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Local Leadership Toward Ending the Opioid Crisis

By Excerpts from the National League of Cities Report of the City-County Task Force on the Opioid Epidemic

Responding to a Crisis

As the opioid epidemic has taken hold, city and county leaders are taking action. The number and scope of programs in place are a testament to the problem-solving skills of local officials. With both determination and imagination, local leaders are expanding prevention and treatment programs and giving more flexibility to public safety personnel who interact daily with individuals struggling with addiction. Knowing that localities cannot end this epidemic alone, these leaders are actively seeking partnerships and exploring innovative strategies that challenge old conventions about the stigma of addiction.
 
In early 2016, the National League of Cities and the National Association of Counties convened a joint task force to identify the local policies and practices that reduce opioid abuse and related fatalities. The task force met twice, in Washington, D.C., and in northern Kentucky. These meetings, coupled with countless conversations with local officials from across the country, including public health directors, prosecutors, law enforcement officials and substance abuse directors, enabled the task force to produce this report and its recommendations.
 
The recommendations are aimed at city and county officials and are divided into four sections: 1) leadership, 2) education and prevention, 3) treatment and 4) public safety and law enforcement. Several of the recommendations are accompanied by existing local practices from cities and counties. The report also includes recommendations for state and federal officials, who are pivotal partners in local efforts to combat opioid misuse, diversion, overdose and death.
 

Leading in a Crisis

Recommendations at a Glance
  • City and county leaders must assume roles of leadership in local efforts to reverse the trends of the opioid crisis.
  • Set the tone in the local conversation on opioids.
  • Convene community leaders.
  • Foster regional cooperation.
  • Educate and advocate to state and federal partners.
  • Ensure progress for all in formulating responses to addiction.
 

Focusing on Prevention and Education

Recommendations at a Glance
  • In order to stem the tide of the opioid epidemic, local leaders must approach prevention and education efforts with the same urgency and determination with which we work to reverse overdoses and arrest drug traffickers.
  • Increase public awareness by all available means.
  • Reach children early, in and outside of schools.
  • Advocate for opioid training in higher education.
  • Embrace the power of data and technology.
  • Facilitate safe disposal sites and take-back days.

Expanding Treatment

Recommendations at a Glance
  • Local leaders should institute policies that expand treatment for individuals struggling with opioid addiction.
  • Make naloxone widely available.
  • Intervene to advance disease control by implementing a clean syringe program.
  • Increase availability of medication-assisted treatments.
  • Expand insurance coverage of addiction treatments.
  • Employ telemedicine solutions.

Reassessing Public Safety and Law Enforcement Approaches

Recommendations at a Glance
  • Law enforcement agencies should focus resources on supply-reduction and aim to divert individuals struggling with addiction from the criminal justice system to appropriate treatments.
  • Reduce the illicit supply of opioids.
  • Consider alternatives to arrest.
  • Divert from the criminal justice system.
  • Facilitate treatment in jails.
  • Support “Ban the Box” initiatives.

Federal and State Recommendations

As we call on city and county officials to lead efforts to address the opioid epidemic across our local communities, we recognize that these local efforts will be far more effective when carried out in partnership with state and federal counterparts. The following recommendations call for state and federal actions that can complement local efforts to reduce the rates of opioid dependence, overdose and deaths in our communities. In crafting the recommendations, the task force referenced the National Governors Association’s 2016 report, “Finding Solutions to the Prescription Opioid and Heroin Crisis: A Road Map for States.”
 

State Recommendations

Establish or strengthen prescription drug monitoring programs (PDMPs)
Most states collect data on controlled substances dispensed in the state, including opioids. States should require medical professionals to use PDMPs to assess potential abuse or diversion before prescribing opioids, and they should require those who dispense opioids to report each prescription to the PDMP within 24 hours.

Institute guidelines for prescribing opioids
In March 2016, the Centers for Disease Control and Prevention (CDC) published opioid prescription guidelines with recommendations to help prescribers determine when to initiate opioids for chronic pain, how to select opioids, set their dosage, duration and discontinuation and how to assess risk and address the harms of opioid use. States should adopt the CDC guidelines or similar guidelines that achieve the same goal.

Support greater availability of medication-assisted treatments
States should assess the factors that limit medication-assisted treatments in their cities and counties and take actions to help increase the availability of such treatments. Barriers to medication-assisted treatments in state statutes should be reassessed and training of primary care physicians in administering medication-assisted treatments should be required or incentivized.

Structure Medicaid programs to promote safe opioid prescription practices and access to treatments
According to the National Association of Medicaid Directors, compared with their privately insured counterparts, Medicaid participants are twice as likely to be prescribed opioids and have six times the risk of opioid-related overdose deaths. States should address these disparities through their Medicaid plans by limiting opioid prescriptions, promoting the use of non-opioid pain management methods and optimizing timely access to medication-assisted treatments like buprenorphine and naltrexone.

Explicitly authorize or remove barriers to clean syringe programs
In addition to protecting communities from the outbreak of infectious diseases like HIV and hepatitis, syringe exchange programs provide important opportunities to connect individuals struggling with drug addiction to treatment services. States should support these programs and remove statutory barriers to their establishment in cities and counties.
 

Federal Recommendations

Expand access to medication-assisted treatments
One of the greatest impediments to the treatment of individuals struggling with addiction is the limited number of practitioners who can prescribe buprenorphine. To prescribe buprenorphine, practitioners must apply for a special license that limits the number of patients they can treat. Recently, the federal government took action to increase the limit from 100 to 275 patients. The federal government must continue to make policy changes to allow other medical professionals (such as nurse practitioners) to dispense such medications.

Provide funding for local efforts to address the opioid crisis
Local governments are struggling to find sufficient funding to provide medication-assisted treatment programs, expand drug abuse prevention and education efforts, purchase sufficient quantities of naloxone and implement useful drug take-back programs. The federal government must quickly pass legislation to provide emergency supplemental funding to assist local governments through grants that would help expand and improve existing efforts to address the opioid epidemic in local communities across the nation.

Partner with local and state officials to reduce the supply of fentanyl and carfentanil
The increasingly lethal synthetic forms of opioid, which can be up to 10,000 times stronger than morphine, are quickly becoming the leading cause of opioid overdose in local communities as drug traffickers lace heroin with these stronger opioids to create a more potent product. First responders often have to use several doses of naloxone to revive persons who have overdosed on heroin laced with fentanyl and carfentanil. The federal government must devote extensive resources to federal, state and local law enforcement efforts to stop the illicit trafficking of fentanyl and carfentanil.

Allow individuals in custody to continue receiving Medicaid benefits until convicted, sentenced and incarcerated, and require states to suspend, rather than terminate, Medicaid for individuals in jail
Under current federal law, federal Medicaid matching funds cannot be used to pay for treatment of jail inmates – an estimated 64 percent of whom struggle with addiction. This statutory exclusion applies not only to individuals who have been convicted of crimes, but also to pre-trial inmates who make up a majority of jail populations and are presumed innocent until proven guilty. To avoid violating the federal exclusion, states typically terminate Medicaid benefits when an inmate is booked into jail, meaning he or she must reapply on release, further interrupting access to treatment in the post-release period when many individuals relapse and overdose. The federal government should provide greater flexibility in the Medicaid program for justice-involved populations and should require states to suspend, rather than terminate, coverage for incarcerated individuals. Doing so will allow counties and cities to better coordinate systems of care and treat previously undiagnosed individuals with substance abuse disorders.
 
 


Reprinted with permission of the National League of Cities (NLC) (www.nlc.org.) To read the full report, please see http://opioidaction.org/report/. Infographic courtesy of NLC.
 
Staff to the task force, primary report authors and ongoing points of contact for this report are: James Brooks and Yucel Ors for the National League of Cities and Hadi Sedigh for the National Association of Counties. Contact James Brooks at (202) 626-3163, brooks@nlc.org, Yucel Ors at (202) 626-3124, ors@nlc.org, and Hadi Sedigh at (202) 942-4213, hsedigh@naco.org.