Establishing the President’s Commission on Combating Drug Addiction and the Opioid Crisis (Executive Order 13784)
What it does
Mandates the establishment of a temporary commission to make recommendations to the President for increasing the efficacy of the federal response to the opioid crisis.
Executive Order 13784, "Establishing the President’s Commission on Combating Drug Addiction and the Opioid Crisis", establishes that the policy of the Executive Office of the President will be to address the crisis of opioid abuse, addiction, and overdose. This order mandates the establishment of the President’s Commission on Combatting Drug Addiction and the Opioid Crisis. The overall objective of the Commission is to study the extent and efficacy of the current federal response to the opioid crisis and to make recommendations that guide further federal response efforts.
Specifically, the mission of the Commission will be to:
- Identify existing federal funding used to combat drug addiction and the opioid crisis;
- Evaluate established federal programs to prevent and treat drug addiction;
- Determine the availability and accessibility of drug addiction treatment services and identify underrepresented areas;
- Review the scientific literature to evaluate the effectiveness of educational messages regarding prescription and illicit opioids;
- Report on the best practices for addiction prevention, including:
- Healthcare provider education;
- Evaluation of prescription practices; and
- Use and effectiveness of State prescription drug monitoring programs;
- Make recommendations on how to improve the federal response to drug addiction and the opioid crisis; and
- Submit formal reports on the aforementioned findings to the President:
- An interim report will be due for submission to the President within 90 days of the order (i.e., June 27, 2017); and
- A final report will be due for submission to the President by October 1, 2017 in the absence of an extension.
The order further regulates the appointment, regulation, and coordination of the Commission:
- Members and the Chair of the Commission will be appointed by the President such that there is a balance of represented viewpoints.
- Members of the Commission will not receive compensation for their appointment on the Commission.
- The Office of National Drug Control Policy will support the Commission and finance the activities of the Commission.
- The Commission is temporary and will terminate 30 days after the submission of its final report in the absence of an extension by the President.
<p>As opioid abuse has increased over the past two decades, the opioid crisis has become one of the largest health crises in America. There has been increasing pressure to devote resources toward its resolution. As a result, the government has taken many initiatives at the state and federal level to combat the opioid crisis. There are many <a href="https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to... federal prevention and treatment programs</a>:</p>
<li>Current prevention efforts
<li>Primary prevention efforts encompass educational initiatives and programs in schools and community forums. They are designed to educate citizens on the harms of nonprescription opioid usage and deter illicit opioid usage.</li>
<li><a href="https://www.cdc.gov/drugoverdose/pdmp/">Prescription Drug Monitoring Programs</a> 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.</li>
<li>Overdose education and naloxone distribution programs are initiatives to improve community response to situations of opioid overdose. These programs are designed to equip likely opioid abusers and the friends and family of likely opioid abusers with the tools to respond to an overdose.</li>
<li>Abuse-deterrent formulas for prescription opioids are made with opioid formulas that are less likely to induce addiction in patients than traditionally prescribed opioids.</li>
<li>Current treatment efforts
<li><a href="https://www.samhsa.gov/medication-assisted-treatment">Medication-Assisted Treatment</a> (MAT) combines behavioral rehabilitation and medication to treat opioid abuse disorder. Programs promoting these treatments have expanded to become more accessible and provide medicinal treatment for those suffering with abuse.</li>
Opioids are substances that attach to opioid receptor sites found on neurons, cells that transmit information between the brain and the rest of the body. This transmission of information is known as neurotransmission. During neurotransmission, chemicals called neurotransmitters spread messages between neurons by either activating or inhibiting those neurons from producing chemical messages. Thus, neurotransmission is naturally regulated by a series of inhibitory and activation signals that control neuronal activation; some neurotransmitters cause neurons to activate while some neurotransmitters prevent neurons from activating.
According to the National Institutes of Health (NIH), opioids function as neurotransmitters capable of activating certain pathways of neuron signaling by binding to their specific opioid receptor sites. The body naturally produces endogenous opioids that bind to and activate opioid receptor sites on neurons to release “feel-good” chemicals such as endorphins, serotonin, oxytocin, and dopamine that control our reaction to painful stimuli.
However, the NIH further states that externally-administered, opioid drugs not produced by the body can disrupt the natural regulation of neurotransmission. These opioid drugs mimic the molecular structure of the brain’s natural opioids to bind to natural opioid receptor sites, activate neurons, and cause neurons to overproduce the “feel-good” neurotransmitters. In this way, these opioid drugs “fool” the nervous system into a state of overstimulation that ultimately results in the excess release of neurotransmitters that produce feelings of relaxation and pleasure.
According to the National Institute on Drug Abuse (NIDA), in addition to producing high levels of neurotransmitters that cause pleasurable feelings, opioid drugs also produce high levels of neurotransmitters, such as dopamine, that cause the desire to repeat behavior. Dopamine signaling activates the brain’s reward system and causes the desire to repeat pleasurable experiences. This desire is referred to as the opioid effect, which promotes addictive behavior.
There are three main types of opioids, distinguished by their synthetic properties:
- Natural opioid: opioids derived from the opium poppy (e.g., morphine, codeine, thebaine);
- Semi-synthetic opioids: opioids created from natural opiates (e.g., hydromorphone, hydrocodone, oxycodone, heroin); and
- Fully synthetic opioids: opioids created entirely synthetically (e.g., fentanyl, pethidine, levorphanol).
While many effects of opioids can be useful for medicinal purposes such as pain relief, some patients develop an addiction to opioids. In such patients, regulated prescription opioid usage devolves into addictive nonprescription opioid abuse. According to NIDA, there is evidence to support that many patients begin using prescription opioid medicine and only resort to illicit opioids when their prescriptions run out. For example, the usage of heroin is nineteen times higher for individuals who began using opioids as prescription medication than those who had no prior prescription access to opioids. Further, 80% of current heroin users self-reported using prescription opioids prior to using heroin. Despite the established link between prescription opioid usage and illicit opioid usage, the NIH reports that the prescription rate has skyrocketed throughout the last three decades.
According to NIDA, around 2.4 million people suffer from opioid addiction. This number is growing dramatically and opioid overdoses are driving the increase in drug overdoses in the United States. NIDA further emphasizes the dangers of this addiction, reporting that opioid addiction has severe mental and physical effects on users. Repeated usage of opioids causes users to develop a tolerance for the substance through desensitizing neurons. NIDA explains that, as a result, users increase their dosages, perpetuating the addiction, and sometimes resulting in overdose.
To combat opioid addiction, there are three main types of corrective treatments available to opioid abusers:
- Pharmalogical treatment (medication-assisted treatment): aims to reduce opiate withdrawal symptoms to allow patients to return to a productive lifestyle instead of constantly seeking the substance. These drugs stimulate opioid receptors but avoid producing the “high” associated with recreational use, allowing the user to shift their dependency away from their drugs with minimal withdrawal symptoms and cravings.
- Methadone is a slow-acting opioid agonist, a drug capable of activating receptors in the brain, that reproduces the euphoric effect of opioids to relieve withdrawal symptoms for 24–36 hours per dose.
- Buprenorphine is a partial opioid agonist which partially reproduces the euphoric effect of opioids, with many time-release formulations.
- Naltrexone is an opioid antagonist, a drug capable of blocking opioid receptors in the brain, that blocks opioid receptors for 20–30 minutes and prevents opioids from inducing feelings of euphoria in the user.
- Naloxone is a drug used for short term overdose reversal instead of long term treatment. It blocks opioid receptors and prevents harmful symptoms such as drowsiness and shortened respiration from continuing.
- Behavioral therapy treatment: targets the psychological and sociological aspects of addiction.
- Cognitive behavioral therapy is a classification of outpatient therapy strategies which provide psychotherapy to patients and attempt to correct the learned behavioral patterns behind drug abuse.
- Contingency management treatment is a form of outpatient therapy that rewards patients for negative drug screens to incentivize healthy living and a stepwise return to independent living.
- Community reinforcement approach is a form of outpatient therapy that makes a substance-free lifestyle more rewarding than a substance-use lifestyle through vocational, familial, and social incentives and reinforcement.
- Family behavior therapy is a form of outpatient therapy aimed at addressing familial problems such as abuse, mistreatment, and conflict that function as risk factors and triggers for drug abuse.
- The matrix model is a form of outpatient therapy that attempts to achieve abstinence by teaching patients about issues of addiction and the self-help and support systems available to them.
- Motivational interviewing is a form of outpatient therapy that provides counseling to patients aimed towards eliciting self-motivation from patients for behavioral change.
- Residential treatment is inpatient therapy that removes patients from toxic environments and helps them to shift to a more positive lifestyle.
- Long-term recovery treatment: groups that provide those who want to live a drug free lifestyle with a support network of recovering narcotic abusers.
- Narcotics Anonymous (NA) is a community-based organization which holds weekly group meetings for recovering drug abusers.
Nicole Schramm-Sapyta, Ph.D., is an Assistant Professor of the Practice in Duke Institute for Brain Sciences and an Adjunct Assistant Professor in the Department of Psychiatry and Behavioral Sciences.
- 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
- Muzyk, Andrew, Chris Trew, Allie Thomas-Fannin, Sanjai Dayal, Reina Maeda, Nicole Schramm-Sapyta, Kathryn Andolsek, and Shelley Holmer. 2017. “An Interprofessional Course on Substance Use Disorders for Health Professions Students.” Academic Medicine. doi:10.1097/ACM.0000000000001766
- Nicole Schramm-Saptya. 2016. “Want to fix Immigration? Fix Addiction.” The Hill. http://origin-nyi.thehill.com/blogs/pundits-blog/healthcare/275153-want-to-fix-immigration-fix-addiction
Li-Tzy Wu, D.Sc., is a Professor in Psychiatry and Behavioral Sciences at Duke University. Her work involves research on substance use disorder and treatment for drug use and alcohol use disorder.
- Wu, Li-Tzy, He Zhu, and Marvin S. Schwartz. 2016. “Treatment Utilization Among Persons with Opioid Use Disorder in the United States.” Drug and Alcohol Dependence 169: 117-127. doi:10.1016/j.drugalcdep.2016.10.015
- Ling, Walter, Larissa Mooney, and Li-Tzy Wu. 2012. “Advances in Opioid Antagonist Treatment for Opioid Addiction.” Psychatric Clinics of North America 35(2): 297-308. doi:10.1016/j.psc.2012.03.002
- Wu, Li-Tzy, George Woody, Chongming Yang, JJ Pan, and Daniel Blazer. 2011. “Abuse and Dependence on Prescription Opioids in Adults: A Mixture Categorical and Dimensional Approach to Diagnostic Classification.” Psychological Medicine 41(3): 653-664. doi:10.1017/S0033291710000954
- Wu, Li-Tzy, George Woody, Chongming Yang, and Daniel Blazer. 2010. “Subtypes of Nonmedical Opioid Users: Results from the National Epidemiologic Survey on Alcohol and Related Conditions.” Drug and Alcohol Dependence 112(1-2): 69-80. doi:10.1016/j.drugalcdep.2010.05.013
Paolo Mannelli, M.D., is an Associate Professor of Psychiatry and Behavioral Sciences. He works with the neurobiological and clinical aspects of substance use disorders, in particular intoxication and withdrawal from opioids, alcohol, and cocaine, and has tested the validity of biological markers of disease. He is involved with pharmacological and public health research for a better understanding of obstacles and barriers to medically assisted treatment of opioid use disorder and other substances.
“Now that opioid overdose deaths have surpassed the yearly death numbers recorded at the peak of the HIV epidemics, we consider adopting a ‘Cascade of Care’ framework similar to the HIV/AIDS to address gaps in opioid use disorder management. This will require close tracking and evaluation of the process from diagnosis to treatment. Success, like in the case of HIV, will ultimately depend on the wide availability of medications and treatment options.”
- Mannelli, Paulo and Li-Tzy Wu. 2016. “Primary Care for Opioid Disorder.” Substance Abuse and Rehabilitation 7:107-109. doi: 10.2147/sar.s69715
- Mannelli, Paulo, Li-Tzy Wu, Kathleen S. Peindl, and David A. Gorelick. 2013. “Smoking and Opioid Detoxification: Behavioral Changes and Response to Treatment.” Nicotine and Tobacco Research 15 (10): 1705-1713. doi: 10.1093/ntr/ntt046
- Mannelli, Paulo, Li-Tzy Wu, Martin Swartz, and George Woody. 2014. “Extended Release Naltrexone Injection is Performed in the Majority of Opioid Dependent Patients Receiving Outpatient Induction: A Very Low Dose Naltrexone and Buprenorphine Open Label Trial.” Drug Alcohol Depend 138: 83-88. doi:10.1016/j.drugalcdep.2014.02.002
- Mannelli, Paulo, Kathleen Peindl, Tong Lee, Kamal Bhatia, and Li-Tzy Wu. 2012. “Buprenorphine-Mediated Transition from Opioid Agonist to Antagonist Treatment: State of the Art and New Perspectives.” Current Drug Abuse Reviews 5(1):52-63. doi:10.2174/1874473711205010052
- Mannelli, Paulo, Kathleen Peindl, Li-Tzy Wu, Ashwin Patkar, and David Gorelick. 2012. “The Combination Very Low-Dose Naltrexone-Clonidine in Management of Opioid Withdrawal.” The American Journal of Drug and Alcohol Abuse 38(3):200-205. doi:10.3109/00952990.2011.644003
- Mannelli, Paulo, Kathleen Peindl, Li-Tzy Wu. 2011. “Pharmacological Enhancement of Naltrexone Treatment for Opioid Dependence: A Review.” Substance Abuse Rehabilitation 2(1):113-123. doi:10.2147/SAR.S15853
- Mannelli, Paulo, Kathleen Peindl, Ashwin Patkar, Li-Tzy Wu, Haresh Tharwani, and David Gorelick. 2011. “Problem Drinking and Low-Dose Naltrexone-Assisted Opioid Detoxification.” Journal of Studies on Alcohol and Drugs 72(3):507-513. doi:10.15288/jsad.2011.72.507
- Mannelli, Paulo, Kathleen Peindl, Ashwin Patkar, Li-Tzy Wu, Chi-Un Pae, and David Gorelick. 2010. “Reduced Cannabis Use Following Low Dose Naltrexone Addition to Opioid Detoxification.” Journal of Clinical Psychopharmacology 30(4):476-478. doi:10.1097/JCP.0b013e3181e5c168
- Mannelli, Paulo, Ashwin Patkar, David Gorelick, Li-Tzy Wu, and Edward Gottheil. 2009. “Very Low Dose Naltrexone Addition in Opioid Detoxification: A Randomized, Controlled Trial.” Addiction Biology 14(2):204-213. doi:10.1111/j.1369-1600.2008.00119.x
Endorsements & Opposition
Proponents of the Commission emphasize the necessity of a comprehensive approach to the opioid crisis and commend the Trump administration for taking the first steps to developing a strategy to combat the crisis.
- Governor Charlie Baker (R-MA) said in a public statement: “The deadly heroin and opioid epidemic can only be broken with a comprehensive effort from all levels of government focused on increasing access to treatment, prevention, and recovery services, and I am pleased to support this bipartisan commission.”
- Governor Chris Christie (R-NJ) said in an interview with NBC: "The opioid initiative is one that's incredibly important to every family in every corner of this country.”
- Zack Cairns, Legislative Associate of Stateside, a government relations consulting firm, wrote: “The Trump Administration has signaled with this Commission that addressing the opioid crisis is a priority and one requiring the collaboration of federal, state and local leaders. The inclusion of Governors Christie, Baker, Cooper and Attorney General Bondi presents an opportunity for state successes and lessons learned to inform the national conversation.”
Nearly all opposition to the Commission argues in unison that the Commission is too shallow of an effort to combat the opioid crisis. This strain of opposition further argues other policies and budget cuts proposed by the Trump administration will decrease drug abuse treatment and education, ultimately hindering the ability of the Commission to effectively combat the opioid crisis.
- Senator Maggie Hassan (D-NH) said in an interview with POLITICO: “I am concerned that rather than show a commitment to increasing resources to boost treatment capacity, President Trump has so far pushed policies that would harm our efforts to combat the crisis.”
- Senator Jeanne Shaheen (D-NH) said in a public statement: “There is a massive gulf between President Trump’s promises to tackle this crisis and the policies this administration has proposed during his first two months in office.”
- Senator Patty Murray (D-WA) said in a public statement: “I’d take President Trump’s proposed efforts on opioids more seriously if he hadn’t spent the last two months trying to derail the historic steps forward on substance abuse treatment through the Affordable Care Act – and if his budget didn’t also include a 20% cut to mental health services, which are so important in the fight against this epidemic.”
- Daniel Raymond, Policy Director of Harm Reduction Coalition, a national advocacy group for those impacted by drug use, said: “I don’t know that there is a lot of enthusiasm for a new commission report because that seems to presuppose that we don’t actually know what needs to be done.… I don’t know how you square the circle by saying ‘we care about the opioid crisis’, then cut budgets, cut access to healthcare and beef up law enforcement strategies rather than providing services and support.”