In-Depth with the U.S. Secretary of Health and Human Services: Fighting the Opioid Epidemic

By John Lavitt 03/07/16

Sylvia Burwell, the U.S. Secretary of Health and Human Services, tells The Fix about the administration's strategies, from naloxone access to medication-assisted treatment.

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Stout Street Clinic

As the United States Secretary of Health and Human Services (HHS) since 2014, Sylvia Mathews Burwell has been the primary overseer of the Obama administration’s response to the opioid epidemic. Under the umbrella of HHS, Secretary Burwell is in charge of the following:

1. Centers for Disease Control and Prevention (CDC)

2. Substance Abuse and Mental Health Services Administration (SAMHSA)

3. National Institutes of Health (NIH)

4. National Institute on Drug Abuse (NIDA)

5. National Institute on Alcohol Abuse and Alcoholism (NIAAA)

6. Food and Drug Administration (FDA) 

7. Health Resources and Services Administration (HRSA)

Except for legal enforcement and judicial interdictions, almost every aspect of the federal response to the drug problem is under the jurisdiction of Director Burwell. Working with Michael Botticelli, the director of the White House Office of National Drug Control Policy, she has been fundamental in the ongoing implementation of the government’s efforts to stop the opioid epidemic. Traveling across the country, she has also taken on a huge public role, helping to explain the efforts to the public at large.

Given her impressive résumé, Secretary Burwell is up to the challenge. As the Director of the White House Office of Management and Budget from 2013 to 2014, she was in charge of the difficult and even controversial task of administering the government shutdown. She served as the deputy director of the OMB under the Clinton administration, as well. Burwell has also served as president of both the Walmart Foundation and the Global Development Program of the Bill and Melinda Gates Foundation.

When you were appointed Secretary of Health and Human Services in 2014, did you have any inkling that the opioid abuse epidemic—both in terms of prescription painkillers and heroin—would become as widespread as it is now on a national scale? Did the extremity of the problem surprise you?

The issue wasn’t new to me. It’s one that is very close to my heart. My home state of West Virginia has the highest drug overdose death rate in the U.S., more than double the national rate. 

I’ve seen the epidemic firsthand. I watched a friend of mine—a talented, vibrant young woman—struggle with addiction and ultimately lose. And as Secretary, I’ve seen the way it impacts our communities without regard to income or geographic area.  

The prescription opioid and heroin epidemic has been building for many years. Since 2009, drug overdose deaths have been the leading cause of injury death in the United States—more than even car crashes. Especially alarming is the continued increases in prescription opioid and heroin overdose deaths. 

HHS has been engaged in addressing this issue for many years, through our agencies, such as the Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Disease Control and Prevention (CDC), and the National Institute on Drug Abuse (NIDA). We know that the current situation is urgent, which is why one of my priorities is to implement the most effective solutions to reverse this trend. 

At HHS, we’ve used the best scientific evidence to determine where to focus our attention to reduce prescription opioid- and heroin-related overdose, death and dependence. This has led us to focus on three key areas:

  • Improving opioid prescribing practices
  • Expanding use of medication-assisted treatment (MAT) to treat opioid use disorders
  • Expanding access to and use of naloxone to reduce overdose deaths

Additionally, just recently, the FDA announced a change in course in how it will approach opioids—their approval, labeling and prescribing. The agency is going to fundamentally re-examine the risk-benefit paradigm for opioids and ensure that it considers their wider public health effects. 

The president’s recently proposed budget continues to expand the fight against opioid abuse, misuse, and overdose with significant new discretionary and mandatory funding in Fiscal Year 2017. The budget proposal includes $1 billion to close the treatment gap. This means ensuring that every American who wants to get treatment for opioid use disorder will have access to treatment.

We need everyone—including federal, state and local government officials, health care providers, drug companies, and family members—to work together to address this nationwide crisis. Fortunately, many are already at work because they recognize our common interest in defeating this epidemic.  

You were previously the president of the Global Development Program of the Bill and Melinda Gates Foundation. While at the foundation, the program you managed was focused on combating world poverty through agricultural development, financial services for the poor, and global libraries. In light of your experience fighting global poverty, do you see similarities between the fight against poverty and the fight against drug abuse?

Like the fight against poverty, the opioid epidemic is a multifaceted challenge. Both of these issues impact an individual’s health, independence and family relationships. They also have impacts at the state and local levels, and demand responses from those areas as well. In addition, there is discrimination and fear that is applied to individuals who are poor and to those who suffer from an opioid use disorder. This discrimination and fear can be a barrier to effectively addressing these issues.

Addressing the opioid epidemic and combating poverty both require multifaceted, targeted approaches that engage a wide spectrum of stakeholders to address the crisis in a meaningful and impactful way. We can’t do this alone. We need all stakeholders to come together to fight the opioid epidemic.  

Sylvia Mathews Burwell with Governor Charlie Baker of Massachusetts. Photo Courtesy of Governor Charlie Baker's Office 

You grew up in West Virginia, and you often return to West Virginia University to speak. In your honor, a scholarship was established to support aspiring WVU political science students. In a November journalism piece entitled "The Needle and the Damage Done: West Virginia's Heroin Epidemic," West Virginia Public Broadcasting highlighted the extremity of the heroin epidemic in your home state. Why is the problem so extreme in West Virginia? Do you see any lessons for the nation at large in what has happened there?

There are a variety of factors at play, enough for a whole other interview. We know that there are issues of poverty and health that confront West Virginians, as well as the fact that prescription drug abuse is a very serious and long-standing problem in the state. In fact, the drug overdose death rate in West Virginia was the highest in the nation in 2014. The problem there, like in other states across the nation, is complex and requires a multi-sector response. 

The good news is that work is underway to address the crisis. West Virginia is leading in this space. The state has instituted mandatory prescription drug monitoring program (PDMP) registration and use to better track opioid prescribing and dispensing; mandatory prescriber education so that prescribers are making the most informed prescribing decisions; the state’s first-ever substance abuse call line for those seeking help and recovery services; and recently-passed legislation giving additional access to naloxone to family members and friends who can administer the drug to reverse an opioid overdose. Law enforcement is an important partner in this work. For example, since 2014, law enforcement in Charleston has worked closely with drug treatment experts to divert non-violent drug offenders to treatment rather than prison as part of the LEAD or Law Enforcement Assisted Diversion program. 

In October of last year, I was fortunate to be able to travel with President Obama to Charleston to not only highlight the problem, but also to have an important conversation with local officials to determine how we can work together with federal, state and local governments, health care providers, community members and families to take steps to reduce opioid drug use and its consequences in our country. I was extremely encouraged to hear from so many people who are working very hard to end the epidemic in West Virginia.

While at the Walmart Foundation, you funded a program in conjunction with Goodwill to empower military veterans with the tools they need to find employment, advance in their careers and ensure long-term financial stability for their families. As Secretary of Health and Human Services, although not directly connected to the Veterans Administration, you certainly are aware of the number of veterans suffering from substance abuse disorders and mental health issues. How can the agencies you administer like SAMHSA and the NIH help to support veterans with addiction issues in the same manner that you supported them in the past? 

Veterans’ issues, particularly mental health and substance use disorder issues, are of critical importance. Veterans have been significantly impacted by the opioid epidemic. A number of studies indicate that veterans are at particularly high risk for opioid use disorders and overdose. To address this issue, the VA implemented its Opioid Safety Initiative nationwide in August 2013, and as I understand it, initial results of the initiative are very encouraging. 

At HHS, we work with our colleagues at the VA in several different ways. SAMHSA helps to fund the Veterans Crisis Line, which connects veterans in crisis and their families and friends with qualified, caring VA responders through a confidential, toll-free hotline, online chat, or through text message. SAMHSA also has awarded a number of treatment and recovery services grants to states and communities that include veterans as a target population.

We also work with the VA through the Office of National Drug Control Policy’s Interagency Prescription Drug Abuse Workgroup, which meets quarterly to track progress on agency actions on prescription drug abuse, coordinate policy and programmatic initiatives, and discuss emerging issues on efforts to reduce prescription drug abuse. The VA was also a key partner in the development of our National Action Plan for Adverse Drug Event Prevention, which was launched in 2014 and included recommended actions related to opioid prescribing, both in the inpatient and community setting. In addition, the VA is a federal partner that has been engaged in the development of the CDC’s opioid prescribing guidelines.  

On October 9, 2014, you spoke to reporters about the federal government response to the Ebola virus. Although it never spread out of control, the CDC, an agency you administer under HHS, was instrumental in providing information and raising public awareness. Do you think other agencies that you administer like SAMHSA and the CDC can play the same role in the opioid abuse epidemic? Given how widespread the opioid epidemic is across the country, can such a response be truly effective?

Agencies across the U.S. Department of Health and Human Services have a role to play. Whether it’s working with state and local officials or communities across the country, we can make a difference. 

We will continually monitor and evaluate these interventions to strengthen and inform our programs and policies, and increase their effectiveness at addressing opioid abuse. Our efforts are not “one size fits all,” nor do they encompass every activity happening in this space. But we are committed to working with partners at every level—federal, state and local—in the public and private sector and on both sides of the aisle to combat this crisis and save lives.

The CDC also works with states, communities, and prescribers to prevent opioid misuse and overdose by tracking and monitoring the epidemic and helping states scale up effective programs like Prescription Drug Monitoring Programs through the Prescription Drug Overdose: Prevention for States program. The CDC recently awarded nearly $20 million to 16 states to advance prevention efforts. In 2016, this program will be expanded to all 50 states and the District of Columbia.

SAMHSA is sponsoring a wide variety of prevention, treatment, and recovery programs, including raising awareness about the effectiveness of naloxone in helping to prevent opioid-related deaths, and the effectiveness and availability of medication-assisted treatment. SAMHSA has sponsored overdose prevention education and training programs that allow wider access to overdose kits. In addition, SAMHSA provides continuing medical education courses on prescribing opioids for chronic pain. Most of these courses include resources that address practice management, legal and regulatory issues, opioid pharmacology, and strategies for managing challenging patient situations. In 2015, SAMHSA awarded nearly $11 million in grants to 11 states to support MAT for opioid use disorders in high need communities. In 2016, this program will award grants to more than 20 states. 

The Office of Rural Health Policy in HHS’ Health Resources and Services Administration (HRSA) also plays a role. HRSA recently announced grant awards of approximately $1.8 million to support rural communities in reducing opioid overdose and death. Recipients, representing 13 states, will use the funding to purchase naloxone, train health care professionals and local emergency responders in the use of naloxone, and facilitate the referral of people with opioid use disorder to substance abuse treatment. This spring, HRSA also plans to award up to $100 million dollars to community health centers to expand substance use disorder treatment services, including medication-assisted treatment in community health centers across the U.S.

The president’s Fiscal Year 2017 includes $1 billion in new mandatory funding over two years to expand access to treatment for prescription drug abuse and heroin use. This funding will boost efforts to help individuals with an opioid use disorder seek treatment, successfully complete treatment, and sustain recovery. It also includes approximately $500 million to continue and build on current efforts across the Departments of Justice (DOJ) and Health and Human Services (HHS) to expand state-level prescription drug overdose prevention strategies, increase the availability of medication-assisted treatment programs, improve access to the overdose-reversal drug naloxone, and support targeted enforcement activities. 

HHS will undertake a review of how pain management is evaluated by patient satisfaction surveys, including a review of how the questions these surveys use to assess pain management may relate to pain management practices and the prescribing of opioid drugs. Do you think this review might come up with alternative treatments for chronic pain management? Should the surveys include diversion questions as well? (Drug diversion is the illegal distribution or abuse of prescription drugs or their use for unintended purposes.) How does this review hope to affect the epidemic?

Fundamentally, our Opioid Initiative is working to reduce opioid dependence, overdose, and death while ensuring access to high-quality, evidence-based pain management, which for certain patients includes the use of prescription opioids. Our review will identify the most current information available on the relationship between patient satisfaction surveys and opioid prescribing. The goal of this review is to understand the role patient satisfaction surveys play in opioid prescribing in an effort to identify if incentives to improve pain care are having the unintended consequence of increasing opioid prescribing—which for many patients may not be the best pain management treatment. 

As part of the HHS Opioid Initiative that you are leading, the CDC is investing $8.5 million on the development of tools and resources to help inform prescribers about appropriate opioid prescribing and track data on prescribing trends. Do you believe this national initiative will help put an end to the pill mills that became particularly infamous in Florida as distributors of OxyContin and other prescription painkillers to dealers and addicts? Is it possible to end prescriber abuse?

HHS is committed to a targeted, evidence-based approach to tackling the opioid epidemic that is focused on prevention, treatment and intervention. We must begin by ensuring powerful opioid medications are prescribed appropriately. 

Based on the best available scientific evidence, the CDC is working on a set of suggested guidelines for prescribers focused on prescribing opioids for chronic pain. The guidelines are targeted at primary care providers who prescribe the majority of prescription opioids. Improving the way opioids are prescribed through clinical practice guidelines can help ensure patients have access to the safest, most effective treatment while reducing the likelihood that people may misuse, abuse or overdose from these powerful drugs.

The CDC’s work on opioid prescribing guidelines is critical to our prevention efforts and will help ensure that health care professionals can make the best-informed prescribing decisions, reducing the overprescribing of opioid pain medication. We also understand that many Americans experience chronic or acute pain and it is important that we continue to ensure that they have access to vital medications to manage it. As we move forward with the CDC guidelines, HHS is working to ensure that these two critical goals are aligned. 

States, as regulators of the practice of medicine, are a critical partner in the effort to reduce prescription opioid abuse. This is particularly true in the case of pill mills and prescribers who are operating outside the bounds of accepted medical practice. HHS continues to work with a number of states to help support their efforts to improve surveillance, maximize prescription drug monitoring programs, and evaluate policies that can reduce pill mills and inappropriate opioid prescribing. As we saw in Florida, a targeted strategy aimed at changing prescribing patterns can result in a substantial decline in opioid overdose deaths. 

On a recent NFL game, I saw an advertisement for a prescription drug that addresses opioid constipation. In this advertisement, an anthropomorphic cartoon opioid pill was featured. As part of the HHS Opioid Initiative, will the federal government use similar mass advertising to publicize the lifesaving resources you are offering as well? Given this ad, are the pharmaceutical companies sending conflicting messages to the public in order to keep their painkiller profits flowing?

HHS agencies are engaging in a number of targeted efforts to educate both the public and health care providers about appropriate opioid prescribing and use, supporting education on medication-assisted treatment for opioid use disorders, as well as on the use of naloxone to reverse opioid overdose. 

The ad is a dramatic sign of just how widespread opioid use is and underlines the challenge we face.

In November, the Food and Drug Administration (FDA) fast-tracked the approval of Narcan nasal spray to treat opioid overdoses. As part of the HHS Opioid Initiative, $1.8 million in grants is being awarded to help rural communities purchase naloxone and train first responders in its use. Given the ease with which the Narcan nasal spray can be administered by just about anyone, should it be offered over-the-counter to reduce the overwhelming national overdose rate?

We know that naloxone is an important and life-saving drug that can stop or reverse the effects of an opioid overdose. The FDA’s recent approval of Narcan, the first nasal spray version of naloxone, is an important step in helping more people have access to this critical drug. Previously, naloxone had only been approved in injectable forms. While some injectable versions can be used by lay people, adding a user-friendly, safe nasal spray version expands the treatment options available to patients, family members, first responders, and communities across the country that are working to reverse the epidemic of prescription opioid and heroin overdoses. 

Our Opioid Initiative is focused on bringing more user-friendly products to market and the NIDA and FDA have been working closely with product developers to accomplish this. In addition, many states have passed laws that enable broader access to naloxone to people who are likely to experience or respond to an overdose. This includes allowing pharmacists to dispense naloxone under a standing order or collaborative practice agreement where patients and family members can get naloxone without first seeing a doctor. These encouraging efforts at the state level, and in collaboration with private sector partners in the pharmacy community, are significantly expanding access to naloxone. 

HHS launched HHS.gov/opioids as a one-stop federal resource with tools and information for families, health care providers, law enforcement, and other stakeholders on prescription drug abuse and heroin use prevention, treatment, and response. What is HHS doing to raise awareness about this resource?

HHS.gov/opioids is a great resource for anyone wishing to learn about the opioid epidemic, but is also an important place for people to find information about prevention, how to find help for themselves or a family member, and learn more about treatment options. This resource is being promoted by agencies and departments across the federal government that are involved in our larger effort to combat the opioid epidemic and save lives. We were excited to see it specifically promoted as part of the president’s recent visit to West Virginia, and we continue to highlight it across the department’s social media platforms, where we can have a direct conversation with the American people. 

You announced that HHS would engage in rulemaking related to the prescribing of products that contain buprenorphine in order to expand access to medication-assisted treatment (MAT). As part of the HHS Opioid Initiative, the department awarded $11 million in new grants to states to support MAT. Do you believe that given the Affordable Care Act’s prioritization of substance abuse disorders, MAT like buprenorphine should be a required service in federally funded treatment programs? 

Studies consistently show that MAT with methadone, buprenorphine, or naltrexone for the treatment of opioid use disorders is the most effective treatment option, but it remains significantly underutilized. One area of focus at HHS is to expand access to and use of MAT.

Updating the current regulation around buprenorphine prescribing is one aspect of our work and is an important step to helping more people get the treatment necessary for recovery. This update is a priority for the department and we are working quickly to move the rule forward. 

In addition to the $11 million awarded to states by SAMHSA, our Health Resources and Services Administration (HRSA) has announced a funding opportunity of up to $100 million to fund MAT in health centers nationwide. 

The Affordable Care Act extended federal parity protections to millions of Americans in the individual and small group markets. It mandated that when coverage for mental health and substance use conditions is provided, it must be generally comparable to coverage for medical and surgical care, making it easier for people who want treatment to be able to get and afford it. 

In October 2015, the president also directed federal agencies to review their benefit requirements, drug formularies, program guidelines, and other policies to identify any barriers individuals with an opioid use disorder might encounter when trying to access medication-assisted treatment. HHS is currently conducting this review to identify opportunities to reduce barriers to access. 

Funding to fight this epidemic is also critical, as evidenced by the president’s FY2017 budget proposal, which seeks to close the treatment gap. 

While everyone, including myself in this interview, is focusing on the opioid abuse epidemic, crystal meth abuse and addiction continues to smolder in both small rural towns and big cities across the country. Particularly prevalent among the gay male population, the use of crystal meth has been linked to rising HIV and hepatitis C infection rates. How is this other drug crisis being addressed by the HHS? 

Preventing substance use and supporting treatment of and recovery from substance use disorders are priorities for the administration and for the department. This commitment is also reflected in the administration’s National Drug Control Strategy.

At HHS, SAMHSA funds a broad range of prevention and treatment programs, targeting all forms of substance use. 

In addition, our National Institute on Drug Abuse (NIDA) and our National Institute on Alcohol Abuse and Alcoholism (NIAAA) fund research to better understand alcohol and other forms of substance use, and to translate promising research findings into policy. 

The Surgeon General is working on the first-ever Surgeon General’s Report presenting the state of the science on substance use, addiction, and health. The report will explore the evidence of prevention, recovery, and treatment on a broad range of substances. 

Our FY2017 budget request for continued investments in HHS' substance use research, prevention, and treatment portfolios underscores our commitment to reducing the social, economic, and health impacts of substance use.

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Growing up in Manhattan as a stutterer, John Lavitt discovered that writing was the best way to express himself when the words would not come. After graduating with honors from Brown University, he lived on the Greek island of Patmos, studying with his mentor, the late American poet Robert Lax. As a writer, John’s published work includes three articles in Chicken Soup For The Soul volumes and poems in multiple poetry journals and compilations. Active in recovery, John has been the Treatment Professional News Editor for The Fix. Since 2015, he has published over 500 articles on the addiction and recovery news website. Today, he lives in Los Angeles, trying his best to be happy and creative. Find John on Facebook, Twitter, and LinkedIn.