Running head: COMPREHENSIVE ADDICTION AND RECOVERY ACT 1

Comprehensive Addiction and Recovery Act

Elaine Dean

Jacksonville University

March 21, 2017

COMPREHENSIVE ADDICTION AND RECOVERY ACT 2

Comprehensive Addiction and Recovery Act

Introduction

S.524. This is the first comprehensive federal legislation in 40 years to unanimously pass

the United States Senate and the House of Representative. On March 10. 2016 this piece of

legislation passed in the Senate with a vote of 94-1 and on May 13th, 2016 it passed in the U.S.

House of Representative by a vote of 400-5 (CADCA, 2016). President Barack Obama officially

signed the bill into law on July 20th, 2016. The provisions of the bill addressed the full

continuum of care from prevention to recovery. It included the six pillars for a coordinated

response which are prevention, treatment, recovery, law enforcement, criminal justice reform,

and overdose reversal (NAATP, 2016).

Factors/Rationale that led to development of policy

There has been an increase in the prevalence of opioid over the last twenty years. The

incidences involving chronic pain has increased, health care cost has exploded and a massive

epidemic with severe adverse consequences has emerged. Relaxation of laws governing the use

of opioids for the treatment of non-cancer pain have resulted in more prescription being written

however, this is also accompanied by aggressive marketing by pharmaceutical companies. In

addition to these factors, there are patients who truly believe that opioids are safe and effective

and present no harm if prescribed by a doctor. These coupled with other sequences of events

have landed the United States in the midst of an unprecedented increase in morbidity and

mortality associated with opioid abuse (Manchikanti et al, 2012). The opioid addiction has

become a fifty state epidemic whether in the form of cheap smuggled heroin or from established

“pill mills”, public health officials are now declaring the current epidemic the worse drug crisis

in American history. In 2015 more than 33,000 individuals died in opioid related-deaths (Brauer,
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2017). Dr. Nora Volkow from the National Institute on Drug Abuse presented some alarming

statistics to the Senate Caucus on International Narcotics Control in May of 2014. An estimated

26.4 million to 36 million individuals globally abuse opioids, with an estimated 2.1 million in the

United States suffering from substance abuse and related prescription pain medication abuse.

Data collected in 2012 showed an estimated 467, 000 Americans addicted to heroin (Volkow,

2014). This is now a serious national crisis transcending across race, gender and class. It causes

destruction to families, friends, and entire communities. It has rendered catastrophic outcome to

individual health, social, and economic welfare. According to the Center for Disease Control and

Preention (CDC) opioid related-deaths have increased significantly. More than six of every ten

deaths involve an opioid. From 2000-2015 more than 500, 000 thousand individuals died from a

drug overdose. The breakdown is that 91 Americans dies every day from an opioid-related

incident (CDC, 2016). It was reported in 2012 that 259 million opioid pain medication

prescriptions were written enough for every adult in America to have a bottle of pill (ASAM,

2017). This troubling epidemic is also aggressively extending into the adolescent population. In

2013, approximately two million teenagers 12 and older in the United States was dependent on

opioids or abused opioids and over 35 million had used an opioid analgesic for non-medicinal

purposes an uptick from 30 million in 2002. 10% percent of high school seniors also admitted to

the use of opioids for non-medicinal purposes at one point or anther making it the second most

abused drug to marijuana (McCarbery, 2015). The sheer width and breadth of these factors with

the accompanying statistics leads us to ask. How did we get here? Not only the extensive

utilization of opioids but the human cost have morphed into a social and economic environment

that is untenable. The American Psychiatric Association understands the crisis and its far-

reaching effects and is actively advocating on behalf of the patient. They took action to reduce
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the stigma and encourage disenfranchised Americans to seek help by replacing the diagnosis of

opioid dependence and opioid abuse with a single diagnosis, opioid use disorder (Levin, 2017).

Benefits to Healthcare

The focus of the CARA legislation is on prevention, treatment, recovery, criminal justice

reform, overdose reversal, and law enforcement should bring changes to the prescription

prescribing practices thus, tightening the ease of access to these powerful drugs via the internet

and other sources, and help to bring changes to drug formulation reducing the risk of the

addictive properties. Although opioids are significantly successful in treating acute pain, long-

term use has been associated with clinically high rate of abuse (Volkow, 2014). The CARA bill

will benefit healthcare by influencing important areas for research to help minimize the harmful

effects of opioid abuse including the identification and implementation of clinical practice that

minimize addiction risk, establishment of guidelines for early detection and management

strategies, changes in the prescription formulation of opioid analgesics to minimize the risk of

abuse and development of safe and effective non-opioid choices. Funding from the bill will help

the urgently needed investigation into the adolescence age group to establish best practice to treat

pain in teenagers, strategies to create diversion and prevent abuse. CARA will make it feasible

for emergency medical personnel to have the life-saving drug naloxone, also under the policy

inmates arrested for drug usage would be offered treatment choices instead of jail time. Drug

dependency of any kind carries with it a certain stigma CARA encourages not only treatment to

American’s who are affected but also offers preventative education CARA bridges the gap in

limited outpatient treatment services and the lack of resources which are crucial to long-term

success of addiction treatment and recovery. It would allow clinicians to partner with

pharmaceutical companies to find alternative effective non-opioids pain relief to address

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individuals in chronic pain. A new evidence-based treatment algorithm would significantly

decrease the number of opioid prescription being written. With prevention and education at the

top of the six pillars, the cost for long-term treatment methodologies would decrease as the

number of individuals in the addictive process would decrease. This would lower cost per

treatment and reduce the tax burden on the American taxpayer. However, the core benefit of the

CARA policy is first prevention but if otherwise it is geared towards helping addictive

individuals with the appropriate services and support towards the ultimate goal of recovery and

abstinence.

Cost(s) related to the policy (fiscal, time factors, manpower)

The opioid abuse and dependency epidemic presents significant economic consequences

to the United States economy. The evidence indicates that individuals who abuse or misuse

opioids incur higher healthcare cost and require additional resources (Florence, Zhon, Luo & Xu,

2016). Researchers from the Center for Disease Control and Prevention (CDC) did a cost

analysis of the opioid abuse including the direct healthcare cost, lost productivity, and the cost to

the criminal justice system. The study estimated the cost of the epidemic at 78.5 billion. Broken

down into individual areas healthcare accounted for one-third of the cost. Approximately 25% of

the cost burden was shouldered by public sources. These include Medicare and Medicaid and

other public insurance as well as government funded programs. Additionally, state and local

government covered 7.7 billion which is related to criminal justice related cost (Florence, Zhou,

Luo & Xu). According to CDC director Tom Frieden, the rising cost of the epidemic is a

tremendous burden to the healthcare system (CDC, 2016). However the study was not without

limitation it was unable to measure the total societal cost of the opioid epidemic this included the

quality of life of the dependent individual and the financial cost to the family The costs that were
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approximated highlighted the magnitude of the healthcare burden associated with opioid use,

overdose, abuse and dependency. Even though the CARA bill was signed into law federal

funding remain uncertain. In September 2016 a temporary funding of seven million was provided

through to December of that year this fell short of the 1.1 billion requested by then President

Obama. Currently, CARA allocates 181 million to fight the opioid addiction, however, this is

revisited yearly and the amount could change. Of the 181 million 25 million is designated for

treatment and recovery. Funding is allocated to entities that provide effective evidence-based

treatment practices for treating opioid addiction. CARA also earmark one million for community

recovery building, this includes collaboration between community organization, primary care

physician, and government agencies. For the fiscal year 2017, President Obama requested 1

billion to be included in the budget for CARA to fight addiction and expand treatment.

Democrats also attempted to include 920 million in funding to the bill however, Republican

voted against both provisions (Fraser, 2016).

Impact on client (stakeholder) satisfaction

Sec.402 of the CARA bill mandates a national stakeholder taskforce. Stakeholders from

healthcare, housing, employment, substance use disorder, law enforcement, and the legal

communities convene to identify the challenges faced by individuals who abuse opioids, This

taskforce presents and exchange valuable information on best practices and recommend ways to

reduce and where possible eliminate collateral consequences. This mandatory collaboration

among stakeholders enhances and improves satisfaction as each group can actively participate in

the success of the bill. With the bill in place and the federal government finally realizing that

opioid addiction is now a public health crisis stakeholders can concentrate on affecting this bill

positively through advocacy and improvement (See Appendix A).

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Impact on clinical outcome

The CARA law will have a significant impact on clinical outcome. The law allows for

first responders including law enforcement and emergency management personnel (EMS) to use

naloxone at the scene of drug overdoses. It also recommends co-prescription of naloxone with

opioids for individuals at high risk for overdose. This will improve the morbidity and mortality

rates of individuals suffering from substance abuse disorder. Advance Registered Nurse

Practitioners are also now able to be certified in medically assisted treatment (MAT) improving

clinical outcome by providing additional professional personnel who can provide effective

treatment and counseling in substance abuse treatment facilities. The law also embodies

continued research, education, and public awareness. Through public drug awareness campaigns,

the CARA bill promotes safe and quilt free drug take-back and disposal programs thus mitigating

the stigma attached to drugs, fear and the extension of use. Monitoring, active surveillance and

data collection are also required under the law to improve access and the expansion of services.

Conclusion

The abuse of prescription and non-prescription continues to be a growing problem in the

United States with challenges that are very complex and taxing on the healthcare system, While

it is imperative that we strike the delicate balance to ensure that individual Americans suffering

from chronic pain get the relief they need it is also imperative that we minimize the potential for

negative consequences. It is well documented that a growing number of people are dying from

drug overdoses after abusing prescription opioids. This is in conjunction with prescription

medication being diverted to the illegal market. The CARA initiatives provide the tool to

develop and implement multipronged evidence-based strategies that is needed to counter the risk

of opioid usage and make all treatment methodologies available.

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References

Brauer, S. M. (2017). Inside a killer drug epidemic: A look at America’s opioid crisis. Retrieved

from http://www.nytimes.com

Drug overdose death in the United States continue to increase in 2015. (2016). Retrieved from

http://www.cdc.gov

Florence, C. S., Zhou, C., Luo, F., & Xu, L. (2016). Economic burden of prescription opioid

Overdose, abuse, and dependence in the United States, 2013. Medical Care, 54(10).

Fraser, D. (2016). Congress approve temporary funding for CARA. Retrieved from

http://www.sovhealth.com

Health care cost from opioids abuse: A state-by-state analysis. (2015). Retrieved from

http://www.drugfree.org

Leven, S. (2017). How the APA is helping address America’s opioid crisis. Retrieved from

http://www.psychiatry.org

Manchikanti, L., Helm, S., Fellows, B., Janta, J., Pampati, V., Grider, J. S., & Boswell, M. V.

(2012). Opioid epidemic in the United States. Pain Physician Journal, 15.

McCarberg, B. (2015). The continued rise of opioid misuse: Opioid use disorder. AJMC.

President Obama signs CARA. (2016). Retrieved from http://www.naatp.org/advocacy/public-

policy/president-obama-sign-cara/jul-23-2016

The comprehensive addiction and recovery act (CARA). (2016). Retrieved from

http://www.cadca.org

Treating opioid addiction as a chronic disease. (2014). Retrieved from

http://www.asam.org/doc/default-source/advocacy/ccm-fact-sheet=11=07-

14.pdf?sfvisn=0
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Volkow, N. (2014). America’s addiction to opioids: Heroin and prescription drugs. Retrieved

from http://www.drugabuse.org/about-nida/legislative-activities/testimony-to-

congress/2015/prescription-opioids-heroin-abuse
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Appendix A

Hyperlink for the Comprehensive Addiction and Recovery Act

http://www.fas.org/sgp/crs/misc/R44493.pdf
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