Illinois’ Response to the Opioid Epidemic: A Public Health Issue Requiring a Medically Based Response
On September 6th, Governor Rauner signed Executive Order 2017-05, establishing the Governor’s Opioid Prevention and Intervention Task Force.[i] Concurrently, the Governor’s Office issued the State of Illinois Opioid Action Plan.[ii] The purpose of the new Task Force is to implement the Action Plan with the stated goals of preventing further spread of the opioid crisis, treating and promoting the recovery of individuals with opioid use disorder, and responding effectively to avert opioid overdose deaths.
The new Task Force is not “new” insofar as it follows in the footsteps of prior bureaucratic entities similarly tasked with addressing the Opioid Crisis in Illinois—notably, the Illinois’ House Bipartisan Task Force on the Heroin Crisis, formed by the Legislature in 2014, and the Illinois Opioid Crisis Response Advisory Council, led by the Illinois Department of Human Services/ Division of Alcoholism and Substance Abuse, formed in January of 2017-- of which the John Howard Association of Illinois is a member alongside a broad coalition of State agency leaders, other community stakeholders, criminal justice reform advocates, and treatment providers.
The John Howard Association of Illinois is heartened by the Governor’s Executive Order and the creation of the newly announced statewide Action Plan to combat opioid abuse, support recovery, and prevent opioid related fatalities. The newly announced Action Plan is broad and has laudable goals, however, it remains general in scope. The specific numbers, benchmarks, quantifiable metrics, infrastructure, expense, and on-the-ground practical resources that ultimately will be needed to effectively stem the tide of Illinois’ Opioid Crisis remain largely undefined under the Action Plan in its current incarnation. While JHA applauds Executive Order 2017-05, the devil is in the details.
It is critical that as the Task Force begins its work, there is continued and increased recognition that opioid addiction is a disease and should be treated as a public health problem, and that incarceration is an inappropriate response to the opioid crisis. JHA strongly advocates that the principles laid out below guide the work of the Task Force.
First, substance use disorder is a bona fide medical condition that has complex biological, behavioral, environmental, and social-context components.[iii] As a chronic and relapsing disorder, it should be treated like other lasting illnesses, where periods of relapse are expected and not deemed “failures,” even after long periods of abstinence. The standard for treatment success is individualized management of the disorder, not a one-size-fits-all, one-step “cure.” There are many pathways to recovery from opioid addiction. Both science and experience make clear that each person should have the right to make individualized treatment choices from a full panoply of treatment options, including medication assisted replacement maintenance therapies such as methadone (the current gold standard for treating opioid addiction), as well as buprenorphine, which scientific evidence has shown to be more effective than abstinence or opioid blockers alone in treating opioid use disorders.[iv]
JHA commends the Governor for expressly recognizing that “substance use disorder is a disease” and that “recovery from substance use disorder is possible” in Executive Order 2017-05. As with any other chronic illness, one particular medication or treatment modality may work for some people, but not others, who may find success through different treatment plans. Prejudice nevertheless remains among some providers, policy-makers, law enforcement officers and judges against maintenance-based medication assisted treatment programs in favor of abstinence-only, “drug-free” programs or programs that offer only opioid antagonists, such as Vivitrol and naltrexone, that block the pharmacologic “high” when using opioids, but which still have little clinical evidence to support their efficacy.[v]
Consistent with best practices and principles of basic human rights, JHA believes that every individual, even those who have been denied their liberty, has the right to choose his or her path to recovery, including whether or not to use medication assisted treatment, fully understanding the potential risks and benefits of all treatment options. Thus, consistent with both the Executive Order’s and Action Plan’s commitment to evidence-based treatment, and in adherence with best practices and the standard of care, any treatment program (both outside and inside jails and prisons) that does not include the option of medication assisted therapy, including replacement maintenance therapy, cannot be deemed evidence-based and should not be supported by the State of Illinois.
Second, Illinois cannot arrest or incarcerate our way out of the opioid epidemic. For too long substance use disorders have been treated as a moral and criminal concern, rather than a public health issue. It is widely accepted that half of all jail and prison inmates meet the DSM-IV criteria for substance abuse dependence.[vi] This fact further delegitimizes the social, criminal justice, and political policies derived from historically mischaracterizing addiction and opioid use disorders as moral failings, rather than health issues. Such policies have served to exacerbate and help generate the current opioid epidemic by further stigmatizing and marginalizing persons with the disorder, and incarcerating them without effective treatment. Incarceration has proven wholly ineffective at ending substance abuse.
About 80 percent of persons in prison abused drugs or alcohol, and roughly 95 percent of those who abused drugs return to drug abuse after release from prison.[vii] Persons returning from prison are also at an extremely high risk for death from drug overdose having reduced drug tolerance after a period of forced abstinence.[viii] Due to grave treatment and programming deficits inside Illinois’ prisons, our system is not able to provide treatment to even a fraction of those who seek or need treatment, leaving many inmates who seek help without options.
In the past year, some important policy changes have occurred which reflect a new paradigm in thinking of and treating opioid use disorder as a health problem, rather than a criminal or moral issue. To that end, new legislation now bars judges in drug courts from prohibiting defendants from receiving medication assisted treatments like methadone for opioid use disorders from physicians, mandates that state-licensed substance abuse programs provide participants with information on medication assisted treatments, including the use of anti-overdose drugs, and expands Medicaid coverage to include payment for methadone treatment of opioid use disorder.[ix]
While initial use of opioids may be voluntary, opioid use disorder is, first and foremost, a brain disease. Persons with the disorder should not be ostracized as criminals, but treated as persons with a chronic medical condition. To the extent that our criminal laws and policies act as a bar to treatment and fail to recognize opioid use disorder as a disease, they should be reexamined and abolished. Consistent with the Governor’s Executive Order recognizing substance use disorder as a disease, JHA recommends that Task Force mandate Illinois to provide a full range of treatment options, including evidence-based medication assisted treatments, to every person, both inside and outside our jails and prisons who desires treatment for opioid abuse regardless of their ability to pay. Using models from other states, this approach can be implemented. We urge the Task Force to consider the example put in place in Rhode Island, which is a model of innovation in implementing standards, evidence-based medication assisted treatment and data-supported best practices, particularly for justice-involved individuals.[x]
Last, the Task Force must engage the public and stakeholders and hold itself publicly accountable by setting specific, tangible, measurable benchmarks and deadlines for accomplishing the goals of the Action Plan. It is also critical as part of public engagement and to ensure accountability that the Task Force hold public meetings, providing adequate public notice of meeting times’ and agendas, and issue regular quarterly public reports, documenting the metrics and concrete steps the Task Force has undertaken to achieve the goals of the Action Plan.
JHA notes that the Task Force is made up entirely of government agencies with no other stakeholder voices or those with lived experience with opioid abuse appointed to it. This poses a danger of the Task Force drifting towards conformity, pedantry, and the kind of bureaucratic “group think” that discourages innovation, rigorous debate, and critical analysis. Further, public input and reporting responsibilities are not articulated in the Executive Order creating the Task Force and outlining its membership and goals. Without buy in and input from the public, transparency in the form of public reporting, and the public accountability which flows from these, the new Task Force will be nothing more than a thinly veiled bureaucratic attempt to appease stakeholders, rather than one that actively problem solves and directly addresses a vital public health need.
For an Action Plan to be an effective management and implementation tool, the plan cannot sit on a shelf. Rather, it must be continually used, reviewed, modified and made tangible by setting quantifiable, measurable benchmarks and the establishment of deadlines that are regularly reported to the public. Further, leaders of the Task Force and those charged with implementation of the Action Plan must be willing to champion evidence-based practices and medically-based policies and standards in the face of negative stereotypes, prejudice and stigma against opioid abusers.
JHA adamantly believes that opioid users and those with a history of opioid abuse, including those who have been incarcerated, must have a central voice in the creation and implementation of the programs and policies designed to serve them. Further, JHA recognizes as a practical matter that government agencies ultimately will be tasked with practical implementation of the action plan. However, doctors, scientific researchers, and addiction treatment experts, not politicians, should have ultimate decision-making power with regard to standards of care and evidence-based best practices in implementing programs and policies under the Action Plan. The importance of the Action Plan succeeding in addressing the opioid crisis cannot be overstated. Its success is essential to ensuring the health, safety and well-being of all Illinois citizens. For success to occur, there must be a joint partnership between government leaders, the public, and community stakeholders engaged as active collaborators in creating and implementing the plan.[xi]
[i] See Illinois Department of Public Health website, Prescription Opioids and Heroin: Resources: Executive Order 2017-05, available at: http://www.dph.illinois.gov/sites/default/files/publications/opioid-task-force-executive-orderseptember-2017-signed.pdf
[ii] Illinois Opioid Action Plan (September, 2017) available at: http://dph.illinois.gov/sites/default/files/publications/illinois-opioid-action-plan-sept-6-2017-final.pdf
[iii] United Nations General Assembly, Resolution S301-1, April 19, 2016, “Joint Commitment to Effectively Addressing and Countering the World Drug Problem, available at: https://documents-dds-ny.un.org/doc/UNDOC/GEN/N16/110/24/PDF/N1611024.pdf?OpenElement; American College of Physicians Position Paper: Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs ( May 16, 2017), available at: http://annals.org/aim/article/2613555/health-public-policy-facilitate-effective-prevention-treatment-substance-use-disorders; American Society of Addiction Medicine, “Public Policy Statement on Pharmacological Therapies for Opioid Use Disorder,” available at: https://www.asam.org/docs/default-source/public-policy-statements/pharmacological-therapies-for-opioid-use-disorder-2013-04-24.pdf?sfvrsn=4; American Psychiatric Association, Position Statement on Treatment of Substance Use Disorders in the Criminal Justice System ( December, 2016), available at: file:///C:/Documents%20and%20Settings/User/My%20Documents/Downloads/Position-2016-Substance-Use-Disorders-in-the-Criminal-Justice-System.pdf; National Institute on Drug Abuse, Principles of Effective Treatment, available at: https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/principles-effective-treatment; Nora D. Volkow, M.D., George F. Koob, Ph.D., and A. Thomas McLellan, Ph.D., “Neurobiologic Advances from the Brain Disease Model of Addiction,” New England J Med 374:363-37 (January 28, 2016), available at: http://www.nejm.org/doi/full/10.1056/NEJMra1511480?af=R&rss=currentIssue&#t=article; National Commission on Correctional Healthcare, Position Statement: Substance Use Disorder Treatment for Adults and Adolescents, available at: http://www.ncchc.org/substance-use-disorder-treatment-for-adults-and-adolescentss; Lorraine M. Rusch, MSc, PhD, “ A Reality Check: The Need for a Deeper Understanding of Opioid Abuse Treatment Options: A Policy Statement From the American College of Clinical Pharmacology,” J Clin Pharmacol. 56(1): 7–10.
(January, 2016), available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4738468/
Alan I. Leshner, “Addiction is a Brain Disease and It Matters,” Science Magazine, 278, 45 (1997), available at: https://www.ecnp.eu/~/media/Files/ecnp/communication/talk-of-the-month/Wim%20van%20den%20Brink/Addiction%20is%20a%20brain%20disease%20and%20it%20matters.pdf; United States Centers for Disease Control: The Science of Drug Abuse and Addiction: The Basics, available at: https://www.drugabuse.gov/publications/media-guide/science-drug-abuse-addiction-basics; Thomas R. Kosten, M.D. and Tony P. George, M.D., “The Neurobiology of Opioid Dependence: Implications for Treatment” Sci Pract Perspect. 1(1): 13–20 (July, 2002), available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851054/
[iv] See Connery HS, “Medication-assisted Treatment of Opioid Use Disorder: Review of the Evidence and Future Directions,” Harvard Rev Psychiatry. 23(2):63-75 (2015), available at: https://www.ncbi.nlm.nih.gov/pubmed/25747920
[v] See Bart G, “Maintenance Medication for Opiate Addiction: the Foundation of Recovery,” Journal of Addict Dis. 31(3):207-25 (2012), available at: https://www.ncbi.nlm.nih.gov/pubmed/22873183. See also Jake Harper, National Public Radio, “Drugmaker of Vivitrol Tries To Cash In On The Opioid Epidemic, One State Law At A Time,” (June 12, 2017), available at: http://www.npr.org/sections/health-shots/2017/06/12/523774660/a-drugmaker-tries-to-cash-in-on-the-opioid-epidemic-one-state-law-at-a-time; Alec MacGillis, ProPublica, “The Last Shot,” (June 27, 2017), available at: https://www.propublica.org/article/vivitrol-opiate-crisis-and-criminal-justice; Daniel Wolfe, Stat News, “Vivitrol Offers the Fantasy of Being Drug-free. But That’s Not the Most Important Thing in Tackling Addiction,” (June 29, 2017), available at: https://www.statnews.com/2017/06/29/vivitrol-methadone-opioids/
[vi] Center for Prisoner Health and Human Rights, “Incarceration, Substance Abuse and Addiction” http://www.prisonerhealth.org/educational-resources/factsheets-2/incarce...
[vii] National Association of Drug Court Professionals, Fact Sheet: The Facts on Drugs and Crime in America, available at: http://www.nadcp.org/sites/default/files/nadcp/Facts%20on%20Drug%20Courts%20.pdf
[viii] Ingrid A Binswanger, Carolyn Nowels, et al, “Return to Drug Use and Overdose After Release from Prison: a Qualitative Study of Risk and Protective Factors,” Addict Sci Clin Pract 7(1): 3 (2012), available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3414824/
[ix] We note that the later policy change, expanding coverage of Illinois Medicaid to include methadone treatment, was enacted over the Governor’s opposition. As a matter of good governance, however, paying for methadone treatment is far more humane, impactful, and cost-effective for the state than incarcerating persons with opioid use disorders. National Institute on Drug Abuse: Understanding Drug Abuse and Addiction: Cost effectiveness of Drug Treatment, available at: https://www.drugabuse.gov/publications/teaching-packets/understanding-drug-abuse-addiction/section-iv/6-cost-effectiveness-drug-treatment. See also State of Illinois Department of Insurance, Annual Report, Working Group Regarding Treatment and Coverage of Substance Abuse Disorders and Mental Illness (January, 2017) (describing changes in Illinois Medicaid coverage for opioid treatment), available at: https://insurance.illinois.gov/newsrls/2017/01/MHSUDWGRptToGA_Jan2017.pdf;Public Act 099-0553, effective January 1, 2017, available at: http://www.ilga.gov/legislation/publicacts/fulltext.asp?Name=099-0553 and Public Act 099-0554, effective January 1, 2017, available at: http://www.ilga.gov/legislation/publicacts/fulltext.asp?Name=099-0554
[x] See Rhode Island Overdose Prevention and Intervention Task Force Action Plan, available at: http://www.governor.ri.gov/documents/press/051116.pdf; Rhode Island Overdose Prevention and Intervention Task Force, Strategic Plan on Addiction and Overdose: Four Strategies to Alter the Course of an Epidemic, available at: http://www.health.ri.gov/news/temp/RhodeIslandsStrategicPlanOnAddictionAndOverdose.pdf
[xi] We note that the Governor’s Executive Order does establish some preliminary 90-day deadlines for the various state agencies that make up the Task Force to” collaborate” and “coordinate” to, inter alia, collect and report data on opioid overdoses, establish a 24-hour hotline for people in Illinois dealing with opioid use disorder, and establish standing order to increase statewide availability of naloxone (an opioid antagonist that effectively prevents fatalities by reversing opioid overdoses). The Executive Order further dictates that the Task Force “shall also coordinate with the Illinois Opioid Crisis Response Advisory Council and other key stakeholders to formulate a detailed implementation plan, including specific activities and metrics for the execution of the strategies set forth in the Opioid Action Plan.” However, the Executive Order does not expressly provide for public Task Force meetings or require public reporting on progress on the Action Plan. JHA believes that as a matter of best practices emphasis also should be given by the Task Force soliciting and giving utmost deference to the opinions of current and former opioid users, and medical and scientific experts in the field of opioid addiction in determining and implementing the strategies set out in the Action Plan. This is not expressly provided for in the Executive Order. See Illinois Department of Public Health website, Prescription Opioids and Heroin: Resources: Governor’s Executive Order 2017-05, available at: http://www.dph.illinois.gov/sites/default/files/publications/opioid-task-force-executive-orderseptember-2017-signed.pdf