providers have relevant information on patients with drug abuse potential.

Opioid abuse, dependence, and addiction screening and treatment comes in many different forms. Screening typically involves a provider’s recommendation that a patient fill out a self-assessment screening test, which helps patients understand their individual risks for substance abuse. Additionally, physicians have several other tools at their disposal, such as drug tests. Treatment options 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 (MAT), 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.

This bill specifically discusses naloxone, a drug used not for treatment but rather for rapid overdose reversal. Naloxone, an opioid antagonist, works by binding to opioid receptors and blocking the effects of other opioids. The drug quickly restores respiration (i.e., breathing) in those with low to no sustainable respiration as a result of overdose. The FDA has approved three forms of the drug: injectable, auto-injectable (commonly known as Evzio), and nasal spray (commonly known as Narcan). Laws vary among states governing naloxone’s distribution, but there is near unanimous support for its distribution among public health officials.  

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 993 was introduced in the House on February 9, 2017, and referred to the House Committee on Energy and Commerce. The following day, it was referred to the Subcommittee on Health.

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

Duke SciPol, “Opioid Abuse Prevention and Treatment Act (HR 993, 115th Congress)” available at http://scipol.duke.edu/content/opiod-abuse-prevention-and-treatment-act-2017-hr-993-115th-congress (04/26/2017).