After months of bipartisan work by eight committees in the House of Representatives and five committees in the Senate, Congress overwhelmingly passed sweeping legislation to help combat the opioid crisis. The new law is one of the most significant legislative achievements of the year—a rare bipartisan response to the public health crisis that led to more than 72,000 drug overdose deaths in 2017, according to data from the Centers for Disease Control and Prevention (CDC). The bill was signed into law by President Trump on Oct. 24.

“We’re encouraged to see Congress set aside their political differences to address this catastrophic problem devastating so many patients, families, and communities,” said Wilford K. Gibson, MD, chair of the AAOS Council on Advocacy. “These comprehensive reforms are much needed, and we look forward to continuing to work with Congress and the federal agencies on their implementation.”

The SUPPORT for Patients and Communities Act (H.R.6) was introduced in June by Rep. Greg Walden (R-Ore.). It includes provisions that touch almost every aspect of the opioid epidemic—from efforts to improve programs for prevention and treatment of substance use disorder, to a mandate that the Postal Service screen packages shipped from overseas for fentanyl.

AAOS was pleased that the final agreement included the Every Prescription Conveyed Securely Act (H.R. 3528), which requires the electronic transmission of prescriptions for controlled substances covered under Medicare Part D, beginning Jan. 1, 2021. Electronic prescribing not only promotes patient safety but also provides data in a format that is conducive to better surveillance of excessive, inappropriate, and nontherapeutic prescribing.

In a September 2017 letter to the bill’s sponsor, Rep. Katherine Clark (D-Mass.), then AAOS President William J. Maloney, MD, wrote: “By requiring prescribers to use an online database where prescriptions are easily monitored and tracked, this bill could help eliminate doctor shopping and duplicative or fraudulent handwritten prescriptions that fuel the opioid epidemic.”

AAOS also was pleased that the final bill authorizes the CDC to award grants to states and localities to improve their Prescription Drug Monitoring Programs (PDMPs), collect public health data, implement other evidence-based prevention strategies, encourage data sharing among states, and support other prevention and research activities.

“By ensuring prescription information relating to opioids and other controlled substances is available in an easy-to-read system, interoperable across state lines, and available in a timely manner, prescribers will be able to access the most accurate and up-to-date information to help them make the best clinical decisions for their patients,” wrote AAOS President David A. Halsey, MD, in a March letter to the House Committee on Ways and Means.

Other significant provisions in the SUPPORT for Patients and Communities Act will:

• expand telehealth services for Medicare and Medicaid substance use disorder treatment programs and require the attorney general to issue regulations on waivers allowing providers to prescribe controlled substances via telemedicine in emergency situations
• reauthorize the Office of National Drug Control Policy, expand other existing programs, and create new programs to prevent substance use disorders and drug overdoses
• provide funding to encourage research and development of new nonaddictive painkillers and nonopioid drugs and treatments
• require the Department of Health and Human Services to report on the impact of federal and state laws and regulations that limit the length, quantity, or dosage of opioid prescriptions
• direct the Government Accountability Office to analyze the barriers for access to substance use disorder treatment medications under various drug distribution models
• direct the Medicaid and Children’s Health Insurance Program Payment and Access Commission to conduct a study on utilization and management controls applied to medication-assisted treatment options in both fee-for-service and managed care Medicaid programs
• require the Department of Labor to work with the Centers for Medicare & Medicaid Services and the secretary of the treasury to provide information on mental health parity compliance

What’s not in the bill

Although the 250-page legislation includes many varied provisions, several proposals did not make it into the final agreement. As the draft moved through the committee process, heavy-handed proposals were watered down, and controversial provisions were eliminated entirely because of a bicameral understanding that Congress needed to quickly pass legislation. Other sections were removed or amended during the final House and Senate conference agreement.

AAOS was extremely pleased that strict limits on prescriptions for controlled substances were not included in the final bill. AAOS strongly believes that national standards on prescription limits without the requisite clinical evidence could inappropriately limit patient access to necessary pain management. Throughout the process, AAOS
advised committees against mandating a one-size-fits-all policy, which would interfere with the vital
patient-physician relationship through the application of blanket prescription limits to all procedures.

The MONITOR Act (H.R.4236) also was not included in the final bill. AAOS supported this legislation, which would establish minimum standards that PDMPs must meet to receive funding from the Account for State Response to the Opioid Crisis. However, the committee decided that the provisions would be better as a second step after first authorizing CDC grants to bolster current PDMPs.

Similarly, efforts to change 42 CFR Part 2—a rule that requires the explicit permission of patients to share substance use disorder records—was not included in the final package. AAOS supported reforming the burdensome 1970s-era privacy law, which inhibits providers from obtaining relevant clinical information and engaging in efficient care coordination. The proposal to amend the laws was controversial from the start and ultimately was eliminated for fear of risking a party-line vote on the larger package.

What’s next for opioid policy?

Although there is no definite timeline laid out for next steps, policymakers will continue to keep an eye on the opioid epidemic long after this bill is signed into law. First and foremost, they will want to know how the provisions are affecting the community. Depending on the success of these efforts and the information gathered from agency reports, Congress will almost certainly revisit some of the more controversial provisions that were not included in the first package. Additionally, new members of Congress will introduce ideas and proposals and want a hand in crafting any future opioid-response legislation.

Finally, annual funding for these measures and other opioid-related policies will continue to be a battle during the appropriations process. This year, Congress allocated $8.5 billion for opioid-related programs, but future funding is not guaranteed. Some members have proposed committing $100 billion over 10 years to fight the epidemic, likening the issue to Congress’ response to the HIV/AIDS epidemic.

The AAOS Office of Government Relations (OGR) will continue to work with Congress and federal agencies as the SUPPORT for Patients and Communities Act is implemented and as new proposals are introduced. For more information on AAOS opioid initiatives, visit www.aaos.org/Advocacy/FDA.

For more information on preoperative pain relief discussions, screening questionnaires, orthopaedic service strategies, and more, visit the AAOS Pain Relief Toolkit at www.aaos.org/Quality/PainReliefToolkit/?ssopc=1.

Stephanie Hazlett, MPH, is a government relations manager in the AAOS OGR.