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Legislators focus on punishing overprescription—with a nod to prevention.

Before Congress reached a compromise on opioid legislation this year, more than 50 bills focused on substance use had been introduced, proposing everything from improving public awareness of the nation’s poison control center to allowing Medicaid to cover treatment for substance use disorders.Margot Sanger-Katz and Thomas Kaplan, “Congress Is Writing Lots of Opioid Bills. But Which Ones Will Actually Help?New York Times, June 20, 2018.

But many of the bills focused on regulating prescriptions, including one to develop best practices for prescription drug monitoring programs.Margot Sanger-Katz and Thomas Kaplan, “Congress Is Writing Lots of Opioid Bills. But Which Ones Will Actually Help?New York Times, June 20, 2018. On prescription drug monitoring programs, see “Prescription Drug Monitoring Best Practices Act of 2018,” H.R. 6608 (115th Congress, 2018).

At the state level, by the end of 2018, more than 30 states had enacted legislation regulating the prescription of opioids, and an estimated 1,300 opioid-related bills have been introduced in state legislatures since 2015.National Conference of State Legislatures, “Prescribing Policies: States Confront Opioid Overdose Epidemic,” October 31, 2018. This legislation has largely focused on limiting the maximum number of days for which opiates can be prescribed, mostly to around a week.National Conference of State Legislatures, “Prescribing Policies: States Confront Opioid Overdose Epidemic,” October 31, 2018. But overprescription—which has been declining since 2012—is only the tip of the iceberg: there is a growing concern about the influx of illegally manufactured synthetic opioids.CDC, “U.S. Opioid Prescribing Rate Maps,” updated October 3, 2018. Synthetic opioids, including fentanyl and its analog carfentanil, are far more potent than most prescription opioids and have contributed to thousands of deaths—and that toll is increasing yearly.Richard Franki, “Fentanyl Analogs Nearly Double Their Overdose Death Toll,” Internal Medicine, July 13, 2018.

In what many have hailed as a bipartisan victory, Congress passed the SUPPORT for Patients and Communities Act, which was signed into law in late October.German Lopez, “Trump Just Signed a Bipartisan Bill to Confront the Opioid Epidemic,” Vox, October 24, 2018. The law expands programs for the use of naloxone among first responders, grants permission for more health care practitioners to prescribe medications for opioid use disorder, and removes some restrictions on using Medicare and Medicaid to access treatment.Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the ‘‘SUPPORT for Patients and Communities Act’’), H.R. 6 (115th Congress, 2018); and Lopez, “Trump Just Signed a Bipartisan Bill,” 2018. It also increases penalties for drug manufacturers and distributors.Lopez, “Trump Just Signed a Bipartisan Bill,” 2018. But while experts and activists agree that the legislation is a positive step, some have expressed concerns that the lack of dedicated funding and the failure to provide for significantly expanded treatment have transformed what could have been a comprehensive response into a band-aid solution.Lopez, “Trump Just Signed a Bipartisan Bill,” 2018. While the law authorizes some small grant programs for, among other things, increased access to treatment, it does not require funding for them, leaving their fate in the hands of a future Congress.H.R. 6 (2018). And even if funding is granted, it may not be prioritized in ways that make the most sense for successful intervention, which has been an Achilles heel of previous programs.See Leo Beletsky, “21st Century Cures for the Opioid Crisis: Promise, Impact, and Missed Opportunities,” American Journal of Law and Medicine 44, no. 2-3 (2018), 359-85. While getting naloxone into the hands of first responders is useful, studies have shown that where it makes the most difference is in the hands of the community, where the people who are most likely to be present for and witness an overdose can administer life-saving aid.World Health Organization, “Information Sheet on Opioid Overdose,” August 2018. This goal is driving legislation like Indiana’s SB 13, which permits community corrections and probation officers—not just first responders—to administer overdose intervention drugs. The Family First Prevention Services Act, enacted as part of the Bipartisan Budget Act of 2018, is a lesser-known source of new federal funds for substance use treatment. Bipartisan Budget Act of 2018, H.R. 1892 (115th Congress, 2018). This package of changes to federal child welfare law would allow, for the first time, federal Title IV-E child welfare funds to be used for mental health, substance use treatment, and parenting education services prior to the removal of a child from the home.National Conference of State Legislatures (NCSL), “Family First Prevention Services Act (FFPSA),” May 15, 2018.